Time to end the distinction between mental and neurological illnesses
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e3454 (Published 24 May 2012) Cite this as: BMJ 2012;344:e3454
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Just by the way - an interesting development being generated by members of the British Psychology Society and others in the South West of England, is the setting up of 'Hubs in Pubs'. These are informal meetings where specialists speak on a topic which is then open to discussion. The meetings are not exclusive to members, are partly social, and open to everybody with an interest or a curiosity. In contrast psychiatry is still a more closed society. Some psychiatrists do campaign for a cultural change which emphasises issues such as a need for concentrating more on values and meanings, the importance of relationships and equal participation in setting research priorities etc but the funding still mainly supports old paradigms. A group of campaigners in psychiatry, Pat Bracken and colleagues published an important article in the Journal of Psychiatry 2012 with the above title, which calls for a genuine change to the culture of mental health. They need funding as much as the cold 'science' research. Projects such as the 'Hubs in Pubs' are at last reflecting that society is changing from doing to, to doing with...
Competing interests: No competing interests
BMJ 2012; 344:e3454
‘Time to end the distiction between mental and neurological illnesses’.
Dear Madam, Sir,
If White, Rickards and Zeman are “witnessing a revolution in the clinical science of the mind” I really must have been on a different planet while working as a Psychiatrist and Neurologist in Central London throughout the recent 12 years. Localizing the ‘disorders of the mind’ in the brain is neither a new idea nor a revolutionary one and will be as helpful as trying to change BBC programming by torturing your radio receiver with a screwdriver, despite our shared knowledge that there is no BBC programme whatsoever as long as your radio does not work.
The simple message to the authors is, that disentangling the constantly changing and complex architecture of how pattern of biological circuits and those of social relations might be interconnected – or disconnected is a bit more complicated compared to what they want make us believe..
Mental stability is not ‘a function of the brain’ but a functioning social construct - as is a good marriage, a decent education or respectable science. All very much real and no ‘myth’ - but not as a substance or an observable object in our brains but as a relational order (wherein our brain plays a crucial role).
Our different levels of consciousness are not just transmitter changes nor simple representations of the outside world, but are the product of a creative tension between stabilized categorical pattern of the subject (growing in its complexity) and its social field or its (later deconstructed) elements. What is even more crucial: the short lived entities subject and environment are dealing with are not empirical sense data but symbols throughout. In mental crisis this symbolic matrix breaks down, our pattern-based construct of reality gets lost and our symbolic language is severely affected.
This is why one would expect ‘symbolic formation’ to play a major role in a scientific approach to psychiatric diagnosis and therapy. But, as we can draw from the White, Rickards & Zeman manifesto the breakdown of ‘symbolic formation’ in our patients continues to be ignored. Its detectable transcultural codes of experience, its invariant building-stones of mental functioning (and drawn from there: a new concept of psychopathology) remain unused.
In neighbouring disciplines as biology, anthropology, mathematics, psychology or philosophy no one doubts that human nature, our language, mathematics and our progressing tools of work-specification are based on and experienced as symbolic constructs. Here, the quote of philosopher Ernst Cassirer, that man is not the ‘animal rationale’ but the ‘animal symbolicum’ has found its true confirmation. Yet in Psychiatry the symbolic message has not hit home.
It is about a century ago that Cassirer researched symbol theories in Germany just as Neurologist Henry Head did in England. Both extended J. van Uexkuell’s universally accepted idea of a receptor and effector system which keeps animals adapted to a certain part of their environment, by adding an entirely new quality which they call the 'symbolic system'.
While in animal physiology sense-perception is divided into more versus less variable components, differentiating basic type-specific patterns from those which are random or related to just a sole situation, the symbolic approach allows for an entirely new quality. Its unique capacity is not a biologically given but has to be drawn up in constant interaction like a mental membrane - separating, selective, connective and protective at the same time. Thus the multitude of human activities culminates in a limited number of ‘symbolic forms’ such as magic, myth, religion, law, science, the arts and a few others, while their underlying patterns can be used again and again in endlessly changing settings – and are lost or altered in mental illness.
