medical profession psychiatry - semmelweis egyetem · 2019-02-14 · origins of modern psychiatry...
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Medical Profession
Psychiatry
Bálint Szuromi, M.D., Ph.D.
Assistant Professor
Semmelweis University
Department of Psychiatry and Psychotherapy
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Psychiatry: the meeting point of
clinical profession, biology, social
sciences, and human care
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Synopsis
• Historical roots
• Scientific background
• Clinical practice
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The Graeco-Roman period
Alcmaeon (ca. 500 B.C.):
mental processes are
located in the brain
Plato (427?-347 B.C.):
tripartie soul of thought,
desire, emotion; rational
part in the brain
Aristotle (384-322 B.C.):
the task of the brain is to
cool the blood Raphael`s Plato
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Hippocrates (460-377 B.C.)
• The body humor hypothesis:
– Black bile – melancholia
– Yellow bile – mania
• Hysteria – disease of uterus
• Paranoia
• Sacred disease - epilepsy
Galen (129-199 A.D.)
• Imagination, reason and
memory
• Morositas – deadening of the
emotional life
• Paraphrosune – paranoia
• Alienation – bizarre behavior
Rubens` Hippocrates
Mural painting depicting
Galen and Hippocrates (Anagni)
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The first ward for the mentally ill:
Hospital of Baghdad
Al-Razi (865-925): scholar of Greek medicine,
philosopher and alchemist
ازیابو بکر محمد بن زكريا الر Textbook of Al-Razi
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Psychiatric Asylums in Europe
Bethlem Hospital, London (1330)
Asylum of Budapest (1886)
Salpêtrière, Paris (1675)
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- experimentation in learning about the human body
- sickness and health in the body relied on the harmony of man, the microcosm,
and Nature, the macrocosm
- using this analogy not in the manner of soul-purification but that humans must have
certain balances of minerals in their bodies
- illnesses of the body and soul had chemical remedies that could cure them –
the concept of medicine
Paracelsus(1493-1541)
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Psychiatric illness is not a consequence of transcendent factors
- De Praestigiis Daemonum et Incantationibus ac Venificiis
(On the Illusions of the Demons and on Spells and Poisons), 1563
- De Lamiis Liber (Book on Witches), 1577
- Pseudomonarchia Daemonum (The False Kingdom of the Demons), 1577
Johann Weyer (1515-1588)
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-“Cerebri anatomi”, 1664 (the term “neurology”)
- “Pathologicae cerebri, et nervosi generis specimen”, 1667
- “Two Discourses concerning The Soul of Brutes, Which is that of the Vital
and Sensitive of Man”, 1672 (the first English work on medical psychology)
Thomas Willis (1621-1675)
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Philippe Pinel (1745-1826)
Humanization of the treatment of the mentally ill
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Origins of modern psychiatry1808 - Johann Christian Reil (1759 -1813): the term Psychiatry (psyche – soul,
iatros – doctor)
America - Benjamin Rush (1745-1813), American Psychiatric Association (1844)
1865 - The first psychiatric university department in Berlin (1882 in Budapest)
1890s - Emil Kraepelin (1856-1926): classification of mental disorders
1908 - Eugen Bleuler (1857-1939): the term Schizophrenia (skhizein – to split,
phren – mind)
1880s - Sigmund Freud (1856-1939): psychoanalysis
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Kraepelin's view
Treated patients with severe mental disorders in asylums
Origin of illness:
brain pathology
Freud's view
Treated less severe outpatients
Origin of illness: repressed unconscious
(sexual) desires,
abnormal psychosexual
development
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The dark side of psychiatry
• Torture of patients in medieval ages
• Patients were closed in large institutions
• Political psychiatry (Soviet Union and Nazis)
• Lobotomy, insulin coma, electroconvulsive therapy in
wake patients
• No scientific bases of mental illness
• Psychoanalysis is a myth and not science
• 1960: antipsychiatry (David Cooper, Thomas Szasz)
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What happens if we reject and forget
psychiatry?
