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APA urging neurology and psychiatry to rejoin?

Discussion in 'Psychiatry' started by Faebinder, Dec 14, 2008.

  1. Faebinder

    Faebinder Slow Wave Smurf
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    This is interesting. Was reading the Psychiatric News by the APA newspaper. It seems there is a push to rejoin neurology and psychiatry together. Mostly due to the largely shared patient population and to step away from the stigma.... This push is called for by Stuart Yudofsky, the chair at Baylor while speaking in Chicago.

    I thought it was interesting but we don't do enough organic outside the brain to join neurology and they don't do enough behavioral for them to sink into psychiatry.. what's everyone's thought on this? Seems like an impossible thing to happen.. and i doubt there is a true push towards this.
     
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  3. Doc Samson

    Doc Samson gamma irradiated
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    Don't know that you could call it a "push" - more a suggestion by Dr. Yudofsky. Personally, I can't see it. Training would be what? 6-7 years long? That's not going to encourage more trainees to pursue the field. It'd also likely mark the death of psychotherapy training for MDs. I just don't see it happening.
     
    #2 Doc Samson, Dec 14, 2008
    Last edited: Dec 14, 2008
  4. whopper

    whopper Former jolly good fellow
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    Read the same article. Agree with Samson. Its more of a suggestion. There are several people who give their opinions at APA meetings that don't come to fruition.
     
  5. Chimed

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    Yeah, I read this, too. I strongly agree with you guys that the fields should not merge and remain separate. I also don't think this would ever happen as there is just too much information and training that would be needed to adequately cover what both specialties do.
     
  6. whopper

    whopper Former jolly good fellow
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    The practices are very different. Yes they both work with the brain, yes there's correlation with both fields, but there's correlation with every field. I've sometimes thought psychiatry curriculums should incorporate Abnormal, General, & Social Psychology college courses.

    If they did merge, I know a lot of neurologists & psychiatrists that don't like working in the other's domain.
     
  7. Chimed

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    Sure. That'd be great, but there is already so much to learn, how would it be worked in? I also think having a course on development would be useful. But I'm interested in C&A, so I'm a bit biased.
     
  8. michaelrack

    michaelrack All In at the wrong time
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    agree that it won't happen. The styles of practice between the 2 specialties are very different- psychiatrists relying on the mental status exam, while neurologists perform detailed neurological exams (at least on new pts).
     
  9. howelljolly

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    What about the 9 combined neuro/psych programs? Apparently, there used to be more, and these have been gradually decreasing. Why is that? I assume that the schedule is manageable, i.e. you won't be a PGY-13. There have been suggestions on this forum to the effect of doing a neuropsych fellowship, rather than a combined residency. Why is that?
     
  10. masterofmonkeys

    masterofmonkeys Angy Old Man
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    Yudofsky would be the co-author of THE neuropsychiatry textbook, so I'm not particularly surprised to hear that.

    That said, I don't really feel a strong desire to be able to localize a lesion only to tell a patient I can't do anything for them. EMG/NCS, TPA, and antiepileptics...they can keep them.

    The only real area of overlap is in behavioral neurology-dementia, parkinsons, huntington's, wilson's, etc. And to be honest, I think that neurologists who go into that area probably should have a better psychology/psychiatry background before specializing in that.
     
    #9 masterofmonkeys, Dec 14, 2008
    Last edited: Dec 14, 2008
  11. whopper

    whopper Former jolly good fellow
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    True. Like a resident who pulled an all nighter & has around 80 hrs of work has the time to take a college course. Its unfortunate, but I learned a lot of clinically relevant stuff in a psychology curriculum, not a psychiatry curriculum.

    Those things could be taught in a psychiatry curriculum, but they'd have to cut clinical work about 10 hrs a week to add a psychology class. Won't happen. Those 10 hrs make residents cheap labor that hospitals want.
     
  12. Faebinder

    Faebinder Slow Wave Smurf
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    My understanding is that neurology labored for 30 years to have this split.. so I dont know how in the world the two specialties would rejoin. Frankly, I can't imagine them agreeing to be back.. Psychiatry would better fit as a neurology subspecialty but the patient population is just huge.
     