Head had published his symbolic findings in 1921 and a two volumes book in 1926 while Cassirer’s remarkable study on the ‘Psychopathology of symbolic Consciousness’ was issued in 1929. It took its strength from intense clinical and theoretical discussions with neurologist Kurt Goldstein, psychologist Kurt Lewin and psychiatrist Ludwig Binswanger. Due to the application of a new symbolic methodology certain settings and clinical symptoms which were seemingly contradictory beforehand now emerge as being compatible within a newly created more abstract geometry of interrelations.
Translated into clinical terms, this approach leads to a much wider understanding of the multilayered architecture of mental health (which German Psychiatrist Blankenburg termed: natuerliche Selbstverstaendlichkeit). It allows for a sustainable point of reference in defining ‘mental illness’ and it might help us understand yet unexplained symptom changes during the course of treatment.
In a clinical setting such ‘symbolic’ procedure demands to let go of the familiar concreteness of ICD/DSM symptomatologies – obviously a step too far for authors White, Rickards and Zeman who defy any idea of having their trained medical approach, or their patient’s behavior as such be deconstructed into what looks like sequences of abstract pattern. Their blunt denial of the very specific symbolic make up of our human species - only to add a lifeless brain psychiatry to the medical sciences, to recruit more doctors into this furtheron ‘neurological’ business or to save our lazy brains from doing a bit more abstract and complex differentiation between ‘neurological’ and ‘mental’ - is not good advice and will turn our discipline from the relegation candidate of the scientific community into its laughing stock.
There is a much more promising (yet more difficult) route still open: in collecting and coordinating findings on semiotic and symbolic research – in contributing to a ‘science of meaning’ (salience) beyond the mere biological function of our animal brains and to integrate this important human source of knowledge into the regular discourse of our discipline.
Approached from this ‘symbolic’ angle, mental health could be defined as the human ability to stabilize early pattern of personal experience, to successfully create, change and integrate‚ Symbolic Forms‘ of social interaction, while establishing an equilibrium between the demands and intentions of selfregulation and environment, adding its newly found results to human tradition.
Mental illness subsequently would no longer be misidentified as a mere disfunction of the brain but regarded as the inability to (stabilize and/or) integrate own pattern of behaviour into a social framework, leading to a breakdown of (different & multiple) layers of ‘symbolic formation’, while the balance between cultural interaction and the emergence of inner preformed pattern is continuously (or constantly) changed towards the latter.
I do agree with White, Richards and Zeman that with a view to the upcoming ICD/DSM revision it is high time for a radical rethinking – but in quite a different way from what they have suggested.
Norbert Andersch
MD, MRCPsych
Consultant Psychiatrist/Neurologist
Praelo/Prela (Imperia)
Italy
norbert.andersch@yahoo.de
www.Neurosemiotics.com
competing interests: none
Competing interests: No competing interests
We are pleased that our suggestion - that mental and neurological conditions should be classified together in one chapter of conditions of the nervous system - has stimulated debate. We made this suggestion for two reasons, one of which has largely been ignored by correspondents. We argue that psychiatric conditions should be classified together with neurological ones, because they are both essentially disorders of the nervous system. But we also argue that psychological and social considerations are vitally important throughout medicine: we are relocating the mind in the brain at the same time as reasserting the importance of the mind in every clinical encounter.
Several correspondents confused classification with either aetiology or treatment approaches (biological versus psychosocial). The classification of a condition is primarily determined by the organ or system affected, not aetiology. So, glomerulonephritis is classified in the chapter for diseases of the genitourinary system, even though the aetiology may be immune. Psychotherapies are useful treatments of many conditions that are not regarded as mental illnesses.1 Balint showed that understanding the psychodynamics of the doctor-patient relationship is useful whatever illness the patient suffers from.2 The corollary is that biological treatments are effective for many mental illnesses, such as depressive illness and schizophrenia. Neither aetiology nor treatments determine classification.
