Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
A TImely Reminder
- Ramanathan Raguram, Ramanathan Raguram, Venkata Subramaniam (22 June 2002)
-
The wall between neurology and psychiatry: its not quite ready to go
- Jesse Dawson (24 June 2002)
-
Some parts of the wall are thicker than others
- Jon Stone, Alan Carson, Michael Sharpe (27 June 2002)
-
Mind-brain integration creates biopsychological understanding in psychiatry
- D B Double (1 July 2002)
-
Re: Some parts of the wall are thicker than others
- Alan Challoner (17 July 2002)
-
Neuropsychiatry is alive and well
- Howard A Ring (24 July 2002)
-
Neurology and Psychiatry,sooner or latter they will be one branch,Neuropsychiatry?
- Abdul Karim Al-Sheikhli (10 November 2002)
-
Need for elimination of mind body dualism
- Hywel B Lewis (17 November 2002)
-
Re: Need for elimination of mind body dualism
- GH Hall (18 November 2002)
-
Psychiatry, Neurology, Neuropsychiatry - What it all means (for our patients)
- Maurice Preter, M.D. (3 January 2003)
|
|
|||
|
Ramanathan Raguram, Professor of Psychiatry National Institute of Mental Health & Neurosciences, Bangalore, INDIA, 560 029, Ramanathan Raguram, Venkata Subramaniam
Send response to journal:
|
The editorial by Mary Baker et al persuasively outlines the need for a closer interaction between the disciplines of Neurology and Psychiatry. One of the major factors contributing to the widening gulf between the two specialities is the inadequate training that is provided to the post graduate students during their period of specialization. The neurologist in training rarely gets an exposure in psychiatry and the reverse is also uncomfortably true. This trend carries over to the exam process too. None of the board exams of psychiatry have a neurologist on their panel and the neurology exam is often conducted in the absence of a mental health professional. It is not surprising then that the perspective of the trainee specialist gets confined to the demands of their own speciality. The coming togther of the two disciplines will occur only when efforts are initiated to address this requirement during the training period. A closer liason between the two specialities is not merely a professional requirement but a pressing clinical need. | |||
|
|
|||
|
Jesse Dawson, Medical Student University of Glasgow, Glasgow, G12 8QQ, UK
Send response to journal:
|
The editorial by Baker et al 1 raises an important issue but does not fully address it. They suggest that the wall between neurology and psychiatry be torn down in the light of recent research highlighting the neurophysiological and pathological basis of many psychiatric illnesses. Historically, psychiatric illness was considered different to others being without real pathological basis, or as being “all in the mind.” A similar divide occurs within psychiatry itself, with the organic and non- organic classification being engrained in the ICD-10 criteria. A “non- organic” depression (by definition of organic) is no less organic than a so-called “organic” case despite the absence of identifiable macro- pathology. Both types are related to an organ (the brain) and are partly explained by abnormalities of neurotransmitter function. This historical perception of psychiatric illness has created a wall between it and other illnesses in the minds of the public and many doctors. This has in-turn bred a culture where psychiatric problems (despite being an integral component of many medical illnesses) are under-recognised and patients often viewed with less compassion than they deserve. Psychological issues (and indeed new undergraduate curricula, designed in part to address this problem) are often described as “touchy-feely.” This mindset is being challenged but is strongly reinforced by the nature of postgraduate training. Having only this week entered the realms of post-graduate medicine, I am probably as good at recognizing and addressing psychiatric problems as I will ever be. Little provision currently exists for training in psychiatry in basic post-graduate medical and surgical training leading to an inevitable loss of skills. This reinforces the wall, to the detriment of patient care, making doctors less willing to confront and less able to detect and manage psychiatric issues. Regardless of how “medical” or “surgical” the illness it is often these issues which matter most to patients. I agree that this wall must be torn down and acknowledge the importance of the recognition that psychiatric illness is also an expression of abnormal brain function. However, this makes only a small dent in the wall. To complete the demolition, attitudes toward psychological issues and psychiatric illness must be changed via an increased emphasis in all types of specialist training. Otherwise, removal of the wall will never be complete and I will remain as afraid of (and as ill equipped to deal with) what lies on the other side. 1. Baker M, Kale R, Menken M. The wall between neurology and psychiatry. BMJ 2002;324:1468-69 (22 June.) |
