精神経誌（2010）112 巻 2 号

166

第回日本精神神経学会総会

シ ⃞ン ⃞ポ ⃞ジ ⃞ウ ⃞ム⃞

Hoped Horizon of Psychiatry
Ravi Gupta（Sleep and Headache Care, India）

Chairpersons Sir and dear friends, ﬁrst of

any objective evidence and variability in the

all I would like to convey my thanks to thebehavior. Then a number of so called objective

Japanese Society of Psychiatry and Neurology

tests were developed to analyze the humanand Japanese Young Psychiatristʼs Organiza-behavior e.g., Thematic Apperception Test,tion for inviting us to this symposium. I would

Inkblot test etc. No matter how rigourously

also like to thank the organizers for their

the assessment criteria were laid for them,still

hospitality and making our stay comfortable.

these tests were not free of fallacies and many

With the permission of chair, may I start mya times provided conﬂicting responses in thepresentation ?

subjects with same category of symptoms.

When we talk about the future, there is aWith these techniques in hand, psychia-need to look in the past and analyze the present.

trists started their practice. The patient wasThe future stems from the present and present

provided with a couch during free association

is based upon the past achievements. So weand psychotherapies and soon it had almost

will make an attempt to see and analyze what

become an emblem for the psychiatrists. Dur-

we have achieved so far; right from the incep-

ing that time, psychiatrists used to spend longtion of psychiatry as a medical branch.

hours with their patients on these couches, lis-

The history of modern psychiatry dates

tening to their patients and trying to disentan-

back to emergence of great thinkers like Sig-

gle their patientʼs unconscious wishes.

mand Freud, Jean Piaget etc. They all werecouches were not only the place for the diagno-

The

medical persons（physicians）, but at the same

sis, but also for the management of illnesses.

time they were very keen observers and ana-

The whole process was divided into a number

lysts of behavior. Their observations resultedof sessions spanning over months.

in development of various theories to explain

While the couches were the place for thehuman behavior. No doubt that the theories“neurotic” or non‑violent patients, psychotic

proposed by them were purely psychological,

patients were detained in the asylums to protect

but still, even after nearly hundred years they

the society. Along with the detention, suchare useful guides in therapeutic management ofpatients were subjected to the electroconvulsive

many psychiatric disorders. However, these

therapy become eﬀective medicines were nottheories were very ﬂuid and they were antago-

available at that time. This had given psychia-

nistic at a number of points owing to absence oftrists a new name, the shock doctor. Even

シンポジウム：The Hoped Horizon of Psychiatry

167

though it was an eﬀective treatment, yet it

the fact that use of newer psychotropic drug

appeared brutal as the modiﬁed ECT was not

resulted in better control of symptoms,

available and patient used to convulse for a

produced lesser adverse eﬀects,and the number

very long time. This had contributed a lot toof wandering lunatics decreased, and that they

the stigmatization of psychiatry, the psychia-

decreased the burden onto asylums and im-trists and even psychiatric patients.

proved qualityof life of patients and their care‑

Finally, in 1952 a molecule was introduced

givers.

in the market.Chlorpromazine which appeared

I think,as psychiatrists,we must work forvery eﬀective in management of violent pa-

the wholesome improvement of psychiatry,thattients and psychiatry for the ﬁrst time tried toincludes academic, clinical, social development

portray itself similar to any other medical

as well as progress in the ﬁeld of research. Thisbranch. This was a turning point in the history

is a diﬃcult but achievable task, provided weof psychiatry,where the focus was shifted from

tryto understand the reasons for stigma,accept

the psychological basis of illnesses to the neur-

the facts and work hard to change the picture.

otransmitters. The biological, and more pre-In my opinion, a number of diﬀerent factors

cise to say, neurobiological studies started toassociated with psychiatric illnesses contributesolve the mystery of neurotransmitters im-to their stigmatization.

plicated in psychiatric illnesses. As our under-nature of symptoms which are purely behavior-

standing for neurotransmitters improved andal;（ii）diagnostic techniques applied which isby serendipity too, a plethora of new phar-

unfortunately purely phenomenological;（iii）

macological molecules were introduced in thein a good number of cases, permanent cure ismarket. If memory serves me right approxi-

not available;（iv）existence of lunacy acts ormately forty new molecules appeared in themental health acts in many countries;（v）fail-market in the past ten years. These drugs were

ure to develop sub‑specialties;（vi）derogatory

claimed to be more selective, more eﬀective

media portrayal of psychiatric patients andand had lesser side eﬀects than their predeces-psychiatrists and lastly,（vii）issues related tosors. Therefore,the psychiatric illnesses could

research. Now we will discuss each of thesebe controlled in a better manner; their progno-

issues one by one.

sis improved and the development so far helped
in de‑stigmatization of psychiatry.

