Book: Psychoanalysis and the Cinema- The Imaginary Signifier

Book Title:

Psychoanalysis and the Cinema- The Imaginary Signifier.

Author(s): Christian Metz.

Year: 1984.

Edition: First (1st).

Publisher: Palgrave Macmillan.

Type(s): Hardcover and Paperback.

Synopsis:

In the first half of the book Metz explores a number of aspects of the psychological anchoring of cinema as a social institution.

In the second half, he shifts his approach…to look at the operations of meaning in the film text, at the figures of image and sound concatenation. Thus he is led to consideration of metaphor and metonymy in film, this involving a detailed account of these two figures as they appear in psychoanalysis and linguistics.

Book: Psychiatric Diagnosis and Classification

Book Title:

Psychiatric Diagnosis and Classification.

Author(s): Mario Maj, Wolfgang Gaebel, Juan Jose Lopez-Ibor, and Norman Sartorius (Editors).

Year: 2002.

Edition: First (1st).

Publisher: Wiley-Blackwell.

Type(s): Hardcover and Kindle.

Synopsis:

This book provides an overview of the strengths and limitations of the currently available systems for the diagnosis and classification of mental disorders, in particular the DSM-IV and the ICD-10, and of the prospects for future developments. Among the covered issues are: The impact of biological research The diagnosis of mental disorders in primary care The usefulness and limitations of the concept of comorbidity in psychiatry The role of understanding and empathy in the diagnostic process The ethical, legal and social aspects of psychiatric classification Psychiatric Diagnosis & Classification provides a comprehensive picture of the current state of available diagnostic and classificatory systems in psychiatry and the improvements that are needed.

What is Capgras Delusion?

Introduction

Capgras delusion is a psychiatric disorder in which a person holds a delusion that a friend, spouse, parent, or other close family member (or pet) has been replaced by an identical impostor. It is named after Joseph Capgras (1873-1950), a French psychiatrist.

The Capgras delusion is classified as a delusional misidentification syndrome, a class of delusional beliefs that involves the misidentification of people, places, or objects. It can occur in acute, transient, or chronic forms. Cases in which patients hold the belief that time has been “warped” or “substituted” have also been reported.

The delusion most commonly occurs in individuals diagnosed with paranoid schizophrenia but has also been seen in brain injury, dementia with Lewy bodies, and other dementia. It presents often in individuals with a neurodegenerative disease, particularly at an older age. It has also been reported as occurring in association with diabetes, hypothyroidism, and migraine attacks. In one isolated case, the Capgras delusion was temporarily induced in a healthy subject by the drug ketamine. It occurs more frequently in females, with a female to male ratio of approximately 3 to 2.

Signs and Symptoms

The following two case reports are examples of the Capgras delusion in a psychiatric setting:

Example 01

Mrs. D, a 74-year-old married housewife, recently discharged from a local hospital after her first psychiatric admission, presented to our facility for a second opinion. At the time of her admission earlier in the year, she had received the diagnosis of atypical psychosis because of her belief that her husband had been replaced by another unrelated man. She refused to sleep with the impostor, locked her bedroom and door at night, asked her son for a gun, and finally fought with the police when attempts were made to hospitalise her. At times she believed her husband was her long deceased father. She easily recognised other family members and would misidentify her husband only.

Example 02

Diane was a 28-year-old single woman who was seen for an evaluation at a day hospital program in preparation for discharge from a psychiatric hospital. This was her third psychiatric admission in the past five years. Always shy and reclusive, Diane first became psychotic at age 23. Following an examination by her physician, she began to worry that the doctor had damaged her internally and that she might never be able to become pregnant. The patient’s condition improved with neuroleptic treatment but deteriorated after discharge because she refused medication. When she was admitted eight months later, she presented with delusions that a man was making exact copies of people—”screens”—and that there were two screens of her, one evil and one good. The diagnosis was schizophrenia with Capgras delusion. She was disheveled and had a bald spot on her scalp from self-mutilation.

Example 03

The following case is an instance of the Capgras delusion resulting from a neurodegenerative disease:

Fred, a 59-year-old man with a high school qualification, was referred for neurological and neuropsychological evaluation because of cognitive and behavioural disturbances. He had worked as the head of a small unit devoted to energy research until a few months before. His past medical and psychiatric history was uneventful. […] Fred’s wife reported that about 15 months from onset he began to see her as a “double” (her words). The first episode occurred one day when, after coming home, Fred asked her where Wilma was. On her surprised answer that she was right there, he firmly denied that she was his wife Wilma, whom he “knew very well as his sons’ mother”, and went on plainly commenting that Wilma had probably gone out and would come back later. […] Fred presented progressive cognitive deterioration characterised both by severity and fast decline. Apart from [Capgras disorder], his neuropsychological presentation was hallmarked by language disturbances suggestive of frontal-executive dysfunction. His cognitive impairment ended up in a severe, all-encompassing frontal syndrome.

Causes

It is generally agreed that the Capgras delusion has a complex and organic basis caused by structural damage to organs and can be better understood by examining neuroanatomical damage associated with the syndrome.

In one of the first papers to consider the cerebral basis of the Capgras delusion, Alexander, Stuss and Benson pointed out in 1979 that the disorder might be related to a combination of frontal lobe damage causing problems with familiarity and right hemisphere damage causing problems with visual recognition.

Further clues to the possible causes of the Capgras delusion were suggested by the study of brain-injured patients who had developed prosopagnosia. In this condition, patients are unable to recognise faces consciously, despite being able to recognise other types of visual objects. However, a 1984 study by Bauer showed that even though conscious face recognition was impaired, patients with the condition showed autonomic arousal (measured by a galvanic skin response measure) to familiar faces, suggesting that there are two pathways to face recognition – one conscious and one unconscious.

In a 1990 paper published in the British Journal of Psychiatry, psychologists Hadyn Ellis and Andy Young hypothesized that patients with Capgras delusion may have a “mirror image” or double dissociation of prosopagnosia, in that their conscious ability to recognise faces was intact, but they might have damage to the system that produces the automatic emotional arousal to familiar faces. This might lead to the experience of recognising someone while feeling something was not “quite right” about them. In 1997, Ellis and his colleagues published a study of five patients with Capgras delusion (all diagnosed with schizophrenia) and confirmed that although they could consciously recognise the faces, they did not show the normal automatic emotional arousal response. The same low level of autonomic response was shown in the presence of strangers. Young (2008) has theorised that this means that patients with the disease experience a “loss” of familiarity, not a “lack” of it. Further evidence for this explanation comes from other studies measuring galvanic skin responses (GSR) to faces. A patient with Capgras delusion showed reduced GSRs to faces in spite of normal face recognition. This theory for the causes of Capgras delusion was summarised in Trends in Cognitive Sciences in 2001.

William Hirstein and Vilayanur S. Ramachandran reported similar findings in a paper published on a single case of a patient with Capgras delusion after brain injury. Ramachandran portrayed this case in his book Phantoms in the Brain[24] and gave a talk about it at TED 2007. Since the patient was capable of feeling emotions and recognising faces but could not feel emotions when recognising familiar faces, Ramachandran hypothesizes that the origin of Capgras syndrome is a disconnection between the temporal cortex, where faces are usually recognised, and the limbic system, involved in emotions. More specifically, he emphasizes the disconnection between the amygdala and the inferotemporal cortex.

In 2010, Hirstein revised this theory to explain why a person with Capgras syndrome would have the particular reaction of not recognizing a familiar person. Hirstein explained the theory as follows:

My current hypothesis on Capgras, which is a more specific version of the earlier position I took in the 1997 article with V. S. Ramachandran. According to my current approach, we represent the people we know well with hybrid representations containing two parts. One part represents them externally: how they look, sound, etc. The other part represents them internally: their personalities, beliefs, characteristic emotions, preferences, etc. Capgras syndrome occurs when the internal portion of the representation is damaged or inaccessible. This produces the impression of someone who looks right on the outside, but seems different on the inside, i.e., an impostor. This gives a much more specific explanation that fits well with what the patients actually say. It corrects a problem with the earlier hypothesis in that there are many possible responses to the lack of an emotion upon seeing someone.

Furthermore, Ramachandran suggests a relationship between the Capgras syndrome and a more general difficulty in linking successive episodic memories because of the crucial role emotion plays in creating memories. Since the patient could not put together memories and feelings, he believed objects in a photograph were new on every viewing, even though they normally should have evoked feelings (e.g. a person close to him, a familiar object, or even himself). Others like Merrin and Silberfarb (1976) have also proposed links between the Capgras syndrome and deficits in aspects of memory. They suggest that an important and familiar person (the usual subject of the delusion) has many layers of visual, auditory, tactile, and experiential memories associated with them, so the Capgras delusion can be understood as a failure of object constancy at a high perceptual level.

Most likely, more than just an impairment of the automatic emotional arousal response is necessary to form the Capgras delusion, as the same pattern has been reported in patients showing no signs of delusions. Ellis suggested that a second factor explains why this unusual experience is transformed into a delusional belief; this second factor is thought to be an impairment in reasoning, although no definitive impairment has been found to explain all cases. Many have argued for the inclusion of the role of patient phenomenology in explanatory models of the Capgras syndrome in order to better understand the mechanisms that enable the creation and maintenance of delusional beliefs.

Capgras syndrome has also been linked to reduplicative paramnesia, another delusional misidentification syndrome in which a person believes a location has been duplicated or relocated. Since these two syndromes are highly associated, it has been proposed that they affect similar areas of the brain and therefore have similar neurological implications. Reduplicative paramnesia is understood to affect the frontal lobe, and thus it is believed that Capgras syndrome is also associated with the frontal lobe. Even if the damage is not directly to the frontal lobe, an interruption of signals between other lobes and the frontal lobe could result in Capgras syndrome.

Diagnosis

Because it is a rare and poorly understood condition, there is no definitive way to diagnose the Capgras delusion. Diagnosis is primarily made on a psychiatric evaluation of the patient, who is most likely brought to a psychiatrist’s attention by a family member or friend believed to be an imposter by the person under the delusion.

Treatment

Treatment has not been well studied and so there is no evidence-based approach. Treatment is generally therapy, often with support of antipsychotic medication.

