A Short Introduction to Psychiatry
Publication Year: 2004
A Short Introduction to Psychiatry is designed to give readers a clear picture of the profession of psychiatry as it is today as well as an understanding of the subject from which to develop further study. The author describes the development of the profession, the route to qualification and the scope of contemporary practice, including the work done by psychiatrists in a range of specialisms - from child psychiatry to addiction services and forensic psychiatry. Drawing on the experience of people who have been through psychiatric treatment, the book also explores what psychiatry is like from the patient's/user's perspective. Many criticisms have been levelled against the profession and the author, Linda Gask, summarizes key debates which have been and continue to be played out between ...
- Front Matter
- Back Matter
- Subject Index
Short Introductions to the Therapy ProfessionsSeries Editor: Colin Feltham
Books in this series examine the different professions which provide help for people experiencing emotional or psychological problems. Written by leading practitioners and trainers in each field, the books are a source of up-to-date information about
- the nature of the work
- training, continuing professional development and career pathways
- the structure and development of the profession
- client populations and consumer views
- research and debates surrounding the profession.
Short Introductions to the Therapy Professions are ideal for anyone thinking about a career in one of the therapy professions or in the early stages of training. The books will also be of interest to mental health professionals needing to understand allied professions and also to patients, clients and relatives of service users.
Books in the series:
A Short Introduction to Clinical Psychology
Katherine Cheshire and David Pilgrim
A Short Introduction to Psychoanalysis
Jane Milton, Caroline Polmear and Julia Fabricius
A Short Introduction to Psychiatry
Linda Gask[Page iii]
© Linda Gask 2004
First published 2004
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, this publication may be reproduced, stored or transmitted in any form, or by any means, only with the prior permission in writing of the publishers, or in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency. Inquiries concerning reproduction outside those terms should be sent to the publishers.
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For my family, John and Suzy, with all my love
Several friends and colleagues kindly agreed to be interviewed and/or read early drafts of particular chapters and they are (in alphabetical order): Elaine Arnold, Tom Brown, Bill Deakin, Dinesh Bhugra, Chris Dowrick, Roger Farmer, Hugh Freeman, Chris Manning, Frank Margison, Max Marshall, Carl May, David Pilgrim, David Richards and Jenny Shaw. Mike Shooter, President of the Royal College of Psychiatrists gave up his precious time to talk to me. I also extend my thanks to the Royal College of Psychiatrists for giving me permission to reproduce material from their website in Appendix 1.
Colin Feltham suggested that I write the book and has been a very helpful editor, reading through drafts and posing some difficult questions. Finally I couldn't have completed this without my husband John, who always supports me even when I get carried away on yet another project.
Appendices[Page 141][Page 142]
Appendix 1: Information on Psychiatry as a Career (Reprinted with Permission from the Royal College of Psychiatrists Website: http://www.rcpsych.ac.uk)[Page 143]
You must first qualify as a medical doctor. To do this, you need to be accepted by a medical school, having passed three good ‘A’ levels in subjects such as Chemistry, Zoology, Physics, Biology or Maths. Some medical schools now accept other ‘A’ levels, too. Getting into medical school is very competitive – it seems to help if candidates not only have good academic qualifications but are also lively, enthusiastic all-rounders with outside interests such as sports or the Arts.
Once you have been accepted by a hospital as a medical student, you will work in a variety of areas, including psychiatry, for the next five years.
Following this, you will work as a House Officer in a hospital for a further year. This can be very tough with hard work and long hours. However, once you get through this, you will become a medical doctor and can specialize in any area you wish – we hope you will choose psychiatry!
Before starting your psychiatric training, we advise young doctors to take an extra job or two in the general medicine or Accident and Emergency departments of a hospital – this always seems to help during your first psychiatric job.
You will then spend a further three years working as a Senior House Officer – during which time you will probably wish to study for the Royal College of Psychiatrists' Membership Examination – the MRCPsych.