• Attempts in Italy as an influence of antipsychiatry
• Patients on the street and behind the bars
• Patients as victims and criminal offenders
• Restriction of psychiatry services due to financial
shortcuts (USA today)
• US Dept. of Justice (1999): 16% of inmates in jails
have severe mental illness
• Human Right Watch Report (2003): on a given day
70000 psychotic patients are in prisons
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Response and development
• Development of neuroscience
Molecular genetics (biobanks), brain imaging,
and pharmacology
• Modern clinical psychiatry and community mental health care
Closing asylums and helping patients find their way back to the community using psychopharmacology, psychotherapy, and social therapy
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Is it true that psychiatric disorders
lack scientific bases?
NO!
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Modern neuroimaging methods allow the
visualization of brain working during thinking,
feeling, and deciding:
- Positron emission tomography
(PET)
- Functional magnetic resonance
imaging (fMRI)
Positron emitting radioligand in the body
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basal ganglia
thalamus
hippocampusamygdala
brainstem
Limbic system
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Frontal lobe: - Higher cognition (lateral part)
- Emotional and social functions (bottom part)
- Schizophrenia
Basal ganglia: - Movement regulation
- Skill and habit learning (feedback and reward)
- Parkinson`s disease
Amygdala: - Emotion, fear, anxiety
- Depression
Hippocampus: - Remembering facts and events (explicit memory)
- Alzheimer`s disease
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Rapoport 2012
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Enlarged ventricles and
smaller hippocampus in
schizophrenia
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Friedman 2008
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Brain activation during auditory hallucinations
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PET shows increased release of the neurotransmitter DOPAMINE
in schizophrenia
Antipsychotic drugs, such as haloperidol, block dopamine in the brain
and reduce hallucinations and delusions
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Depression = the level of serotonin is too low in your brain?
No, but depressed patients (C) have fewer transporter molecules
pumping back serotonin from the synaptic cleft to the neuron
Antidepressants, such as Prozac, act on these molecules
Oquendo et al., 2007
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The genetics of the serotonin transporter affects your
vulnerability to stress
Serotonin transporter
short (s) and long (l) versions
Hariri et al., 2002; Caspi et al., 2003
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Cells are abnormally localized and disorganized in the
brain of schizophrenia patients
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The effect of antidepressants (venlafaxine) and
interpersonal psychotherapy on brain activation (fMRI)
Martin et al., 2001
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Psychiatry in practice
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Clinical practice
• What is the definition of a psychiatric
disorder?
• What kind of disorders do we treat?
• What methods do we use?
• How does the system work?
• What is the perspective for a mentally ill?
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Simple questions, difficult answers
Have you ever
• felt depressed or anxious?
• had problems with attention and memory?
• felt that strange things happen to you?
• believed that ghosts and aliens exist?
• been frightened?
• had sleeping problems or nightmares?
• had problems with alcohol or drugs?
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If so, do you have a psychiatric disorder?
Psychiatric disorder:
• fulfil official diagnostic criteria
• severe and prolonged
symptoms
• functional impairment
(academic, work, social life)
DSM-5: Diagnostic and Statistical Manual of Mental Disorders (2013)
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How to make a diagnosis in
psychiatry?
• Exploration (+ physical examination)
• Observation
• Heteranamnesis
• Diagnostic questionnaires/interviews
• Rating scales
• Laboratory tests
• Imaging
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Mental disorders
• Psychotic disorders
• Mood disorders
• Anxiety disorders
• Substance use disorders
• Eating disorders
• Organic mental disorders
• Neurodevelopmental disorders
• Etc.
