Skip to main content Accessibility help
×
Home
Hostname: page-component-5cfd469876-d8lm2 Total loading time: 0.332 Render date: 2021-06-23T14:33:38.738Z Has data issue: false Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true }

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

Published online by Cambridge University Press:  02 January 2018

Michael Fitzgerald
Affiliation:
Trinity College Dublin, Ireland
Corresponding
Rights & Permissions[Opens in a new window]

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.

Type
Editorial
Creative Commons
Creative Common License - CCCreative Common License - BY
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.
Copyright
Copyright © 2015 The Author

The relationship between psychiatry and neurology remains a controversial topic, with strong voices opposing a merger, whereas others point out that the future lies with the neurologist/psychiatrist or neuropsychiatrist. Reference Fitzgerald1 Either way, it highlights the growing disparity in how the disciplines are currently defined and the many areas of overlap.

History of the relationship between neurology and psychiatry

The term ‘neurology’ originated with English physician Thomas Willis following his study of brain anatomy in the 1660s, according to Millon. Reference Millon2 Subsequently in 1808, Johann Christian Reil, a German physician and philosopher, gave us the term ‘psychiatrie’. However, the two disciplines had common origins. Krishnamoorthy Reference Krishnamoorthy3 points out that the ancients, including Hippocrates, believed that all psychopathology arose in the brain and that this is clearly reflected in writings well into the nineteenth century. On the other hand, this was not a universally held view and some of the ancients believed that hysteria was because of a wandering womb. Even so, the 1845 seminal work on mental illness by Wilhelm Griesinger in Mental Pathology and Therapeutics still has a modern ‘ring’ to it in the 21st century. He was a major clinical and academic researcher in a number of hospitals in Europe at the time. The one-time unity of the disciplines was also reflected in the title of the journal Griesinger founded in 1867, Archives of Psychiatry and Neurology. For Griesinger, mental diseases were essentially brain diseases, according to Millon.

Over the years there has been considerable opposition to Griesinger. In an interview with Poole, Reference Poole4 William Alywn Lishman was severely critical of Griesinger because he ‘tried to make the whole of psychiatry brain science’. I would concur with Lishman that Griesinger went too far and especially ignored environmental influences. I believe the biopsychosocial model of psychiatry can only operate via the brain and Johansson Reference Johansson5 is correct in his assertion that all mental life will eventually be mapped onto ‘a neuronal substrate’. The split between medicine and psychiatry was lamented by Silas Weir Mitchell as early as 1894. He expressed the view that when the ‘treatment of the insane’ passed completely out of the hands of the profession at large and ‘into those group of physicians (psychiatrists) who constitute a sect apart… what evil this has wrought, what harm it has done to us’, as noted by Andreason. Reference Andreason6 This split became even more pronounced in the USA between 1935 and 1975, when psychoanalysis largely took over psychiatry there, further increasing the gap between neurology and medicine generally. Ironically, psychoanalysts are now trying to reconnect with neurology through neuropsychoanalysis, according to Solms. Reference Solms7

The advent of diagnostic imaging has brought a certain degree of clarity to the field. Kandel points out that had imaging been available in 1895 when Freud wrote Project for a Scientific Psychology he might have directed psychoanalysis along very different lines, keeping it ‘in close relationship with biology as outlined in that essay’. Reference Kandel8 It is worth noting that Freud was a superb neuropathologist and neurological scientist, as evidenced in the very ambitious but highly relevant Project for a Scientific Psychology. Reference Freud9 However, the work also signalled his subsequent move away from traditional science.

Why are psychiatry and neurology separate?

Many views have been expressed on why psychiatry and neurology are separate. In response to White et al’s Reference White, Rickards and Zeman10 assertion that it is time to end the distinction between mental and neurological illnesses, Ikkos points out that neurology’s expertise is the nervous system and its disorders, whereas psychiatry’s expertise is affect and its disorders. Reference Ikkos11 Furthermore, he argues that, conceptually, neurology is necessarily at a different level of abstraction from the nervous system. This argument, however, is not the least bit persuasive to me. Miller notes that ‘psychiatry was neurology without physical signs’, Reference Miller12 whereas Holmes points out that ‘only psychiatry can encompass the social brain’. Reference Holmes13 There is absolutely no reason why neurologists cannot embrace the social brain and indeed many do today. I believe the split between neurology and psychiatry is in fact artificial.

