Time to end distinction between mental and neurological illnesses article- comments from discussion within the Academic Faculty
The article raises an interesting and timely debate. As we advance our knowledge of the mind and brain, the apparent distinction between them appears to lessen, which leads us to re-examine the commonalities between psychiatry and neurology, in scientific approach, disease classification and clinical practice. We all need to recognise the very significant contributions made to our understanding of mental disorders by neuroscientific research.
It is true that as scientific advances have been made in understanding the workings of the brain and its interaction with the environment we are in a much stronger position to understand the pathophysiology of mental and neurological illnesses and their response to treatments. Brain imaging, genetics and other techniques have helped enormously in unpacking some of the complex interactions between genes, phenotype, behaviour and environment. It is also true to say that as our scientific understanding advances, we have been able to invoke abnormalities in CNS systems traditionally the domain of neurology such as cerebellum and basal ganglia in a better understanding of mental symptoms.
However, it seems premature to remove a distinction between mental and neurological illness altogether. Certainly, we need to question whether its removal will improve clinical science and practice, and ask what the consequences are for patients.
The authors propose that distinguishing organic and functional is irrational. We can suppose that (if we had sufficient technical knowhow and resolution of techniques) we could in theory find a brain trace for all human thought, feeling , experience and behaviour; although we are a long way off that at present. We may recognise that brain activity correlates with all these, and activity in certain brain networks and their structural configuration may predispose people to behave in certain ways, modified by their environment, family and social context. However, in psychiatry at least at present, we are more certain about defining behaviour than about its cause. Why, for instance do people with similar physical disorders react so differently? Much more research is needed. And Psychiatry is very good at formulating and making sense of behaviour and mental illness which guides appropriate treatment. Psychiatrists are also expert at understanding how social antecedents and context interact with the person and their mental illness; and can integrate these levels of understanding to inform the best treatment. If, as the article points out, we want this ‘mind’ approach improving in the rest of medicine, psychiatrists rather than neurologists are the ones to do it.
The article states that beliefs, feelings and consequent behaviour are important in maintaining ill health and disability.Although weneed to recognise that we arestill a long way from identifying the physical basis for much of this, it is vital that we continue this endeavour. But the means by which we do so is best served by two specialties working closely in parallel, and with mutual respect for their respective contributions. We do, however, support the idea of more flexible and integrated training between psychiatry and neurology, and other medical specialties. A more rounded training across specialties may well produce better doctors.
Psychiatry deals daily with human nature with all its complexities, and is the only discipline in medicine to make understanding and managing these complexities its core activity. Here, we need Psychiatry to lead the way in disentangling human complexity. We question whether removing a distinction between mental and neurological illness will enhance this endeavour.
There are many causes of stigma, here the recognition and respect for psychiatry and the patients we look after, is enhanced by recognising the distinct contribution we make to medicine as well as the overlap with other specialties. We need to nurture a healthy mutual respect between specialties in the future generation of doctors. Hence we need a balance, where specialties work alongside each other.
The article rightly recognises the point that the ‘mind’ needs attention across the whole of medicine. To achieve this, we need well trained doctors in the mind and brain.
Peter Woodruff 29/05/12