Psychologists and psychiatrists have classified psychological disorders intocategories. Classification allows clinicians and researchers to describe disorders,predict outcomes, consider treatments, and encourage research into their etiology.
Insanity
Insanity is not a diagnostic label that psychologists use.Rather, it is a legal term that refers to the inability to takeresponsibility for one’s actions. The law does not consider mostpeople with psychological disorders to be insane. People can use aninsanity defense only if they were unable to distinguish right fromwrong at the time they committed a crime.
The DSM
Psychologists and psychiatrists use a reference book called the Diagnostic and Statistical Manual of Mental Disorders(DSM) to diagnose psychological disorders. TheAmerican Psychiatric Association published the first version of theDSM in 1952. It has been revised several times, and the newestversion is commonly referred to as the DSM-IV.
The DSM-IV uses a multi-axial system of classification,which means that diagnoses are made on several different axes or dimensions. TheDSM has five axes:
- Axis I records thepatient’s primary diagnosis.
- Axis II recordslong-standing personality problems or mental retardation.
- Axis III records anymedical conditions that might affect the patient psychologically.
- Axis IV records anysignificant psychosocial or environmental problems experienced by thepatient.
- Axis V records anassessment of the patient’s level of functioning.
Psychologists and Psychiatrists
People sometimes use the wordspsychologist and psychiatristinterchangeably, but they are not the same.Psychologist is a broad term that refers toanyone with advanced training in psychology who conductspsychological testing, research, or therapy. A psychiatrist has a medical degree andtreats patients with mental and emotional disorders. Apsychiatrist can also prescribe medication.
Criticisms of the DSM
Although the DSM is used worldwide and considered a veryvaluable tool for diagnosing psychological disorders, it has been criticized forseveral reasons:
- Some critics believe it can lead to normal problems of livingbeing turned into “diseases.” For example, a child who displays theinattentive and hyperactive behavior normally seen in young childrencould be diagnosed with attention-deficit/hyperactivity disorder by anoverzealous clinician. In earlier versions of the DSM,homosexuality was listed as a disorder.
- Some critics argue that including relatively minor problems such ascaffeine-induced sleep disorder in the DSM will causepeople to liken these problems to serious disorders such as schizophrenia orbipolar disorder.
- Other critics argue that giving a person a diagnostic label can beharmful because a label can become a self-fulfilling prophecy. A childdiagnosed with attention-deficit/hyperactivity disorder may have difficultyovercoming his problems if he or other people accept the diagnosis as thesole aspect of his personality.
- Some critics point out that the DSM makes the processof diagnosing psychological disorders seem scientific when, in fact,diagnosis is highly subjective.
In general, psychologists view the DSM as a valuable toolthat, like all tools, has the potential for misuse. The DSMcontains many categories of disorders, and the following sections will cover afew of these categories.
Culture and Psychological Disorders
Most of the major disorders listed in theDSM are found worldwide, although culturalfactors often influence the symptoms and course of disorders.Culture-bound disorders, on the other hand, are limited tospecific cultural contexts. They may or may not be linked to DSM diagnostic categories. One example of aculture-bound syndrome described in the DSM is dhat, a condition that occurs in India andis characterized by anxiety, hypochondria, discharge of semen,whitish urine color, weakness, and exhaustion. Similarconditions exist in Sri Lanka and China.
APA’s goal in revising DSM-5 was to thoroughly update the text of the manual to incorporate new research findings that have appeared since DSM-5 was published in 2013. Text changes were proposed by subject matter experts and then reviewed by the DSM-5-TR editors and the DSM Steering Committee. The DSM-5-TR also includes changes to criteria sets generated through the iterative revision process in place that allows mental health professionals to propose evidence-based additions or deletions of diagnostic categories, or changes to existing criteria. In some cases, adjustment to the wording of diagnostic criteria were made because of issues identified during the text revision process. All changes to diagnostic criteria were approved by the DSM Steering Committee and APA Assembly and Board of Trustees.
A psychiatrist is a medical doctor who specializes in the treatment of mental disorders. Because psychiatrists hold a medical degree and are trained in the practice of psychiatry, they are one of the few professionals in the mental health field able to prescribe medications to treat mental health issues. Much like a general practice physician, a psychiatrist may perform physical exams and order diagnostic tests in addition to practicing psychotherapy.