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Psychotic disorders
Psychosis: loss of contact with reality
Delusion, hallucination, strange or bizarre
behavior, emotional disturbance
• Schizophrenia ~1%
• Schizoaffective disorder
• Paranoia
• Psychosis due to other mental illness
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A story of a famous mathematician, John Nash, who lived with
SCHIZOPHRENIA:
- Hallucinations (e.g. voices in your head giving you messages)
- Delusions (e.g. false beliefs of persecution or special power)
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Mood disorders
• Major depression (unipolar) ~3%
• Bipolar disorder ~1%
– depression
– mania
– mixed
• Dysthymia
• Cyclothymia
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Van Gogh Hemingway
DEPRESSION: abnormal sadness, loss of joy and
motivation, decreased energy, desperation, and suicide
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Anxiety disorders
• Panic disorder ~4-5%
• Generalized anxiety
• Phobias
– agoraphobia
– social phobia ~10%
– specific
• Obsessive-compulsive
disorder ~2-3%
• PTSD
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Substance use disorders
• Nicotine
• Alcohol
• Cannabis
• Amphetamine
(speed, ecstasy)
• Cocaine
• Heroine
• Designer drugs
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Cannabis and schizophrenia
Gene-environment interaction
Psychosis (SCH) risk for COMT Val158 carrier
cannabis users
Caspi, 2005
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Eating disorders
• AnorexiaWeight loss > 15%
Fear of becoming fat
Disturbance in body experience
• Bulimia
• Binge eating
• Night eating
• Muscle dysmorphia
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Organic mental disorders
• Dementias
• Alzheimer’s disease
• Vascular dementia
• More than 100 types…
• Mental retardation
• Psychiatric disorders due
to internal or neurological
conditions
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Neurodevelopmental disorders
Childhood disoders that continue
into adulthood• Attention deficit hyperactivity disorder
(ADHD)
– 60% of children with ADHD
– Stimulants treatment
– Decreases rate of criminality, accidents,
mortality
• Autism spectrum disorder (ASD)
– Treatment???
– Social and life skill programs
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Suicide
• Suicide attempt
– Risk factors: untreated depression, psychosis, SUD,
social problems
– 50% of schizophrenia and bipolar patients
• Completed suicide
– 2-40/100.000 people/year worldwide
– ~10% of schizophrenia patients
– ~20% of bipolar patients
PREVENTION WITH APPROPRIATE TREATMENT!
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Mental health system
• Outpatient departments
Community care, private practice
• Hospitals
Forms of admission:
– Voluntary
– Involuntary
(in case of violent or
self dangerous behavior)
• Long-term programs for patients with SUD
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Therapeutical approaches
• Pharmacotherapy
• Biological treatments– ECT (electroconvulsive therapy)
– Psychosurgery (for OCD)
– Light therapy
• Psychotherapy
• Social therapy
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Psychotherapy
Interaction and communication between 2 (or
more) persons
Aims of psychotherapy
• reduction of symptoms, increasing coping skills, better
insight and personality development
Non-specific factors
• understanding, acceptance, empathy, congruence
Specific factors
• gaining insight into the unconscious, modifying abnormal
thinking, correcting abnormal relationships
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Modern psychotherapy
COGNITIVE BEHAVIOR
THERAPY
• Focusing on abnormal thinking
(e.g. extreme pessimism and
hopelessness in depression)
INTERPERSONAL
PSYCHOTERAPY
• Focusing on human relationships
(e.g. dispute, role changes, grief,
communication skills)
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Modern social therapy
Instead of large institutions to “store” the
patients:
1. Case manager that helps the patient in
everyday activity
2. Sheltered houses
3. Supported employment
4. Daytime “hospitals” and clubs
5. Social skill training
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Forensic psychiatry
Meeting point of psychiatry and the law
Assessment
• Supervision of involuntary admissions
• Court ordered psychiatric assessment of offenders (expert
wittnessing)
Treatment
• Inpatient and outpatient treatment of offenders with mental disorders
• Psychiatric care in prison and police custody
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Concluding remarks I.
• The roots of psychiatry: religion, alchemy,
philosophy, psychology, and neuroscience
• From black bile and demons to
“mindreading” techniques of fMRI/PET and
genes
• From torture and misery to humanity and
empathy
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Concluding remarks II.
Psychiatry is (one of) the
- most colorful
- most difficult
- most challenging
- most exhausting
- most prospective discipline of medicine.
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Thank you for your attention!