Brief History

Capgras syndrome is named after Joseph Capgras, a French psychiatrist who first described the disorder in 1923 in his paper co-authored by Jean Reboul-Lachaux, on the case of a French woman, “Madame Macabre,” who complained that corresponding “doubles” had taken the places of her husband and other people she knew. Capgras and Reboul-Lachaux first called the syndrome “l’illusion des sosies”, which can be translated literally as “the illusion of look-alikes.”

The syndrome was initially considered a purely psychiatric disorder, the delusion of a double seen as symptomatic of schizophrenia, and purely a female disorder (though this is now known not to be the case) often noted as a symptom of hysteria. Most of the proposed explanations initially following that of Capgras and Reboul-Lachaux were psychoanalytical in nature. It was not until the 1980s that attention was turned to the usually co-existing organic brain lesions originally thought to be essentially unrelated or accidental. Today, the Capgras syndrome is understood as a neurological disorder, in which the delusion primarily results from organic brain lesions or degeneration.

In Popular Culture

In the Memoirs Found in a Bathtub novel by the Polish writer Stanisław Lem, first published in 1961, the narrator inhabits a paranoid dystopia where nothing is as it seems, chaos seems to rule all events, and everyone is deeply suspicious of everyone. In the end, it is revealed that the world is filled by phantom body doubles.

A central character in Richard Powers’s 2006 novel The Echo Maker suffers from Capgras Delusion subsequent to traumatic brain injury.

The protagonist in the movie Synecdoche, New York, who is named Caden Cotard (played by Philip Seymour Hoffman), goes to see his ex-wife at her apartment, and, as he enters the building, one of the resident call boxes is taped with the name “Capgras”. He is then misidentified as his ex-wife’s cleaning lady, Ellen Bascomb, as he tries to enter the apartment, and, later in the film, he actually comes to play the role of Ellen Bascomb in his own play. Throughout the film, Cotard enlists actor-doubles to play actors, and, as the film progresses, the actor-doubles are in turn then given actors-doubles.

In “Dorado Falls,” an episode from the seventh season of the television series Criminal Minds, a Navy SEAL develops Capgras delusion as the result of an automobile accident. His experience with classified military missions causes him to become extremely paranoid, and he begins killing the people he sees on a regular basis, believing them to have been replaced by duplicates who are plotting against him.

What is Anti-Psychiatry?

Introduction

Anti-psychiatry is a movement based on the view that psychiatric treatment is more often damaging than helpful to patients. It considers psychiatry a coercive instrument of oppression due to an unequal power relationship between doctor and patient, and a highly subjective diagnostic process. Wrongful involuntary commitment is an important issue in the movement. It has been active in various forms for two centuries. Anti-psychiatry originates in an objection to what some view as dangerous treatments.

In the 1960s, there were many challenges to psychoanalysis and mainstream psychiatry, where the very basis of psychiatric practice was characterised as repressive and controlling. Psychiatrists involved in this challenge included Thomas Szasz, Giorgio Antonucci, R. D. Laing, Franco Basaglia, Theodore Lidz, Silvano Arieti, and David Cooper. Others involved were L. Ron Hubbard (science fiction author & founder of scientology), Michel Foucault, Gilles Deleuze, Félix Guattari, and Erving Goffman. Cooper coined the term “anti-psychiatry” in 1967, and wrote the book Psychiatry and Anti-psychiatry in 1971. Thomas Szasz introduced the definition of mental illness as a myth in the book The Myth of Mental Illness (1961), Giorgio Antonucci introduced the definition of psychiatry as a prejudice in the book I pregiudizi e la conoscenza critica alla psichiatria (1986).

Contemporary issues of anti-psychiatry include freedom versus coercion, racial and social justice, effects of antipsychotic medications, mental illness unintentionally induced by medical therapy, personal liberty, social stigma, and the right to be different.

Examples of historically dangerous treatments include electroconvulsive therapy, insulin shock therapy, and brain lobotomy. A more recent concern is the significant increase in prescribing psychiatric drugs for children in the beginning of the 21st century. There were also concerns about mental health institutions. All modern societies permit involuntary treatment or involuntary commitment of mental patients.

Brief History

Precursors

The first widespread challenge to the prevailing medical approach in Western countries occurred in the late 18th century. Part of the progressive Age of Enlightenment, a “moral treatment” movement challenged the harsh, pessimistic, somatic (body-based) and restraint-based approaches that prevailed in the system of hospitals and “madhouses” for people considered mentally disturbed, who were generally seen as wild animals without reason. Alternatives were developed, led in different regions by ex-patient staff, physicians themselves in some cases, and religious and lay philanthropists. The moral treatment was seen as pioneering more humane psychological and social approaches, whether or not in medical settings; however, it also involved some use of physical restraints, threats of punishment, and personal and social methods of control. And as it became the establishment approach in the 19th century, opposition to its negative aspects also grew.

According to Michel Foucault, there was a shift in the perception of madness, whereby it came to be seen as less about delusion, i.e. disturbed judgment about the truth, than about a disorder of regular, normal behaviour or will. Foucault argued that, prior to this, doctors could often prescribe travel, rest, walking, retirement and generally engaging with nature, seen as the visible form of truth, as a means to break with artificialities of the world (and therefore delusions). Another form of treatment involved nature’s opposite, the theatre, where the patient’s madness was acted out for him or her in such a way that the delusion would reveal itself to the patient.

According to Foucault, the most prominent therapeutic technique instead became to confront patients with a healthy sound will and orthodox passions, ideally embodied by the physician. The cure then involved a process of opposition, of struggle and domination, of the patient’s troubled will by the healthy will of the physician. It was thought the confrontation would lead not only to bring the illness into broad daylight by its resistance, but also to the victory of the sound will and the renunciation of the disturbed will. We must apply a perturbing method, to break the spasm by means of the spasm…. We must subjugate the whole character of some patients, subdue their transports, break their pride, while we must stimulate and encourage the others (Esquirol, J.E.D., 1816). Foucault also argued that the increasing internment of the “mentally ill” (the development of more and bigger asylums) had become necessary not just for diagnosis and classification but because an enclosed place became a requirement for a treatment that was now understood as primarily the contest of wills, a question of submission and victory.

The techniques and procedures of the asylums at this time included “isolation, private or public interrogations, punishment techniques such as cold showers, moral talks (encouragements or reprimands), strict discipline, compulsory work, rewards, preferential relations between the physician and his patients, relations of vassalage, of possession, of domesticity, even of servitude between patient and physician at times”. Foucault summarised these as “designed to make the medical personage the ‘master of madness'” through the power the physician’s will exerts on the patient. The effect of this shift then served to inflate the power of the physician relative to the patient, correlated with the rapid rise of internment (asylums and forced detention).

Other analyses suggest that the rise of asylums was primarily driven by industrialization and capitalism, including the breakdown of the traditional family structures. And that by the end of the 19th century, psychiatrists often had little power in the overrun asylum system, acting mainly as administrators who rarely attended to patients, in a system where therapeutic ideals had turned into mindless institutional routines. In general, critics point to negative aspects of the shift toward so-called “moral treatments”, and the concurrent widespread expansion of asylums, medical power and involuntary hospitalisation laws, in a way that was to play an important conceptual part in the later anti-psychiatry movement.

Various 19th-century critiques of the newly emerging field of psychiatry overlap thematically with 20th-century anti-psychiatry, for example in their questioning of the medicalisation of “madness”. Those critiques occurred at a time when physicians had not yet achieved hegemony through psychiatry, however, so there was no single, unified force to oppose. Nevertheless, there was increasing concern at the ease with which people could be confined, with frequent reports of abuse and illegal confinement. For example, Daniel Defoe, the author of Robinson Crusoe, had previously argued for more government oversight of “madhouses” and for due process prior to involuntary internment. He later argued that husbands used asylum hospitals to incarcerate their disobedient wives, and in a subsequent pamphlet that wives even did the same to their husbands. It was also proposed that the role of asylum keeper be separated from doctor, to discourage exploitation of patients. There was general concern that physicians were undermining personhood by medicalising problems, by claiming they alone had the expertise to judge it, and by arguing that mental disorder was physical and hereditary. The Alleged Lunatics’ Friend Society arose in England in the mid-19th century to challenge the system and campaign for rights and reforms. In the United States, Elizabeth Packard published a series of books and pamphlets describing her experiences in the Illinois insane asylum, to which she had been committed at the request of her husband.

Throughout, the class nature of mental hospitals, and their role as agencies of control, were well recognised. And the new psychiatry was partially challenged by two powerful social institutions – the church and the legal system. These trends have been thematically linked to the later 20th century anti-psychiatry movement.

As psychiatry became more professionally established during the nineteenth century (the term itself was coined in 1808 in Germany, as “Psychiatriein”) and developed allegedly more invasive treatments, opposition increased. In the Southern US, black slaves and abolitionists encountered Drapetomania, a pseudo-scientific diagnosis for why slaves ran away from their masters.

There was some organised challenge to psychiatry in the late 1870s from the new speciality of neurology. Practitioners criticised mental hospitals for failure to conduct scientific research and adopt the modern therapeutic methods such as nonrestraint. Together with lay reformers and social workers, neurologists formed the National Association for the Protection of the Insane and the Prevention of Insanity. However, when the lay members questioned the competence of asylum physicians to even provide proper care at all, the neurologists withdrew their support and the association floundered.

Early 1900s

It has been noted that “the most persistent critics of psychiatry have always been former mental hospital patients”, but that very few were able to tell their stories publicly or to confront the psychiatric establishment openly, and those who did so were commonly considered so extreme in their charges that they could seldom gain credibility. In the early 20th century, ex-patient Clifford W. Beers campaigned to improve the plight of individuals receiving public psychiatric care, particularly those committed to state institutions, publicizing the issues in his book, A Mind that Found Itself (1908). While Beers initially condemned psychiatrists for tolerating mistreatment of patients, and envisioned more ex-patient involvement in the movement, he was influenced by Adolf Meyer and the psychiatric establishment, and toned down his hostility since he needed their support for reforms. In Germany there were similar movements which used the term “Antipsychiatrie”.