|||
|
|
|||
|
Jon Stone, Research Fellow in Neurology Dept Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, Alan Carson, Michael Sharpe
Send response to journal:
|
The editorial by Baker et al highlights the nonsensical way in which psychiatric and neurological disorders and the doctors who look after them have been divided over the last 100 years and how modern neuroscience is bringing them closer together again. Where is the wall between the two specialities at its thickest? Not in academic research where distinctions between mind and brain in schizophrenia, Parkinson's disease and depression are already largely abandoned. Perhaps in training then? It's true that opportunities for a neurologist to gain psychiatric skills (and vice versa) - in the UK and US anyway - are limited and there is huge scope for improvement. But generally the patient with Parkinson's disease who also has delusional disorder will receive attention and treatment. Similarly, psychiatrists continue to look for neurological disease in their patients much more often than they find it. The thickest part of the wall and the greatest challenge to these two disciplines are the patients who helped to put it up in the first place. Freud, cited in the article as a prototypical neuropsychiatrist, was initially a neurologist but he abandoned the clinico-pathological model in order to explain hysteria - a proposal that drove the greatest schism between the disciplines of mind and brain. Up to one third of all new neurology outpatients have symptoms such as dizziness, numbness, pain, weakness and blackouts that are unexplained by disease or 'functional'. Neither neurology nor psychiatry are particularly interested in them and basic neuroscience has made only embryonic inroads in to their understanding. Important aspects of functional neurological symptoms, such as illness beliefs and the interaction of cultural factors, may forever remain outside the reach of the scanner. To truly break down the wall, neurology and psychiatry must not simply focus on those symptoms where biology has permitted dialogue. In the 19th century, physicians of nervous disorders brought important social, psychological and biological perspectives to the symptoms they observed. Lets hope in our rush to examine the brains of our patients we do not forget to listen to what they are saying. |
|||
|
|
|||
|
D B Double, Consultant Psychiatrist and Honorary Senior Lecturer Norfolk Mental Health Care NHS Trust and University of East Anglia, Carrobreck, Norwich NR6 5BE
Send response to journal:
|
Baker et al argue that advances in neuroscientific understanding mean that the wall between neurology and psychiatry should be torn down.1 Their intention appears to be mind-brain integration. However, they fail in this aim because they seem to wish to eliminate the notion of mental dysfunction. Adolf Meyer was fond of calling the attempt to reduce mental dysfunction to brain pathology a "neurologising tautology".2 What is achieved by concluding that schizophrenia and other functional mental illnesses are disorders of the brain? The hypothesis that mental dysfunction is caused by brain pathology has not been decided by the evidence. The kinds of processes that underlie mental illness at the biological level may be no different from those that produce thoughts, feelings and behaviour amongst the "normal".3 One professional organisation, the Dutch Association for Psychiatry and Neurology, represented both neurologists and psychiatrists in the Netherlands until 1974. Separate sections for neurology and psychiatry were only created from 1962. The increasing separation of psychiatry and neurology encouraged a multicausal, biopsychosocial approach to psychiatry as opposed to the one-sided somatic emphasis of neurology.4 Maybe the reason that Baker et al cannot see any difference between psychiatry and neurology is that biomedical approaches have become so dominant in modern psychiatry that a biopsychological view is seen as almost heretical.5 Although neurologists have the same issues as other doctors in relating to patients, they do not encounter the ideological conflicts of psychiatrists. For example, a professional dilemma of psychiatrists is the conflict between their separate status as scientific medical specialists and the need to be more than medical specialists if they are to influence other mental health professionals. Psychiatrists play a social role in controlling mental disturbance through the Mental Health Act. The model of mental illness adopted affects how patients are treated and the Critical Psychiatry Network believes that psychiatric practice does not need to be justified by postulating brain pathology as the basis for mental illness (www.criticalpsychiatry.co.uk).
