Should psychiatry merge with neurology

[Pharmohaulic]

Or at least go in the direction of a more neurologic based field such as neuropsychiatry? Or maybe even a specialty area of neurology?

I know that years and years ago, the two fields used to be all one.

People that are dealing with "mental issues," it's either psychosocial in nature (like due to persons environment, etc) and so in that case should be handled by a psychologist or social worker, or it's medical in nature, often neurologic.

It's like modern psychiatry separates the mind and brain and doesn't recognize that they are connected and many disorder's that cause peoples behaviors and emotions stem from the mind and might have an organic cause... so they make a diagnosis (that's just a subjective test) after 10 minutes, then give tons of haldol and such to treat the symptoms, but don't diagnose the underlying physiologic cause (they'll state its a chemical imbalance but again with no test to prove it).

If that's the case and the persons underlying cause of their issue stem's from altered function in the brain, then shouldn't that technically be handled by neurologist?

Or a psychiatrist will put a medical diagnosis on something that really isn't an illness (like if someone is depressed because a relative died, they'll say the person has major depressive disorder)

It's like they trie to have one foot in neurology and the other in psychology but don't appropriately address either.


What do you think?

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[GUH]

Or at least go in the direction of a more neurologic based field such as neuropsychiatry? Or maybe even a specialty area of neurology?

I know that years and years ago, the two fields used to be all one.

People that are dealing with "mental issues," it's either psychosocial in nature (like due to persons environment, etc) and so in that case should be handled by a psychologist or social worker, or it's medical in nature, often neurologic.

It's like modern psychiatry separates the mind and brain and doesn't recognize that they are connected and many disorder's that cause peoples behaviors and emotions stem from the mind and might have an organic cause... so they make a diagnosis (that's just a subjective test) after 10 minutes, then give tons of haldol and such to treat the symptoms, but don't diagnose the underlying physiologic cause (they'll state its a chemical imbalance but again with no test to prove it).

If that's the case and the persons underlying cause of their issue stem's from altered function in the brain, then shouldn't that technically be handled by neurologist?

Or a psychiatrist will put a medical diagnosis on something that really isn't an illness (like if someone is depressed because a relative died, they'll say the person has major depressive disorder)

It's like they trie to have one foot in neurology and the other in psychology but don't appropriately address either.


What do you think?

No. And good luck convincing most Neurologists to handle all the Psychiatric cases.

 

[typhoonegator]

Shouldn't ENT and OMFS just merge? I mean, they both deal with the head and neck. And don't get me started about rheumatology and allergy/immunology. No diagnostic or therapeutic nuance there. Shouldn't all EM and IM physicians know toxicology? Let's get rid of them too.

By your definition, acute and chronic pain management should also just be handled by neurologists, because pain is registered and experienced by the brain, right? Palliative care, too.

Your post seems more about denigrating psychiatry than asking a real question about the utility of approaching organic and multifactorial brain disease from different therapeutic perspectives. I know a lot of psychiatrists, and a lot of behavioral neurologists, and I don't know anybody who "doesn't realize that the mind and brain are connected". I also have yet to meet a psychiatrist liaison who consistently labels an appropriate grief response or adjustment disorder as MDD. In fact, the temporal relationship between psychiatric symptoms and the death of a relative would obviate an MDD diagnosis, by the very definition of the disease.

So what do I think? I think psychiatry and neurology both serve vital roles in the care of patients with psychiatric and neurologic disease, with an enormous degree of overlap. I greatly appreciate my psychiatry colleagues, and I find them consistently helpful in the care of my neurocritical care population in the acute and subacute setting.

 

[Electricity]

> I also have yet to meet a psychiatrist liaison who consistently labels an appropriate grief response or adjustment disorder as MDD. In fact, the temporal relationship between psychiatric symptoms and the death of a relative would obviate an MDD diagnosis, by the very definition of the disease.

Overall I agree with your point, so I don't want to nitpick, but just for my own clarification: are you referring to the bereavement exclusion, and if so, are you considering the DSM-5 which removed that exclusion when you make this claim [1, 2]?

