Volume 8 Issue 11 November, 2018
During the period of MBBS training, psychiatry is an enigma due to limited exposure to the branch. Students can have different perceptions about the nature of psychiatry as a discipline, especially when it comes to making a career choice. In a survey on attitudes towards psychiatry in MBBS students in our college we found that though 88% of students felt treating psychiatric disorders was the most challenging in medicine, 69% felt that psychiatry was too inexact and lacked a scientific basis. This perception is probably due to lack of investigative procedures in diagnosis of psychiatric disorders. This may be a boon or a bane; as modern medicine moves towards embracing technology, psychiatry is one of the few branches of medicine where the art of eliciting signs and symptoms is still crucial to the scientific clinical methods. As William Osler has famously said “Medicine is a science of uncertainty and art of probability.”
Psychiatry: Literally the term psychiatry means treating (iatry) the soul (psyche – greek word for butterfly which represents the human soul). Professor Johann Christian Reil of University of Halle in Germany is credited with introducing the term ‘psychiatry’ in 1808 and said that only the very best physicians would have the skills to become psychiatrists. For the purpose of studying psychiatry as a branch of medicine; mind can be understood as an integrative response of the brain to all internal and external stimuli in the form of awareness (consciousness), thoughts (cognition), emotions (affect) and motor response (behavior). This triad of cognition, affect and behavior forms the core basis of evaluation and diagnosis in psychiatry. For example, consider a student who is waiting for the result to be announced. He is probably thinking “what if I fail?” [Cognition], he is feeling anxious [affect] and probably fidgeting and pacing around the room [behavior].
The Art: How are approaches and techniques in psychiatry different from that in medicine? Probably the most important difference in psychiatry is the lack of any test to quantitatively measure signs and symptoms e.g. delusions and hallucinations are subjective experiences of a patient and cannot be measured. They can only be told by the patient and understood by the psychiatrist and to understand these experiences the psychiatrist must learn the ‘art of empathic listening’. Empathy is the art of understanding the subjective experience of another individual by precise, insightful, persistent and knowledgeable questioning.
The Science: Diagnosis and treatment in psychiatry is as much a scientific process as it is in other disciplines of medicine. The signs and symptoms elicited may be either qualitative or quantitative aberrations from normal mental functions. Let’s take the example of a student who has failed in her exams. It would be expected that she is emotionally upset about it. But however, if this student experiences a sad mood throughout the day, has lost interest in all activities, feels a lack of energy continuously for 2 weeks this would be a quantitative variation qualifying for a diagnosis of depression. In addition, if the student is experiencing suicidal thoughts this would be a qualitative aberration. An additional criterion for diagnosis would be if the student has not been attending her classes, not interacting with friends. This is termed as dysfunction and is an essential criterion for diagnosis and which is why the term ‘disorder’ is used to describe psychiatric conditions. Using an analogy of diabetes, a fasting sugar greater than 126mg/dl would be quantitative variation qualifying for diagnosis of diabetes. In addition, the presence of diabetic neuropathy would be a qualitative variation.
A study by Kendell in (1971) showed that psychiatrists in the US & the UK had gross differences in diagnosing schizophrenia. This introduced an important scientific method in psychiatry which was the use of classificatory systems such as DSM and ICD to maintain uniformity of diagnosis across clinicians, and ease of research. The etiology of disease in psychiatry is understood by the concept of biopsychosocial model. Disorders result from interaction of biological, psychological and social factors and this is the essence of all psychiatric evaluation, diagnosis and management. Another important scientific method is the use of structured rating scales which is an objective way to quantify symptom severity and response to treatment. Psychiatry is probably one branch of medicine that still retains the fine balance of art and science in medicine making it an enriching experience. In the words of Dr. Nancy Andreasen, former editor of American journal of psychiatry and pioneer of neuroimaging research in psychiatry:
- “We chose psychiatry because we want to understand the human mind and spirit as well as the human brain.”
- “Every person whom we encounter is a new adventure, a new voyage of discovery, a new life story, a new person”
- “This is what makes psychiatry challenging, intellectually rich, complex, and even enjoyable”
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