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Do psychiatry and neurology need a close partnership or a merger?

  • Michael Fitzgerald (a1)
Summary

Advances in neuroscience in recent years have blurred the boundaries between psychiatry and neurology. They now have more in common than what divides them and this signals a return to their origins. Many have called for a merger of the two disciplines, which would offer a more holistic approach, whereas others vigorously reject such a move. Limiting neurology to the study of the nervous system and psychiatry to the social brain or affect and its disorders is no longer sustainable. The ongoing separation of the disciplines has had an impact on diagnosis and treatment, on professional isolation and on funding psychiatric research.

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Copyright
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence to Michael Fitzgerald (profmichaelfitzgerald@gmail.com)
Footnotes
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See pp. 134-5, this issue.

Declaration of interest

None.

Footnotes
References
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BJPsych Bulletin
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Do psychiatry and neurology need a close partnership or a merger?

  • Michael Fitzgerald (a1)
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eLetters

Psychiatry is more than Neuropsychiatry

In his editorial, Fitzgerald (1) rehashes the well-trodden arguments for the reunification of neurology and psychiatry, suggesting the time has finally come. What he fails to address is that the trend in every sphere of medicine is towards further specialisation and not integration. Why psychiatry and neurology should be the exception to the rule goes unanswered.

It is only ever academic psychiatrists, appearing out of touch with clinical practice, who propose that psychiatry has advanced to the point where it is indistinguishable from neurology. On the contrary, despite the calls for psychiatry to become a clinical neuroscience discipline (2), psychiatric practice has remained untouched by developments in neuroscience. To be sure, neuroscience is a core basic science for psychiatry. But the claims that psychiatric disorders are simply brain disorders, or that our observations or interventions are not worth a jot if not based in neuroscience are part of a creeping trend towards neuroessentialism in every sphere of life (3). Psychiatrists do not simply deal with brain diseases, to claim otherwise is to impoverish our field. Psychiatry is at its best when embracing a pluralistic approach to the disparate range of problems that fall under our gaze. To neglect insights from the psychological, sociological and anthropological sciences and the narrative approach to formulation does a disservice to our patients. The patient who becomes suicidal after her boyfriend leaves her and the patient who becomes panic-stricken and housebound after a rape do not have problems that can be made sense of in the same way as the patient with visual hallucinations and bradykinesia, or the patient with impulse control problems after a brain injury. Put simply, even if we accept the claim that psychiatric problems are brain disorders, many problems can be effectively treated without thinking about the brain.

Psychiatrists could certainly benefit from a stronger training in clinical neuroscience and neurology in general, and neuropsychiatry and behavioural neurology in particular. But as Alwyn Lishman said "You have got to have a finger in every pie in psychiatry and be ready to turn your hand to whatever is the most important avenue: an EEG one day, a bit of talking about a dream another day. You just follow your nose. All psychiatrists should be all types of psychiatrist" (4). I could not agree more.

References:

1. Fitzgerald M. Do psychiatry and neurology need a close partnership or a merger? BJPsych Bull Jun 2015, 39: 105-7

2. Insel TR, Quirion R. Psychiatry as a clinical neuroscience discipline. JAMA 2005; 294: 2221-4

3. Reiner PB. The Rise of Neuroessentialism. in The Oxford Handbook of Neuroethics (Iles J, Sahakian B. eds.) 161-175, Oxford: Oxford University Press, 2011

4. Poole NA. Interview with Professor William Alwyn Lishman Psychiatrist 2013; 37: 343–4

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Conflict of interest: None Declared

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Can psychiatry and neurology "simply" merge?

I appreciate Prof. Fitzgerald's citation of my 2005 article, titled, "Why psychiatry and neurology cannot simply merge" (1); however, Prof. Fitzgerald seems to have misconstrued the essential nature of my argument. He positions his discussion of my article just after the statement, "The chorus of disapproval against neuropsychiatry has certainly grown". But I would like to assure Prof. Fitzgerald that I am not, nor have I ever been, part of such a "chorus." A careful reading of my article will show that the key word in my argument is "simply". I am not opposed in any way to integrating neurology and psychiatry; rather, I argue that certain types of "bridging" concepts and constructs would be necessary to bring about such a union.

I describe neuropsychiatry as "a vitally important transitional stage in the development of brain science". Indeed, I would argue that neuropsychiatry is the crucible within which the discourses of psychiatry and neurology will eventually “bond", producing a narrative that incorporates the dialectical and subtextual understanding of psychiatry into the framework of neurophysiology and neuropathology. But until such a meta-narrative has evolved, there cannot be a genuine merger of psychiatry and neurology. Or rather, we should say that—without such a meta-narrative - the nature of the merger would be more like the grafting of an oak branch onto a maple tree than the hybridization of two varieties of rose (1).

I fully agree with Prof. Fitzgerald that "the separation of neurology from psychiatry has led to a separation of the brain from the mind - the physical from the mental - which has been unhelpful for both disciplines." That said, I do not accept the view that psychiatric disease is best described as "brain disease", or that mental constructs are "reducible" to mere physiological or neuroanatomical terms. But this is a complicated philosophical issue best left for a longer communication (2).

Stated briefly, I believe that "disease" is most usefully predicated of persons - not minds or brains - and that there are ways in which a union of neurology and psychiatry could contribute to a very rich understanding of the human person, and how personhood is undermined and compromised by disease states like schizophrenia (3).

References:

1. Pies R. Why psychiatry and neurology cannot simply merge. J Neuropsychiatry Clin Neurosci 2005;17:304-309.

2. Pies R. Mind-language in the age of the brain: is "mental illness" a useful term? J Psychiatr Pract. 2015 Jan;21(1):79-83. doi: 10.1097/01.pra.0000460625.25676.59

3. Pies R: Trivializing the suffering of psychosis. Psychiatric Times. Dec. 22, 2014. Accessed at: http://www.psychiatrictimes.com/blogs/couch-crisis/trivializing-suffering-psychosis

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Conflict of interest: None Declared

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RE: Do psychiatry and neurology need a close partnership or a merger?

Keith E Dudleston, Retired Consultant Psychiatrist, Retired
01 June 2015

Professor Fitzgerald is worried about the serious recruitment crisis in psychiatry. His answer is to advise psychiatrists to abandon their specialty and “return home to neurology”. In his opinion a merger of the two professions would encourage clinicians to focus upon careful clinical analysis and diagnosis, reduce professional isolation and stigma, enhance status, and so improve recruitment. This may or may not be true, but I wonder about the attitude of neurologists is to his proposal. The working life of a general adult psychiatrist is not easy and I think neurologists are likely to resist his advances. I don’t know many who would be willing to regularly attend community based mental health act assessments in inconvenient circumstances, subject themselves to cross examination by enthusiastic lawyers in front of their patients at Mental Health Tribunals, defend their practice at critical legalistic external inquiries or subject themselves to the restrictions imposed by “new ways of working”. Psychiatric practice certainly needs to be reformed but a more practical analysis of our problems is urgently required. In my opinion our college must lead on these issues. If it continues to equivocate it will quickly become an irrelevance.

Reference:

1. Fitzgerald M. Do psychiatry and neurology need a close partnership or a merger? BJPsych Bull Jun 2015, 39 (3) 105-107
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Conflict of interest: None Declared

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