Following this, you will be ready for Higher Training as a Specialist Registrar. During this period, you will choose which of the six psychiatric speciality areas you wish to concentrate upon during the next three/four years.What are the Various Specialties within Psychiatry?General Adult Psychiatry
The majority of psychiatrists in the UK work within this broad category, which involves the care of people with mental health problems [Page 144]in many settings. Psychiatrists may be based in mental or university hospitals, psychiatric units in general hospitals, in the community, or a mixture of these. Because of the diversity of patients and psychiatric conditions requiring treatment and care, an adult general psychiatrist must be skilled in numerous treatment techniques. Psychiatrists in this area must also have the knowledge and skills required to organize and administer a psychiatric service for a specific population. General adult psychiatrists may have a special interest in, for example, neuropsychiatry, the rehabilitation and care of patients with chronic disabilities, drug and/or alcohol problems or eating disorders. They work closely with multi-disciplinary teams which can include community psychiatric nurses, social workers, psychologists and occupational therapists. This specialty also entails close liaison with hostels, crisis intervention centres, residential homes and sheltered workshops.Psychiatry of Old Age
This is a rapidly expanding specialty: the number of old people in this country has increased dramatically, and is likely to continue to do so. In psychiatric units at present, about 45 per cent of residents and 25 per cent of people admitted are aged 65 years or more. A major challenge for this area of psychiatry is the treatment and care of people suffering from senile dementia, but most specialists in the field deal with the full range of psychiatric disorders affecting patients over the age of 65. Much ill health in old people is a mixture of physical and mental conditions, and so an active interest in general medicine is required. Psychiatrists working in this specialty are based in hospitals, geriatric units, day-care centres, or in the community. Experience in general medicine, geriatrics, general practice and psychology is particularly valuable.Child and Adolescent Psychiatry
Psychiatrists working in this area are primarily concerned with the intellectual, emotional and behavioural mental health problems of children from birth until school-leaving age. The development of a close working relationship with the child concerned – and their family – is essential. Skills in diagnostic assessment, including interviewing and examination, are particularly valuable. You would use a variety of treatments ranging from individual psychotherapy to behavioural and family therapy. You could be based in hospitals, child guidance clinics, day units, special schools (boarding and day) for children experiencing difficulties, or in community and remand homes. It may also be necessary to engage in Court activities.[Page 145]Forensic Psychiatry
This is concerned with the interaction between and overlap with psychiatry and the law. The forensic psychiatrist cares for and treats offenders with mental health problems in a number of different settings: general and special hospitals, crisis intervention centres, and prisons.
In addition, forensic psychiatrists work with the courts in the elucidation of medico-legal problems such as criminal responsibility, fitness to plead and the management of mentally abnormal offenders.
Special skills are needed in assessing behavioural abnormalities, understanding and using security as a means of control and treatment, writing reports for Courts and lawyers and giving evidence in Courts of law.
Forensic psychiatry is challenging, since it sometimes involves dealing with very disturbed patients, who may have violent tendencies.Psychiatry of Learning Disability (Formerly Mental Handicap)
Psychiatrists working in this area are concerned with the prevention, diagnosis and treatment of the mental health problems which often occur in people with learning disability. For example, a patient with Down's Syndrome may also suffer from depression or anxiety. Psychiatrists in this area work closely with the patient's family, taking into consideration their care and education. In addition to psychiatric and administrative skills, expertise in related subjects such as paediatrics, neurology, genetics, biochemistry and psychology are required. To an increasing extent, learning disability psychiatrists work in teams based in special schools and training centres, hospitals, residential hostels and sheltered workshops.Psychotherapy
All psychiatrists need some basic psychotherapeutic skills, but specialists in this area are also required to assess and treat people with, for example, psychoneuroses, personality and behavioural disorders, and sexual and interpersonal problems. In addition to specialized treatment procedures, psychotherapists need expertise in the application of psychotherapeutic principles, including the psychodynamic use of the doctor–patient relationship as part of the general management of all patients with mental health and psychosomatic disorders.
Psychotherapists also need to be skilled in cognitive and behavioural therapies. During training, it may be necessary to experience personal psychotherapy. This gives psychiatrists a valuable insight into their patients' problems.
[Page 146]An increasing number of psychotherapists work closely with various clinical teams in hospitals, child and adolescent units, child guidance clinics, student health centres, and in doctors' surgeries.Are There Opportunities for Psychiatrists Wishing to work in the Armed Forces?
Yes. Psychiatrists in the Armed Forces provide help with mental health problems to about 500,000 men, women and children in the UK and overseas. In addition to Service personnel, those entitled to benefit from the Defence Medical Services include civilians employed by the Ministry of Defence overseas (such as schoolteachers, welfare professionals, shopkeepers and administrative staff) and the families of Service personnel and other entitled civilians.
