Monday, 22 September 2014

Mindless Neurology and Brainless Psychiatry

How much do your MS symptoms overlap between the realms of neurology and psychiatry? Is there really a difference between the two?

The pioneers of neuroscience moved freely between neurology, neuropathology, psychiatry and psychology. Charcot who first described MS as 'sclerose en plaques' was first and foremost interested in  hysteria; classically a psychiatric symptom.



The two 'brain sciences' began to separate in the middle of the 20th century and there are controversial theories as to why this happened.

Some believe it was the result of the neurologists' obsession with localising areas of the brain with a specific function; i.e. parts of the cerebral cortex with sensation and movement. Psychiatric disorders which were inherently 'more complicated' could not be so easily localised and were exiled from neurology textbooks as a result.

Psychiatrists were also keen to divorce themselves from neurologists; most notable Sigmund Freud - the 'father of psychoanalysis' who interpreted mental disorders in primarily psychological terms.



Another theory attributes the separation as part of an 'anti-psychiatry movement'; a group of individuals led by RD Laing who were keen to convince the field that mental disorders were largely of environmental cause rather than disorders of the brain.



There are many strong arguments to convince that neurology and psychiatry are part and parcel and I will try to convince you of this using MS as the case study where possible.

Neurological disorder can present with psychological symptoms

There are many examples of MSers presenting with psychological symptoms such as low mood, depression and bipolar disorder which in my last post I tried to convince you may be part of the same disease process rather than a simple cause and effect model.

Psychological disorder can present with neurological symptoms

This one is slightly more difficult to relate to MS but is largely the domain of 'functional neurology'; where a patient will present with a symptom e.g. difficulty walking that does not appear to correlate with a structural disturbance

Neurological Disease can cause a psychological reaction

Examples of reactive depression and anxiety following a diagnosis of MS are well described in the literature

Psychological disorder can cause a neurological reaction

Again difficult to relate to MS but another example being depression as a risk factor for new onset epilepsy.

In reality, there is an increasing acceptance of neurological dimensions to psychiatric illness.  For example, functional imaging and MRI has shown that patients with schizophrenia show evidence of brain atrophy and ventricular enlargement.

We must also remember that many drugs cross this divide - for example antidepressants are often used for migraine and anti-epileptics can be used to stabilise mood.

Professor Zeman of Exeter University attempts to find ways that the two 'brain sciences' can be re-united in his article 'Neurology is psychiatry - and vice versa.' He suggests that neurology trainees should spend time in psychiatric institutions and similarly that training psychiatrists should have some experience in a neurology service. He also argues that joint-clinics could help, where specialists from both fields could lend assistance.

Do you feel like your neuro is well equipped to deal with the psychological components of your condition?

Do you feel you could benefit from a multi-disciplinary clinic setting - i.e. where you could see various specialists in one go? Perhaps this could be extended to a more wider approach where a clinic appointment would involve assessments from a neurologist, psychiatrist, MS nurse, physiotherapist, dietician etc all in one go. 


Neurology is Psychiatry - Adam Zeman
http://pn.bmj.com/content/14/3/136.full.pdf+html?sid=f1029229-2e6a-4d1f-8679-5616628e9c2e  



18 comments:

  1. Dear Arie, how about spending some time in the clinics? :-) Neurology is not psychiatry in the same way that orthopedic surgery is not rheumatology and it is not rehabilitation medicine ( although all of them can be treating similar or sometimes even the same condition).
    PS Please use your time wisely, thanks.

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  2. What happened to your feel good posts Arie?

    To answer your questions no I don't think neuro's are well equipped to deal with the psychological side of things. Even if they were I doubt a 20 minute consultation once a year would quite cut it.

    Yes I think a more multi disciplinary approach would be useful but not all in one go. Access to counselling may be of benefit. I was diagnosed out of the blue following a severe attack and sent on my merry way. It was quite simply the most devastating and darkest period of my life. I ended up making my own referral to an MS nurse and paid privately to see a psychologist.

    I think the psychological aspect of living with the disease is gravely underestimated.

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    1. Thanks for your response which was really helpful. I agree - these things need to be done sensitively and without a time pressure.

      I wonder whether peer-to-peer counselling would help where newly diagnosed MSers could be put in touch with someone who has gone through the same thing and is therefore in the best position to understand.

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    2. p.s. More Role Models to come... However I got a mixed reception for this!!

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  3. " Re.Do you feel like your neuro is well equipped to deal with the psychological components of your condition?"
    Not really that is why the role of the neuropsychiatrist is so important. A general psychiatrist with an interest in neurology i'm not sure is enough. A neurologist with an interest in psychiatry could be ok, I expect there are not many of these.
    There is only one NHS neuropsychiatrist in my county he is in great demand with a 12 month waiting list. There is a general psychiatrist with an interest in neurology but he's only private for neuro-psychiatry appointments. If I did see a neuropsychiatrist I would like to be able to ask questions about neurology and psychiatry connected to MS and not just me being assessed psychiatrically.