Some correspondents argue that this proposal would paradoxically increase stigmatisation of those suffering from a mental illness. We agree that some studies suggest that considering mental illnesses as biological, rather than psychosocial in origin, leads to greater stigmatisation by the public. But this is not relevant to our proposal, which supports both biological and psychosocial aetiologies. Moreover, the studies cited do not consider the effect of stigmatisation on patients themselves and their families,3 healthcare professionals or commissioners of services.4 We argue that including “mental illnesses” in the same chapter as neurological conditions would reduce stigma and discrimination by professional groups in particular. We also think it will be an important step towards ending the world-wide scandal whereby the majority of people suffering from a mental illness receive no treatment, whether they are living in either the developed or developing world.5
Some strongly expressed arguments reflected the fear that the discipline of psychiatry was threatened by our proposal; specifically that neurologists might “take over” psychiatry. We suggest that neurologists have enough to do already! We were particularly disappointed by the response from the Royal College of Psychiatrists. This response came across arguably as being more concerned to protect the discipline of psychiatry than to improve the care of our patients. We believe that the reintegration of psychiatry into medicine, symbolised by the change in classification suggested, would benefit patients both within psychiatry and medicine more generally. The resultant change in professional attitudes, more frequent interchange of students and trainees between mental health and medicine, and the wider adoption of a biopsychosocial model of illness6, will enhance the quality of care provided by all healthcare professionals. Our proposal is not “premature” but long overdue.
PD White, Professor of psychological medicine, Barts and The London School of Medicine, Queen Mary University London, London, UK
H Rickards, Consultant neuropsychiatrist, Department of Neuropsychiatry, Birmingham University, UK
AZJ Zeman, Professor of cognitive and behavioural neurology, Peninsula College of Medicine and Dentistry, University of Exeter, UK
1. Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999;80:1-13.
2. Balint M. The doctor, his patient and the illness. Oxford, England: International Universities Press. 1957.
3. Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M. Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. Lancet 2009;373:408-15.
4. Sartorius N. Stigma and mental health. Lancet 2007;370:810-11.
5. Wang PS, Aguilar-Gaxiola S, Alonso J, Angermeyer MC, Borges G, Bromet EJ. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet 2007;370:841-50.
6. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, et al. No health without mental health. Lancet 2007;370:859-77.
Competing interests: Dr Rickards and Professor Zeman have no competing interests. Professor White has done voluntary and paid consultancy for the Department of Health for England, the Department for Work and Pensions (UK) and a re-insurance company.
28th June 2012
CLASSIFICATION OF MENTAL AND NEUROLOGICAL DISORDERS
Professor White and colleagues (1) are quite right to draw attention to the inconsistencies and double counting in current classifications of mental and neurological disorders, especially ICD-10, as others have done over many years (2). There never was a clear line of demarcation between diseases of the brain and mind, either when neurology and psychiatry diverged in the late 19th and early 20th centuries, and even less so as they have converged in recent decades (3). That is why some countries never abandoned the discipline of neuropsychiatry and this country revived it through the British Neuropsychiatry Association (BNPA) in the last 25 years.
However their proposal that classifications of psychiatric and neurological diseases should be merged as disorders of the nervous system, based on a simple but contested philosophical position, is I suggest both impractical and unrealistic in our present state of knowledge. For example, it is not enough to say that there are brain imaging findings in various psychiatric diseases, including conversion disorder. The relevance of such findings in many of these disorders is still far from clear and it is not established that they are the aetiological neural substrates for these disorders. The fact that emotional pathways are involved in conversion disorder does not turn a psychogenic disorder into a neurological disorder, especially as the hallmark of conversion disorder is that it is inconsistent with our understanding of neuroanatomy and neurophysiology (4). Nor is it enough to say that psychotropic drugs act on the brain when it should be added that the best results are usually obtained when medication is combined with psychotherapy. Another difficulty is that there are no clear lines of demarcation between several psychiatric disorders and current classifications of mental illness are infused with “comorbidity” or “spectrum” disorders (5). Furthermore, the authors do not discuss psychodynamic mechanisms which are an understandable requirement for many psychiatrists.
