Do we need psychiatrists?

[Hard24Get]

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I am not trying to provoke an argument, I just want to discuss:

If depression/schizophrenia, etc, etc, etc, are behavioral/cognitive problems with an organic basis (as evidenced by research and their responsiveness to meds), why don't these diseases fall under the auspices of behavioral neurology? Behavioral modification and counseling, etc, can be done by a therapist working closely with the neurologist.

The psychiatrist seemed to make more sense when we weren't sure if there was a biological basis for psychological problems. Wouldn't treating psychiatric illnesses in neurology be easier for patients to accept they have an actual disease? Aren't we stigmatizing certain illnesses by separating out psychiatry and neurology? Besides, one has to know neurology to be a good psychiatrist and vice versa, so why not combine these residencies and people can then subspecialize from there?

Just wondering what people think.

 

[14022]

I think you make a good argument, and perhaps several years from now this may be the case.

Keep in mind neurologists make diagnoses with neuroimaging, biopsies, and laboratory studies. These methods have been well-studied and are based on a solid understanding of the pathophysiology of their illnesses.

Psychiatrists diagnose based on meeting a certain number of criteria for a certain amount of time which are listed in a single book (DSM-IV). No one really knows the diagnostic accuracy of these tests and the specific diagnosis among a subset of diseases probably will not have any bearing on the choice of therapy or prognosis. I doubt any psychiatrist would ever say "they have depressed mood, anhedonia, no appetite, and insomnia, but they don't have depression since they do not have that necessary fifth symptom to give them the diagnosis. Once they start losing concentration, feel worthless, or lose their energy, then I will treat them for their disease." Or "this person has heard voices for 5 and half months. Two more weeks of it and they will have schizophrenia so I can give them their risperidone then."

What I am trying to say is that in neurology, the diagnosis is arguably the most important part of their job, especially since therapy is not always available for many of the diseases. In psych, making the specific diagnosis is not really that important. The most important part of their job is the use of medical and behavioral therapies (unlike neuro) to try and alter behavior. As neuroimaging continues to improve and the biologic basis of psychiatric disease is better understood, this may change. This is why many say that the field that will most drastically change over the next 20-30 years is psychiatry. It will revolutionize the field.

 

[Astrocyte]

Every psychological phenomenon has biological basis. Psychology and neurobiology are just two ways of looking at the same thing - the brain.

But this does not mean psych and behavior neuro should be combined. The current setup gives people a choice of approach, although the two approaches might converge in practice. Besides, for those few who are into both, they can do psych/neuro combined program.

 

[Solideliquid]

Neurologists treat organic problems. For one most of the neurologists did not get into the field to primarily treat depression and other psychiatric disorders. If they wanted to do that they would have gotten into psych.

Round and round we go. The two fields are inter-related, and both have psych and neuro on the boards, but they treat (sometimes slightly overlapping) different problems.

EDIT: About the new imaging research, perhaps in 10-15 years with the new imaging in psych, disorders in psych will also be considered "organic" as we will be able to point and say THERE IS THE PROBLEM.

 

[Hard24Get]

Every psychological phenomenon has biological basis. Psychology and neurobiology are just two ways of looking at the same thing - the brain.

But this does not mean psych and behavior neuro should be combined. The current setup gives people a choice of approach, although the two approaches might converge in practice. Besides, for those few who are into both, they can do psych/neuro combined program.

That's all fine and dandy for the physician world, but what about the message being sent to the general public? Why is ok to have Alzheimer's and not to be bipolar? I don't see nuts like Tom Cruise running around disparaging treatment for people with Parkinson's. I'm not even saying the residencies HAVE to be combined, but perhaps our definitions need to change. By definition, neurologists treat organic diseases of the nervous system. Psychiatrists treat "emotional disturbance and abnormal behavior" - this definition doesn't acknowledge the organic root of the problem. Many neurological diseases manifest with emotional disturbance and abnormal behavior but the patients aren't burdened with the same stigmata. I think we need to start acknowledging the advances in understanding psychological problems, like those Scholes mentioned, by reconsidering the boundaries between these two specialties.

 

[Astrocyte]

That's all fine and dandy for the physician world, but what about the message being sent to the general public? Why is ok to have Alzheimer's and not to be bipolar? I don't see nuts like Tom Cruise running around disparaging treatment for people with Parkinson's. I'm not even saying the residencies HAVE to be combined, but perhaps our definitions need to change. By definition, neurologists treat organic diseases of the nervous system. Psychiatrists treat "emotional disturbance and abnormal behavior" - this definition doesn't acknowledge the organic root of the problem. Many neurological diseases manifest with emotional disturbance and abnormal behavior but the patients aren't burdened with the same stigmata. I think we need to start acknowledging the advances in understanding psychological problems, like those Scholes mentioned, by reconsidering the boundaries between these two specialties.

But I don't think hiding psych d/o under larger neuro umbrella will change public perception. What will is public education. A good example is depression. Compared to 20yrs ago, there is much less stigma associated with it now.

 

[8744]

Not to mention that the public confuses psychologists and psychiatrists.

 

[Leukocyte]

Neurology and psychiatry share the same medical accrediting board. It is only a matter of time until both fields get combined into one specialty.

 

[HA123]

i agree. the subject shouldn't be, "do we need psychiatrists?" but "do we need psychiatrists and neurologists?" clearly we need the expertise of both fields, but as the research in psychiatry progresses towards a more and more organic basis, maybe it will blend with what we refer to as neurology (which wouldn't be a turf issue, more of a semantic one). but things like this happen all the time, at least regarding certain pathologies with specialty overlap (eg stroke, should a neurologist treat this or a vascular specialist like a cardiologist, vascular surgeon, neuro-interventionalist, neurosurgeon, or my favorite new specialty, cardiovascular medicine?)

 

[Miklos]

Neurology and psychiatry share the same medical accrediting board. It is only a matter of time until both fields get combined into one specialty.

I'm not trying to provoke a flame war, because I respect neurologists and their work a great deal.

However, I believe that the skillset inherent in being an effective psychiatrist differs somewhat (maybe even significantly) from being a neurologist.

How do I know this?

Because, neurologists rarely seem to pass up opportunities to turf patients (yes, even organic ones) with behavior problems. In general, they just don't seem to be comfortable with 'that sort' (please excuse the phrase) of patient population.

 

[Poety]

I would have loved to have done neuro/psych (realized I liked it too late), perhaps a fellowship in it or something when I finish residency, I agree neuro and psych are intertwined.

 

[TheWowEffect]

Psychiatry and Neurology have always shared a common ground and will continue to do so. Kraepelin(the father of Modern Psychiatry) and Alzheimer were contemporaries and worked in the same lab. One decided to study Schizophrenia and the other studied Dementia. Epilepsy was once the domain of Psychiatry and now Psychiatrists are trying to get back Dementia and also stall the progress of Tourette's to Neurology. So this constant fluidity between Psychiatry and Neurology has always been there. A lot of us might know that even Frued was a Neurologist

I would like to think of them both as being the subspecialities of Internal Medicine, with each having its own niche. Neurology is evolving like any other field of Medicine and Psychiatry even more so. We just can't sit here and speculate on what should be what. Prediction is a dangerous thing to indulge in.It would be too far fetched to claim that Psychiatry would cease to exist.

The main issue associated with Psychiatry is the stigma attached with Psychiatric diseases. As the field become more biologic, this will gradually go away. The field is still at an infantile stage, where Internal Medicine was 100 years ago. So give it sometime and it'll surprise you.

 

[skypilot]

The reason they won't combine is that there is plenty of business for both of them. 🙂 Medicine seems to be getting more specialized not less. I don't think Psychiatrists want to treat stroke patients and Neurologists aren't interested in managing the meds for manic depressives.

 

[Hard24Get]

i agree. the subject shouldn't be, "do we need psychiatrists?" but "do we need psychiatrists and neurologists?"

That's true. I guess I was biased because I am interested in neurology 😀

Because, neurologists rarely seem to pass up opportunities to turf patients (yes, even organic ones) with behavior problems. In general, they just don't seem to be comfortable with 'that sort' (please excuse the phrase) of patient population.

I don't know if I agree with the opiniont that you and Skypilot seem to share. Many neurologists I talk to were interested in psych as well, and vice versa. Behavioral problems are the manifestation of the nervous system, I just don't see how we can arbitrarily divide the two fields. I myself would not mind treating psych patients during my residency, though I probably wouldn't subspecialize in that area. It seems unconscionable for Neurologists not to respect psychiatry and vice versa, though I agree that the bias does exist for some. 🙁

 

[Anasazi23]

Psychiatry and Neurology are indeed accredited by the same body, and in fact, share many disorders (dementia, TBI-related behavioral disturbance, and many childhood neuropsychiatric disorders). In years past, epilepsy was under the psychiatric umbrella, until greater understanding was reached. The epileptoid personality is still studied and discussed.

I feel that you cannot be a great psychiatrist without a solid foundation in neurology, and vice versa. The neurology boards are about 40% psychiatry, while the psychiatry boards are about 40% neurology. This is a reflection of that understanding.

While neuropsychiatry residencies do exist, there are relatively few of them, and a few have closed down. In this age of massive medical information and exponential research findings, the fields remain divergent in many ways. I think that neurology is an extremely valuable field, and has many specialized treatments and knowledge of disease states that psychiatrists are not as well versed in. The same hold true for psychiatry.

Behavioral neurology in exclusivity implies that there is no psychosocial basis to any psychiatric disorders. This, of course, if false. Therefore, behavioral neurology will continue to exist and likely grow, as it should, while psychiatry and its subspecialties do the same. As a future neurologist, you'll do well to put good effort into your psychiatry rotation, and always keep psychiatric factors salient in your mind when treating patients.

We (psychiatry and neurology) are in the unique(?) position of having two specialties dedicated to the same organ system.

 

[fourthyearmed]

Has Tom Cruise discovered StudentDoctor.net? That's who you sound like.

 

[banannie]

following from what others have written, it does seem that over the past 100 years, disorders such as epilepsy and alzheimers, for which explanations have become increasingly biological and reductionistic (and hence, less stigmatizing) have been moved out of the realm of psychiatry and into the domain of neurology. so it would seem that, gee, if we could just find the "gene" or the "part of the brain" or the "neurotransmitter" that controls all the other psychiatric disorders, we'd be golden, and everything could just be a matter of a medicine or procedure.

but i think that no matter how far our biological explanatory power "advances" there will always be things that defy reductionistic explanation. there will always be a need for physicians who diagnose and treat based on an understanding of the complex biological, psychological and social forces that all interplay. don't forget, a significant number of psychiatric disorders are "culture-bound." that doesn't make them invalid -- people suffer from them, and treatment helps. but it does make me skeptical that there will ever be a time that problems-of-living can all be treated with a pill. i think that patients with psychiatric problems need physicians trained in a medical model -- but trained in a way that enables them to step outside of the limitaions of a straight up biopharmacologic mechanism approach. i disagree that psychiatric disorders are ultimately nervous system disorders, but maybe that's just my own worldview.

the fact that the number of people institutionalized in psychiatric facilities is a fraction of what it once was owes a great deal to the fact that biological explanatory power has increased. but far from being a cure-all, we now have a huge number of mentally ill people falling through the cracks of our mental health care system. i'm afraid that we're doing our patients an injustice if we invest solely in a better-living-through-science approach to their treatment. so many structural factors still exist, and I think that psychiatrists are better equipped to help patients address them.

anyway, take all with a grain of salt, i'm just a med student.

 

[Doc Samson]

Combining psychiatry and neurology into one specialty? So that'd be a 7 year residency (4 + 4 - 1 for currently shared specialty training)... not sure there'd be too many people willing to go through that.

The stigma related to psychiatric illness is a product of fear of psychiatric illness. People fear what they don't know, and they belittle what they fear. The lay public's fear/stigmatization will change very little with increased understanding of pathologic mechanism (see the h/o HIV), only effective treatment reduces the panic (again, see HIV).

 

[PublicHealth]

This has been discussed at length:

http://www.ncbi.nlm.nih.gov/entrez/..._uids=12153815&query_hl=1&itool=pubmed_docsum

 

[Poety]

Combining psychiatry and neurology into one specialty? So that'd be a 7 year residency (4 + 4 - 1 for currently shared specialty training)... not sure there'd be too many people willing to go through that.

The stigma related to psychiatric illness is a product of fear of psychiatric illness. People fear what they don't know, and they belittle what they fear. The lay public's fear/stigmatization will change very little with increased understanding of pathologic mechanism (see the h/o HIV), only effective treatment reduces the panic (again, see HIV).

So true 👍 Until there are CURES, the stigma of psychiatric illness will remain. Furthermore, people don't tend to like illnesses that control/influence behavior, in all of history this type of affliction has had negative stigmatisms attached to it. Just think of CP, MR, and even MS.

 

[Psyclops]

As a student of pschology I feel the need to remind some of those discussing on this board that it's generally considred best to avoid the brain-mind dualism. Physiological (brain state) changes generally lead to changes in behavior and cognition (mind-state). And behavior and even mere congintion changes the underlying brain-states. I think it's important to remember that many psychiatric disorders can be induced without physically maniputlating the brain, merely by exposure to certain stimuli. And the oposite is true as well.

Neural corelates of behavior and conciousness are not neccessarily useful.

 

[lowbudget]

Oh. This thread isn't what I thought it was going to be.

But to answer the question: Yes, I do.

 

[mig26x]

Yes, I think we need them.

 

[Psyclops]

I think we need them, in fact if you follow the news we need a heck of alot momre of them.

 

[bigfrank]

I am not trying to provoke an argument, I just want to discuss:

If depression/schizophrenia, etc, etc, etc, are behavioral/cognitive problems with an organic basis (as evidenced by research and their responsiveness to meds), why don't these diseases fall under the auspices of behavioral neurology? Behavioral modification and counseling, etc, can be done by a therapist working closely with the neurologist.

The psychiatrist seemed to make more sense when we weren't sure if there was a biological basis for psychological problems. Wouldn't treating psychiatric illnesses in neurology be easier for patients to accept they have an actual disease? Aren't we stigmatizing certain illnesses by separating out psychiatry and neurology? Besides, one has to know neurology to be a good psychiatrist and vice versa, so why not combine these residencies and people can then subspecialize from there?

Just wondering what people think.

Sure, let's adopt your method. So then.........

A neurologist that specializes in "behavioral/cognitive problems with an organic basis = Psychiatrist.

Get it?

 

[psych2b]

Sure, let's adopt your method. So then.........

A neurologist that specializes in "behavioral/cognitive problems with an organic basis = Psychiatrist.

Get it?

👍 😍

 

[psych2b]

On my neurology rotation at the beginning of 4th year (MS-4), I asked my team's residents and attendings what the exact difference was between neurology and psychiatry, and they were universally offended. No one could give me a one-line answer, just "It's obvious, duh." or "One's organic, the other not." But, I argued that psychiatry has organic bases, but I guess the difference is in treatment?
Anyone have a one-liner easy way to differentiate the two (neuro & psych)? 🙂

 

[Hurricane]

On my neurology rotation at the beginning of 4th year (MS-4), I asked my team's residents and attendings what the exact difference was between neurology and psychiatry, and they were universally offended. No one could give me a one-line answer, just "It's obvious, duh." or "One's organic, the other not." But, I argued that psychiatry has organic bases, but I guess the difference is in treatment?
Anyone have a one-liner easy way to differentiate the two (neuro & psych)? 🙂

Heh, a psychiatrist once told me that neurologists were "only interested in the rodent part of the brain" 😉

But seriously, while the two have a lot of similarities, and are overseen by the same board, they are also very different. There is some truth to what the above psychiatrist said in that neurology is mostly concerned with diseases resulting in "functional" deficits - motor, sensory, brainstem, etc. Psych on the other hand deals more with diseases resulting behavioral and cognitive deficits. Take a walk through the psych ward and then the general neurology floor and you can see how different the patient populations are. One reason people choose one over the other is because of the type of patients they want to interact with.

Another important differentiating factor is the types of treatments. The OP seemed concerned that neuroimaging was going to demonstrate organic causes of all the psych diseases and thus relegate psych to a subspecialty of neurology. Well, neuroimaging also shows that psychotherapy - which can be as or more effective than drugs in some cases - causes fMRI changes. So yeah, the diseases have an organic basis, but so does psychotherapy, and people who go into neurology aren't typically interested in being trained in psychotherapy.

I really don't see a need for the fields to compete, or for one to engulf the other. I see them more as two circles on a venn diagram with some overlap, but a lot of separate parts too.

 

[mysophobe]

Combining psychiatry and neurology into one specialty? So that'd be a 7 year residency (4 + 4 - 1 for currently shared specialty training)... not sure there'd be too many people willing to go through that.

They already exist, and people go through them. They're 5 years.

 

[Doc Samson]

They already exist, and people go through them. They're 5 years.

Took a quick browse through FRIEDA... some are 5 years, most are 6. Either way, seems you'd have to cut out a lot of training from both disciplines to fit it into that time. Couldn't find a curriculum from any of the programs, but I'd guess they'd focus on neuropsychiatry and skimp on training in peripheral nervous system/neuromuscular disease from the neurology side, and psychotherapy from psychiatry. Either way, seems like it actually creates a (perhaps unecessary) 3rd discipline focused solely on the overlap.