  13. whopper

    whopper Former jolly good fellow
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    OT, but there's another interesting article on the potential of oxytocin as a possible medication for psychiatric benefit.

    When I was in undergrad, I took Psychological Endrocrinology. The professor was lame, but the material was very good & so was the textbook. Oxytocin could hold several psychiatric benefits, but no one has yet to make a med that could exploit this value.

    It could have several benefits in family therapy, couples therapy, social phobia, anxiety, social interaction & bonding.
     
  14. masterofmonkeys

    masterofmonkeys Angy Old Man
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    we could just tell people to have more sex instead.
     
  15. Chimed

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    That could be helpful for autistic spectrum DO's.
     
  16. strangeglove

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    In my (admittedly chauvinistic) view, neurologists generally have a pretty rudimentary grasp of the relationship between brain and behavior. They tend to learn as much about these concepts as is necessary to be able to localize lesions, which is pretty gross knowledge. In fact, they don't really need to know much more in order to do their job, which is to diagnose and prevent the death of neurons and muscle. In other words, a neurologist doesn't need to know what the prefrontal cortex does in order to keep it from being damaged by re-perfusion injury after an ischemic stroke. In fact, neurologists are especially clueless when it comes to the function of the prefrontal cortex (also called the "silent cortex" by early neurologists and neurosurgeons because lesions there failed to produce discernible deficits). We, on the other hand, are intimately concerned with the functions of this part of the brain, whether we know it or not, since it is responsible for much of higher mental functioning - what we in psychiatry consider to be ego functions, such as impulse control, affect regulation, synthetic integration, etc. Of course, most psychiatrists don't really understand brain function very well, either. But the future of this field will depend a great deal on understanding how brain processes give rise to the mind (i.e. cognitive neuroscience), so psychiatrists will need to learn this. However, this doesn't mean that we need more training in neurology, since, as I mentioned above, neurologists don't really learn much of this anyway. It would be better, in my opinion, for psychiatry training to include more rigorous training in cognitive neuroscience. This points to the distinction between neurology, which is a clinical discipline concerned with the diseases of the central nervous system as a tissue, and neuroscience, which is a science of the relationship between nervous system function and the mind. Don't get me wrong: There are some neurologists who really understand the subtleties of cognitive neuroscience, but their interest is truly academic, since they can do an excellent job treating patients without it. My guess is there are now many more psychiatrists who have this understanding, and this understanding actually helps them in the care of their patients.
     
  17. toby jones

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    Interesting to hear practical concerns that people have with this. The idea has been kicked around for a while now with respect to theoretical considerations.

    The American Psychological Association threatened to sue the American Psychiatric Association if they stated that mental disorders were 'biological' (and not 'or psychological') in the DSM.

    On the one hand the thought is that mental disorders are neurological at base (so mental disorders result from neurological malfunction).

    On the other hand the thought is that you can have cognitive or behavioral dysfunction without an underlying neurological malfunction. Just like how you can have a software dysfunction that doesn't entail a hardware fault.

    The concern really comes from an inference (which probably doesn't follow) that if a disorder is biological then interventions are most likely to be successful if they target the biology fairly directly (e.g., with medication) or if a disorder is cognitive then interventions are most likely to be successful if they target the cognitive processes fairly directly (e.g., cognitive restructuring). I guess... That is part of the politics behind controversy over whether mental disorders should or shouldn't be regarded as 'cognitive' or 'social' or 'biological' or 'genetic' or 'neurological' at any rate...
     
  18. Faebinder

    Faebinder Slow Wave Smurf
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    That's a pretty good analogy I'll have to use someday. Psychologists are the software engineers, Psychiatrists are the hardware engineers, Neurologists are the electrical engineers or possibly, the big fat electrician with pants down his ass that comes to fix things and gets a lot of money for a 15 minute job. :whistle:
     
  19. nancysinatra

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    That's a pretty outdated stereotype. They are able to do more and more for their patients in neurology nowadays, especially with strokes. And come on, psychiatrists are not exactly surgeons--in and out, with the patient cured an on their way. We are hardly the ones to be bragging about our cure rates. Now that I think about, we don't do ANY elective procedures, do we? We're struggling to keep up with the necessary treatments!! So I think we shouldn't be making fun of neurologists who are making strides in their field, which is also a hard one.

