From the Editor

Psychiatry and neurology: Sister neuroscience specialties with different approaches to the brain

Neurologists and psychiatrists diag- medical history, social history, family Henry A. Nasrallah, MD history, review of systems, and physical Editor-in-Chief nose and treat disorders of the brain’s hardware and software, respectively. examination. Despite those many differences in The brain is a physically tangible assessing and treating neurologic vs structure, while its mind is virtual psychiatric disorders of the brain, there and intangible. is an indisputable fact: Every neurologic Every patient with a disorder is associated with psychiatric brain/mind disorder Not surprisingly, neurology and psy- manifestations, and every psychiatric chiatry have very different approaches illness is associated with neurologic should receive both to the assessment and treatment of brain symptoms. The brain is the most com- neurologic and and mind disorders. It reminds me of plex structure in the universe; its devel- ophthalmology, where some of the fac- opment requires the expression of 50% psychiatric evaluation ulty focus on the hardware of the eye of the human genome, and its major task and treatment (cornea, lens, and retina) while others is to generate a mind that enables every focus on the major function of the eye— human being to navigate the biopsy- vision. Similarly, the mind is the major chosocial imperatives of life. Any brain function of the brain. lesion, regardless of size and location, Clinical neuroscience represents the will disrupt the integrity of the mind in shared foundational underpinnings of one way or another, such as speaking, neurologists and psychiatrists, but their thinking, fantasizing, arguing, under- management of brain and mind disor- standing, feeling, remembering, plot- ders is understandably quite different, ting, enjoying, socializing, or courting. albeit with the same final goal: to repair The bottom line is that every patient and restore the structure and function of with a brain/mind disorder should ide- this divinely complex organ, the com- ally receive both neurologic and psychi- mand and control center of the human atric evaluation, and the requisite dual soul and behavior. interventions as necessary.1 If the focus To comment on this In Table 1 (page 5), I compare and is exclusively on either the brain or the editorial or other topics contrast the clinical approaches of these mind, clinical and functional outcomes of interest: henry.nasrallah 2 sister clinical neuroscience specialties, for the patient will be suboptimal. @currentpsychiatry.com beyond the shared standard medical Neuropsychiatrists and behavioral templates of history of present illness, neurologists represent excellent bridges continued on page 8 Current Psychiatry 4 March 2019 Table 1 Neurology and psychiatry: Differences and similarities Neurology Psychiatry Editorial Staff EDITOR Jeff Bauer Neurological examination Mental status examination SENIOR EDITOR Sathya Achia Abraham A focus on localizing the “lesion” The “lesion” is a widely distributed circuit that is hard ASSISTANT EDITOR Jason Orszt guided by objective signs and to localize and is guided by a mixture of objective WEB ASSISTANTS symptoms (eg, motor symptoms, and subjective signs and symptoms unrelated Tyler Mundhenk, Kathryn Wighton sensory symptoms, reflexes, to sensory/motor brain functions (eg, speech, cranial nerves, spinal cord and mood, affect, thought, suicidal/homicidal impulses, Art & Production Staff peripheral symptoms, infections, perceptual aberrations, false beliefs, insight, judgment, CREATIVE DIRECTOR Mary Ellen Niatas tumors, degeneration, injury, and neurocognition, and social cognition) ART DIRECTOR Pat Fopma pain) DIRECTOR, JOURNAL MANUFACTURING Michael Wendt Laboratory tests are common No diagnostic laboratory tests because most PRODUCTION MANAGER Donna Pituras and useful in diagnosis of many psychiatric illnesses are syndromes, not diseases with neurologic diseases specific biologies Publishing Staff Impaired level of consciousness Consciousness usually clear but reality testing is PUBLISHER Sharon Finch may occur impaired DIRECTOR eBUSINESS DEVELOPMENT Alison Paton Several diagnostic and No diagnostic procedures (yet) but some therapeutic SENIOR DIRECTOR OF SALES therapeutic procedures neuromodulation procedures (ECT, TMS, VNS) Tim LaPella Seizures are an illness Seizures are a treatment CONFERENCE MARKETING MANAGER Kathleen Wenzler Simple genetics, often Mendelian Complex genetics, numerous risk genes, CNVs, epigenetics, and pleiotropy Editor-in-Chief Emeritus Touching the patient is an essential Touching is often avoided, except to assess EPS, and James Randolph Hillard, MD part of the neurologic exam at one time (during the psychoanalysis era) was taboo Frontline Medical Communications Patients often bedridden Patients predominantly ambulatory PRESIDENT/CEO Alan J. Imhoff No stigma, respected by the Stigma is (unfortunately) common, mental illness is CFO Douglas E. Grose public, and antineurology feared by the public, and antipsychiatry movements SVP, FINANCE Steven Resnick movements do not exist have existed for decades VP, OPERATIONS Jim Chicca Sympathy and support by family Fear and avoidance by family and friends VP, SALES Mike Guire and friends VP, SOCIETY PARTNERS Mark Branca Wheelchair for severe physical Asylums, the mental equivalent of a wheelchair for VP, EDITOR IN CHIEF Mary Jo Dales disability commonly used severe long-term disability, have been (regrettably) VP, EDITORIAL DIRECTOR, CLINICAL CONTENT Karen Clemments abandoned CHIEF DIGITAL OFFICER Lee Schweizer Neurologic examination is heavily Psychiatric examination is heavily auditory, but visual VP, DIGITAL CONTENT & STRATEGY visual observations are helpful Amy Pfeiffer Chronicity is common Chronicity is common PRESIDENT, CUSTOM SOLUTIONS JoAnn Wahl Focus on physical weakness Focus on emotional pain and anguish VP, CUSTOM SOLUTIONS Wendy Raupers and pain VP, MARKETING & CUSTOMER ADVOCACY Jim McDonough Full insurance coverage Limited insurance coverage VP, HUMAN RESOURCES & FACILITY Homelessness uncommon Homelessness common OPERATIONS Carolyn Caccavelli DATA MANAGEMENT DIRECTOR Mike Fritz Substance abuse comorbidity Substance abuse rates as primary and comorbid CIRCULATION DIRECTOR Jared Sonners occurs at general population rates conditions are higher than the general population CORPORATE DIRECTOR, RESEARCH Neuroinflammation and oxidative Neuroinflammation and oxidative stress are emerging & COMMUNICATIONS Lori Raskin stress are common mechanisms as common mechanisms DIRECTOR, CUSTOM PROGRAMS White and gray matter pathology White and gray matter pathology have been Patrick Finnegan common established in several psychiatric disorders In affiliation with Global Academy for Neurodegeneration common Neurodegeneration and progression are common Medical Education, LLC Death is often caused by the brain Death is often self-inflicted PRESIDENT David J. Small, MBA lesion Patients very motivated to be Patients often avoid or even resist treatment treated 7 Century Drive, Suite 302 Forensic issues rare and laws do Forensic issues very common and laws often constrain Parsippany, NJ 07054 not interfere with clinical care or urgent clinical care, especially procedures such Tel: (973) 206-3434 major invasive procedures as physical restraints, IM medications for severe Fax: (973) 206-9378 psychosis or violence, or neuromodulation procedures www.frontlinemedcom.com such as ECT Subscription Inquiries: [email protected] Patients are hospitalized Involuntary hospitalization is common voluntarily Published through an CNVs: copy number variations; ECT: electroconvulsive therapy; EPS: extrapyramidal symptoms; educational partnership TMS: transcranial magnetic stimulation; VNS: vagus nerve stimulation with Saint Louis University

