Neurology is psychiatryand vice

versa
Adam Zeman
Correspondence to
Professor Adam Zeman,
Cognitive Neurology Research
Group, University of Exeter
Medical School, St Lukes
Campus, Magdalen Road, Exeter
EX1 2LU, UK;
A.Zeman@exeter.ac.uk
Published Online First
3 February 2014
To cite: Zeman A. Pract
Neurol 2014;14:136144.
ABSTRACT
This paper explores the relationship between
neurology and psychiatry. It marshals evidence
that disorders of the brain typically have
neurological and psychologicalcognitive,
affective, behaviouralmanifestations, while
disorders of the psyche are based in the brain.
Given the inseparability of neurological and
psychiatric disorders, their disease classifications
should eventually fuse, and joint initiatives in
training, service and research should be strongly
encouraged.
ONCE THEY WERE UNITED
The idea that the brain is the source of
our experience and behaviour is very
ancient. In a famous passage, written
around two-and-a-half-thousand years
ago, Hippocrates (figure 1) stated his
uncompromising view:
Men ought to know that from the brain,
and from the brain only, arise our plea-
sures, joys, laughters and jests, as well as
our sorrows, pains, griefs and tears.
Through it we think, see, hear, and
distinguish the ugly from the beautiful,
the bad from the good, the pleasant
from the unpleasant sleeplessness,
inopportune mistakes, aimless anxieties,
absent-mindedness, and acts that are
contrary to habit. These things that we
suffer all come from the brain
Madness comes from its moistness.
1
There were opposing theories, includ-
ing Aristotles suggestion that the brains
main function was to cool the blood,
and, through the Middle Ages, aspects of
our mental lives were often linked to
organs other than the brain. The heart,
for example, racing with joy, slowing
with grief, can seem a natural home for
the emotions, so that in the 16th century
Shakespeare could ask:
Tell me where is fancy bred,
Or in the heart, or in the head?
2
But the attention of seekers after the
physical home of the mind refocused on
the brain soon afterwards. Less than a
hundred years later, after Harveys dem-
onstration that the heart was a pump at
the centre of the circulatory system,
Thomas Willis (figure 2), Oxford phys-
ician and founding member of the Royal
Society, author of De Cerebri Anatome,
confessed that he was addicted to the
opening of heads, thereby to unlock the
secret places of mens minds.
3
The exploration of those secret places
was waylaid by the false promise of phren-
ology in the 18th century, but got under-
way in earnest during the 19th, when, for
example, Broca and Wernicke, localised
language to the left hemisphere and
showed that separate areas control the
programming of fluent speech and lan-
guage comprehension. Broca (figure 3),
echoing Hippocrates and Willis, was to
write: The great regions of the mind cor-
respond to the great regions of the
brain.
4
The pioneers of clinical neuroscience in
the 19th century, like Broca and
Wernicke, moved freely between the
subject areas that are now delimited by
neurology, neuropathology, psychiatry
and psychology: their intimate intercon-
nection was taken for granted. Charcot
(figure 4) described sclerose en plaques
(multiple sclerosis) but was fascinated by
hysteria. Alois Alzheimer (figure 5) was a
psychiatrist and neuropathologist. Before
describing the disease that bears his name,
he wrote his dissertation on general
paralysis of the insane, caused, of course,
by syphilis. Constantin von Economo
(figure 6), who documented the clinical
and neuropathological features of enceph-
alitis lethargica, held a chair of Psychiatry
and Neurology in Viennas Clinic for
Psychiatry and Nervous Diseases. Camillo
Golgi (figure 7) was encouraged to pursue
his fundamental research on the physical
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136 Zeman A. Pract Neurol 2014;14:136144. doi:10.1136/practneurol-2013-000761
basis of mental disorders by a psychiatrist mentor,
Cesare Lombroso: his silver stain allowed Santiago
Ramn y Cajal (figure 8) to show that the brain was, like
other organs, built from individual cells, our neurones.
BUT THEN THEY CAME APART
By the middle of the last century, when the senior
readers of this journal were entering neurology,
matters had greatly changed. In the UK and the USA,
and to some degree throughout the world, neurology
and psychiatry had split apart from one another
Figure 3 Pierre Broca (Courtesy of US National Library of
Medicine).
