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In this essay we will discus about:- 1. Definition of Psychiatry 2. Branches of Psychiatry 3. Historical Aspects.
Essay # 1. Definition of Psychiatry:
Psychiatry is in one of the most interesting, exciting, creative, productive and developing phases of its long history. Stimulated by the rapid acquisition of new scientific knowledge, and pressurized by external factors requiring empirically documented objectification, the field is undergoing a significant transformation.
The medical speciality concerned with the study, diagnosis, treatment and prevention of mental abnormalities and disorders.
But the hypocrisy of a few and the curiosity of others, has made this field also a victim of the fatal preposition “Divide and Rule” and has resulted in new fields such as biological psychiatry, social psychiatry, cultural psychiatry, industrial ‘ psychiatry etc.
The urgency of the need to merge these tributaries into a single psychiatry is still not sufficiently recognized. Independent of the personal gains, contemporary medicine must recognize and deal with all the aetiopathogenic forces that affect an individual who has become ill. The psychiatric care must be multidisciplinary and interdisciplinary in its perspective.
Essay # 2. Branches of Psychiatry:
The different branches in Psychiatry are:
a. Child Psychiatry:
The science of healing or curing disorders of the psyche in children (i.e., those below 12 years of age). So is the psychiatry concerned with Adolescents i.e., Adolescent Psychiatry.
b. Geriatric Psychiatry:
The branch of psychiatry that deals with disorders of old age; it aims to maintain old persons independently in the community as long as possible and to provide long-term care when needed.
c. Community Psychiatry:
The branch of psychiatry concerned with the provision and delivery of a coordinated program of mental health care to a specified population.
d. Asylum Psychiatry:
The field of Psychiatry that deals with major mental disorders under treatment in institutions (a term coined by Ernest Jones).
e. Forensic Psychiatry:
(Legal Psychiatry) Psychiatry in its legal aspects, including criminology, penology, commitment of the mentally ill, the psychiatric role in compensation cases, the problems of releasing information to the court, of expert testimony.
f. Social Psychiatry:
In psychiatry, the stress laid on the environmental influences and the impact of the social group on the individual. The emphasis is on etiology, purposes of treatment and prevention.
g. Cultural Psychiatry:
Cultural Psychiatry (Comparative Psychiatry). The branch of psychiatry concerned with the influence of the culture on the mental health of members of that culture. When the focus is on different cultures, the term transcultural psychiatry is used.
h. Industrial Psychiatry:
The branch of psychiatry that deals with the worker’s adjustment to his job and with the effects of the business organization on its members.
i. Descriptive Psychiatry:
It refers to any system of psychiatry that is based primarily on the study of symptoms and phenomena.
j. Dynamic Psychiatry:
It is concerned with internal unconscious drives or energies that are presumed to determine behaviour.
k. Experimental Psychiatry:
It refers to the use of chemical agents in the development of a science of human behaviour, and particularly to research on the properties and pathways of action of the psychotomimetics.
I. Pastoral Psychiatry:
The branch of psychiatry that relates to religion and particularly, to the integration of psychiatry and religion for the purpose of alleviating emotional ailments the psychotherapeutic role that the clergyman must often play in his relations to his parishioners.
m. Infant Psychiatry:
The branch of psychiatry concerned with the foetal behaviour, with emphasis on the direct observation of the effect of maternal behaviour (e.g., the effects of maternal sleep, movement, behaviour, drugs, environmental influences) on foetus.
n. Political Psychiatry:
Political Psychiatry (Psychopolitics) .The application of psychiatric knowledge or theory to the process of government (e.g., in shaping a policy).
Essay # 3. Historical Aspects of Psychiatry:
The history of Psychiatry is at the same time a very old and a very new field of study. It is considered to be the oldest art of medicine because the mental disorders were among the first types of illnesses to be recognized. The oldest prescription is in Egyptian medicine which calls for exhibition of green stone as a fumigation against hysteria.
i. Greek Psychiatry:
In the 6th Century B.C., the Greek philosophers of Ionia believed that human mind was composed of atoms in motion, and mental illness occurred when there were changes in the size and motions of the atoms, in the amount of humours and vital substances. They believed Mania and Lyssa are the dreaded Goddesses sent by angry God.
Heraclitus (535-470 B.C.):
A philosopher, believed that mental health depended not only on the integrity of body parts but on an equilibrium between opposite psychological tendencies that existed in the soul. He recognized soma and psyche.
Hippocrates (450-355 B.C.):
The Father of Medicine. He believed that the body contained four essential humours – blood, phlegm, yellow bile and black bile – which were secreted by different organs, possessed different qualities, and varied with the seasons.