White et al do not offer any practical mechanisms to address the classification issues they have raised. Having worked closely with WHO on a Global Campaign against Epilepsy I have observed how some of the inconsistencies in ICD-10 have arisen (2). WHO maintains that it is concerned with public health aspects of diseases, not organs such as the brain or heart. However WHO makes an exception for the “mind” which has its own administrative department, with a small subsection concerned only with some neurological disorders such as epilepsy, dementia, Parkinson’s disease, multiple sclerosis and migraine. A much greater number of neurological disorders including stroke, neoplasm, trauma, perinatal and congenital diseases are distributed through various sections of “Non-communicable Diseases”. Thus the Division of Mental Health seriously under-estimates the burden of neurological diseases and classification issues are discussed by separate groups of psychiatrists and neurologists with very little cross-fertilisation. These classification issues will not be resolved until comparable groups of psychiatrists and neurologists meet together to agree both the principles and the details of psychiatric and neurological classification (4). The BNPA, which is a Society for psychiatrists and neurologists, is the obvious forum to initiate such a process in this country.
Edward H Reynolds, Honorary Senior Lecturer, Department of Clinical Neurosciences,
King’s College, London UK.
reynolds@buckles.u-net.com
Competing interests. I was a founding neurologist of the BNPA.
1. White PD, Rickards H, Zeman AZJ. Time to end the distinction between mental and neurological illnesses. BMJ 2012; 344: e3454 (16 June).
2. Reynolds EH. Brain and Mind: A challenge for WHO. Lancet 2003; 361: 1924-5.
3. Reynolds EH. Structure and function in neurology and psychiatry. BJPsychiat. 1990; 157: 481-90.
4. Reynolds EH. Hysteria, conversion and functional disorders. BJPsychiat. 2012, in press.
5. Goldberg D. Should our major classifications of mental disorders be revised? BJPsychiat. 2010; 196: 255-6.
Competing interests: I was a founding neurologist of the BNPA.
In an article published in the British Journal of Psychiatry June 2012) Jeremy Holmes Psychiatrist/therapist describes what may be 'Psychodynamic Psychiatry's green shoots' or a psychoanalytically informed psychiatry which could also be understood as a hybrid or amalgamation of several different but related therapies currently used for helping people with mental health problems.
The main difference from historical psychoanalytical practice seems to be the emphasis on investigating a person's brain using scans to monitor actual changes to specific sites such as the amygdala, throughout a course of therapy (Neuropsychoanalysis). The therapy to is to be carried out in a sensitive and empathatic manner by well trained therapists ('psychodynamic psychiatry provides a 'science of intimacy'). It is strangely rather chilling to imagine the thought of such a deliberately contrived relationship being set up in order to bring about changes to a person's brain and personality. Jeremy Holmes is all too right to claim that psychiatry needs the humanising influence of practices which acknowledge the meanings and values people put on their lives and its difficulties but the very title of 'Psychiatry' is so loaded with negativity and stigma, in a way that 'Psychology' is not as much, it would be good to find a new more relevant name for integrated psychiatry.
Competing interests: No competing interests
In 1967 the neurologist Henry Miller (1) provocatively stated that ‘psychiatry was neurology without physical signs’ . It was unclear then whether Miller was half a century behind, or ahead, of his time. In their call for diagnostic fusion between psychiatry and neurology, White et al (2) clearly think it was the latter. In their view, psychiatric illnesses are brain diseases and should be classified as such.
