What is Psychiatry?
The term psychiatry (literally “medical treatment of the soul”) was first coined by the German physician Johann Christian Reil in 1808.
Psychiatry derives from the Greek words psyche (spirit or soul) and iatreuo (to heal), describes that branch of medicine that deals with the “spirit” rather than the “body” of a sick person. It is a medical specialty devoted to the diagnosis, prevention, and treatment of mental disorders.
Unlike other medical specialties that deal with visible pathology of palpable bodily parts, the purviews of psychiatry are not physical entities but an intangible mental life. Thus, at the very heart of psychiatry lie theories about subjective experiences and human normality, theories that frame the psychiatric constructs of a mental disorder.
Psychiatry has several subspecialties such as addiction psychiatry, child and adolescent psychiatry, community psychiatry, consultation-liaison psychiatry, emergency psychiatry, forensic psychiatry, geriatric psychiatry, and social psychiatry.
Psychiatrists are physicians (Doctors of Medicine or Doctors of Osteopathy) who specialize in the prevention, diagnosis, and treatment of mental, addictive, and emotional disorders.
For example, these areas include: psychoses, depression and other mood disorders, anxiety disorder, substance abuse disorders, developmental abilities, sexual dysfunctions, and adjustment reactions (Reed, 2005).
Psychiatrists have received specialized training in the biological, psychological, and social components of illness, and can order laboratory tests and prescribe medications, as well as evaluate and treat psychological and interpersonal problems.
Psychiatrists also intervene with individuals and families who are coping with crises and other problems. Psychiatric training includes:
- broad skills in psychiatric and medical diagnosis,
- formal psychotherapies, and
Some psychiatrists have received further training in more specialized areas such as psychoanalysis, alcohol and substance abuse, geriatrics, neuropsychiatry, or forensic psychiatry.
The Disturbed Patient
The disturbed patient is the main focus of psychiatry.
Although regarded as one of the newest branches of medicine, psychiatry has its roots in antiquity, for throughout history and in almost all societies, some people have been observed to exhibit disturbed behavior that has required more than treatment of their bodies to get them well again.
Indeed in many parts of Africa maintaining strict tradition, traditional healers including priest-physicians use various methods to treat the sick, among whom are those invariably considered to be sick in ‘spirit’.
Psychiatry deals with two main groups of disturbed person:
- People who might be having difficulty in adjusting to society again after an unfortunate event, and who therefore develop problems like insomnia, poor appetite, palpitations and other symptoms. Whilst their reaction to their problems leads to suffering and may reduce their ability to function, most of us can understand their complaints as they are extreme degrees of usual phenomena.
- People who exhibit behavior more difficult to understand, such as ‘a boy in Maiduguri covered with dust, completely naked, who was in the habit of haunting the market roundabout and throwing garbage at car as they passed by’ (Westley, 1993). Such people are very sick; they might lose touch with reality around them and become a problem for themselves, their family and their society.
Psychiatry or Mental Health?
Psychiatry deals with the diagnosis and treatment of problems involving the two groups of persons mentioned above.
Mental health is much broader and should include all those factors that enhance the comfort and happiness or quality of life of the individual — the composition of the family, their relationships with other people, adequate housing, access to schooling, money and ready cash, employment, etc.
Whereas psychiatry has predominantly to do with medicine, mental health Opens in new window involves many disciplines and sectors.
Assessing the Patient
- The Interview
The most important method of assessing the patient with a psychiatric problem is the interview. Nevertheless, since people express themselves not only in words but also by their body language Opens in new window, it is essential to observe the patient’s behavior and bodily expressions during the interview.
Through interviewing the patient and his immediate relations, we can obtain the history of his illness or disorder. Where a patient is unwilling or unable to speak, describe in the notes what actually happens in the interview, and how the patient behaves. In either case, it is essential to augment such information with a third party account by relatives, friends and any significant others.
It is also very helpful to assess the patient further through psychological tests e.g., of intelligence and personality; best done by a clinical psychologist, and the study of various relevant documents (certificates, letters, drawings) of the patient. By these means a picture can be built up of the physical, psychological and social aspects of the patient’s life, and the way in which the current illness developed.
As resources are scarce in Africa, this ideal assessment often cannot be made. However, even when work is very heavy, this basic framework helps to organize the clinician’s thinking while making the best assessment possible.