These include‑（i）No doubt, symptoms are primarily behavioral in psychiatric illnesses, but these are

But wait a minute, stop and think, is thenot the only illnesses which manifest as change

picture that we are seeing real or is it just ain behavior. If we look impartially, almost all

mirage? Have we reallysucceeded in establish-

medical illnesses produce behavioral symptoms,

ing the psychiatry as a truly medical branch ?

and a number of so called “medical disorder”

Well,if you ask for myopinion,I donʼt think we

produce only behavioral symptoms‑ e.g., delir-are. Psychiatry is still stigmatized and a num-ium, Alzheimerʼs dementia, Dementia with

ber of people criticize the existence of psychia-

Lewy Bodies, Irritable Bowel Syndrome, Nut-try as a medical branch. Dr Thomas Szaz,whocracker esophagus etc. Besides these illnesses,

himself is a professor in psychiatry,had argued

all painful conditions induce a change in behav-

a lot against psychiatry. This happened despite

ior. However, contrary to the other medical

精神経誌（2010）112 巻 2 号

168

illnesses, psychiatric illnesses usually aﬀect

evidences,and anything that is once declared as

caregivers more as compared to suﬀerers. In

pathological is rarely reclassiﬁed as normaladdition, many of the psychiatric illnesses run

condition variant.

relapsing‑remitting or chronic course,which inThirdly,for a number of psychiatric illnes-

turn increases the burden on the caregivers.

ses, permanent cure is not possible even withThis is an important reason for the stigmatiza-

the rigorous eﬀorts. This is owing to our poortion of psychiatric illnesses.

understanding in the pathophysiology of psychi-

Another reason,which I feel plays a part inatric illnesses and to the fact that environmen-

stigmatization is phenomenological nature oftal factors especially the behavior of surround-the diagnosis of illnesses. This usually gives aing people play an important role in deciding

feeling to the medical fraternity and to thethe course of illness. It is sometimes easy topatients and their caregivers that nothing is

make the patient learn to change their dysfun-

wrong with the body.

A number of otherctional behavior, but it is often a Herculean

medical illnesses e.g., Parkinsonʼ
s Disease,task to request the surrounding persons care‑

Dementia, Epilepsy, Angina, Asthma, Appendi-

givers to change their behavior in favor ofcitis, Fibromyalgia, Chronic fatigue syndrome

patient. This raises a question ; is behavioral

etc are diagnosed based upon clinical picturechange unique to psychiatric illness? Well,myonly and laboratory investigations rarely dem-answer is “No”
. Akin to psychiatric disorders

onstrate any pathology, even than physiciansa number of diﬀerent medical problems require

investigate the disorders and earn the patientʼschange in behavior, e.g., diabetic patients arefaith that illness is purely physical. On thesupposed to increase physical work and have toother hand, we psychiatrists usually refrain

refrain themselves from sweets; cardiac pa-

from ordering the laboratory investigations,tients have to improve physical working andand this gives a feeling that illness is psycholog-

lessen their fat intake and so on ! The list may

ical rather than neurobiological.

be endless! However, in these illnesses, be-To make the situation worse, the diagnos-

havioral change is required at a gross level andtic criteria keeps on changing with every newusually in form of habit‑change, without any

edition of ICD‑10 or DSM ‑IV, without any

need to change the perception and expression ofcontribution from neurobiological studies,emotions. In addition, these illnesses do not

resulting in a doubt towards the existence of

require behavioral change of the surrounding

psychiatric illnesses. This culminates in a situ-persons, making it easy to control the condi-

ation where in one edition of diagnostic criteriation.

a given person is placed in the diseased catego-

Another concern is the chronic or relapsingry and subsequent edition may refer same be-remitting course of psychiatric illnesses. For

havior as “normal”. This ﬂuidity in diagnosis

this, there is a need to educate the people thatposes the diﬃculty in providing a concrete

many of the prevalent medical illnesses run a

ground to psychiatric illnesses. Although, therelapsing‑remitting or chronic course viz.,diagnostic criteria for many non‑psychiatricosteoarthritis, hypertension, coronary artery

illnesses also keep on changing with time, thedisease, Parkinsonʼs Disease, CVA, diabetes,changes are usually supported by objective

hypothyroidism to name a few. Now let usシンポジウム：The Hoped Horizon of Psychiatry

169

think, what can we do to reduce the chronicity

that relatives are against him and wants toin psychiatry?

We, the psychiatrists mustsnatch his property. In such condition,how dounderstand that symptom remission is not the

we decide whether the person is sane or not ?

goal of treatment. Rather, the aim is to bringShould we give him antipsychotics sedatives toout a permanent change in behavior to prevent

control his motor activity? Should we label

relapses.

