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. 2002 Oct 5;325(7367):778.

Wall between neurology and psychiatry

Neuropsychiatry is alive and well

Howard A Ring 1
PMCID: PMC1124289  PMID: 12364318

Editor—In your theme issue on neurodegenerative disease, the “wall between neurology and psychiatry” is referred to on several occasions. In the editorial by Baker et al the need for a fundamental alliance between mental health and brain illness is discussed.1 Kale in his article makes a case for the proposition that “the mind is a function of the brain.”2 Not only do I and many of my colleagues agree with this: we and others have also made big steps in removing this “wall” between the two specialties. Although Kale goes on to consider the dualism that has psychiatrists and neurologists who think that the two are separate, it seems to me that this belief in the distinction between “neurological” and “psychiatric” disease is often held by some among the general public and the wider medical community, where it arises from a stigmatising view of psychiatry. It suits some to be able to consider “real” neurological disease arising from brain pathology as distinct from psychiatric disturbances arising from weak moral fibre or bad breeding.

graphic file with name neurology.f1.jpg

ARTWORK BY HANS-ULRICH OSTERWALDER/SPL

There have always been both neurologists and psychiatrists who have understood the close relation between these two fields of endeavour. In the United Kingdom two national professional bodies currently exist that are specifically focused on the interrelation between physical brain state and behaviour and affect. The British Neuropsychiatry Association is a multidisciplinary grouping of psychiatrists, psychologists, neurologists, and other interested healthcare professionals devoted to exploring the relations between these fields. The Special Interest Group in Neuropsychiatry of the Royal College of Psychiatrists is a forum in which psychiatrists are currently working to further the recognition of, and seek increased resources for, the many patients whose needs transcend narrow neurological or psychiatric models of diagnosis and care.

References

  • 1.Baker MG, Kale R, Menken M. The wall between neurology and psychiatry. BMJ. 2002;324:1468–1469. doi: 10.1136/bmj.324.7352.1468. . (22 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Kale R. Neuroimaging. BMJ. 2002;324:1529. . (22 June.) [Google Scholar]
BMJ. 2002 Oct 5;325(7367):778.

Some parts of the wall are thicker than others

Jon Stone 1,2,3, Alan Carson 1,2,3, Michael Sharpe 1,2,3

Editor—The editorial by Baker et al highlights the nonsensical way in which psychiatric and neurological disorders and the doctors who look after them have been divided over the past 100 years and how modern neuroscience is bringing them closer together again.1-1

Where is the wall between the two specialties at its thickest? Not in academic research, where distinctions between mind and brain in schizophrenia, Parkinson's disease, and depression are already largely abandoned. Perhaps in training? It is true that opportunities for a neurologist to gain psychiatric skills (and a psychiatrist to gain neurological skills)—in the United Kingdom and United States anyway—are limited and the scope for improvement is huge. But generally a patient with Parkinson's disease who also has delusional disorder will receive attention and treatment. Similarly, psychiatrists continue to look for neurological disease in their patients much more often than they find it.

The thickest part of the wall and the greatest challenge to these two disciplines is in the area of functional neurological symptoms or neurological symptoms unexplained by disease. Freud, cited in the article as a prototypical neuropsychiatrist, was initially a neurologist, but he abandoned the clinicopathological model to explain hysteria. It was this proposal that drove the greatest schism between mind and brain 100 years ago.

Up to one third of all new neurology outpatients have symptoms such as dizziness, numbness, pain, weakness, and blackouts that are neither explained by disease nor “functional.” Neither neurology nor psychiatry is particularly interested in them, and basic neuroscience has made only embryonic inroads into their understanding. Important aspects of functional neurological symptoms, such as illness beliefs and the interaction of cultural factors, may forever remain outside the reach of the scanner. To break down the wall truly, neurology and psychiatry must not simply focus on those symptoms where biology has permitted dialogue. In the 19th century physicians of nervous disorders brought important social, psychological, and biological perspectives to the symptoms they observed. Let's hope in our rush to examine the brains of our patients we do not forget to listen to what they are saying.

References

  • 1-1.Baker MG, Kale R, Menken M. The wall between neurology and psychiatry. BMJ. 2002;324:1468–1469. doi: 10.1136/bmj.324.7352.1468. . (22 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
BMJ. 2002 Oct 5;325(7367):778.

Integration of mind and brain creates biopsychological understanding in psychiatry

D B Double 1

Editor—Baker et al argue that advances in neuroscientific understanding mean that the wall between neurology and psychiatry should be torn down.2-1 Their intention seems to be the integration of mind and brain, but they fail in this aim because they seem to wish to eliminate the notion of mental dysfunction.

Adolf Meyer was fond of calling the attempt to reduce mental dysfunction to brain pathology a neurologising tautology.2-2 What is achieved by concluding that schizophrenia and other functional mental illnesses are disorders of the brain? The hypothesis that mental dysfunction is caused by brain pathology has not been decided by the evidence. The kinds of processes that underlie mental illness at the biological level may be no different from those that produce thoughts, feelings, and behaviour among “normal” people.2-3

The Dutch Association for Psychiatry and Neurology represented both neurologists and psychiatrists in the Netherlands until 1974. Separate sections for neurology and psychiatry were created only from 1962. The increasing separation of psychiatry and neurology encouraged a multicausal, biopsychosocial approach to psychiatry as opposed to the one sided somatic emphasis of neurology.2-4 Maybe the reason that Baker et al cannot see any difference between psychiatry and neurology is that biomedical approaches have become so dominant in modern psychiatry that a biopsychological view is seen as almost heretical.2-5

Although neurologists have the same issues as other doctors in relating to patients, they do not encounter the ideological conflicts of psychiatrists. For example, a professional dilemma of psychiatrists is the conflict between their separate status as scientific medical specialists and the need to be more than medical specialists if they are to influence other mental health professionals. Psychiatrists have a social role in controlling mental disturbance through the Mental Health Act. The model of mental illness adopted affects how patients are treated, and the Critical Psychiatry Network (www.criticalpsychiatry.co.uk) believes that psychiatric practice does not need to be justified by postulating brain pathology as the basis for mental illness.

References

  • 2-1.Baker M, Kale R, Menken M. The wall between neurology and psychiatry. BMJ. 2002;324:1468–1469. doi: 10.1136/bmj.324.7352.1468. . (22 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-2.Winters E, editor. The collected papers of Adolf Meyer. 1-4. Baltimore: Johns Hopkins Press; 1951-2. [Google Scholar]
  • 2-3.Double DB. Training in anti-psychiatry. Clin Psychol Forum. 1992;46:12–14. [Google Scholar]
  • 2-4.Oosterhuis H, Wolters S. The changing professional identity of the Dutch psychiatrist. In: Gijswijt-Hofstra M, Porter R, editors. Cultures of psychiatry. Amsterdam: Rodopi; 1998. [PubMed] [Google Scholar]
  • 2-5.Double DB. Integrating critical psychiatry into psychiatric training. In: Newnes C, Holmes G, Dunn C, editors. This is madness too. Ross-on-Wye: PCCS Books; 2001. [Google Scholar]

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