Figure 4 Jean-Martin Charcot.
Figure 1 Hippocrates.
Figure 2 Thomas Willis (Portrait of Thomas Willis. History of
Medicine Collections. Historical Images in Medicine. David M
Rubenstein Rare Book & Manuscript Library, Duke University).
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Zeman A. Pract Neurol 2014;14:136144. doi:10.1136/practneurol-2013-000761 137
they were practised by different doctors, differently
trained, working in different buildings, usually in dif-
ferent parts of town. The era of mindless neurology
and brainless psychiatry was in full swing. How did
this happen?
Several influences conspired together, some origin-
ating within neurology, others within psychiatry. In
the wake of the remarkable discoveries of Broca,
Wernicke, Hughlings Jackson and others, neurologists
became cerebral cartographers, keen to localise
functions and lesions in the brain with maximum pre-
cision, preferably within a single Brodmann area
(figure 9). This led quite naturally to a focus on low
hanging fruitelementary aspects of sensation and
motor control lent themselves readily to this
approach; some discrete cognitive functions, like face
recognition for example, could also be neatly loca-
lised. But mood disorders, obsessive compulsive dis-
order, autism, schizophrenia were much less tractable
Figure 5 Alois Alzheimer.
Figure 6 Constantin von Economo.
Figure 7 Camillo Golgi (Wellcome Collection).
Figure 8 Santiago Ramn y Cajal (Reproduced with
permission from Cajal Neuro Research Foundation).
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138 Zeman A. Pract Neurol 2014;14:136144. doi:10.1136/practneurol-2013-000761
to localisationalists, and were exiled from neurology
partly for this reason.
Powerful forces within psychiatry had also been
pulling neurology and psychiatry apart. One of these
forces owed much to a man whose initial training,
interests and ambitions were neurologicalSigmund
Freud (figure 10). Educated in Vienna toward the
close of the 19th century, the young Freud was fasci-
nated by the relationship between mind and brain. He
investigated the local and systemic properties of
cocaine, dissected the nervous system of lamprey and
crayfish, studied aphasia and wrote an early manu-
script on the neurological basis of mind, his Project
for a Scientific Psychology. But after studying with
Charcot in Paris, and encountering the puzzling phe-
nomena of hysteria and hypnosis, his intellectual dir-
ection changed. While he never lost his interest in
neurology, he developed the hugely influential theory
of psychoanalysis which interpreted mental disorder
in primarily psychological terms, and sent 20th
century psychiatry on its own unique trajectory.
A third influence was fed by a recurring line of
thought about psychiatry, which crystallised in the
20th century in the antipsychiatry movement asso-
ciated with Laing
5
(figure 11) and Szasz.
6
This
movement rejected the medical model of mental dis-
orders, downplaying the role of the brain and the
body. Instead, antipsychiatry underlines the import-
ance of the social and economic environment in
engendering mental illness, and recognises the (real)
risk that psychiatry may be abused by oppressive
regimes, as it was in the last century in Russia, China
and elsewhere. The moving 1960s film One Flew
over the Cuckoos Nest, which depicts psychiatry as a
tool of control and oppression in the USA, captured
the spirit of antipsychiatry (figure 12). Whatever view
one takes of mental illness, antipsychiatry provides a
salutary reminder that conceptions of mental illness
cross the uncertain boundary between science and
society.
One other influence may have played a part.
Though attitudes to the relationship between mind
and body have varied from culture to culture and time
to time, the broad distinction may be a human uni-
versal. Surveys, including one conducted among
Edinburgh undergraduates 10 years ago
7
(figure 13),
reveal notably dualistic view of mind and brain
among scientists and laymen. If we are indeed all
Descartes babies
8
at the start of our lives, we have a
predisposition to oppose mind and body, or mind and
brain, despite their intimate inter-relationships. This
can lead to an unreasonably sharp distinction between
the specialists who care for their disorders.
NEUROLOGY IS PSYCHIATRY
There is a sense in which all illness is psycho-
somaticthe processes by which we detect, ponder
Figure 9 A colourised version of Brodmanns cytoarchitectonic
map (with acknowledgment to Professor Emeritus Mark Dubin,
University of Colorado-Boulder).
