But what's the borderline between neurology and psychiatry? What makes one disease "neurological" and another "mental"? Are some psychiatric disorders more "neurological" than others?It's a rather philosophical question and you could discuss it for as long as you wanted. Rather than doing that I thought I'd have a look to see which disorders are, at the moment, considered to fall into each category.
To do this I did a quick search the archives of two journals, Neurology which the world's leading journal of... well, guess, and the American Journal of Psychiatry. I looked to see how many papers from the past 20 years had either a Title or an Abstract which referred to various different diseases. You can see the results above. Note that the total number of papers varied, obviously, and I've only plotted the proportion.
Some interesting results. Schizophrenia, which is probably considered "the most neurological" psychiatric disorder, is in fact the least talked about in Neurology. Depression is top amongst the "core" psychiatric ones.
Autism occupies a middle ground, discussed by psychiatrists at 70% and neurologists at 30%. That didn't surprise me, but what did was that ADHD is almost as neurological as autism. Mental retardation is also intermediate, though it's 30:70 in favour of neurology. Whether autism is really less neurological than mental retardation, is a good question.
Then out of the disorders with a known neuropathology, Alzheimer's disease, Huntington's disease and "dementia" (which overlaps with Alzheimer's) are a bit psychiatric while stuff like headache and epilepsy is almost 100% neurological. Why this is, is not entirely clear, since both dementia and epilepsy are caused by neurological damage, and they can both cause "psychiatric" symptoms.
I suspect the difference is that it's just much harder to treat Alzheimer's, Huntington's and dementia. With epilepsy or meningitis, neurologists have a very good chance of controlling the symptoms and few patients will be left with ongoing psychiatric problems. But with the neurodegenerative disorders, neurologists can't really do much, leaving a large pool of people for psychiatrists to study.
Someone once said that neurologists take all of the curable diseases and leave psychiatrists with the ones they can't help. These figures suggest that there may be some truth in this.
36 comments:
This is a really interesting question with a long and interesting history. We've got a few posts and linked publications looking at the emergence of neurology which can add some texture.
I decided to search for a few other terms and put the raw numbers below.
Neurology then AJ Psych
Total articles per journal:
20451 vs 9485
It's worth keeping in mind that, if you do proportional percents, Neurology has published twice as many articles in the 1990-present time frame.
Stroke 2365 vs 53
Treatment 8390 vs 5255
Drug 4957 vs 3235
Rehabilitation 427 vs 294
"DSM" 48 vs 1041
In general, I differ on saying Neurologist take the curable diseases. I think they take the diseases that have cleaner diagnoses. They can precisely classify dementias or localize a stroke because on a few bedsides tests, but cures are separate. The arguments over DSM show that psychiatry doesn't go for clean, unified diagnoses.
Perhaps it has less to do with some kind of abstract domain boundary and more to do with things we know something about versus things we wished we knew something about but we don't so we just make crap up. Sure, that may sound a tad cynical, but it's never stopped me from diagnosing people with the DSM.
On another note, isn't it interesting how much sociocultural research we can do with simple search engine results?
bsci: Thanks. The total publications point is important (and I forgot to check) but it's not clear that it would be appropriate to correct for that: arguably, all that means is that Neurology publishes lots of articles about all the many other neurological disorders, while the Am J Psych publishes fewer papers because psychiatry only has, about, 8 or 10 main topics.
So I don't know whether or not to correct for it.
A Bitter Pill: It is amazing. "Gathering" this data took me 15 minutes. 20 years ago, it would have taken... well, you'd have had to read and manually categorize 30,000 abstracts. Even at 2 minutes per abstract (bare minimum) that's, er, 1000 man-hours of work.
It might also be worth reflecting on the influence of teaching practice.
When I did my Psych degree, just over 20 years ago, Autism, Alzheimers and epilepsy were dealt with in the Neuropsychology module as was anything with a genetic basis and brain injury.
Mind you, my Neuro lecturer's primary research interest was Alzheimers, sadly for personal reasons (father), which made for an interesting if rather harrowing lecture.
Schizophrenia was, however, dealt with only in the Clinical Psychology module alongside depression and personality disorders.
Funny, I was just asking myself the same question and I couldn't have asked for a better answer.
I'm reading "Doctoring The Mind" by Richard Bental, I certainly recommend it for another perspective on this debate.
Great work, as always!
Neuroskeptic: I've *love* to speak with you more about this, if you're willing. There's a lot of cool things we could do with this.
I'm a really big fan of massive data aggregation (I made this site with my wife: http://www.brainscanr.com ) and I think that something like what you've done here (and related ideas) can be really useful and informative...
Also amusing:
http://blog.ketyov.com/2011/02/measuring-cupertino-effect-in-amygdale.html
:)
Email me, if you want to chat more.
Autism is 100 % neurological. I state this with a certainty based on 30 years reading up on the matter. It's due to a different wiring of the CC.
Autism like symptoms maybe psychiatric, and get grouped within autism clouding the issue.
for example:
http://www.ncbi.nlm.nih.gov/pubmed/21128874?dopt=Abstract
Bradley: Glad you liked it, that sounds interesting, I'll be in touch!
If you and Brad are talking, the one think I'd love to see would be a flexible time component for this type of search. I dug out Neuroskeptic's script for pubmed hits per year to see how these terms changed with time, but tweaking that script to be journal specific would have taken slightly more time than I was going to spend on this.
It would be very cool to track terms' migrations between neurology and psychology. For example, the term "medication" in psychiatry journals probably has had much more growth than in neurology and I suspect neurologists are trying to stake out larger areas like depression.
Yeah over time would be awesome & should be do-able. Making the script work by journal ought to be easy.
Actually...it already should work. Because PubMed takes plaintext queries all you need to do is input "nature"[Journal], or whatever, as a search term and it ought to work.
However off the top of my head this might screw up the parsing if it assumes that the search term doesn't include special characters. Even if it did, though, would be easy to fix.
I don't quite understand those findings because, in the UK at least, Alzheimer's disease is very much in the domain of the psychiatrist (but is also seen by the neurologist and geriatrician) - and that's despite our knowledge of the pathology.
Maybe the US puts dementia more in the realm of the neurologist and so that skews the global publishing literature?
Psychiatry does seem to have dug itself into some weird middle ground between neurology and psychology (and to some degree, sociology). I seem to think that it suits psychiatry to never actually find the cause of its disorders - while continually reporting that they are so close - just to secure the future of the speciality from the other disciplines.
There's a "back door" way of querying the pubmed database that I used for brainscanr. It's much faster and you can automate your queries if you want to run a batch.
So you did a "quick search" on two arbitrarily selected journals and expect to draw some sort of definitive or empirical conclusions from this "quick search"?
Seriously?
But, heck, makes for a great blog entry that gives us absolutely no new information or something we can hang our hats on.
As a neurologist, i've always thought that the fields originally divided along the mind /brain dualism of western thought. As psychiatric diseases became more pharmacologically oriented that changed to a somatic / behavioral split. For example, neurological care of Alzheimer's Disease often ends as agitation and other behavioral manifestations become more prominent than the neurological loss of function in the cognitive domain.
It's strange that Tourette Syndrome, a neurodevelopmental disorder, that has a similar prevalence to autism, has been omitted. It is almost certainly a neurological disorder (it includes movements, sensory integration issues, reduced inhibition and increased urine flow). However in many countries patients are referred to psychiatrists rather than neurologists despite the evidence for it not being a psychological condition and the fact that people are 'born with it'. It tends to be life long despite psychiatrists' assertions that it usually disappears by adulthood a fact not borne out by patients' own experiences.
I find the dualism behind this post a bit over-simplified. It's not a case of neurology OR psychiatry: they are just different levels of description. After all, psychiatrists will often prescribe drugs, which have their effects via neurotransmitters, and neurologists will use behavioural signs and symptoms for diagnosis.
deevybee: Oh I agree. There is overlap. That's why I did this, to try to find out where the overlap actually is, because while I think everyone has a kind of intuitive sense of what's "neurology" and what's "psychiatry" it's not clear how accurate this is (e.g. my intuition was that schizophrenia would be more neurology than ADHD, which was completely wrong.)
Does this take into account the total number of publications submitted and accepted by these journals?
In short, there are a number of issues with this story. In my research, and in the work of a number of other sociologists and historians, it has become clear that there were a number of groups: alienists, physicians with interests in nervous diseases, physicians with interests in mental diseases, psychoanalysists, physiologists, regular physicians, psychiatrists and neurologists. All of these fields were highly contingent upon local circumstances. British culture, for instance, was opposed to specialization, and therefore it is common to find people self-identifying as physicians whom we would now call neurologists or psychiatrists as late as 1950. Germany and France had similar idiosyncratic divisions, but in Germany there was a tradition of experimental psychology, which added a deeper physiological layer earlier to German psychiatry and neurology. The US had specialists earlier (mid-19th century), but as George Beard once put it, those specialists mainly wanted excuses to go society meetings, and so it was hard to know who the "electrologists, neurologists, alienists, and psychiatrists" were since they all tended to go to the same meetings (usually for the purposes of advertising). It was only in the 1920s and 1930s in the USA and Canada (and frankly in much of Europe) that the divisions between the fields began to take on real institutional meanings and meanings in terms of practice. The Rockefeller Foundation was instrumental in moving psychiatry towards a biological outlook, especially after 1930. That pattern may have perhaps begun in Russia earlier with Pavlov, and in Britain with Sherrington, Ferrier, and Jackson. But largely the so-called pioneers were outliers. Even the names of the journals - hybrids most of them - captured this strange institutional history. Its a long story. If you want to know more, read my paper on neurology at Johns Hopkins, linked on my blog under "our publications" (www.dictionaryofneurology.com)
Karen: No it doesn't, but I am not 100% sure that it ought to take that into account because it might be more appropriate to use the raw data as I have done; see bsci's comment (2nd in the thread) for more on that.
I have used your illustration in a blog post without requestion permission to do so in advance, but will remove it if you request that it not be used because you believe that this is not fair use of the illustration.
No problem at all, thanks for the link! In general anyone is free to reproduce my stuff and do anything with it so long as you credit it & link back to the original.
Psychiatry,is necessarily a dumping ground for unknown problems. If we learn a mood disturbance is caused by thyroid, then it's an endocrine disorder. The moment you know what the actual cause of a psychiatric sx is, it is no longer a psychiatric disorder, by definition.
Leaving aside Autism and ADHD and mental retardation that seem to tread both worlds, it seems clear that even when the underlying pathology seems to be related to the same system (say dopamine system implicated in both dopamine and schizophrenia) the disorders are more or less clearly marked as belonging to either brain (neurology) or mind (psychiatry) . This itself should hone opur intuitions that there indeed is a brain/mind dichotomy (different levels of explanation) and extreme reductionism serves no purpose or is even harmful.
I'm gradually graduating to viewing the mind/brain dichotomy as useful (too less space to go into it in detail here) and definitely this post encourages that line of thinking and was a worthwhile effort on your part to let the data speak.
Great post but I think you underestimated the frequency of psychiatric disorders found in epilepsy. 50% patients have depression an about 8% have psychoses in refractory temporal lobe epilepsy. Epilepsy & Behavior journal is uniquely devoted to the rapid dissemination of the most current information available on the behavioral aspects of seizures and epilepsy.
It might be interesting to plot alongside each disease name the date at which it was recognized as a disease. I wonder if things don't just "age" into the neurological category and out of the psychiatric one over time.
No, it's much simpler than that - anything that can be seen on MRI (and by tests such as evoked potentials/nerve conduction studies, blood tests - for example mitochondrial dysfunction) are considered 'neurological'. When either the correct tests haven't been done and/or the people examining the tests are too ignorant to 'see' the injury/disease then they claim there is no injury/disease therefore it's 'all in their minds'. It should be bourn in mind that no evidence of injury is not evidence of no injury.
We see this over and over again in medicine: at one time stomach ulcers were 'definitely caused by stress', some doctors are still under this misapprehension when they are actually caused by infection. Whiplash victims are told (if correct tests have not been done) that they are malingering and there is no way they could really be suffering cognitive impairments and mobility problems, veins and arteries are not investigated for dissection and few are given appropriate MRIs. This is due to pressure from powerful insurers. Soldiers and others are told they are suffering from PTSD when actually they have neurological illness/injury and if the correct tests were carried out this would be easy to verify. Just look at some of the ridiculous statements around PTSD such as it 'causes' brain injury! Same reason as above, governments do not wish to be liable for brain and neurological injury and once a person has been given a psychiatric diagnosis then all physical tests can be denied and prevented: the poor people are 'so mentally ill they are somatising' - how sinister is that?.
In days past people with epilepsy were considered 'mad' (psychiatric diagnosis) just as those with (until proper tests are done) purely 'psychiatric' labels now are told they only suffer from 'mental health problems'. ME/CFS was, until recently, still under NICE's (in the UK) psychiatric heading even though the WHO had for a long time listed them as neurological. Only Canada appears to be doing the correct tests on sufferers. You won't find what you don't look for. Again, insurers do not wish to pay for expensive neurological investigations and treatments.
Pharmaceutical companies pay for 'research' that 'proves' the efficacy of their products. Peer review is rarely independent - you only have to look at where they get their funding from. Science ceases to be science when there is no wish to seek the truth.
