Neurology and Psychiatry Merger

[bGMx]

I'm medical student going through my rotations and one of the interesting questions I have been asking every service is what role psychiatry has in their practice, or what do they want when they consult psychiatry for their patients. I'm curious what the opinion is of merging psychiatry and neurology-- on an intuitive level, it appears the field is heading in that direction without acknowledging it, I'm curious as to all of your inputs.

To clarify this position, one of the exciting frontiers of psychiatry appears to be using some level of neural network mapping to individualize treatment. This seems more based in the physical domain than therapeutic modalities many of us are excited to learn and practice. To be even more basic, many of our pharmacologics are manipulating the central nervous system through altering physical parameters in the brain. I don't understand why there would be a continued divide between the nervous system and consciousness, seems arbitrary in definition. Why wouldn't psychiatry be a subset of neurology, one which is concerned with the emergent properties of the nervous system?

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[Alemo]

A short answer is that the behavioral/affective/consciousness parts of the brain are just too much to consider for neurologists concerned with gross abnormalities of the brain. I’ve never met an underworked neurologist.

But yes, I think we as psychiatrists need to gain familiarity with treating, say, autoimmune encephalitis with steroid infusions.

 

[wolfvgang22]

Practically speaking it's impractical to try to manage both the psychiatric and neurological conditions many of my patients have at the same time on every patient. For example, I have a patient who has migraine, Bipolar I disorder, tics, radiculopathy, partner relational problems, and ADHD. I'm far too busy trying to assist the patient with their psychiatric symptoms to be doing EEGs, EMGs, Botox, and treating Parkinsons or getting called upon to do medical floor consults for neurology. Good psychiatry takes time. Don't get me wrong, I do often treat migraines and tics before referring to neurology like primary care does, and treat parkinsonism caused by antipsychotics, but I'm busy enough without being a neurologist full tiime..

 

[TexasPhysician]

I can see from an outside perspective how combining them seems rational, but from a practical perspective, these fields aren’t similar at all. Nor do I believe that we are moving that way.

I think I have more in common with the local dermatologist than neuro.

 

[clausewitz2]

Why wouldn't psychiatry be a subset of neurology, one which is concerned with the emergent properties of the nervous system?

Emergent properties, formally speaking, are properties of a system that are not reducible to any particular component or part of that system, but are just properties of the system as a whole. you can say we are altering physical parameters of the brain with our pharmacology, but can you make any quantitative estimates of precisely what will change (or even the sign of the change) in any of those parameters that will be consistent from person to person with a given dose of a given medication?

Imagine the brain as a desktop. Neurology has opened up the case and is concerned that the hardware is in good shape, and can often diagnose particular problems based on characteristic problems that pop up when particular bits of hardware are damaged. Psychiatry has a monitor showing the GUI, which we are trying to debug by throwing rocks at various bits of the tower.

 

[clausewitz2]

Practically speaking it's impractical to try to manage both the psychiatric and neurological conditions many of my patients have at the same time on every patient. For example, I have a patient who has migraine, Bipolar I disorder, tics, radiculopathy, partner relational problems, and ADHD. I'm far too busy trying to assist the patient with their psychiatric symptoms to be doing EEGs, EMGs, Botox, and treating Parkinsons or getting called upon to do medical floor consults for neurology. Good psychiatry takes time. Don't get me wrong, I do often treat migraines and tics before referring to neurology like primary care does, and treat parkinsonism caused by antipsychotics, but I'm busy enough without being a neurologist full tiime..

I think headache and epilepsy to some extent are areas where the overlap between neuro and psychiatry practically speaking is a bit more pronounced and many of those patients would probably be better served by the relationship between the fields being a little closer. There is another world in which they stayed part of psychiatry and we learned to read EEGs in residency as a matter of routine.

 

[Celexa]

An increase in the relevance of neurobiological understanding to the field of psychiatry in no way means the fields are converging. If anything they diverge more as the amount of knowledge you need to practice good medicine increases, which is how all new fields of medicine develop. And neurology and psychiatry are VERY different fields and attract people with different temperaments and preferences. I see absolutely no trend towards the fields merging.

 

[clausewitz2]

And neurology and psychiatry are VERY different fields and attract people with different temperaments and preferences.