Figure 10 Sigmund Freud. Credit: PA.
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Zeman A. Pract Neurol 2014;14:136144. doi:10.1136/practneurol-2013-000761 139
and report the symptoms of illness are all thoroughly
psychological, and these have a major effect on the
experience and the outcome of disease. Neurology
has an especially close relationship with the psyche
because the brain is the central organ of neurological
and psychological processes. Indeed, whereas we tend
to be educated in medicine in the belief that neur-
ology and psychiatry are correctly allocated separate
chapters in our student textbooks, disorders of the
central nervous system typically have neurological and
psychologicalcognitive, affective, behavioural
manifestations.
9
Even brain regions that were once
regarded as safely neurological, like the basal ganglia
and cerebellum, are proving to be deeply involved in
psychological processes and psychiatric disorder.
10 11
Here are four types of relationship between neurology
and psychiatry/psychologyI will give some examples
of each:
Neurological disorder can present with psychological
symptoms.
Psychological disorder can present with neurological
symptoms.
Neurological disorder can cause a psychological reaction.
Psychological disorder can cause a neurological reaction.
Neurological disease can present with psychological
symptoms
In cognitive neurology, neurological disease presenting
with psychological symptoms, mostly cognitive and
behavioural ones, is the rule, not the exception, but
such symptoms crop up in every neurology clinic.
Cases I have encountered personally as a general neur-
ologist over the years have included a patient sec-
tioned because of his chaotically dangerous behaviour
caused, we later discovered, by his neuroacanthocyto-
sis
12
; a man delivered to hospital by the police with
intermittent fluent dysphasia and a background
thought disorder, whose left temporal arteriovenous
malformation was probably responsible for both
13
; a
woman unable to recognise close members of her
family by sight, whose prosopagnosia had been caused
by epilepsy arising from a venous angioma in the left
fusiform gyrus.
14
Examples of neurological conditions presenting
with psychological symptoms abound in every cat-
egory of disorder
9 15
: cerebrovascular disease can
cause cognitive decline, acute mood disorder, sudden
behavioural change; multiple sclerosis can present
with depression, mania or subcortical dementia; epi-
lepsy can give rise to transient and persistent memory
impairment, abrupt changes of mood, ictal, postictal
and interictal psychosis; the early symptoms of variant
Creutzfeldt-Jakob disease takes sufferers to the psy-
chiatrists office
16
; the recently described encephalitis
associated with antibodies to NMDA receptors typic-
ally causes psychotic symptoms at the outset
17
; many
neurodegenerative disorders are primarily conditions
of the psycheAlzheimers disease, dementia with
Lewy bodies, frontotemporal dementia. A recent
monograph on the differential diagnosis of psychosis
devotes 141 pages to its general medical and
Figure 13 Attitudes to mind and brain, from Demertzi et al
7
.
Figure 11 R D Laing.
Figure 12 Screen shot of Jack Nicholson in One Flew Over
the Cuckoos Nest.
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140 Zeman A. Pract Neurol 2014;14:136144. doi:10.1136/practneurol-2013-000761
neurological causes, but only 17 pages to primary psy-
chiatric disease.
18
Psychological disorder can present with neurological
symptoms
Around one-third of the patients who come to our
neurology clinics have symptoms that are either not
at all or only somewhat explained by neurological
disease.
19
Such symptoms are not, therefore, a side
issue for neurologists but among the common pro-
blems we encounter. These symptoms are perfectly
real to those who experience them, and it can be diffi-
cult, especially in the course of a relatively brief
neurological consultation, to distinguish symptoms
due to neurological disease from those due to psycho-
logical disorder. There is a temptation which many of
us will recognise from hard experience, to label symp-
toms that we find mysterious as functional, when
this reflects the limitations of our knowledge of neur-
ology rather than the nature of the problemas
Thomas Willis wrote in the 17th century, hysteria
can be the subterfuge of ignorance.
20
However, we
should not shy away from making the diagnosis of
symptoms without disease in the large group of
patients in whom it is accurate: there is reassuring evi-
dence that misdiagnosis is rare.
21
Patients with functional disorder are, as a group,
just as disabled as patients with neurological disease,
but more likely to have given up work.