His reliance on rich donors and his need for approval from experts led him to hand over to psychiatrists the organisation he helped found, the National Committee for Mental Hygiene which eventually became the National Mental Health Association. In the UK, the National Society for Lunacy Law Reform was established in 1920 by angry ex-patients who sought justice for abuses committed in psychiatric custody, and were aggrieved that their complaints were patronisingly discounted by the authorities, who were seen to value the availability of medicalised internment as a ‘whitewashed’ extrajudicial custodial and punitive process. In 1922, ex-patient Rachel Grant-Smith added to calls for reform of the system of neglect and abuse she had suffered by publishing “The Experiences of an Asylum Patient”. In the US, We Are Not Alone (WANA) was founded by a group of patients at Rockland State Hospital in New York, and continued to meet as an ex-patient group.

In the 1920s, extreme hostility to psychiatrists and psychiatry was expressed by the French playwright and theatre director Antonin Artaud, in particular, in his book on van Gogh. To Artaud, imagination was reality. Much influenced by the Dada and surrealist enthusiasms of the day, he considered dreams, thoughts and visions no less real than the “outside” world. To Artaud, reality appeared little more than a convenient consensus, the same kind of consensus an audience accepts when they enter a theatre and, for a time, are happy to pretend what they are seeing is real.

In this era before penicillin was discovered, eugenics was popular. People believed diseases of the mind could be passed on so compulsory sterilisation of the mentally ill was enacted in many countries.

Early 1930s

In the 1930s several controversial medical practices were introduced, including inducing seizures (by electroshock, insulin or other drugs) or cutting parts of the brain apart (lobotomy). In the US, between 1939 and 1951, over 50,000 lobotomy operations were performed in mental hospitals. But lobotomy was ultimately seen as too invasive and brutal.

Holocaust historians argued that the medicalisation of social programmes and systematic euthanasia of people in German mental institutions in the 1930s provided the institutional, procedural, and doctrinal origins of the mass murder of the 1940s. The Nazi programmes were called Action T4 and Action 14f13. The Nuremberg Trials convicted a number of psychiatrists who held key positions in Nazi regimes. For instance this idea of a Swiss psychiatrist: “A not so easy question to be answered is whether it should be allowed to destroy lives objectively ‘unworthy of living’ without the expressed request of its bearers. (…) Even in incurable mentally ill ones suffering seriously from hallucinations and melancholic depressions and not being able to act, to a medical colleague I would ascript the right and in serious cases the duty to shorten – often for many years – the suffering” (Bleuler, Eugen, 1936: “Die naturwissenschaftliche Grundlage der Ethik”. Schweizer Archiv Neurologie und Psychiatrie, Band 38, Nr.2, S. 206).

1940s and 1950s

The post-World War II decades saw an enormous growth in psychiatry; many Americans were persuaded that psychiatry and psychology, particularly psychoanalysis, were a key to happiness. Meanwhile, most hospitalised mental patients received at best decent custodial care, and at worst, abuse and neglect.

The psychoanalyst Jacques Lacan has been identified as an influence on later anti-psychiatry theory in the UK, and as being the first, in the 1940s and 50s, to professionally challenge psychoanalysis to re-examine its concepts and to appreciate psychosis as understandable. Other influences on Lacan included poetry and the surrealist movement, including the poetic power of patients’ experiences. Critics disputed this and questioned how his descriptions linked to his practical work. The names that came to be associated with the anti-psychiatry movement knew of Lacan and acknowledged his contribution even if they did not entirely agree. The psychoanalyst Erich Fromm is also said to have articulated, in the 1950s, the secular humanistic concern of the coming anti-psychiatry movement. In The Sane Society (1955), Fromm wrote “”An unhealthy society is one which creates mutual hostility [and] distrust, which transforms man into an instrument of use and exploitation for others, which deprives him of a sense of self, except inasmuch as he submits to others or becomes an automaton”…”Yet many psychiatrists and psychologists refuse to entertain the idea that society as a whole may be lacking in sanity. They hold that the problem of mental health in a society is only that of the number of ‘unadjusted’ individuals, and not of a possible unadjustment of the culture itself”.

In the 1950s, new psychiatric drugs, notably the antipsychotic chlorpromazine, slowly came into use. Although often accepted as an advance in some ways, there was opposition, partly due to serious adverse effects such as tardive dyskinesia, and partly due their “chemical straitjacket” effect and their alleged use to control and intimidate patients. Patients often opposed psychiatry and refused or stopped taking the drugs when not subject to psychiatric control. There was also increasing opposition to the large-scale use of psychiatric hospitals and institutions, and attempts were made to develop services in the community.

In the 1950s in the United States, a right-wing anti-mental health movement opposed psychiatry, seeing it as liberal, left-wing, subversive and anti-American or pro-Communist. There were widespread fears that it threatened individual rights and undermined moral responsibility. An early skirmish was over the Alaska Mental Health Bill, where the right wing protestors were joined by the emerging Scientology movement.

The field of psychology sometimes came into opposition with psychiatry. Behaviourists argued that mental disorder was a matter of learning not medicine; for example, Hans Eysenck argued that psychiatry “really has no role to play”. The developing field of clinical psychology in particular came into close contact with psychiatry, often in opposition to its methods, theories and territories.

1960s

Coming to the fore in the 1960s, “anti-psychiatry” (a term first used by David Cooper in 1967) defined a movement that vocally challenged the fundamental claims and practices of mainstream psychiatry. While most of its elements had precedents in earlier decades and centuries, in the 1960s it took on a national and international character, with access to the mass media and incorporating a wide mixture of grassroots activist organisations and prestigious professional bodies.

Cooper was a South African psychiatrist working in Britain. A trained Marxist revolutionary, he argued that the political context of psychiatry and its patients had to be highlighted and radically challenged, and warned that the fog of individualised therapeutic language could take away people’s ability to see and challenge the bigger social picture. He spoke of having a goal of “non-psychiatry” as well as anti-psychiatry.

“In the 1960s fresh voices mounted a new challenge to the pretensions of psychiatry as a science and the mental health system as a successful humanitarian enterprise. These voices included: Ernest Becker, Erving Goffman, R.D. Laing; Laing and Aaron Esterson, Thomas Scheff, and Thomas Szasz. Their writings, along with others such as articles in the journal The Radical Therapist, were given the umbrella label “antipsychiatry” despite wide divergences in philosophy. This critical literature, in concert with an activist movement, emphasized the hegemony of medical model psychiatry, its spurious sources of authority, its mystification of human problems, and the more oppressive practices of the mental health system, such as involuntary hospitalisation, drugging, and electroshock”.
The psychiatrists R D Laing (from Scotland), Theodore Lidz (from America), Silvano Arieti (from Italy) and others, argued that “schizophrenia” and psychosis were understandable, and resulted from injuries to the inner self-inflicted by psychologically invasive “schizophrenogenic” parents or others. It was sometimes seen as a transformative state involving an attempt to cope with a sick society. Laing, however, partially dissociated himself from his colleague Cooper’s term “anti-psychiatry”. Laing had already become a media icon through bestselling books (such as The Divided Self and The Politics of Experience) discussing mental distress in an interpersonal existential context; Laing was somewhat less focused than his colleague Cooper on wider social structures and radical left wing politics, and went on to develop more romanticised or mystical views (as well as equivocating over the use of diagnosis, drugs and commitment). Although the movement originally described as anti-psychiatry became associated with the general counter-culture movement of the 1960s, Lidz and Arieti never became involved in the latter. Franco Basaglia promoted anti-psychiatry in Italy and secured reforms to mental health law there.

Laing, through the Philadelphia Association founded with Cooper in 1965, set up over 20 therapeutic communities including Kingsley Hall, where staff and residents theoretically assumed equal status and any medication used was voluntary. Non-psychiatric Soteria houses, starting in the United States, were also developed as were various ex-patient-led services.

Psychiatrist Thomas Szasz argued that “mental illness” is an inherently incoherent combination of a medical and a psychological concept. He opposed the use of psychiatry to forcibly detain, treat, or excuse what he saw as mere deviance from societal norms or moral conduct. As a libertarian, Szasz was concerned that such usage undermined personal rights and moral responsibility. Adherents of his views referred to “the myth of mental illness”, after Szasz’s controversial 1961 book of that name (based on a paper of the same name that Szasz had written in 1957 that, following repeated rejections from psychiatric journals, had been published in the American Psychologist in 1960). Although widely described as part of the main anti-psychiatry movement, Szasz actively rejected the term and its adherents; instead, in 1969, he collaborated with Scientology to form the Citizens Commission on Human Rights. It was later noted that the view that insanity was not in most or even in any instances a “medical” entity, but a moral issue, was also held by Christian Scientists and certain Protestant fundamentalists, as well as Szasz. Szasz was not a Scientologist himself and was non-religious; he commented frequently on the parallels between religion and psychiatry.

Erving Goffman, Gilles Deleuze, Félix Guattari and others criticised the power and role of psychiatry in society, including the use of “total institutions” and the use of models and terms that were seen as stigmatizing. The French sociologist and philosopher Foucault, in his 1961 publication Madness and Civilization: A History of Insanity in the Age of Reason, analysed how attitudes towards those deemed “insane” had changed as a result of changes in social values. He argued that psychiatry was primarily a tool of social control, based historically on a “great confinement” of the insane and physical punishment and chains, later exchanged in the moral treatment era for psychological oppression and internalized restraint. American sociologist Thomas Scheff applied labelling theory to psychiatry in 1966 in “Being Mentally Ill”. Scheff argued that society views certain actions as deviant and, in order to come to terms with and understand these actions, often places the label of mental illness on those who exhibit them. Certain expectations are then placed on these individuals and, over time, they unconsciously change their behaviour to fulfil them.

Observation of the abuses of psychiatry in the Soviet Union in the so-called Psikhushka hospitals also led to questioning the validity of the practice of psychiatry in the West. In particular, the diagnosis of many political dissidents with schizophrenia led some to question the general diagnosis and punitive usage of the label schizophrenia. This raised questions as to whether the schizophrenia label and resulting involuntary psychiatric treatment could not have been similarly used in the West to subdue rebellious young people during family conflicts.

Since 1970

New professional approaches were developed as an alternative or reformist complement to psychiatry. The Radical Therapist, a journal begun in 1971 in North Dakota by Michael Glenn, David Bryan, Linda Bryan, Michael Galan and Sara Glenn, challenged the psychotherapy establishment in a number of ways, raising the slogan “Therapy means change, not adjustment.” It contained articles that challenged the professional mediator approach, advocating instead revolutionary politics and authentic community making. Social work, humanistic or existentialist therapies, family therapy, counselling and self-help and clinical psychology developed and sometimes opposed psychiatry.

