psychiatric

• adj.

• 精神医学の、精神医学で用いる。精神科の

関

psychiatrically, psychiatrics, psychiatry

　

WordNet

1. relating to or used in or engaged in the practice of psychiatry; "psychiatric disorder"; "psychiatric hospital" (同)psychiatrical
2. the branch of medicine dealing with the diagnosis and treatment of mental disorders (同)psychopathology, psychological medicine

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1. 精神病学,精神医学

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2013/11/20 10:29:23」(JST)

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Not to be confused with Psychology.

The word psyche comes from the ancient Greek for soul or butterfly. The fluttering insect appears in the coat of arms of Britain's Royal College of Psychiatrists

Psychiatry is the medical specialty devoted to the study, diagnosis, treatment, and prevention of mental disorders. These include various affective, behavioural, cognitive and perceptual abnormalities. The term was first coined by the German physician Johann Christian Reil in 1808, and literally means the 'medical treatment of the soul' (psych-: soul; from Ancient Greek psykhē: soul; -iatry: medical treatment; from Gk. iātrikos: medical, iāsthai: to heal). A medical doctor specializing in psychiatry is a psychiatrist. (For a historical overview, see Timeline of psychiatry.)

Psychiatric assessment typically starts with a mental status examination and the compilation of a case history. Psychological tests and physical examinations may be conducted, including on occasion the use of neuroimaging or other neurophysiological techniques. Mental disorders are diagnosed in accordance with criteria listed in diagnostic manuals such as the widely used Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, and the International Classification of Diseases (ICD), edited and used by the World Health Organization. The fifth edition of the DSM (DSM-5) is scheduled to be published in 2013, and its development is expected to be of significant interest to many medical fields.

The combined treatment of psychoactive medication and psychotherapy has become the most common mode of psychiatric treatment in current practice, but current practice also includes widely ranging variety of other modalities. Treatment may be delivered on an inpatient or outpatient basis, depending on the severity of functional impairment or on other aspects of the disorder in question. Research and treatment within psychiatry as a whole are conducted on an interdisciplinary basis, sourcing an array of sub-specialties and theoretical approaches.

Controversy has often surrounded psychiatry, and the term anti-psychiatry was coined by psychiatrist David Cooper in 1967. The anti-psychiatry message is that psychiatric treatments are ultimately more damaging than helpful to patients, and psychiatry's history involves what may now be seen as dangerous treatments (e.g., Electroconvulsive therapy, lobotomy). Two charismatic psychiatrists who came to personify the movement against psychiatry were R.D. Laing and Thomas Szasz. Some ex-patient groups have become very anti-psychiatric, often referring to themselves as "survivors".

Theory and focus

"Psychiatry, more than any other branch of medicine, forces its practitioners to wrestle with the nature of evidence, the validity of introspection, problems in communication, and other long-standing philosophical issues" (Guze, 1992, p.4).

Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It has been described as an intermediary between the world from a social context and the world from the perspective of those who are mentally ill.

Those who specialize in psychiatry are different than most other mental health professionals and physicians in that they must be familiar with both the social and biological sciences. The discipline is interested in the operations of different organs and body systems as classified by the patient's subjective experiences and the objective physiology of the patient. Psychiatry exists to treat mental disorders which are conventionally divided into three very general categories: mental illness, severe learning disability, and personality disorder. While the focus of psychiatry has changed little throughout time, the diagnostic and treatment processes have evolved dramatically and continue to do so. Since the late 20th century, the field of psychiatry has continued to become more biological and less conceptually isolated from the field of medicine.

Scope of practice

Disability-adjusted life year for neuropsychiatric conditions per 100,000 inhabitants in 2002.

  no data

  less than 10

  10-20

  20-30

  30-40

  40-50

  50-60

  60-80

  80-100

  100-120

  120-140

  140-150

  more than 150

While the medical specialty of psychiatry utilizes research in the field of neuroscience, psychology, medicine, biology, biochemistry, and pharmacology, it has generally been considered a middle ground between neurology and psychology. Unlike other physicians and neurologists, psychiatrists specialize in the doctor-patient relationship and are trained to varying extents in the use of psychotherapy and other therapeutic communication techniques. Psychiatrists also differ from psychologists in that they are physicians and only their residency training (usually 3 to 4 years) is in psychiatry, and their graduate medical training is identical to all other physicians. Psychiatrists can therefore counsel patients, prescribe medication, order laboratory tests, order neuroimaging, and conduct physical examinations.

Ethics

Like other purveyors of professional ethics, the World Psychiatric Association issues an ethical code to govern the conduct of psychiatrists. The psychiatric code of ethics, first set forth through the Declaration of Hawaii in 1977, has been expanded through a 1983 Vienna update and, in 1996, the broader Madrid Declaration. The code was further revised in Hamburg, 1999. The World Psychiatric Association code covers such matters as patient assessment, up-to-date knowledge, the human dignity of incapacitated patients, confidentiality, research ethics, sex selection, euthanasia, organ transplantation, torture, the death penalty, media relations, genetics, and ethnic or cultural discrimination.

In establishing such ethical codes, the profession has responded to a number of controversies about the practice of psychiatry. Controversy has surrounded the use of lobotomy and electro-convulsive therapy. Discredited psychiatrists, who operated outside the norms of medical ethics, include Harry Bailey, Samuel A. Cartwright, Henry Cotton, and Andrei Snezhnevsky.

Approaches

Psychiatric illnesses can be conceptualised in a number of different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. Mental illness can be assessed, conversely, through a narrative which tries to incorporate symptoms into a meaningful life history and to frame them as responses to external conditions. Both approaches are important in the field of psychiatry, but have not sufficiently reconciled to settle controversy over either the selection of a psychiatric paradigm or the specification of psychopathology. The notion of a "biopsychosocial model" is often used to underline the multifactorial nature of clinical impairment. In this notion the word "model" is not used in a strictly scientific way though. Alternatively, a "biocognitive model" acknowledges the physiological basis for the mind's existence, but identifies cognition as an irreducible and independent realm in which disorder may occur. The biocognitive approach includes a mentalist etiology and provides a natural dualist (i.e. non-spiritual) revision of the biopsychosocial view, reflecting the efforts of Australian psychiatrist Niall McLaren to bring the discipline into scientific maturity in accordance with the paradigmatic standards of philosopher Thomas Kuhn.