Military psychiatrists are trained as general adult psychiatrists. They may have a special interest in the maintenance of fitness and morale, and in the study of combat stress, both physical and psychological. Service psychiatrists are based more and more in the community, and are supported by community psychiatric nurses or social workers.
All doctors working within the Armed Forces enlist as military personnel, and undergo some general military training. Before starting specialist psychiatric training, it is usual for Service doctors to spend one or two years undertaking general medical duties to enable them to acquire an understanding of the conditions of life among the Armed Forces.How is Training Organized?General Training
During your general training in a medical school – lasting approximately 5–6 years – you could choose an ‘elective’ period in psychiatry (about 3–4 months). You would then carry on working in pre-registration posts (i.e. House Officer posts) for a period of one year. After this, you become registered with the General Medical Council (GMC). In your post-registration period working as a Senior House Officer, you should try to gain experience recognized by the Royal College of Psychiatrists, such as working in general practice or general medicine.Basic Specialist Training
Your basic specialist training in psychiatry takes place on College-approved and recognized Rotational Training Schemes, and lasts three years; you would spend about six months each in as many [Page 147]specialties as are offered by the training scheme – as well as fulfilling the basic requirement to train (initially for one year) in general adult and old age psychiatry. You should ensure that your particular area of interest, i.e. psychotherapy or forensic, is covered by your training scheme. Details of recognized training schemes are available from the College on request. After initial training, and at least one year's experience of general psychiatry, you would be ready to sit for Part I of the College Membership examination – the MRCPsych.The MRCPsych (Membership) Examination
The emphasis of the Membership exam is on clinical work:
Part I consists of a Multiple Choice Question (MCQ) Paper and a clinical examination which will be a test of clinical skills in assessment.
Part I must be passed within three years of full-time approved psychiatric training (or equivalent period of part-time training).
Part II consists of a second clinical examination, much broader than the first, two MCQ papers, an Essay Paper and a paper containing questions on basic sciences and clinical topics.
Once you have successfully obtained Part I, you should work as an SHO in rotating specialty posts for a further 2/3 years, after which time you would be eligible to take Part II of the examination. If you pass, you are awarded the MRCPsych, and become a Member of the College. To summarize, to obtain the MRCPsych, you would need:
Higher Specialist Training
- a minimum of one year's psychiatric experience before taking the Part I
- two to three years' further training before taking the Part II (although this period can be shorter if you have other training that is recognized by the College, such as general practice medicine, general medicine, etc). Full details are available on request from the Examinations Department of the College.
Higher specialist training entails working as a Specialist Registrar or Lecturer for a further three/four years. During higher specialist training, there is an opportunity to work in general adult psychiatry, or you can opt for one of the specialties as listed above, with a special interest in another sub-specialty such as forensic or liaison psychiatry. After completion of higher specialist training, you could apply for posts such as Senior Lecturer, Consultant or Professor of Psychiatry.
[Page 148]Further information is available from:
Head of Postgraduate Educational Services
The Royal College of Psychiatrists
17 Belgrave Square
London SW1X 8PG (email: email@example.com)Flow Chart of Training as a Psychiatrist in the UK and Eire
Appendix 2: Glossary of Some Terms Used in the Text[Page 149]
Affective disorders: disorders characterized by a primary disturbance of mood such as depression or elation. Depression often co-exists with anxiety in the community although anxiety disorders are classified separately.
Amnesia: loss of memory.
Anorexia: loss of appetite. This occurs in many physical and mental disorders (e.g. depression) and should be distinguished from the eating disorder anorexia nervosa in which there is deliberate restriction of food intake, weight loss, disturbed body image and amenorrhoea. Anorexia nervosa is traditionally viewed as a ‘neurotic’ illness even though the behaviour of a person with the disorder may seem to defy the test of ‘understandability’ and therefore seem to have more in common with psychotic thinking (see Jaspers 1913).
Assertive Community Treatment: provision of community-based, multidisciplinary care to individuals with long-standing psychiatric illnesses who have previously been, or are at risk of, hospitalization. ACT services are flexible and support people who may have a history of non-engagement with treatment.
Aversion therapy: negative conditioning. The unwanted behaviour (for example alcohol abuse, sexual deviation) is paired with painful or unpleasant stimuli until it is extinguished.
Barbiturates: a group of drugs that are central nervous system depressants. Widely prescribed in the past for insomnia, they are now rarely prescribed for this reason, because of serious problems with addiction and lethality in overdose.
