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 Waguih William IsHak
Editor

Atlas of Psychiatry
Striatum

Nucleus
accumbens

VTA
Meso-cortic pathway
AMY

Meso-limbic pathway

SNc
Nigrostriatal pathway

123
Atlas of Psychiatry
Waguih William IsHak
Editor

Atlas of Psychiatry
Editor
Waguih William IsHak
Cedars-Sinai Health System
Department of Psychiatry and Behavioral Neurosciences
University of California Los Angeles
David Geffen School of Medicine
Los Angeles, CA, USA

ISBN 978-3-031-15400-3    ISBN 978-3-031-15401-0 (eBook)

https://doi.org/10.1007/978-3-031-15401-0

© Springer Nature Switzerland AG 2023

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been
made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my love Asbasia (Hanan) Mikhail-IsHak, MD, FACEP, our sons William
and Michael, our parents William Makram IsHak, MD, Nawara Yacoub
Dawoud-IsHak, MD, Mrs. Aziza Mikhail and Mr. Aboelkhair Mikhail, and
our siblings Rafik William IsHak, MD, FRCS, Albert Mikhail, MD, and Mrs.
Lamia Maalouf, for their inspiration, encouragement, and love.
Foreword

The Atlas of Psychiatry is the first of its kind in psychiatry, currently the only discipline that
does not have a comprehensive atlas for visual learning about the whole field. The Atlas has
been developed for clinicians, trainees, and students who need a visual guide describing basic,
clinical, and scholarly information. It is a large full-color hardback with extensive drawings
and clinical images, printed on glossy paper and also available in various electronic formats.
The audience is a wide-scope readership adopting a user-friendly method to familiarize with
psychiatry and psychiatric disorders, in contrast to the traditional text-only-based volumes.
The Atlas of Psychiatry chapters have been written by world-class experts in the field, in
addition to a number of chapters that Dr. IsHak has written with his team on a variety of topics.
Each chapter includes figures, illustrations, and tables covering each psychiatric disorder, with
images and tables potentially describing epidemiology, etiology, pathophysiology, phenome-
nology, and treatment. The psychiatric disorders are classified using the latest diagnostic clas-
sification systems, with images created or curated and described by authors in each scientific
area and diagnosis. Experts in each aspect of psychiatry and psychiatric disorders have syn-
chronized the text and imagery content with the mission of delivering a clear and lucid expla-
nation of each topic. The Atlas of Psychiatry is an innovative and important contribution to the
field.

Maurizio Fava, MD
Harvard Medical School, Psychiatrist-In-Chief, Department
of Psychiatry Director, Division of Clinical Research, Mass
General Research Institute; Executive Director, Clinical
Trials Network & Institute Associate Dean for Clinical
& Translational Research, Slater Family Professor of
Psychiatry, Boston, MA, USA

vii
Preface

The Atlas of Psychiatry is a visual guide intended for a diverse readership looking for a visual
method to learn cutting-edge, and scholarly information about psychiatry and psychiatric dis-
orders. The goal is to inform the reader by describing basic science and theory, as well as clini-
cal and therapeutic information using imagery and text to show and tell about the field.
We hope that the Atlas will be useful for physicians of all specialties especially internal
medicine, primary care, family medicine, psychiatry, and neurology, health care professionals
especially nurses, nurse practitioners, physician assistants, and medical assistants, mental
health care professionals especially psychologists, social workers, psychotherapists, substance
use counselors, and spiritual counselors, trainees especially medical students, residents, fel-
lows, and graduate students, researchers, as well as hospital, clinic, and treatment programs
staff especially leaders, middle management, and program personnel.
Chapters 1–11 cover the landmark theories and concepts, key contributors, illustrations,
must-see images, and detailed tables to describe the aspects of topic in each chapter. Chapters
12–24 describe the psychiatric disorders including epidemiology, etiology, pathophysiology,
phenomenology, and treatment, using illustrations, must-see images, and detailed tables as
well. Chapter 25 ends the book with a futuristic collection of directions where the field could
be following in the next decade.
This Atlas was only made possible because of so many supportive and nurturing individuals
for whom this editor is eternally grateful. I truly hope that the Atlas of Psychiatry will be a
helpful and useful contribution.

Los Angeles, CA Waguih William IsHak

ix
Acknowledgments

I am deeply grateful for supportive and nurturing figures throughout my career, and it gives
utmost pleasure to acknowledge them in the Atlas of Psychiatry. I begin with William Makram
IsHak, MD (may he rest in peace) who instilled psychological mindedness and reading the
master pieces in psychological sciences, then Cairo University amazing Professors Yehia El
Rakhaway, Emad Hamdy Ghoz, Tarek S. Gawad, Abdelhamid Hashem, Samir Aboelmagd,
Nahed Khairy, Zeinab Nasser, Zakaria Halim, Salwa Erfan, and Soad Moussa, followed by the
Milieu Therapy psychiatry masters: Professors Refaat Mahfouz, Ahmed Abdallah, Yehia Jaffer,
and Hassib El-Defrawi, to NYU’s incredible Professors Robert Delgado, Brian Ladds, Zebulon
Taintor, Eric Peselow, Adam Wolkin, Leonard Adler, Martin Kahn, Richard Hanson, Kim
Hopper, David Nardacci, Martin Geller, Asher Aladjem, Samuel Slipp, Richard Oberfield,
Howard Silbert, Henry Weinstein, Howard Welsh, Murray Alpert, George Nicklin, Bertina
Baer, and Bruce Rubenstein.
I am very thankful for the phenomenal care of Samy Rizk, MD, and Mrs. Mary-Terez Rizk,
the life-changing fortunes by Norman Sussman, MD, and Nancy Hanna, MD as well as the
priceless mentorship of Professors Carol Bernstein, Manuel Trujillo, Virginia Sadock, and
Benjamin Sadock. I continue to cherish the invaluable advice and career opportunities from
Professor Shlomo Melmed Cedars-Sinai’s Dean of the Medical Faculty, Peter Panzarino, MD,
Thomas Trott, MD, PhD, Saul Brown, MD, PhD, and Mark Rappaport, MD, and continue to
value the precious guidance from Professors Lloyd Sederer, Sherwyn Woods, Laura Roberts,
Robert Cohen, Robert Pechnick, Daniel Berman, Russell Poland, Fawzy I. Fawzy, Thomas
Strouse, George Awad, Edward Feldman, Rebecca Hedrick, and especially Bruce Gewertz,
MD —Cedars-Sinai’s Surgeon-in-Chief, as well as Professor and STAR*D PI A. John Rush,
Nobel Laureate Louis Ignarro, and Harvard Mass General’s Psychiatrist-in-Chief Maurizio
Fava, for having the most profound impact on my career involvements. I remain appreciative
of Itai Danovitch, MD unwavering and genuine support of all my professional endeavors at
Cedars-Sinai.
I was inspired and given growth opportunities and learned a great deal from leaders, teach-
ers, colleagues, collaborators, and dear friends over the years, who appear on page xi and xii
of The Textbook of Clinical Sexual Medicine. I gratefully acknowledge my debt to them, as
they have contributed in a fundamental way (albeit indirectly) to the creation of the Atlas of
Psychiatry.
I also would like to especially thank Nadina Persaud, Lee Klein, and Melanie Zerah the
staff at Springer for their outstanding professional work and patience throughout the duration
of this project.
This book is dedicated to the medical students, residents, and faculty at Cairo University
School of Medicine, Dar El-Mokattum Milieu Therapy Hospital, New York University School
of Medicine (NYU), Cedars-Sinai Medical Center, and the David Geffen School of Medicine
at the University of California at Los Angeles (UCLA).

Waguih William IsHak

xi
Contents

1 Introduction to Psychiatry�����������������������������������������������������������������������������������������   1

Darlene Rae King and Adam Brenner
2 
Epidemiology of Psychiatric Disorders��������������������������������������������������������������������� 29
William W. Eaton
3 
The Biopsychosocial Model of Evaluation and Treatment in Psychiatry ������������� 57
Luma Bashmi, Alexander Cohn, Shawna T. Chan, Gabriel Tobia,
Yasmine Gohar, Nathalie Herrera, Raymond Y. Wen, Waguih William IsHak,
and Katrina DeBonis
4 Neurobiological Sciences: Neuroanatomy, Neurophysiology,
and Neurochemistry��������������������������������������������������������������������������������������������������� 91
Alexander J. Steiner, Leslie Aguilar-Hernandez, Rasha Abdelsalam,
Krista Q. Mercado, Alexandra M. Taran, Lucas E. Gelfond, and Waguih
William IsHak
5 Psychosocial Sciences: Theories and Applications��������������������������������������������������� 147
Paloma Garcia, Michael W. Ishak, and Manuel Trujillo
6 
Assessment: Interview, History, Physical, and Mental Status Examination��������� 185
Rob Poole, Robert Higgo, and Tom Lorenz
7 Diagnostic Testing: Rating Scales and Psychological and
Neuropsychological Tests������������������������������������������������������������������������������������������� 201
Shane S. Bush and Noah K. Kaufman
8 
Diagnostic Neuroimaging and Laboratory Tests����������������������������������������������������� 227
Nian Liu, Fei Li, Zhiyun Jia, Taolin Chen, Haoyang Xing, Ying Chen, Su Lui,
and Qiyong Gong
9 
Psychiatric Emergencies: Suicide and Violence������������������������������������������������������� 259
Basant K. Puri
10 
Biological Treatments: Psychopharmacology, Brain Stimulation,
and Innovations����������������������������������������������������������������������������������������������������������� 275
Tiffany E. Schwasinger-Schmidt and Matthew Macaluso
11 Psychosocial Treatments: Psychotherapy, Behavioral,
and Cultural Interventions����������������������������������������������������������������������������������������� 303
Manuel Trujillo
12 
Neurodevelopmental, Disruptive, Impulse-Control, and Conduct Disorders������� 361
Elizabeth Dohrmann and Benjamin Schneider
13 Neurocognitive Disorders������������������������������������������������������������������������������������������� 407
Jothi Ramalingam, Adith Mohan, and Perminder S. Sachdev

xiii
xiv Contents

14 Substance-Related and Addictive Disorders������������������������������������������������������������ 437

Mira Zein and Itai Danovitch
15 Schizophrenia
 Spectrum and Other Psychotic Disorders��������������������������������������� 469
Alaina V. Burns and Stephen Marder
16 Bipolar
 and Related Disorders ��������������������������������������������������������������������������������� 493
Ashley Ngor, Alexander J. Steiner, Sarin Pakhdikian, David Okikawa,
Demetria Pizano, Lidia Younan, Samantha Cohen, and Waguih William IsHak
17 Depressive Disorders��������������������������������������������������������������������������������������������������� 531
Eric L. Goldwaser and Scott T. Aaronson
18 Anxiety
 Disorders and Obsessive-­Compulsive and Related Disorders����������������� 569
Sophie M. D. D. Fitzsimmons, Neeltje M. Batelaan,
and Odile A. van den Heuvel
19 Trauma-
 and Stressor-Related Disorders and Dissociative Disorders������������������� 597
Samoon Ahmad
20 Somatic
 Symptom and Related Disorders ��������������������������������������������������������������� 635
Maria Kleinstäuber
21 Eating
 Disorders, Feeding, and Elimination Disorders������������������������������������������� 671
Demetria Pizano, Netasha Pizano, Christopher Martin, Paloma Garcia,
and Waguih William IsHak
22 Sexual
 Dysfunctions, Gender Dysphoria, and Paraphilic Disorders��������������������� 711
Sam Nishanth Gnanapragasam, Fraser Scott, and Dinesh Bhugra
23 Sleep-Wake Disorders������������������������������������������������������������������������������������������������� 727
Luigi Ferini-Strambi, Andrea Galbiati, Marco Sforza, Francesca Casoni,
and Maria Salsone
24 Personality Disorders������������������������������������������������������������������������������������������������� 755
Paul S. Links, James Ross, and Philippe-Edouard Boursiquot
25 The
 Future of Psychiatry������������������������������������������������������������������������������������������� 773
Waguih William IsHak, Naira Magakian, William W. Ishak,
Asbasia A. Mikhail, and Russell Lim
Index������������������������������������������������������������������������������������������������������������������������������������� 855
Contributors

Scott T. Aaronson, MD Sheppard Pratt Health System, Baltimore, MD, USA

Rasha Abdelsalam, MD Department of Psychiatry and Behavioral Neurosciences, Cedars-­
Sinai Medical Center, Los Angeles, CA, USA
Leslie Aguilar-Hernandez, BA Department of Psychiatry and Behavioral Neurosciences,
Cedars-Sinai Medical Center, Los Angeles, CA, USA
Samoon Ahmad, MD Department of Psychiatry, NYU Grossman School of Medicine, New
York, NY, USA
Luma Bashmi, MA Department of Health Psychology, School of Medicine, Royal College
of Surgeons in Ireland-Bahrain, Busaiteen, Kingdom of Bahrain
Neeltje M. Batelaan, MD, PhD Department of Psychiatry, Amsterdam UMC, Vrije
Universiteit Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands
Dinesh Bhugra, CBE, PhD, MPhil, MSc, MA Institute of Psychiatry, Psychology &
Neuroscience, King’s College London, London, UK
Philippe-Edouard Boursiquot, MD Department of Psychiatry and Behavioural
Neurosciences, McMaster University, Dundas, ON, Canada
Adam Brenner, MD Department of Psychiatry, The University of Texas Southwestern
Medical Center, Dallas, TX, USA
Alaina V. Burns, MD, MPH Department of Psychiatry and Biobehavioral Sciences, Adult
Division, UCLA-Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
Shane S. Bush, PhD, ABPP Long Island Neuropsychology, PC, Lake Ronkonkoma, NY,
USA
Francesca Casoni, MD, PhD Department of Clinical Neurosciences, Neurology, Sleep
Disorders Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
Shawna T. Chan, MD Department of Psychiatry and Biobehavioral Sciences, David Geffen
School of Medicine at UCLA, Los Angeles, CA, USA
Taolin Chen, PhD Huaxi MR Research Center (HMRRC), Department of Radiology, West
China Hospital of Sichuan University, Chengdu, China
Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital
of Sichuan University, Chengdu, China
Ying Chen, PhD Huaxi MR Research Center (HMRRC), Department of Radiology, West
China Hospital of Sichuan University, Chengdu, China
Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, Chengdu, China
Samantha Cohen, MA Department of Psychiatry and Behavioral Neurosciences, Cedars-­
Sinai Medical Center, Los Angeles, CA, USA

xv
xvi Contributors

Alexander Cohn, MD Department of Psychiatry and Biobehavioral Sciences, David Geffen