Subspecialties

Various subspecialties and/or theoretical approaches exist which are related to the field of psychiatry. They include the following:

• Addiction psychiatry; focuses on evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders, and of individuals with dual diagnosis of substance-related and other psychiatric disorders.
• Biological psychiatry; an approach to psychiatry that aims to understand mental disorders in terms of the biological function of the nervous system.
• Child and adolescent psychiatry; the branch of psychiatry that specialises in work with children, teenagers, and their families.
• Community psychiatry; an approach that reflects an inclusive public health perspective and is practiced in community mental health services.
• Cross-cultural psychiatry; a branch of psychiatry concerned with the cultural and ethnic context of mental disorder and psychiatric services.
• Emergency psychiatry; the clinical application of psychiatry in emergency settings.
• Forensic psychiatry; the interface between law and psychiatry.
• Geriatric psychiatry; a branch of psychiatry dealing with the study, prevention, and treatment of mental disorders in humans with old age.
• Liaison psychiatry; the branch of psychiatry that specializes in the interface between other medical specialties and psychiatry.
• Military psychiatry; covers special aspects of psychiatry and mental disorders within the military context.
• Neuropsychiatry; branch of medicine dealing with mental disorders attributable to diseases of the nervous system.
• Social psychiatry; a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental wellbeing.

In larger healthcare organizations, both public and private, psychiatrists often serve in senior management roles, where they are responsible for the efficient and effective delivery of mental health services for the organization's constituents. For example, the Chief of Mental Health Services at most VA medical centers is usually a psychiatrist, although psychologists occasionally are selected for the position as well.^{[citation needed]}

In the United States, psychiatry is one of the specialties which qualify for further education and board-certification in pain medicine, palliative medicine, and sleep medicine.

Industry and academia

Practitioners

Main article: Psychiatrist

All physicians can diagnose mental disorders and prescribe treatments utilizing principles of psychiatry. Psychiatrists are either: 1) clinicians who specialize in psychiatry and are certified in treating mental illness; or (2) scientists in the academic field of psychiatry who are qualified as research doctors in this field. Psychiatrists may also go through significant training to conduct psychotherapy, psychoanalysis and cognitive behavioral therapy, but it is their training as physicians that differentiates them from other mental health professionals.

Research

Psychiatric research is, by its very nature, interdisciplinary. It combines social, biological and psychological perspectives to understand the nature and treatment of mental disorders. Clinical and research psychiatrists study basic and clinical psychiatric topics at research institutions and publish articles in journals. Under the supervision of institutional review boards, psychiatric clinical researchers look at topics such as neuroimaging, genetics, and psychopharmacology in order to enhance diagnostic validity and reliability, to discover new treatment methods, and to classify new mental disorders.

Clinical application

Diagnostic systems

See also Diagnostic classification and rating scales used in psychiatry

MRI or CT images may assist in a diagnosis by ruling out other conditions.

Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole this remains a research topic.

Diagnostic manuals

See also: Diagnostic and Statistical Manual of Mental Disorders

Three main diagnostic manuals used to classify mental health conditions are in use today. The ICD-10 is produced and published by the World Health Organisation, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders, produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States. It is currently in its fourth revised edition and is also used worldwide. The Chinese Society of Psychiatry has also produced a diagnostic manual, the Chinese Classification of Mental Disorders.

The stated intention of diagnostic manuals is typically to develop replicable and clinically useful categories and criteria, to facilitate consensus and agreed upon standards, whilst being atheoretical as regards etiology. However, the categories are nevertheless based on particular psychiatric theories and data; they are broad and often specified by numerous possible combinations of symptoms, and many of the categories overlap in symptomology or typically occur together. While originally intended only as a guide for experienced clinicians trained in its use, the nomenclature is now widely used by clinicians, administrators and insurance companies in many countries.

The DSM has attracted praise for standardizing psychiatric diagnostic categories and criteria. It has also attracted controversy and criticism. Some critics argue that the DSM represents an unscientific system that enshrines the opinions of a few powerful psychiatrists. There are ongoing issues concerning the validity and reliability of the diagnostic categories; the reliance on superficial symptoms; the use of artificial dividing lines between categories and from 'normality'; possible cultural bias; medicalization of human distress and financial conflicts of interest, including with the practice of psychiatrists and with the pharmaceutical industry; political controversies about the inclusion or exclusion of diagnoses from the manual, in general or in regard to specific issues; and the experience of those who are most directly affected by the manual by being diagnosed, including the consumer/survivor movement. The publication of the DSM, with tightly guarded copyrights, now makes APA over $5 million a year, historically adding up to over $100 million.

Treatment

General considerations

A psychiatric patient room in the United States.

Individuals with mental health conditions are commonly referred to as patients but may also be called clients, consumers, or service recipients. They may come under the care of a psychiatric physician or other psychiatric practitioners by various paths, the two most common being self-referral or referral by a primary-care physician. Alternatively, a person may be referred by hospital medical staff, by court order, involuntary commitment, or, in the UK and Australia, by sectioning under a mental health law.

Persons who undergo a psychiatric assessment are evaluated by a psychiatrist for their mental and physical condition. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance full blood counts serum drug levels, renal function, liver function, and/or thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for serious and disabling conditions, such as those unresponsive to medication. The efficacy and adverse effects of psychiatric drugs may vary from patient to patient.

For many years, controversy has surrounded the use of involuntary treatment and use of the term "lack of insight" in describing patients. Mental health laws vary significantly among jurisdictions, but in many cases, involuntary psychiatric treatment is permitted when there is deemed to be a risk to the patient or others due to the patient's illness. Involuntary treatment refers to treatment that occurs based on the treating physician's recommendations without requiring consent from the patient.

Inpatient treatment

Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, people receiving psychiatric treatment are more likely to be seen as outpatients. If hospitalization is required, the average hospital stay is around one to two weeks, with only a small number receiving long-term hospitalization.^{[citation needed]}

Psychiatric inpatients are people admitted to a hospital or clinic to receive psychiatric care. Some are admitted involuntarily, perhaps committed to a secure hospital, or in some jurisdictions to a facility within the prison system. In many countries including the USA and Canada, the criteria for involuntary admission vary with local jurisdiction. They may be as broad as having a mental health condition, or as narrow as being an immediate danger to themselves and/or others. Bed availability is often the real determinant of admission decisions to hard pressed public facilities. European Human Rights legislation restricts detention to medically certified cases of mental disorder, and adds a right to timely judicial review of detention.^{[citation needed]}

Injections are one of many ways to administer psychiatric medication.

Patients may be admitted voluntarily if the treating doctor considers that safety isn't compromised by this less restrictive option. Inpatient psychiatric wards may be secure (for those thought to have a particular risk of violence or self-harm) or unlocked/open. Some wards are mixed-sex whilst same-sex wards are increasingly favored to protect women inpatients. Once in the care of a hospital, people are assessed, monitored, and often given medication and care from a multidisciplinary team, which may include physicians, pharmacists, psychiatric nurse practitioners, psychiatric nurses, clinical psychologists, psychotherapists, psychiatric social workers, occupational therapists and social workers. If a person receiving treatment in a psychiatric hospital is assessed as at particular risk of harming themselves or others, they may be put on constant or intermittent one-to-one supervision, and may be physically restrained or medicated. People on inpatient wards may be allowed leave for periods of time, either accompanied or on their own.