Current Psychiatry Vol. 18, No. 3 5 From the Editor continued from page 4

Table 2 across these 2 sister specialties. There are Subspecialties of psychiatry twice as many psychiatrists as neurolo- and neurology approved by gists, but very few neuropsychiatrists or the ABPN behavioral neurologists. The American Board of Psychiatry and Neurology Psychiatry (ABPN) has approved several board • Addiction psychiatry certifications for both specialties, and • Child and adolescent psychiatry When will the several subspecialties as well (Table 2). • Consultation-liaison psychiatry When will the ABPN approve neuro- ABPN approve (formerly psychosomatic medicine) psychiatry and behavioral neurology as neuropsychiatry and • Forensic psychiatry • Geriatric psychiatry subspecialties, to facilitate the integra- behavioral neurology tion of the brain and the mind,2 and to Neurology as subspecialties? bridge the chasm between disorders of • Brain injury medicine the brain and mind? • Clinical neurophysiology • Epilepsy • Neurocritical care Henry A. Nasrallah, MD • Neuromuscular medicine Editor-in-Chief • Pain medicine • Sleep medicine (available to both References psychiatrists and neurologists) 1. Nasrallah HA. Toward the era of transformational neuropsychiatry. Asian J Psychiatr. 2015;17:140-141. • Vascular neurology 2. Nasrallah HA. Reintegrating psychiatry and neurology is long overdue: Part 1. April 30, 2014. ABPN: American Board of Psychiatry and https://www.cmeinstitute.com/pages/lets-talk. Neurology aspx?bid=72. Accessed February 11, 2019.

Current Psychiatry 8 March 2019