School of Medicine at UCLA, Los Angeles, CA, USA
Itai Danovitch, MD, MBA Department of Psychiatry and Behavioral Neurosciences, Cedars-­
Sinai Medical Center, Los Angeles, CA, USA
Katrina DeBonis, MD Department of Psychiatry and Biobehavioral Sciences, David Geffen
School of Medicine at UCLA, Los Angeles, CA, USA
Elizabeth Dohrmann, MD Los Angeles County Department of Mental Health, Los Angeles,
CA, USA
William W. Eaton, PhD Department of Mental Health, Johns Hopkins Bloomberg School of
Public Health, Baltimore, MD, USA
Lidia Younan, MD Cedars-Sinai Medical Center, Los Angeles, CA, USA
Maurizio Fava, MD Harvard Medical School, Boston, MA, USA
Luigi Ferini-Strambi, MD Università Vita-Salute San Raffaele, Milan, Italy
Department of Clinical Neurosciences, Neurology, Sleep Disorders Center, IRCCS San
Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
Sophie M. D. D. Fitzsimmons, MBBCh, MSc Department of Psychiatry and Department of
Anatomy and Neurosciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam
Neuroscience, Amsterdam, Netherlands
Andrea Galbiati, PhD Università Vita-Salute San Raffaele, Milan, Italy
Department of Clinical Neurosciences, Neurology, Sleep Disorders Center, IRCCS San
Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
Paloma Garcia, BA Brown University, Providence, RI, USA
Lucas E. Gelfond, BA Brown University, Providence, RI, USA
Sam Nishanth Gnanapragasam, BSc, MBBS, MRCPsych South London and Maudsley
NHS Foundation Trust, London, UK
Yasmine Gohar, MA, PhD, AMFT, APCC Psychiatry Department, The Behman Hospital,
Cairo, Egypt
Eric L. Goldwaser, DO, PhD Department of Psychiatry, Weill Cornell Medicine, New York,
NY, USA
Qiyong Gong, MD, PhD Huaxi MR Research Center (HMRRC), Department of Radiology,
West China Hospital of Sichuan University, Chengdu, China
Department of Radiology, West China Xiamen Hospital of Sichuan University, Xiamen, China
Nathalie Herrera, MD Cedars-Sinai Medical Center, Los Angeles, CA, USA
Odile A. van den Heuvel, MD, PhD Department of Psychiatry and Department of Anatomy
and Neurosciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam
Neuroscience, Amsterdam, Netherlands
Robert Higgo, MB ChB, MSc, FRCPsych Centre for Mental Health and Society, Prifysgol
Bangor University,, Wrexham, Wales, UK
Michael W. Ishak, BA Candidate Princeton University, Princeton, NJ, USA
Waguih William IsHak, MD, FAPA Cedars-Sinai Health System, Department of Psychiatry
and Behavioral Neurosciences, University of California Los Angeles, David Geffen School of
Medicine, Los Angeles, CA, USA
Contributors xvii

William W. Ishak, BA Brown University, Providence, RI, USA

Zhiyun Jia, PhD Department of Nuclear Medicine, West China Hospital of Sichuan
University, Chengdu, China
Noah K. Kaufman, PhD, ABN, ABPdN, ABPP Center for Neuropsychological Studies, Las
Cruces, NM, USA
Darlene Rae King, MD Department of Psychiatry, The University of Texas Southwestern
Medical Center, Dallas, TX, USA
Maria Kleinstäuber, PhD Department of Psychology, Utah State University, Logan, UT,
USA
Fei Li, PhD Huaxi MR Research Center (HMRRC), Department of Radiology, West China
Hospital of Sichuan University, Chengdu, China
Functional and Molecular Imaging Key Laboratory of Sichuan Province, West China Hospital
of Sichuan University, Chengdu, China
Russell Lim, MD Department of Psychiatry, University of California, Davis, Davis, CA,
USA
Paul S. Links, MD, FRCPC Department of Psychiatry and Behavioural Neurosciences,
McMaster University, Dundas, ON, Canada
Nian Liu, PhD Huaxi MR Research Center (HMRRC), Department of Radiology, West
China Hospital of Sichuan University, Chengdu, China
Department of Radiology, Affiliated Hospital of North Sichuan Medical College,
Nanchong, China
Tom Lorenz, MB, ChB, BSc, MRCPsych Department of Child and Adolescent Psychiatry,
Betsi Cadwaladr University Health Board, Flintshire, Wales, UK
Su Lui, PhD Huaxi MR Research Center (HMRRC), Department of Radiology, West China
Hospital of Sichuan University, Chengdu, China
Department of Radiology, West China Xiamen Hospital of Sichuan University, Xiamen, China
Matthew Macaluso, DO Department of Psychiatry and Behavioral Neurobiology, UAB
Depression and Suicide Center, Heersink School of Medicine, The University of Alabama at
Birmingham, Birmingham, AL, USA
Naira Magakian, MD Cedars-Sinai Medical Center, Los Angeles, CA, USA
Stephen Marder, MD Semel Institute for Neuroscience at UCLA, VA Desert Pacific Mental
Illness Research, Education, and Clinical Center (VISN 22 MIRECC), Los Angeles, CA, USA
Christopher Martin, MD David Geffen School of Medicine at UCLA, Charles R. Drew
University of Medicine and Science, Los Angeles, CA, USA
Krista Q. Mercado, BS Department of Ecology and Evolutionary Biology, University of
California, Los Angeles, Los Angeles, CA, USA
Asbasia A. Mikhail, MD, FACEP Department of Emergency Medicine, Huntington Hospital,
Pasadena, CA, USA
Adith Mohan, MRCPsych Department of Psychiatry, Northern Beaches Hospital, Frenchs
Forest, NSW, Australia
Ashley Ngor University of California, Los Angeles, Los Angeles, CA, USA
David Okikawa, MD David Geffen School of Medicine, University of California, Los
Angeles, Los Angeles, CA, USA
xviii Contributors

Sarin Pakhdikian, DO Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas,
Las Vegas, NV, USA
Demetria Pizano, MA University of Alabama at Birmingham, Birmingham, AL, USA
Netasha Pizano, MA University of California, Santa Barbara, Santa Barbara, CA, USA
Rob Poole, MBBS, FRCPsych Centre for Mental Health and Society, Prifysgol Bangor
University, Wrexham, Wales, UK
Basant K. Puri, PhD, MB, MSc, FRMS, FRSB University of Winchester, Winchester, UK
Jothi Ramalingam, MBBS Department of Psychiatry, Northern Beaches Hospital, Frenchs
Forest, NSW, Australia
James Ross, MD, MHPE, FRCPC Department of Psychiatry, Schulich School of Medicine
and Dentistry, University of Western Ontario, Parkwood Mental Health Institute, London, ON,
Canada
Perminder S. Sachdev, MD, PhD Department of Psychiatry, Northern Beaches Hospital,
Frenchs Forest, NSW, Australia
Maria Salsone, MD, PhD Department of Clinical Neurosciences, Neurology, Institute of
Molecular Bioimaging and Physiology, National Research Council, Sleep Disorders Center,
IRCCS San Raffaele Scientific Institute, Milan, Italy
Benjamin Schneider, MD David Geffen School of Medicine, University of California at Los
Angeles, Los Angeles, CA, USA
Tiffany E. Schwasinger-Schmidt, MD, PhD Department of Internal Medicine, University of
Kansas School of Medicine-Wichita, Wichita, KS, USA
Fraser Scott, BA, BMBCh, MRCPsych South London and Maudsley NHS Foundation
Trust, London, UK
Marco Sforza, MSc Università Vita-Salute San Raffaele, Milan, Italy
Department of Clinical Neurosciences, Neurology, Sleep Disorders Center, IRCCS San
Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
Alexander J. Steiner, PsyD Executive Mental Health, Inc., Los Angeles, CA, USA
Alexandra M. Taran, BS Department of Integrative Biology, Oregon State University,
Corvallis, OR, USA
Gabriel Tobia, MD Department of Psychiatry, Brigham and Women’s Faulkner Hospital,
Boston, MA, USA
Manuel Trujillo, MD Department of Psychiatry, New York University School of Medicine,
New York, NY, USA
Raymond Y. Wen, BS, PharmD-c San Diego Health, Skaggs School of Pharmacy and
Pharmaceutical Sciences, University of California, San Diego, CA, USA
Haoyang Xing, PhD Huaxi MR Research Center (HMRRC), Department of Radiology, West
China Hospital of Sichuan University, Chengdu, China
Research Unit of Psychoradiology, Chinese Academy of Medical Sciences, Chengdu, China
Mira Zein, MD, MPH Department of Psychiatry and Behavioral Sciences, Department of
Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA,
USA
About the Editor

Waguih William IsHak, MD, FAPA is Professor and Clinical

Chief of Psychiatry at Cedars-Sinai and Clinical Professor of
Psychiatry at the David Geffen School of Medicine at the
University of California Los Angeles (UCLA). Dr. IsHak has
nearly 35 years of experience in psychiatry, psychotherapy, and
psychopharmacology, with specific training and expertise in
sexual medicine and outcome measurement in psychiatric dis-
orders particularly depressive symptom severity, functioning,
and quality of life. He is researching innovative ways to mea-
sure and improve the detection and treatment of depression in
people seeking medical care, in order to remove behavioral
barriers to wellness. Dr. IsHak has lectured and published on
quality of life as a critical outcome measure of healthcare inter-
ventions, mood disorders especially depression, sexual medi-
cine, and outcome measurement in psychiatry as well as
computer applications in psychiatry. He was also the author
and designer of Health Education Programs for the Public,
including the Online Depression Screening Test (ODST),
Online Screening for Anxiety (OSA), and Online Screening
Tests for Sexual Disorders. He has edited and authored six
books: this volume, The Handbook of Wellness Medicine
(Cambridge University Press, 2020), the Textbook of Clinical
Sexual Medicine (Springer Nature, 2017), Guidebook of Sexual
Medicine (A&W Publishing, 2008), Outcome Measurement in
Psychiatry: A Critical Review (APPI, 2002), and On Call
Psychiatry (WB Saunders, 2001). Dr. IsHak’s research has
been funded by NARSAD, National Institute of Health, and the
Patient Centered Outcomes Research Institute (PCORI) espe-
cially on depression in heart disease. The Personalized Wellness
Program is the latest program aiming at enhancing patient-cen-
tered care to promote health and wellness. His articles have
appeared in many prestigious journals, such as JAMA
Psychiatry, Journal of Clinical Psychiatry, Harvard Review of
Psychiatry, Journal of Affective Disorders, Journal of Sexual
Medicine, Journal of Graduate Medical Education, and Quality
of Life Research. He is a member of several professional societ-
ies, including the American Psychiatric Association, the
American Association of Directors of Psychiatry Residency
Training, and the International Society of Sexual Medicine. Dr.
IsHak was awarded the 2002 and 2010 Golden Apple Teaching
Award, Department of Psychiatry, Cedars-Sinai Medical
Center; 2007 Outstanding Medical Student Teaching Award,

xix
xx About the Editor

Department of Psychiatry and Biobehavioral Science at UCLA;

2011 Excellence in Education Award, David Geffen School of
Medicine at UCLA; 2012 Parker J. Palmer Courage to Teach
Award, Accreditation Council for Graduate Medical Education;
and 2012 Nancy Roeske Award for Excellence in Medical
Student Education, American Psychiatric Association, was
elected to the Gold Humanism Honor Society in 2012, and has
been on Super Doctors list from 2012 to 2023. Dr. IsHak served
as a Chief proctor and examiner for the American Board of
Psychiatry and Distinguished fellow of the American
Psychiatric Association.
 Introduction to Psychiatry
Darlene Rae King and Adam Brenner
What’s going through your mind? How do billions of cells
orchestrate life, generate the experience of the soul, and
create who we are as a person? What then are mental disor-
ders, and how do we treat them? These are questions psy-
chiatrists ponder. Modern science has led to marvelous
breakthroughs in medicine for diseases that can be physi-
cally described and modeled, but diseases of the mind
remain perplexing. The mind is the final frontier, and much
remains to be understood and discovered. For those that are
afflicted by mental illness, discoveries cannot come fast
enough, and as psychiatrists, it is our privilege to work at
the intersection of medicine, neuroscience, culture, and
D. R. King (*) · A. Brenner
Department of Psychiatry, The University of Texas Southwestern
Medical Center, Dallas, TX, USA
e-mail: darlene.king@utsouthwestern.edu;
adam.brenner@UTSouthwestern.edu
© Springer Nature Switzerland AG 2023
W. W. IsHak (ed.), Atlas of Psychiatry, https://doi.org/10.1007/978-3-031-15401-0_1
1
technology to help alleviate patient suffering and incorpo-
rate new knowledge as it becomes available. We set out to
treat mental illness and understand the inner workings of
the mind: things that are in some ways still mysterious but
are clearly highly complex. Those who enter psychiatry
understand the lifelong learning involved and feel comfort-
able operating within a gray space. Patients must be consid-
ered from multiple viewpoints to construct an accurate
formulation and help treat their mental illness. If the state
of the specialty is still appealing after hearing all the above,
then know that Psychiatry is one of the up-and-­coming
fields of medicine (Fig. 1.1).
1
2 D. R. King and A. Brenner

Fig. 1.1 Aspects of

psychiatry

Medicine
Culture

Psychiatrist
Technology
Neuroscience

Brief History
The history of psychiatry is filled with fascinating narra-
tives, breakthroughs, and cautionary tales. It is easy to
look upon earlier attempts to ease psychological suffer-
ing and see them as outlandish or even horrifying. But, as
you look through the following timeline, consider that we
are still operating with very little understanding of how
the mind works and that even today, it is possible we are
making our own mistakes. If history has anything to offer
up, it is that the pathophysiology of psychosis, depres-
sion, or other mental pathologies are extraordinarily
complex, and as we work to uncover their mysteries, we
must remain humble and thoroughly consider hypotheses
and their evidence to prevent harming future patients
(Fig. 1.2) [1].
 1

Pre-Historic 2000 BCE 450 BCE

people drilled holes into Babylonian cuneiform text Hippocrates says mental illness
skulls to treat epilepsy or describes epilepsy and originates within the body. Introduces
4000 psychosis "melancholia" the concept of "humors"

Pre-History Pre-Historic 2000 1900 BCE 1000 BCE 100 BCE

Mental illness thought to Hysterical disorders thought The brain was described in Chinese Texts describe
be due to supernatural forces. to be caused by spontaneous Egyptian papyrus, but not found acupuncture points and
Introduction to Psychiatry

Shamans or spiritual priests uterus movement within female to be useful for reincarnation. treatments. Acupuncture may
were looked to for help. body. increase norepinephrine levels
and help improve depressed
mood.

