Re: Time to end the distinction between mental and neurological illnesses
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.
28 June 2012
Edward H Reynolds
Consultant Neurologist
King's College University of London
Department of Clinical Neurosciences, Western Education Centre, Bessemer Road, London SE5 9RS
Rapid Response:
Re: Time to end the distinction between mental and neurological illnesses
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.