Should Psychiatry and Neurology Merge as a Single Discipline?

On August 27, 2009, at SUNY Upstate Medical University in Syracuse, NY, the Department of Psychiatry Grand Rounds featured a debate titled “Resolved: Psychiatry and Neurology Should Merge as a Single Discipline.” Professor Chaitanya Haldipur, MD, organized the conference.

The principal presentations were by Ronald Pies, MD, for the affirmative, and Robert Daly, MD, for the negative. Also participating were Jeremy Shefner, MD, PhD (chairman, department of neurology) for the affirmative, and Mantosh Dewan, MD (chair, department of psychiatry) for the negative.

We believe that the issues being debated here have important long-term implications for psychiatry, and we are pleased to present these revised versions of the 2 principal presentations.

IN SUPPORT OF THE RESOLUTION:

by Ronald Pies, MD

I want to begin by suggesting that the question being debated, “Resolved: psychiatry and neurology should merge as a single discipline,” is actually a bit misleading. To understand why, I need to take you back over 150 years, to 1859. That year marked the publication of a remarkable manual of medical diagnosis and treatment by the Boston physician Ira Warren. New Warren’s Household Physician was intended as a “brief description, in plain language, of all the diseases of men, women, and children.”¹

The chapter, “Diseases of the Brain and Nerves”-what I call, the DSM-Minus-IV-is a gem of holistic thinking.² Dr Warren essentially unified afflictions often called “neurological disorders” with those nowadays considered in the domain of psychiatry. Thus, various types of brain inflammation, chorea, and neuralgia are addressed in the same chapter as “derangement of mind” or “insanity.” Indeed, the good doctor seems uncomfortable with Cartesian dualism, noting that “some have supposed insanity to be a mental disorder merely, having nothing to do with the body. They might as well suppose the delirium of fever to be a disease of the mind only.”^1(p195)

Under the general rubric of “insanity,” Dr Warren includes only 5 main types: melancholy, monomania (“insanity on one subject”), mania, dementia, and idiocy. (This last category-in which “the brain is not large enough to be the organ of intelligence”-is similar to what neurologists today would call anencephaly.) Closing out Dr Warren’s “DSM” is hypochondria-apparently not a cause of insanity but nevertheless, in Dr Warren’s view, a brain disease characterized by “constant fear, anxiety, and gloom.”^1(p197)

What conclusion should we draw from Dr Warren’s classification, besides the fact that it is a good deal more compact than DSM-V is likely to be? In brief, we must conclude that as of 1859, there was no clear separation between neurology and psychiatry, at least on the level of general medical diagnosis. On the contrary, diagnoses in the 2 disciplines were essentially unified under the rubric, “Diseases of the Brain and Nerves.”

In the United States, it was really only in the years following the Civil War that psychiatry and neurology began to diverge as professions, owing in large part to the split between academic neurologists, such as Professor S. Weir Mitchell, and the so-called asylum psychiatrists. The latter were largely nonacademics, looked on with some disdain by the neurologists-and perhaps with good reason. As Professor Mitchell himself put it in his acerbic lecture to the Annual Meeting of Asylum Superintendents in 1894, “Where are your careful scientific reports? . . . You live alone, uncriticized, unquestioned, out of the healthy conflicts and honest rivalries that keep us neurologists up to the mark of fullest possible competence.”³

In subsequent years, as Dr Leon Eisenberg has pointed out, the split between neurology and psychiatry as professions became even wider as Freud’s psychoanalytic approach gained ground and as the etiology of psychotic disorders eluded the rudimentary neuropathological investigations available at the time. But this divergence of the 2 fields was essentially an artifact of professional rivalries and turf battles-not the result of well-conceived philosophical arguments or scientific discoveries. In Dr Warren’s 1859 text, neurological and psychiatric disorders, so-called, still sat comfortably side by side in the same chapter.

In short, the resolution we ought to be debating today is:

“Resolved: psychiatry and neurology should re-unite as a single discipline.”

And, indeed, I would argue that they should-although, I believe that such a reunification cannot proceed without certain kinds of linguistic and philosophical “bridging devices.” In fact, in the article, “Why Psychiatry and Neurology Cannot Simply Merge,”⁴ I took the position that simply “mooshing” the 2 fields together in some haphazard way would be unwise and unworkable.

Bringing neurology and psychiatry together is not like bringing about a merger between Chrysler and Fiat. If anything, it is more like creating a third language out of English and German, or French and Spanish.

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