[1]: http://psychcentral.com/blog/archives/2013/05/31/how-the-dsm-5-got-grief-bereavement-right/

[2]: http://www.medscape.com/viewarticle/803884_10

> The bereavement exclusion in DSM-IV, which has been removed in DSM-5, was intended to exclude individuals experiencing depressive symptoms lasting less than 2 months after the death of a loved one from a diagnosis of MDD. ... A categorical exclusion of MDD for 2 months after the death of a loved one wrongly presumes that nobody can become seriously depressed while also grieving.

 

[typhoonegator]

I am not a psychiatrist or behavioral neurologist, but the DSM-5 elimination of the bereavement exclusion still does not remove the clinician from the responsibility to consider social and ethnic norms when applying the diagnostic criteria for MDD (see the note under criterion C in the DSM-5), and specifically begs the physician to exercise clinical judgement when depressive symptoms occur proximate to a major loss.

Overall it was a good decision to remove the exclusion because it was sort of a "gotcha" requirement that probably prevented people from getting treatments they could have benefited from. And you still need two weeks of persistent symptoms. But allowing the possibility of major depression as part of grief does not somehow make it an automatic diagnosis, as was intimated by the first poster.

 

[Asklepian]

I think that it is an interesting point that we divide our organ system up into two specialties, rather than subspecialize within a general specialty. Personally, I am hopeful that as we elucidate the underlying mechanisms of the brain and its circuitry we will eliminate this arbitrary line between behavioral/syndromic and better-pathologized conditions which characterize the particular specialties. It would be within reason at that time to subspecialize in an area more particular to one of the two fields as they stand currently.

Neurology residents get very little psychiatric training (1 month), and psychiatry residents get very little neurology training (2 months). I think it is important that a Psychiatrist, who is a learned doctor of conditions affecting the brain should know how to read CTs and MRIs of the brain, and to at least have basic training in EEG, LP, and other neurologic foundations. In the same regard, it is not suiting for a neurologist to have a poor understanding of PNES, depression, anxiety, psychosis, and mania. Yes, there is some working knowledge, but definitely not to the same extent.

There are many of us interested in seeing the gap close, and a reunification come to pass. As the "black box" that is the brain becomes clearer, I anticipate that this will be the case.

 

[Spinothalamic]

I agree that it will be interesting when we learn more about the pathophysiology behind both psychiatric and neurologic conditions. However, even if the fields ever "merged", the merge would probably just be superficial at best, as the majority of conditions are best treated by one of the specialties already.

As for neurology and psych trainees receiving more training in the other specialty--it sounds good in theory but probably isn't practical in my opinion as far as procedures/techniques (go just adding more time training in techniques that won't ever be used). There is an opportunity cost to everything whether it be less learning of another neurologic subspecialty or adding time to residency training.

 

[northernpsy]

Your post seems more about denigrating psychiatry than asking a real question about the utility of approaching organic and multifactorial brain disease from different therapeutic perspectives. I know a lot of psychiatrists, and a lot of behavioral neurologists, and I don't know anybody who "doesn't realize that the mind and brain are connected". I also have yet to meet a psychiatrist liaison who consistently labels an appropriate grief response or adjustment disorder as MDD. In fact, the temporal relationship between psychiatric symptoms and the death of a relative would obviate an MDD diagnosis, by the very definition of the disease.

So what do I think? I think psychiatry and neurology both serve vital roles in the care of patients with psychiatric and neurologic disease, with an enormous degree of overlap. I greatly appreciate my psychiatry colleagues, and I find them consistently helpful in the care of my neurocritical care population in the acute and subacute setting.

On behalf of the psychiatrists of SDN: We love you too.
The OP seems to be seriously overestimating how often it is possible to attribute someone's psychiatric symptoms to a lesion that can be localized with our current understanding of the brain.

 

[Pharmohaulic]

I agree that it will be interesting when we learn more about the pathophysiology behind both psychiatric and neurologic conditions. However, even if the fields ever "merged", the merge would probably just be superficial at best, as the majority of conditions are best treated by one of the specialties already.

As for neurology and psych trainees receiving more training in the other specialty--it sounds good in theory but probably isn't practical in my opinion as far as procedures/techniques (go just adding more time training in techniques that won't ever be used). There is an opportunity cost to everything whether it be less learning of another neurologic subspecialty or adding time to residency training.

