Patient population in psychiatry vs. neurology

[romanjetfighter]

A therapist who works in an outpatient psychiatric department who has many family members who are doctors, discouraged me from psychiatry because the patients wear you out. They have personality disorders, working with patients who aren't lucid, under the influence of sedatives/psychiatric drugs, speaking gibberish, etc. They're all kind of in their own world. She told me neurology was better because of the patient population.

How do you feel about your patients? Do they annoy you at times? Is it depressing? Lonely to mostly work with people who aren't completely there mentally?

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[Shikima]

It's all draining work. Don't sweat that right now, worry about getting into and through medical school first.

 

[TheRiddler]

In psychiatry, you can rarely help a patient. In neurology, you never can.

 

[OldPsychDoc]

Neurology has patients with "personality disorders, aren't lucid, under the influence of sedatives/psychiatric drugs, speaking gibberish, etc" as well--the only difference is that they want help for something else, and those problems aren't the main topic of treatment. At least in psych it's what we do. (And I could be mean and suggest that the neuro docs are the ones "kind of in their own world", but I've met a few decent ones...

 

[Shikima]

Vascular dementia anyone?

 

[splik]

The majority of patients in a neurology clinic have at least one symptom that cannot be neurologically explained and often have significant psychopathology. I have never met a patient with intractable epilepsy who didn't have a severe personality disorder. In fact many neurological patients who are treatment-resistant have underlying personality pathology. The difference is most neurologists are totally helpless and unable to deal with these patients, whereas most psychiatrists are somewhat able to deal with these patients and some are very good at working with them. Additionally, many neurological patients have extremely vague symptoms such as chronic pain, dizziness, headaches for which neurology is again totally unable to offer anything for and these patients often have depression, anxiety, and personality pathology. Conversion disorder including psychogenic non-epileptic seizures are common, and neurologists are not very good at working with these patients. In fairness most psychiatrists aren't very good with them either but that's because we don't see them too often and again some psychiatrists do specialize in working with these patients whereas it is rare for a neurologist to specifically want to treat these patients.

As for patients who "aren't lucid" - delirium and dementia are or the borderland of psychiatry and neurology and you see these patients in both. Delirium is in my opinion simply the most fascinating condition ever. The presentation is so variable, the experience unique, often terrifying, ranging from the indolent to the dystopic, with a long differential of causes from something as common as constipation to as rare as neurosarcoidosis. I think dementia is pretty interesting too.

Both psychiatrists and neurologists drug patients with sedatives, neuroleptics, thymoleptics etc.

A neurological patient is more likely to be speaking gibberish (i.e. be dysphasic) than a psychiatric patient. If you think a patient is speaking "gibberish" it is because you cannot understand them, not because they are not understandable. I am fluent in crazy though

Neurology and psychiatry are fairly divergent specialties, it is rare that medical students find themselves trying to choose between them.

 

[dl2dp2]

I think the main difference is very easy to explain: AGE. Most neurological patients are older, unless you do pediatric. There are a few 40/50s, but the vast majority is 60s+. If you find general inpatient IM depressing like I do, you'll find neurology depressing, and I think in neurology the problem extends into the outpatient world. Try to make dying people die a little later with very little quality of life is depressing to me. The typical neurology patient--even outpatient--is a 65+ man/woman who had a stroke. Just think about that for a second.

I would say the typical psychiatric outpatient is in the 20-50 age span. There is a much larger latitude, and why often psychiatrists don't take Medicare.

This is definitely person dependent, but for me neurology was way more draining because you can't have a conversation (per above) with many of your patients. It creates this sense of helplessness.

Your typical psych patient is a 30ish man/woman who has a first episode or recurrent episode of depression or anxiety. What are the odds that he/she gets better with a round of treatment? about 80%. Almost every patient in my clinic is improving. It's pretty awesome.

 

[Nasrudin]

I don't think we're giving neurology a fair shake. OP, make this query in the neurology forum to give you the panoply of opinion on the matter.

As a futurist I'm committed to my science fiction roots in that this current dichotomy of brain and behavior will not always be there. I disagree with one nuance of Splik's point of view that neurology is a reductionist science that somehow misses the mystic whatever of behavioral phenomenon. They just approach the problem looking for organic brain causes.

For example a problematic, abnormal brain--whether from anoxic brain injury, metabolic problems, seizures, masses, or other sources--will often have behavioral manifestations. A seizure in the right part of the brain might produce religious ecstasy. That doesn't mean the neurologists have a misguided perspective. And in my experience they do a lot to manage behavior in their patients. I worked with a pediatric neurologist last month and the children who were born with abnormal brains did indeed have behavior symptoms in the context of seizures and learning and cognition problems of all varieties.