The chorus of disapproval against neuropsychiatry has certainly grown. Pies argues that psychiatry and neurology cannot simply merge because they use ‘significantly different narratives or… discourses’. Reference Pies14 He also claims that psychiatry is grounded in human subjectivity and existential concerns and is a ‘discourse of interlacing and multi-layered meanings’ and a ‘narrative about narratives’. Neurology, on the other hand, he believes is fundamentally ‘a discourse of neuroanatomical and neurophysiological relationships’. When a neurologist examines a patient with symptoms not corresponding to known neurological pathways, which Pies sees as ‘functional, supratentorial or psychogenic’, then the patient should be deferred or referred to the psychiatrist. Essentially, Pies’ description of psychiatry has echoes of psychoanalysis. For example, he asserts that psychiatry’s discourses should be understood as a dialectic between a text and a presumed subtext – ‘not unlike the dialectic between p’shat and d’rash in Talmudic exegesis. That is, beneath the literal words or surface meaning of a biblical text (p’shat), there lies a realm of figurative, allegorical, and mystical meanings that must be explicated (d’rash)’. Reference Pies14 Indeed, his description of psychiatry relates to that of the mid-nineteenth century, in my view.

An editorial by Baker et al in the BMJ in 2012 stated that it is time to tear down the wall between neurology and psychiatry advances in neuroscience. Reference Baker, Kale and Menken15 In response to this editorial, Bailey et al presented the orthodox psychiatric reaction. They point out that most mental disorders, given our current state of knowledge, have no unequivocal biomarkers and classification has to rely, however imperfectly, on clinical signs and symptoms. Reference Bailey, Burn, Craddock, Mynors-Wallis and Tyrer16 They were against a merger of neurology and psychiatry, but in favour of a close working relationship.

The advances in neuroscience prompted Stone & Sharpe to pose a key question: will greater understanding of neuroscience mean that psychiatry will simply follow neurology in abandoning the patients that fail to fit into a reductionistic paradigm? Reference Stone and Sharpe17 However, I believe that if there were a merger, patients would be less likely to fall through the ‘cracks’. Excessive specialisation is the greatest reason for bringing neurology and psychiatry together. Indeed, even at a research level progress is more likely to occur at the interfaces between specialties and subspecialties. One reason for the lack of progress in psychiatric research in recent years has been because of the excessive specialisation and subspecialisation.

Why bring neurology and psychiatry together?

One of the most compelling arguments for bringing the two disciplines together is that their boundaries are becoming increasingly blurred. Ramachandran observed this fact and declared it was only a matter of time before psychiatry becomes just another branch of neurology. Reference Ramachandran18 I would dispute that aspect of the argument; there is no question of one discipline ‘swallowing’ up the other. Instead it would be a merger of two equal partners: neurology and psychiatry. If it were to occur, both disciplines would enrich each other enormously.

The separation of the two disciplines has had a somewhat negative impact on diagnosis and treatment. Kanner points out that, in neurology, the separation from psychiatry has led to comorbid disorders being underrecognised and undertreated. Reference Kanner19 In effect, 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. If a merger did occur, the neuropsychiatrist could provide a more holistic approach to the diagnosis and treatment of a patient. In fact, all neurologists and psychiatrists practise basic counselling and brief therapy to varying degrees. It is noteworthy that there are similar brain changes after the treatment of obsessive-compulsive disorder with either medication or behaviour therapy. This increases the link somewhat between neurology and psychiatry.

Aarli points out that psychiatry and neurology have a common route and both share a common basis in neuroscience. Reference Aarli20 He also notes that there is much more that unites neurology and psychiatry than divides them. Neurobiological conditions like epilepsy, autism, dementia, delirium, Tourette syndrome, intellectual disability, dyspraxia, speech and language problems are all overlapping. Between neurology and psychiatry Henningsen favours overcoming ‘dualistic’ and often ‘irrational splits’ in the classification and in the practice of medicine. Reference Henningsen21 He agrees with the idea of subsuming mental disorders under ‘disorders of the brain’ because this gives greater clarity and simplicity. Kandel finds it useful to consider that psychiatry and psychoanalysis work at the level of individual nerve cells and their synaptic connections. Reference Kandel8 Neurology and psychiatry are simply two ‘sides of the same coin’. Certainly in the area of neural plasticity, neurology and psychiatry overlap.