I thought I was torn between neurology and psychiatry as a medical student. Turns out I was torn between psychiatry and being Oliver Sacks. The choice was easy once I realized neurology as an actual job had nothing to do with being Oliver Sacks in 99.7% of cases.

 

[Merovinge]

An increase in the relevance of neurobiological understanding to the field of psychiatry in no way means the fields are converging. If anything they diverge more as the amount of knowledge you need to practice good medicine increases, which is how all new fields of medicine develop. And neurology and psychiatry are VERY different fields and attract people with different temperaments and preferences. I see absolutely no trend towards the fields merging.

This is very true and the part missed by people are who are not MDs. Being a specialist is much more involved now than at any point in history and this is only going to become more so the case as the science evolves. Compare the difference in being an auto mechanic in 1950 vs 2020 (outside of maybe EVs) compared to being a doctor in 1950 and present day, it's probably in the ten's of thousands % difference in medical knowledge and capability in the past 70 years. Cars still just go vroom vroom for the most part.

 

[FlowRate]

I think headache and epilepsy to some extent are areas where the overlap between neuro and psychiatry practically speaking is a bit more pronounced and many of those patients would probably be better served by the relationship between the fields being a little closer. There is another world in which they stayed part of psychiatry and we learned to read EEGs in residency as a matter of routine.

This is very true and the part missed by people are who are not MDs. Being a specialist is much more involved now than at any point in history and this is only going to become more so the case as the science evolves

I did a rotation in medical school where 1/3 of my time was spent in a regional headache specialty clinic. Which has made it hard for me to consider treating patients' headaches given I know enough to know that a proper headache history takes time that I already spent trying to get the rest of their psychiatric history. There's not a lot of overlap there.

Not sure how many have read through the ICHD-3 but it's worth perusing at least once to get a feel for the range of headache diagnoses. Patients call things migraines but often they are... not migraines.

Just an example of what you're both saying about the volume of knowledge in specialty areas continually growing and not necessarily meshing well with all the stuff we do on a practical day to day basis.

I do agree there is a lot of overlap in terms of something like 30% of neuro outpatients having FNSD. But it's the neuro expert stuff that figures out it's FNSD.

 

[clausewitz2]

I did a rotation in medical school where 1/3 of my time was spent in a regional headache specialty clinic. Which has made it hard for me to consider treating patients' headaches given I know enough to know that a proper headache history takes time that I already spent trying to get the rest of their psychiatric history. There's not a lot of overlap there.

I am aware that a proper headache history takes a good chunk of time, I had similar experiences in training. But it's not so different in many ways from addressing sleep, which also requires a lot of specialized history taking to do a decent job with. You're right that it involves lots of questions that aren't part of the standard psychiatric interview otherwise, but how much of that is just because historically we have been treating, say, bipolar d/o and have not happened to be treating icepick headaches?

It's like anything else in history-taking for me; a couple of brief questions to establish if there is a problem or it is a concern for the patient, and drill down only in the area relevant to the difficulties they are having or the particular issues that brought them in. That often means going into areas they didn't explicitly mention, obviously, but if i ask someone about having headaches and they say "I don't really get headaches" or "maybe once a month, 3/10, not a big deal", cool, don't need to do anything more. If the answer is "I missed two days of work last week because of my headaches", seems relevant to invest the time.

I come at this from a perspective of getting pretty close follow-up, shifting to 90 minute intakes, and almost never covering all the areas I want to cover or ideally would cover in the first interview. I also aggressively pre-screen with self-report checklists to better identify the areas that absolutely have to get covered thoroughly straight away.

 

[birchswing]

Emergent properties, formally speaking, are properties of a system that are not reducible to any particular component or part of that system, but are just properties of the system as a whole. you can say we are altering physical parameters of the brain with our pharmacology, but can you make any quantitative estimates of precisely what will change (or even the sign of the change) in any of those parameters that will be consistent from person to person with a given dose of a given medication?

Imagine the brain as a desktop. Neurology has opened up the case and is concerned that the hardware is in good shape, and can often diagnose particular problems based on characteristic problems that pop up when particular bits of hardware are damaged. Psychiatry has a monitor showing the GUI, which we are trying to debug by throwing rocks at various bits of the tower.