    I wouldn't mind it if the two fields joined. I like the way that neurology looks at problems. I find it really beneficial to thinking about psychiatric problems. I don't see why it has to be one way or the other. For example, take depression. Ok, you can't "localize" depression as a lesion the way we can localize a brain tumor or an abscess. But if we could be a BIT MORE SPECIFIC than we currently are as to what causes depression and where, would that be so bad? No, I think that would in fact be helpful. (And anyway, neurology has a type of localization known as "diffuse" so it's not like psychiatric diseases can't be localized.) And if the two fields did join then we could collaborate on areas like cognitive neuroscience and memory.

    I would sure rather be lumped in with neurology than with medicine. Or god help me Ob/Gyn.
     
  20. howelljolly

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    I agree. If Neuro and Psych were combined, I'd have NO second thoughts about going into it. Each field could offer something to the other. I agree that we could be more specific about certain things. I also liked the way they look at problems, and I think it would change paradigms in treatment if psych solved problems that way.
     
  21. Doc Samson

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    Why on earth should we want to be lumped in with anybody? That's what really bugged me about the original article - Yudofsky was suggesting that be recombining with Neurology we would reestablish our medical legitimacy. I say we're already legitimate.
     
  22. nancysinatra

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    Oh, well, I agree with that. I was just joking. Although once I saw someone say that psychiatry was a "specialty" within medicine, but I always wondered if it was a typo. I just meant that if we HAD to team up with another specialty I personally would choose neurology. I would not choose, say, dermatology, or aerospace medicine, or some others.

    Anyway, here I was arguing for the legitimacy of neurology, a field I didn't choose, so it stands to reason I already believe in the legitimacy of the field I DID choose.

    Also I didn't read the article so I didn't realize this debate stemmed from an insecurity about legitimacy. I thought it had some intellectual underpinning, which sounded interesting to me.
     
  23. michaelrack

    michaelrack All In at the wrong time
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    agree with you about ob/gyn. But I think it would be great if psychiatry was joined with internal medicine.
     
    #22 michaelrack, Dec 18, 2008
    Last edited: Dec 18, 2008
  24. nancysinatra

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    Why do you think that? Do you think we have more in common with medicine than with neurology? I'm just curious. I feel like with medicine, you can remove a lot of organs one by one and the body can keep working--even the heart and lungs (ie. bypass machine)--but you can't get by without the brain. You also CAN'T separate the brain FROM the mind which is why I'd lean toward neurology. People talk about the mind and the body being inseparable, but really, they're not. I can at least imagine separating the two, because, as I said, you can take one organ away at a time and the person remains alive. But if there is no mind, there is no behavior except coma or death.

    (Ok, I do realize behavior is affected by physical health in other ways, but we have to draw the line somewhere!)

    However, I have been rethinking my comment about aerospace medicine not being a good thing to be lumped in with. It actually would be really cool to do experiments with them and go on flights together. Also talk about a time where if a patient loses their cool, you really want a psychiatrist around. And hyperbaric medicine too. Those situations pose unique psychological challenges to people. So I recant that statement.
     
  25. masterofmonkeys

    masterofmonkeys Angy Old Man
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    The only places that action potentials actually ORIGINATE are in sensory organs. Without a body, there is no mind.
     
  26. howelljolly

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    :cool: probably the most brilliant statement youve ever made.
     
    #25 howelljolly, Dec 18, 2008
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  27. nancysinatra

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    But neurology works with the entire nervous system. So what if we could isolate the peripheral nerves too? I grant you, the peripheral nerves are somewhat "body" and not entirely "mind." Ok, ok.

    Still a lot of the body is expendable, you gotta admit.