Psychoanalysis was increasingly criticised as unscientific or harmful. Contrary to the popular view, critics and biographers of Freud, such as Alice Miller, Jeffrey Masson and Louis Breger, argued that Freud did not grasp the nature of psychological trauma. Non-medical collaborative services were developed, for example therapeutic communities or Soteria houses.

The psychoanalytically trained psychiatrist Szasz, although professing fundamental opposition to what he perceives as medicalisation and oppressive or excuse-giving “diagnosis” and forced “treatment”, was not opposed to other aspects of psychiatry (for example attempts to “cure-heal souls”, although he also characterises this as non-medical). Although generally considered anti-psychiatry by others, he sought to dissociate himself politically from a movement and term associated with the radical left-wing. In a 1976 publication “Anti-psychiatry: The paradigm of a plundered mind”, which has been described as an overtly political condemnation of a wide sweep of people, Szasz claimed Laing, Cooper and all of anti-psychiatry consisted of “self-declared socialists, communists, anarchists or at least anti-capitalists and collectivists”. While saying he shared some of their critique of the psychiatric system, Szasz compared their views on the social causes of distress/deviance to those of anti-capitalist anti-colonialists who claimed that Chilean poverty was due to plundering by American companies, a comment Szasz made not long after a CIA-backed coup had deposed the democratically elected Chilean president and replaced him with Pinochet. Szasz argued instead that distress/deviance is due to the flaws or failures of individuals in their struggles in life.

The anti-psychiatry movement was also being driven by individuals with adverse experiences of psychiatric services. This included those who felt they had been harmed by psychiatry or who felt that they could have been helped more by other approaches, including those compulsorily (including via physical force) admitted to psychiatric institutions and subjected to compulsory medication or procedures. During the 1970s, the anti-psychiatry movement was involved in promoting restraint from many practices seen as psychiatric abuses.

The gay rights movement continued to challenge the classification of homosexuality as a mental illness and in 1974, in a climate of controversy and activism, the American Psychiatric Association membership (following a unanimous vote by the trustees in 1973) voted by a small majority (58%) to remove it as an illness category from the DSM, replacing it with a category of “sexual orientation disturbance” and then “ego-dystonic homosexuality,” which was deleted in 1986, although a wide variety of “paraphilias” remain. The diagnostic label gender identity disorder (GID) was used by the DSM until its reclassification as gender dysphoria in 2013, with the release of the DSM-5. The diagnosis was reclassified to better align it with medical understanding of the condition and to remove the stigma associated with the term disorder. The American Psychiatric Association, publisher of the DSM-5, stated that gender nonconformity is not the same thing as gender dysphoria, and that “gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.” Some transgender people and researchers support declassification of the condition because they say the diagnosis pathologizes gender variance and reinforces the binary model of gender. It has been noted that gay activists in the 1970s and 1980s adopted many of Szasz’s arguments against the psychiatric system, but also that Szasz had written in 1965 that: “I believe it is very likely that homosexuality is, indeed, a disease in the second sense [expression of psychosexual immaturity] and perhaps sometimes even in the stricter sense [a condition somewhat similar to ordinary organic maladies perhaps caused by genetic error or endocrine imbalance]. Nevertheless, if we believe that by categorising homosexuality as a disease we have succeeded in removing it from the realm of moral judgement, we are in error.”

Increased legal and professional protections, and a merging with human rights and disability rights movements, added to anti-psychiatry theory and action.

Anti-psychiatry came to challenge a “biomedical” focus of psychiatry (defined to mean genetics, neurochemicals and pharmaceutic drugs). There was also opposition to the increasing links between psychiatry and pharmaceutical companies, which were becoming more powerful and were increasingly claimed to have excessive, unjustified and underhand influence on psychiatric research and practice. There was also opposition to the codification of, and alleged misuse of, psychiatric diagnoses into manuals, in particular the American Psychiatric Association, which publishes the Diagnostic and Statistical Manual of Mental Disorders.

Anti-psychiatry increasingly challenged alleged psychiatric pessimism and institutionalised alienation regarding those categorised as mentally ill. An emerging consumer/survivor movement often argues for full recovery, empowerment, self-management and even full liberation. Schemes were developed to challenge stigma and discrimination, often based on a social model of disability; to assist or encourage people with mental health issues to engage more fully in work and society (for example through social firms), and to involve service users in the delivery and evaluation of mental health services. However, those actively and openly challenging the fundamental ethics and efficacy of mainstream psychiatric practice remained marginalised within psychiatry, and to a lesser extent within the wider mental health community.

Three authors came to personify the movement against psychiatry, and two of these were practising psychiatrists. The initial and most influential of these was Thomas Szasz who rose to fame with his book The Myth of Mental Illness, although Szasz himself did not identify as an anti-psychiatrist. The well-respected R.D. Laing wrote a series of best-selling books, including The Divided Self. Intellectual philosopher Michel Foucault challenged the very basis of psychiatric practice and cast it as repressive and controlling. The term “anti-psychiatry” was coined by David Cooper in 1967. In parallel with the theoretical production of the mentioned authors, the Italian physician Giorgio Antonucci questioned the basis themselves of psychiatry through the dismantling of the psychiatric hospitals Osservanza and Luigi Lolli and the liberation – and restitution to life – of the people there secluded.

Challenges to Psychiatry

Civilisation as a Cause of Distress

In recent years, psychotherapists David Smail and Bruce E. Levine, considered part of the anti-psychiatry movement, have written widely on how society, culture, politics and psychology intersect. They have written extensively of the “embodied nature” of the individual in society, and the unwillingness of even therapists to acknowledge the obvious part played by power and financial interest in modern Western society. They argue that feelings and emotions are not, as is commonly supposed, features of the individual, but rather responses of the individual to their situation in society. Even psychotherapy, they suggest, can only change feelings in as much as it helps a person to change the “proximal” and “distal” influences on their life, which range from family and friends, to the workplace, socio-economics, politics and culture.

R.D. Laing emphasized family nexus as a mechanism by which individuals become victimized by those around them, and spoke about a dysfunctional society.

Inadequacy of Clinical Interviews Used to Diagnose ‘Diseases’

An aetiology common to bipolar spectrum disorders has not been identified. Patients cannot be identified just by clinical interviews. A neurobiological basis of bipolar disorder has not been discovered. In making a bipolar spectrum disorder diagnosis based solely on a clinical interview, a false positive cannot be avoided.

Psychiatrists have been trying to differentiate mental disorders based on clinical interviews since the era of Kraepelin, but now realise that their diagnostic criteria are imperfect. Tadafumi Kato writes, “We psychiatrists should be aware that we cannot identify ‘diseases’ only by interviews. What we are doing now is just like trying to diagnose diabetes mellitus without measuring blood sugar.”

Normality and Illness Judgements

In 2013, psychiatrist Allen Frances said that “psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests”.

Reasons have been put forward to doubt the ontic status of mental disorders. Mental disorders engender ontological scepticism on three levels:

  • Mental disorders are abstract entities that cannot be directly appreciated with the human senses or indirectly, as one might with macro- or microscopic objects.
  • Mental disorders are not clearly natural processes whose detection is untarnished by the imposition of values, or human interpretation.
  • It is unclear whether they should be conceived as abstractions that exist in the world apart from the individual persons who experience them, and thus instantiate them.

In the scientific and academic literature on the definition or classification of mental disorder, one extreme argues that it is entirely a matter of value judgements (including of what is normal) while another proposes that it is or could be entirely objective and scientific (including by reference to statistical norms). Common hybrid views argue that the concept of mental disorder is objective but a “fuzzy prototype” that can never be precisely defined, or alternatively that it inevitably involves a mix of scientific facts and subjective value judgments.

One remarkable example of psychiatric diagnosis being used to reinforce cultural bias and oppress dissidence is the diagnosis of drapetomania. In the US prior to the American Civil War, physicians such as Samuel A. Cartwright diagnosed some slaves with drapetomania, a mental illness in which the slave possessed an irrational desire for freedom and a tendency to try to escape. By classifying such a dissident mental trait as abnormal and a disease, psychiatry promoted cultural bias about normality, abnormality, health, and unhealth. This example indicates the probability for not only cultural bias but also confirmation bias and bias blind spot in psychiatric diagnosis and psychiatric beliefs.

It has been argued by philosophers like Foucault that characterizations of “mental illness” are indeterminate and reflect the hierarchical structures of the societies from which they emerge rather than any precisely defined qualities that distinguish a “healthy” mind from a “sick” one. Furthermore, if a tendency toward self-harm is taken as an elementary symptom of mental illness, then humans, as a species, are arguably insane in that they have tended throughout recorded history to destroy their own environments, to make war with one another, etc.

Psychiatric Labelling

Mental disorders were first included in the sixth revision of the International Classification of Diseases (ICD-6) in 1949. Three years later, the American Psychiatric Association created its own classification system, DSM-I. The definitions of most psychiatric diagnoses consist of combinations of phenomenological criteria, such as symptoms and signs and their course over time. Expert committees combined them in variable ways into categories of mental disorders, defined and redefined them again and again over the last half century.

The majority of these diagnostic categories are called “disorders” and are not validated by biological criteria, as most medical diseases are; although they purport to represent medical diseases and take the form of medical diagnoses. These diagnostic categories are actually embedded in top-down classifications, similar to the early botanic classifications of plants in the 17th and 18th centuries, when experts decided a priori about which classification criterion to use, for instance, whether the shape of leaves or fruiting bodies were the main criterion for classifying plants. Since the era of Kraepelin, psychiatrists have been trying to differentiate mental disorders by using clinical interviews.

Experiments Admitting “Healthy” Individuals into Psychiatric Care

In 1972, psychologist David Rosenhan published the Rosenhan experiment, a study questioning the validity of psychiatric diagnoses. The study arranged for eight individuals with no history of psychopathology to attempt admission into psychiatric hospitals. The individuals included a graduate student, psychologists, an artist, a housewife, and two physicians, including one psychiatrist. All eight individuals were admitted with a diagnosis of schizophrenia or bipolar disorder. Psychiatrists then attempted to treat the individuals using psychiatric medication. All eight were discharged within 7 to 52 days. In a later part of the study, psychiatric staff were warned 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 be actors. The study concluded that individuals without mental disorders were indistinguishable from those suffering from mental disorders.