<I am not a doctor or medical student>

From articles I've read, it seems like the effects of SSRIs are fairly predictable on changes in areas of the brain and their size, even with a single dose across depressed and non-depressed patients, and antipsychotics have a reliable brain atrophy effect. I am not sure if that is different than what you mean from parameters.

 

[FlowRate]

I am aware that a proper headache history takes a good chunk of time, I had similar experiences in training. But it's not so different in many ways from addressing sleep, which also requires a lot of specialized history taking to do a decent job with. You're right that it involves lots of questions that aren't part of the standard psychiatric interview otherwise, but how much of that is just because historically we have been treating, say, bipolar d/o and have not happened to be treating icepick headaches?

It's like anything else in history-taking for me; a couple of brief questions to establish if there is a problem or it is a concern for the patient, and drill down only in the area relevant to the difficulties they are having or the particular issues that brought them in. That often means going into areas they didn't explicitly mention, obviously, but if i ask someone about having headaches and they say "I don't really get headaches" or "maybe once a month, 3/10, not a big deal", cool, don't need to do anything more. If the answer is "I missed two days of work last week because of my headaches", seems relevant to invest the time.

I come at this from a perspective of getting pretty close follow-up, shifting to 90 minute intakes, and almost never covering all the areas I want to cover or ideally would cover in the first interview. I also aggressively pre-screen with self-report checklists to better identify the areas that absolutely have to get covered thoroughly straight away.

Apologies if I implied that you specifically wouldn't know some of those things, I could have structured the post better to highlight that, as you point out with sleep, it takes additional time and expertise. I get hour-slot intakes and am slightly discouraged from frequent follow-ups. PCP's in our system do a lot of first line headache management. So for me it's something that's not always easy to add when patients otherwise need all of our intake time for their more primary presenting complaints and there are other avenues for that care.

 

[splik]

These threads get repeated ad nauseam. The trend in medicine is for increasing subspecialization so the idea that neurology and psychiatry would somehow merge would be counter to that trend. Psychiatry is a much larger specialty than neurology so the idea it would somehow be subsumed under a small specialty does not make sense. Neurology is still largely an academic specialty (and neurologists tend to subspecialize with fellowship training being the rule), whereas psychiatry is a community based specialty. There was a time about 20 yrs ago where combined neurology-psychiatry residencies were in vogue and there were prophesies the two fields could merge again. Well, most of those programs no longer exist. There are very few people who wish to train in both. The specialties are quite divergent. Community psychiatry is just so far removed from neurology and neuroscience and would not be enhanced by having a more neuromedical bent for the most part.

The interface of psychiatry and neurology (behavioral neurology and neuropsychiatry) is a very small field. It is not a popular fellowship choice for either neurologists or psychiatrists. It is a very niche area that is primarily housed in academic departments. There are a few areas at the interface of neurology and psychiatry that both neurologists and psychiatrists can train in including behavioral neurology/neuropsychiatry, movement disorders, epilepsy, headache medicine, sleep medicine, pain medicine, and brain injury medicine.

it is also interesting that most neurologists and psychiatry have no interest in treating patients with the most common (and prototypical) neuropsychiatric disorder, which is functional neurological disorder.

However, I do not see psychiatry becoming more like neurology even as we learn more about the neural underpinnings of consciousness and affective experience. It would be the death of the specialty if that day ever came and our patients would be much worse off for it. We deal with a lot of different problems in psychiatry, many of which are not best understood by looking at the brain.

 

[Alemo]

However, I do not see psychiatry becoming more like neurology even as we learn more about the neural underpinnings of consciousness and affective experience. It would be the death of the specialty if that day ever came and our patients would be much worse off for it. We deal with a lot of different problems in psychiatry, many of which are not best understood by looking at the brain.

I agree that the patient interfacing part of psychiatry won't become like neurology (neurologists don't ask their patients "What thoughts do you have about not being able to move your legs?"), and conversely, no psychiatrist is going to tell patients "We don't have time to talk about your worries; you're depressed because the psychiatry machine shows a hypofunctioning Brodmann area here."