1200

Middle Ages & Renaissance

If a physician cannot identify the
1634 cause of a disease, it is believed to
Bedlam priory officially declared a 1596-1650 be caused by the devil. Women are
formal "madhouse". A favorite London Descartes coins "Cartesian viewed as more susceptible to hysteria
past-time was going to see the patients Dualism": cognito ergo sum. and melancholy. Hysteria is often
1700 which were put on display. "I think, therefore, I am". confused with sorcery.

1692 1600 1500 1247

Salem Witch Trials: famous outbreak of Priory of St. Mary of Bethleham
“hysteria”. Several young girls present with founded in London. Originally
staring, uncontrollable jumps, and sudden opened to heal impoverished
1745-1814
movements and are believed to be “possessed”. persons, by 1377 it housed the
Dr. Benjamin Rush, coined
In all, 19 women were hanged as “witches” and mentally ill and became England's
“The Father of Psychiatry”
over 100 were kept in detention. Only when the first asylum, known to many as "Bedlam".
postulated that madness
Colonial governor’s wife was accused, was
was an arterial disease or
an end put to the trial and further arrests.
inflammation of the brain.
He invented the
Tranquilizing Chair to
“control” the flow of blood to
the brain by reducing motor
activity and lowering the
pulse. It did not. He also
believed in blood letting.

1800

1792
Moral Therapy Movement
Mentally ill do not need to be
restrained. It is best to treat
with a calm and harmonious
environment where they can
be close to nature and have
predictable routines.
1796
York Retreat implements
moral therapy and all 30 of
their patients were
discharged "cured or
improved". Sparked the
asylum movement.

Fig. 1.2 History of psychiatry timeline. Top Images from left to right: Trepanned cranium; Descartes; Salem witch trials; Tranquility Chair; Thirteen Founders; Bleuler; Brain atrophy;
Cuneiform text; Humors; Bedlam; Moral Therapy; York Retreat; Alzheimer Neurons; Freud Tooth; AA recovery symbol; Lobotomy MRI; Community; Anti-Psychiatrists; DSM; fMRI
Sofa; Kraepelin; Camphor Seizure; ECT Machine; Thorazine; Lithium; Deinstitutionalization. [2–9]
3

Bottom Images from left to right: Shaman; Egyptian; Canopic jars; Acupuncture; middle ages fire;

1952
Chlorpromazine Egas Moniz receives Nobel
becomes first
line psychiatric
treatment people received lobotomy.
1963
Community services
become an
alternative to mental
health hospitals with
the passing of the
Community Mental
Health Act.
1968
Lithium introduced
as mood stabilizer
for bipolar disorder.
1968
Anti-Psychiatry Movement led by
R.D. Liang, MD; Thomas Szasz and
Foucault. Stated that mental illness was
a myth determined by social constructs.
Fig 1.2 (continued)
4
1864 1901
Griesinger, Morel and Alzheimer focus Freud publishes "The Psychopathology
on physically examining neural structures of Everyday Life" and establishes the
to elucidate the mechanism of degeneration field of psychoanalysis. Patients would
of thought. The following is an illustration by lie down on the couch below while Freud
one of Alzheimer’s students showing neurons sat behind them taking notes to encourage
1800 in various stages of neurofibrillar alteration. free association.
1840 1900 1911
Asylum superintendents form Bleuler coins the term 1917
their own professional bodies. schizophrenia. He Wagner Jauregg
One of these later became American describes central features receives nobel prize
Psychiatric Association. including flattened affect, in medicine for
loss of volition, loose malaria treatment of
associations and cerebral syphilis. It
interpersonal withdrawal. was responsible for
10% of total
admissions and 30%
of private admissions.
In the image above,
patients with
dementia and syphilis
were noted to have
brain atrophy and
enlarged sulci (right).
1939 1933
Alcoholics Anonymous Henry Cotton, MD removes teeth,
Founded, based on principles tonsils and bowel thought to be
of fellowship, mutual support sources of minor infection that
of sobriety and spirituality. caused mental illness
1949 1938 1935 1919
Ugo Cerletti uses a weak electrical First induced seizure induced Kraepelin differentiates between
Prize for Lobotomy. From current to induce seizure in first in schizophrenic patient viz schizophrenia and manic-depressive
1939–1951, over 50,000 patient with schizophrenia. ECT camphor inhalation. disorder. He called schizophrenia
was born. "dementia praecox"
1980
Deinstitutionalization
1980 1990 2000
DSM III created to Introduction of fMRI
standardize diagnoses
D. R. King and A. Brenner
1 Introduction to Psychiatry 5

Medicine symptoms are used, even if the mechanism behind that treat-
ment is not fully known. Mental health and the treatments for
What is the difference between a psychologist, psychiatrist, mental illness determine the scope of psychiatry. Psychiatrists
and neurologist (Fig. 1.3)? are medical doctors and as such have experience in prescrib-
A psychologist is someone with an academic degree, usu- ing medication. Psychiatrists are also educated in and per-
ally a masters or PhD, who specializes in the study of thought form a variety of psychotherapy modalities.
and behavior. They conduct experiments to test theories of Neurology is another branch of medicine. Neurologists
human behavior. The graduate degree can be more research-­ focus on treating illnesses that originate from lesions in the
focused (PhD) or clinically focused (PsyD). Clinical psy- brain or nervous system. While there is a lot of overlap
chologists can do additional training in a clinical setting to between neurology and psychiatry in that many neurological
provide talk therapy to patients, such as cognitive behavioral illnesses are complicated by abnormalities in cognition or
therapy, or perform neuropsychological assessments better behavior, psychiatry remains the field of medicine that
to describe a person’s deficits or personality pathology. focuses on illnesses that affect the mind. It is crucial to have
Clinical psychologists do at least 1 year of clinical training a specialty that is an expert in illnesses whose manifestation
as an intern prior to graduation [10]. is in subjective experience and changes in behavior. An
Psychiatry is a branch of medicine. It is not based on the- often-used analogy is that the brain is the hardware, and the
ory but on practice. When someone has symptoms of mental mind is the software. The difference between neurology and
illness, treatments that have been shown to decrease those psychiatry falls along these lines.

Research
Therapy
Projects Prescribe
Didactics Medication
Weekly

Pathology Hospital
Pharma Teach Academic Clinical
Organ & Clinic
-cology work Work
Systems
Surgery
Students Settings Optional
COLLEGE
Pediatrics Fellowship
Clinical
Any Major Physiology Areas PSYCHIATRY 4 years 1-2 yrs
Internal Psychiatry
Extracurriculars
+More Medicine
Family RESIDENCY
Medicine
Internships PSYCHIATRIST
Study Neurology Step 3 Psychiatry
Anatomy Board Exam Board Exam
Courses 2 YR
Clinical
Clerkships
OB-GYN
MEDICAL
4 years
Take MCAT SCHOOL Choose
Specialty
M.D. Granted! NEUROLOGY
Optional
Take GRE RESIDENCY
Match to
Fellowship
Acceptance Residency 4 years 1-2 yrs
Acceptance to Step 2
to Medical Board Exam Step 3 NEUROLOGIST
Graduate School Board Exam
Step 1
School Board Exam
Didactics Clinical
Academic
Weekly Work
Work
GRADUATE
Clinical
Research SCHOOL Focus
Focus Teach
Mental Prescribe
Students Hospital
PhD PsyD Health
Research
& Clinic
Medication
Pick Area of Focus Projects
Site Settings
Master’s Thesis
General Psychology Exam
~4-6 yrs Dissertation
~3-5 yrs
1-YR CLINICAL
INTERNSHIP
PsyD CLINICAL
Granted! PSYCHOLOGIST

Clinical
PhD Granted! Competency
Exam

PSYCHOLOGIST

Fig. 1.3 Career paths for psychiatry, psychology, and neurology

6 D. R. King and A. Brenner

Psychopharmacology patients about the indication for medication, why it will be

Psychopharmacology is a valuable part of psychiatry. For
patients suffering from mental illness, medications can
make all the difference. Psychiatry relies most heavily on
three major classes of medications: antidepressants, anti-
psychotics, and mood stabilizers. It is important to under-
stand the mechanism of action of these drugs, what they are
useful in treating and how to manage their side effects. It is
so rewarding to see a patient who is afflicted by symptoms
take medication, experience relief, and return to baseline
functioning.
The administration of psychiatric medications has chal-
lenges though. While prejudice against mental illness has
been declining, stigma remains a major barrier for patients
and is most obvious during discussions about medication.
Unlike drugs for diabetes or bacterial infection, patients are
much more hesitant to start an antidepressant or mood stabi-
lizer. It is important to explore all the concerns a patient has
and continue the discussion over time. It is vital to teach
helpful to them, and common side effects [11].
In addition to overcoming stigma, another challenge faced
in the realm of psychopharmacology is that patients may lack
insight into their mental illness. In these cases, adherence is a
major problem that, if not addressed, results in a repetitive
cycle of hospitalization improvement on medication dis-
charge nonadherence to medication decline in readmission.
Fortunately, effective interventions are possible to break this
cycle, such as access to regular community care, working
closely with family, and/or recommending a long-­ acting
injectable. Lastly, it is also important to be aware of the cost
of medications because the best medication is one that a
patient can and will take. If a medication is too expensive, the
added financial stress or the inability to access the medication
will negate its clinical benefit. Overall, psychopharmacology
is a crucial piece of psychiatry requiring medical knowledge
of the medications and when to use them, but also how to
overcome challenges such as stigma, nonadherence, and cost
to deliver the best care to the patient (Figs. 1.4 and 1.5) [11].

Will I be able to This is just stress,

afford this not depression.
medication?

Is there something
Will it make wrong with me?
Am I going to be
me go crazy? on this medication
forever?

What will
others think?
Mr. Smith, based on
your depressed mood, weight
Mr. Smith, your labs showed
loss, insomnia, decreased
elevated HgA1c and cholesterol.
interest in hobbies, and strong
I'd like to start some medications
feelings of hopelessness, I’d like
to decrease your blood
to start a medication to treat
sugar and cholesterol. Hmmm...l don't
your depression.
know...what are
Okay, sounds the side effects?
good!

Okay, sounds
good!

Fig. 1.4 Psychiatric medication conversation versus that in other specialties

 1 Introduction to Psychiatry 7

Hospitalization Interventional Psychiatry

Starts Meds Interventional psychiatry utilizes modalities such as elec-

Improvement
troconvulsive therapy, magnetic seizure therapy, transcra-
nial magnetic stimulation, or ketamine/esketamine to treat
psychiatric conditions, especially treatment resistant-­
depression. Some interventions are aimed at the induction
Psychosis

of seizures, while others intervene through more focused

Discharge
stimulation of areas of the brain. Growing an understand-
ing of circuit dysfunction (how different focal areas of the
brain interact) is central to the development work in
neurostimulation. This is an exciting area of psychiatric
practice, offering novel ways to ameliorate and treat psy-
chiatric illness.
Stops Meds Maintenance We are still in the early days of interventional psychia-
try, with new modalities continuing to appear and optimal
use of older modalities still being defined. It has long been
appreciated that ECT is one of the most effective treat-
ments for depression, but it is not risk-free. Some patients
have significant cognitive side effects. However, MST has
been shown to be just as effective as ECT, with fewer
memory effects [12]. There is still much work to be done
Long-Acting in studying the frequency of treatments and the intensity of
Injectable (LAI) treatments for optimum recovery in the areas of interven-
Family Support tional psychiatry (Fig. 1.6).
Community Care

Fig. 1.5 Pharmacology and psychosis cycle

Transcranial magnetic
stimulation
Focal

Magnetic
field
TMS coil

Magnetic seizure
therapy (MST)
Spatial resolution

MST twin
Cl Cl
coll
NH NH2

O O
H OH
(R)-Ketamine (2R,6R)-HNK Electroconvulsive
therapy (ECT)
Cl Cl

NH2 NH
Electrode
O O
Non-focal

(S)-Norketamine (S)-Ketamine

Pharmacological Subconvulsive Convulsive

Type of intervention

Fig. 1.6 Interventional Psychiatry treatments. (From Hashimoto et al. [13]; with permission)
8 D. R. King and A. Brenner

