What determines the scope of neurology vs psychiatry?

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pathologyDO

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Alright, this may be a naive question but I was just pondering it.

My reason for thinking about this is that I am interested in the future of psychiatry.

The scope of psychiatry, from what I have read using the search function here on SDN, seems to be within behavioral problems. However, mental ******ation, dementia, and alzheimer's are types of behavioral problems too and yet it normally falls under the scope of a neurologist, according to the following graph:

neurologypsychiatry.jpg


What this makes me think, then, is that psychiatry is a field who's scope is those conditions that have so far only simple biological understanding at the cellular/molecular level. For instance, we cannot really say what exactly causes schizophrenia, including the combination of genes, environmental factors, nor exactly what is happening at the biological, physiological level in detail. We can say some associated genes or that certain medications work, but we cannot really determine the exact cause.

Now I know, you're probably saying this isn't 100% accurate. Maybe not even 75% accurate, but this is just a naive assumption I have came to.

Having said this, I now wonder what will happen to psychiatry if we have a major breakthrough in the understanding of conditions such as schizophrenia, PTSD, bipolar disorder, etc. etc. such that one can determine the exact biological causes and the therapy to best treat these conditions. Yes, I know, these conditions may never be curable, only managed. But one would be obtuse to not consider the possibility that in our lifetimes we may have scientific breakthroughs that lead to a much deeper biological, if not complex genetic/epigenomic, understanding of these conditions

If we did move to such a greater understanding of these conditions, would the scope of healing these patients more pertain to a neurologist given the circumstances?

tl;dr

If we come to understand the root biological causes and exact genes (I know they are largely multifactorial and complex, but with computing and technology we can probably do amazing things in the future) of conditions under the scope of psychiatry right now, will those conditions become to be under the scope of neurology instead?

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we won't find "the root biological causes and exact genes" for schizophrenia, mania, panic etc because this are artificial constructs that do not map on to nature and thus to do not represent phenotypes for which there are genes.

also this is just looking at what constructs are popular ina neurological vs a psychiatric journal. if for example you took psychosis instead of schizophrenia you would find many more articles in neurology on this topic.

so you are mostly incorrect - psychiatry concerns itself with behavioral, emotional and cognitive problems largely (and psychiatrists deal more with dementia than neurologists do but more from a practical management point than diagnosis). neurology concerns itself more with physical symptoms and signs.

however, it is true that historical those diseases that were found to have a neurological cause e.g. neurosyphilis, Huntington's became the province of psychiatry and were no longer the province of psychiatry. having said that 100 years ago, depressive and anxiety disorders as well as hysterical symptoms were treated by neurologists and not psychiatrists at all.
 
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we won't find "the root biological causes and exact genes" for schizophrenia, mania, panic etc because this are artificial constructs that do not map on to nature and thus to do not represent phenotypes for which there are genes.

also this is just looking at what constructs are popular ina neurological vs a psychiatric journal. if for example you took psychosis instead of schizophrenia you would find many more articles in neurology on this topic.

so you are mostly incorrect - psychiatry concerns itself with behavioral, emotional and cognitive problems largely (and psychiatrists deal more with dementia than neurologists do but more from a practical management point than diagnosis). neurology concerns itself more with physical symptoms and signs.

however, it is true that historical those diseases that were found to have a neurological cause e.g. neurosyphilis, Huntington's became the province of psychiatry and were no longer the province of psychiatry. having said that 100 years ago, depressive and anxiety disorders as well as hysterical symptoms were treated by neurologists and not psychiatrists at all.

Thank you for your response.

If there isn't a behavioral, emotional, or cognitive issue, then basically psychiatry isn't interested, right?

In reference to the bolded - while I understand that the artificial constructs are made to understand the behavioral, emotional, and cognitive problems, there is still likely a underlying, biological cause that is due to complex genetic/epigenetic/environmental factors. If we elucidated those root causes leading to the set of behaviors and symptoms, we could use gene therapy or provide very effective medication, which could potentially get rid of all the aforementioned trifecta of problems associated with the psychiatric illnesses.

Honestly what I am saying now implies something much more profound than what I originally was thinking, which is kindof making me feel even more niave haha. So if we did come to figure out how to essentially cure the behavioral/emotional/cognitive symptoms of psychiatric illness before they even occur, then I suppose psychiatry would be a much smaller field with less individuals needed.
 