|
|||
|
|
|||
|
Alan Challoner, Retired
Send response to journal:
|
One particular thicker part of the wall is in the area of learning disability, or what used to be called mental handicap, and earlier still mental retardation. Historically, subjects have been cared for by consultant psychiatrists. This emanated from their incarceration in the asylums along with others whose mental and social conditions were deemed to need a separation from society. David Hartley, a philosopher who contributed developmental approaches to psychiatry, wrote in his Observations on man, his frame, his duty, and his expectations, published in 1749, on a theory of mental organisation and behaviour patterns which took in some aspects of Locke's association of ideas with Newton's thoughts on the flow of nervous impulses in a movement akin to fluidity. He seemed to understand that the flow of impulses went through what we now know as neural circuits, and that this applied regardless of whether the brain was normal or changed by disease or affection. His view was that the mentally ill differed from normal because they misunderstood past or future facts of a common nature in a way that separated from others in similar situations. This he noted affected their happiness, memory and discourse; and the connective consciousness was impaired. He suspected that, "the poor judgement of children and idiots, the dotage of old people, drunkenness, deliriums, recurrent ideas, violent passions, melancholy and madness", were all connected to an imperfection of reasoning. John Gregory, who was both a professor of philosophy and of physic as well as being physician to the King in Scotland, combined both the psychological and the medical approach to dealing with the affections of the mind. He advised that both these sciences should be combined and was very much against the theorisers. He attempted to bring about a more rational approach by the use of comparative psychological studies in order to gain a better understanding of human behaviour. This led much later to the introduction of the behaviouristic schools of psychology and the development of the idea that behaviour could be modified by conditioning probably first introduced by Sir Kenelm Digby in 1644. The question which needs to be asked is whether those who have (and had) learning disabilities, were in fact mentally ill. Alternatively, was their behaviour a response to their lack of understanding, and the failure of others to recognise and accept their limitations? To understand the concept of mental illness it might be helpful to have two questions answered; what are the clinical understandings attached to psychosis and neurosis in psychiatry, and what is it about the malfunctioning subject or his poor adjustment to his social environment that contributes to the diagnosis being made that he is 'ill'. Having asked these questions it will not be unusual to find that there are differing answers dependent upon who is responding. It is therefore commonly accepted that the determination of such a diagnosis will depend on the society in which the person lives. Thus, R Benedict argued that, 'the concept of the normal is properly a variant of the good. It is that which society has approved. A normal reaction is that which falls within the limits of expected behaviour for a particular society.' ["Anthropology and the Abnormal", Journal of General Psychology. January 1934.] A different slant is put forward by H W Dunham. '...judgements about who is mentally disturbed or can be regarded as a mental case will vary in different social milieus, communities and subcultures'. [Sociological Theory and Mental Disorder. Wayne State Univ. Press, 1959.] Regardless of the theories, the practical result was that many of those with 'learning disability', found themselves in hospitals because relatives could not, or would not, cope with them at home. The lack of appropriate and sufficient staff to give adequate care and education, led to behavioural problems, which were reduced through psychotropic medication. Fortunately, most of these hospitals have now closed. However, many of those who have been rehabilitated into the community are still under the care of a psychiatrist, and are often still being medicated as they were before. Neurology and psychology had very little input into their lives, and it was this wall which needed to be reduced. | |||
|
|
|||
|
Howard A Ring, Senior Lecturer in Psychiatry Royal London Hospital E1 1BB
Send response to journal:
|
Editor – In your issue of 22 June 2002 devoted to neurodegenerative disease, the “wall between neurology and psychiatry” is referred to on several occasions. In the editorial by Baker, Kale and Menken1 the need for a “fundamental alliance between mental health and brain illness” is discussed. In the article by Kale2 a case is made for the proposition that “the mind is a function of the brain”. Not only do I and many of my colleagues agree with this: we and others have also made significant steps in removing this “wall” between the two specialities. Although Kale goes on to consider the dualism that has “psychiatrists and neurologists who think that the two are separate”, it seems to me that this belief in the distinction between ‘neurological’ and ‘psychiatric’ disease is often held by some amongst the general public and the wider medical community, where it arises from a stigmatising view of psychiatry. It suits some to be able to consider ‘real’ neurological disease arising from brain pathology as distinct from psychiatric ‘disturbances arising from weak moral fibre or bad breeding’. There have always been both neurologists and psychiatrists who have understood the close relationship between these two fields of endeavour. In the UK there currently exist two national professional bodies specifically focussed on the inter-relationship between physical brain state and behaviour and affect. The British Neuropsychiatry Association is a multidisciplinary grouping of psychiatrists, psychologists, neurologists and other interested healthcare professionals devoted to exploring the relationships between these fields. The Special Interest Group in Neuropsychiatry of the Royal College of Psychiatrists is a forum in which psychiatrists are currently working to further the recognition of and to seek increased resources for the many patients whose needs transcend narrow neurological or psychiatric models of diagnosis and care. Howard Ring senior lecturer in psychiatry and chair of the royal college of psychiatrists’ special interest group in neuropsychiatry Barts and the London School of Medicine, Medical Sciences Building, Mile End Road, London E1 4NS Telephone: 020 7882 7552 Fax: 020 7882 7551 h.a.ring@qmul.ac.uk 1. Baker MG, Kale R, Menken M. The wall between neurology and psychiatry. BMJ 2002;1468-1469. 2. kale R. Neuroimaging. BMJ 2002;1529 |