Bipolar disorder: affective disorder characterized by episodes of both mania and depression. Also known as manic-depressive psychosis but this term is now much less used.
Catatonic schizophrenia: one of the sub-groups of schizophrenia characterized by the presence of one or more states of abnormal movement such as stupor (unresponsiveness with immobility and [Page 150]mutism but retention of consciousness), maintenance of rigid postures or facial expressions (grimacing) or idiosyncratic involuntary movements (known as mannerisms). For a fuller description see Sims (2003).
Cognitive-behaviour therapy (CBT): an active, structured, directive and time-limited therapy which is based on the belief that the way a person perceives himself, the world and the future determines his mood and his behaviour. The therapy has both cognitive (focusing on identification and challenging of negative thoughts) and behavioural (focusing on goal-setting and behavioural activation) components.
Comorbid (comorbidity): occurrence of more than one disease in the same time in the same person. More popular as a concept in American than in European traditions of psychiatric diagnosis and classification.
Culture-bound syndromes: syndromes (characteristic patterns of symptoms and behaviour) that appear to be limited to certain societies or cultures.
Degeneration: the notion that inherited mental illness worsened steadily over the generations – causing progressive deterioration within families and within the population as a whole. This idea was popular within nineteenth-century psychiatry. It is but one step, however, from applying eugenic principles to improve the genetic stock – the path pursued by the Nazis.
Delusion: a false, unshakeable idea or belief which is out of keeping with the person's educational, cultural and social background.
Dementia praecox: term coined by Morel in 1857 to describe psychoses with a poor prognosis (deterioration or ‘dementia’) which often begin in early life (praecox). Kraepelin differentiated psychosis with a better prognosis (manic-depressive psychosis) from dementia praecox which later became generally known as schizophrenia (see below).
Desensitization: a form of behaviour therapy which is particularly effective in treatment of phobia.
Electro-convulsive therapy (ECT): the treatment of mental disorders, most commonly severe depression, by passing an electric current through the brain with the use of general anaesthesia and a muscle relaxant.
Electronarcosis: obsolete early variety of ECT.
[Page 151]Flooding: effective behavioural treatment for phobia which involves prolonged exposure to the situation which is avoided.
General systems theory: a movement in scientific theory which sought to discover general patterns, trends and structural characteristics in all types of system – natural, social and technological. It was a reaction against the fragmented acquisition of knowledge resulting from excessive specialization.
Hallucination: an apparent perception of an external object when no such object is present. Hallucinations may be experienced in all the sensory domains – visual, auditory, tactile and olfactory.
Health Maintenance Organizations (HMOs): organized health care delivery system to be found in the USA which provides enrollees with comprehensive health care (which may be limited for certain illnesses – particularly mental illnesses) for a fixed term in return for regular payment of premiums.
Huntington's disease: inherited neuropsychiatric disorder which results in progressive disability from disorders of movement (chorea), depression and dementia.
Hypothalamo–pituitary–adrenal (HPA) axis: part of the endocrine system (hormones) which plays an important part in coping with stress. The hypothalamus and pituitary gland are located in the brain and the adrenal glands just above the kidneys. When a person is under stress the hypothalamus triggers the pituitary to release a hormone which finally triggers the adrenals to release cortisol. Many people with mood disorders appear to have a cortisol regulation system which is not working effectively.
Hysteria: old-fashioned term for dissociative (conversion) disorder which implies the behaviour of illness (for example paralysis of a limb) without evidence of physical pathology. There is continued debate about the usefulness of the term – see Sims (2003) for a comprehensive discussion.
Insulin coma treatment: obsolete treatment which involved the induction of coma through the administration of insulin.
Leucotomy, lobotomy: psychosurgical procedure which involved destruction of an area of brain tissue. Still performed for intractable illnesses in a small number of specialist centres.
Loosening of associations: a type of disorder of the expression of thought in speech, in which there is incompleteness of the development [Page 152]of ideas. The person's conversation sounds muddled and their thoughts seem to veer off until they may appear unrelated to whatever apparently initiated them.
Managed behavioural healthcare organization (MBHO): an organized system of behavioural health care delivery – usually to a defined population of members of HMOs and other managed care structures. Also known as a ‘carve-out’. See Talbott and Hales (2001) for more detailed description.
Managed care: the general term used to describe a variety of arrangements in health care financing, organization and delivery in which an entity other than the directly treating physician is managing or over-seeing payments for medical services. The commonest type of managed care programme separates mental health provision from general health provision, with mental health care being provided by a large behavioural health organization. This split of the physical from the mental once again perpetuates Cartesian dualism through the justification of twentieth-century economics.
Manic-depressive psychosis: see bipolar disorder.
Mental state examination: the psychiatric equivalent of the physical examination which seeks to create a record of behavioural and psychological data elicited by examination at the time of the interview as well as by contemporaneous observation. Data are traditionally recorded under the headings: appearance and general behaviour, talk or speech, mood, thought content (including abnormal beliefs and perceptions), cognitive state and insight (see Goldberg and Murray, The Maudsley Handbook of Practical Psychiatry (2002), which is a widely used text for psychiatric trainees).
Mono-Amine Oxidase Inhibitors (or MAOIs): early type of antidepressant. Rarely used now because of potentially dangerous interactions with certain foods and numerous other drugs.
Neuroimaging: brain imaging is a computer-assisted graphic representation of brain structure. Methods used include X-ray computerized axial tomography (CT or CAT scanning), NMR (nuclear magnetic resonance, which uses magnetic field instead of radiation to produce images), PET (positron emission tomography, which employs chemicals tagged with radio-isotopes) and SPECT (single photon emission computed tomography, which uses radiopharmaceutical agents or radioactive gas).
Neuroleptic: a drug which has a specific anti-psychotic effect and is not simply achieving its effect by tranquillization.
[Page 153]Neuroradiological/neuroradiologists: the study of the brain originally using X-rays but now involving a wide variety of imaging techniques (see neuroimaging).
Obsessional neurosis/obsessive-compulsive disorder: a disorder characterized by persistent, disturbing, unwanted, anxiety-provoking, intruding thoughts, ideas, images and/or impulses to perform repetitive acts (rituals). Typically the person regards these as alien or absurd.
Pathoplastic: pathoplastic factors change the way in which an illness presents; for example, cultural factors commonly do this even if they do not actually cause the illness in the first place.
Phenomenology: the study of events in their own right, rather than from the point of view of inferred causes. In psychiatry it is specifically:
The observation and categorization of abnormal psychological events, the internal experiences of the patient and his consequent behaviour. An attempt is made to observe and understand the psychological event or phenomenon, so that the observer can, as far as possible, know for himself what the patient's experience must feel like. (Sims 2003: 3)
Phobias: unreasonable and inappropriate fears.
Psychiatric genetics: study of the inheritance of biological variation as it pertains to the aetiology of psychiatric illnesses.
Psychodynamic (or psychoanalytically orientated) psychotherapy: psychotherapy theoretically rooted in the ideas of Freud and those who followed him. Based on theories which represent symptomatic behaviour as determined by the interplay between intra– and extra-psychic forces (for example family conflict, early experiences, current life stresses).
Psychoneuroendocrinologists/psychoneuroendocrinology: study of the endocrine system as a likely site for biochemical abnormalities that are significant in the aetiology of psychiatric illnesses. Recent research has focused on the central regulatory actions of the HPA axis.
Psychopharmacology: the study of the behavioural effects of drugs.
Psychosurgery: the use of (neuro)surgical means to treat mental illness.
Randomized controlled trials (RCTs): an experimental design in which subjects are randomly assigned to the experimental group [Page 154](which receives the treatment or intervention under investigation) or to the control group (which receives no treatment, or a placebo).
Schizophrenia: a term coined by Bleuler for what is probably a group of disorders rather than a single disorder which is characterized by disturbance of multiple psychological processes (language and communication, thought content, mood, affect, sense of self, relationship to the external world, volition and motor behaviour). There has been considerable debate about the diagnostic criteria over the last few decades. However, within psychiatry, the criteria used in the International Classification of Disease (ICD-10) and the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) are now generally applied in both clinical care and research.
Schizophrenogenic family: now considered to be an obsolete and discredited term but once used to describe a family (or specifically, mother) which was thought to have produced or fostered the development of schizophrenia in the child.
Service user: modern term for a person who uses psychiatric services. Alternative terms (patient, consumer) are still debated.
SSRIs (Selective Serotonin Reuptake Inhibitors): modern anti-depressants which act specifically on the serotonin neurotransmission system in the brain which is thought to be of key importance in the genesis of depression.
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