In many developed countries there has been a massive reduction in psychiatric beds since the mid 20th century, with the growth of community care. Standards of inpatient care remain a challenge in some public and private facilities, due to levels of funding, and facilities in developing countries are typically grossly inadequate for the same reason.^{[citation needed]}

Outpatient treatment

Outpatient treatment involves periodic visits to a psychiatrist for consultation in his or her office, or at a community-based outpatient clinic. Initial appointments, at which the psychiatrist conducts a psychiatric assessment or evaluation of the patient, are typically 45 to 75 minutes in length. Follow-up appointments are generally shorter in duration, i.e., 15 to 30 minutes, with a focus on making medication adjustments, reviewing potential medication interactions, considering the impact of other medical disorders on the patient's mental and emotional functioning, and counseling patients regarding changes they might make to facilitate healing and remission of symptoms (e.g., exercise, cognitive therapy techniques, sleep hygiene—to name just a few). The frequency with which a psychiatrist sees people in treatment varies widely, from once a week to twice a year, depending on the type, severity and stability of each person's condition, and depending on what the clinician and patient decide would be best.

Increasingly, psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of "talk therapy." This shift began in the early 1980s and accelerated in the 1990s and 2000's. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment.For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model.

Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.

History

Ancient

Starting in the 5th century BCE, mental disorders, especially those with psychotic traits, were considered supernatural in origin, a view which existed throughout ancient Greece and Rome. The beginning of psychiatry as a medical specialty is dated to the middle of the nineteenth century., although one may trace its germination to the late eighteenth century.

Early manuals about mental disorders were created by the Greeks. In the 4th century BCE, Hippocrates theorized that physiological abnormalities may be the root of mental disorders. In 4th to 5th Century B.C. Greece, Hippocrates wrote that he visited Democritus and found him in his garden cutting open animals. Democritus explained that he was attempting to discover the cause of madness and melancholy. Hippocrates praised his work. Democritus had with him a book on madness and melancholy.

Religious leaders often turned to versions of exorcism to treat mental disorders often utilizing cruel and barbaric methods.

Middle Ages

Main article: Islamic psychology

Specialist hospitals were built in Baghdad in 705 AD, followed by Fes in the early 8th century, and Cairo in 800 AD.^{[citation needed]}

Physicians who wrote on mental disorders and their treatment in the Medieval Islamic period included Muhammad ibn Zakarīya Rāzi (Rhazes), the Arab physician Najab ud-din Muhammad^{[citation needed]}, and Abu Ali al-Hussain ibn Abdallah ibn Sina, known in the West as Avicenna.

Specialist hospitals were built in medieval Europe from the 13th century to treat mental disorders but were utilized only as custodial institutions and did not provide any type of treatment. Founded in the 13th century, Bethlem Royal Hospital in London is one of the oldest lunatic asylums. By 1547 the City of London acquired the hospital and continued its function until 1948. It is now part of the National Health Service and is an NHS Foundation Trust.

Many consider Philippe Pinel to be the father of modern psychiatry.

Early modern period

In 1621, Oxford University mathematician, astrologer, and scholar Robert Burton published the English language The Anatomy of Melancholy, What it is: With all the Kinds, Causes, Symptomes, Prognostickes, and Several Cures of it. In Three Maine Partitions with their several Sections, Members, and Subsections. Philosophically, Medicinally, Historically, Opened and Cut Up. Burton wrote "I write of melancholy, by being busy to avoid melancholy. There is no greater cause of melancholy than idleness, no better cure than business." Unlike English philosopher of science Francis Bacon, Burton assumes that knowledge of the mind, not natural science, is humankind's greatest need.

In 1656, Louis XIV of France created a public system of hospitals for those suffering from mental disorders, but as in England, no real treatment was applied. In 1713 the Bethel Hospital Norwich was opened, the first purpose-built asylum in England, founded by Mary Chapman. In 1758 English physician William Battie wrote his Treatise on Madness which called for treatments to be utilized in asylums. Thirty years later, then ruling monarch in England George III was known to be suffering from a mental disorder. Following the King's remission in 1789, mental illness came to be seen as something which could be treated and cured. The French doctor Philippe Pinel introduced humane treatment approaches to those suffering from mental disorders. As a result of his work, the Governor of the Bicêtre psychiatric hospital in Paris released psychiatric patients from their chains in 1793, beginning what has been called the bright epoch of psychiatry. At the York Retreat, a Quaker-run asylum in England which opened in 1796, a form of moral treatment evolved independently from Pinel under the lay stewardship of the tea and coffee merchant William Tuke. Tuke's Retreat became a model throughout the world for humane and moral treatment of patients suffering from mental disorders. The York Retreat inspired similar institutions in the United States, most notably the Brattleboro Retreat and the Hartford Retreat (now the Institute of Living).

19th century

In 1808, Johann Christian Reil coined the term psychiatry (Greek "ψυχιατρική", psychiatrikē) which comes from the Greek "ψυχή" (psychē: "soul or mind") and "ιατρός" (iatros: "healer").

In the early 1800s, psychiatry made a significant advance in diagnosis of mental illness by broadening the category of mental disease to include mood disorders, in addition to disease level delusion or irrationality. Jean-Étienne Dominique Esquirol, a student of Pinel, made the first elaboration of what was to become our modern depression, lypemania, one of his affective monomanias (excessive attention to a single thing).

At the turn of the century, England and France combined had only a few hundred individuals in asylums. By the late 1890s and early 1900s, this number had risen to the hundreds of thousands. The United States housed 150,000 patients in mental hospitals by 1904. German speaking countries housed more than 400 public and private sector asylums. These asylums were critical to the evolution of psychiatry as they provided places of practice throughout the world.

On continental Europe, universities often played a part in the administration of the asylums and, because of the relationship between the universities and asylums, scores of psychiatrists were being educated in Germany. However, because of Germany's individual states and the lack of national regulation of asylums, the country had no organized centralization of asylums or psychiatry. Britain, unlike Germany, possessed a national body for asylum superintendents - the Medico-Psychological Association - established in 1866 under the Presidency of William A.F. Browne.

In the United States in 1834 Anna Marsh, a physician's widow, deeded the funds to build her country's first financially stable private asylum. The Brattleboro Retreat marked the beginning of America's private psychiatric hospitals challenging state institutions for patients, funding, and influence. Although based on England's York Retreat, it would be followed by specialty institutions of every treatment philosophy.

In 1838, France enacted a law to regulate both the admissions into asylums and asylum services across the country. This was the year in which William A.F. Browne achieved his appointment as Superintendent of the Crichton Royal at Dumfries in southern Scotland.

Emil Kraepelin studied and promoted ideas of disease classification for mental disorders.