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So I guess what this thread has really turned into is the question of what the future of psychiatry will be with the rapid advancement of technology and understanding of genetics/epigenetics.
 
It comes down to the approach. Interpersonal vs physical findings. Etiology is secondary though obviously the two are connected. I was thinking though that if diagnostic criteria of depression, schizophrenia, autism, ADHD, or maybe personality disorders..etc will become more rooted in physical findings, imaging and lab results, then maybe modern psychiatry can be split into one half joining neurology (or staying on its own, but unlikely) and the other half (the therapy and psychoanalysis part) becoming purely the domain of psychologists. I hope that never happens, because what makes psych special right now is that it's not all about lab tests and med management. It's the psychotherapy/importance of interpersonal connections in both diagnosis and treatment (in addition to med management) that really makes the field so exciting.
 
It comes down to the approach. Interpersonal vs physical findings. Etiology is secondary though obviously the two are connected. I was thinking though that if diagnostic criteria of depression, schizophrenia, autism, ADHD, or maybe personality disorders..etc will become more rooted in physical findings, imaging and lab results, then maybe modern psychiatry can be split into one half joining neurology (or staying on its own, but unlikely) and the other half (the therapy and psychoanalysis part) becoming purely the domain of psychologists. I hope that never happens, because what makes psych special right now is that it's not all about lab tests and med management. It's the psychotherapy/importance of interpersonal connections in both diagnosis and treatment (in addition to med management) that really makes the field so exciting.

Yes, this is the kind of outcome I have been drawing a conclusion to as well. There is a lot of if/and/but's in there, however I think considering what could happen is worth the discussion. Especially for those of us just now entering med school whom wont be practicing for another 8 years, giving plenty of time for major advancements.
 
..If there isn't a behavioral, emotional, or cognitive issue, then basically psychiatry isn't interested, right? ...

I'd also restate this as "If there IS a behavioral or emotional issue, then basically NEUROLOGY isn't interested".

Much of what draws us to psychiatry is the desire to delve into these things. Even if we know that a behavior has resulted from a structural neurologic problem, it is still generally the expertise of psychiatrists that is sought to manage that issue, whether therapeutically or pharmacologically.
 
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I'd also restate this as "If there IS a behavioral or emotional issue, then basically NEUROLOGY isn't interested".

Precisely. Even if the "neurobiology" of borderline personality disorder, including a single mendelian-inheritance X-linked dominant gene, were suddenly discovered tomorrow, neurologists would stuff their ears with their bow-ties and whistle while walking away.
 
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I'd also restate this as "If there IS a behavioral or emotional issue, then basically NEUROLOGY isn't interested".
Ditto this. The biggest surprise for me on the graphic is the idea that any neurologist would view depression as even 1% of their responsibility/domain, let alone 15%
 
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I'd also restate this as "If there IS a behavioral or emotional issue, then basically NEUROLOGY isn't interested".

Much of what draws us to psychiatry is the desire to delve into these things. Even if we know that a behavior has resulted from a structural neurologic problem, it is still generally the expertise of psychiatrists that is sought to manage that issue, whether therapeutically or pharmacologically.

Interesting. So you believe under such circumstances, family docs would still refer the pharmacological treatment to psychiatrists rather than a neurologist or treating the patient themselves?

Precisely. Even if the "neurobiology" of borderline personality disorder, including a single mendelian-inheritance X-linked dominant gene, were suddenly discovered tomorrow, neurologists would stuff their ears with their bow-ties and whistle while walking away.

Haha, this is hilarious.


So wait a minute... Are you two saying that neurologists are not really involved at all in pharmacological treatments? So do they just do "tests" and such all day, make a diagnosis, and then refer everything else to a psychiatrist?
 
Ditto this. The biggest surprise for me on the graphic is the idea that any neurologist would view depression as even 1% of their responsibility/domain, let alone 15%

That's not at all what the graph is saying. It's showing the proportion of hits in a neurological and psychiatric journal when searching articles for the term depression. That neurologists mention depression in their articles does not imply they are claiming ownership of the condition.
 
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Interesting. So you believe under such circumstances, family docs would still refer the pharmacological treatment to psychiatrists rather than a neurologist or treating the patient themselves?
That's what they do already...