The overlap is also evident in medical journals relevant to the disciplines. In a study of papers published in Neurology and the American Journal of Psychiatry, Price Reference Price22 found that less than 5% of papers in the American Journal of Psychiatry were on meningitis, epilepsy and headache and that less than 5% of papers in Neurology focused on schizophrenia, panic and mania. The proportions for attention-deficit hyperactivity disorder were 23% in Neurology and 77% in the American Journal of Psychiatry; for autism 30% in Neurology and 70% in the American Journal of Psychiatry; for ‘mental retardation’ 70% in Neurology and 30% in the American Journal of Psychiatry. As one can see, there is considerable overlap. Similarly, Raja showed that neurological disease affected 13.05% of acute and 68.9% of chronic psychiatric patients. Reference Raja23

Professional isolation from medicine

The question of professional isolation has also emerged. The separation of psychiatry from neurology has led Levine to comment that, over the past 30 years, psychiatry has become professionally, geographically and managerially separate from the rest of medicine. Reference Levine24 In many places this isolation has seriously damaged psychiatry and caused major recruitment and funding problems.

In a paper entitled ‘Wake-up Call for British Psychiatry’, Craddock et al were concerned about the evolution of unclear responsibility in psychiatry, which reduces medical student interest because of not being ‘proper doctors’, and modern psychiatry, diminishing the value of careful diagnosis and reducing psychiatry to a ‘nonspecific psychological support’. Reference Craddock, Antebi, Attenburrow, Bailey, Carson and Cowen25 Combining neurology and psychiatry would reduce these problems. It is well-known that medicine and psychiatric illness are closely allied. The merger of neurologists and psychiatrists would improve the care of the patient at the interface and moreover may reduce stigma. Bullmore et al Reference Bullmore, Fletcher and Jones26 believe that the merger would reduce stigma, however Jorm & Oh Reference Jorm and Oh27 did not find that brain v. social aetiology affected stigma in their formal study. Read et al, Reference Read, Haslam, Sayce and Davies28 in their review paper, said that biological psychiatry increases stigma, whereas Bullmore et al Reference Bullmore, Fletcher and Jones26 suggested the opposite. This issue remains controversial and opinions as described vary.

There is a great deal of similarity in the training of neurologists and psychiatrists from medical school onwards. At the present time, all psychiatrists are required to spend a minimum of 6 months to a year working in neurology and vice versa. Joint training in neurology and psychiatry would be helpful. These individuals would be dual trained and would require both Royal Colleges to come together to produce this dual-trained neurologist/psychiatrist, as happens in the USA and Germany. Indeed, it may be easier to recruit this neurologist/psychiatrist in the future. In a study of trainers and trainees in psychiatry/neurology, Schon et al Reference Schon, MacKay and Fernandez29 found that psychiatrists were even keener on links between neurology and psychiatry training than neurologists, with psychiatric specialist registrars significantly more in favour.

In conclusion, psychiatrists should return home to neurology and medicine and leave non-medical interventions to non-medical practitioners, for example in relation to specialist or long-term psychotherapy. Neurologists and psychiatrists need to merge into neuropsychiatry or some acceptable title. The merger would admittedly not be easy, but it would be beneficial to both fields in the long term and to patients at a clinical level.

Footnotes

See pp. 134-5, this issue.

Declaration of interest

None.