The brain was regarded as a seat of life, and its normal functioning required a harmony between the humours. Crasis is the appropriate interaction between internal and external forces while dyscrasis is the presence of excessive bodily humour which had to be removed by purging.
The smaller excess of body humours produced choleric (black bile), melancholic (yellow bile), phlegmatic (phlegm) and sanguine (blood) personalities. The Hippocratic authors gave first rational classification to mental diseases, including epilepsy, mania, depression, paranoia (which today called mental deterioration), postpartum psychosis, organic toxic delirium, and phobias.
They described some of the symptoms of “hysteria” and named it believing that it was confined to women and was caused by wandering uterus (Thus, marriage and intercourse were the recommended cure).
Plato (427-347 B.C.):
The philosopher divided the soul into three parts located in different parts of the body:
i. Appetitive represents peremptory desires, physical lusts and greed (Freud later termed it as ‘id’).
ii. Rational which was immortal and divine and located in the brain. (Freud called it ‘Superego’).
iii. Spirited affective. Freud called it ‘Ego’.
According to him appetitive and rational are in conflict and the spirited-affective can be enlisted on either side. Plato said ‘health is the result of harmony between body and mind whereas disharmony between them results in ‘mania’ or ‘gross ignorance’. Plato distinguished two kinds of madness — one resulted from human ailments when the appetitive soul lost the domination of the rational and other was produced by time disturbances of the soul.
Aristotle (384-322 B.C.):
Plato’s pupil believed that the soul was the centre of psychic life, located in the heart, derived its energy from natural heat and that it was vulnerable to changes in temperature, black bile and the emotions.
Cold black bile leads to apoplexy, numbness, fearfulness and becoming disheartened.
Hot black bile produced cheerfulness, bursting into song, ecstasy and the eruption of sores.
Music is the release of repressed emotions or passions, that is abreaction.
Passion must be purged continuously to avoid violence.
Theatre is collective cathartic device. Aristotle first accurately described the affections of desire, anger, fear, courage, envy, joy, hatred and pity.
Other Contributions:
Greek philosophers also advocated three psychological therapies for mental illnesses—the therapy of the world, induced sleep and dream divination. Words were used to alleviate illness in different ways—as prayers, magical incantations, cheering speeches, rhetorical speeches meant to persuade and Plato’s verbal dialectics.
ii. Roman Psychiatry:
The Romans made advances in legal psychiatry and the laws in fifth century B.C. deprived the mentally ill of freedom of action and declared them legally incompetent.
Asclepiades (1st Century A.D.):
He described:
Phrenitis—A fever which is accompanied by mental excitement.
Mania—Excitement with fever.
Cicero (106-43 B.C.):
Extremes of anger, fear and pain could cause psychic disorders and ‘libido’ (he first used this term) is the strong passion or a violent desire.
Seneca (4-65 A.D.). He said
Reason is the basis for proper human behaviour.
Passions cause perturbances of soul.
Galen (130-200 A.D.):
The greatest Roman physician who divided the soul into three parts:
i. Concupiscible (carnal appetites and desires) located in liver.
ii. Irascible (courage and anger)-located in heart.
iii. Rational (reason or intellect)-located in the brain.
He believed that diseases were caused by adverse external influences (such as bad diet and bad air) acting on an existing predisposition (an abnormality of a humour) and that psychological disorders caused physical disorders and vice versa. He wrote a treatise ‘On Melancholia’.
Areataeus (1st Century A.D.):
He described the influence of emotions on mental functioning.
Soranus (1st and 2nd Century A.D.):
He advocated the humanitarian treatment of mentally ill.
Constantinus Africanus (1020-1087 A.D.):
Constantinus Africanus wrote a book ‘De Melancholia’.
Aquinas described many psychotic symptoms and said ‘hallucination’ is the combination of natural and supernatural Phenomenon.
Saint Augustine (345-430 A.D.):
Saint Augustine wrote a book ‘Confession’ which was first book that centered on psychological introspection and on psychological autobiographical insights. It has been rated as “the earliest fore runner of psychoanalysis” “psychoanalysis without a psychoanalyst listening and interpreting the confessions.”
iii. Other Contributors:
Jonathan Weyer (1515-1588) is often believed to the ‘First Psychiatrist’ who described various symptoms and signs of toxic psychosis, senile psychosis, epilepsy, nightmares, folie-a-deux delusions and paranoia.
P. Pinel (1745-1826) Founder of ‘Modern Psychiatry’.
Melancholia:
Disturbance in intellectual functioning.