She managed all their issues.

So clearly there is overlap.

I actually think neuroscientists and computer engineers will eventually be leading the way for both fields. #PadawanDreams

 

[Jorje286]

Once you come to an understanding of problematic behavior, you're actually going to be one of the few people on the side of the patient. Most psychiatric patients are problematic not because they are mischievous, but because they have a disease that is taking their thought pattern in a certain way and they simply don't know any better. As OPD said, you're going to see patients with problematic personalities and behavior everywhere, but the difference is that in psych you will learn to understand it, empathize with and even relate to it.

Neurologists from my experience are not the empathetic type. I've witnessed first hand dismissive treatment and heard many stories. This is probably a harsh generalization, but I do think there's an element of truth to it. The irony is that despite the common presentations in neuro and psych patients and the fact that the two specialties deal with the same organ system, they couldn't be further at odds in their approach. Neurologists are trained to approach things from a very systematic, programmed manner and are not good at dealing with complex emotions/behaviors and most psychiatrists have no clue when in need to rule out neurological disease.

 

[OldPsychDoc]

As a futurist I'm committed to my science fiction roots in that this current dichotomy of brain and behavior will not always be there. I disagree with one nuance of Splik's point of view that neurology is a reductionist science that somehow misses the mystic whatever of behavioral phenomenon. They just approach the problem looking for organic brain causes.
...
I actually think neuroscientists and computer engineers will eventually be leading the way for both fields. #PadawanDreams

Getting a bit closer... http://www.scientificamerican.com/article/consciousness-might-emerge-from-a-data-broadcast/

 

[peppy]

It sounds like that therapist might be burnt out on doing therapy.
Fair enough - therapy burns me out too (though I do recognize it is a good treatment and refer patients to therapy often). I find the medical/biological aspects of psychiatry much more interesting and rewarding.

As a fan of the biological side of psych, I do find neurology intellectually fascinating, so I don't think it is a bad specialty. However I think neuro can definitely be emotionally draining, just in a different way than psych.

Neurologists have to diagnose/manage grim conditions such as ALS, Huntingtons disease, multiple system atrophy, debilitating strokes, comatose/braindead patients, frontotemporal dementia (any dementia, really, but I find FTD especially sad because it often takes down fairly young people and the socially inappropriate behavior it causes can be so disruptive/traumatic for family). With those conditions, neurologists are often in the situation where they have to tell people "I know what's wrong but there isn't anything that current medicine can do to fix it".
Some people might find that a helpless feeling.

TPA can help some people dramatically but it can also cause grave harm (and many people show up to the Er too late for it to even be an option)

Parkinson's disease can be kinda depressing too despite being fairly treatable as neuro problems go...yes carb/levo or deep brain stimulation can help a lot of people, but they're not curative. Ultimately the PD progresses no matter what you do, and advanced PD can be very frustrating for the pt.

As others said, yes, Neurologists see a ton of psychiatric patients...just like Family Med and Emergency Med get to interact with a ton of psych patients. I think their interactions with psych patients are more stressful than they are for us because we are simply used to it and see it as our job to deal with it, while for them it is a distraction from what they are trying to accomplish.

 

[Nasrudin]

Getting a bit closer... http://www.scientificamerican.com/article/consciousness-might-emerge-from-a-data-broadcast/

Fantastic Article! Thanks a lot.

 

[whopper]

For me, I mix up my clinical work and this prevents me from getting drained. If I did private practice all day long 5 days/week yes I would be drained. I do it 2x/week.

This is a reason why some people go into other areas of psychiatry. ER psychiatry-the person's out of your hair at the end of the day. Inpatient-they're out when you discharge them. Outpatient, they could continue to annoy you day after day.

 

[SomeDoc]

I found the acute inpatient neurology s/p CVA cases and chronic, (albeit relatively rapid) progressive neurodegenerative outpatient cases more depressing than most acute inpatient psychiatric cases. There wasn't much that could be done, except for mitigation of symptoms. Outpatient psychiatric care can be rewarding, I've found. I also find inpt psych allows the clinician to help restore some degree of function in the patient- such as in the manic or acutely psychotic patient, who when discharged after a few days, is able to go back to school, and function in an improved capacity. The neurodegenerative issues in psychiatry seem to be more protracted in progression whenever applicable, which perhaps leads to some adjustment of emotional reaction on part of the clinician.

 

[shan564]

Every hospital is full of patients whose medical problems are caused by poor self-care, which is caused by their underlying psych problems. On psychiatry, at least we get to treat that part.