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April 30, 2014

Reintegrating Psychiatry and Neurology Is Long Overdue: Part 1

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Henry A. Nasrallah, MD

Saint Louis University School of Medicine, St. Louis, Missouri

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For over a century, neurology and psychiatry were united in one discipline and one department in medical schools, representing a brain specialty. Neuropsychiatry dealt with all aspects of that divinely complex organ, from sensory, motor, vascular, or neoplastic to cognition, speech, thought, emotions, and behavior. Upon graduating from a unified neuropsychiatric department, some physicians focused on the physical brain disorders such as stroke, epilepsy, Parkinson’s, or multiple sclerosis, while others focused on the mental brain disorders such as psychosis, depression, anxiety, or pathological behaviors. This is not different from contemporary ophthalmology departments, where graduates of training programs subspecialize in disorders of the cornea, the lens, the retina, neuro-opthalmology, or ocular infectious diseases.

So why did the unified brain specialty split during the 1950s? Although multifactorial, a prominent reason was the rise of the theoretical, nonempirical psychoanalytic model that permeated and dominated psychiatric departments in that era. That was in stark contrast with the empirical, nontheoretical neurologic training and practice. The “organic vs. functional” dichotomy was accentuated, and the jargon of psychiatry alienated neurologists, who adhered to traditional medical terminology. This led to the “secession” of neurology that created separate journals and associations and a separate board exam. For the past 60 years, psychiatry and neurology retreated into their respective silos in all medical schools and rarely interacted clinically, an amazing paradox given that they dealt with the same organ! However, the alienation became so entrenched that cynics regarded psychiatry as brainless and neurology as mindless!

Fortunately, the neuroscience revolution came to the rescue and has elucidated the multiple links between brain and mind. The past 3 to 4 decades witnessed unprecedented advances in elucidating brain-behavior linkages and the neuroanatomic, neurochemical, neurophysiologic, and neurologic correlates of mental functions. Thanks to breakthroughs in structural and functional neuroimaging and accelerating advances in molecular neurogenetics, the medical foundations of psychiatry have become well established. The neuropsychiatrists of a century ago always assumed that the mind is a product of cortical activity, but they lacked the technological tools to demonstrate it.

Thus, from a conceptual perspective, the splitting of neurology and psychiatry is no longer justified. However, reunification, while urgently desirable, will be slow because practitioners on both sides, trained and inculcated with the model of brain-mind dualism, may be reluctant to merge, and many might remain entrenched in their “separateness.” Nevertheless, the shift to a modern, scientifically valid paradigm of integrating psychiatry and neurology has begun and will ultimately be widely adopted. A motivated cadre of neuropsychiatrists and behavioral neurologists must serve as leaders and catalysts to overcome the inertia of decades of alienation.

In my next blog entry, I’ll discuss the numerous practical advantages of reuniting neurology and psychiatry into a single discipline.

Financial disclosure:Dr Nasrallah is a consultant for Boehringer-Ingelheim, Genentech, Gruenthal, Janssen, Lundbeck, Merck, Otsuka, Roche, and Sunovion; has received grant/research support from Roche, Forest, and Otsuka; has received honoraria from Boehringer-Ingelheim, Forum, Genentech, Gruenthal, Janssen, Lundbeck, Merck, Otsuka, Roche, and Sunovion; and is a member of the speakers/advisory boards for Janssen, Otsuka, Genentech, Forum, Merck, and Sunovion.

Category: Medical Conditions , Mental Illness , Psychosis
Link to this post: https://www.psychiatrist.com/blog/reintegrating-psychiatry-and-neurology-is-long-overdue-part-1/
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12 thoughts on “Reintegrating Psychiatry and Neurology Is Long Overdue: Part 1

  1. The time has come. We are already there: neuropharmacology; pet scans, fmri and neural circuitry. Equivalent mei and pet scan findings for medication effect and psychotherapy effect. The time is now.
  2. I couldn’t agree more…I am actually a psychiatry resident looking to do a fellowship in Neuropsychiatry after I’m done my residency…I find it an exciting prospect…:)
  3. And we now have the Connectome that will hopefully disclose deficits in Brain Diseases;, including the psychiatric and the neurological.
  4. There is no question that reintegration makes sense, however what is needed is a common framework that integrates brain function and behavior. See orientationtheory.org
  5. As a psychiatric nurse practitioner I have always wanted to see the union of these specialties. Imagine a mental health center with comprehensive facilities including brain imaging, ECT, EMDR, TMS, DBT, neuropsych testing, research, rEEG and so on.
    I’ve had the frustration of working on an in-patient psychiatric unit without the ability to have a CT scan or MRI done on site. Medical care as basic as an IV or an NG tube requires the client be sent to a local hospital. The integration of care is LONG overdue.
  6. I’m a Neuropsychiatrist double boarded and subspecialized in Pain Medicine (ABPM). In my view it is not possible to practice psychiatrically informed pain medicine, without a combined psychiatry/neurology base (actually its called neuropsychiatry). Otherwise one would be constantly confused about the nature of pain syndromes (mostly neuropathic) and whether there is a “psychosomatic” component that involves the de novo generation of ‘non anatomic’ pain symptoms from psychiatric disorders (very rare in reality). The combined approach makes pain far more clear in terms of diagnosis and treatment.
  7. The future plan is to integrate the Texas A & M Health Science Center College of Medicine MS iii Clerkship into a Neuropsychiatry rotation with the focus on understanding the Brain and it’s
    dysfunction as a whole rather than separate disciplines..starting Academic Year 15-16. It is Time for Freud and Oppenheim to be reunited.
  8. I think this essential. Advances in all the scientific disciplines related to the brain are happening at an accelerating rate. Psychiatry would benefit from a greater grounding in science that would be afforded it by integration with neurology. Psychotherapy should also be revisited as a potential vehicle for making targeted changes in gene expression. Mental illness is often associated with epigenetic changes driven by psychological stress which may respond to psychotherapeutic intervention. A number of peripheral markers have been identified that could track progress.
  9. In my country there is a shortage of neurologists and of psychiatrists. Psychiatrists end up doing both, especially because of the co-morbidities in neuro and psychiatry. If I could have a formal neuropsychiatry fellowship, I would be oh so well rounded.
  10. I am a retired psychiatrist after 43 yrs in the field. As an intern in Internal Medicine, I took 5 mos in Neurology for which I am so grateful, before my psychiatric residency. I was able to utilize this background in treating and diagnosing all types of diseases in pts. across the board, such as a recent pt. with B-12 deficiency with neurological sx, already that had been missed by his PCP, by merely looking into his CBC showing a macrocytic anemia. I had a forever grateful 35yr old teacher in return. Numerous other examples with thyroid disease, Parkinson’s. etc. Hope re-integrating the 2 fields becomes a reality again.
  11. In fact, there is a range where psychiatry and neurology are connected. However, they are two different specialties, with different issues. Likewise, cardiology and pneumology, for example, have a range in common, but that does not justify the replacement of these two specialties by a single “cardiopneumology”.

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