Mania:
Excessive nervous excitement with or without delirium.
Dementia:
Disturbance in thought process.
Idiocy:
Obliteration of intellectual faculties and affects.
Felix Platter (1536-1614) Swiss Physician who wrote the First Psychiatric Medical Textbook – ‘Praxis Medica’
Franz Josef Gall (1758-1828) Identified 27 organs in brain, 14 of which cannot be modified by education. He coined the form ‘Phrenology’.
Comments:
Even after these theories, mental illness was considered as demoniac illness which led to showing of cruelty to mental patient (e.g., Flogging and Beating) to drive out evil spirit ‘Witch hunting’ leading to killing of the patients.
Mount Cassino (in Italy) was first place to provide humanitarian treatment for mental ill patients.
Indian Culture:
Atharva Veda (700 B.C.) described the role of Psychotherapy, drugs (Rauwolfia) and divine agents in treatment.
Chinese:
“The Yellow Emperors classic of Internal Medicine” mentioned about the symptoms and treatment of mental illness.
Judaic:
Nebuchadnezzar (king of Babylon) became depressed, irritable and fell into lycanthropy- a form of mental disorder in which the patient imagines himself to be a wolf or other wild beast. It was probably a form of melancholia.
Modern Trends:
A. Hospital Care: (including Social and Legal Aspects):
(a) Social Aspect (Human Care):
Pinel (in 1795) was first to inaugurate humane treatment in Paris. He provided liberty and work to the mental patients who were previously chained for their destructive behaviour. Social reform continued and Benjamin Rush (1745-1813) in U.S.A. and Connoly and Tuke in U.K. were the real founders of Modern Social Psychiatry.
(b) Legal Aspects:
The Romans made several advances in legal psychiatry. There were laws defining the ability of the mental ill to marry, divorce and make wills and their responsibility for crimes. When such laws were applied, the mentally ill were evaluated by judges, not physicians.
Paolo Zacchia (1584 -1659) was known as the father of Legal Medicine U.K.
I. In 1890 Lunacy Act:
To provide hospital accommodation (certificates and judicial order perquisites).
II. 1930 Mental Treatment Act:
It enabled all mental hospitals to take voluntary admission.
III. 1959 Mental Health Act:
It made revolutionary change in psychiatric care (certification removed and judicial order required only in certain cases). It formed the basis for community psychiatry (i.e. treatment of patients in OPD, Day Hospitals and in the patients home). India followed U.K. in formulating the following laws.
IV. 1912 Indian Lunacy Act:
Indian Lunacy Act (modified on 1st Oct, 1931) It regulated the admission, treatment and discharge of lunatics.
V. 1987 Mental Health Act:
The act use the term ‘mentally ill person’ instead of ‘lunatic’ and defines various regulations concerning mental hospitals, psychiatric centres and nursing homes.
VI. 1985 The Narcotic Drugs and Psychotropic Substance Act (NDPSA):
It regulates production, possession, transportation, import, export, sale, purchase or use of any narcotic drug or psychotropic substance.
(c) First Mental Hospitals:
First Mental Hospitals 1409 Valencia (dedicated to Spanish Priest Gilbert Jofre) 1547 — St. Belhelem (by Henry the VIII) now BEDLAM. In India in 1743 (Bombay).
Development of Psychological Methods and Treatment:
Psychology:
Word was coined by Gockel (German Philosopher) in 1590 (1547-1628).
Paracelsus (Swedish Physician, 15th Century):
Health and illness were controlled by astral bodies such as stars and moon (Lunacy is a relic of these theories which allege that mentally ill people are affected by moon).
Mesmer:
Ill health is because of disturbance in the body of a fluid called Animal Magnetism. People treated with this go into trance. James Braid coined word ‘Hypnosis’
Charcot:
He said that hypnosis and suggestion are the keys to psychiatric treatment.
Pierre Janet (1859-1947) (French Physician):
He worked on psychological automatism, hysteria, amnesia, fugue, anorexia, tics. He developed the concepts of Psych asthenic/ due to loss of function of soul, la belle indifference literally meaning ‘beautiful indifference’ shown by a hysteric towards his illness and ‘Dissociation’.
Other Concepts:
W. Griesinger (1817-1868):
Mental disease could be explained on the basis of physical changes in the brain.
Sigmund Freud:
Sigmund Freud (7th May 1856 to 1939, born in Moravia and passed most of his life in Austria) also called ‘The Father of Psychology’.