Critics such as Robert Spitzer placed doubt on the validity and credibility of the study, but did concede that the consistency of psychiatric diagnoses needed improvement. It is now realised that the psychiatric diagnostic criteria are not perfect. To further refine psychiatric diagnosis, according to Tadafumi Kato, the only way is to create a new classification of diseases based on the neurobiological features of each mental disorder. On the other hand, according to Heinz Katsching, neurologists are advising psychiatrists just to replace the term “mental illness” by “brain illness.”

There are recognised problems regarding the diagnostic reliability and validity of mainstream psychiatric diagnoses, both in ideal and controlled circumstances and even more so in routine clinical practice (McGorry et al.. 1995). Criteria in the principal diagnostic manuals, the DSM and ICD, are inconsistent. Some psychiatrists who criticise their own profession say that comorbidity, when an individual meets criteria for two or more disorders, is the rule rather than the exception. There is much overlap and vaguely defined or changeable boundaries between what psychiatrists claim are distinct illness states.

There are also problems with using standard diagnostic criteria in different countries, cultures, genders or ethnic groups. Critics often allege that Westernised, white, male-dominated psychiatric practices and diagnoses disadvantage and misunderstand those from other groups. For example, several studies have shown that African Americans are more often diagnosed with schizophrenia than Caucasians, and men more than women. Some within the anti-psychiatry movement are critical of the use of diagnosis as it conforms with the biomedical model.

Tool of Social Control

According to Franco Basaglia, Giorgio Antonucci, Bruce E. Levine and Edmund Schönenberger whose approach pointed out the role of psychiatric institutions in the control and medicalisation of deviant behaviours and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups. According to Mike Fitzpatrick, resistance to medicalisation was a common theme of the gay liberation, anti-psychiatry, and feminist movements of the 1970s, but now there is actually no resistance to the advance of government intrusion in lifestyle if it is thought to be justified in terms of public health.

In the opinion of Mike Fitzpatrick, the pressure for medicalisation also comes from society itself. As one example, Fitzpatrick claims that feminists who once opposed state intervention as oppressive and patriarchal, now demand more coercive and intrusive measures to deal with child abuse and domestic violence. According to Richard Gosden, the use of psychiatry as a tool of social control is becoming obvious in preventive medicine programmes for various mental diseases. These programmes are intended to identify children and young people with divergent behavioural patterns and thinking and send them to treatment before their supposed mental diseases develop. Clinical guidelines for best practice in Australia include the risk factors and signs which can be used to detect young people who are in need of prophylactic drug treatment to prevent the development of schizophrenia and other psychotic conditions.

Psychiatry and the Pharmaceutical Industry

Critics of psychiatry commonly express a concern that the path of diagnosis and treatment in contemporary society is primarily or overwhelmingly shaped by profit prerogatives, echoing a common criticism of general medical practice in the United States, where many of the largest psychopharmaceutical producers are based.

Psychiatric research has demonstrated varying degrees of efficacy for improving or managing a number of mental health disorders through either medications, psychotherapy, or a combination of the two. Typical psychiatric medications include stimulants, antidepressants, anxiolytics, and antipsychotics (neuroleptics).

On the other hand, organisations such as MindFreedom International and World Network of Users and Survivors of Psychiatry maintain that psychiatrists exaggerate the evidence of medication and minimize the evidence of adverse drug reaction. They and other activists believe individuals are not given balanced information, and that current psychiatric medications do not appear to be specific to particular disorders in the way mainstream psychiatry asserts; and psychiatric drugs not only fail to correct measurable chemical imbalances in the brain, but rather induce undesirable side effects. For example, though children on Ritalin and other psycho-stimulants become more obedient to parents and teachers, critics have noted that they can also develop abnormal movements such as tics, spasms and other involuntary movements. This has not been shown to be directly related to the therapeutic use of stimulants, but to neuroleptics. The diagnosis of attention deficit hyperactivity disorder on the basis of inattention to compulsory schooling also raises critics’ concerns regarding the use of psychoactive drugs as a means of unjust social control of children.

The influence of pharmaceutical companies is another major issue for the anti-psychiatry movement. As many critics from within and outside of psychiatry have argued, there are many financial and professional links between psychiatry, regulators, and pharmaceutical companies. Drug companies routinely fund much of the research conducted by psychiatrists, advertise medication in psychiatric journals and conferences, fund psychiatric and healthcare organisations and health promotion campaigns, and send representatives to lobby general physicians and politicians. Peter Breggin, Sharkey, and other investigators of the psycho-pharmaceutical industry maintain that many psychiatrists are members, shareholders or special advisors to pharmaceutical or associated regulatory organisations.

There is evidence that research findings and the prescribing of drugs are influenced as a result. A United Kingdom cross-party parliamentary inquiry into the influence of the pharmaceutical industry in 2005 concludes: “The influence of the pharmaceutical industry is such that it dominates clinical practice” and that there are serious regulatory failings resulting in “the unsafe use of drugs; and the increasing medicalisation of society”. The campaign organisation No Free Lunch details the prevalent acceptance by medical professionals of free gifts from pharmaceutical companies and the effect on psychiatric practice. The ghostwriting of articles by pharmaceutical company officials, which are then presented by esteemed psychiatrists, has also been highlighted. Systematic reviews have found that trials of psychiatric drugs that are conducted with pharmaceutical funding are several times more likely to report positive findings than studies without such funding.

The number of psychiatric drug prescriptions have been increasing at an extremely high rate since the 1950s and show no sign of abating. In the United States antidepressants and tranquilisers are now the top selling class of prescription drugs, and neuroleptics and other psychiatric drugs also rank near the top, all with expanding sales. As a solution to the apparent conflict of interests, critics propose legislation to separate the pharmaceutical industry from the psychiatric profession.

John Read and Bruce E. Levine have advanced the idea of socioeconomic status as a significant factor in the development and prevention of mental disorders such as schizophrenia and have noted the reach of pharmaceutical companies through industry sponsored websites as promoting a more biological approach to mental disorders, rather than a comprehensive biological, psychological and social model.

Electroconvulsive Therapy

Psychiatrists may advocate psychiatric drugs, psychotherapy or more controversial interventions such as electroshock or psychosurgery to treat mental illness. Electroconvulsive therapy (ECT) is administered worldwide typically for severe mental disorders. Across the globe it has been estimated that approximately 1 million patients receive ECT per year. Exact numbers of how many persons per year have ECT in the United States are unknown due to the variability of settings and treatment. Researchers’ estimates generally range from 100,000 to 200,000 persons per year.

Some persons receiving ECT die during the procedure (ECT is performed under a general anaesthetic, which always carries a risk). Leonard Roy Frank writes that estimates of ECT-related death rates vary widely.

  • The lower estimates include:
    • 2-4 in 100,000 (from Kramer’s 1994 study of 28,437 patients);
    • 1 in 10,000 (Boodman’s first entry in 1996);
    • 1 in 1,000 (Impastato’s first entry in 1957); and
    • 1 in 200, among the elderly, over 60 (Impastato’s in 1957).
  • Higher estimates include:
    • 1 in 102 (Martin’s entry in 1949);
    • 1 in 95 (Boodman’s first entry in 1996);
    • 1 in 92 (Freeman and Kendell’s entry in 1976);
    • 1 in 89 (Sagebiel’s in 1961);
    • 1 in 69 (Gralnick’s in 1946);
    • 1 in 63, among a group undergoing intensive ECT (Perry’s in 1963–1979);
    • 1 in 38 (Ehrenberg’s in 1955);
    • 1 in 30 (Kurland’s in 1959);
    • 1 in 9, among a group undergoing intensive ECT (Weil’s in 1949); and
    • 1 in 4, among the very elderly, over 80 (Kroessler and Fogel’s in 1974-1986).

Political Abuse of Psychiatry

Psychiatrists around the world have been involved in the suppression of individual rights by states in which the definitions of mental disease have been expanded to include political disobedience. Nowadays, in many countries, political prisoners are sometimes confined and abused in mental institutions. Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine. The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials.

Under the Nazi regime in the 1940s, the “duty to care” was violated on an enormous scale. In Germany alone 300,000 individuals that had been deemed mentally ill, work-shy or feeble-minded were sterilized. An additional 200,000 were euthanised. These practices continued in territories occupied by the Nazis further afield (mainly in eastern Europe), affecting thousands more. From the 1960s up to 1986, political abuse of psychiatry was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia, as well as in Western European countries, such as Italy. An example of the use of psychiatry in the political field is the “case Sabattini”, described by Giorgio Antonucci in his book Il pregiudizio psichiatrico. A “mental health genocide” reminiscent of the Nazi aberrations has been located in the history of South African oppression during the apartheid era. A continued misappropriation of the discipline was later attributed to the People’s Republic of China.

K. Fulford, A. Smirnov, and E. Snow state: “An important vulnerability factor, therefore, for the abuse of psychiatry, is the subjective nature of the observations on which psychiatric diagnosis currently depends.” In an article published in 1994 by the Journal of Medical Ethics, American psychiatrist Thomas Szasz stated that “the classification by slave owners and slave traders of certain individuals as Negroes was scientific, in the sense that whites were rarely classified as blacks. But that did not prevent the ‘abuse’ of such racial classification, because (what we call) its abuse was, in fact, its use.” Szasz argued that the spectacle of the Western psychiatrists loudly condemning Soviet colleagues for their abuse of professional standards was largely an exercise in hypocrisy. Szasz states that K. Fulford, A. Smirnov, and E. Snow, who correctly emphasize the value-laden nature of psychiatric diagnoses and the subjective character of psychiatric classifications, fail to accept the role of psychiatric power. He stated that psychiatric abuse, such as people usually associated with practices in the former USSR, was connected not with the misuse of psychiatric diagnoses, but with the political power built into the social role of the psychiatrist in democratic and totalitarian societies alike. Musicologists, drama critics, art historians, and many other scholars also create their own subjective classifications; however, lacking state-legitimated power over persons, their classifications do not lead to anyone’s being deprived of property, liberty, or life. For instance, a plastic surgeon’s classification of beauty is subjective, but the plastic surgeon cannot treat his or her patient without the patient’s consent, so there cannot be any political abuse of plastic surgery.