So wait a minute... Are you two saying that neurologists are not really involved at all in pharmacological treatments? So do they just do "tests" and such all day, make a diagnosis, and then refer everything else to a psychiatrist?
No--what we are saying is that neurologists really want nothing to do with the problematic behaviors that get people referred to psychiatry, regardless of whether or not the underlying neurobiology is known.
 

I was thinking the same thing when I saw this thread just now. There's something from that thread that I thought was a useful analogy: neurologists deal with the hardware and psychiatrists deal with the software. We're both dealing with brain diseases where there is a great deal of overlap. Like others have said neurologists are generally not interested in disorders that are primarily behavioral in nature and I know for sure that I'm not interested in disorders that are primarily structural/electrical in nature, but appreciate the ability to collaborate with my colleagues on patients whose conditions straddle that line carefully enough to need both specialties involvement.
 
Ok. But isn't it interesting that T Grandin was protected from the psychiatry model of thinking when she was 1st diagnosed by a neurologist who assured the family that her issue was a brain problem rather than any prevailing psych views that looked at child developmental d.o.s as parenting faults. Grandin says that this neuro structural dx helped direct her mother to create a structure and active learning environment suited for her daughter to allow her to grow to the best of her potential.

Neuro + psych are both fascinating to me.

I have seen the neuro temperament that was described here with the hands off idea to any behavioral problems. Quite astonishing, it's like a polar opposite even though there's no need to be so divided about the 2 fields.

It's all related + in my very early days of learning as an intern, it continues to amaze me how much healthier we would be all around - providers too - if we addressed our psychiatric health along with our physical health issues.

2 good viewpoints to listen to in audio story form: this american life: dr. Gilmer and mr. Hyde, #492. A psychiatrist figures out the neuro underlying problem. Next, view is from the radiolab story about mel blanc called: what's up doc? From 11/6/12. Here, a resident/future neurosx figures out how to get to a m blanc's psyche to wake him up from a coma. Very good stories. Enjoy.
 
I concur BlueLotus as being interested in both fields. I like the fact that psych allows you to get to know the story behind the man/woman, while neuro allows you to understand the underlying causes of the ailment. In all honesty, I think most medical specialties should strive to understand the person they are treating. It makes for better health care. Plus, I have research interests in both fields, so that's why I'm interested in these specialties. I haven't shadowed a doc in either field, so I may get on rotation and discover I completely hate it. However, I have always been fascinated with emotional, behavioral, and cognitive thinking as well as how the brain is physically wired since middle school. The brain is the only organ besides the heart that you can describe in an abstract and proverbial sense. I may end up pursuing a dual residency. Who knows?!
 
My rule of thumb is that if you can do something about it, it's psych. If you can only recommend PT/OT it's neuro.
 
My rule of thumb is that if you can do something about it, it's psych. If you can only recommend PT/OT it's neuro.

I'm guessing this is mostly sarcasm, but the foundation for such sarcasm is still absurd. Neurologists can do a lot for many different things. There are some things they can't do much for. But the same can certainly be said for psych.
 
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Psychiatry as a field is an off-shoot of Neurology, more or less, so it's not surprising that there's a lot of overlap. If you need to do a detailed physical exam and order tests, it's probably Neurology, otherwise it's probably Psychiatry.
 
I feel like the answers to the OP's question have been somewhat lackluster. To use the example above, once the biological nature of borderline personality disorder is discovered, it wont be long before a treatment is also found, whether procedural or pharmacological. What then happens to psychiatry? Will its scope be affected? I'm genuinely interested in this question as I'll be working in the field for the next 30-40 years at least.
 
I feel like the answers to the OP's question have been somewhat lackluster. To use the example above, once the biological nature of borderline personality disorder is discovered, it wont be long before a treatment is also found, whether procedural or pharmacological. What then happens to psychiatry? Will its scope be affected? I'm genuinely interested in this question as I'll be working in the field for the next 30-40 years at least.
I promise you, you will have borderlines to work with.


The ones I work with already have kids...
 
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I feel like the answers to the OP's question have been somewhat lackluster. To use the example above, once the biological nature of borderline personality disorder is discovered, it wont be long before a treatment is also found, whether procedural or pharmacological. What then happens to psychiatry? Will its scope be affected? I'm genuinely interested in this question as I'll be working in the field for the next 30-40 years at least.

I’m trying to think of any psychiatric illness in which we have discovered a better understanding and this lead to an effective treatment or a cure. The last one I can think of is general paresis of the insane. Maybe Limes disease I guess. Don't worry, there will be plenty of work to do for a very long time.
 
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Biological reductionism really grinds my gears. You have a 25 year old female patient who presents to you complaining of feelings of hopelessness, crippling anxiety, and intrusive suicidal thoughts. She's a high school drop out who married young. She has two small children at home. She has an abusive husband. He's never laid a hand in her, but he's manipulative and controlling. He has isolated her completely from anyone who may have once cared. She is completely financially and emotionally dependent on him. She asked her parents once if she could come back home. Get out from under. Find herself again. They said, "You made your bed. Now lie in it." She has no resources and no one really to talk to. She doesn't see life ever getting any better. She meets DSM criteria for major depressive disorder and panic disorder.

What do you recommend?

Ah, gene therapy. Got it. Unless Gene is the name of the LCSW across the hall, good luck with that.
 
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Biological reductionism really grinds my gears. You have a 25 year old female patient who presents to you complaining of feelings of hopelessness, crippling anxiety, and intrusive suicidal thoughts. She's a high school drop out who married young. She has two small children at home. She has an abusive husband. He's never laid a hand in her, but he's manipulative and controlling. He has isolated her completely from anyone who may have once cared. She is completely financially and emotionally dependent on him. She asked her parents once if she could come back home. Get out from under. Find herself again. They said, "You made your bed. Now lie in it." She has no resources and no one really to talk to. She doesn't see life ever getting any better.

What do you recommend?

Ah, gene therapy. Got it.
What would you recommend psych wise? I've had plenty of psych attendings tell me "there's no cure for s%@! life syndrome"
 
Sure there is. It's just HARD. And expensive. My hypothetical patient is probably screwed, but not because "there is no cure", but because society has chosen not to invest in it. Gene therapy is way sexier than providing some sort of residential treatment program where a person like this could have housing and support while getting away from her awful situation and learning the life skills she will need to live independently. Not to mention the legal support she will need to make sure she is able to remain parent to her children. But let's say such a thing did exist and she did it and she no longer met criteria for MDD and Panic disorder. Was this somehow not a psychiatric intervention because no one's genes got manipulated? I bet the changes to her physiology were real, marked, and likely measurable. Why doesn't that count?
 
To use the example above, once the biological nature of borderline personality disorder is discovered, it wont be long before a treatment is also found, whether procedural or pharmacological.
This isn't true as a rule. There are plenty of diseases in which we understand the biological underpinnings but are essentially powerless to treat, such as Rhett's, Lesch-Nyhan, Fragile X, etc.
 
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Plus we already have a treatment for Borderline Personality Disorder. It's called DBT. And it works. (I'm not saying there isn't room for innovation in the treatment of BPD. These people struggle and if there's something even more effective for treating it out there undiscovered, I'm all for it. Just don't discount what we have already just because it's not a chemical).
 
Plus we already have a treatment for Borderline Personality Disorder. It's called DBT. And it works. (I'm not saying there isn't room for innovation in the treatment of BPD. These people struggle and if there's something even more effective for treating it out there undiscovered, I'm all for it. Just don't discount what we have already just because it's not a chemical).
though as an aside DBT is not a treatment for BPD and was never meant to be. It was developed for control recurrent suicidal behaviors in patients who seemed to best fit this "borderline" category, and has been shown to be helpful in managing other maladaptive behaviors in these patients. DBT is only the first phase of treatment. One study is currently looking at using PE as the second phase of treatment for patients with BPD from what I understand. There are also other treatments that better tackle the underlying character disturbance in BPD which DBT does not really address. But yes I get your point, there are effective interventions and any new treatments are unlikely to come in a pill.
 
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DBT works on BPD patients who are motivated, compliant with treatment recommendations and willing to make the effort. Of course, what doesn’t work for patients who meet these criteria? Given the right patients, I think I could empirically validate tidally wink therapy.
 
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DBT works on BPD patients who are motivated, compliant with treatment recommendations and willing to make the effort. Of course, what doesn’t work for patients who meet these criteria? Given the right patients, I think I could empirically validate tidally wink therapy.
Isn't that true for any intervention? Any therapy but also any medication management?

And isn't this true for any chronic condition, including diabetes and hyperlipidemia?
 
Isn't that true for any intervention? Any therapy but also any medication management?

And isn't this true for any chronic condition, including diabetes and hyperlipidemia?