His main contributions were:
a. Used hypnosis and developed free association as treatments (in Psychoanalysis)
b. Gave structure of Mind (Topographical theory – conscious, preconscious and unconscious, Psychodynamic theory – Id, Ego, Superego)
c. Gave various defence mechanisms of Ego.
d. Developed the stages of Psychosexual development (i.e., Oral, Anal, Phallic (oedipal), latency and Libido)
e. Interpretation of dreams.
f. Properties of cocaine.
Emil Kraepelin (1855-1926) (German Psychiatrist). Divided mental illness into Dementia Precox (a term used for chronic mental illness with poor prognosis i.e. for schizophrenia) and Manic Depressive Psychosis (a term first used by him).
Eugen Bleuler (1857-1961) (Swiss Psychiatrist) coined terms ‘Schizophrenia’ ‘Autism’ and ‘Amibivalence’. He gave 4 ‘A’s of Schizophrenia (Ambivalence, Autism, Affective Incongruity and Abnormalities of Association).
Carl G Jung (1875-1961) of Zurich gave the following concepts:
a) Psyche consists of 4 elements (Behaviour, Emotion, Cognition and Images).
b) Archetypes (has outer shell and deeper shell).
c) Collective Unconscious (consisting of man’s religious and cultural striving) and Personal unconscious.
d) Personality types (introvert-extrovert).
e) Word Association techniques.
f) Schizophrenic processes.
g) Components of Personality (Anima and Persona)
Alfred Adler (1870-1937):
He gave:
a) Personality theory. (Human destiny is the product of choice and will).
b) Theory of Individual Psychology including a theory of aggression (power instinct) producing neurotic symptoms and resulting from organ inferiority
c) Concepts of overcompensation, masculine protest, inferiority complex and use of organ jargon (e.g., “pain in the neck” etc.).
d) Started one of the first Child Guidance Centres.
Otto Rank (1884 -1939) gave the concept that birth is the prototypal traumatic event in life and the cause of all neurosis lay in the individual’s attempt to overcome this trauma with associated ‘primary’ anxiety. His method (will therapy) involved a re-experiencing of separation from the mother figure (therapist) in an effort to strengthen the will.
Karl Abraham (1877-1925) contributed by giving the concepts of:
a) Relationship of pregenital stages of personality development to character disorders.
b) Basic ambivalence and increased oral eroticism underlie depression.
Wilhelm Reich (1897-1972) published “On Character Analysis”:
a) Theory of character defenses (armor) as habitual attitudes and ways of behaviour that mask inner feelings and basic conflicts.
b) Character formation and types.
Sander Rado (1890-1972) developed concepts of:
a) Adaptational psychodynamics.
b) Self is action self and conscience is action self.
Eric Berne (1910-1970) gave Transactional analysis consisting of:
a) Ego states—child, adult and parent.
b) Transaction — a stimulus from ego state of one person and arouses corresponding response in another.
c) Games — Interaction between different ego states and persons.
d) Strokes— Reinforcement.
e) Scripts — Success or failure in life is determined by a personal conformity to important early transactions.
f) Contracts — between different ego states.
H.S. Sullivan (1894 – 1949) contributed the concepts of:
a) Interpersonal relationships
b) Sociological events.
Anna Freud (1895 – 1982) (Freud’s daughter) wrote “The Ego and the Mechanisms of Defense” (1946). She gave some ego’s defence mechanisms and described man’s ways of making psychological adaptation to inner conflict.
Hermann Rorschach (1884 – 1922) wrote ‘Psychodiagnostik’ (1921) (Ink Blot Test) – a projective test of personality.
Johann Christian Heinroth (1773 – 1843) coined term ‘Psychosomatic’.
Edmin Husrel – described Phenomenology.
James Papez – Gave theory of emotions and described famous ‘Papez-circuit’ of emotions.
Organic or Biological Approach:
It paid due attention to physical factors in mental illness and initiated somatic treatment methods.
Morgagni (in 18th Century) believed that mental illness is an organic illness.
Alois Alzheimer (1864-1915) reported first case of progressive dementia in 1906.
Antoine Bayle (1799-1858). In 1826, stated that general paresis of insane is a separate clinical entity.
Neuropsychiatrists founded the biological, constituent and organic type of psychiatry.
Adolf Meyer (1866-1950) introduced the concepts of Psychobiology (Eragasiology)
W. Griessinger (1817-1868) Mental disease could be explained on the basis of physical changes in the brain.
Reynolds (1969) discovered Enkephalins in brain (on simulation of para aqueductal areas, amygdala).
Hans Kosterlitz (1960s) discovered Opiate Receptors in brain.
Eric Simon ‘Endorphins (Endogenous morphine like compound) in brain.
The other main types of biological methods of treatment are given in Table 2.1:
