Neurology-psychiatry integration

I've hesitated before (see previous post) in case I undermine an enthusiastic psychiatric trainee, who has just been successful in getting a journal paper published. In the same issue of BJPsych Bulletin, mentioned in my previous post, Thomas Reilly has a special article concluding there is no dividing line between neurology and psychiatry (see article). Perhaps he needs to read my previous post because he incorrectly comes to this conclusion because he believes psychiatric illness is a neuropathological disorder.

What worries me is what trainees are being taught. I've no objection to Thomas Reilly getting neurological training. It might help in his understanding of the differences between neurology and psychiatry. Of course all doctors should have a biopsychosocial understanding, as he suggests. I'm not wanting to overemphasise the difference between psychiatry and the rest of medicine. But psychiatry primarily treats functional disorders not organic. Of course, conversion disorders may present to neurologists but it may well be the skill of their neurological examination that makes the diagnosis, because they don't find the expected signs. Medicine is full of cases with "unexplained symptoms" that never get referred to a psychiatrist and the psychological origin of the problems is missed. I hope that Thomas Reilly does become slick in neurological examination, as the best of neurologists are. But in practice, he'll not need that skill very much in his assessment of psychiatric patients. What he needs to develop is his psychological formulation of cases (see another previous post).

Functional and organic psychiatry

Alwyn Lishman (see interview in The Psychiatrist), the author of the classic book Organic Psychiatry, knows more about neuropsychiatry than most people, so when he says that Wilhelm Griesinger was too narrow in his approach to psychiatry, this needs to be taken seriously. Nonetheless, Michael Fitzgerald looks to Griesinger to justify his argument in a BJPsych Bulletin editorial that neurology and psychiatry should merge into a single speciality, although he agrees that Griesinger went too far in ignoring environmental influences. In fact, Griesinger was not quite as reductionistic in his view that mental diseases are brain diseases as is commonly assumed (Marx, 1972). He suggested that the initial phase of mental illness did not involve structural changes. Structural change only occurred in what he called the second phase, in which mental image formation or will were affected, and also in the third phase, which implied deterioration and incurability (see my book chapter).

I've commented before on the issue about the merger of neurology and psychiatry when two of the main references from Fitzgerald's paper were first published (see previous post and BMJ letter). Ronald Pies is more of an advocate for Fitzgerald's position than Fitzgerald seems to realise, although if the merger happened, Pies thinks there will be a need for “certain kinds of linguistic and philosophical ‘bridging devices’” (see my book review). The main problem with the proposal for merger is that it is based on a mistaken notion that mental illness is brain disease (eg. see previous post). Ernst von Feuchtersleben published his book in the same year as Griesinger in 1845 and questioned whether mental disorders were always due only to disorders of the brain.  He argued for a functional understanding of mental disorder, which of course has a biological basis. As I keep saying, although mind is enabled by the brain, it is not reducible to it.

Psychiatry should look to von Feuchtersleben for its origins rather than Griesinger. This would cement its relationship with the rest of medicine better than Fitzgerald's proposal. It is in fact Fitzgerald's misunderstanding that undermines the relationship between doctor and patient.  Relations between people should not be reduced to objective connections in the brain. I've said before (eg. see previous post) that psychiatry should be seen as the pre-eminent medical speciality. The current president of the Royal College of Psychiatrists seems to agree with me in a tweet.