    You can't make the reverse statement, that without mind, there is no body. For there are sponges and plants. Also, the BODY is technically necessary for every single specialty within medicine and surgery, and in fact, for every job held by every human. So, for psychiatry to ally itself with internal medicine--I mean, the profession of art history or the profession of plumbing could make the same argument, and ally themselves with internal medicine, claiming that they are inextricably linked, and that without healthy bodies their fields too will die out. (I guess all I'm saying is that your point makes argues for neurology itself being a subset of internal medicine. That doesn't convince me that psychiatry is closer to medicine than to neurology...)

    I would say the only field of medicine that doesn't require a body is cytopathology--don't they just look at cell aspirates? They could work in a prokaryotic world.

    But, I get your point! :)
     
    #26 nancysinatra, Dec 18, 2008
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  28. howelljolly

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    But isnt Psychiatry without Neurology just Psychology?
     
  29. Doc Samson

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    Psychiatry without Neurology is psychotherapy - if you choose to equate this with psychology, that's your business.
     
  30. strangeglove

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    No. As I discussed above, neurology, which is the clinical discipline concerned primarily with diagnosing and preventing the death of neurons and muscle, needs to be distinguished from neuroscience, which is the scientific discipline concerned with understanding the relationship between mind and brain. In a future where we treat depression, for example, with a neurobiological approach, we will need to know the function of brain areas that are abnormally active in this disorder. We're not quite there yet with this approach, but we won't get there any faster by learning how to administer tPA and test reflexes, but we will by including more training in basic systems and cognitive neuroscience in psychiatry training. To reiterate, this would be very different from clinical neurology training as it exists today.
     
  31. toby jones

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    There are a few fields in the vicinity:

    Neuroscience (the science of neurons in both homo sapiens and in other species). Typically thought to be biology.

    Cognitive Neuroscience (an attempt to merge neuroscience with cognitive psychology so we have an understanding of the neurobiological underpinnings of cognitive tasks such as memory, emotion, attention etc typically in homo sapiens though animal models for ethical concerns). Typically thought to be psychology - though also often recognized as interdisciplinary with computer science / engineering, cognitive psychology, philosophy, psychiatry, neurology etc.

    Cognitive Neuropsychology (an attempt to model mental processing computationally / informationally on the basis of single and double dissociations and lesions etc insofar as it relates to behavioral and cognitive activity. Typically thought to be cognitive psychology.

    Neurology and psychiatry (and oncology and pediatrics and ob gyn etc) are all thought to be specialities within general medicine (I was probably the person who said that psychiatry was that. They are specializations within medicine is the thought there.

    There is much controversy over whether there is a legitimate theoretical distinction between neurology and psychiatry at the end of the day. People have tried to cash it out in a number of ways but each of these are fraught with counter-examples (e.g., mental vs neural, central vs peripheral, behavioral vs neural etc).

    I have tried to get my head around the differences in practice between being a neurologist and being a psychiatrist because even if there isn't a legitimate theoretical distinction there might well be a legitimate practical distinction that is worth keeping.

    What is the difference between neurology and clinical cognitive neuropsychology? I'd be interested to know what it is and whether it is tenable - aside from the difference in psychology vs medical backgrounds...

    Some theorists have argued that psychiatry needs to merge with neurology. Some theorists have argued that psychiatry needs to merge with neurobiology. Some theorists have argued that psychiatry needs to merge with clinical cognitive neuroscience. Some theorists have argued that psychiatry needs to merge with cognitive neuropsychology.

    Psychology is a diverse field. Important to distinguish between the science behind psychology and applications with respect to fields that focus on treatments.

    The software / hardware distinction is in full force in cognitive psychology though it is still fairly unheard of in biology and in medicine. It originates in Marr who was a vision scientist. He thought that there were three distinct levels at which we could understand or investigate the visual system (or the mind/brain more generally. The lowest level is the hardware level (that of neuroscience - individual neurons and populations of neurons). The next level is the algorithmic level (that of the 'rules' or 'computations' that are implemented by neurons and populations of neurons). The next level is the level of task description (where what we are modeling is some adaption or solution to a particular problem such as focusing light on the back of the retina).

    In order to get clearer on what psychiatry would be without neurology we need to get clearer on the distinction between psychiatry and neurology. Theoretically... I'm all for the model that attempts to integrate the subject matter of both psychiatry and neurology with cognitive neuroscience - where cognitive neuroscience is supplimented with both a social/cognitive level of description and with genetics/epigenetics. So... One level higher and one level lower. With respect to application...

    How much of psychiatry consists in neuroimaging and testing of reflexes? I could be off... But I got the impression that was the bread and butter of neurology... People have tried... And tried and tried and tried... But neuroimaging simply isn't diagnostic for far and away the majority of mental disorders at present. Mental disorders seem to be BEHAVIORAL. Even if a person had all the neurological indicators... If their behavior wasn't what we consider to be 'maladaptive' or 'dysfunctional' then there would seem to be something weird about considering them to be disordered and intervening...

    Maybe the real issue is: What would psychiatry be without pharma?

    There is a concern that psychiatry shouldn't be a specialist field within medicine because it deals with behavioral dysfunction rather than the dysfunction of a system that is internal to the organism. I don't know... But there has been quite a bit written on 1) The distinction between disorder and its absence (and in particular the contribution of science and the contribution of social and / or moral norms to determining that). 2) The distinction between neurology and psychiatry and psychology (both theoretically and practically). And 3) What kinds of mental disorders there really are.
     
  32. toby jones

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  33. howelljolly

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    Very true, but I think that the way neurology solves problems would be helpful to the practice of psychiatry, and I see your point. (in many ways I still live in my fanasy world of what I think psychiatry should be, rather than what it is) ...and for some reason, it seems to be the closest we can get to some established clinical neuroscience... Probably because of the cost, and the time consumption you send the patient to someone else to get neuropsych testing done. But the neurologists and especially the neuropsych guys (PhDs, from what Ive seen) have a way of picking apart signs and symptoms. The neuropsych doc might tell you, that a patient who has a Cluster B d/o has some objective impairment in cognitive flexibility which affects not only personality, but decision making, and everything else. By targeting very specific things we would think about problems differently. We say that schizophrenic patients have positive and negative symptoms, and leave it at that. But what is working too much? What's missing?

    For example... Capgrass syndrome (my brother has been replaced by an impostor). Maybe the problem is that these patients simply do not have that normal visceral, pit of the stomach twist, or heart skips a beat in anticipation/recognition of seeing someone they know very closely. They have the same reaction as they would with a waiter in a diner, that theyve never met. Capgrass syndrome may be different than other delusional disorders for this reason... that the specific "lesion" is the lack of the visceral kick of recognition. Though the patient may not be able to pinpoint this as the reason they think this is an impostor, its their "gut feeling". Target that "lesion" and maybe we can make a difference.
     
  34. whopper

    whopper Former jolly good fellow
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    Psychology is a very broad field.

    It is the academic and applied discipline involving the scientific study of mental processes and behavior. That is very broad.

    That goes from studying people scream in the floor of the stock market, designing a dashboard, studying why pilots blanked out in their phantom jets in combat (sensory overload), understanding why no one called the police to help Kitty Genovese, trying to get more bang for your buck in advertising....

    There are several psychologists who have no experience with psychotherapy.

    I have seen some psychologists know more about psychopharmacology more than several psychiatrists--because that psychologist studied it immensely and was involved in research in that area.

    Clinical Psychology deals more with what we on the board tend to equate with psychology (and that's a very specific branch), and so does Counseling.
     
    #33 whopper, Dec 19, 2008
    Last edited: Dec 19, 2008
  35. howelljolly

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    Nice posts Toby, where have you been hiding?

    I think to say that the practice of neurology is in tPA and testing reflexes, is a mistake.
    Leaving tPA aside (in my area, a State designated stroke center needs only an Emergency Physician, a certifed CVA nurse, and a Radiologist on site... the neurologist can stay in bed for the next day and a half for all they care)...
    Neurology asks, what is it that the patient can't do? They cant feel something, they cant hold their hand still, cant reach for an object.
    What does psychiatry ask (in my mind)? What cant the patient do? They cant get full range of affect, cant control their emotions, cant control their impulses.
    In neurology, theres usually an organic lesion to be blamed, but in psychiatry, theres something else. And until we find out what that something is....

    Freud was a neurologist.
     
  36. howelljolly

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    True. And I totally agree with the last point. So what makes a PhD psychologist who did one post-doc in clinical psych, and another in psychopharm, different from a psychiatrist (besides presciption writing privileges)? I think that the psychiatrist, is/should be uniquely suited to draw on their knowlege of medicine and neurology to make their paradigm of mental illness and therapy into that of a Psychiatrist.
     
  37. biogirl215

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    Couldn't the argument be made (and I've seen it before) that psychotherapy (particularly CBT/BT) actually constitutes a neurobiological intervention, and some cases, the most (or at least a very effective one)?

    Also, I think it would be beneficial if Abnormal Psychology/Psychopathology was added to or better incorporated into med school curriculum --enough specialties see it and have little training in how to handle it (from example, sadness=clinical depression).
     
  38. howelljolly

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    I've heard that CBT has been shown to generate the same changes on fMRI as pharmacologic therapy. But, since we have yet to understand how and why, I dont think most people will really accept that this is a neurobiological intervention.

    I thought that abnormal psychology/ and psychopathology were already part of med school curriculum. In my MS-1 behavioral science class, we went through Kaplan and Saddock, from cover to cover.
     
  39. Faebinder

    Faebinder Slow Wave Smurf
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    I think we would benefit from more neuroscience involvement in the field though I start to wonder... if some day tests are conducted to measure the level of psychosis or mood disorder then will we start seeing neurology taking our piece of the pie? We already know the brain lobe involved in schizophrenia and the genes are known now, we just cannot test their combination that leads to schizophrenia. Once we some tests that actually differentiate axis II from axis I insurance companies will cheer and show their gratitude by refusing to pay for all the borderlines, antisocials, and malingerers trying to be admitted.
     
  40. billypilgrim37

    billypilgrim37 Unstuck in Time
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    Almost every neurologist I've ever met would rather drink battery acid than spend more than 30 seconds in the same room with a patient with psychosis or a mood disorder. The few that don't feel that way become epileptologists.

    Psychiatry may be interested in neurology, but I don't think neurology cares that we even exist.
     
  41. nancysinatra

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    Well, then what other kind of intervention is it? It affects people's thinking and behavior (or else it doesn't, but in that case it's just an ineffective intervention)--which means it is working in some way on people's brains. So how is that not neurobiological?
     
  42. howelljolly

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    Because we still haven't solved the mind-brain problem yet.

    I dont remember the fMRI studies, but for the sake of argument, assume that since fMRI is not currently suggested to assess the clinical effectiveness of CBT, and prognosis of the disease.......
    that the number of subjects that did show fMRI changes as well as behavioral changes, were not different from the number of subjects who showed behavioral changes without fMRI changes.

    That would suggest that CBT has absolutely nothing to do with neurobiology.

    So to say that something either affects the brain and behavior, or it does not, is logically sound, and impossible to say in many aspects of psychiatry.

    Psychiatry has many of these sorts of examples, which doesnt make psych look very good.
     
  43. masterofmonkeys

    masterofmonkeys Angy Old Man
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    I've got a pretty simple way to look at the difference between neurology and psychiatry:

    Neurology is concerned with pathology intrinsic to the CNS and PNS

    Psychiatry is concerned with pathology in the interaction between brain and environment.

    By which I mean in stroke, the neurologist is concerned with the fact that an area of the brain is not functioning appropriately. I.e. broca's area.

    In contrast, a psychiatrist is concerned with a schizophrenic's disengagement from the physical and social world.

    The problem with psychiatry's legitimacy is that in trying to justify our existence we are trying to use medical models of disease.

    The reductionist cause-effect model of medicine is a fundamentally ill-fitting approach to understanding the pathology of brain and behavior.