Their mistake is to prescribe treatment before adequate diagnosis. True, psychiatry is in trouble: poor recruitment, underfunding (21% of illness; 13% resources), uncertain identity, stigma, competition from psychology. True, trivially, that psychiatric disorders have brain correlates. Also, neurology has lost some of its allure; no longer the intellectual pinnacle, pre-neuroimaging, it once was. Neurologists are equally prone to complain about inadequate resources. But the suggestion for fusion is absurd. As Craddock et al (3) put it ‘psychiatry is the only specialty in which its practitioners are fully trained doctors, incorporating psychology and social-based knowledge and skills as major components of training. The absence of such skills in other medical specialties is a common cause of patient dissatisfaction’. Psychiatry needs to work collaboratively with all medical specialties, not just neurology; cutting-edge epigenetics shows how many of White et al’s ‘brain-diseases’ result from the environmental and developmental processes which psychodynamic psychiatry is beginning to unravel (4). What’s needed is new thinking, not nostalgia.
Let neurologists see their illnesses as psychiatric if they will -- vice versa, never. Only psychiatry can encompass the ‘social brain’ (5) that is, or should be, the future of a truly biopsychosocial medicine.
Jeremy Holmes j.a.holmes@btinternet.com
University of Exeter
UK
1 Miller, H. Depression. bmj 1967 1 257-62
2 White, P, Rickards, A., Zeman, A. bmj 2012 344: e3454
3 Craddock et al British Journal of Psychiatry 2008 193 6-9
4 Holmes, J. British Journal of Psychiatry 2012 200 439-441
5 Dunbar, R. Evolutionary Anthropology 1998 6 178-190
Competing interests: No competing interests
White, Rickards and Zeman are surely right to challenge the dichotomy between Psychiatric diagnosis and classification of other medical disorders although the link might usefully be made more widely than with neurological disorder. Whilst it is axiomatic that psychiatric disorder is mediated through the nervous system the aetiology is often outside the strict domain of neurology. Similarly, the psychological aspects of illness involve all specialities so that all doctors have to be prepared to consider known physical causes of psychiatric disorder and to be alert to psychological dysfunction as both causes and effects of a patient’s distress. The absence of robust neurological correlates to many psychiatric disorders is hardly a good reason to negate the authors’ thesis. In my own specialty irritable bowel syndrome confounded most attempts to elucidate its pathophysiology but it still formed an accepted part of ‘organic’ gastroenterology, albeit with consideration of social and other influences.
It is indeed the case that patients are more concerned with good care than with classification and Michael Albert has correctly identified the estrangement of Psychiatry from the rest of Medicine as a large part of the problem. Over the last 30 years Psychiatry has become professionally, geographically and managerially separate from the rest of Medicine in many parts of the country. Having a serious ‘physical’ illness in a hospital without physicians or surgeons is a real worry, as is serious psychiatric illness in a hospital without prompt access to psychiatric opinion.
It was not always like this. During my own training in Bristol, and later at ‘The London’, there were close professional links between the professorial departments of Medicine and Psychiatry, the two being a short walk from each other. As a Physician-in-training in both places I was grateful for the regular sessions in which the Professor of Psychiatry joined part of the Medical Unit ward rounds to discuss the possible psychological or psychiatric aspects of every patient’s illness. We reciprocated this much-valued service by attending promptly to any medical concerns on the psychiatric ward. I guess this might be less common nowadays; perhaps it’s called progress but I doubt that many current arrangements are anywhere near as good for patients.
Competing interests: No competing interests
White and colleagues1 lament the dichotomy between mental and neurological illnesses and blame the classificatory systems for this. However, it is possible that the psychiatrists might have estranged themselves from the rest of medicine.
The mental health services have broken away completely from the mainstream medicine. Their training, funding, organisation of services and provision of services are all separate and different from the rest of healthcare in the UK.
The UK is one of the very few countries in the world where one can become a fully qualified psychiatrist without having any postgraduate experience in neurology or any other medical specialties. In many countries, trainees learn psychiatry and neurology together in their initial years and choose their specialty towards the end of their training. Moreover, in many countries many disorders such are epilepsy are managed by psychiatrists and not neurologists.
Medical students’ career preferences are often influenced by their placement experience. I asked 40 medical students to rank their career choices before and after their 4th year, the year in which they had their psychiatry placement. Compared to all other specialties psychiatry had the greatest drop in preference ranking following placement in the specialty. Perhaps there is some scope for psychiatry to present a more welcoming and positive perspective.