Psychiatrists may work as part of a mental health team, often consulting with primary care physicians, social workers, occupational therapists, and psychiatric nurses.
Psychiatrists will also work with—but should not be confused with—psychologists. Psychologists are not medical doctors and cannot prescribe medications except in New Mexico, Louisiana, Illinois, Iowa, and Idaho.
Moreover, psychiatrists are directed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) issued by the American Psychiatric Association. While psychologists often refer to the DSM-5, they also rely on standardized psychological tests—such as the Minnesota Multiphasic Personality Inventory—to direct care.
Concentrations
According to the Occupational Outlook Handbook issued by the Bureau of Labor Statistics, “psychiatrists are primary mental health physicians.” Among their core responsibilities are the diagnosis and treatment of mental health conditions.
Psychiatrists will use a variety of techniques to determine whether a person’s symptoms are psychiatric, the result of a physical illness, or a combination of both. This requires the psychiatrist to have a strong knowledge of general medicine, psychology, neurology, biology, biochemistry, and pharmacology.
Perhaps more so than any other medical doctor, psychiatrists are skilled in doctor-patient relationships and trained to use psychotherapy and other therapeutic communication techniques to qualitatively diagnose and monitor mental conditions. Treatment may be delivered on an outpatient basis or on an inpatient basis in a psychiatric hospital.
The types of mental disorders are far-ranging. A few of the more well-known types can be broadly characterized as follows:
- Anxiety disorders, including generalized anxiety disorder (GAD), panic disorder (PD), phobias, and social anxiety disorder (SAD)
- Obsessive-compulsive and related disorders, including obsessive compulsive disorder (OCD), trichotillomania, and hoarding disorder
- Eating disorders, including anorexia nervosa (AN), binge eating disorder, and bulimia nervosa (BN)
- Mood disorders, including bipolar disorder (BD), major depressive disorder (MDD), and substance-induced mood disorder (SIMD)
- Personality disorders, including borderline personality disorder (BPD), narcissistic personality disorder (NPD), obsessive-compulsive personality disorder (OCPD), and paranoid personality disorder (PPD)
- Psychotic disorders, including schizophrenia, schizoaffective disorder, and substance-induced psychotic disorder (SIPD)
- Specific learning disorders, including dyscalculia and dyslexia
Procedural Expertise
Psychiatry is situated in a middle ground between psychology (the study of behavior and the mind) and neurology (the study of the brain and nervous system). In practice, a psychiatrist will consider symptoms of mental health conditions in two ways:
- Assessing the impact of a disease, physical trauma, or substance use on a person’s behavior and mental state
- Evaluating symptoms in association with a person’s life history and/or external events or conditions (such as emotional trauma or abuse)
The approach, known as the biopsychosocial model, requires the psychiatrist to use multiple tools to render a diagnosis and dispense the appropriate treatment.
Mental Status Examination
Mental status examinations (MSE) are an important part of the clinical assessment of a psychiatric condition. It is a structured way of observing and evaluating a person’s psychological function from the perspective of attitude, behavior, cognition, judgment, mood, perception, and thought processes.
Depending on the presumed condition, the psychiatrist would use a variety of psychological tests to establish the presence of characteristic symptoms and rate their severity. Based on the results, the psychiatrist would refer to the DSM-5 to see if the symptoms meet the diagnostic criteria for the mental disorder.
Examples include:
- Anxiety tests such as the Beck Anxiety Inventory (BAI) and Liebowitz Social Anxiety Scale (LSAS)
- Depression tests such as the Hamilton Depression Rating Scale (HAM-D) and the Beck Hopelessness Scale
- Eating disorder tests such as the Minnesota Eating Behavior Survey (MEBS) and the Eating Disorder Examination (EDE)
- Mood disorder tests such as the My Mood Monitor Screen and the Altman Self-Rating Mania Scale (ASRM)
- Personality disorder tests such as the Shedler-Westen Assessment Procedure (SWAP-200) and the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD)
- Psychosis tests such as the Scale for the Assessment of Negative Symptoms (SANS) and the Scale for the Assessment of Positive Symptoms (SAPS)
Biomedical Diagnosis
As with many medical conditions, the diagnosis of mental illness will often involve a process of elimination to explore and exclude all possible causes. Known as a differential diagnosis, the process would involve a combination of MSE and biomedical tests to differentiate the presumed cause from others with similar symptoms.
The biomedical tools used by a psychiatrist may include:
- A physical examination
- Brain imaging studies such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) to check for tumors, hemorrhage, or lesions
- Electroencephalogram (EEG) to identify irregularities in brain electrical activity, including epilepsy, a head injury, or a cerebral blood obstruction
- Blood tests to evaluate blood chemistry, electrolytes, liver function, and kidney function that may directly or indirectly impact the brain
- Drug screening to detect illicit or pharmaceutical drugs in a blood or urine sample
- STD screening to detect syphilis, HIV, and other sexually transmitted infections that can affect the brain
Psychotherapy
Psychotherapy is integral to both the diagnosis and treatment of mental illness. It involves meeting with patients on a regular basis to talk about their problems, behaviors, feelings, thoughts, and relationships. The goal of the psychiatrist is to help people find solutions to their problems by exploring thought patterns, behaviors, past experiences, and other internal and external influences.
People undergoing psychotherapy might meet with their psychiatrist individually or as part of a family or group session. Depending on the diagnosis and/or severity of symptoms, psychotherapy may be used for a specific period of time or an ongoing basis.
Many people who’ve experienced a major depressive episode are likely to have another. A 2014 meta-analysis looked at the long-term relapse rates of depression after psychotherapy. Researchers found an average relapse rate of 0.39, but people who’d had psychotherapy were less likely to experience relapse than those who’d undergone comparison treatments.
Psychiatric Medications
Medications are commonly used in psychiatry, each of which has differing properties and psychoactive effects. A psychiatrist needs to be well versed in both the mechanism of action (how a drug works) and pharmacokinetics (the way a drug moves through the body) of any prescribed medication.
Combination drug therapy (the use of two or more drugs) is often used in psychiatry and may require ongoing adjustments to achieve the intended effect. Finding the right combination may take time and is often a process of trial-and-error.
The medications used in psychiatry are broadly classified by six different classes:
- Antidepressants used to treat depression, anxiety disorders, eating disorders, and borderline personality disorder
- Antipsychotics used to treat schizophrenia and psychotic episodes
- Anxiolytics used to treat anxiety disorders
- Depressants, such as hypnotics, sedatives, and anesthetics. used to treat episodic anxiety, insomnia, and panic
- Mood stabilizers used to treat bipolar disorder and schizoaffective disorder
- Stimulants used to treat ADHD and narcolepsy
Other Treatments
Other interventions may be used when a mental disorder is treatment-resistant or intractable (difficult to control). These include:
- Deep brain stimulation (DBS), involving the implantation of electrical probes to stimulate parts of the brain in people with severe depression, dementia, OCD, or substance abuse
- Electroconvulsive therapy (ECT), involving the external delivery of electrical currents to the brain to treat severe bipolar disorder, depression, or catatonia
- Psychosurgery, using surgical techniques like cingulotomy, subcaudate tractotomy, and limbic leucotomy to sever specific circuits in the brain associated with severe OCD and depression
Despite evidence of their benefits, all of these interventions are considered highly controversial, with variable results and degrees of success.
Subspecialties
There are a number of subspecialties in psychiatry that allow practitioners to focus on specific conditions or groups. These include:
- Addiction psychiatry
- Adolescent and child psychiatry
- Forensic psychiatry (the application of psychiatry in criminal, courtroom, or correctional settings)
- Geriatric psychiatry (psychiatry for older populations)
- Neuropsychiatry (mental disorders associated with nervous system injuries or disease)
- Occupational psychiatry (psychiatry in the workplace, particularly occupations in which risk, danger, or grief are common)
- Psychosomatic medicine (the application of psychiatry in a medical setting, such as diagnosis and treatment of delirium)
Training and Certification
To become a psychiatrist, you would first need to obtain a bachelor’s degree and complete the prerequisite courses in biology, chemistry, advanced math, physics, and social science. You would also need to maintain a strong grade point average (usually 3.71 or higher) and pass the Medical College Admission Test (MCAT).