22
They are dis-
tinguished by their relatively high symptom count,
often including pain. They are more likely to be suf-
fering from depression, anxiety or panic than matched
controls with neurological disorder. They are, interest-
ingly, less willing to entertain the possibility that stress
might be relevant to their symptoms, and less eager
that their doctor should enquire about their emotional
state.
Neurologists, not surprisingly, differ in their enthu-
siasm for managing patients with such problems.
Some find the phenomenon of disabling symptoms in
the absence of diseaseoften linked to an individuals
life story, personality and moodintriguing and chal-
lenging; others prefer to focus on treating the neuro-
logical diseases in which they have particular
expertise. But any neurologist with a general neur-
ology clinic must be able to recognise, explain and
make a plan for patients presenting in this way. In my
experience, the chances of achieving this are raised by
making it clear from the start, for example, by asking
appropriate questions in the functional enquiry, that
every patients psychological state is of interest and
might be relevant to diagnosis. This facilitates later
discussion of functional disorder, if it proves neces-
sary, and opens the door to psychological or psychi-
atric approaches to treatment if these are required.
But as we are about to see, these approaches are often
needed, also, in patients with neurological disease.
Neurological disease can cause a psychological reaction
Disorders of the brain often disturb the processes
which govern mood and behaviour and thereby give
rise directly to psychological symptoms. But the diag-
nosis of a neurological disorder and its consequences
for the sufferers lifethe resulting impairment, dis-
abilities and handicapsare also potentially major life
events. These can cause reactive anxiety, panic,
depression and sometimes psychosis, which will
warrant attention in their own right.
Rates of psychiatric diagnosis among patients seeing
neurologists are correspondingly high. The risk of
depression in, for example, epilepsy, multiple sclerosis
and Parkinsons disease is markedly higher than in the
background population.
15
These sequelae are some-
times more readily treated than the underlying neuro-
logical problem, and doing so can greatly improve a
patients quality of life.
Psychological disorder can cause a neurological reaction
The opposite relationshipthe effect of psychological
state on neurological processes and symptomsmay
be less obvious but is increasingly well documented.
For example, depression proves to be a risk factor for
new onset epilepsy, and is linked, possibly by way of
elevated levels of circulating corticosteroids, to hippo-
campal atrophy and memory impairment.
23
Indeed,
the study of neurological and psychiatric comorbid-
ities has become a focus of cutting edge research. But
this relationship, between symptoms we regard as
psychological and disorders we regard as neuro-
logical, seriously understates the importance of the
relationship between our psychological lives and
neural processes: for if one can reasonably argue that
neurology is psychiatry, just as strong a case can be
made for the opposite assertion.
PSYCHIATRY IS NEUROLOGY
Psychiatry has been described as neurology without
signs, but the link between the two disciplines is not
always obvious. The common psychiatric disorders
are not caused by straightforwardly identifiable lesions
in the braina normal MRI scan of the brain in a
patient with devastating psychiatric disorder is a famil-
iar and sobering sight; psychiatric illnesses are often
highly sensitive to social factors, as the antipsychia-
trists insisted; they are usually suspected and almost
always confirmed on the basis of subjective symp-
tomspatients reports of their altered experience.
But, on reflection, none of these features sharply dis-
tinguishes psychiatric from neurological disorders,
and contemporary neuroscience has begun to furnish
the techniques required to illuminate the neurological
dimensions of psychiatric illness. I will briefly
mention some examples of findings from structural
and functional imaging, neurogenetics and
neuropharmacology.
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Zeman A. Pract Neurol 2014;14:136144. doi:10.1136/practneurol-2013-000761 141
The profound effects of schizophrenia on percep-
tion, thought, intellectual capacity, emotion and
behaviour strongly suggest that there must be a perva-
sive, underlying, neurological disorderbut this has
been very hard to identify. Early reports of ventricular
enlargement in sufferers led to much controversy. A
meta-analysis of structural imaging studies of 1424
patients with a first-episode psychosis indicated that at
this early stage of the disorder, there was ventricular
enlargement and corresponding whole brain and hip-
pocampal atrophy, though close to the limits of detec-
tion by existing methods.
