Psychiatry is still accustomed to treating constellations of symptoms. This limits people from pursuing "diagnoses" in the "neurological sense." The tendency exists because its "lesions" are still afloat. When the occasional eager intern orders an mri, people will roll their eyes (yes, even neuro colleagues, who sometimes aren't thrilled to evaluate nebulous psych pts in the first place). Many things get called "schizophrenia" (anything from a methamphetamine-fried brain to the guy in status that the ED said is "crazy," who happened to be on psych meds, and where it happens to be hard to order EEGs for anyone). Hmm, I see schizophenia, in its "purest" form, as a neurodegenerative disorder which hasn't quite been ferreted out yet...
Another reason no one is eager to "diagnose" is because there are many who argue the "treatment is the same" (guy with post stroke mania--> Li+ or VPA, and by the way, it's now bipolar disorder).
Where it gets "hairy" is when you "see psychosis" but don't always have objective evidence about what's causing it or how long you need to treat it and your meds are causing long term cognitive impairment which leads to more functional impairment --> eventually depression (then they go from being schizophrenics to schizoaffective). Again though, some people are comfortable taming symptoms, often because no one tends to point a finger;
that's the standard of care (to treat symptoms and pretend to treat diagnoses). Whereas in neuro, you miss that gumba and bam.
Regarding psychiatrists' shyness in the realm of medicine and/or neuro:
There are rumors out there that "solutions" have been considered, i.e., making it such that the intern year is identical for both neurologists and psychiatrists. The fourth year in psychiatry might be eliminated, but that is likely to help fill fellowships (which isn't ultimately a bad thing, i.e., a geropsychiatrist tends to get more training in areas of "cross polination.")
Psychiatrists used to have to do a transitional year or perhaps even a medicine prelim year, but that got knicked some time ago by the abpn, unclear why.
Finally, as scandalous as this will sound, we all know different fields attract different "types." On the whole, psychiatry tends to attract people who are "chill," and either don't possess or don't aspire to possess, a certain ridiculous work ethnic. People either become glorified pharmacists, therapists, or both, and to many, this brings gratification. Things are further supported by a great job market, climbing, comfortable salary (for many, rivaling IM hospitalists' income right out of residency), and a good lifestyle. The reality is, psych and neuro are both broad, somewhat nebulous by reputation, and eclectic compared to the rest of medicine (very broadly speaking of course). Psychiatry, however, has been superficially watered down to mania, psychosis, anxiety, and depression, when in fact there is a hell of a lot more crawling in the background. Basically, it's a dumping ground where zebras roam and you either pull your hair out strand-by-strand and then do a pain, sleep, behavioral neuro or headache fellowship or you totally revel in it. The point is, "hunting for an answer" is not a part of the "culture" in psychiatry and only rarely is there a "consequence" if in fact some argue there should be one.
Hey, even Sacks likes hallucinations (maybe just the organic visual ones though? Since the "auditory" psych ones simply represent a schizophrenic's loss of agency relating to one's internal thoughts).
Good point. Psychiatrists and neurologists are certified by he same Board (ABPN), the difference supposedly being the emphasis given to psychiatric and neurologic disorders. There supposedly should be enough "cross-training" to allow competent neurologists to diagnose and manage most of the "basic" psychiatric disorders and vice versa, at least to a better degree than other medical specialists.
Sigmund Freud, who was trained as a neurologist and did some research on, I believe, the nervous systems of eels, opined that eventually all mental illness would be understood as disorders of the nervous system, when we finally understood the organic basis of mental illness...
Clement raises the important issue of failing to recognize organic illness as the cause of psychiatric symptoms. This is a real potential medicolegal pitfall for psychiatrists (and anyone else for that matter). This pitfall involves not only such things as brain tumors, strokes, MS, and HD, but also such things as delirium caused by intoxications and metabolic derangements.
IMHO the risk for misdiagnosing neurologic conditions is greater for psychiatrists, especially for those who put on blinders and refuse, for whatever reason, to remember that they are physicians. Modern psychiatry training programs do, appropriately, promote the "medical model" and seek to instill competence in both basic general medicine and neurology.
Unfortunately there are some psychiatrists who for various reasons choose to forget that they are physicians. They, for example, feel that it is not their job to perform basic medical H&P's on their patients. They even go so far as to defer the treatment of psych med side effects (e.g. metabolic syndrome, bone marrow suppression, and even EPS) to "medical doctors." These are the same folks who loudly object to the attempts of psychologist to prescribe psych medications....