However, the new idea that mental illness could be ameliorated during the mid-nineteenth century were disappointed. Psychiatrists were pressured by an ever increasing patient population. The average number of patients in asylums in the United States jumped 927%. Numbers were similar in England and Germany. Overcrowding was rampant in France where asylums would commonly take in double their maximum capacity. Increases in asylum populations may have been a result of the transfer of care from families and poorhouses, but the specific reasons as to why the increase occurred is still debated today. No matter the cause, the pressure on asylums from the increase was taking its toll on the asylums and psychiatry as a specialty. Asylums were once again turning into custodial institutions and the reputation of psychiatry in the medical world had hit an extreme low.

Argentina's government put numerous obstacles in the way of hospital development. For example in Buenos Aires, 1880s to 1980s, mental hospitals suffered serious overcrowding and appalling living conditions; lack of suitable staff and resources; and low rates of confinement compared to similar periods in modern nations.

20th century

Disease classification and rebirth of biological psychiatry

The 20th century introduced a new psychiatry into the world. Different perspectives of looking at mental disorders began to be introduced. The career of Emil Kraepelin reflects the convergence of different disciplines in psychiatry. Kraepelin initially was very attracted to psychology and ignored the ideas of anatomical psychiatry. Following his appointment to a professorship of psychiatry and his work in a university psychiatric clinic, Kraepelin's interest in pure psychology began to fade and he introduced a plan for a more comprehensive psychiatry. Kraepelin began to study and promote the ideas of disease classification for mental disorders, an idea introduced by Karl Ludwig Kahlbaum. The initial ideas behind biological psychiatry, stating that the different mental disorders were all biological in nature, evolved into a new concept of "nerves" and psychiatry became a rough approximation of neurology and neuropsychiatry. However, Kraepelin was criticized for considering schizophrenia as a biological illness in the absence of any detectable histologic or anatomic abnormalities. While Kraepelin tried to find organic causes of mental illness, he adopted many theses of positivist medicine, but he favoured the precision of nosological classification over the indefiniteness of etiological causation as his basic mode of psychiatric explanation.

Following Sigmund Freud's death, ideas stemming from psychoanalytic theory also began to take root. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices instead of warehoused in asylums. By the 1970s the psychoanalytic school of thought had become marginalized within the field.

Otto Loewi's work led to the identification of the first neurotransmitter, acetylcholine.

Biological psychiatry reemerged during this time. Psychopharmacology became an integral part of psychiatry starting with Otto Loewi's discovery of the neuromodulatory properties of acetylcholine; thus identifying it as the first-known neurotransmitter. Neuroimaging was first utilized as a tool for psychiatry in the 1980s. The discovery of chlorpromazine's effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disease, as did lithium carbonate's ability to stabilize mood highs and lows in bipolar disorder in 1948. Psychotherapy was still utilized, but as a treatment for psychosocial issues. In the 1920s and 1930s, most asylum and academic psychiatrists in Europe believed that manic depressive disorder and schizophrenia were inherited, but in the decades after World War II, the conflation of genetics with Nazi racist ideology thoroughly discredited genetics. Now genetics were once again thought to play a role in mental illness. Molecular biology opened the door for specific genes contributing to mental disorders to be identified.

Transinstitutionalization and the aftermath

Asylums: Essays on the Social Situation of Mental Patients and Other Inmates is a 1961 book by sociologist Erving Goffman. The book is one of the first sociological examinations of the social situation of mental patients, the hospital. Based on his participant observation field work, the book details Goffman's theory of the "total institution" and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor," suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them. Asylums was a key text in the development of deinstitutionalization.

In 1963, US president John F. Kennedy introduced legislation delegating the National Institute of Mental Health to administer Community Mental Health Centers for those being discharged from state psychiatric hospitals. Later, though, the Community Mental Health Center's focus was diverted to provide psychotherapy sessions for those suffering from acute but mild mental disorders. Ultimately there were no arrangements made for actively and severely mentally ill patients who were being discharged from hospitals. Some of those suffering from mental disorders drifted into homelessness or ended up in prisons and jails. Studies found that 33% of the homeless population and 14% of inmates in prisons and jails were already diagnosed with a mental illness.

In 1973, psychologist David Rosenhan published the Rosenhan experiment, a study with results that led to questions about the validity of psychiatric diagnoses. Critics such as Robert Spitzer placed doubt on the validity and credibility of the study, but did concede that the consistency of psychiatric diagnoses needed improvement.

Psychiatry, like most medical specialties has a continuing, significant need for research into its diseases, classifications and treatments. Psychiatry adopts biology's fundamental belief that disease and health are different elements of an individual's adaptation to an environment. But psychiatry also recognizes that the environment of the human species is complex and includes physical, cultural, and interpersonal elements. In addition to external factors, the human brain must contain and organize an individual's hopes, fears, desires, fantasies and feelings. Psychiatry's difficult task is to bridge the understanding of these factors so that they can be studied both clinically and physiologically.

Controversy

Mental illness myth

Since the 1960s there have been many challenges to the concept of mental illness itself. Thomas Szasz wrote The Myth of Mental Illness (1960) which said that mental illnesses are not real in the sense that cancers are real. Except for a few identifiable brain diseases, such as Alzheimer’s disease, there are "neither biological or chemical tests nor biopsy or necropsy findings" for verifying or falsifying psychiatric diagnoses. There are no objective methods for detecting the presence or absence of mental disease. Szasz argued that mental illness was a myth used to disguise moral conflicts. He has said "serious persons ought not to take psychiatry seriously -- except as a threat to reason, responsibility and liberty".

Sociologists such as Erving Goffman and Thomas Scheff said that mental illness was merely another example of how society labels and controls non-conformists; behavioural psychologists challenged psychiatry's fundamental reliance on unobservable phenomena; and gay rights activists criticised the APA's listing of homosexuality as a mental disorder. A widely-publicised study by Rosenhan in Science was viewed as an attack on the efficacy of psychiatric diagnosis.

These critiques targeted the heart of psychiatry:

They suggested that psychiatry's core concepts were myths, that psychiatry's relationship to medical science had only historical connections, that psychiatry was more aptly characterised as a vast system of coercive social management, and that its paradigmatic practice methods (the talking cure and psychiatric confinement) were ineffective or worse.

Medicalization of normality

For many years, marginalized psychiatrists (such as Peter Breggin, Paula Caplan, Thomas Szasz) and outside critics (such as Stuart A. Kirk) have "been accusing psychiatry of engaging in the systematic medicalization of normality". More recently these concerns have come from insiders who have worked for and promoted the APA (e.g., Robert Spitzer, Allen Frances). In 2013, Allen Frances said that "psychiatric diagnosis still relies exclusively on fallible subjective judgments rather than objective biological tests".