24
Autism, like
schizophrenia, is a pervasive disorder which often
lacks obvious neural correlates. A recent study measur-
ing five morphological variables in the brains of
people with autism and then applying a sophisticated
statistical approach (support vector machine analysis)
distinguished autistic from control brains with a sen-
sitivity of 90% and specificity of 80%.
25
Meta-analyses suggest that there are reductions of hip-
pocampal volume in depression,
26
and changes in hip-
pocampal, amygdalar and cingulate volumes in
post-traumatic stress disorder.
27
Functional imaging, more than any other approach
to understanding the brain, has revolutionised think-
ing about mind and brain over the past 30 years by
rendering vividly visible the neural basis of previously
invisible mental processes. The techniques are in some
respects crude, and the apparent localisation of cogni-
tive activity by functional MRI (fMRI) in the brain of
a dead salmon urges caution in the interpretation of
its results.
28
Yet, functional imaging approaches hold
out great promise in understanding the elusive neural
basis of psychiatric disorder, with notable results, for
example, in the study of Charles Bonnet syndrome,
where the content of hallucinations associated with
visual loss correlates with regional activations
29
;
depression, in which there is evidence for network
dysfunction with areas of hyperactivation and hypoac-
tivation
30
; and even in the study of hysteria where
there are reversible changes in thalamus, caudate and
putamen contralateral to regional sensory symp-
toms.
31
The developing study of the human connec-
tome,
32
the architecture of connections that creates
the functional networks of the brain, and the novel
techniques that facilitate this, such as resting-state
fMRI
33
and analysis using graph theoretical ana-
lysis,
34
are likely to be especially valuable in psych-
iatry, for which the previous approach to neurological
analysismapping the brain small area by areawas
probably inappropriate.
The genetic study of psychiatric disorder is in the
midst of a growth spurt, but there are already suggest-
ive findings and a likelihood that these will lead to a
restructuring of psychiatric diagnoses over time.
35
Risk factors for psychosis have been identified at the
level of single genes, and in relation to disorders
caused by these. For example, the lifetime risk of
psychosis in velo-cardio-facial syndrome is around
30%.
18
In general, psychiatric risk is likely to be
determined by contributions from many genes which
are individually of small effect: genome-wide associ-
ation studies are locating such genes including
ZN804A which influences the risk of schizophrenia
and CACNA1C which modulates the risk of bipolar
disease.
35
Variations in copy numbers are proving to
be common risk factors for disorders previously
regarded as distinct, for example, autism, schizophre-
nia and learning disability.
35
The path leading from
genotype to psychiatric phenotype will undoubtedly
be a complex one in which genegene and geneenvir-
onment interactions will play a key role. Imaging gen-
etics is identifying the effects of genetic variation on
patterns of brain activity.
36
Neuropharmacology provides a final example of the
seamless boundary between neurology and psychiatry.
However difficult it is to define their relationship in
theory, the indispensable British National Formulary
quietly but logically includes drugs working on the
central nervous system in a single chapter, regardless
of which specialism predominantly uses themand,
of course, many drugs cross the divide: neurologists
prescribe antidepressants to reduce migraine and
cataplexy; psychiatrists prescribe antiepileptics to sta-
bilise mood. This is not surprising as the systems
based in the brain stem that neurologists-in-training
come to know as the ascending activating system,
regulating conscious state, overlap massively with the
systems psychiatrists-in-training encounter as key regu-
lators of motivation and mood (figure 14).
SOME RELEVANT SIDE ISSUES: ORGANISM AND
FUNCTION; MIND AND MATTER;
BIOPSYCHOSOCIAL MEDICINE
Medicine and medics tend to be suspicious of philoso-
phy, but just a few abstract points require a mention
here. First, we should be cautious, at least, in our use
of the terms functional and organic. We continue
to deploy these, despite Kinnier Wilsons comment in
his 1940 textbook that the antithesis between
organic and functional disease states lingers at
the bedside and in medical literature, though it is
transparently false and has been abandoned long since
by all contemplative minds.
37
It is transparently
false because all our patients are organisms, and all
their disorders involve upsets of functioning: this dis-
tinction presumes and perpetuates the misleading,
dualistic distinction between mindless matter and mat-
terless mind. It is surely revealing that we find it so
difficult to do without a distinction that makes so
little sense. The rather different distinction between
functional and structural disorder is more
coherent.