I see where you are coming from... but psychiatry in my opinion and the opinions of others cannot keep going in the direction that it is.. they need to have more evidence based diagnostic features.

They function in diagnosis order of the "mind." The mind is not an organ but rather a phenomenon of a specific organ (the brain). To be a true medical specialty, they need to diagnosis the pathology of the actual organ system... you can't diagnosE and put a medical application to something you can't see (the mind).

And yes I understand a person's "mind" (and is neurological underpinnings) can be directly impacted by ones experiences and environment... but that's what we already have social workers and psychologists for.

So for instance... a psychiatrist diagnoses someone with schizophrenia based on their symtoms of paranoia and hallucinations. Their test is based on a 15 minute assessment of that person and their behaviors. Rather than trying to determine the underlying physiological cause of their symtoms they ssume it's a "chemical imbalance" (again, just simply based on symptoms) and say, "you have schizophrenia" and then proceed to prescribe medication just treat the symptoms and not the underlying cause.

It's like someone going to the cardiologist and saying they are having chest pain/discomfort... and rather than running tests the cardiologist just saying based on subjective symtoms observation, "hmm looks like It could be angina," and then send the patient home with pain killers to treat the symtoms rather than running tests or appropriately diagnosing or treating the underlying cause of the disease.

 

[northernpsy]

What underlying physiological causes are you referring to? What non-pharmacological treatments are you proposing for psychosis?
It's hard to discuss this without a grasp on what exactly you think we're missing and what we're supposed to do instead.

 

[typhoonegator]

So for instance... a psychiatrist diagnoses someone with schizophrenia based on their symtoms of paranoia and hallucinations. Their test is based on a 15 minute assessment of that person and their behaviors. Rather than trying to determine the underlying physiological cause of their symtoms they ssume it's a "chemical imbalance" (again, just simply based on symptoms) and say, "you have schizophrenia" and then proceed to prescribe medication just treat the symptoms and not the underlying cause.

This is literally how neurologists diagnose and manage parkinsonism and many other diseases. Why are you singling out psychiatry?

 

[TUGM]

History and physical is apparently a lost art among the newer generation of physicians and physicians-to-be. Also, of course there is research currently being done to find the mind-body connection you're looking for...

In the meantime, our colleagues in psychiatry are doing what they do best. Just because the mind cannot be imaged doesn't mean it cannot be measured or observed.

 

[bustbones26]

A psychiatrist friend of mine once said, "you guys are in charge of the hardware and we are in charge of the software". Sort of true, but some cases where I would disagree.

Sure, there are areas of overlap. I have met psychiatrists that take care of dementia patients just as much as (and in some cases better than) general neurologists. ADHD? I'm pretty sure that a child neurologist can handle this as well as a psychiatrist. In the subspecialty of headache medicine, yes, there are some "big wigs" in the field where their primary specialty is psychiatry. There are a number of psychiatrists that know the science and pharmacology behind sleep medicine very well.

The overlap? Well we all see anxiety, depression, and bipolar disorder but at the end of the day I consider the psychiatrist an expert, especially in the cases that are refractory and definitely in cases that require hospitalization. Primary care providers constantly prescribe SSRI/SNRIs and that certainly did not make psychiatrists obsolete.

So, that being stated, a neurologist might argue that perhaps they can polish their proficiency in the above areas and match the skills of a psychiatrist? That being stated, I would argue that in my general neurology training I have never managed any schizophrenia spectrum disorders, had zero training in psychotherapy, nor managed the "real crazy" patients that required heavy duty drugs such as thorazine, lithium, etc. I'm sure there are psychiatrist out there that use benzodiazepines and antipsychotics that I either never heard of before or the last time I heard of them was in the medical school. I surely never managed ECT. I would also argue that psychiatrist have heavy duty training in psychopharmacology, much more than a neurologist. Which is sort of shame considering we "borrow" many of their drugs.
If a physician sought dual training, which I suppose one could do, that perhaps would make them a very solid physician and valuable toward either side of the coin. That being stated, a lot of time!!!

 

[SeniorWrangler]

Sigmund Freud, who trained as a neurologist, started off wanting to do exactly what the OP is talking about. He couldn't do it because it's really hard. We still can't do it because nobody knows how the brain gives rise to the mind.