There should be more joined-up medicine and insurers should not have so much power, the separation of medical specialties causes problems. Even if people who suffer from these neurological problems cannot be 'cured' having the correct information and explanation is in itself very healing. Psychiatric drugs cause further brain and neurological (and other) injuries, they should not be used at all let alone on those with already compromised brains and neurological systems - visible (at this time in history) or not. In the future people will laugh at the crass and ridiculous labelling of physical injury and disease as 'purely psychiatric' just as we laugh about bloodletting and the use of arsenic and mercury as cures, these were very widespread in their time, doctors stated as fact that they cured and everyone dangerously believed them. Why do so few medics ever question what they are told and taught?
People do not imagine physical symptoms, people do not want to be ill. Doctors must learn to listen to patients and believe what they are told and if they look in the right places and in the correct ways they will find physical proof for the symptoms.
Neurology treats real brain diseases while Psychiatry has unproven, assumed brain diseases. There's no such thing as "mind disease" (or "mental illness") but there IS a "brain disease". A mind cannot be sick but a brain can be. Every sickness in the mind is actually a sickness in the brain so all the "mental illnesses/disorders" are actually assumed brain diseases. If they have ever been proven to be a REAL brain disease, I'm pretty sure the disease is then transferred to Neurology.
Philosophically speaking too, curing the "mind" is as senseless as curing a person's soul. The mind is an abstract concept of the brain.
Psychiatry is not scientific. It's a social field masquerading as a medical field.
This is why I'm not surprised that schizophrenia is ACTUALLY the least talked about disease in Neurology given so-called schizophrenia is actually the most advertised closest to being neurological as a psychiatric "disease".
I don't think that it is a matter of "brain" vs. "mind" anymore, but something more in terms of symptom-manifestations and complains. Neurologists will usually diagnose and treat more clear-cut neural symptoms e.g. weakness, motor dificulties, trouble speaking, loss of consciousness etc. these symptoms are usually found in more clear-cut neuro-pathologies e.g. stroke and neuro-degeneration. On the other hand psychiatry diagnoses and treats more "complicated" mental complains like false perceptions, greatly exaggerated emotional responses, disturbed personalities, loss of volition, derailed thinking etc. These type of symptoms and complains can also be found in various "organic" disorders like dementias, hormonal problems, delirium due to medical conditions, epilepsies and others, but it is STILL the psychiatrist's domain to treat them (sometimes in cooperation with the primary-care doctor e.g. the neurologist, endocrinologist etc.). Modern psychiatry is more about symptom manifestations regardless of aetiology (organic or "less organic") rather than the purely psychological stuff. There is a whole sub-specialty of psychiatrists called consult-liaison psychiatrists (or "psychosomatic medical specialists" in the US) who focus on psychiatric disorders in the context of clear-cut medical pathology as well as the other way-round (unexplained "somatic" symptoms). Truth also is that neurologists don't like to treat stuff like anxiety, obsessions and hallucinations and like their more specific sensory problems and motor difficulties. Modern neurologists tend to move away from anything "mental" whereas modern psychiatrists tend to move into purely "medical conditions" that manifest with "mental problems". Great article by the way
In fact Neurologists (with due respect) indulge in diagnosis hunting and handle most poor prognosis ailments where as Psychiatrists have better medications to manage the ills even in the absence of a etiological diagnosis.
Waiting for the day when there is just one field - Neuropsychiatry.
This is definitely a subject that's surrounding to me so Im golden that you wrote around it. I'm also cheerful that you did the matter few righteousness.
Ross Finesmith MD
Thank you very much for all your comments on this feed. I have a Ph.D. in clinical social work, and come from a very different perspective than the "mere organic perspectives, arguments and analyses" with regard to "neurology and psychiatry". As many of you know, in the history and research in clinical social work, the term "bio-psycho-social" perspective was coined to "look at all biological, psychological and social" dimensions for evaluation and intervention "need and efficacy". I do believe, or at least have observed, that clinical social and psychology probably does a better job of "dealing with so called 'mental disorders", "mood disorders", "mental health" or "emotional health". Psychiatry seems to be stuck between "neurology, psychology and clinical social work" with a desire to "have the priveleges of a medical profession". Am I correct...or am I being too hasty? Also, are there
any universities and departments where neurologists work closely with clinical social workers...beyond "family medical history gathering, discharge planning, patient and family support during diagnosis and treatment...and management of certain research programs"?
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