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Neuroimaging distinction between neurological and psychiatric disorders

  • Nicolas A. Crossley (a1), Jessica Scott (a1), Ian Ellison-Wright (a2) and Andrea Mechelli (a3)



It is unclear to what extent the traditional distinction between neurological and psychiatric disorders reflects biological differences.


To examine neuroimaging evidence for the distinction between neurological and psychiatric disorders.


We performed an activation likelihood estimation meta-analysis on voxel-based morphometry studies reporting decreased grey matter in 14 neurological and 10 psychiatric disorders, and compared the regional and network-level alterations for these two classes of disease. In addition, we estimated neuroanatomical heterogeneity within and between the two classes.


Basal ganglia, insula, sensorimotor and temporal cortex showed greater impairment in neurological disorders; whereas cingulate, medial frontal, superior frontal and occipital cortex showed greater impairment in psychiatric disorders. The two classes of disorders affected distinct functional networks. Similarity within classes was higher than between classes; furthermore, similarity within class was higher for neurological than psychiatric disorders.


From a neuroimaging perspective, neurological and psychiatric disorders represent two distinct classes of disorders.

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This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

Corresponding author

Andrea Mechelli, Department of Psychosis Studies, Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, UK. Email:


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See editorial, pp. 373–374, this issue.

Declaration of interest




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Neuroimaging distinction between neurological and psychiatric disorders

  • Nicolas A. Crossley (a1), Jessica Scott (a1), Ian Ellison-Wright (a2) and Andrea Mechelli (a3)


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Neuroimaging distinction between neurological and psychiatric disorders

  • Nicolas A. Crossley (a1), Jessica Scott (a1), Ian Ellison-Wright (a2) and Andrea Mechelli (a3)
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Neuroimaging distinction between neurological and psychiatric disorders - was there really one?

Akshay Nair, Leonard Wolfson Clinical Training Fellow, UCL
18 November 2015

Dear Editor of the BJPsych,

I read with great interest the article by Crossley et al (2015) (1) and, whilst commending their work, I was surprised to arrive at the opposite conclusion to that of the authors. In their meta-analysis of structural MRI correlates of ‘psychiatric’ and ‘neurological’ conditions they find that both classifications appear to correlate with some distinct regional brain volume changes. In their discussion of these findings they conclude that their analysis lends weight to the argument that the disorders may be thought of as belonging to two distinct classes. I was surprised at this conclusion and would ask the reader to consider that these results may actually suggest the opposite for the following three reasons.

Firstly, given the established functional organisation of brain anatomy one might, a priori, predict that different clinical symptoms (hallucinations versus motor apraxia for example) are associated with dysfunctional activity in spatially distinct brain regions. With this in mind, the finding that the ‘psychiatric’ and ‘neurological’ classes affected different brain structures is perhaps not surprising. Personally, I found the considerable overlap between the classes the most interesting finding. This finding suggests that disease specific ‘lesions’ have a considerable effect on wider neural network structure. Understanding of the mechanisms of these shared findings requires input from both specialities.

Following on from this it is important to remember the grey matter volume reduction was reliably found in both classes of disorder albeit in some different brain regions. A finding more parsimonious with the authors’ conclusion would have been if there was no evidence of volume loss in one set of disorders versus the other. This would clearly have segregated the conditions. Instead we must now accept that the presence of structural brain changes does not de facto indicate a ‘neurological’ condition as compared to a ‘psychiatric’ one. Undoubtedly, the aetiological mechanisms of volume changes are not the same across disorders, no classically defined ‘psychiatric’ condition is driven by known progressive proteinopathy, for example. However, the finding that both sets of conditions are associated with structural brain changes clearly establishes both as ‘disorders of the central nervous system’.

Finally, from a clinical perspective, the symptoms patients suffer from do not sit neatly on either side of the classical ‘psychiatric’ and ‘neurological’ divide and the findings from this paper may go some way as to explaining why. To segregate these classes based on a few regional differences in grey matter volume may appear somewhat artificial especially in face of the clinical burden of ‘psychiatric’ symptoms in ‘neurological’ patients and visa versa. Furthermore, I do not believe that either group of patients are best served by the call to keep the intellectual framework of these two groups of disorders separate.

Importantly, accepting that there are neurobiological similarities between traditionally ‘neurological’ and ‘psychiatric’ conditions does not equate to saying that either clinical speciality should feel threatened by the other. The considerable differences in clinical approach, decision making and support structures employed by neurologists and psychiatrists are sufficiently distinct that we should not feel threatened to admit that the disorders we are seeing manifest from dysfunction of the same organ. Accepting this stance will, hopefully, facilitate the cross-fertilisation of knowledge and lead to improved care for both sets of patients.

Your Sincerely,

Dr. Akshay Nair MRCPsych

Leonard Wolfson Clinical Training Fellow, Institute of Neurology, UCL

& SpR in General and Older Adult Psychiatry, South London and Maudsley NHS Trust.

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Conflict of interest: None Declared

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