Neuroscience

The Diagnostic and Statistical Manual of Mental Disorders

Self-report
(DSM) was written to standardize diagnoses across the
country and minimize subjectivity. This yielded reliability
in diagnosis, but did these diagnostic criteria accurately
reflect underlying pathology in the brain or specific genetic
abnormalities? Psychiatric illnesses are often called syn-
dromes in that they usually present with common clinical Behavior
symptoms, but the exact cause of the constellation of symp-
toms may be different or unknown [14]. Schizophrenia, for
example, can present in a variety of ways with high interin-
dividual variability. Such variability often calls into ques-
tion whether it is one illness or several different illnesses
that have not yet been differentiated. Genetics research into
DSM disorders has repeatedly found that a given disorder
Physiology
might be associated—though weakly—with genetic poly-
morphisms at many sites resulting in numerous potential
disease mechanisms. In addition, a particular mechanism
might be found to be implicated in several different DSM
disorders (Fig. 1.7) [15].
Several decades of research had accordingly produced rela-
tively little to show in terms of defining the etiologies of psy- Neural circuits
chiatric disorders. The NIMH developed a new strategy to
‘deconstruct’ the current disorders into intermediate areas of
neurobiological function and aim research efforts at these
‘domains.’ This new Research Domain Criteria (RDoC) is
aimed at relating core psychological processes to biological Cells
processes, with the hope that this will provide a new framework
for defining the boundaries of psychiatric disorders and their
subtypes based on empirical data from genetics and neurosci-
ence. The emphasis will be on neural circuits but will extend Molecules
‘downwards’ to the genetic and molecular elements and
‘upwards’ to the level of individuals, families, and social con-
texts. This approach may yield progress. RDoC was applied in
subjects with psychosis who would typically be diagnosed with
Genes
schizophrenia. Based on a large biomarker panel, subjects were
able to be classified into three categories which have become
known as “biotypes” (Fig. 1.8; Table 1.1) [16, 17].
In addition to biotypes, neuroscience research is also elu- Fig. 1.7 Psychiatric factors that influence the mental illness
cidating more models to help describe behaviors and link
behavior to anatomy and neural pathways within the brain. Another way to think about brain connectivity is to map
Nervous tissue varies depending on its location inside the functional areas in the cortex. Functional cortex maps today
brain. Cortical neurons and the global organization of such have usually been made by stimulating small areas and not-
neurons can be seen in Fig. 1.9. ing the effect. Figure 1.11 shows approximate functions of
When thinking about neurons and brain connectivity, it is different regions of the cortex.
helpful to know what a synapse is, and what neurotransmit- The human connectome project is also underway which
ters are most common at these synapses. An understanding seeks to map functional connectivity within the brain [18].
of synapses and neurotransmitters is very useful for Connectomes use MRI sequences to build a wiring diagram
understanding how medication and other chemical sub-
­ based on water molecules diffusing across white matter
stances interfere with these biological components (Fig. 1.10; tracts where spontaneous fluctuations contribute to positive
Table 1.2). and negative correlates that are then used to form a lesion
1 Introduction to Psychiatry 9

Fig. 1.8 Schema of the Schizophrenia Schizoaffective Disorder Psychotic Bipolar Disorder
bipolar and schizophrenia
network

Biotype 1

Cognitive
control Biotype 2
Sensorimotor
reactivity

Psychosis

Biotype 3

Table 1.1 Summary of research domains and biologic correlates

Negative affect Positive affect Cognition
Fear Reward seeking Attention
Distress Gratification Perception
Aggression Habit formation Memory
Executive function
Basolateral amygdala Mesolimbic dopamine system Parietal areas (attention)
Hippocampus Orbital frontal cortex Thalamic and occipital (perception)
Ventral medial prefrontal cortex Ventral and dorsal striatum Dorsolateral prefrontal cortex
Hippocampus
Anterior cingulate
Social processes Regulatory systems Sensorimotor systems
Attachment Arousal Motor actions
Parenting Sleep Agency
Separation anxiety Circadian rhythms Habit
Facial recognition Innate motor patterns
Oxytocin Reticular activating systems Inferior parietal cortex
Vasopressin Ventral tegmental area Posterior parietal cortex
Locus ceruleus Premotor cortex
Thalamus
Cerebellum
Somatosensory cortex
Sensorimotor basal ganglia
Hypothalamus
Motor cortex
Brainstem
Occulomotor system
From Tamminga et al. [16]; with permission
10
Fig. 1.9 Cortical and cerebral tissue
network with the goal of localizing neuropsychiatric symp-
toms (Fig. 1.12). Figure 1.13 shows the process by which
connectomes are created. Data is obtained from MRI images.
Images are labeled with five tissue types which are used to
create a fiber orientation distribution (FOD) that is then used
to create tractograms using anatomical constraints. A con-
nectivity matrix is generated from the tractogram and
network-­based statistics test for the white matter connectiv-
ity effects [19].
One of the major systems that concern psychiatry is the
limbic system shown in Fig. 1.14.
The limbic system is associated with basic emotional and
motivational processes such as anger, pleasure, sex, and gen-
eral survival. It consists of the limbic lobe (cingulate gyrus,
cingulate sulcus, and parahippocampal gyrus), hippocam-
pus, amygdala, hypothalamus, mammillary bodies, thala-
mus, and fornix. Neurons in the limbic system also extend
down into the brainstem and into other areas of the brain
such as the frontal cortex. Sensory neurons of the olfactory
system are also linked to the limbic system and influence
D. R. King and A. Brenner
memory formation and bring olfactory sensation into con-
sciousness. These structures are explained in more detail in
Fig. 1.15.
Emotions are thought to arise in the amygdala, brainstem,
and hypothalamus. An anatomic correlation with how emo-
tions may be initiated, expressed, and become conscious is
illustrated in Fig. 1.16. The frontal lobe is one area involved
in maintaining consciousness.
The amygdala can be considered the emotional “sensor”
of the brain. It receives emotional inputs from the rest of the
body, cortex, sensory cells, and hypothalamus. When the
amygdala fires, it sends information through the emotional
circuit shown in Fig. 1.17 and causes physical changes in the
body. Input from the frontal lobe evokes conscious aware-
ness of emotions. Positive emotions follow a slightly sepa-
rate circuit to include an area of the brainstem to produce
dopamine and a sense of positive reinforcement [20]. The
amygdala’s role in whether sensory information becomes
conscious or not is depicted in Fig. 1.18. The figure shows
two routes, a slow and accurate route, and a quick route. The
1 Introduction to Psychiatry 11

Dendrite Axons TYPES OF SYNAPSE

One of this neuron’s many
Dendritic dendrites is enlarged to show
spine various Synapse Structures,
according to where the axons
Neu of other neurons impinge on it.
ron
Cell body

Axosomatic Axospinodendritic Axodendritic Axoaxospinodendritic

synapse synapse synapse synapse

Axon Neurotubule

Axon
membrane

Microfilament Axon end

bulb
1

Neurotransmitter 2
molecules

Mitochondrion
Membrane
Presynaptic channel opens
membrane
Ions pass
Positive ions through channel
Synaptic cleft
3
Postsynaptic
membrane

Receptor site

Emptying
vesicle

1.) Synaptic vesicles store
neurotransmitters for release into
the synaptic cleft. Neurotransmitters
are produced in the neural soma
and transported through
neurotubules to the axon to be
stored in the synaptic vesicles.
2.) Synaptic vesicles fuse with the
axon end bulb membrane when
signalled by an action potential to
release the neurotransmitter
molecules into the synaptic cleft.
The neurotransmitters diffuse
across the cleft to the post-synaptic
membrane and interact with the
receptor sites.
3.) Neurotransmitters fit into the
post-synaptic receptor sites,
opening the channels, which allow
ions to pass through the channel.
This flow of ions creates
depolarization which if strong
enough will continue the action
potential that initially triggered
synaptic vesicle release.

Fig. 1.10 Structure of a synapse. (1) Synaptic vesicles store neu-
rotransmitters for release into the synaptic cleft. Neurotransmitters are
produced in the neural soma and transported through neurotubules to
the axon to be stored in the synaptic vesicles. (2) Synaptic vesicles fuse
with the axon end bulb membrane when signaled by an action potential
to release the neurotransmitter molecules into the synaptic cleft. The
neurotransmitters diffuse across the cleft to the post-synaptic mem-
brane and interact with the receptor sites. (3) Neurotransmitters fit into
the post-synaptic receptor sites, opening the channels, which allow ions
to pass through the channel. This flow of ions creates depolarization
which if strong enough, will continue the action potential that initially
triggered synaptic vesicle release
12 D. R. King and A. Brenner

Table 1.2 Common neurotransmitters and their post-synaptic

effects [20]
Excitatory and Mostly
Inhibitory inhibitory excitatory Excitatory
Serotonin Dopamine Acetylcholine Glutamate
Glycine Noradrenaline Aspartate
Gamma aminobutyric Histamine
acid (GABA)

Fig. 1.12 Sagittal view of human connectome or tractogram (From

Wikicommons. Author jgmarcelino from Newcastle upon Tyne, UK. 22
April 2010. https://creativecommons.org/licenses/by/2.0/deed.en. No
changes)

Fig. 1.11 Functional areas of the brain. The medial brodmann areas link areas that are associated with hearing, vision, memory, emotional insight,
and emotional reactions. The lateral brodmann areas include Broca’s area and are based on nerve-cell body arrangements
1 Introduction to Psychiatry
Fig. 1.13 Process of creating a
connectome
Fig. 1.14 Anatomy of the
limbic system
Cingulate gyrus
CoIumn of fornix
Mammillary bodies
Olfactory
bulbs
Fig. 1.15 A focus on structures of the limbic system. Cingulate Cortex:
The cingulate cortex shares extensive neural pathways with other brain
regions. It is involved in motivational processing as it connects to the
reward centers of the brain (orbitofrontal cortex, basal ganglia, and insula).
It also contributes to orienting attention, consolidation of long-term mem-
ory, and processing of emotionally relevant stimuli [21]. Stria Terminalis:
Pathways from the stria terminalis link the amygdala to the rest of the
brain and play a role in anxiety and stress responses [21]. Frontal Cortex:
The frontal cortex works in conjunction with the limbic system to produce
conscious feelings. It then modifies these emotions to fit socially accept-
able norms. It is also considered the “action cortex” as it contributes to
skeletal and ocular movement as well as speech control. The prefrontal
cortex is the largest part of the frontal cortex and is responsible for reason-
ing [22]. Olfactory Complex: Olfactory bulbs carry information directly
to the amygdala and hypothalamus to mediate behavioral, emotional,
motivational, and physiological effects of odors and smell. Information is
also projected through the thalamus to the orbitofrontal cortex to help with
the perception and discrimination of odors [23]. Thalamus: The thalamus
is a structure located near the center of the brain, which allows for nerve
fiber connections to the cerebral cortex in all directions. It is a major relay
station filtering information between the brain and body. Its connection to
the limbic system allows the thalamus to be involved in learning and epi-
sodic memory. It is also involved in sleep regulation and wakefulness. The
13
Fornix
Midbrain
Hippocampus
Amygdala
Hypothalamus
Pons
Parahippocampal
gyrus
thalamus is divided into five major functional components: reticular and
intralaminar nuclei (arousal, pain), sensory nuclei (medial geniculate
nucleus for auditory, lateral geniculate nucleus for visual, and ventrobasal
complex for somatosensory and vestibular), effector nuclei (motor lan-
guage), associative nuclei (cognitive functions), and limbic nuclei (mood
and motivation) [24]. Hippocampus: The hippocampus plays a crucial
role in the storage and retrieval of episodic memories. Episodic memory is
recollections about a specific event occurring at a certain time and place.
Patients with hippocampal damage struggle to create new episodic memo-
ries [25]. Amygdala: The amygdala receives afferent input from many
sites within the brain, including the olfactory bulb, olfactory nucleus,
medial frontal cortex, dorsomedial thalamic nucleus, hypothalamus, and
dorsal raphe nuclei. These sites provide internal and external information
that contribute to threat analysis and emotional responses. The amygdala
plays a role in acquired and innate emotional reactions, particularly fear,
anxiety, and rewarding properties of stimuli [23]. Corpus Callosum: The
corpus callosum facilitates communication between the left and right
hemispheres. Hypothalamus and mammillary body: The hypothalamus
integrates autonomic response and endocrine function with behavior con-
cerned with controlling blood pressure, body temperature, drive for water
or salt, emergency responses to stress, energy metabolism, and hormonal
control. The mammillary bodies assist with recollective memory, emotion,
and goal-directed behaviors [26]
14 D. R. King and A. Brenner

Cingulate Cortex Stria Terminalis Frontal Cortex

Olfactory Complex Corpus Callosum

Nasal bones

Hypothalamus and
Mammillary body
Thalamus

Hippocampus

Amygdala
Lateral Medial Medial Hypothalamus Mammillary
nucleus ventral dorsal body
posterior nucleus
nucleus
1 Introduction to Psychiatry 15

Fig. 1.16 Anatomical

representation of the
expression of emotions

Emotions arise: Conscious expression

The amygdala, hypothalamus and brainstem The amygdala and hypothalamus (blue)
give rise to emotion that is not yet conscious. are active in expressing emotion, while the
The orbitofrontal and cingulate cortex thalarnus (green) maintains consciousness.
contribute to conscious feelings.

Emotions expressed: Disgust

The thalamus in conjunction with the This cutaway shows the insula (red−also in
amygdala and hypothalamus ensure that top scan), part of which is active during the
emotions remain conscious. generation of emotion. particularly disgust.

Fig. 1.17 Processing

emotions through an emotion
circuit in the brain
16 D. R. King and A. Brenner

Conscious and unconscious routes play a role in the processing of

emotional stimuli. The unconscious route is rapid and also error
prone. It involves the amygdala to sense threat and produce
immediate physiological reactions. The conscious route is more
thoughtful and accurate. It involves the sensory cortex and the
hippocampus working in conjunction with the thalamus to confirm
or modify the initial response in a feedback recognition loop.

Hippocampus:
Perceived information is
Sensory Cortex: encoded into memories.
Input from the thalamus Information is transmitted
is assessed slowly for back to the thalamus to
conscious awareness. weigh in on appropriateness
of initial response for future
sensations.

Thalamus:
Relays sensory information
to the amygdala and
cortical areas to be
evaluated.

Hypothalamus:
Amygdala: Signals from the amygdala
Instantly judges emotional travel to the hypothalamus
input and communicates and trigger hormonal
with other parts of the brain release for physiological
to take immediate physical responses such as
Key action. This occurs increased heart rate,
Conscious Route unconsciously and is not diaphoresis and muscle
always accurate. contraction.

Unconscious Route

Fig. 1.18 Conscious and unconscious routes

quick route is in place to react very quickly to threats or
rewards which involves the amygdala. The slow route is pro-
cessed through the frontal lobes and is more thoughtful.
In addition to the limbic system, another important region
of the brain is the insula. The insula is thought to be respon-
sible for the feeling of “self” and the ability to distinguish
ourselves from others. In being aware of others, the insula
also plays a role in triggering empathic feelings. fMRI scans
had shown insula activity when participants watched another
person in pain. This phenomenon is shown in Fig. 1.19. The
insula also works as part of the process of bringing our emo-
tional state into consciousness.
1 Introduction to Psychiatry
Fig. 1.19 fMRI showing insula activity when participants witnessed
another individual in pain
Culture and Society
Treating mental illness requires more than knowing the psy-
chopathology, psychopharmacology, or presentation of an
illness. The missing piece is knowledge about the context
within which the illness arose. We have a growing evidence
base demonstrating that childhood trauma and deprivation
lead to adult psychiatric illnesses and that the social envi-
ronment has an enormous impact on whether and how adults
recover from serious mental illness. Different racial and eth-
nic communities are subject to very different exposure to
these ‘social determinants of mental health,’ leading to sig-
nificant disparities and inequities in mental health and treat-
ments [27]. In addition, humans are interpersonal creatures,
and our close attachments shape our development and
impact our health throughout our lives. Friendship has been
shown to decrease inflammation and extend longevity [28].
While we see an individual patient in our office, it is impor-
tant to realize that each patient is a member of a complex
network of relationships that further exist within a larger
societal structure ruled by various cultural dynamics
(Fig. 1.20) [29].
17
Work
School
Religion Language
Hobbies
Ethnicity
Family
Nationality
Beliefs
Community
Heritage
Fig. 1.20 Cultural factors
Pathology often arises out of isolation or when an indi-
vidual begins to struggle to function within the cultural and
societal framework. This should not be surprising—the
human brain and human culture co-evolved over millennia,
creating a new kind of primate that was both gifted at and
dependent on accumulated social learning. Different social
structures and cultures have a profound impact on the preva-
lence and presentation of many psychiatric illnesses. As psy-
chiatrists, we often see patients afflicted by environments so
harsh or isolation so intense that medication will do very
little to improve their psyche (Fig. 1.21).
It is only when their environment improves or they gain
more support in their life that change occurs. In this way, we
see that relationships can help or hinder a person’s growth
and well-being. When treating patients from a culture differ-
ent from your own—and even your own, it is also important
to be both humble and curious and know that false assump-
tions can be made that might lead to the wrong diagnosis and
ineffective treatment. The DSM encourages the use of the
18
Fig. 1.21 Child trauma has a lasting effect
Fig. 1.22 Psychiatrist listening to a patient
D. R. King and A. Brenner
cultural formulation to thoroughly explore cultural factors
with patients to ensure that patients are well understood so
that an individualized treatment plan can be established [30].
Narrative Meaning and Psychotherapy
A unique aspect of human beings, compared to all other social
animals, is our use of language to create narrative meaning
from our experiences. Each patient’s experience of childhood
adversities or social determinants of mental health is unique
because what it meant to them subjectively cannot be under-
stood without careful listening. Similarly, each patient with a
serious mental illness has a powerful story to tell of how their
identity, relationships, and hopes for the future have been
impacted. Psychiatrists learn how to listen carefully to their
patients to integrate this subjective dimension into their under-
standing of the patient’s condition. At the same time, connect-
ing with the patient’s story is one of the most powerful ways to
build an effective treatment alliance (Fig. 1.22) [31].
1 Introduction to Psychiatry 19

Technology
Technology can be both a blessing and a curse. As new tech-
nologies are created, new opportunities to study how they
influence our mental health also arise as well as new ethical
dilemmas. While computers have made information more
convenient and accessible than ever before, online gaming
and social media introduce new challenges, as many users
are finding some of these sites highly addictive. What impli-
cations will this have on the future and on the mental health
of children and adolescents? Social media and mobile phone
apps not only provide information with one swipe but also
collect information just as easily. What do your online use
patterns tell us about your mental health? How ethical is it to
collect this anonymously and utilize it for research, market-
ing, or health care? With the creation of more technology, we
must also think about how it may be influencing our com-
munity and us.
Another area of innovation and development is in the
arena of mobile phone applications. There are already many
apps in the marketplace that say they promote mental well-
ness by offering meditation, CBT, journaling, mood track-
ing, and even smoking cessation. The effectiveness of these
apps and whether they are beneficial or not remains to be
seen and is an area of active research. For any app, it is
important to evaluate it, considering your overall goal,
­privacy settings, evidence, and usability of the app. This
method is described in more detail on the APA website and is
known as the app evaluation model (Fig. 1.23) [32, 33].
Technology is expanding to offer new mental health treat-
ments, but as always, ethics and evidence must take priority
to avoid repeating the mistakes of the past.

Data
Level 5 : Data Integration Ownership
Access/Export

Clinically Actionable

Therapeutic Alliance

Level 4 : Ease of use Specific to Users / Accessibility

Short Term Usability Long Term Usability

First Impressions Clinical Validity

Level 3 : Evidence Based
Impressions After Using User Feedback Supporting

Level 2 : Privacy/Security Data Collected Data Storage Deleting Personal Data

Personal Health Information Security Measures in Place Privacy Policy

Level 1 : Background Info Business Model Credibility Medical Claims

Technical Costs / Advertising Stability

Level 1 : Background Info Level 2 : Privacy/Security Level 4 : Ease of use

• Does the app identify funding sources and
conflicts of interest?
• Does the app identify ownership?
• Does the app come from a legitimate source?
• Where does app info originate?
• Are there additonal or hidden costs?
• Does the app need an active internet
connection?
• On what plaforms does the app operate?
• Has the app been updated in the last 180
days?
• Is there a privacy policy? • Are there potential barriers to access?
• Does the app declare data use and purpose? • Can the user easily understand how to
• Does the app describe use of PHI? use the app?
• Can you opt out of data collection or delete • Is the app easy to use on a long-term basis?
data? • Does the app clearly define its functional scope?
• Are data maintained on the device or the web?
• Does the app explain security systems used? Level 5 : Data Integration
Level 3 : Evidence Based • Do you own your data?
• Can you easily access your data?
• Does the app do what it claims to do? • Can you easily share your data?
• Is app content correct, well-written and • Does the app lead to any postive behavior
relevant? change?
• Are references included with the app? • Does the app improve therapeutic alliance between
• Is there evidence of benefit from end user patient and provider?
feedback?

Fig. 1.23 App Evaluation model (From Lagan et al. [32]; Creative Commons Attribution 4.0 International License, http://creativecommons.org/
licenses/by/4.0/)
20
Subspecialties of Psychiatry
Entering a career in psychiatry means choosing to work in a
field that is still forming, growing, and constantly reassess-
ing its identity. Psychiatrists often report greater career satis-
faction and lower levels of burnout compared to other
specialties. It is highly customizable with options to further
specialize by doing a fellowship after completing residency.
Addiction Psychiatry
In 2014, it was estimated that 20.1 million adults in the
United States have a substance use disorder, and of those,
about 7.9 million adults have both a substance use disorder
and mental illness [34]. The COVID-19 pandemic has also
greatly affected those with substance use disorders.
According to the CDC, over 81,000 drug overdose deaths
have occurred in the United States from June 2019 to May
2020. This is the highest number of overdose deaths ever
recorded in a 12-month period and is thought to be due to the
covid-19 pandemic (Fig. 1.24) [35].
Addiction psychiatry focuses on helping individuals com-
pelled to use addictive chemical substances despite the
adverse consequences that severely limit their function, rela-
tionships, and mental health. Addiction psychiatrists are
trained in understanding the psychosocial, environmental,
and genetic factors that all play a role in addiction. They pre-
scribe medications such as naltrexone or opioid replacement
therapies, which have shown to be effective in reducing crav-
ings and compulsive use. Addiction psychiatry fellows learn
how to effectively combine medication, psychotherapy, and
motivational interviewing to be optimally effective in help-
ing patients with addiction recover. The alcoholics anony-
mous model is free and welcoming to all. It is one of the
most effective paths to abstinence and lowers health care
Fig. 1.24 Percentage of
overdose deaths involving
opioid and stimulant Most Overdose
combinations (Data from Deaths Involve
CDC [37]) One or More
Illicit Drugs
The 10 most frequently
occurring opioid and stimulant
combinations accounted for
76.9% of overdose deaths.
Illicitly Manufactured Fentanyls*
Heroin
Prescription Opioids
Cocaine
Methamphetamine
D. R. King and A. Brenner
costs. There are over two million members in AA worldwide
(Fig. 1.25) [35].
Child and Adolescent Psychiatry
The CDC reports that 1 in 6 children aged 2–8 has a mental,
behavioral, or developmental disorder. The percentage of
children diagnosed with depression or anxiety between the
ages of 2–17 increases each year. As children age, it becomes
more common to receive a diagnosis of depression or anxiety
(Fig. 1.26).
Child and adolescent psychiatrists work with children
and their families to effectively manage and treat mental,
behavioral, and developmental disorders. Early diagnosis
and treatment of children with these conditions can make
all the difference in their quality of life going forward.
Childhood symptoms can differ from those that appear in
adult mental illness. It is important to recognize moderate
to severe symptoms that persist over time that may indicate
either progression towards a mental illness or neurobiologi-
cal disorder. Symptoms in children can change, overlap,
and appear very different from those found in adults.
Figure 1.27 shows how the brain continues developing
throughout childhood to adulthood, a likely contributor to
these differences.
The National Institute of Mental Health (NIMH) recom-
mends that children with depression plus severe attention
deficit hyperactivity disorder (ADHD) symptoms such as
mood changes and temper outbursts be evaluated for bipolar
disorder [36]. Figure 1.28 shows a SPECT scan of a 7-year-­
old boy with enlarged ventricles and symptoms of irritability,
paranoia, and auditory and visual hallucinations. At the time
of imaging, he was diagnosed with Bipolar I, but due to the
enlarged ventricles and thought disorder, the schizoaffective
disorder may also be likely [36].
19.8%
10.5%
10.3%
9.2%
6.3%
5.5%
5.1%
3.7%
3.3%
3.2%
1 Introduction to Psychiatry 21

Fig. 1.25 Alcoholics Anonymous Group

Fig. 1.26 Prevalence of Age

mental disorders in children 0 1 2 3 4 5 6 7 8 9 10 11 12
varies by age
Boys
Conduct disorders
Girls Prevalence 4% 3x boys
Girls = Boys
Emotional disorders <aged 10.3% Aged 10+ (by
GAD most common adolescence
25% mild
depression)

School refusal
School
1% school
refusal
absences

Elimination disorders
10% aged 5, 5% aged 10

Hyperkinetic disorders/ADHD
UK prevalence < 1% 3x boys

Developmental disorders; prevalence 0.2% 3x boys

Sleep disorders:
common Psychosis (rare)
3% night terrors
22 D. R. King and A. Brenner

Perceptual areas
fully myelinated. Very weak
Very little frontal frontal lobe
lobe myelination. connections

Myelination
These images show the progression
of myelination from age 5 to age 20.
Myelination increases the
connectivity between different
regions of the brain to facilitate the
transmission of electrical signals.
This allows a person to fully perceive
and interpret sensory information as
well as make sound decisions about
future actions. The better the
connectivity, the better the decisions
on how to act on sensory input.
5 YEARS 8 YEARS

Frontal Myelination Myelination

connections achieved is achieved
continuing to between throughout
form, posterior frontal lobes the entire
brain and perceptual brain but new
connections areas, but links continue
better formed. connections to form.
are still
forming and
being
redesigned.

12 YEARS 18 YEARS 20 YEARS

Full myelination Partial myelination No myelination

Fig. 1.27 Myelination process from childhood to adulthood

Consultation-Liaison Psychiatry
Physical illness often affects the emotional state of a
patient. A patient hospitalized for burn wounds with severe
pain may become depressed, resulting in weight loss, anhe-
donia, feelings of hopelessness, decreased motivation, and
even suicidal thoughts. Depression and other mental ill-
nesses in hospitalized patients can result in increased mor-
bidity and mortality as well as prolonged hospital stays.
Consult-liaison psychiatrists specialize in diagnosing and
treating patients who are being cared for on medical or sur-
gical services in the hospital. Consult-liaison psychiatrists
may also work closely with services where psychiatric
morbidity is the highest and has the greatest effect on treat-
ing patient’s medical condition as oncology, pain, pediat-
rics, or geriatric services [38]. Figure 1.29 shows how
stress can lead to mental or physical illness. There are few
illnesses that only affect the body and not the mind, and
vice versa. Many patients referred to the consult-liaison
service have medical comorbidities in conjunction with
psychiatric illness or behavioral disturbances. Psychiatrists
in this field work diligently to determine which symptoms
are due to an underlying medical condition and which
symptoms are primarily psychiatric in nature.
1 Introduction to Psychiatry 23

Consult-liaison training provides expertise in the manage-

ment of delirium and agitation, assessment of capacity to
make medical decisions, and conflict resolution between the
patient and the primary medical team. Capacity is an impor-
tant topic to be familiar with and means that a patient can
understand their illness, what is recommended for treatment
of the illness, and the consequences of accepting or rejecting
the treatment. Figure 1.30 describes the key features of
capacity.

Forensic Psychiatry

Forensic psychiatry works at the intersection of psychiatry

Fig. 1.28 SPECT scan of a 7-year-old boy experiencing paranoia and
hallucinations (Reprinted from Taylor [36]; with permission)
and the law. Forensic psychiatrists perform evaluations for
criminal and civil matters. Forensic psychiatrists are experts
at analyzing the complex questions of causation and account-
ability around mental illness and criminal behavior. Forensic
psychiatry fellows learn to evaluate referred inmates and
civilians. Some of their work includes writing a professional
opinion concerning an inmate’s consideration for a “Not
Guilty By Reason of Insanity (NGRI)” plea. When an indi-
vidual is unable to work with an attorney for behavioral or

Fig. 1.29 Relationship 1. Coincidental occurence

between stress, mental illness, Mental illness
and physical illness

Stress

Physical illness

2. Mental illness causes physical illness

. Drugs/alcohol abuse
. Deliberate self harm
. Accidents (Due to
↓ impluse control, ↓concentration, medication)
. Psychotropic medication side-effects

3. Physical illness causes mental illness

. Organic psychiatric disorders

(e.g. delirium)
. Prescribed drugs (e.g. steroids can
cause depressive disorder)
24 D. R. King and A. Brenner

DO PRINCIPLE DON’T

ASSUME PEOPLE Assume someone lacks

RETAIN
“Last time I saw you, you
said it might help my blood
pressure if I lost weight, I
didn’t like the sound of the
side effects the blood
pressure tablets might have”
USE OR WEIGH
“I dont want to take the tablets
if I can avoid it. I think I could
try harder to lose weight. Even
if I do nothing I’ve got a good
chance of being OK”
Formally assess capacity
Take the time to help people
understand and make
decisions. If they may regain
capacity and it is possible to
wait, then do so
HAVE CAPACITY capacity on the basis of
UNLESS PROVED factors such as their age or
OTHERWISE diagnosis
View capacity as a static
HELP PEOPLE
phenomenon−it will change
MAKE THEIR OWN over time and will be affected
DECISIONS by the way in which you
communicate information

PEOPLE HAVE THE

Base your assessment of Conclude that someone
RIGHT TO MAKE
capacity on how the person doesn’t have capacity
WHAT YOU THINK
UNDERSTAND arrives at their decision, not because you disagree with
ARE UNWISE
COMMUNICATE on what they decide their decision
DECISIONS
“If I take the tablets,
my risk of having a heart “I've decided not to take
attack or stroke in the next the tablets. I’m going to
10 years will go down from make more effort to lose Use whatever means
15% to 10%” WHEN SOMEONE
weight and come to see available to decide what the Assume you know what is
you again in a few LACKS CAPACITY,
person would have wanted best for other people
months” ACT IN THEIR BEST
for themselves if they had
INTERESTS
capacity

WHEN SOMEONE
Think about the least LACKS CAPACITY
intrusive and restrictive DO NOT RESTRICT Do more than is necessary
means of achieving what is THEIR LIBERTY
in the person’s best interests MORE THAN IS
NECESSARY

Fig. 1.30 Elements of mental capacity

Geriatric Psychiatry

It is estimated that about 20% of individuals age 55 and

Fig. 1.31 Jail cell
developmental reasons, a forensic psychiatrist will evaluate
for competency to stand trial. If a person is deemed incompe-
tent to stand trial because of mental illness, they receive
treatment and are periodically reevaluated by a forensic psy-
chiatrist until competency is achieved. On the civil side,
some of the things forensic psychiatrists do include disabil-
ity, return to work, and testamentary capacity evaluations
(Fig. 1.31).
older have a mental health condition, including depression,
bipolar disorder, anxiety disorders, or severe cognitive
impairment [39]. Depression is not a normal part of aging
and can increase the risk of suicide. When treating depres-
sion in geriatric patients, it is important to reduce sensory
isolation, help with isolation and provide geriatric doses for
medications. Figure 1.32 summarizes the management of
depression in geriatric adults.
Men age 85 and older have a suicide rate of 45.23 per
100,000, approximately four times as high as the general
population [39]. Geriatric psychiatry fellows are trained in
the diagnosis and treatment of psychiatric and neurocogni-
tive disorders of the elder. A strong emphasis is placed on
learning to help families, patients, and caregivers manage
mental illness and neurocognitive impairment in the aging
population. Brain changes are normal as a person progresses
in age; however, some changes, such as Parkinson’s and
other dementias, produce pathological changes. The follow-
ing figures compare a typical adult brain to a normal geriatric
brain and finally, compare all three to that of a person with
Parkinson’s disease (Figs. 1.33 and 1.34).
1 Introduction to Psychiatry 25

Fig. 1.32 Treating

depression in older people
Reduce sensory
isolation, e.g. glasses, Treating Talking therapies
hearing aids depression
in older
people

Reduce
ECT for severe
social isolation,
depression, especially if
e.g. day centers, other
refusing fluids or food
daytime activities Medication

Subarachnoid space
Basal ganglia Basal ganglia Enlargement of the
Imaging is reflective Imaging shows brighter Subarachnoid space subarachnoid space
of normal basal areas of intensity due Typical area of the due to decreased brain
ganglia cells. to the presence of iron. subarachnoid space. volume over time.

27-Year-old 87-Year-old 27-Year-old 87-Year-old

Basal ganglia:
The basal ganglia is involved in motor function. These MRI
scans show the differences between the basal ganglia of a
27 year old and that of an 87 year old.
Subarachnoid space:
As the brain ages, the subarachnoid space increases due
to shrinkage in brain volume. This puts elderly individuals
at risk for shearing of vessels in the subarachnoid space
with a fall or other physical trauma leading to hemorrhage.

Ventricles White-matter tract

Ventricles have visibly White-matter tract White matter tracts
Ventricles enlarged and general Normal white matter change in appearance
Typical size of ventricles reduction in gray matter tracts are seen in the perhaps due to
in the younger brain. can also be seen. 27 year old scan. fewer glial cells.

27-Year-old 87-Year-old 27-Year-old 87-Year-old

Ventricles: White-matter tracts

Ventricles enlarge with age due to the reduction of gray White matter tracts consist of glial cells which translates
matter overtime. They also help cushion the brain from to “neural glue”. These cells support neurons and help
injury and carry hormones. them operate more efficiently.

Fig. 1.33 Changes in brain structures with age

26 D. R. King and A. Brenner

Fig. 1.34 Mean parametric maps of functional dopamine utilization differences between healthy young, healthy aged, and Parkinson’s brain [40]
1 Introduction to Psychiatry
Future of Psychiatry
In addition to providing medication, psychiatrists also pro-
vide hope, guidance, and encouragement to patients. To
enjoy a career in psychiatry, it helps to be empathic and
enjoy talking to patients about their struggles. Overall, psy-
Fig. 1.35 Psychiatry as a
tool to improve lives
27
chiatry is a very rewarding field where the treatment of one
patient can provide direct relief to them, have a positive
impact on their families and communities, and benefit gen-
erations to come (Fig. 1.35). For more about the future of
psychiatry, see Chap. 25.
Psychiatry
28 D. R. King and A. Brenner

References 20. Carter R, Aldridge S, Page M, Parker S. The human brain book.
New York: DK Publishing; 2019.
21. Jumah F, Dossani R. Neuroanatomy, cingulate cortex. Treasure
1. Porter R. Madness a brief history. New York: Oxford University
Island, FL: StatPearls Publishing; 2021.
Press; 2002.
22. El-Baba R, Schury M. Neuroanatomy, frontal cortex. Treasure
2. Bynum B, Bynum H. Trepanned cranium. Lancet.
Island, FL: StatPearls Publishing; 2021.
2018;392(10142):112.
23. Kandel E, Schwartz J, Jessell T. Principles of neural science. 4th ed.
3. Wilson J, Reynolds E. Texts and documents. Translation and analy-
New York: McGraw-Hill; 2000.
sis of a cuneiform text forming part of a babylonian treatise on
24. Torrico T, Munakomi S. Neuroanatomy, thalamus. Treasure Island,
epilepsy. Med Hist. 1990;34(2):185–98.
FL: StatPearls Publishing; 2021.
4. G. d. Champeaux, I Simboli del medio evo, Milan; 1981.
25. Knierim J. The hippocampus. Curr Biol. 2015;25(23):R1116–21.
5. Berchtold N, Cotman C. Evolution in the conceptualization of
26. Peterson D, Reddy V, Mayes D. Neuroanatomy, mammillary bod-
dementia and Alzheimer’s disease: Greco-Roman period to the
ies. Treasure Island, FL: StatPearls Publishing; 2021.
1960s. Neurobiol Aging. 1998;19(3):173–89.
27. Shim R, Compton M. Addressing the social determinants of
6. Rahimi M, Shokri F, Hassanian-Moghaddam H, et al. Severe cam-
mental health: if not now, when? If not US, who? Psychiatr Serv.
phor poisoning, a seven-year observational study. Environ Toxicol
2018;69:844–6.
Pharmacol. 2017;52:8–13.
28. Snyder-Mackler N, Burger J, Gaydosh L, Belsky D, Noppert
7. Dambricourt-Malassé A, Cao B, You Q, Zhang P. Agro-­
G, Campos F, Bartolomucci A, Yang Y, Aiello A, O’Rand A,
pastoral rituals and shaman dances of Dahongyan rock painting,
Harris K, Shively C, Alberts S, Tung J. Social determinants
Guizhou, southwestern China, new investigations. Quanter Int.
of health and survival in humans and other animals. Science.
2019;507:43–52.
2020;368(6493):eaax9553.
8. Myers D. Klinische psychologie: therapie, In: Psychologie; 2014.
29. Robbins M, Howe-Martin L. Beyond the therapy dyad: the impor-
9. Baxter W. American psychiatry celebrates 150 years of caring.
tance of systems and culture. In: Psychotherapy: a practical intro-
Psychiatr Clin N Am. 1994;17(3):683–93.
duction. Philadelphia, PA: Wolters Kluwer; 2021. p. 211–36.
10. Loyola University Department of Psychology. Clinical psychol-
30. American Psychiatric Association. DSM-5® handbook on the cul-
ogy program; 2020. https://www.luc.edu/psychology/graduate/.
tural formulation interview. Washington, DC: American Psychiatric
Accessed 5 Oct 2020.
Association Publishing; 2020.
11. Goldberg JF, Ernst CL. The psychiatrist as physician. In: Managing
31. Brenner A, Howe-Martin L. Psychotherapy: a practical introduc-
the side effects of psychotropic medications. Washington, DC:
tion. Philadelphia, PA: Wolter-Kluwer; 2020.
American Psychiatric Association; 2019. p. 3–45.
32. Lagan S, Aquino P, Emerson MR. Actionable health app evalua-
12. National Institute of Mental Health. Brain Stimulation
tion: translating expert frameworks into objective metrics. NPJ
Therapies; June 2016. https://www.nimh.nih.gov/health/top-
Digit Med. 2020;100(3):1–8.
ics/brain-­s timulation-­t herapies/brain-­s timulation-­t herapies.
33. American Psychiatric Association. App Advisor; 2020. https://
shtml#:~:text=Magnetic%20seizure%20therapy%20(MST)%20
www.psychiatry.org/psychiatrists/practice/mental-­health-­apps.
borrows,than%20that%20used%20in%20rTMS. Accessed 5 Oct
Accessed 5 Oct 2020.
2020.
34. SAMHSA. Substance Use & Mental Illness in U.S. Adults,; 2014.
13. Hashimoto K. Rapid-acting antidepressant ketamine, its metabo-
https://www.samhsa.gov/sites/default/files/infographics/nsduh-­
lites and other candidates: a historical overview and future perspec-
infographic.jpg. Accessed 3 March 2021.
tive. Psychiatry Clin Neurosci. 2019;73(10):613–27.
35. Stanford Medicine News Center. Alcoholics anonymous most
14. Heldt MJ. Diagnosis. In: Memorable psychiatry. Jonathan Heldt;
effective path to alcohol abstinence. 11 Mar 2020. https://med.
2018. p. 3–15.
stanford.edu/news/all-­news/2020/03/alcoholics-­anonymous-­most-­
15. Weinberg D, Lenroot R, Jacomb I. Cognitive subtypes of schizo-
effective-­path-­to-­alcohol-­abstinence.html. Accessed 2021.
phrenia characterized by differential brain volumetric reductions
36. Taylor EH. Atlas of bipolar disorders. Boca Raton, FL: CRC Press;
and cognitive decline. JAMA Psychiatry. 2016;73(12):1251–9.
2006.
16. Tamminga CA, Pearlson G, Stan A, Gibbons R, Padmanabhan J,
37. Center for Disease Control. Overdose Deaths Accelerating During
Keshavan M, Clementz B. Strategies for advancing disease defi-
COVID-19 Press Release; 17 December 2020. https://www.cdc.
nition using biomarkers and genetics: the bipolar and schizophre-
gov/media/releases/2020/p1218-­overdose-­deaths-­covid-­19.html.
nia network for intermediate phenotypes. Biol Psychiatry Cogn
Accessed 3 March 2021.
Neurosci Neuroimaging. 2017;2(1):20–7.
38. Stevens L, Rodin I. Psychiatry: an illustrated colour text. London:
17. Clementz B, Sweeney J, Hamm J, Ivleva E, Ethridge L, Pearlson G,
Churchill Livingstone; 2010. p. 16.
et al. Identification of distinct psychosis biotypes using brain-based
39. Centers for Disease Control and Prevention and National
biomarkers. Am J Psychiatry. 2016;173:373–84.
Association of Chronic Disease Directors. The State of Mental
18. The Human Connectome Project. Neuroimaging and Martinos
Health and Aging in America Issue Brief I: What do the data tell us?
Center for Biomedical Imaging, Consortium of the Human
2008. https://www.cdc.gov/aging/pdf/mental_health.pdf. Accessed
Connectome Project; 2020. http://www.humanconnectomeproject.
March 2021.
org/. Accessed 2 Oct 2020.
40. Cumming P. Imaging dopamine. New York: Cambridge University
19. Osetreich L, Randeniya R, Garrido M. White matter connectivity
Press; 2009.
reductions in pre-clinical continuum of psychosis: a connectome
study, vol. 40. Wiley Periodicals; 2019. p. 529–37.
 Epidemiology of Psychiatric Disorders
William W. Eaton
Introduction: What Is a Case?
Epidemiology is the study of diseases in populations [1].
Some have simplified the definition to be the study of rates—
i.e., the study of a fraction with a numerator including cases
of disease and a denominator including the entire population
[2]. The purpose of epidemiologic research is to estimate the
burden of the disease on the population, to suggest clues to
the etiology of the disease, and to help design strategies to
prevent or treat the disease in the population [3].
Many diseases have a simple cause (e.g. a germ) and a
straightforward and valid test as to the presence of the dis-
ease (viewing the presence of the germ in a blood sample), as
well as a simple treatment (e.g., an antibiotic). If a disease is
viewed as a distinct change in the function of the neurology
and physiology of the organism, then it is clear that this strict
definition of disease is not appropriate in psychiatry, where
the more general term disorder is used for describing the ill-
nesses. The complex nature of the target illnesses produces
important problems for psychiatric epidemiology. There are
five textbooks in psychiatric epidemiology [4–8].
One important problem is deciding which behaviors
observed by the therapist or complaints reported by the sub-
ject should be treated as symptoms and signs of medical ill-
ness. Similar to blood pressure, there is a wide range of
W. W. Eaton (*)
Department of Mental Health, Johns Hopkins Bloomberg School
of Public Health, Baltimore, MD, USA
e-mail: weaton1@jhu.edu
© Springer Nature Switzerland AG 2023
W. W. IsHak (ed.), Atlas of Psychiatry, https://doi.org/10.1007/978-3-031-15401-0_2
2
thresholds in psychiatric signs and symptoms, which require
decisions as to when the disorder is actually present and
when treatment is merited. There is added complexity for
psychiatry because the co-occurrence of a range of different
signs and symptoms at different thresholds will contribute to
the decision as to the presence of a disorder. These complexi-
ties are an area where psychiatric epidemiology produces
useful information facilitating a decision about criteria for
the presence or absence of a disorder. In some cases, such as
schizophrenia, the presentation of the disorder is relatively
similar from country to country, as in Fig. 2.1 from the
International Pilot Study of Schizophrenia (IPSS) [9]. The
IPSS was one of the earliest international collaborative stud-
ies in the field of psychiatric epidemiology based on hospital
admissions. The syndrome profiles for persons diagnosed
with schizophrenia are similar in high-income countries such
as Denmark and London to low-income situations such as
Cali, Colombia, and Agra, India. For example, the psycho-
motor disorder is reported in less than 20% of patients in all
five countries, but distorted self-perception is reported in
more than 80% of patients in all five countries. For many
other psychiatric disorders, the symptom profile is more
complex and varies around the world, making it a statistical
and clinical challenge to decide precisely how to define a
case of disorder [10, 11].
29
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the happy adventurers had hauled their boats, two entire planks of
the Red Eric were devoted to the kindling of a large cooking-fire, and
they enjoyed a bountiful and savage feast.
Such is an experience of Arctic life; of the hardships endured by
the heroic men who go forth to do the work of Science and
Civilization.
Returning to the seals, we may remark that, according to a
scientific authority, the angle of weedy rock on which a phoca is
accustomed to rest with his family comes to be regarded as his
property, and no other individuals of his species are entitled to lay
claim to it. Although in the water these animals congregate together
in numerous herds, and protect and courageously defend one
another, yet, when they have once emerged from their favourite
element, they regard themselves on their own space of rock as in a
sacred domicile, where no comrade has a right to intrude on their
domestic tranquillity. If any stranger approach this family centre, the
chief—or shall we call him the father?—prepares to repel by force
what he considers an unwarrantable encroachment; and a terrible
combat invariably ensues, which terminates only with the death of
the lord of the rock, or the compulsory retreat of the intruder.
But a family never seizes upon a larger tract than it absolutely
requires, and lives peaceably with neighbouring families, from which
it is seldom separated by a greater interval than forty or fifty paces. If
compelled by necessity, they will even live on amicable terms at
much closer quarters. Three or four families will share a rock, a
cavern, or an ice-floe; but each occupies the place allotted to it at the
original apportionment, and shuts himself within it, so to speak, nor
ever meddles with individuals of another family.
 THE OTARY.
Our modern naturalists divide the Phocidæ into two distinct
orders: the Phocæ properly so called, which have no external ears,
but only an auditory orifice on the surface of the head; and the
Otariæ, which are provided with external organs.
The remarks we have been making apply more particularly to the
common seal (Phoca vitulina), or small Spitzbergen seal, which
measures from four to five feet in length. The Greenland or harp seal
(Phoca Grœnlandica), to which we have already alluded, is larger
and fatter, and is distinguished by the changes of colour it undergoes
before it reaches maturity. We have also spoken of the bearded seal
(Phoca barbata), which sometimes attains a length of ten feet, and is
known, not only by its size, but its thick and strong moustaches. The
hooded seal (Stemmatopus cristatus) is distinguished by the globular
and expansible sac situated on the summit of the head of the males.
This species grows to the length of seven or eight feet, and inhabits
the waters of Newfoundland and Greenland.
The value of the seal to the Eskimo tribes will best be understood
from a description of the uses to which various parts of the animal
are applied in an Eskimo hut.
 THE HOODED SEAL.
We will suppose this hut to measure about five or five and a half
feet in height, and about ten feet in diameter. The walls are made of
stones, moss, and the bones of seals, narwhals, whales, and other
ocean-creatures. They are not arched, but recede inward gradually
from the foundation, and are capped by long oblong slabs of slate-
stone extending from side to side. We enter: the flooring consists of
thin flat stones. At the back part of the hut the floor rises about a
foot, and this breck, as the elevation is called, serves both as couch
and seat, being covered with a thick layer of dried moss and grass,
under seal-skins, dog-skins, and bear-skins. Similar elevations are
placed at the corners in front; under one of which will lie, perhaps, a
litter of pups, with their mother, and under the other a portion of
seal’s meat. In the square front of the hut, above the passage-way, a
window is inserted; the light being admitted through a square sheet
of strips of dried intestines, sewed together. The entrance is in the
floor, close to the front wall, and is covered with a piece of seal-skin.
Seal-skins are hung about the walls to dry. At the edge of the breck,
on either side, sits a woman, each busily engaged in attending to a
smoky lamp, fed with seal’s oil. These lamps are made of soapstone,
and in shape resemble a clam-shell, being about eight inches in
diameter. The cavity is filled with oil obtained from seal’s blubber;
and on the straight edge the flame burns quite vividly, the wick which
furnishes it being made of moss. The business of the women is
apparently to prevent the lamps from smoking, and to keep them
supplied with blubber, large pieces of which are placed in the cavity,
the heat drawing out the oil. About three inches above this flame
hangs, suspended from the ceiling, an oblong square pot made of
the same material as the lamp, in which a joint of seal is simmering
slowly. Above this hangs a rack, made of bare rib-bones, bound
together crosswise, on which stockings and mittens, and various
garments made of seal-skin, are laid to dry. No other fire can be
seen than that which the lamps supply, nor is any other needed. So
many persons are crowded into the confined interior that it is
insufferably hot, while the whole place reeks with the smell of seal-
flesh, seal-oil, and seal-skin!

It is natural enough that we should here introduce an account of

the Eskimo mode of catching seals. The great season of the seal-
hunt is the spring, when the inoffensive phocæ gambol and sport in
the open water-ways near the coasts, or clamber on the ice-floes to
enjoy the rays of the tardy sun. They are of a wary and timid
disposition, and we may suppose that their traditions have taught
them to be on their guard against man; but as all their habits and
ways are well known to the Eskimo, they do not succeed in eluding
his dexterous perseverance. Sometimes the hunter attires himself in
a seal-skin, and so exactly imitates their appearance and
movements that he approaches within spear-range of them before
the disguise is detected; or else he creeps into their haunts behind a
white screen, which is propelled in front of him by means of a sledge.
As the season verges upon midsummer less precaution becomes
necessary; the eyes of the seals being so congested by the fierce
radiance of the sun that they are often nearly blind. In winter they are
assailed while labouring at their breathing-holes, or when they rise
for the purpose of respiration.
If an Eskimo satisfies himself that a seal is working away beneath
the ice, he takes up his station at the suspected point, and seldom
quits it, however severe the weather, until he has captured the
animal. To protect himself from the freezing blast, he throws up a
snow-wall four feet in height, and seating himself in its shade, he
rests his spears, lines, and other appliances on a number of little
forked sticks inserted into the snow, in order that he may move them,
when wanted, without making the slightest noise. He carries his
caution to such an excess, that he even ties his own knees together
with a thong to prevent his garments from rustling! about
 AN ESKIMO SEAL-HUNTER.
To discover whether the seal is still gnawing at the ice, our patient
watcher makes use of his keep-kuttuk; a slender rod of bone, no
thicker than ordinary bell-wire, cleverly rounded, with a knob at one
end and a sharp point at the other.
This implement he thrusts into the ice, and the knob, which
remains above the surface, informs him by its motion whether the
animal is still engaged in making his hole; if it does not move, the
attempt is given up in that place, and the hunter betakes himself
elsewhere. When he supposes the hole to be nearly completed, he
stealthily raises his spear, and as soon as he can hear the blowing of
the seal, and knows therefore that the ice-crust is very thin, he drives
it into the unsuspecting animal with all his might; and then hacks
away with his sharp-edged knife, or panna, the intervening ice, so as
to repeat his blows, and secure his victim. The neituk, or Phoca
hispida, being the smallest seal, is held while struggling, either by
the hand, or by a line one end of which is twisted round a spear
driven into the ice. In the case of the bearded seal, or oguka, the line
is coiled round the hunter’s leg or arm; for a walrus, round his body,
the feet being at the same time firmly planted against a hummock of
ice, so as to increase the capability of resistance. A boy of fifteen
can kill a neituk, but the larger animals can be mastered only by a
robust and experienced adult.
We come now to speak of the Whale, which, in size, is the
sovereign of the Arctic seas, and the grandest type of marine life.
Whales (Cetacea) are, as most persons now-a-days know, an
order of aquatic mammals, distinguished by their fin-like anterior
extremities, and by the peculiarity that the place of the posterior
extremities is supplied by a large horizontal caudal fin, or tail; while
the cervical bones are so compressed that the animal, externally at
least, seems to have no neck.
The general form of the whale, notwithstanding its position
among the Mammalia, is similar to that of the fishes, and the
horizontal elongation of the body, the smooth and rounded surface,
the gradual attenuation of the extremities of the trunk, and the
magnitude of the fins and tail, are specially adapted to easy and swift
motion in the water. The arrangement of the bones composing the
anterior limb is very curious. The whole of the fin consists of exactly
the same parts as those which we find in the human hand and arm;
but they are so concealed beneath the thick cutaneous or
integumentary envelope, that not a trace of bone is visible. In this
respect an intermediate organization is shown by the fore limbs of
the seal.
The posterior extremity, in all the Cetacea, is either absolutely
deficient, or else rudimentary. If rudimentary, its sole vestige consists
of certain small bones, the imperfect representation of a pelvis,
suspended, as it were, in the flesh, and unconnected with the spinal
column. Here we may observe a remarkable difference between the
whale and the seal: in the latter, as we have seen, there is a short
tail, and the posterior extremities perform the office of a true caudal
fin; in the former this important organ of progression consists, to use
Mr. Bell’s words, of “an extremely broad and powerful horizontal disc,
varying in figure in the different genera, but in all constituting the
principal instrument of locomotion.” In fishes the tail is set vertically,
but in whales horizontally; and it has been well said that the
admirable adaptation of such a peculiarity in its position to the
requirements of the animal forms a fresh and beautiful illustration of
the infinite resource and foresight of the Creative Wisdom.
Thus: the fishes, respiring only the air contained in the dense
liquid medium in which they live, require no access to the
atmosphere; and, therefore, their progression is chiefly confined to
the same region. But the whales, breathing atmospheric air, must
necessarily come to the surface for each respiration; and hence they
need a powerful instrument or lever, the position of which shall apply
its impulse in a vertical direction, so as to impel their colossal bulk
from the lowest depths of ocean to the surface every time the lungs
require to receive a fresh supply of atmospheric air. The greatest
rapidity of motion is effected by alternate strokes of the tail against
the water, upwards and downwards; but the usual progression is
accomplished by an oblique lateral and downward impulse, first on
one side and then on the other, just as a boat is propelled by a man
with a single oar in the art of “sculling.” The extent of the tail in some
of the larger species is really immense; the superficies being no less
than about a hundred square feet, and its breadth considerably
exceeding twenty feet.
The common, right, or Greenland whale (Balæna mysticetus) has
been, for centuries, the object of man’s systematic pursuit, on
account of its valuable oil and scarcely less valuable baleen.
 THE GREENLAND WHALE.
This whale seldom exceeds fifty to sixty feet in length, or thirty to
forty in girth, and, therefore, is by no means the head of its family. As
in other species, the body is thick and bulky forwards, largest about
the middle, and tapers suddenly towards the tail. The head is
colossal; broad, flat, and rounded beneath, and narrow above; it
forms about a third of the animal’s entire length, and is about ten or
twelve feet broad. Its lips—such lips!—are five or six feet thick. They
do not cover any teeth, but they protect a pair of very formidable
jaws. The cavernous interior of the mouth is filled up with two series
of whalebone laminæ, about three hundred in each, which require
particular description. The whalebone, or baleen, as it is called,
consists of numerous parallel plates, layers, or laminæ, each of
which is formed of a central coarse fibrous layer lying between two
that are compact and externally polished. But this outer part does not
completely cover the inner; a kind of edge is exposed, and this edge
terminates in a loose fringed or fibrous extremity. Moreover, at the
base of each plate of baleen lies a conical cavity, covering a pulp
which corresponds with it; and this pulp is sunk within the substance
of the gum or buccal membrane stretched over the palate and upper
jaw.
The compact outer layers of the baleen plate are continuous with
a white horny layer of the gum, which passes on to the surface of
each plate; and the pulp may be regarded, therefore, as the
secreting organ of the internal coarse structure only. The filaments of
the fringe are exceedingly numerous, and so fill up the mouth-cavity
as to form a very efficient and ingenious sieve or strainer; and as the
esophagus, or “swallow,” of the whale is so confined as to be unable
to admit of the passage even of the smaller fish, and the food of the
whale consequently is limited to minute organisms, such as the
medusæ, this skilfully devised construction is absolutely requisite in
order to retain the whole of those which are taken into the mouth.
The mode in which the whale feeds may be thus described:—
The broad waters of the Arctic seas teem with innumerable
shoals of molluscous, radiate, and crustaceous animals, and these
are frequently so numerous as absolutely to colour the wave-
surface.
When a whale, therefore, desires food, it opens its colossal
mouth, and a host of these organisms is, as it were, swept up by the
great expanse of the lower jaw: as the mouth closes, the water is
ejected, and the life it contained is imprisoned by the appliance we
have attempted to describe.
If we consider the number of whales found in the Northern seas,
and the mighty bulk of each individual, our imagination entirely fails
to appreciate the countless myriads of minute organisms which must
be sacrificed to their due nourishment.
One of the principal products of the Greenland whale is its
baleen, or whalebone, with the domestic uses of which our readers
will be familiar; but the large quantities of oil which it yields are still
more valuable. A whale sixty feet in length will supply fully twenty
tons of pure oil.
Besides the common whale, our hunters find in the seas of the
North the razor-backed whale, or northern rorqual (Balænoptera
physalis), characterized by the prominent ridge which extends along
its mighty back. This monster of the deep attains a length, it is said,
of one hundred feet, and measures from thirty to thirty-five feet in
circumference. But its yield of oil and baleen is less than that of the
right or Greenland whale, and as its capture is a task of difficulty and
danger, the whalers seldom attack it. In its movements it is more
rapid and restless, and when harpooned it frequently plunges
downward with such force and velocity as to break the line. In
several respects it differs from the Greenland species; and
particularly in the nature of its food, for it feeds upon fishes of
considerable size.
Some of our naturalists affirm that several species of rorquals
exist in the Arctic seas; and the pike whale, so called from the
resemblance of its mouth to that of a pike, is frequently described as
an independent species. Others, however, are of opinion that the
pike is simply the young of the monster we have been describing.
The rorqual is very voracious, and preys extensively upon fishes; as
many as six hundred cod, to say nothing of smaller “fry,” having been
found in the stomach of a single individual.
While the Greenland whale is being rapidly driven back into the
icy wildernesses beyond Behring Strait, on the west, and the creeks
and gulfs beyond Baffin Bay, on the east, the rorquals, including the
Balænoptera rostratus (or beaked whale), Balænoptera musculus,
and Balænoptera boöps, still frequent the open waters,—their pursuit
being, as we have shown, more difficult and less profitable. They are
generally found in attendance on the herring-shoals, of which they
are the assiduous and destructive enemies. Off Greenland,
Spitzbergen, and Novaia Zemlaia they are found in considerable
numbers.
Our whalers go forth every year in well-provided ships, and
supplied with the best and most formidable weapons which scientific
ingenuity can devise. Still they find the enterprise one of peril and
hardship, and it is universally recognized as requiring in those who
embark in it no ordinary powers of endurance, as well as courage,
patience, and perseverance. Yet the Asiatic and American tribes do
not fear to confront the ocean-leviathan with the simplest of arms.
The Aleüt embarks in his little skiff, or baidar, and catching sight of
his prey, stealthily approaches it from behind until he nearly reaches
the monster’s head. Then he suddenly and dexterously drives his
short spear into the huge flank, just under the fore fin, and retreats
as swiftly as his well-plied oars can carry him. If the spear has sunk
into the flesh, the whale is doomed; within the next two or three days
it will perish, and the currents and the waves will hurl the vast bulk
on the nearest shore, to be claimed by its gallant conqueror. And as
each spear bears its owner’s peculiar mark, the claim is never
disputed.
Occasionally the baidar does not escape in time, and the
exasperated leviathan, furiously lashing the waters with its tail, hurls
the frail boat high up into the air, as if it were a reed, or sinks it with
one crushing blow. No wonder that those of their race who undertake
so hazardous a calling are held in high repute among the Aleüts. To
sally forth alone, and encounter the whale in the icy waters of the
Polar Sea, is a task demanding the utmost intrepidity and the utmost
tranquillity of nerve.
Many of the whales thus daringly harpooned are lost. It is on
record that, in the summer of 1831, one hundred and eighteen
whales were struck near Kadjack, and of these only forty-three were
found. The others either drifted to far-off shores and lonely unknown
isles, or became the prey of sharks and ocean-birds. Wrangell states
that of late years the Russians have introduced the use of the
harpoon, and engaged some English harpooneers to teach the
Aleüts the secret of their craft; and, therefore, the older and more
hazardous method, which the Aleüts had learned from their
forefathers, will soon be a thing of the past.