38
The second general point is that in the background
of the debate over the relationship between neurology
and psychiatry lies the philosophical debate over the
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142 Zeman A. Pract Neurol 2014;14:136144. doi:10.1136/practneurol-2013-000761
relationship between mind and matter.
39
This is a fas-
cinating and possibly insoluble philosophical conun-
drum, but the main argument of this article does not
depend at all on reaching a solution to this ancient
philosophical question. The argument that neurology
is psychiatry and vice versa doesnt make any assump-
tions about the nature of matter or mind, and, in par-
ticular, is not mind-denying. Rather, it insists that to
understand and manage disorders of the brain, we
need to take into account experience, behaviour and
physiology at all times. This is a practical message,
usefully encapsulated in the concept of biopsychoso-
cial medicine
40
: every disorderindeed every
moment of healthy functioninghas biological, psy-
chological and social dimensions. Doctors ignore any
one of these at their peril.
SO WHAT?
The first practical upshot of the argument made here
is that neurological and psychiatric disease classifica-
tions should be fused.
41
This would draw the two
professions together and encourage them to collabor-
ate more intensively, with benefits for service and
research. But however good an idea this may be, the
massive institutional barriers mean that it will not
happen anytime soon.
There are more realistic short-term and middle-term
goals. Neurologists-in-training should spend some
time, at least 6 months, working in an appropriate
psychiatric training post, probably in a department of
psychological medicine rather than on a psychiatry
ward, from which the lessons learned would be less
easily transferred to the neurology clinic.
Psychiatrists-in-training, likewise, should, where pos-
sible, spend a similar period working in a neurology
service. This innovation would meet a felt need
among trainees, enhance collaboration between the
specialties and ensure that neurologists develop some
psychiatric skills, and psychiatrists gain confidence in
neurology. More or less everyone agrees that this is a
good idea but few training programmes have achieved
it. Excuses involving the differing lengths of junior
attachments in the two specialties are feeble. Lets do
it!
Among patients with disorders that plainly cross the
traditional dividefor example, in the dementias or
in the case of patients with symptoms without
diseasejoint consultations, though expensive, can
be highly effective and should be arranged more
often. In general, liaison between neurologists and
psychiatrists should increase, and psychological ser-
vices, which are often needed but in short supply,
should be made more available and be more fully inte-
grated into neurology departments.
Finally, the intimate relationship between these spe-
cialisms implies that joint research should be encour-
aged by research leaders and funding bodies.
Neurology and psychiatry have much to learn from
one another. This message is old news in neurosci-
ence: basic research tends to move freely between
Figure 14 The pharmacology of the brainstem activating systems: A shows the origin and distribution of the central noradrenergic
pathways in the rat brain; B the dopaminergic pathways; C the cholinergic pathways; D the serotonergic pathways. CTT, central
tegmental tract; dltn, dorsolateral tegmental nucleus; DNAB, dorsal noradrenergic ascending bundle; DR, dorsal raphe; DS, dorsal
striatum; HDBB, horizontal limb nucleus of the diagonal band of Broca; Icj, islands of Calleja; IP, interpeduncular nucleus; LC, locus
ceruleus; MFB, medial forebrain bundle; MS, medial septum; NBM, nucleus basalis magnocellularis (Meynert in primates); OT,
olfactory tubercle; PFC, prefrontal cortex; SN, substantia nigra; tpp, tegmental pedunculopontine nucleus; VDBB, vertical limb nucleus
of the diagonal band of Broca; VNAB, ventral noradrenergic ascending bundle; VS, ventral striatum (from Robbins & Everitt 1995).
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Zeman A. Pract Neurol 2014;14:136144. doi:10.1136/practneurol-2013-000761 143
neurological and psychiatric contexts, and many neu-
roscientists would regard the kernel of this paper as
plumb obvious. Things are very different in the clinic.
Medicine should not be left behind.
Acknowledgements I am very grateful to Nick Craddock, Jon
Stone, Michael Trimble and Peter White for their penetrating
comments on this paper, and to Joanne Veale for her help with
permissions.
Competing interests None.
Provenance and peer review Commissioned; externally peer
reviewed. This paper was reviewed by Jon Stone, Edinburgh, UK.
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