References

1 Fitzgerald, M. All future psychiatrists should be neuropsychiatrists (letter). Psychiatrist 2013; 37: 309.CrossRefGoogle Scholar
2 Millon, T. Masters of the Mind: Exploring the Story of Mental Illness from Ancient Times to the New Millennium. Wiley, 2004.Google Scholar
3 Krishnamoorthy, ES. Medicine: an expanding interphase. Frontline 1999; 16: 1 (http://www.frontline.in/static/html/fl1611/16110770.htm).Google Scholar
4 Poole, NA. Interview with Professor William Alwyn Lishman. Psychiatrist 2013; 37: 343–4.CrossRefGoogle Scholar
5 Johansson, CF. Levels of analysis in explaining mental illness (eLetter). Br J Psychiatry 2009; 28 April: doi:10.1192/pb.bp.113.044305 (http://bjp.rcpsych.org/content/194/4/293.full/reply).Google Scholar
6 Andreason, N. Introduction. Am J Psychiatry 1994; 151 (June suppl): 14.Google Scholar
7 Solms, M. Freud returns. Sci Am Mind 2006; April/May: 2834.Google Scholar
8 Kandel, ER. Psychiatry, Psychoanalysis and the New Biology of Mind. American Psychiatric Publishing, 2005.Google Scholar
9 Freud, S. Project for a Scientific Psychology. Hogarth Press, 1895.Google Scholar
10 White, PD, Rickards, H, Zeman, AZJ. Time to end the distinction between mental and neurological illnesses (eLetter). BMJ 2012; 344: e3454.CrossRefGoogle Scholar
11 Ikkos, G. Re: Time to end the distinction between mental and neurological illnesses (eLetter). BMJ 2012; 344: e3454.Google Scholar
12 Miller, H. Depression. BMJ 1967; 1: 257–62.CrossRefGoogle ScholarPubMed
13 Holmes, J. Minding the brain. BMJ 2012; 345; e4581.CrossRefGoogle Scholar
14 Pies, R. Why psychiatry and neurology cannot simply merge. J Neuropsychiatry Clin Neurosci 2005; 17: 304309.CrossRefGoogle ScholarPubMed
15 Baker, MG, Kale, R, Menken, M. The wall between neurology and psychiatry advances in neuroscience indicate it's time to tear it down. BMJ 2012; 324: 1468–69.Google Scholar
16 Bailey, S, Burn, W, Craddock, N, Mynors-Wallis, L, Tyrer, P. Re: Time to end the distinction between mental and neurological illnesses (eLetter). BMJ 2012; 344: e3454.CrossRefGoogle Scholar
17 Stone, J, Sharpe, M. Neurology, psychiatry, and neuroscience (letter). Am J Psychiatry 2003; 160: 1013.CrossRefGoogle Scholar
18 Ramachandran, V. The Emerging Mind. Reith Lecture Series. Profile Books, 2003.Google Scholar
19 Kanner, AM. When did neurologists and psychiatrists stop talking to each other? Epilepsy Behav 2003; 4: 597601.CrossRefGoogle ScholarPubMed
20 Aarli, JA. Neurology and psychiatry: ‘oh, east is east and west is west …’ Neuropsychiatr Dis Treat 2005; 1: 285–6.Google Scholar
21 Henningsen, P. Re: Time to end the distinction between mental and neurological illnesses (eLetter). BMJ 2012; 344: e3454.Google Scholar
22 Price, H. Neurology vs psychiatry: the social production of knowledge. Society Pages (Sociological Images). 2011; 9 Sept (http://thesocietypages.org/socimages/2011/09/09/neurology-vs-psychiatry-the-social-production-of-knowledge/).Google Scholar
23 Raja, M. Neurological diagnoses in psychiatric patients: the uncertain boundaries between neurology and psychiatry. Ital J Neurol Sci 1995; 16: 153–8.Google ScholarPubMed
24 Levine, D. Re: Time to end the distinction between mental and neurological illnesses (eLetter). BMJ 2012; 344: e3454.Google Scholar
25 Craddock, N, Antebi, D, Attenburrow, MJ, Bailey, A, Carson, A, Cowen, P, et al. Wake-up call for British psychiatry. Brit J Psychiatry 2008; 193: 69.CrossRefGoogle ScholarPubMed
26 Bullmore, E, Fletcher, P, Jones, PB. Why psychiatry can't afford to be neurophobic. Brit J Psychiatry 2009; 194: 293–5.CrossRefGoogle ScholarPubMed
27 Jorm, AF, Oh, E. Desire for social distance for people with mental disorders. Aust NZ J Psychiatry 2009; 43: 183200.CrossRefGoogle ScholarPubMed
28 Read, J, Haslam, N, Sayce, L, Davies, E. Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatr Scand 2006; 114: 303–18.CrossRefGoogle ScholarPubMed
29 Schon, F, MacKay, A, Fernandez, C. Is shared learning the way to bring UK neurology and psychiatry closer: what teachers, trainers and trainees think. J Neurol Neurosurg Psychiatry 2006; 77: 943–6.CrossRefGoogle ScholarPubMed
Submit a response

eLetters

No eLetters have been published for this article.
You have Access
Open access
9
Cited by

Send article to Kindle

To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Do psychiatry and neurology need a close partnership or a merger?
Available formats
×

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

Do psychiatry and neurology need a close partnership or a merger?
Available formats
×

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

Do psychiatry and neurology need a close partnership or a merger?
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *