How does knowing neurology make you a better psychiatrist?

[AD04]

I'm about to start reading through Kaufman's this week. I flipped through the textbook and it seems kind of boring.

Some people say that you don't need a neurology textbook to pass the board exam. That doesn't give me any motivation to plow through either.

For those that read Kaufman's or other neurology textbooks and really know their neurology, how has it helped you with care for psychiatric patients? Please provide details.

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[Shikima]

You need to know it. Period.

 

[Monocles]

You need to know it. Period.

That doesn't really answer OP's question though. :\

PGY-1 here, neurology in general doesn't really make you better psychiatrist. However there are many aspects of neurology that have overlap with psychiatry and it's good to have a *basic* knowledge of those things.

For example, a lot of organic brain diseases such as stroke or tumors can have psychiatric manifestations. When you are doing CL or geri psych a lot of times both neuro and psych get consulted on the dementia/delirium cases. A lot of times when patients have psychosis you think to yourself, "**** is this first break psychosis or is there underlying neuro problems causing this?"

I wouldn't recommend reading neuro textbooks either (actually against the idea of forced reading in general during residency, but that's another discussion), but eventually as you are working with patients you'll realise that you have a neurological question... which can either me answered with a neuro consult or some googling/uptodating of your own.

tl;dr you can probably practice and would be licensed as a psychiatrist without neurology, but it is very helpful to have some basic knowledge of it.

 

[clausewitz2]

Knowing enough neurology to know how to take a good headache or seizure history can really help clarify a clinical picture and help you determine the extent to which someone needs to actually see a neurologist posthaste. Also migraineurs, like most human beings, appreciate being taken seriously and there is a lot you can do to help manage headaches even in the inpatient settings typical of the first two years of psych residency that can be very helpful but that you are not going to read about in a psych textbook or get a lecture on.

 

[AD04]

You need to know it. Period.

Ok, Asian dad.

tl;dr you can probably practice and would be licensed as a psychiatrist without neurology, but it is very helpful to have some basic knowledge of it.

That's what I gathered from my experience. Helped with making better decisions on whether to get neurology consults or not when I'm primary.

I'll probably go through the book either way.

 

[Asklepian]

I will have to disagree with the majority of people, and say that knowing neurology is extremely important to provide the best patient care. All kinds of pathologic processes which are considered in the domain of primary neurology masquerade as purely psychiatric at times. Understanding a full differential may entirely change a patient's outcome. Some examples off the top of my head include the 3% of all new onset psychosis which turns out to be autoimmune encephalitis, processes on the Morvan continuum where patients may present with acute psychosis and insomnia which looks similar to bipolar disorder, knowing semiology of epileptic seizures vs PNES, etc. The appropriate diagnosis and treatment are paramount in many of these cases. In a patient with NMDA-r Ab+ encephalitis, purely calling them psychotic and starting a neuroleptic is not enough. This person may end up even needing inpatient psychiatric hospitalization (which happens), and ultimately they could have been "cured" with immunomodulatory therapy.

There are countless answers to this question, but I find it naive and a bit lazy to suggest that it is not important to know neurology well. Both specialties are based in the same organ system. The brain doesn't discriminate. Knowing neurophysiology, anatomy, pathology, etc. is extremely important. Psych and neuro comorbidities run hand in hand, and it is best to have a good base in both areas. I recently got to have lunch with the Editor-in-Chief of JAMA Psychiatry who is from Germany, and he pointed out that his friends in Europe often tease him because in their psychiatry residency they do two years of neurology and learn how to read MRIs, EEGs, etc. while here in the states we get two months in a categorical psych residency.

Can you get by without the knowledge? Sure. Will you be as good of a doc? Maybe. But as someone training in both paths, I think I have a unique perspective coming from both camps and I'm able to tell you it is entirely eye-opening and improves my diagnostic acumen and clinical skills handily.

-A

 

[slappy]

I'm about to start reading through Kaufman's this week. I flipped through the textbook and it seems kind of boring.

Some people say that you don't need a neurology textbook to pass the board exam. That doesn't give me any motivation to plow through either.

For those that read Kaufman's or other neurology textbooks and really know their neurology, how has it helped you with care for psychiatric patients? Please provide details.

Kaufman, even the latest version, has a ton of errors (including a lot of conceptual errors). Go with the basic neuroanatomy book the neuro residents read (the title escapes me at the moment).

 

[Bartelby]

Some examples I can think of where knowing neurology has helped me or close colleagues:

Identifying dementia masquerading as a psychotic disorder, including in atypical presentations where young-ish patients have ended up on inpatient psych wards.
Evaluating pseudoneurological "conversion" symptoms, such as paralysis or blindness.
Catching CJD that had been sent to the psych ward, and getting the patient routed to the right place.
Identifying when a "catatonia" consult actually has hypoactive delirium.
Carefully examining the phenomenology of various toxidromes (pupil size, alterations in speech, generally altered cerebellar function, different types of nystagmus) and withdrawal syndromes, especially in patients with other comorbidities and in patients where the etiology of symptoms is in question.
Evaluating neurological complaints, including malingered ones, on the inpatient psych ward (are you really going to consult neuro for every single neurologically-related complaint on your ward?).
Evaluating medication side effects (especially medication-induced parkinsonism and dyskinesias).
Understanding and educating patients about issues like neuropathy, and better understanding myself when a symptom does or doesn't sound "psychosomatic."
Evaluating patients with seizures versus psychogenic nonepileptic seizures versus "other" (syncope, dissociation, etc).

That's off the top of my head. Being able to recite, for example, all the genes responsible for each neurological disorder isn't important in the real world. Having a working clinical understanding of neurological disorders, and being able to tell the difference between them and psychiatric ones, is very important. Getting it wrong can have a really negative impact on the care you provide, and if you got it wrong because you don't know basics about neurology then the blame falls on you.

 

[DD214_DOC]

It doesn't make you a better psychiatrist. It makes you a better physician. It also helps you recognize when you need to work-up a possible neurological etiology for a patient presenting with primarily psychiatric symptoms. The rest of medicine typically operates on the paradigm of, "psych symptoms = psych", so it falls to the psychiatrist to be able to recognize when psych symptoms = a neurological disorder, a metabolic disorder, an autoimmune disorder, etc. I would always tell residents and fellows not to be dismissive of their medicine and neuro rotations, because that stuff is actually important and useful. I had zero time for those who liked to play the, "herp a derp I'm a psych resident I don't need to know that medicine stuff har har" card.

 

[Shikima]

It doesn't make you a better psychiatrist. It makes you a better physician. It also helps you recognize when you need to work-up a possible neurological etiology for a patient presenting with primarily psychiatric symptoms. The rest of medicine typically operates on the paradigm of, "psych symptoms = psych", so it falls to the psychiatrist to be able to recognize when psych symptoms = a neurological disorder, a metabolic disorder, an autoimmune disorder, etc. I would always tell residents and fellows not to be dismissive of their medicine and neuro rotations, because that stuff is actually important and useful. I had zero time for those who liked to play the, "herp a derp I'm a psych resident I don't need to know that medicine stuff har har" card.

Herp a derp?
kek.

 

[NeuroKlitch]

I will have to disagree with the majority of people, and say that knowing neurology is extremely important to provide the best patient care. All kinds of pathologic processes which are considered in the domain of primary neurology masquerade as purely psychiatric at times. Understanding a full differential may entirely change a patient's outcome. Some examples off the top of my head include the 3% of all new onset psychosis which turns out to be autoimmune encephalitis, processes on the Morvan continuum where patients may present with acute psychosis and insomnia which looks similar to bipolar disorder, knowing semiology of epileptic seizures vs PNES, etc. The appropriate diagnosis and treatment are paramount in many of these cases. In a patient with NMDA-r Ab+ encephalitis, purely calling them psychotic and starting a neuroleptic is not enough. This person may end up even needing inpatient psychiatric hospitalization (which happens), and ultimately they could have been "cured" with immunomodulatory therapy.

There are countless answers to this question, but I find it naive and a bit lazy to suggest that it is not important to know neurology well. Both specialties are based in the same organ system. The brain doesn't discriminate. Knowing neurophysiology, anatomy, pathology, etc. is extremely important. Psych and neuro comorbidities run hand in hand, and it is best to have a good base in both areas. I recently got to have lunch with the Editor-in-Chief of JAMA Psychiatry who is from Germany, and he pointed out that his friends in Europe often tease him because in their psychiatry residency they do two years of neurology and learn how to read MRIs, EEGs, etc. while here in the states we get two months in a categorical psych residency.

Can you get by without the knowledge? Sure. Will you be as good of a doc? Maybe. But as someone training in both paths, I think I have a unique perspective coming from both camps and I'm able to tell you it is entirely eye-opening and improves my diagnostic acumen and clinical skills handily.

-A

did you do a neuropsych fellowship or combined residency?

 

[grapefruit17]

Vascular dementia patient admitted to our inpatient unit. Hx of multiple strokes, Mi, CABG, uncontrolled DM, hyperlipemia and morbid obesity. 30+ year smoking hx of 2-3 packs per day (so yea you get the picture).

He looks at me and says "my face starts to this weird tingling sensation and my arm feels strange". Neuro consult team was busy at the moment. Turns out it was benign and he just wanted pain meds, but could have been scary if it turned out to be legit. Also doing a good physical led me to believe his symptoms were prob bs.

 

[grapefruit17]

Also I've had some pretty rare genetic/neuro disorders admitted to the unit.

 

[Candidate2017]

I'm about to start reading through Kaufman's this week. I flipped through the textbook and it seems kind of boring.

Some people say that you don't need a neurology textbook to pass the board exam. That doesn't give me any motivation to plow through either.

For those that read Kaufman's or other neurology textbooks and really know their neurology, how has it helped you with care for psychiatric patients? Please provide details.

Because many non-psych doctors have a, "I don't need to know psych" attitude and automatically punt to psych whenever dealing with difficult personalities or when patients have vague, difficult to treat conditions. Neuro has lots of these patients and types of conditions.

 

[NickNaylor]

If nothing else, I would argue that psychiatry and much of neurology ultimately have to do with the same organ, thus it is reasonable to understand - at least at a basic level - what can go wrong with that organ if only to think about how seemingly non-psychiatric disorders may cause psychiatric symptoms.

Do you need to be able to diagnose a rare subtype of spinal cerebellar ataxia has a psychiatrist? No, I would argue you don't. Do you need to understand - at a basic level - the disease process and apply that knowledge to think about how this disorder may impact a person psychiatrically? Sure, I think that's well within your purview. Obviously not all neurologic disorders present with psychiatric symptoms or cause psychiatric dysfunction, but I don't think that it's unreasonable that psychiatrists understand the basics of many neurological disorders given the clear overlap in studying dysfunction of the brain.

 

[Asklepian]

did you do a neuropsych fellowship or combined residency?

Currently undergoing combined residency.