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    1. I agree... This field should be expanded.

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    2. The MS specialist neuropsychiatrist or MS neuropsychiatrist.

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  4. Very good post
    The neurologist is not equipped to deal with psychiatrist issues and the psychiatrist doesn't seem to know much about MS
    The multi-disciplinary you mention should have a clinical psychologist too

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  5. Ah Arie, this is an area I've been interested in for years. More specifically psychoneuroimmunology. PIN for short. Wiki is as good as any place for someone to look this up: http://en.m.wikipedia.org/wiki/Psychoneuroimmunology

    Also psycho-neuro-endocrinology (perhaps more fitting as it is the endocrine system that 'governs' the immune system.

    In particular I'm interested in the role of stress. Every single relapse I've had has been triggered by stress. A particular type of emotional stress such a death of a loved one or relationship breakup (though not always with this :)). Work stress has no affect (and I have quite a bit of that), flu and raised body temperature has no affect. But I can almost guarantee with two weeks of an uncontrollable stressful event I will have relapse. Been like this for 25 years. And while it is impossible to stop this type of stress, I can reframe my response to the stress - yoga, meditation, mindfulness all help. I still have extremely mild RRMS (no disability, no cognitive problems so far). I won't go into my pet theories (I'm a social scientist, though this involved studying psychology, I'm not a medical one) but I do think there is a big connection. The days of Cartesian dualism in medicine should be long over, and PIN is getting more established as a discipline. Apologies for typos, writing this on my Google Nexus7 tablet so tricky to check spelling.

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    1. Have just read up on Wikipedia - I agree - this is a very interesting field and worth looking in to specifcally with regards to MS.

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    2. Anon 8.34pm and Arie I agree with you both and think that Psychoneuroimmunology will be very interesting and in my opinon an extremely important field with regards to MS.

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    3. Stress can surppress the immune system.
      -Shrink the thymus gland (Selye)
      A study of students and examination stress (Kiecolt-Glaser)
      - Suppress T cell function.
      - Suppress natural killer cell function.
      - Reactivate latent viruses (herpes virus; EPV).

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  6. Steroids come with side effects, some could be classed as psychiatric. Including irritability, feeling low, behavioural changes and euphoria. Nervousness, changes in emotions, restlessness, anxiousness, sleep problems. Sleep problems can bring there own difficulties. Essential medications may also exacerbate the MSers anxiety.
    When I had oral steroids I had some side effects and didn't read the bottle.

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  7. Interesting post. It that case; does it follow that psychological therapies can affect neurology? Will undertaking, say mindfulness or a course of CBT, have the potential to change brain structures? Certainly it seems that stress plays a part in relapses. Personally I'd like to less pathologising of MSers psychological state - depression and anxiety are wholly normal reactions to living with a progressive, degenerative and all round rubbish illness. Are the rates of depression in ms really that much higher than in a comparable illness that doesn't have neurological involvement (if such a thing exists, severe rheumatoid arthritis perhaps).Perhaps get more psychologists and counsellors into ms clinics instead of the psychiatrists?
    I ought to declare my own CoI perhaps, I'm a psychologist as well as an ms patient

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    1. I agree; it may just be something to do with living with a chronic condition. However one of my recent posts described a study using the Swedish National Database which suggested that depression and bipolar disorder may precede the onset of MS so there is obviously controversy in this field.

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    2. It's unlikely there would be no one with MS that would not also have bipolar,I suspect some people with MS would have bipolar regardless of the MS. Regarding Sweden, I remember reading a long time ago that as a population, depression and bipolar are relatively high in Sweden compared to some other countries. So it doesn't suggest to me that people with MS are necessarily are at a higher risk in general. Yes, you are more likely to be depressed with MS, because it is such a horrible disease. I suspect it is similar for someone with ALS or Parkinson's. Maybe for some people with MS it is part of the disease process but far from everyone. I feel neurologists need ensure this isn't conflated.

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  8. RD Laing was not only hugely controversial but he also caused a massive amount of pain for the parents of schizophrenics by suggesting it was their parenting that was in some way responsible for their children's condition.
    Fortunately science has corrected this erroneous hypothesis, though more recently I've seen Oliver James resurrecting it in some of his articles.

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  9. I suppose I would find it comforting to be comprehensibly evaluated. Though I get the impression that the state of science hasn't got that far and I understand resources are tight.

    If I was comprehensibly evaluated it would be good to be under the care of specialists that could help with any problems discovered.I suppose holistic care as ProfG.'s tube map and not having to wait for therapy until I have been vociferous enough.

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