Hard disagree about the second half though. Making treatments decisions (aside from developing human based therapies based in reciprocal conversation, language, and self-awareness) is hopefully (eventually) going to involve more of the brain (understanding more about affective and perceptive function).

 

[SeniorWrangler]

I would encourage any young psychiatrist to learn more neuroscience, it’s really interesting stuff with a lot of applicability.

I go to more neurology meetings and pain meetings than Psychiatry meetings, honestly. And I don’t feel that I’m missing that much.

 

[RevDO]

However, I do not see psychiatry becoming more like neurology even as we learn more about the neural underpinnings of consciousness and affective experience. It would be the death of the specialty if that day ever came and our patients would be much worse off for it. We deal with a lot of different problems in psychiatry, many of which are not best understood by looking at the brain.

If psychiatry should not concern itself with neuroscience (an understanding of the brain/its functioning) then what does it have to offer? Giving people medications without attempting to understand the neural underpinnings of how they work? Our medications are not very impressive in many regards. So perhaps therapy? But this seems to take a back-burner in most residency programs, probably better off left to PsyDs and PhDs who devote all their time to it. Where does that leave us? Attempting to change the societal issues that contribute to mental health problems (poverty, crime, etc)? Seems big for a psychiatrist to tackle, maybe go into politics or lobbying.

We can make a big difference for patients with mania/psychotic symptoms but what about the seemingly endless supply of depression/anxiety? For the situation-dependent depressive/anxious symptoms? A bit of woo and a bandaid for social problems?

Do we not have a duty to our patients to continue learning?

 

[nexus73]

If psychiatry should not concern itself with neuroscience (an understanding of the brain/its functioning) then what does it have to offer? Giving people medications without attempting to understand the neural underpinnings of how they work? Our medications are not very impressive in many regards. So perhaps therapy? But this seems to take a back-burner in most residency programs, probably better off left to PsyDs and PhDs who devote all their time to it. Where does that leave us? Attempting to change the societal issues that contribute to mental health problems (poverty, crime, etc)? Seems big for a psychiatrist to tackle, maybe go into politics or lobbying.

We can make a big difference for patients with mania/psychotic symptoms but what about the seemingly endless supply of depression/anxiety? For the situation-dependent depressive/anxious symptoms? A bit of woo and a bandaid for social problems?

Do we not have a duty to our patients to continue learning?

I suspect advances in neuroscience to the point it would benefit psychiatric care are a long ways off (famous last words). Researchers have been pushing the biological research front the last 15-20 years and we don't really have anything to show for it.

 

[TexasPhysician]

If psychiatry should not concern itself with neuroscience (an understanding of the brain/its functioning) then what does it have to offer? Giving people medications without attempting to understand the neural underpinnings of how they work? Our medications are not very impressive in many regards. So perhaps therapy? But this seems to take a back-burner in most residency programs, probably better off left to PsyDs and PhDs who devote all their time to it. Where does that leave us? Attempting to change the societal issues that contribute to mental health problems (poverty, crime, etc)? Seems big for a psychiatrist to tackle, maybe go into politics or lobbying.

We can make a big difference for patients with mania/psychotic symptoms but what about the seemingly endless supply of depression/anxiety? For the situation-dependent depressive/anxious symptoms? A bit of woo and a bandaid for social problems?

Do we not have a duty to our patients to continue learning?

There is a lot of middle ground between ignoring neuroscience and looking at the brain (imaging, gross interpretation) for all of the answers.

“Looking at the brain” is a waste of time for most psychiatric patients. Until technology greatly improves, psych is not going to be managed anything like neuro. Maybe decades from now that changes.

 

[OldPsychDoc]

Psychiatry MUST treat the bio-, the psycho, and the social.
We're unique among specialties for that.
Most neurologists will run screaming away from anything "behavioral", however neurochemically based it might be--because it takes an understanding of the psychosocial context in which those behaviors are expressed, and that takes a lot of patience, and effort in the non-biological realm. Not to be too hard on my colleagues, but 90% + of neurology is "plumbing and packaging" -- psychiatry is about how the brain puts all those neurons together, how they interact with the environment, and how one organism with a brain interacts differently with another organism with a brain.
Your proposed merger is several decades, if not centuries, off.