|||
|
|
|||
|
Abdul Karim Al-Sheikhli, Loc Consultant Psychiatrist The Medical Centre,2 Manor Court Avenue,Nuneaton CV11 5HX,UK
Send response to journal:
|
10th No,2002 Dear Editor,It was very interesting to read the Editorial of Baker,Kale and Menken,The wall between Neurology and Psychiatry(1),There are a large number of studies which indicate that many psychiatric disorders,which many of them used to be called as functional,are due to structural/functional disturbance of the brain,they came through the developments in the radio-imaging techniques of the investigation of brain structure/function ,CT scan of the brain,MRI brain,PE tomography,..etc. It could be the continuation of seperation between Psychiatry and Neurolgy through the continuation of stigma attached to Psychiatry,both to patients and those who are working in the branch,although less evident in the developed world,but very clear in the developing counteries,I built that opinon from my previous experience in Iraq,Jordan and UK. I always pay great respect to Emil Kraeplin who introduce the tem dementia preacox ,and to the recent findings of the studies of radio-imaging techniques on psychiatric patients,so i think sooner or latter the bounderies between the two branches will be abolished? References 1.Baker MG,Kale R,Menken M,The wall between Neurology and Psychiatry,BMJ,2002;1468-1469 Competing interests: None declared |
|||
|
|
|||
|
Hywel B Lewis, Research Physician SIMBEC Research Ltd. CF48 4DR
Send response to journal:
|
I write with reference to your theme issue on neurodegenerative disease and the editorial by Baker et al on the need for a fundamental alliance between mental health and brain illness [1]. Subsequent responses have disussed 'the wall between neurology and psychiatry' I think that the old notions of Cartesian dualism that permeate our language lead to considerable muddled thinking in this respect and it is time to realise that resolution of the 'mind-body problem' is needed for practical purposes in the practice of medicine as well as for philosophical reasons, e.g. dealing with so called 'psychosomatic' illnesses. Bertrand Russell in putting forward the idea that mental events and brain events are identical [2] is pointing in the right direction. In her book 'Neurophilosophy' [3] Patricia Churchland makes the case for developing a change in language to resolve the difficulty that some people have in accepting mind-body identity. Yours sincerely Dr H. Bernard Lewis
References: 1 Baker MG,Kale R, Menken M. The wall between neurology and psychiatry, BMJ 2002;324:1468-0 [22 June] 2 Bertrand Russell 'Portraits from Memmory', pages: 135 - 153 3 Patricia Smith Churchland 'Neurophilosophy: Toward a Unified Science of the Mind Brain' Competing interests: None declared |
|||
|
|
|||
|
GH Hall, retired physician EX1 2HW
Send response to journal:
|
Descartes was no fool. Semantic contortions won't dispose of the gap between our thinking (as experienced) and what is going on in the brain. Schopenhauer pointed out that however much we got to know about the physical activity of the brain it could tell us nothing about the quality of the consciousness within. To wish this difference away is to miss the real mystery of our existence. It reminds me a little of the suggestion in the Lancet many years ago that the government solve the problems of the NHS by passing an "Abatement of Illness" act. Competing interests: None declared |
|||
|
|
|||
|
Maurice Preter, M.D., Assistant Professor of Psychiatry and Neurology University of Mississippi Medical Center, Jackson, MS 39211, USA
Send response to journal:
|
This is a timely topic and I will try to add to it, rapid-response style.
To begin, I was somewhat, maybe naively dismayed to learn that the thoroughly anti-scientific and harmful dichotomy between neurology and psychiatry training tracks is not the privilege of a few high-tech countries that for a number of reasons, undervalue clinical skills. These reasons include competition for the enormous medical pie among "providers", rendering individual physicians undefended by corrupt and inefficient medical organizations vulnerable to economic pressures from equipment industries (trying to sell expensive imaging) and pharmaceuticals (trying to sell expensive pharmaceuticals). Regrettably, according to Drs. Raguram and Subramaniam, the same seems to be the case in India, a country whose medical education system - though only encountered through my Indian-born colleagues here in the U.S. - has always impressed me by its focus on outstanding clinical-diagnostic skills. Stone et al. posit that "the thickest part of the wall and the greatest challenge to these two disciplines are the patients who helped to put it up in the first place." My own experience as a neurologist-psychiatrist disconfirms this statement. Most patients, especially "neurology" patients - many of which suffer from anxious, depressive or post-traumatic co-morbidity - are enormously appreciative once they see the outcome of a more comprehensive approach to their brain/mind disease. It is certainly true that patients relying on for-profit insurance coverage are not encouraged to seek comprehensive - spell: time-intensive and prima facie, expensive - consultation. From the patients' perspective then, neuropsychiatry is of great interest not just for academic sophisticates, but first and foremost because a combined approach improves treatment outcome and the quality of life of chronically diseased patients (since that is what most neurology and psychiatry patients are). Further, the drain on medical and economic resources caused by split treatment is immense. It has been estimated that untreated or poorly treated migraines in the U.S. - that is just migraine- cost around forty billion dollars a year (reference on file). One of the causes for this enormous bill is the failure of the current health care system to address the migraine patient as a complex human being who is in pain, rather than as a dysfunctional, aching and inflamed brain that simply needs a costly shot-in-the-arm to reintegrate the workforce. The same is true for other neurological diseases, e.g. Parkinson disease, epilepsy, and multiple sclerosis to name but a few. Competing interests: None declared |
|||