BACKGROUND
Those of us on this side of the debate, who criticize psychiatry for medicalizing and drugging virtually every problem of human existence, sometimes ask the question: If all these problems are truly illnesses of the brain, then why are they not being treated by neurologists?
The standard psychiatric response to this question has been: neurology deals with nervous system illnesses that result in problems of movement, sensation, physical pain, etc.; psychiatry deals with nervous system problems that result in disordered thinking, feeling, and general behavior. Psychiatry has never produced the proof that these latter problems are caused by illnesses of the brain/nervous system, but that’s a separate issue.
PROPOSED UNIFICATION OF PSYCHIATRY AND NEUROLOGY
Earlier this month, Henry Nasrallah, M.D., editor-in-chief of Current Psychiatry, wrote an editorial titled: Let’s tear down the silos and reunify psychiatry and neurology! Thanks to yobluemama2 on Twitter for flagging Dr. Nasrallah’s article. (Incidentally, “tear down the silos” is a modern metaphor for: remove the barriers to communication.)
Dr. Nasrallah’s main theme is that in the past, neurology and psychiatry were one specialty. He states that:
“Disorders of the ‘mind,’ such as emotions, thought, or behavior, were rightfully regarded as manifestations of cerebral pathology, and research was based on that model.”
He tells us that psychiatry and neurology drifted apart for two reasons:
“1) Freudian theory and psychoanalysis and 2) the inability to localize the brain ‘lesion’ associated with psychiatric disorders.”
So psychiatry and neurology drifted apart because many psychiatrists abandoned a strictly neurological formulation of human troubles, and embraced Freud’s psychoanalytic model. Others, perhaps, became disenchanted with neurology’s failure to identify any neuropathology underlying problems of thinking, feeling, and general behavior.
Dr. Nasrallah attributes the failure to find these neural pathologies to the fact that the sophisticated brain assessment tools of today were not available in the old days.
“The ‘mind’ was therefore divorced, so to speak, from its physical foundation, the brain, and mental illness was erroneously re-conceptualized as ‘psychological,’ not neurological!”
Much has been lost, Dr. Nasrallah tells us, by “…the rupture of diseases of the human brain from diseases of the mind, which includes the most advanced functions of that brain.”
But, he assures us, psychiatry and neurology are reconciling and reintegrating, and this movement is being driven by:
- “The neuropharmacological revolution”
- “The explosive growth of neuroscience”
- “The computerization revolution”
- “…advances in molecular and cellular neurobiology”
- “The molecular genetics revolution”
- “The recognition, over the past 2 decades, that anomalies of neurochemistry and neuroplasticity are the underpinnings of psychiatric illness.”
Dr. Nasrallah assures his readers that:
“…the majorities on both sides of the chasm understand the merits of abandoning the fallacious dualism of brain and mind and of merging the two disciplines into the neuropsychiatric specialty that our revered founders upheld and practiced.”
and that:
“The unification of diseases of the brain and diseases of the mind will lead to a higher quality of care and will diminish the stigma of mental illness.”
The time has come, he tells us:
“…to tear down the silos of neurology and psychiatry and reunify the disciplines, as they were 100 years ago.”
ANALYSIS
Psychiatry is increasingly under attack on the grounds that its concepts are spurious, and its practices are destructive, stigmatizing, and disempowering.
Dr. Nasrallah and several other psychiatric “thought leaders” are hard at work spinning these criticisms, but not adducing any evidence to support the validity of their assumptions or the benefits of their practices. Psychiatry is a cult – a system of strongly-held beliefs coupled with pressure on insiders to conform, and hostility towards outsiders.
Merging psychiatry and neurology would, of course, bestow a measure of perceived credibility on psychiatry – but would not alter the fact that the medicalization of virtually every human problem is conceptually unwarranted, and destructive in practice. But it would, nevertheless, be a great PR victory for psychiatry, in their quest for legitimacy and respectability. So we can probably expect to see this theme re-echoed in the coming months.
Dr. Nasrallah cites eight references in support of his proposal to merge psychiatry and neurology. I checked these articles, and found that there were a total of 23 authors. Their specialties break down as follows:
Psychiatrists 13; Neurologists 5; Psychiatrist and neurologist(double specialty) 1; Other (MBA, MPA) 2; Unclear (probably psychiatrists) 2 Total 23
It is difficult to draw firm conclusions from a simple count of this sort, but it does suggest that there is more enthusiasm for the merger within psychiatry than there is within neurology. This is not surprising. Neurology is a legitimate and respected medical specialty. Psychiatry is a cult, masquerading as a medical specialty.