    This is because the brain is not a pancreas or an adrenal gland, but a self-modifying structure. More importantly, self-modification is a normal and healthy property of the brain.

    The brain is a complex entity that, by means of both negative and more importantly positive feedback, changes not only in reaction to the environment but also how it reacts to the environment.

    The reductionist biomedical model simply does not have enough scope or nuance to truly capture the nature of an adaptive biological system.

    I have long contended that in our approach to understanding the brain in health and disease we need to develop a mindset more similar to that of exercise physiologists or system ecologists. These are fields that are built on the recognition that the subjects they study are in constant flux.

    Contrast the endocrinologist's approach to organic hypothyroidism with that of the exercise physiologist's approach to low to low-normal levels of thyroid hormone or impaired DST response.

    The endocrinologist will look at someone's thyroid hormone levels and determine if the cause is pituitary or hypothalamic in nature, and then proceed to titrate the dose of exogenous thyroid hormone in order to restore this person to normal physiologic levels.

    The exercise physiologist will look at someone with a mildly elevated TSH and reduced free T4 and look at their sleep patterns, stress levels, nutrition, and exercise habits. By manipulating these variables, they can often normalize thyroid function.

    The reductionist medical model would fail the person with mild behaviorally-induced thyroid dysfunction because it doesn't treat the thyroid as an organ in flux.

    Similarly, while there are cases of truly endogenous depression and anxiety, people whose symptoms aren't even abrogated in the slightest by psychotherapy, nurition, exercise, or other behavioral interventions, they are the exception, not the rule.

    If I took two normal weight twins, currently engaged in watching endless hours of sportscenter and pigging out on pizza all day whose only physical activity was to change the channel with a remote, and then took one of them and subjected him or her to a comprehensive plan of exercise, nutrition, and rest, within one year, we would find numerous physiological differences between the two. Differences in HPA and HPG axis functioning, thyroid hormone, growth hormone, testosterone, insulin sensitivity, blood vessel density, heart function, and muscle fiber distributions, mRNA expression, glycogen concentration, and VO2 max would all be apparent. From a biochemical and physiological perspective, many would find it hard to believe they were genetically identical.

    Yet both would be considered 'healthy' through the lens of the biomedical perspective.

    More significantly, we would be looking at two people with vastly different phenotypes despite having the same genotype and the same basic logic of function of physiology.

    Exercise physiology is the science of understanding this. It is the search for understanding the rules by which the body changes itself in response to environmental conditions. In both directions. From 'normal' to 'robustly healthy' and from 'normal' to 'diseased'.
    Psychiatry, like all of medicine, has heretofore concerned itself with looking at the pathologic state and the 'normal' state and enumerating the differences between the two.

    If we are truly to get a handle on the pathophysiology of the brain we must gain a better understanding of the normal rules of how it changes. From 'average' to 'depression/anxiety' resistant and from 'average' to 'depressed/anxious'. Or studying those with similar susceptibilities to bipolar or schizophrenia, and determining how the brain changes in those who develop these disorders and those who don't.

    In a more medically-related analogy, the development of metabolic syndrome is a classic example of normal somatic adaptation that continues to the point of pathology. Some are more susceptible than others, but at the end of the day, this is a consequence of the normal rules of physiological adaptation. This is also why in the early stages of Type 2 Diabetes, intensive exercise and diet modification will resolve the hyperglycemia and hyperinsulinemia in 90% of cases.

    Depression, anxiety, schizophrenia, and bipolar disorder are likewise syndromes that show themselves as a range of abnormalities including noradrenergic, serotonergic, chonlinergic, and dopaminergic pathways in the brain, and in addition in depression and anxiety are often accompanied by abnormalities in the HPA, HPG, and HPT axes. And much like the metabolic syndrome, early intervention can result in the resolution of symptoms and a much reduced morbidity and severity of disease (even to a degree in schizophrenia and bipolar DO).

    I firmly believe that we will find this to be true for most psychiatric disorders, especially mood and anxiety disorders. Longitudinal studies in these areas even show that individuals who rely on medication rather than combination, psychotherapy, or lifestyle modification develop more severe disease with a higher frequency of recurrence.