The bedrock of political medicine is coercion masquerading as medical treatment. In this process, physicians diagnose a disapproved condition as an “illness” and declare the intervention they impose on the victim a “treatment,” and legislators and judges legitimate these categorisations. In the same way, physician-eugenicists advocated killing certain disabled or ill persons as a form of treatment for both society and patient long before the Nazis came to power.

From the commencement of his political career, Hitler put his struggle against “enemies of the state” in medical rhetoric. In 1934, addressing the Reichstag, he declared, “I gave the order… to burn out down to the raw flesh the ulcers of our internal well-poisoning.” The entire German nation and its National Socialist politicians learned to think and speak in such terms. Werner Best, Reinhard Heydrich’s deputy, stated that the task of the police was “to root out all symptoms of disease and germs of destruction that threatened the political health of the nation… [In addition to Jews,] most [of the germs] were weak, unpopular and marginalized groups, such as gypsies, homosexuals, beggars, ‘antisocials’, ‘work-shy’, and ‘habitual criminals’.”

In spite of all the evidence, people ignore or underappreciate the political implications of the pseudotherapeutic character of Nazism and of the use of medical metaphors in modern democracies. Dismissed as an “abuse of psychiatry”, this practice is a controversial subject not because the story makes psychiatrists in Nazi Germany look bad, but because it highlights the dramatic similarities between pharmacratic controls in Germany under Nazism and those that have emerged in the US under the free market economy.

The Swiss lawyer Edmund Schönenberger claims that the strongholds of psychiatry are instruments of domination and have nothing to do with care, the law, or justice.

“Therapeutic State”

The “therapeutic state” is a phrase coined by Szasz in 1963. The collaboration between psychiatry and government leads to what Szasz calls the “therapeutic state”, a system in which disapproved actions, thoughts, and emotions are repressed (“cured”) through pseudomedical interventions. Thus suicide, unconventional religious beliefs, racial bigotry, unhappiness, anxiety, shyness, sexual promiscuity, shoplifting, gambling, overeating, smoking, and illegal drug use are all considered symptoms or illnesses that need to be cured. When faced with demands for measures to curtail smoking in public, binge-drinking, gambling or obesity, ministers say that “we must guard against charges of nanny statism”. The “nanny state” has turned into the “therapeutic state” where nanny has given way to counsellor. Nanny just told people what to do; counsellors also tell them what to think and what to feel. The “nanny state” was punitive, austere, and authoritarian, the therapeutic state is touchy-feely, supportive – and even more authoritarian. According to Szasz, “the therapeutic state swallows up everything human on the seemingly rational ground that nothing falls outside the province of health and medicine, just as the theological state had swallowed up everything human on the perfectly rational ground that nothing falls outside the province of God and religion”.

Faced with the problem of “madness”, Western individualism proved to be ill-prepared to defend the rights of the individual: modern man has no more right to be a madman than medieval man had a right to be a heretic because if once people agree that they have identified the one true God, or Good, it brings about that they have to guard members and non-members of the group from the temptation to worship false gods or goods. A secularisation of God and the medicalisation of good resulted in the post-Enlightenment version of this view: once people agree that they have identified the one true reason, it brings about that they have to guard against the temptation to worship unreason – that is, madness.

Civil libertarians warn that the marriage of the State with psychiatry could have catastrophic consequences for civilisation. In the same vein as the separation of church and state, Szasz believes that a solid wall must exist between psychiatry and the State.

“Total Institution”

In his book Asylums, Erving Goffman coined the term ‘total institution’ for mental hospitals and similar places which took over and confined a person’s whole life. Goffman placed psychiatric hospitals in the same category as concentration camps, prisons, military organisations, orphanages, and monasteries. In Asylums Goffman describes how the institutionalisation process socialises people into the role of a good patient, someone ‘dull, harmless and inconspicuous’; it in turn reinforces notions of chronicity in severe mental illness.

Law

While the insanity defence is the subject of controversy as a viable excuse for wrongdoing, Szasz and other critics contend that being committed in a psychiatric hospital can be worse than criminal imprisonment, since it involves the risk of compulsory medication with neuroleptics or the use of electroshock treatment. Moreover, while a criminal imprisonment has a predetermined and known time of duration, patients are typically committed to psychiatric hospitals for indefinite durations, an unjust and arguably outrageous imposition of fundamental uncertainty. It has been argued that such uncertainty risks aggravating mental instability, and that it substantially encourages a lapse into hopelessness and acceptance that precludes recovery.

Involuntary Hospitalisation

Critics see the use of legally sanctioned force in involuntary commitment as a violation of the fundamental principles of free or open societies. The political philosopher John Stuart Mill and others have argued that society has no right to use coercion to subdue an individual as long as he or she does not harm others. Mentally ill people are essentially no more prone to violence than sane individuals, despite Hollywood and other media portrayals to the contrary. The growing practice, in the United Kingdom and elsewhere, of Care in the Community was instituted partly in response to such concerns. Alternatives to involuntary hospitalisation include the development of non-medical crisis care in the community.

In the case of people suffering from severe psychotic crises, the American Soteria project used to provide what was argued to be a more humane and compassionate alternative to coercive psychiatry. The Soteria houses closed in 1983 in the United States due to lack of financial support. However, similar establishments are presently flourishing in Europe, especially in Sweden and other North European countries.

The physician Giorgio Antonucci, during his activity as a director of the Ospedale Psichiatrico Osservanza of Imola, refused any form of coercion and any violation of the fundamental principles of freedom, questioning the basis of psychiatry itself.

Psychiatry as Pseudoscience and Failed Enterprise

Many of the above issues lead to the claim that psychiatry is a pseudoscience. According to some philosophers of science, for a theory to qualify as science it needs to exhibit the following characteristics:

  • Parsimony, as straightforward as the phenomena to be explained allow (see Occam’s razor);
  • Empirically testable and falsifiable (see Falsifiability);
  • Changeable, i.e. if necessary, changes may be made to the theory as new data are discovered;
  • Progressive, encompasses previous successful descriptions and explains and adds more; and
  • Provisional, i.e. tentative; the theory does not attempt to assert that it is a final description or explanation.

Psychiatrist Colin A. Ross and Alvin Pam maintain that biopsychiatry does not qualify as a science on many counts.

Psychiatric researchers have been criticised on the basis of the replication crisis and textbook errors. Questionable research practices are known to bias key sources of evidence.

Stuart A. Kirk has argued that psychiatry is a failed enterprise, as mental illness has grown, not shrunk, with about 20% of American adults diagnosable as mentally ill in 2013.

According to a 2014 meta-analysis, psychiatric treatment is no less effective for psychiatric illnesses in terms of treatment effects than treatments by practitioners of other medical specialties for physical health conditions. The analysis found that the effect sizes for psychiatric interventions are, on average, on par with other fields of medicine.

Diverse Paths

Szasz has since (2008) re-emphasized his disdain for the term anti-psychiatry, arguing that its legacy has simply been a “catchall term used to delegitimise and dismiss critics of psychiatric fraud and force by labelling them ‘antipsychiatrists'”. He points out that the term originated in a meeting of four psychiatrists (Cooper, Laing, Berke and Redler) who never defined it yet “counter-label[led] their discipline as anti-psychiatry”, and that he considers Laing most responsible for popularising it despite also personally distancing himself. Szasz describes the deceased (1989) Laing in vitriolic terms, accusing him of being irresponsible and equivocal on psychiatric diagnosis and use of force, and detailing his past “public behaviour” as “a fit subject for moral judgment” which he gives as “a bad person and a fraud as a professional”.

Daniel Burston, however, has argued that overall the published works of Szasz and Laing demonstrate far more points of convergence and intellectual kinship than Szasz admits, despite the divergence on a number of issues related to Szasz being a libertarian and Laing an existentialist; that Szasz employs a good deal of exaggeration and distortion in his criticism of Laing’s personal character, and unfairly uses Laing’s personal failings and family woes to discredit his work and ideas; and that Szasz’s “clear-cut, crystalline ethical principles are designed to spare us the agonising and often inconclusive reflections that many clinicians face frequently in the course of their work”. Szasz has indicated that his own views came from libertarian politics held since his teens, rather than through experience in psychiatry; that in his “rare” contacts with involuntary mental patients in the past he either sought to discharge them (if they were not charged with a crime) or “assisted the prosecution in securing [their] conviction” (if they were charged with a crime and appeared to be prima facie guilty); that he is not opposed to consensual psychiatry and “does not interfere with the practice of the conventional psychiatrist”, and that he provided “listening-and-talking (“psychotherapy”)” for voluntary fee-paying clients from 1948 until 1996, a practice he characterises as non-medical and not associated with his being a psychoanalytically trained psychiatrist.

The gay rights or gay liberation movement is often thought to have been part of anti-psychiatry in its efforts to challenge oppression and stigma and, specifically, to get homosexuality removed from the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders. However, a psychiatric member of APA’s Gay, Lesbian, and Bisexual Issues Committee has recently sought to distance the two, arguing that they were separate in the early 70s protests at APA conventions and that APA’s decision to remove homosexuality was scientific and happened to coincide with the political pressure. Reviewers have responded, however, that the founders and movements were closely aligned; that they shared core texts, proponents and slogans; and that others have stated that, for example, the gay liberation critique was “made possible by (and indeed often explicitly grounded in) traditions of antipsychiatry”.

In the clinical setting, the two strands of anti-psychiatry – criticism of psychiatric knowledge and reform of its practices – were never entirely distinct. In addition, in a sense, anti-psychiatry was not so much a demand for the end of psychiatry, as it was an often self-directed demand for psychiatrists and allied professionals to question their own judgements, assumptions and practices. In some cases, the suspicion of non-psychiatric medical professionals towards the validity of psychiatry was described as anti-psychiatry, as well the criticism of “hard-headed” psychiatrists towards “soft-headed” psychiatrists. Most leading figures of anti-psychiatry were themselves psychiatrists, and equivocated over whether they were really “against psychiatry”, or parts thereof. Outside the field of psychiatry, however – e.g. for activists and non-medical mental health professionals such as social workers and psychologists – ‘anti-psychiatry’ tended to mean something more radical. The ambiguous term “anti-psychiatry” came to be associated with these more radical trends, but there was debate over whether it was a new phenomenon, whom it best described, and whether it constituted a genuinely singular movement. In order to avoid any ambiguity intrinsic to the term anti-psychiatry, a current of thought that can be defined as critique of the basis of psychiatry, radical and unambiguous, aims for the complete elimination of psychiatry. The main representative of the critique of the basis of psychiatry is an Italian physician, Giorgio Antonucci, the founder of the non-psychiatric approach to psychological suffering, who posited that the “essence of psychiatry lies in an ideology of discrimination”.