With regards to the actual content of Dr. Nasrallah’s editorial, there’s nothing new. It’s the same old unproven, illogical assertions. There are a couple of items, however, that deserve comment.
Firstly:
“Because neuropsychiatric disorders are the leading cause of burden of disease worldwide, early recognition and intervention, as well as prevention, are top public health priorities.”
Note the word “neuropsychiatric.” What Dr. Nasrallah is trying to do here is create the impression that the merger has already happened. It’s standard psychiatric spin. If you repeat a falsehood often enough, people start to believe it. It’s the same tactic that they used with the so-called chemical imbalances.
Secondly:
“Breakthrough advances in molecular and cellular neurobiology, which are linking behavior, thought, affect, and cognition with specific signaling pathways. This has led to the scientific epiphany that psychiatric brain disorders cannot be localized (as neurologic brain disorders are) because they are caused by disrupted neural circuits and connectivity and are not localized in cortical or subcortical regions.”
This is really slick. For decades they sang the song of chemical imbalances and localized pathology as the underlying causes of problems in thinking, feeling, and behavior. Now it’s becoming clear that that particular Holy Grail is never going to be found, so psychiatry has shifted its Quest (with a capital Q) to “disrupted neural circuits,” which conveniently cannot be localized. This is a bit like a computer repair person telling you that your computer doesn’t work because of a circuitry problem. Wow!
THE CULT OF PSYCHIATRY
I expressed the belief earlier that psychiatry is a cult. Dr. Nasrallah calls for the “…merging of the two disciplines into the neuropsychiatric specialty that our revered founders upheld and practiced.” Doesn’t that feel a bit cultish? He doesn’t specify who these revered founders are, but earlier in the piece he mentions Kraepelin, Alzheimer, Freud, and Meyer, and it seems that these are the revered founders – because (and I kid you not) they were all neuropsychiatrists!
I don’t know much about Alois Alzheimer. Perhaps he would be an appropriate patriarch figure for Dr. Nasrallah’s merger, but Emil Kraepelin, Sigmund Freud, and Adolf Meyer seem to me unlikely candidates.
Dr. Kraepelin did indeed promote the notion that problems in thinking, feeling, and behavior were caused by brain malfunctions. But he was also a strong proponent of eugenics and “racial hygiene,” and expressed the belief that Jewish people have a strong disposition towards mental disorders. (Textbook of Psychiatry, 1909) Or perhaps Dr. Nasrallah isn’t really fussy in the bestowal of reverence.
Dr. Freud, whatever his original training, is remembered as the inventor of the “talking cure,” and avidly promoted the notion that the best way to help troubled people is to listen to them. This doesn’t sound like a founder of bio-psychiatry. Of course, Freud was also dogmatic and dictatorial, and routinely considered his own strongly held opinions adequate proof for his various theories. So maybe he would be a good candidate!
Adolf Meyer, according to Wikipedia,
“… is most remembered for reframing mental disease as biopsychosocial ‘reaction types’ rather than as biologically-specificable natural disease entities. In 1906 he reframed dementia praecox [i.e. schizophrenia] as a ‘reaction type,’ a discordant bundle of maladaptive habits that arose as a response to biopsychosocial stressors.” (emphasis added)
Hardly a founder (revered or otherwise) of reductionist bio-psychaitry.
Dr. Nasrallah exhorts his psychiatric colleagues to merge with neurologists, “…and reunify the disciplines, as they were 100 years ago.” This sounds like the beginning of a psychiatric golden age myth.
And the future, he assures us, will be just wonderful…
“Patients will benefit, because every psychiatric patient deserves a full neurological assessment and treatment and every neurologic patient deserves a full psychiatric assessment and treatment.”
So if you consult a neurologist for peripheral neuropathy, say, you will get a full psychiatric evaluation and psychiatric treatment!
BY THE WAY
According to Dollars for Docs, Dr. Nasrallah received $897,079 from various pharmaceutical companies between 2009 and 2012. In fact, Dollars for Docs lists Dr. Nasrallah as the seventh highest earner in their list of Top Earners, doctors who received money for speaking and consulting for pharmaceutical companies. And as we all know, pharmaceutical companies don’t give money away for nothing.