    Obviously it's not an easy job and would require intense long-term study of the brain functioning of a host of individuals with the genetic and phenotypic risk factors for the development of psychiatric illness, but it's the only way we'll be able to truly claim we have a handle on this whole business.

    /end rant.
     
    #42 masterofmonkeys, Dec 20, 2008
    Last edited: Dec 20, 2008
  44. howelljolly

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    Nicely put.

    and thats why i love psychiatry
     
  45. nancysinatra

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    I'm a bit confused here... So half the CBT patients had fMRI changes plus behavior changes, and half had no fMRI changes plus behavior changes. But all had behavior changes? And that's supposed to prove that CBT is not "neurobiological?" Why? Are you saying that it proves that CBT doesn't effect the brain? All that proves to me is that CBT doesn't effect the brain in a way that shows up on fMRI.

    Also, I do not see how solving the mind-brain problem is going to take the brain out of the pathway between CBT and behavior. It might clarify how the brain creates thought, and how thought leads to behavior, but all of that is still happening in the brain. As opposed to the stomach, the kidneys, or an object outside of the person. So it still seems "neurobiological" to me.

    I don't really see the need for experiments or evidence to show that psychological aspects of existence are "neurobiological." I'm saying this because humans are biological, and psychology goes on in the brain, rather than in, say the arms or the feet. The brain is made up of nervous tissue. Just because there's a whole lot we don't understand about the "mind-brain" relationship doesn't mean that the brain tissue isn't involved in thinking and psychological activity. Otherwise, creatures without nervous systems would have psychological activity.

    If people think there is a "mind" that is physically separate from the brain, and this mind is what things like CBT act upon, then why does thinking become impaired and/or stop when the brain tissue is compromised? Wouldn't CBT then work upon people who are brain dead? Or even dead? Since, if the mind is not "neurobiological" it should continue to exist without the brain, I guess.

    Maybe I am misunderstanding something. I seriously do not understand some of the parsing out of terminology. We don't understand the brain that well--so I don't think we need that many different terms to describe it!
     
  46. howelljolly

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    I see your point, and I dont suppose I could come up with a reasonable response. :rolleyes:
     
  47. toby jones

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    It would be something of a miracle if talk therapy didn't alter behavior by way of altering neurobiology. That being said, we might want to retain a distinction instead of rendering it meaningless. I mean, by the same token surely talking to a priest or taking placebo or whatever must similarly effect their behavioral changes by way of altering neurobiology - there simply isn't another way.

    Perhaps it comes down to how more or less direct vs indirect the interventions are. For example, delivering a medication seems to be a fairly direct neurobiological intervention whereas talking to someone thereby altering the production and / or release and / or metabolization and / or uptake of neurotransmitters is less direct.

    Just because the distinction is a little bit blurry doesn't mean it isn't worthwhile...

    I'm not really sure what the recommendation is... What day to day differences would result in that.

    I agree that psychiatry is legitimately enough regarded as a branch of medicine (I think that psychiatry has much to show the rest of medicine, actually). It doesn't need to be reductionist or to focus on neurobiology in order to be legitimately regarded as a branch of medicine. Many feel differently, though. For instance... If psychiatry wasn't so involved with pharma then many feel that it would not legitimately be regarded as a branch of medicine.
     
  48. biogirl215

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    Given the topic of this thread, did many/any of you psych residents and attendings consider neurology?
     
  49. billypilgrim37

    billypilgrim37 Unstuck in Time
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    Such an Aussie thing to say.

    Back where I come from, there's also the Pahr and Guh-Race of Jaysus Cuh-Rist and the Hoooo-ley Spirit-uh.

    And don't forget the Imperio Curse.

    Yes, but after four weeks of "wow, your stroke really sucks, here's some aspirin," not even the awesomeness of the rest of the field could dull the pain.
     
  50. howelljolly

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    Im not a resident or an attending, but I did my undergraduate in psychology, and did two years of research in neurology. Ive considered both. Now Im considering neither.
     
  51. biogirl215

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    Can I ask why?
     

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