Medicalization of deviance

See also: Medicalization

The concept of medicalization is created by sociologists and used for explaining how medical knowledge is applied to a series of behaviors, over which medicine exerts control, although those behaviors are not self-evidently medical or biological. According to Kittrie, a number of phenomena considered "deviant", such as alcoholism, drug addiction and mental illness, were originally considered as moral, then legal, and now medical problems. As a result of these perceptions, peculiar deviants were subjected to moral, then legal, and now medical modes of social control. Similarly, Conrad and Schneider concluded their review of the medicalization of deviance by supposing that three major paradigms may be identified that have reigned over deviance designations in different historical periods: deviance as sin; deviance as crime; and deviance as sickness. According to Franco Basaglia and his followers, whose approach pointed out the role of psychiatric institutions in the control and medicalization of deviant behaviors and social problems, psychiatry is used as the provider of scientific support for social control to the existing establishment, and the ensuing standards of deviance and normality brought about repressive views of discrete social groups. As scholars have long argued, governmental and medical institutions code menaces to authority as mental diseases during political disturbances.

Political abuse

See also: Political abuse of psychiatry and Political abuse of psychiatry in the Soviet Union

In some instances psychiatrists have been involved in the suppression of individual rights by states wherein the definitions of mental disease had been expanded to include political disobedience. Nowadays, in many countries, political prisoners are sometimes confined to mental institutions and abused therein. Psychiatry possesses a built-in capacity for abuse which is greater than in other areas of medicine. The diagnosis of mental disease can serve as proxy for the designation of social dissidents, allowing the state to hold persons against their will and to insist upon therapies that work in favour of ideological conformity and in the broader interests of society. In a monolithic state, psychiatry can be used to bypass standard legal procedures for establishing guilt or innocence and allow political incarceration without the ordinary odium attaching to such political trials. In Nazi Germany in the 1940s, the 'duty to care' was violated on an enormous scale: A reported 300,000 individuals were sterilized and 100,000 killed in Germany alone, as were many thousands further afield, mainly in eastern Europe. From the 1960s up to 1986, political abuse of psychiatry was reported to be systematic in the Soviet Union, and to surface on occasion in other Eastern European countries such as Romania, Hungary, Czechoslovakia, and Yugoslavia. A "mental health genocide" reminiscent of the Nazi aberrations has been located in the history of South African oppression during the apartheid era. A continued misappropriation of the discipline was subsequently attributed to the People's Republic of China.

Electroconvulsive therapy

Electroconvulsive therapy (ECT) was one treatment that the anti-psychiatry movement wanted eliminated. They say that ECT damages the brain and has been used as a tool for discipline. Sometimes ECT has been used as punishment or as a threat and there have been isolated incidents where the use of ECT was threatened to keep the patients "in line".

A meta-analysis done in 2003 concluded that ECT is "an effective short-term treatment for depression, and is probably more effective than drug therapy."

In 2010, John Read and Richard Bentall co-authored a literature review on "The effectiveness of electroconvulsive therapy". It examined placebo-controlled studies and concluded ECT had minimal benefits for people with depression and schizophrenia. The authors said "given the strong evidence of persistent and, for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified".

Other studies say that ECT is an effective tool for certain illnesses at certain stages, and can save lives. ECT is currently performed under general anaesthetic in a medically supervised environment. The most common side effects include headache, muscle soreness, confusion, and temporary loss of recent memory.

Deinstitutionalisation

The prevalence of psychiatric medication helped initiate deinstitutionalization, the process of discharging patients from psychiatric hospitals to the community. The pressure from the anti-psychiatry movements and the ideology of community treatment from the medical arena helped sustain deinstitutionalization. Thirty-three years after deinstitutionalization started in the United States, only 19% of the patients in state hospitals remained. Mental health professionals envisioned a process wherein patients would be discharged into communities where they could participate in a normal life while living in a therapeutic atmosphere. Psychiatrists were criticized, however, for failing to develop community-based support and treatment. Community-based facilities were not available because of the political infighting between in-patient and community-based social services, and an unwillingness by social services to dispense funding to provide adequately for patients to be discharged into community-based facilities.

Pharmaceutical industry ties

Psychiatry has greatly benefitted by advances in pharmacotherapy. However, the close relationship between those prescribing psychiatric medication and pharmaceutical companies, and the risk of a conflict of interest, is also a source of concern. The costs of developing new drugs are immense, and it is not surprising that the marketing of these drugs is ruthless. For example, pharmaceutical company funds have contributed more than $1.7 million to the annual conference of the American Psychiatric Association. This marketing by the pharmaceutical industry has a profound influence on practicing psychiatrists, which has an impact on prescription. Child psychiatry is one of the area's in which prescription has grown massively. In the past, it was rare, but nowadays child psychiatrists on a regular basis prescribe psychotropic drugs for children, for instance ritalin.

Several prominent academic psychiatrists have refused to disclose financial conflicts of interest, which further undermines public trust in psychiatry. Charles Grassley led a 2008 Congressional Investigation which found that well-known university psychiatrists (such as Joseph Biederman, Charles Nemeroff, and Alan Schatzberg), who had promoted psychoactive drugs, had violated federal and university regulations by secretly receiving large sums of money from the pharmaceutical companies which made the drugs.

In an effort to reduce the potential for hidden conflicts of interest between researchers and pharmaceutical companies, the US Government issued a mandate in 2012 requiring that drug manufacturers receiving funds under the Medicare and Medicaid programs collect data, and make public, all gifts to doctors and hospitals.

Prisoner experimentation

Main article: Experimentation on prisoners

Prisoners in psychiatric hospitals have been the subjects of experiments involving new medications. Vladimir Khailo of the USSR was an individual exposed to such treatment in the 1980s. However, the involuntary treatment of prisoners by use of psychiatric drugs is not limited to Khailo. In July 2012, reporters learned that "mind altering drugs" have also been injected into prisoners at Guantanamo Bay.

Anti-psychiatry

Main article: Anti-psychiatry

Vienna's Narrenturm — German for "fools' tower" — was one of the earliest buildings specifically designed as a "madhouse". It was built in 1784.

Controversy has often surrounded psychiatry, and the anti-psychiatry message is that psychiatric treatments are ultimately more damaging than helpful to patients. Psychiatry is often thought to be a benign medical practice, but at times is seen by some as a coercive instrument of oppression. Psychiatry is seen to involve an unequal power relationship between doctor and patient, and a highly subjective diagnostic process, leaving too much room for opinions and interpretations. Every society, including liberal Western society, permits compulsory treatment of mental patients. The World Health Organization (WHO) recognizes that "poor quality services and human rights violations in mental health and social care facilities are still an everyday occurrence in many places", but has only recently taken the first steps to improve the situation globally.

Psychiatry's history involves what some view as dangerous treatments. Electroconvulsive therapy was one of these, which was used widely between the 1930s and 1960s and is still in use today. A brain surgery called lobotomy was another practice that was ultimately seen as too invasive and brutal. In the US, between 1939 and 1951, over 50,000 lobotomy operations were performed in mental hospitals. Valium and other sedatives were over-prescribed, which led to an epidemic of dependence. There was also concern about the significant increase in prescribing psychiatric drugs for children.