In the 1990s, a tendency was noted among psychiatrists to characterize and to regard the anti-psychiatric movement as part of the past, and to view its ideological history as flirtation with the polemics of radical politics at the expense of scientific thought and enquiry. It was also argued, however, that the movement contributed towards generating demand for grassroots involvement in guidelines and advocacy groups, and to the shift from large mental institutions to community services. Additionally, community centres have tended in practice to distance themselves from the psychiatric/medical model and have continued to see themselves as representing a culture of resistance or opposition to psychiatry’s authority. Overall, while antipsychiatry as a movement may have become an anachronism by this period and was no longer led by eminent psychiatrists, it has been argued that it became incorporated into the mainstream practice of mental health disciplines. On the other hand, mainstream psychiatry became more biomedical, increasing the gap between professionals.

Henry Nasrallah claims that while he believes anti-psychiatry consists of many historical exaggerations based on events and primitive conditions from a century ago, “antipsychiatry helps keep us honest and rigorous about what we do, motivating us to relentlessly seek better diagnostic models and treatment paradigms. Psychiatry is far more scientific today than it was a century ago, but misperceptions about psychiatry continue to be driven by abuses of the past. The best antidote for antipsychiatry allegations is a combination of personal integrity, scientific progress, and sound evidence-based clinical care”.

A criticism was made in the 1990s that three decades of anti-psychiatry had produced a large literature critical of psychiatry, but little discussion of the deteriorating situation of the mentally troubled in American society. Anti-psychiatry crusades have thus been charged with failing to put suffering individuals first, and therefore being similarly guilty of what they blame psychiatrists for. The rise of anti-psychiatry in Italy was described by one observer as simply “a transfer of psychiatric control from those with medical knowledge to those who possessed socio-political power”.

Critics of this view, however, from an anti-psychiatry perspective, are quick to point to the industrial aspects of psychiatric treatment itself as a primary causal factor in this situation that is described as “deteriorating”. The numbers of people labelled “mentally ill”, and in treatment, together with the severity of their conditions, have been going up primarily due to the direct efforts of the mental health movement, and mental health professionals, including psychiatrists, and not their detractors. Envisioning “mental health treatment” as violence prevention has been a big part of the problem, especially as you are dealing with a population that is not significantly more violent than any other group and, in fact, are less so than many.

On 07 October 2016, the Ontario Institute for Studies in Education (OISE) at the University of Toronto announced that they had established a scholarship for students doing theses in the area of antipsychiatry. Called “The Bonnie Burstow Scholarship in Antipsychiatry,” it is to be awarded annually to an OISE thesis student. An unprecedented step, the scholarship should further the cause of freedom of thought and the exchange of ideas in academia. The scholarship is named in honour of Bonnie Burstow, a faculty member at the University of Toronto, a radical feminist, and an antipsychiatry activist. She is also the author of Psychiatry and the Business of Madness (2015).

Some components of antipsychiatric theory have in recent decades been reformulated into a critique of “corporate psychiatry”, heavily influenced by the pharmaceutical industry. A recent editorial about this was published in the British Journal of Psychiatry by Moncrieff, arguing that modern psychiatry has become a handmaiden to conservative political commitments. David Healy is a psychiatrist and professor in psychological medicine at Cardiff University School of Medicine, Wales. He has a special interest in the influence of the pharmaceutical industry on medicine and academia.

In the meantime, members of the psychiatric consumer/survivor movement continued to campaign for reform, empowerment and alternatives, with an increasingly diverse representation of views. Groups often have been opposed and undermined, especially when they proclaim to be, or when they are labelled as being, “anti-psychiatry”. However, as of the 1990s, more than 60% of ex-patient groups reportedly support anti-psychiatry beliefs and consider themselves to be “psychiatric survivors”. Although anti-psychiatry is often attributed to a few famous figures in psychiatry or academia, it has been pointed out that consumer/survivor/ex-patient individuals and groups preceded it, drove it and carried on through it.

Criticism

A schism exists among those critical of conventional psychiatry between radical abolitionists and more moderate reformists. Laing, Cooper and others associated with the initial anti-psychiatry movement stopped short of actually advocating for the abolition of coercive psychiatry. Thomas Szasz, from near the beginning of his career, crusaded for the abolition of forced psychiatry. Today, believing that coercive psychiatry marginalises and oppresses people with its harmful, controlling, and abusive practices, many who identify as anti-psychiatry activists are proponents of the complete abolition of non-consensual and coercive psychiatry.

Criticism of antipsychiatry from within psychiatry itself object to the underlying principle that psychiatry is by definition harmful. Most psychiatrists accept that issues exist that need addressing, but that the abolition of psychiatry is harmful. Nimesh Desai concludes: “To be a believer and a practitioner of multidisciplinary mental health, it is not necessary to reject the medical model as one of the basics of psychiatry.” and admits “Some of the challenges and dangers to psychiatry are not so much from the avowed antipsychiatrists, but from the misplaced and misguided individuals and groups in related fields.”

What is Psychiatry?

Introduction

Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders. These include various maladaptations related to mood, behaviour, cognition, and perceptions. Not to be confused with Clinical Psychology or psychology.

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 clinical concepts listed in diagnostic manuals such as the International Classification of Diseases (ICD), edited and used by the World Health Organisation (WHO) and the widely used 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 2013 which re-organized the larger categories of various diseases and expanded upon the previous edition to include information/insights that are consistent with current research.

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. An inpatient may be treated in a psychiatric hospital. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis with other professionals, such as epidemiologists, nurses, or psychologists.

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’ (psych- ‘soul’ from Ancient Greek psykhē ‘soul’; -iatry ‘medical treatment’ from Gk. iātrikos ‘medical’ from iāsthai ‘to heal’).

A medical doctor specialising in psychiatry is known as a psychiatrist.

Theory and Focus

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 specialise 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 very general categories:

  1. Mental illnesses;
  2. Severe learning disabilities; and
  3. Personality disorders.

While 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 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 specialise 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 post-graduate training called residency (usually 4 to 5 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.

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 organisation’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, 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.

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. 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. Both approaches are 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 notion of a “biopsychosocial model” is often used to underline the multifactorial nature of clinical impairment. In this notion the word model is not used in a strictly scientific way though. Alternatively, a “biocognitive model” acknowledges the physiological basis for the mind’s existence but identifies cognition as an irreducible and independent realm in which disorder may occur. The biocognitive approach includes a mentalist aetiology and provides a natural dualist (i.e. non-spiritual) revision of the biopsychosocial view, reflecting the efforts of Australian psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn.

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. Behaviourism 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.

Practitioners

Refer to Psychiatrist.

All physicians can diagnose mental disorders and prescribe treatments utilising principles of psychiatry. Psychiatrists are trained physicians who specialise 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, non-profit, 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 behavioural therapy, it is their training as physicians that differentiates them from other mental health professionals.

As a Career Choice

Psychiatry was not a popular career choice among medical students, even though medical school placements are rated favourably. 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 interesting 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 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.
  • Brain Injury Medicine.
  • Child and adolescent psychiatry is the branch of psychiatry that specialises in work with children, teenagers, and their families.
  • Clinical neurophysiology.
  • Consultation-liaison psychiatry, also known as psychosomatic medicine. Liaison psychiatry is the branch of psychiatry that specialises in the interface between other medical specialties and psychiatry.
  • Epilepsy.
  • Forensic psychiatry.
  • Geriatric psychiatry is a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in the elderly.
  • Hospice and palliative medicine.
  • Pain medicine.
  • Sleep medicine.

Additional psychiatry subspecialties, for which ABPN does not offer certification, include:

  • Biological psychiatry is an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system.
  • Cognition diseases as in various forms of dementia.
  • 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 utilises medical science generally, and psychiatric knowledge and assessment methods in particular, to help answer legal questions.
  • 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.
  • Learning disability.
  • Military psychiatry covers special aspects of psychiatry and mental disorders within the military context.
  • Neurodevelopmental disorders.
  • 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.

In larger healthcare organisations, 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 Veterans Administration (VA) medical centres 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.

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.

Clinical Application

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 utilises 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 utilise genetics during the diagnostic process but on the whole this remains a research topic.

Diagnostic Manuals

Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-10 is produced and published by the WHO, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States. It is currently in its fifth revised edition and is also used worldwide. The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.

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 aetiology. 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; medicalisation 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.

Treatment

General Considerations

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 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-utilisers in the United States in 2012.

Inpatient Treatment

Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalised for six months or more, with some cases involving hospitalisation for many years.

Average inpatient psychiatric treatment stay has decreased significantly since the 1960s, a trend known as deinstitutionalisation. Today in most countries, people receiving psychiatric treatment are more likely to be seen as outpatients. If hospitalisation is required, the average hospital stay is around one to two weeks, with only a small number receiving long-term hospitalisation. However, in Japan psychiatric hospitals continue to keep patients for long periods, sometimes even keeping them in physical restraints, strapped to their beds for periods of weeks or months.

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 United States 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 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 favoured 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 put in physical restraints 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, programmes 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 crisis where patients are a direct threat to themselves or others. Alternatives to psychiatric hospitals that may actively offer more therapeutic approaches include rehabilitation centres or “rehab” as popularly termed.

Outpatient Treatment

Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office, or at a community-based outpatient clinic. Initial appointments, at which the psychiatrist conducts a psychiatric assessment or evaluation of the patient, are typically 45 to 75 minutes in length. Follow-up appointments are generally shorter in duration, i.e. 15 to 30 minutes, with a focus on making medication adjustments, reviewing potential medication interactions, considering the impact of other medical disorders on the patient’s mental and emotional functioning, and counselling patients regarding changes they might make to facilitate healing and remission of symptoms (e.g. exercise, cognitive therapy techniques, sleep hygiene – to name just a few). The frequency with which a psychiatrist sees people in treatment varies widely, from once a week to twice a year, depending on the type, severity and stability of each person’s condition, and depending on what the clinician and patient decide would be best.