Psychiatrists are the only health care professionals who, despite having no evidence base, claim to be able to predict, modify and control people’s future behaviour and accept blame when their predictions go wrong and/or their preventive measures don’t work e.g. when their patients commit self harm, suicide or homicide. No other medical professional including neurologists would accept blame if one of their patients who is massively obese, hypertensive and diabetic, who smokes and drinks heavily and does not follow medical advice and who had a number of cerebrovascular incidents dies months from a stroke after a consultation with them.
Doctors occasionally treat patients who are too unwell to know that they are unwell. However, in order to start treating such a patient, even if the psychiatrist has known the patient for years, the psychiatrist has to convince a social worker, and in order to continue treatment, the psychiatrist has to convince a legal professional and a lay person, none of whom are medically qualified, and get their blessings.
Thus, many of the practises of psychiatrists are alien to the rest of the medical profession. The best step towards integrating psychiatry and the rest of medicine would be for psychiatrists to start training and behaving like the rest of their medical colleagues. Changing classificatory systems and policies won’t achieve this.
1 White PD, Rikards H, Zeman AZJ. Time to end distinction between mental and neurological illnesses. BMJ 2012; 344:3454.
Competing interests: No competing interests
White and colleagues, in their call to end the distinction between mental and neurological illness (1), trot out the old (but intuitive) canard that such reclassification will reduce discrimination against people with mental disorder. In fact, sociological studies show the exact opposite is true. Subscription to biological/genetic causal attributions of the aetiology of mental disorder (rather than psychosocial explanations) is associated with greater belief that the mentally disordered are dangerous, unpredictable and antisocial (2); people who think that mental illness is ‘an illness like any other’ desire greater social distance from the mentally disordered (3), even being less prepared to enter into romantic relationships with them (4). Such attitudes hold true in a variety of cultures (5).
Whilst the mechanism is contentious (probably involving the perception that the physically ill cannot be cured or control their symptoms) (6), we should be mindful of the harmful effects upon mentally disordered patients of labelling them as having neurological disease.
(1) White PD, Rickards H, Zeman AZJ. Time to end the distinction between mental and neurological illnesses. BMJ 2012;344:e3454
(2) Read J, Haslam N, Sayse L, Davies E. Prejudice and schizophrenia: a review of the ‘mental illness is an illness like any other’ approach. Acta Psychiatrica Scandinavica 2006, 114: 303-318.
(3) Eker D. Effect of type cause on attitudes toward mental illness and relationships between attitudes. International Journal of Social Psychiatry 1985, 31:243-251.
(4) Read J, Harre N. The role of biological and genetic causal beliefs in the stigmatisation of 'mental patients'. Journal of Mental Health 2001, 10: 223-235.
(5) Dietrich S, Beck M, Bujantugs B, Kenzine D, Matschinger H, Angermeyer M. The relationship between public causal beliefs and social distance toward mentally ill people. Australian and New Zealand Journal of Psychiatry 2004, 38: 348–354.
Competing interests: No competing interests
Re: Time to end the distinction between mental and neurological illnesses
Wading through some of the responses, I find myself cherry picking good and bad points in almost every reply. This rather indicates that the whole exercise is largely philosophical, and could be left to continue and so keep psychologists and psychiatrists arguing among themselves and off our backs.
The real problem is not the existence of definitions and interactions, but, the arbitrary power given to psychiatrists, and the imposition of their, largely useless, treatments and drugs, on people who have been traduced by definitions of opinion, instead of properly investigated to get at the cause of their illness. While 'diagnosis' by opinion of who shouts the loudest, is allowed, patients will continue to suffer, and be tortured by the medical establishment, for the sin of having a disease with no current accepted biomarker or cure.
Competing interests: Having been condemned to a lifetime of largely uninvestigated 'ME', and torture by psychobabble and denial of diagnostic service. I have a vested interest in opposing the arbitrary power and the opinions of psychiatrists.