- Attitude to the Patient
The encounter between the clinician and the patient is like the host who receives a visitor to his home. In many African homes, there is a pattern with several steps, as illustrated by the Akan of Ghana:
- The visitor is allowed in with a hug or handshake and a word of welcome and is then offered a seat.
- He is offered a drink or some fruit against his presumed tiredness.
- He is asked for the reasons for the visit (even when this is already known by the host).
- After he has given his reasons (uninterrupted by the host), he is welcomed once more and politely asked if he might want to add any more, or alternatively if he might want to emphasize a particular point.
- The host then tells the visitor what has happened to him since the two last met.
- Next, the host might reply to the visitor’s point of emphasis.
- Finally, if the host and visitor want to discuss the matters further, a date and place is agreed.
In the first two steps the host wants to make the visitor feel safe and comfortable, and to show his interest in his immediate welfare.
The next two steps allow the visitor to say whatever he might have in mind without being interrupted, whilst the next steps allow the host to give his opinion on the matter.
The last step is at the heart of the psychiatric interview, when both listen and talk so that they can both derive benefit from the interview.
- The Interview in Practice
Whilst it might be impractical to offer a drink or fruit to our patients, the process outlined above is otherwise easily replicated in the clinic. We greet the patient and introduce ourselves to him.
- We offer him a seat or, if he is lying down, ensure he is comfortable. Then we ask him to introduce himself by asking for his personal details such as age, occupation, marital status (see under history below).
- We ask him, ‘What has brought you to us?’, not ‘What is wrong with you?’.
- After he has described his problems, we ask him to emphasize for us what he considers to be his most worrying complaint or problem.
- We attempt to understand his problems better by asking relevant questions on his background (see under history below).
- We summarize our views and suggest what measures, including investigations, need to be done.
For those familiar with the techniques of interviewing, it is easy to discern two important phases in the process outlined above — establishment of rapport, which merges smoothly into the phase of fact finding and problem solving.
That is to say, we first seek to establish a good working relationship with the patient, who is thus encouraged to participate actively in finding a solution to his problem.
- Dispelling Stigma
We must remember that, in most societies, the mentally ill are stigmatized by many. The person in front of the clinician may have been laughed at, despised and even abused because of his illness. It is essential that he is treated with respect, dignity and kindness by the person from whom he is seeking help.
|Box X-1 | History of the Patient|
|Personal details||Record name, age, sex, marital status, job and source of referral.|
|Reason for referral||Ask about events and symptoms leading to their presentation.|
|History of present illness||Ask about when the illness started, any events that have precipitated the illness, clinical symptoms and the course of the illness since it started. Ask about the patient’s understanding of the illness.|
|Family history||Include childhood experiences (including developmental milestones), schooling, occupational history, marital/relationship history and social circumstances now.|
|Past medical history||Record any serious illnesses and ask about epilepsy and head injury.|
|Past psychiatric history||Record previous illnesses, what treatment the patient had, if any, and if the treatment was effective.|
|Use of drugs and alcohol||If used, record the amount and any harmful effects, including dependence.|
|current medication used|
|Previous personality before illness||Are the current problems an illness or part of the patient’s personality?|
- Mental state examination
The interview and observations made during this phase provide data on the mental functioning of the patient.
While the patient tells his story, the clinician concerns himself with both what the patient says and how s/he says it, and asks himself whether and how the patient by his nature and behavior differs from other people in his environment.
The mental state summarizes the impressions gained by the doctor into the mental functioning of the patient before and also throughout the interview.
Observe, analyse and record the following areas of mental state: the general nutritional state, posture, dress, self care, facial expression and any abnormal movements.
Ending the Psychiatric Interview
After a detailed history and mental state examination, the interviewer should not end the interview abruptly. The patient should be asked, “Is there any issues left which the patient wants to discuss?” The patient should be given a chance to ask questions. The patient should be informed about the summary of the diagnosis and treatment options available.
- Adapted from:
- Essentials of Psychiatry By Dr Sandeep K Goyal
- Principles of Medicine in Africa, as edited by Eldryd Parry, Richard Godfrey, Geoffrey Gill, David Mabey
- The Behavior of the Laboratory Rat: A Handbook with Tests, as edited by Ian Q. Whishaw, Bryan Kolb