Absolutely, but diabetes treatment providers tend to be less prone to beat proponents of non-DBT therapy over the head with their sanctimonious un-randomized non-head to head “empirically validated” data. Clearly this is a pet peeve of mine, and I am not anti-DBT. I just want to point out that DBT’s being validated as effective doesn’t say anything about its effectiveness relative to other approaches and it frequently excludes patients who need help. Other than that, it is the end all Cat’s meow for BPD.
 
That wasn't the point. The point was someone appeared to be saying, "won't it be great when we have something to treat BPD?" And this within an entire thread that seemed to discount any treatment that wasn't pharmacological or manipulating someone's genes around. I just felt the need to point out that we're not exactly without anything in our toolbox when it comes to BPD. Psychotherapy and environmental interventions work and are still psychiatric treatments. Discounting them is a huge pet peeve of mine and doing so also excludes patients who need help.
 
The definitions of the boundaries are artificial and something that the laws of science don't follow. In any field of medicine there's going to be overlap and if the attendings are bad, and I've noticed this happen in about 50% of cases in the gray area between fields, someone gets into a pissing-match that they shouldn't have to deal with the problem, ignoring contribution that person could make to the person's well-being.

In hospital politics, this often happens because the attending on the other side is trying to play turf war. In outpatient, it's usually because attendings cannot bill for talking to another doctor and receptionists play the game of "don't let anyone talk to the attending even if it's another attending."
 
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Why dont they combine neurology and psychiatry in one field and name it brainology?
 
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Interesting. So you believe under such circumstances, family docs would still refer the pharmacological treatment to psychiatrists rather than a neurologist or treating the patient themselves?

Family docs, internists, etc. attempt to manage psychiatric disorders all the time. Some do a better job than others. However, this is how you end up with alprazolam 2 mg being used QID to manage simple anxiety. Anything more complicated than depression and most will refer or institute non-optimal therapy in my experience.

On the consult service that I'm currently on, we routinely get consulted for "depression" because a patient was "tearful." Make of that what you will. Some physicians have absolutely no interest in managing issues like that. I'd say at least 25% of the time the patients aren't even depressed - they simply have an adjustment disorder or have behaviors that are appropriate given the context.

So, yes, even though basic psychiatric diseases could theoretically managed by PCPs, most of the time they don't seem to be - or at least not well.
 
Neurology treats the brain as an organ that suffers from inflammation, ischemia, abnormal excitability, infection, degeneration. Many of these problems are analogous to pathology of the liver, heart, lungs, etc. You don't have to know about how the brain relates to the mind in order to be a good neurologist. Same for psychiatrists, at this point. However, as psychiatrists, we are treating problems of the mind, and as we advance our understanding of neuroscience we will be increasingly using this understanding to treat these problems. Even if they found an infectious cause for schizophrenia (just for argument's sake), psychiatrists would still be required to manage the behavioral manifestations of this disorder while it was being "cured" by neurologists. Our skill set is all about helping patients to change/tolerate/learn thoughts, feelings and behaviors, whatever their underlying cause may be.
 
I've been thinking about this difference and reading the responses. To help boil it down I would consider our Neurology compadres similar to IM docs with a Neurological focus where as Psychiatry, vicarious of the training, are students of behaviors and studying patterns how it relates to behavior development.
 
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I feel like the answers to the OP's question have been somewhat lackluster. To use the example above, once the biological nature of borderline personality disorder is discovered, it wont be long before a treatment is also found, whether procedural or pharmacological. What then happens to psychiatry? Will its scope be affected? I'm genuinely interested in this question as I'll be working in the field for the next 30-40 years at least.

Psychiatry several decades ago was basically psychotherapy. It is now includes psychotherapy and pharmacology. There are psychiatrists doing sleep medicine, pain medicine as well as some procedures like ECT, TMS, botox and neuropsychiatry. Clinical neurophysiology is a psychiatry subspecialty also.

Things change but the change does not have to be unilateral. Psychiatrists of today would be neurologists 100 years ago. Scope is a fluid and to think of it in concrete terms is myopic.
 
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For Freud the physician, you have to go on Trivia Cocaine.
 
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Yes. He sure was. I reported a question as incorrect to Trivia Crack. They wanted to know Freud's profession. And I chose "physician". They marked that wrong in favor of "psychologist". Stupid Trivia Crack.

trivia crack can be so enraging as someone who as any sort of specialized knowledge about anything
 
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