The Eskimos devote the month of August to the whale-fishery,

and for this purpose they assemble in companies, and plant a colony
of huts on some bold headland of the Polar coast, where the water is
of depth sufficient to float their destined victim.
 As soon as a whale’s colossal bulk is seen outstretched on the
water, a dozen kayaks or more cautiously paddle up in the rear, until
one of them, shooting ahead, comes near enough on one side for
the men to drive the spear into its flesh with all the force of both
arms. To the spear are attached an inflated seal-skin and a long coil
of thong. The whale dives immediately it is stricken. After awhile it
reappears, and the signal being given by the floating seal-skin buoy,
all the canoes again paddle towards their prey. Again the opportunity
is seized for launching the fatal spears; and this process is repeated
until the exhausted whale rises more and more frequently to the
surface, is finally killed, and towed ashore.
Captain M’Clure fell in with an Eskimo tribe off Cape Bathurst
which hunted the whale in this primitive fashion, but the females, as
well as the men, engaged in the pursuit. An omaiak, or woman’s
boat, he says, is “manned by ladies,” having as harpooneer a
chosen man of the tribe; and a shoal of small fry, in the form of
kayaks, or single-men canoes, are in attendance. The harpooneer
singles out “a fish,” drives into its flesh his weapon, to which an
inflated seal-skin is attached by means of a walrus-hide thong. The
wounded fish is then incessantly harassed by the men in the
kayacks with weapons of a similar description; and a number of
these, driven into the unfortunate whale, baffle its efforts to escape,
and wear out its strength, until, in the course of a day, it dies from
exhaustion and loss of blood.
Sherard Osborn tells us that the harpooneer, when successful,
becomes a very great personage indeed, and is invariably decorated
with the Eskimo order of the Blue Ribbon; that is, a blue line is drawn
across his face over the bridge of his nose. This is the highest
honour known to the heroes of Cape Bathurst; but it carries along
with it the privilege of the decorated individual being allowed to take
unto himself a second wife!

In the waters of Novaia Zemlaia, Greenland, and Spitzbergen is

found the narwhal, or sea unicorn (Monodon monoceros), which was
at one time the theme of so many extravagant legends. It belongs to
the Cetacea, but differs from the whale in having no teeth, properly
so called, and in being armed with a formidable horn, projecting
straight forward from the upper jaw, in a direct line with the body.
This horn, or tusk, the use of which has not been satisfactorily
ascertained, is harder and whiter than ivory, spirally striated from
base to point, tapers throughout, and measures from six to ten feet
in length. Mr. Bell remarks that it would be a strange anomaly if the
apparent singleness of this weapon were real. In truth, both teeth are
invariably found in the jaw, not only of the male, but of the female
also; but in ordinary (though not in all) cases one only, and this in the
male, is fully developed, the other remaining in a rudimentary
condition—even as both do in the female.

NARWHALS, MALE AND FEMALE.

The narwhal, from mouth to tail, is about twenty feet long, though
individuals measuring thirty feet are sometimes met with. Its head is
short, and the upper part convex; its mouth small; its spiracle, or
respiratory vent, duplicate within; its tongue long; the pectoral fins
small. The back, which is convex and rather wide, has no fins, and
sharpens gradually towards the tail, which, as in other Cetacea, is
horizontal. The food of the narwhal, whose habits are remarkably
pacific, consists of medusæ, the smaller kinds of flat fish, and other
marine animals.

A striking spectacle which frequently greets the eye of the

voyager in the Arctic seas is that of a shoal of dolphins gambolling
and leaping, as if in the very heyday of enjoyment. The beluga,
sometimes called the white whale (Delphinus leucos), attracts
attention by the dazzling whiteness of its body and the swiftness of
its movements. It frequents the estuaries of the Obi and the Irtish,
the Mackenzie and the Coppermine, which it sometimes ascends to
a considerable distance in pursuit of the salmon. Its length varies
from twelve to twenty feet; it has no dorsal fin; and its head is round,
with a broad truncated snout.

A SHOAL OF DOLPHINS.
 The black dolphin (Globicephalus globiceps) is also an inhabitant
of the Polar seas, both beyond Behring Strait, and between
Greenland and Spitzbergen. It is, however, frequently met with in
waters further south. Its length averages about twenty-four feet, and
its circumference ten feet. Its smooth oily skin is bluish-black on the
upper, and an obscure white on the lower, parts of the body. Twenty-
two or twenty-four strong interlocking teeth in each jaw form its
formidable apparatus of offence and defence; its dorsal fin is about
fifteen inches high; its tail five feet broad; the pectoral fins are long
and narrow, and well adapted to assist their owner in its rapid
movements. It consorts with its kind in herds of several hundreds,
under the guidance of some old and wary males, whom the rest
follow as docilely as a flock of sheep their bell-wether; hence the
Shetlanders term it the “ca’ing whale.” Large shoals are frequently
stranded on the shores of Norway, Iceland, and the Orkney, Faroe,
and Shetland Isles, furnishing the inhabitants with a welcome booty.

To the same latitudes belong the ferocious orc or grampus

(Delphinus orca), the tiger of the seas, which not only attacks the
porpoise and dolphin, but even the colossal whale. Its broad deep
body is black above and white beneath; the sides are marbled with
black and white. There are thirty teeth in each jaw, those in front
being blunt, round, and slender, while those behind are sharp and
thick; and between each is a space fitted to receive those of the
opposite jaw when the mouth is closed. The back fin of the grampus
is of great size; sometimes measuring as much as six feet in length,
from the base to the tip. The grampus generally voyages in small
squadrons of four or five individuals, following each other in single
file, and alternately rising and sinking in such a manner as to
resemble the undulatory motions of a huge kraken or sea-serpent.
 Among the inhabitants of the Polar Ocean must certainly be
included the Polar bear (Thalassarctos maritimus), since it swims
and dives with great dexterity, and, moreover, is often found on the
drifting ice-floes at a distance of eighty to one hundred miles from
land. It is a creature of great strength, great fierceness, and great
courage, though we may not accept the exaggerated accounts of it
which enliven the narratives of the earlier voyagers.

POLAR BEARS.
A noble creature is the Polar bear, says Sherard Osborn, whether
we speak of him by the learned titles of “Ursus maritimus,”
“Thalassarctos maritimus,” or the sailors’ more expressive
nomenclature of “Jack Rough!” With all her many wonders,
continues this lively writer, never did Nature create a creature more
admirably adapted to the life it has to lead. Half flesh, half fish, the
seaman wandering in the inhospitable regions of the North cannot
but be struck with the appearance of latent energy and power its
every action attests, as it rolls in a lithe and swaggering way over the
rough surface of the frozen sea; or, during the brief Arctic summer,
haunts the broken and treacherous “pack” in search of its prey.
 When not too loaded with fat—and it seems to fatten readily—the
pace of the bear is leisurely and easy, yet at its slowest it is equal to
that of a good pedestrian; and when alarmed or irritated, its speed is
surprising, though not graceful. On level ice, it flings itself ahead, as
it were, by a violent jerking motion of the powerful fore paws, in what
has been described as an “ungainly gallop;” but it always makes,
when it can, for rough ice, where its strength and agility are best
displayed, and where neither man nor dog can overtake it. In the
Queen’s Channel, during Captain M’Clure’s expedition, more than
one bear was seen making its way over broken-up ice, rugged and
precipitous as the mind can picture, with a truly wonderful facility;
their powerful fore paws and hind legs enabling them to spring from
piece to piece, scaling one fragment and sliding down another with
the activity of a huge quadrumane rather than that of a quadruped.
Evidently it is conscious of its superiority in such rough and perilous
ground, and is generally found at the edge of the belts of hummocks
or broken ice which intersect most ice-fields, or else amongst the
frozen pack-ice of channels such as Barrow’s and the Queen’s.
There is, however, another reason why bears keep among
hummocks and pack-ice—namely, that near such spots water
usually first makes its appearance in the summer. Seals,
consequently, are most numerous there; while the inequalities of the
floe afford shelter to the bears in approaching their prey. During
summer the colour of the Polar bear is of a dull yellowish hue,
closely resembling that of decaying snow or ice. The fur is then thin,
and the hair on the soles of their feet almost wholly rubbed off, as
with the other animals of Arctic climes; but in the autumn, when the
body has recovered from the privations of the previous winter, and a
thick coating of blubber overlays his carcass to meet the exigencies
of another season of scanty fare, the feet, as the season advances,
are beautifully incased and feathered with hair, and the animal’s
colour usually turns to a very pale straw, which, from particular points
of view, as the light strikes it, looks white, or nearly so. The nose and
lips are of a jetty black; the eyes vary in colour. Brown is common,
but some have been seen with eyes of a pale gray. Their sense of
smell is peculiarly acute, facilitated no doubt by the peculiar manner
in which the pure keen air of the North carries scent to very
considerable distances.
Sherard Osborn states that bears have been seen to follow up a
scent, exactly as dogs would do; and the floes about Lowther Island,
in 1851, looked as if the bears had quartered there in search of
seals, after the fashion of a pointer in the green fields of England.
The snorting noise which they make as they approach near indicates
how much more confidence they place in their scent than in their
vision; though both, when the hunter is concerned, are apt to
deceive them.
The Polar bear attains to very formidable proportions; but when
seamen speak of monsters fifteen feet in length, their auditors may
be excused for withholding their belief. Ten feet would seem to be a
maximum; and the bear need be large, strong, and muscular to
master the large Arctic seal, especially the saddle-back and bladder-
nose species. For though it swims well and dives well, it neither
swims nor dives as well as the seal, and would therefore have but
little chance of obtaining a sufficient livelihood if it could not attack
and capture its victim on the ice-floes.
The seal, on the other hand, fully aware of its danger, and of the
only means of escaping from it, always keeps close to the water,
whether it be the hole it has gnawed and broken through the ice, or
the open sea at the floe edge.
And when it lies basking on the floating ice, and apparently
apathetic and lethargic, nothing can exceed its vigilance. With its
magnificent eyes it is able to sweep a wide range of the horizon,
however slightly it turns its head; its keenness of hearing adds to its
security. There is something peculiarly striking in its continuous
watchfulness. Now it raises its head and looks around; now it is
intent on the slightest sound that travels over the crisp surface of the
ice; now it gazes and listens down its hole, a needful precaution
against so subtle a hunter as old Bruin! It would seem impossible to
surprise an animal so vigilant and so wary; and, indeed, in
circumventing its prey the bear exhibits an astuteness and a skill