Three authors came to personify the movement against psychiatry, and two of these were practicising psychiatrists. The most influential of these was R.D. Laing who wrote a series of best-selling books, including The Divided Self. Thomas Szasz rose to fame with his book The Myth of Mental Illness. Michael Foucault challenged the very basis of psychiatric practice and cast it as repressive and controlling. The term "anti-psychiatry" was coined by David Cooper in 1967.

Divergence within psychiatry which generated the anti-psychiatry movement in the 1960s and 1970s, is still present. Freedom versus coercion, mind versus brain, nature versus nurture, and the right to be different, remain contemporary issues.

Psychiatric survivors movement

See also: Outline of the psychiatric survivors movement

The psychiatric survivors movement arose out of the civil rights ferment of the late 1960s and early 1970s and the personal histories of psychiatric abuse experienced by some ex-patients rather than the intradisciplinary discourse of antipsychiatry. The key text in the intellectual development of the survivor movement, at least in the USA, was Judi Chamberlin's 1978 text, On Our Own: Patient Controlled Alternatives to the Mental Health System. Chamberlin was an ex-patient and co-founder of the Mental Patients' Liberation Front. Coalescing around the ex-patient newsletter Dendron, in late 1988 leaders from several of the main national and grassroots psychiatric survivor groups felt that an independent, human rights coalition focused on problems in the mental health system was needed. That year the Support Coalition International (SCI) was formed. SCI's first public action was to stage a counter-conference and protest in New York City, in May, 1990, at the same time as (and directly outside of) the American Psychiatric Association's annual meeting. In 2005 the SCI changed its name to Mind Freedom International with David W. Oaks as its director.

See also

• Biopsychiatry controversy
• Telepsychiatry
• Bullying in psychiatry
• Psychiatry organizations
• List of psychiatry journals

References

Notes

Cited texts

• Gask, L. (2004). A Short Introduction to Psychiatry. London: SAGE Publications Ltd., p. 113 ISBN 978-0-7619-7138-2
• Guze, S.B. (1992). Why Psychiatry Is a Branch of Medicine. New York: Oxford University Press, p. 4. ISBN 978-0-19-507420-8
• Leigh, H. (1983). Psychiatry in the practice of medicine. Menlo Park: Addison-Wesley Publishing Company. ISBN 978-0-201-05456-9
• Lyness, J.M. (1997). Psychiatric Pearls. Philadelphia: F.A. Davis Company, p. 3. ISBN 978-0-8036-0280-9
• Shorter, E. (1997). A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons, Inc. ISBN 978-0-471-24531-5

Further reading

• Berrios G E, Porter R (1995) The History of Clinical Psychiatry. London, Athlone Press
• Berrios G E (1996) History of Mental symptoms. The History of Descriptive Psychopathology since the 19th century. Cambridge, Cambridge University Press
• Ford-Martin, Paula Anne Gale (2002), "Psychosis" Gale Encyclopedia of Medicine, Farmington Hills, Michigan
• Hirschfeld et al. (2003). "Perceptions and impact of bipolar disorder: how far have we really come?". J. Clin. Psychiatry 64 (2): 161–174. doi:10.4088/JCP.v64n0209. PMID 12633125. 
• McGorry PD, Mihalopoulos C, Henry L et al. (1995). "Spurious precision: procedural validity of diagnostic assessment in psychiatric disorders". American Journal of Psychiatry 152 (2): 220–223. PMID 7840355. 
• MedFriendly.com, Psychologist, Viewed 20 September 2006
• Moncrieff J, Cohen D (2005). "Rethinking models of psychotropic drug action". Psychotherapy & Psychosomatics 74 (3): 145–153. doi:10.1159/000083999. 
• Burke, C. (February 2000). "Psychiatry: a "value-free" science?". Linacre Quarterly 67/1: 59–88. 
• National Association of Cognitive-Behavioral Therapists, What is Cognitive-Behavioral Therapy?, Viewed 20 September 2006
• van Os J, Gilvarry C, Bale R et al. (1999) A comparison of the utility of dimensional and categorical representations of psychosis. Psychological Medicine 29 (3) 595-606
• Walker, Evelyn, and Perry Deane Young (1986). A Killing Cure. New York: H. Holt and Co. xiv, 338 p. N.B.: Explanatory subtitle on book's dust cover: One Woman's True Account of Sexual and Drug Abuse and Near Death at the Hands of Her Psychiatrist. Without ISBN
• Williams J.B., Gibbon M., First M., Spitzer R., Davies M., Borus J., Howes M., Kane J., Pope H. (1992). "The structured clinical interview for DSM-III-R (SCID) II: Multi-site test-retest reliability". Archives of General Psychiatry 49 (8): 630–636. doi:10.1001/archpsyc.1992.01820080038006. PMID 1637253. 
• Hiruta, Genshiro. (edited by Dr. Allan Beveridge) "Japanese psychiatry in the Edo period (1600-1868)." History of Psychiatry, Vol. 13, No. 50, 131-151 (2002).

External links

• Psychiatry Online
• New York University Psychiatry Video Lectures

UpToDate Contents

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• 1. 他の病状に影響を与える心理的要因：臨床的特徴、評価、および診断psychological factors affecting other medical conditions clinical features assessment and diagnosis [show details]
  …for patients who are psychologically distressed, compared with patients with the same medical disorders without psychological distress . Several studies have documented that psychiatric problems in medical …
• 2. 癌患者に生じる精神障害の臨床的特徴と診断：概要clinical features and diagnosis of psychiatric disorders in patients with cancer overview [show details]
  … developed psychiatric disorders, compared with patients who were free of psychiatric disorders (hazard ratio 1.7, 95% CI 1.2-2.3). This topic reviews the clinical features and diagnosis of psychiatric disorders …
• 3. 重度の精神障害者への包括型地域生活支援プログラムassertive community treatment for patients with severe mental illness [show details]
  … In patients with severe mental illness and a history of frequent or prolonged psychiatric hospitalizations, ACT has been shown to be efficacious in reducing psychiatric hospitalizations, improving …
• 4. 小児や青年の自殺念慮と自殺行動：評価およびマネージメントsuicidal ideation and behavior in children and adolescents evaluation and management [show details]
  …Treatment options include hospitalization, medication for underlying psychiatric disorders such as major depression, more frequent psychological intervention, mobilizing supports, and access to crisis intervention …
• 5. 重度の精神疾患患者に見られる心血管疾患の発症リスクのマネージメントapproach to managing increased risk for cardiovascular disease in patients with severe mental illness [show details]
  … Lifespans in people with severe mental illness (SMI) are reduced by 15 to 25 years compared with the general population . Cardiovascular disease (CVD) represents the most common natural cause of this …

English Journal

• Can individuals with schizophrenia be instructed to deliberately feign memory deficits?

