Psychiatry

A

Drugs

Psychotropic drugs (see Psychoactive Drugs) are by far the most commonly used organic treatment. The first to be discovered were the antipsychotics, used primarily to treat schizophrenia. The phenothiazines are the most frequently prescribed class of antipsychotic drugs. Others are the thioxanthenes, butyrophenones, and indoles. All antipsychotic drugs diminish such symptoms as delusions, hallucinations, and thought disorder. Because they can reduce agitation, they are sometimes used to control manic excitement in manic-depressive patients and to calm geriatric patients. Some childhood behavior disorders respond to these drugs.

Despite their value, the antipsychotic drugs have drawbacks. The most serious is the neurological condition tardive dyskinesia, which occurs in patients who have taken the drugs over extended periods. The condition is characterized by abnormal movements of the tongue, mouth, and body. It is especially serious because its symptoms do not always disappear when the drug is stopped, and no known treatment for it has been developed.

Most psychotropic drugs are chemically synthesized. Lithium carbonate, however, is a naturally occurring element used to prevent, or at least reduce, the severity of shifts of mood in manic-depression (see Depression). It is especially effective in controlling mania. Psychiatrists must monitor lithium dosages carefully, because only a small margin exists between an effective dose and a toxic one.

Three major classes of antidepressant drugs are used. The tricyclic and tetracyclic antidepressants, the most frequently prescribed, are used for the most common form of serious depression. Monoamine oxidase (MAO) inhibitors are used for so-called atypical depressions. Serotonin-selective reuptake inhibitors (SSRIs) are effective against both typical and atypical depressions. Although all three classes are quite effective in relieving depression in correctly matched patients, they also have disadvantages. The tricyclics and tetracyclics can take two to five weeks to become effective and can cause such side effects as oversedation and cardiac problems. MAO inhibitors can cause severe hypertension in patients who ingest certain types of food (such as cheese, beer, and wine) or drugs (such as cold medicines). SSRI drugs, such as fluoxetine (Prozac), take 2 to 12 weeks to become effective and can cause headaches, nausea, insomnia, and nervousness.

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Anxiety, tension (see Stress-Related Disorders), and insomnia are often treated with drugs that are commonly called minor tranquilizers. Barbiturates have been used for the longest time, but they produce more severe side effects and are more often abused than the newer classes of antianxiety drugs (see Drug Dependence). Of the new drugs, the benzodiazepines are the most frequently prescribed, very often in nonpsychiatric settings.

The stimulant drugs, such as amphetamine—a drug that is often abused—have legitimate uses in psychiatry. They help to control overactivity and lack of concentration in hyperactive children (see Hyperactivity) and to stimulate the victims of narcolepsy, a disorder characterized by sudden, uncontrollable episodes of sleep.

B

Other Organic Treatments

Another organic treatment is electroconvulsive therapy, or ECT, in which seizures similar to those of epilepsy are produced by a current of electricity passed through the forehead. ECT is most commonly used to treat severe depressions that have not responded to drug treatment. It is also sometimes used to treat schizophrenia. Other forms of organic treatment are much less frequently used than drugs and ECT. They include the controversial technique psychosurgery, in which fibers in the brain are severed; this technique is now used very rarely (see Lobotomy).

C

Psychotherapy

The most common nonorganic treatment is psychotherapy. Most psychotherapies conducted by psychiatrists are psychodynamic in orientation—that is, they focus on internal psychic conflict and its resolution as a means of restoring mental health. The prototypical psychodynamic therapy is psychoanalysis, which is aimed at untangling the sources of unconscious conflict in the past and restructuring the patient's personality. Psychoanalysis is the treatment in which the patient lies on a couch, with the psychoanalyst out of sight, and says whatever comes to mind. The patient relates dreams, fantasies, and memories, along with thoughts and feelings associated with them. The analyst helps the patient interpret these associations and the meaning of the patient's relationship to the analyst. Because it is lengthy and expensive, often several years in duration, classical psychoanalysis is now infrequently used.

More common are shorter forms of psychotherapy that supplement psychoanalytic principles with other theoretical ideas and scientifically derived information. In these types of therapy, psychiatrists are more likely to give the patient advice and try to influence behavior. Some use techniques derived from behavior therapy, which is based on learning theory (although these methods are more commonly used by psychologists).

Besides psychotherapy, the other major form of nonorganic treatment used in psychiatry is milieu therapy. Usually carried out in psychiatric wards, milieu therapy directs social relations among patients and staff toward therapeutic ends. Ward activities, too, are planned to serve specific therapeutic goals.

In general, psychotherapy is relied on more heavily for the treatment of neuroses and other nonpsychotic conditions than it is for psychoses. In psychotic patients, who usually receive psychoactive drugs, psychotherapy is used to improve social and vocational functioning. Milieu therapy is limited to hospitalized patients. Increasingly, psychiatrists use a combination of organic and nonorganic techniques for all patients, depending on their diagnosis and response to treatment.

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