Next, you would enroll in medical school to obtain either a Doctor of Medicine (MD) or Doctor of Osteopathic Medicine (DO) degree. Medical school typically consists of two years of classroom studies followed by two years of clinical rotations in different medical facilities.
Upon completion of medical school, you would start a four-year residency in psychiatry. The first year would involve general residency training followed by three years of focused work in psychiatry (including psychopharmacology, substance abuse, and cognitive behavioral therapy).
After the completion of residency, you would need to secure a medical license in the state in which you intend to practice. This would involve a national test and, in some states, a state exam.
Doctors with an MD degree would take the three-part U.S. Medical Licensing Examination (USMLE), while those with a DO degree could opt to complete the Comprehensive Osteopathic Medical Licensing Examination (COMLEX) instead.
Once you have passed the exam, you are eligible to apply for board certification. The certification is granted by the American Board of Psychiatry and Neurology (ABPN), a member of the American Board of Medical Specialties (ABMS).
ABPN certification must be renewed every 10 years. Medical licenses must also be renewed as per the laws of the state.
Appointment Tips
Meeting with a psychiatric for the first time can be extremely stressful. It generally helps to know what to expect and which questions to ask to get the most out of an appointment.
Expect to spend an hour or two on your first visit. Many psychiatrists will start the exam by taking your vitals (temperature, heart rate, and blood pressure) to establish a baseline. There may also be a possibility of a blood draw. If your symptoms warrant it, your doctor may send you for further testing or scans.
When starting out, the psychiatrist will ask a lot of questions to better understand the nature of your symptoms as well as your family history, medical history, prior treatments, and substance use. It also helps to bring along a complete list of medications you take, both prescription and non-prescription.
Try to be as honest and open as you can during the evaluation, staying on topic so that the process can be structured and focused.
Since this will be your first meeting, take the opportunity to learn who your psychiatrist is. Feel free to ask about the psychiatrist’s credentials and how the practice works. Examples include:
- What experience do you have dealing with my condition?
- Do you specialize in my condition or treat others?
- What are your training and background?
- Can I contact you in a crisis?
- Who will cover for you on holidays or when you’re away?
Press Play for Advice On Dealing With Crisis Fatigue
Hosted by Editor-in-Chief and therapist Amy Morin, LCSW, this episode of The Verywell Mind Podcast shares strategies for dealing with crisis fatigue. Click below to listen now.
Follow Now: Apple Podcasts / Spotify / Google Podcasts
You should also participate as a full partner in your care, asking relevant questions like:
- What is this test used for?
- How did you reach your diagnosis?
- What is the treatment plan?
- Do I need medication, or can I manage without?
- How did you decide this was the best treatment for me?
- What side effects might I expect?
- Are there ways to manage the side effects?
- When should I start feeling better?
- How will I know if I’m getting better?
- What should I do if the side effects are intolerable?
Be sure to write down your questions in advance so that you don’t forget anything. You should also take notes to ensure you have an accurate record of your discussion. If at any stage you feel uncertain about a course of treatment, do not hesitate to seek a second opinion. This is especially true if a drug or treatment has risks or significant side effects.
If you need to find a psychiatrist, ask your primary care doctor for referrals (ideally ones who specialize in your condition). You can check their certification online by using the ABPN verification system.
A Word From Verywell
Psychiatry can be a rewarding career, but it requires individuals with focus and an innate sense of empathy and patience. Although psychiatrists approach diagnosis and treatment in a very structured way, they must have flexibility in knowing when it’s time to change or stop treatment.
While psychiatrists tend to work normal office hours, there may be crises in the middle of the night or weekends that demand immediate attention. As with other mental healthcare workers, professional support and firm boundaries are important for preventing burnout and compassion fatigue.
Day-to-day duties can vary depending on the specialty area and employment sector. A psychiatrist in a hospital may deal with an ever-changing roster of acute mental disorders, while those in private or group practices may have a specific scope of practice and a more routine schedule.
According to the Bureau of Labor Statistics, as of 2019 an estimated 27,900 psychiatrists work in the United States. The demand for psychiatrists is expected to grow by 12% between 2019 and 2029, a rate much higher than average.
In 2020, the median annual income for a psychiatrist in the United States was $217,100, according to the Bureau of Labor Statistics. Psychiatrists in outpatient care centers tend to make slightly more than those in hospitals or private practice.