However, such change cannot be

him with anypsychiatric diagnosis? And above

achieved by pharmacotherapy only and psycho-

all, should we admit detain him in the hospitaltherapy plays an important role in these cir-even for the observation ? Remember, admis-

cumstances. Psychotherapies are time consum-

sion for even few hours can be used as plea

ing but they have a deﬁnite biological basis andagainst him in the court of law by his relatives

work on learning principle. A number of func-to get rid of him. In such a case,he would lose

tional neuroimaging studies have shown that

his share from his property and other assets.

psychotherapies change the functional network

This is just one example how these acts can bein brain. Therefore, I advocate use of thesemisused.

techniques during the treatment.

In my opinion,subjects with HIV infection

There is also a need to spend more energy

or open pulmonary tuberculosis or hepatitis B

in exploring the objective diagnostic techniques

infection are more dangerous to the societyand develop new therapeutic technique whichthan a violent psychiatric patient as many of

can replace the stigmatizing previous therapeu-

them do not have overt symptoms and yet theytic options like physical restrain and electro‑

are infectious. Such a spread of infection may

convulsive therapy. In the past ten years, a

be at times life threatening. Likewise, can we

number of articles proposed the gene therapy

prevent the smoking and alcoholism by any

for psychiatric disorders, although it is yet inact ? Many countries have forbidden smokinginfantile stage. Similarly, trans‑cranial mag-at public places,but it is a well known fact that

netic stimulation is now under investigation forsmokers keep on releasing the carcinogens evena number of psychiatric disorders, and withhours after their last smoke, known as passive

such progress, future appears bright.

smoking.

Similarly, drunken drivers him a

Fourthly, I feel that lunacy acts or mental

number of people every year. Despite such ahealth acts have done harm rather than protect-huge problem, there is no law to control theiring rights of psychiatric patients. A plethora ofmovement in the society and to bind them fornews reports conﬁrm that these acts are often

adequate treatment. I feel this is the right timeused to ruin the psychiatric patients from exer-

to reconsider importance and need of mental

cising their rights.

Consider a hypothetical

health acts in the management of psychiatricsituation : a male of around 50years is brought

patients which provide power to the mental

to the emergencyroom of a psychiatric hospital

health workers to detain the psychiatric pa-

for behaving abnormally and committing vio-tients against their will in certain circum-

lent acts for ten days by his relatives. The man

stances.

is tied with the ropes and he is abusing his

Fifthly, I feel that we ourselves are also

relatives,pleads that he is not insane and trying

responsible for the stigmatization. We do not

to hit them for bringing him there. He also says

talk about the neurobiological or medical basis

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精神経誌（2010）112 巻 2 号

170of psychiatric illnesses and often there is aviolent, destructive and psychiatrists as jokers.

gross discrepancy in explanation of illness andThere is a strong need for invoking the sense ofits treatment. Many of us explain the path-

responsibility in the media persons so that theyogenesis based on（abandoned） psychologicalwork towards de‑stigmatization. Lastly, as I

theories or talk non‑speciﬁcally about thehave already discussed there is a need to in-change in neurotransmitters in brain as thecrease the research,particularly neuro‑biologi-

cause of psychiatric illness. When it comes tocal research in developing countries. An article

treatment, we often prescribe pills and do not

published in British Journal of Psychiatry byuse non‑pharmacological management. This

Saxena throws more light on this issue andcreates a doubt in the patientʼs and care‑giverʼ
sdiscusses the 10 90 divide in the ﬁeld of re-mind regarding psychiatric illnesses and stig-search. The article categorically mentions thematize. Despite so much progress most of theneed of more research in developing countries

psychiatrists feel more comfortable with Schiz-as they（we）contribute approximately 10% toophrenia, M ood disorders or substance abuse

total research despite catering more than 90%

patients. A number of psychiatrists are notof world population. Moreover, a number of

eﬃcient in dealing with dementia, delirium,

articles consider the pharmaco‑genomics andneuropsychiatric illnesses, sleep disorders, pri-suggest that pharmacological research data

mary headaches, eating disorders and neuro‑

from developed countries cannot be applied todevelopmental disorders. Same is the case withother countries.

sub‑specialties like child psychiatry, geriatricIn the end,I would like to state that psychi-psychiatry,neuropsychiatry,CL psychiatry etc.

atry as a specialty has bright future and will be

Next, the media is also responsible forof utmost importance, providing we try to re-stigmatization. M edia portrays a negative or

move stigma attached with it, work hard on

derogatory image of psychiatric patients andnew frontiers and develop the sub‑specialties.

even of psychiatrists. Patients are often posed