 

[smalltownpsych]

Short answer is no. My experience has been that there is more overlap with psychology and psychiatry than there is with neurology and psychiatry. Might even be more overlap with neurology and neuropsychology, the neuropsych folk could better answer that one.
It also seems like the field of psychiatry is moving away from the trend toward an emphasis on the purely neurobiological and neurochemical and an understanding of how the thoughts and behaviors and environment interact in a complex way with the neurobiological system. At least that is what most of the psychiatrists posting on here are talking about.

 

[mistafab]

Have you been in a hospital or clinic?

Neurologists hate psychiatric patients. Most specialties do as well. That’s why psychiatrists care for them and often advocate that they get even basic medical care

No merger in the near future. The ABPN is an artifact of a simpler time.

 

[allantois]

There is probably more wisdom to be discovered applicable to psychiatry in ancient Buddhist texts than in brain mapping

 

[wanderer534]

I think I have more in common with the local dermatologist than neuro.

Can you elaborate on this please? What are all the commonalities between you and the local dermatologist? Thank you!

 

[TexasPhysician]

Can you elaborate on this please? What are all the commonalities between you and the local dermatologist? Thank you!

We both treat diseases that are often chronic but greatly improved with treatment. Sometimes curable or complete remission. Medications aren’t perfect and switching meds isn’t uncommon. Both practices are well positioned for an out of network business.

 

[deleted1100659]

There is probably more wisdom to be discovered applicable to psychiatry in ancient Buddhist texts than in brain mapping

but..for only the small fee of $5,000 the amen clinic will map your brain and tell you how deficient you are in neurotransmitters. Then I dont know where it goes from there, im guessing the second part, the treatment part, probably is another $5,000

When I was in residency we did consult rotation a ton, including call shifts..If I had to neuro consults and psych consults I think I would have resigned, lol. Its bad enough that a lot of community places are trying to push for "total care model" where the psychiatrist also does the primary care role as well.

 

[TexasPhysician]

but..for only the small fee of $5,000 the amen clinic will map your brain and tell you how deficient you are in neurotransmitters. Then I dont know where it goes from there, im guessing the second part, the treatment part, probably is another $5,000

When I was in residency we did consult rotation a ton, including call shifts..If I had to neuro consults and psych consults I think I would have resigned, lol. Its bad enough that a lot of community places are trying to push for "total care model" where the psychiatrist also does the primary care role as well.

Take these vitamins. Talk to your local psych about stimulants and SSRI’s.

 

[Stagg737]

We both treat diseases that are often chronic but greatly improved with treatment. Sometimes curable or complete remission. Medications aren’t perfect and switching meds isn’t uncommon. Both practices are well positioned for an out of network business.

Also, almost every dermatologist I've met as (mostly) jokingly asked if I'd like to join their practice as a consultant so they don't have to follow-up with all their derm/psych patients.

 

[comp1]

There are combined neuro/psych residencies. Like most combined programs, people generally end up doing one or the other. I'm guessing the OP is pre-clinical because I just can't conceptualize this view of them being at all similar after having rotated through both. They have just gone off in very different directions and have their own territories quite defined.

 

[Fabio001]

Agree with most of the sentiments expressed above. Neurology and psychiatry deal with similar organs, and both benefit from a knowledge base with some overlap at the ground leve, but the actual practice of the two differs widely. After rotating in both services, very few would consider themselves torn between the two specialties.

Having said that, I do remember really enjoying headache clinic in residency. I have also wondered very recently about why epilepsy isn't more within the purview of psychiatry, as others (myself included) have had similar questions regarding pain management.

 

[Mad Jack]

Generally, neurologists don't want to do psychiatry and psychiatrists don't want to do neurology. The ideas of pathway mapping and whatnot are not well established and many of the clinics that claim to use things like functional mapping to guide treatment come off as scams. Our fields can certainly inform one another, and there are a very small number of true neuropsych people out there, but generally the overlap is small in day-to-day practice.

 

[michaelrack]

It makes more sense for neurology to become a subspecialty of IM.

 

[allantois]

It makes more sense for neurology to become a subspecialty of IM.

Does anyone in medicine like to do neuro exams besides neurologists? lol