• Raffard S1, Capdevielle D, Boulenger JP, Gely-Nargeot MC, Bayard S.
• Cognitive neuropsychiatry.Cogn Neuropsychiatry.2014 Sep;19(5):414-26. doi: 10.1080/13546805.2014.896251. Epub 2014 Mar 21.
• Introduction. Neuropsychological tests are increasingly applied in research studies and clinical practice in psychiatry. In this context, the detection of poor effort is crucial to adequately interpret data. We measured schizophrenia patients' performance on a memory test designed to detect excessiv
• PMID 24650282

• Amelioration of psychiatric symptoms through exposure to music individually adapted to brain rhythm disorders - a randomised clinical trial on the basis of fundamental research.

• Müller W1, Haffelder G, Schlotmann A, Schaefers AT, Teuchert-Noodt G.
• Cognitive neuropsychiatry.Cogn Neuropsychiatry.2014 Sep;19(5):399-413. doi: 10.1080/13546805.2013.879054. Epub 2014 Jan 24.
• Introduction. This pilot study examined, whether long-term exposure of psychiatric patients to music that was individually adapted to brain rhythm disorders associated with psychoticism could act to ameliorate psychiatric symptoms. Methods. A total of 50 patients with various psychiatric diagnoses w
• PMID 24460405

• Attention-deficit/hyperactivity disorder subtypes and substance use and use disorders in NESARC.

• De Alwis D1, Lynskey MT2, Reiersen AM1, Agrawal A3.
• Addictive behaviors.Addict Behav.2014 Aug;39(8):1278-85. doi: 10.1016/j.addbeh.2014.04.003. Epub 2014 Apr 13.
• BACKGROUND: Attention-deficit/hyperactivity disorder (ADHD) is associated with substance use and substance use disorders (SUD). However, relatively little is known about the relationship between DSM-IV ADHD subtypes and substance use or DSM-IV abuse/dependence in epidemiological samples.METHODS: Dat
• PMID 24821471

Japanese Journal

• メタボローム解析による精神疾患バイオマーカーの探索 (AYUMI メタボローム解析の進歩)

• 佐藤 基
• 医学のあゆみ 249(4), 293-297, 2014-04-26
• NAID 40020046402

• 著明な貧血と血小板減少と末梢血の異常細胞で発見された転移性乳癌の１例

• 太田 誠介,笠原 明宣,水野 翔馬,深津 遥香,木下 修,野口 敏生,岸本 信康,松村 正
• 岡山医学会雑誌 126(1), 31-34, 2014-04-01
• … We report the case of a 60-year-old woman who had been treated for one year at a psychiatric hospital for suspected schizophrenia, and was referred to our hospital on March 23, 2011 for consultation regarding complete blood count abnormalities: hemoglobin, 4.8g/㎗ ; …
• NAID 120005425652

• 私のカルテから SSRIが奏効した月経前不快気分障害(PMDD)を合併した精神障害について

• 伊藤 陽,熊倉 恵子,清水 敬三 [他]
• 精神医学 56(4), 323-326, 2014-04
• NAID 40020046638

Related Links

• Enthralled in Essence

2010年3月17日 ... う29a PSYCHIATRICになります。 カットがアリスだったので多分アリス本かな。 魔理沙 本になっちゃったらごめんなさい。 あ、普通に男性向けの本（まあエロ本ですなｗ）の 予定なので良い子はスルーしましょう。 あと紅月ノ宴に申し込みしたい ...

Related Pictures

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★リンクテーブル★

リンク元	「100Cases 34」「失神」「psychiatry」「精神医学」「精神医学的」
拡張検索	「neuropsychiatric」「psychiatrically」
関連記事	「psychiatrics」

「100Cases 34」

　　[★]

☆case34　てんかん発作

■症例

23歳　アフリカ-カリブ系　女性　銀行の店員

主訴：てんかん発作

現病歴：強直間代発作を2回起こしたところを母親が目撃していた。娘の行動は次第におかしくなり、また娘は自分のことを話している声が聞こえていた(幻聴)。最近、頭痛を訴えていた。体重が減少し、脱毛があった。盗汗と主に足と手の小関節に及ぶflitting 関節痛を訴えていた。服用薬なし。タバコ1日5-10本、アルコール10 unit/week(缶ビール(350ml)6本弱)

既往歴：特記なし(medical or psychiatric history)

家族歴：

生活歴：

・身体診断

意識：眠そうだが痛みに反応。頚部硬直：なし。頭髪：薄く斑状。体温38.5℃。リンパ節：たくさんの部位で触知。

心拍：104/分、整。血圧：164/102 mmHg。心血管系、呼吸器系、腹部：異常なし。

神経所見：focal anormalityなし(局所性異常)。乳頭浮腫：認めず。

・検査

(血液生化学)

上昇：erythrocyte sedimentation rate、urea、creatinine

低下：hemoglobin、white cell count、platelet

正常：mean corpuscular volume、sodium、potassium、glucose

(腰椎穿刺)

上昇：leukocytes、CSF protein

正常：CSF glucose

(尿検査)

蛋白：＋＋＋。血尿：＋＋＋。赤血球：＋＋。赤血球円柱：あり。

(その他)

胸部X線：異常なし。ECG：洞性頻脈。頭部CT：正常。CSFグラム染色：陰性(光顕レベルで細菌なし)

■glossary

fall out　(毛髪などが)抜ける

night sweat 盗汗、寝汗

tonic-clonic generalized seizure 全般性強直間代発作

flit　vi (鳥・蝶など)すいすい/ひらひら飛ぶ、飛び回る、飛翔する。(人が)軽やかに通る、行き交う。(時が)(飛ぶように)すぎる。(幻想など)去来する、よぎる、(表情が)かすめる

drowsy　adj. 眠い。眠そうな。眠気を誘う。ものうい。眠ったような

stiffness　n. 堅いこと、堅ぐるしさ、がんこさ

delirium tremens 振戦譫妄

hypertensive encephalopathy 高血圧性脳症

alopecia　脱毛症

African-Caribbean アフリカ-カリブ系

fit n.　(病気の)発作。引きつけ、痙攣。(感情の)激発、一時的興奮、気まぐれ

chorea n. 舞踏病

recreational drug 耽溺性があり乱用される脱法薬物

urgent adj. (物・事が)急を要する、緊急の、背拍質(pressing)。(～を)緊急に必要とする(in)。(S is ～ (with O1) for [in] O2)(人が)(O1(人)に)O2(物・事)をしつこく求める。(人に/～するように)催促する(for/to do)。(要求などが)執拗な。

□てんかん発作

・新規発生したてんかん発作の原因(ICU.805-806)

・薬物中毒(テオフィリンなど)

・薬物からの離脱(アルコールなど)

・感染症(髄膜炎、膿瘍など)