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.

Brief History

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, Hippocrates theorised that physiological abnormalities may be the root of mental disorders. In 4th to 5th Century B.C. Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy. During the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin, a view which existed throughout ancient Greece and Rome,[98] as well as Egyptian regions. Religious leaders often turned to versions of exorcism to treat mental disorders often utilising methods that many consider to be cruel or barbaric methods. Trepanning was one of these methods used throughout history.

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, 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.

The first bimaristan was founded in Baghdad in the 9th century, and several others of increasing complexity were created throughout the Arab world in the following centuries. Some of the bimaristans contained wards dedicated to the care of mentally ill patients, most of whom suffered from debilitating illnesses or exhibited violence. Specialist hospitals such as Bethlem Royal Hospital in London were built in medieval Europe from the 13th century to treat mental disorders, but were used only as custodial institutions and did not provide any type of treatment.

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 created a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was applied.

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.

The introduction of moral treatment was initiated independently by the French doctor Philippe Pinel and the English Quaker William Tuke. In 1792 Pinel became the chief physician at the Bicêtre Hospital. Patients were allowed to move freely about the hospital grounds, and eventually dark dungeons were replaced with sunny, well-ventilated rooms. Pinel’s student and successor, Jean Esquirol (1772-1840), went on to help establish 10 new mental hospitals that operated on the same principles.

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 around 1850. Many state hospitals in the United States were built in the 1850s and 1860s on the Kirkbride Plan, an architectural style meant to have curative effect.

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 institutionalisation 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.

By the 1970s, however, the psychoanalytic school of thought became marginalized within the field. Biological psychiatry re-emerged during this time. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi’s discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter. Neuroimaging was first utilised as a tool for psychiatry in the 1980s. The discovery of chlorpromazine’s effectiveness in treating schizophrenia in 1952 revolutionised treatment of the disorder, as did lithium carbonate’s ability to stabilise mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilised, but as a treatment for psychosocial issues.

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centres for those being discharged from state psychiatric hospitals. Later, though, the Community Mental Health Centres focus shifted to providing psychotherapy for those suffering from acute but less serious mental disorders. Ultimately there were no arrangements made for actively following and treating severely mentally ill patients who were being discharged from hospitals, resulting in a large population of chronically homeless people suffering from mental illness.

Controversy and Criticism

Controversy has often surrounded psychiatry, with scholars producing critiques. It has been argued that psychiatry: is too influenced by ideas from medicine, causing it to misunderstand the nature of mental distress; that its use of drugs is in part due lobbying by drug companies resulting in distortion of research; that the concept of “mental illness” is often used to label and control those with beliefs and behaviours that the majority of people disagree with; and that it confuses disorders of the mind with disorders of the brain that can be treated with drugs. Critique of psychiatry from within the field comes from the critical psychiatry group in the UK.

The term “anti-psychiatry” was coined by psychiatrist David Cooper in 1967 and was later made popular by Thomas Szasz. The word “Antipsychiatrie” was already used in Germany in 1904. The basic premise of the anti-psychiatry movement is that psychiatrists attempt to classify “normal” people as “deviant;” 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 the frontal lobectomy (commonly called, a lobotomy). Several former patient groups have been formed often referring to themselves as “survivors.” In 1973, the Rosenhan experiment was conducted to determine the validity of psychiatric diagnosis. Volunteers feigned hallucinations to enter psychiatric hospitals, and acted normally afterwards. They were diagnosed with psychiatric disorders and were given antipsychotic drugs. The study was conducted by psychologist David Rosenhan, a Stanford University professor, and published by the journal Science under the title “On being sane in insane places”.

The Church of Scientology is critical of psychiatry, whereas others have questioned the veracity of information the Church of Scientology provides to the public.

Book: A Little Bit Of Meditation

Book Title:

A Little Bit Of Meditation – An Introduction To Mindfulness.

Author(s): Amy Leigh Mercree.

Year: 2017.

Edition: First (1st).

Publisher: Sterling Publishing.

Type(s): Hardcover, Paperback, and Kindle.

Synopsis:

In this new entry in the Little Bit Of series, spirituality author Amy Leigh Mercree explores the history of meditation and its origins as well as its practical applications.

She outlines how meditation can decrease anxiety and improve the quality of our experience on earth, in addition to discussing the physical, emotional, mental, and spiritual ramifications of maintaining a regular meditation practice.

She also includes a selection of easy-to-follow guided meditations.

Book: A Historical Dictionary of Psychiatry

Book Title:

A Historical Dictionary of Psychiatry.

Author(s): Edward Shorter.

Year: 2005.

Edition: First (1st).

Publisher: OUP USA.

Type(s): Hardcover and Kindle.

Synopsis:

This is the first historical dictionary of psychiatry. It covers the subject from autism to Vienna, and includes the key concepts, individuals, places, and institutions that have shaped the evolution of psychiatry and the neurosciences.

An introduction puts broad trends and international differences in context, with an extensive bibliography for further reading. Each entry gives the main dates, themes, and personalities involved in the unfolding of the topic. Longer entries describe the evolution of such subjects as depression, schizophrenia, and psychotherapy.

The book gives ready reference to when things happened in psychiatry, how and where they happened, and who made the main contributions. In addition, it touches on such social themes as “women in psychiatry,” “criminality and psychiatry,” and “homosexuality and psychiatry.” A comprehensive index makes immediately accessible subjects that do not appear in the alphabetical listing.

Bringing together information from the English, French, German, Italian, and Scandinavian languages, the dictionary rests on an enormous base of primary sources that cover the growth of psychiatry through all of Western society.

What is the Impact of Early Manifesting Disorders in the Frame of General Mental Morbidity & of the Effect of Intervention?

Research Paper Title

What happens to children and adolescents with mental disorders? Findings from long-term outcome research.

Background

Research on the long-term outcome of mental disorders originating in childhood and adolescence is an important part of developmental psychopathology.

Methods

After a brief sketch of relevant terms of outcome research, the first part of this review reports findings based on heterotypic cohort studies.

The major second part of this review presents findings based on long-term outcome studies dealing with homotypic diagnostic groups. In particular, the review focuses on the course and prognosis of ADHD, anxiety disorders, depression, conduct disorders, eating disorders, autism spectrum disorders, schizophrenia, and selective mutism.

Results

Findings mainly support the vulnerability hypothesis regarding mental disorders with early manifestation in childhood and adolescence as frequent precursors of mental disorders in adulthood.

Conclusions

The discussion focuses on the impact of early manifesting disorders in the frame of general mental morbidity and of the effect of interventions, which is not yet sufficiently discernible.

Reference

Steinhausen, H-C. (2020) What happens to children and adolescents with mental disorders? Findings from long-term outcome research [German]. Zeitschrift fur Kinder- und Jugendpsychiatrie und Psychotherapie. 41(6), pp.419-431. doi: 10.1024/1422-4917/a000258.

Is the Association between Mental Disorders & Cardiovascular Disease Spurious or Real?

Research Paper Title

PsyCoLaus: mental disorders and cardiovascular diseases: spurious association?

Background

Cardio-vascular diseases (CVD), their well established risk factors (CVRF) and mental disorders are common and co-occur more frequently than would be expected by chance.

However, the mechanisms underlying this association are still poorly understood.

The main study questions of PsyCoLaus, the psychiatric arm of CoLaus, are:

  • Do mental disorders increase vulnerability to CVRF and CVD?
  • Do CVRF and CVD promote the development of mental disorders?
  • Do CVRF/ CVD and mental disorders share common pathogenetic processes?

The longitudinal project adds a comprehensive psychiatric evaluation to the CoLaus investigation.

A better understanding of the psychological, physiological and behavioural links underlying CVD/ CVRF and mental disorders will result in the development of more specific and efficient strategies of prevention and treatment for both psychiatric and CVD/CVRF, two major elements of burden of disease.

Reference

Preisig, M., Waeber, G., Mooser, V. & Vollenweider, P. (2020) PsyCoLaus: mental disorders and cardiovascular diseases: spurious association? Revue Medicale Suisse. 7(315), pp.2127-2129.

Book: The Maudsley Prescribing Guidelines in Psychiatry

Book Title:

The Maudsley Prescribing Guidelines in Psychiatry (The Maudsley Prescribing Guidelines Series).

Author(s): David M. Taylor, Thomas R.E. Barnes, and Allan H. Young.

Year: 2018.

Edition: Thirteenth (13th).

Publisher: Wiley-Blackwall.

Type(s): Paperback and Kindle.

Synopsis:

The revised 13th edition of the essential reference for the prescribing of drugs for patients with mental health disorders.

The revised and updated 13th edition of The Maudsley Prescribing Guidelines in Psychiatry provides up-to-date information, expert guidance on prescribing practice in mental health, including drug choice, treatment of adverse effects and how to augment or switch medications.

The text covers a wide range of topics including pharmacological interventions for schizophrenia, bipolar disorder, depression and anxiety, and many other less common conditions. There is advice on prescribing in children and adolescents, in substance misuse and in special patient groups. This world-renowned guide has been written in concise terms by an expert team of psychiatrists and specialist pharmacists.

The Guidelines help with complex prescribing problems and include information on prescribing psychotropic medications outside their licensed indications as well as potential interactions with other medications and substances such as alcohol, tobacco and caffeine. In addition, each of the book’s 165 sections features a full reference list so that evidence on which guidance is based can be readily accessed.

This important text: Is the world’s leading clinical resource for evidence-based prescribing in day-to-day clinical practice and for formulating prescribing policy Includes referenced information on topics such as transferring from one medication to another, prescribing psychotropic medications during pregnancy or breastfeeding, and treating patients with comorbid physical conditions, including impaired renal or hepatic function. Presents guidance on complex clinical problems that may not be encountered routinely Written for psychiatrists, neuropharmacologists, pharmacists and clinical psychologists as well as nurses and medical trainees, The Maudsley Prescribing Guidelines in Psychiatry are the established reference source for ensuring the safe and effective use of medications for patients presenting with mental health problems.