・頭部外傷

・虚血障害(虚血あるいはびまん性)

・占拠性病変(腫瘍あるいは血腫)

・代謝性障害(肝性脳症、尿毒症性脳症、敗血症、低血糖、低ナトリウム血症、低カルシウム血症など)

・合併症(ICU.805-806)

・全身性てんかん発作の場合：高血圧、乳酸アシドーシス、高体温、呼吸障害、誤嚥、肺水腫、横紋筋融解、自傷、不可逆性の神経学的障害(30分間以上てんかん発作が持続した場合)

■可能性の高い診断

　全身性エリテマトーデス systemic lupus erythematosus(SLE)

■鑑別診断のポイント

　自己免疫疾患は多彩な症状を示す。そのため、個々の症状に着目して鑑別診断をあげるのではなく、症状や検査値の異常を総合的に見て判断する必要がある。

■解答

　(第1パラグラフ)SLEの病態

精神症状：(SLEは脳で血管炎を呈することで生じる)うつ(depression)、統合失調症様の精神病、痙攣(fits)、舞踏病(chorea)、脳梗塞/脊髄梗塞

脳脊髄液：白血球増多(leukopenia)、蛋白増加

血液：自己免疫性溶血貧血(Coombs'-positive hemolytic anemia)がありうる。白血球減少と血小板減少症は普通にみられる。

腎症状：ループス腎炎は普通に見られ、顕微鏡的血尿・タンパク尿、ネフローゼ、あるいは腎不全が現れるかもしれない。

関節症状：変形を伴わない関節痛(PIP関節(近位指節間関節)、MP関節(中手指節関節)、手関節)

　(第2パラグラフ)SLEの確定診断のための検査・治療

　・すぐにすべきことは降圧薬、抗痙攣薬の投与

　・確定診断のために次の検査を行っていく(もっとも、症例の提示された所見で(日本の？)SLEの診断基準を満たすけど)

　　・検疫血清検査：抗DNA抗体、C3、C4

　　・腎生検：ループス腎炎の程度を把握

　・治療：活動性の感染がないことを確認　←　薬物療法ではステロイドや免疫抑制薬を使うため

　　・ステロイド静脈内投与、あるいはシクロホスファミドなどの細胞毒性薬(cytotoxic agents)の投与

　　・重症、治療抵抗性だったら血漿交換を行う。

■鑑別診断　頭痛/精神病的様態(psychiatric features)/痙攣

・髄膜炎、脳炎

・レクリエーショナルドラッグの中毒(例えばコカイン)

・脳腫瘍

・急性のアルコール禁断症状：振戦譫妄

・高血圧脳症

■KEYPOINT

・SLEは特に若いアフリカ系-カリブ系に普通に一般的

・SLEでは主に神経症状と精神症状をを伴って現れることがある

・白血球低下と血小板の低下はしばしばSLEを示唆する

□tonic-clonic seizure 強直間代発作

　意識消失とともに全身の随意筋に強直痙攣が生じ(強直痙攣期tonic convulsion)、次いで全身の筋の強直と弛緩とが律動的に繰り返される時期(間代痙攣期clonic convulsion)を経て、発作後もうろう状態を呈する一連の発作。

□350ml アルコール5%

350x0.05/10=1.75 unit

□細胞毒性薬

　免疫抑制薬や抗腫瘍薬として用いられる。

antimetabolites

アザチオプリン azathioprine

メトトレキセート methotrexate

ミコフェノール酸 mycophenolic acid, ミコフェノール酸モフェチル mycophenolate mofetil

レフルノミド leflunomide

alkylating agents

シクロホスファミド cyclophosphamide

「失神」

　　[★]

英

syncope, faint

関

一過性意識障害

定義

• 1. 発作的に起こる脳の血流低下による一過性の意識消失
• 2.

• 一過性の意識消失の結果、姿勢が保持できなくなり、かつ自然に、また完全に意識の回復が見られること(失神の診断・治療ガイドライン)
• 発症は比較的速やかであり、意識は多くの場合速やかに回復する。「意識障害」のうちで、特異な臨床像を持った1 つの症候である。(失神の診断・治療ガイドライン)

• 3. 元来、一過性の全脳虚血による一時的な意識消失で、かつ数秒から数分で意識を回復する物を指していたが、現在ではあいまい、より広義となっている。例えば、てんかん発作、低血糖、過換気、一過性脳虚血発作を含んでいる。(IMD.241)　←　ホント？誰かが誤用しつづけているだけなんちゃうか？

症状

• 眼前暗黒感、めまい感、悪心などの前駆症状に引き続き、顔面が蒼白となり、ついに意識が消失

意識消失までの時間経過と症状

• 脳への血流停止が5-10秒程度で失神、10秒前後で筋弛緩・尿失禁、15秒以上で痙攣を生じる、らしい(参考2)　　←　根拠となる文献を調査中

原因

救急での覚え方

• SYNCOPE

• situational
• vasovagal
• neurogenic
• cardiac
• orthostatic hypotension
• psychiatric
• everything else

QB.C345

• 心臓：不整脈(→Adams-Stokes症候群)、大動脈弁狭窄症、閉塞性肥大型心筋症、心筋梗塞、心臓腫瘍、原発性肺高血圧症
• 心外：

• 起立性低血圧
• 局所的脳血流低下：subclavian steal症候群
• 血管迷走神経反射
• 循環血液量の一過性の低下：胸腔内圧の上昇(排尿、咳嗽)
• 過換気症候群：過換気による動脈血炭酸ガス分圧の低下　→　脳血管収縮　→　脳血流が減少

研修医当直御法度 症例帳 p.36

		(%)
1	血管迷走神経性失神	39.5
2	体位性低血圧による失神	7.6
3	心血管性失神	4.1
4	目撃者なしの痙攣	8.8
5	低血糖	1.8
6	ヒステリー	0.6
7	原因不明	37.6

参考

• 1. 失神の診断・治療ガイドライン(2007)

http://www.j-circ.or.jp/guideline/pdf/JCS2007_inoue_h.pdf

• 2. 失神　国立療養所西札幌病院循環器科 別役徹生

http://www.aurora-net.or.jp/life/heart/saizensen/86/index.html

「psychiatry」

　　[★]

• 精神医学、精神科

関

psychiatric、psychiatrics、psychiatrist

同

精神医学

　 　

「精神医学」

　　[★]

英

psychiatry、psychiatrics、psychiatric

関

精神医学者、精神医学的、精神科

「精神医学的」

　　[★]

英

psychiatric、psychiatrically

関

精神医学

「neuropsychiatric」

　　[★]

• 神経精神医学的な、精神神経性の、精神神経の

関

neuropsychiatrically

　

「psychiatrically」

　　[★]

• 精神医学的に

関

psychiatric

「psychiatrics」

　　[★]

• 精神医学

関

psychiatric、psychiatry