Does Mind Meet Brain in Residency? (And What About the Body?)

The 2001 annual meeting theme was “Mind Meets Brain,” and one “Residents Summit” was convened there to address this dichotomy in terms of training. In this setting, four eminent psychiatrists debated the situation.

The speakers included Drs. Stuart Yudofsky, co-editor of APPI’s Textbook of Neuropsychiatry and chair of psychiatry at Baylor; William E. Greenberg, a psychoanalyst and director of the Harvard Longwood residency program; Frances Levin, director of addiction psychiatry training at the New York State Psychiatric Institute; and James Strain, an analyst and director of C/L psychiatry at Mt. Sinai Hospital in New York City, and I moderated. This issue’s column summarizes this conversation.

Dr. Yudofsky’s view set the pace: It is artificial to separate neurology and psychiatry, he said; instead, we should have one specialty. The mind/brain dichotomy is new to medicine. In 19th-century Germany, he argued, it was right. Then a leader of the field, such as Greisinger, was a professor both of psychiatry and neurology, and there was no difference in the training. Physicians who cared for persons with dementia, general paresis, and melancholy were trained in both fields. Greisinger and his followers, including Alzheimer, Nissl, Kraepelin, and Freud, drove the “neuropsychiatry” of the time: an integrated conceptualization of mind and brain. With this in mind, Dr. Yudofsky proposed that our education should not further a separation between “neurologic” and “psychiatric.” Thus, he argued, the training of psychiatrists should include neuroanatomy and neurobiology and that of neurologists should include dynamics and interpersonal relations so as to reduce the artificially maintained divide.

The second speaker was Dr. Greenberg, who, unlike Dr. Yudofsky, argued that the current mind/brain balance is right, but that “we are not yet effectively teaching it.” After all, he noted, because of the work of some of today’s best-known biological psychiatrists (for example, Kandel and Nemeroff), we are forging new understandings between psychology and biology. And psychoanalysts, such as Fishman at the Boston Psychoanalytic Institute, are analyzing the neurobiology of psychoanalytic concepts. These are the types of findings we should be applying to training.

For Dr. Greenberg, however, the problem is that the brain and mind rarely coexist in the training supervisor. To this point he lamented the conclusion of anthropologist T.M. Luhrman’s book, Of Two Minds, that trainees are urged to join a psychodynamic or a biological “camp.” For Dr. Greenberg, residents know that they must understand the brain, but they also know that, to care for patients, they need to consider the range of etiological factors and a range of therapies. The provisional answer? The best residents “shop around” among supervisors to get and consider every perspective and apply those that help the patient.

Thus, for the most part, the current mind/brain model has worked, but perhaps the biopsychosocial approach does not get taught. For Dr. Greenberg, all programs owe their residents the opportunity to make an independent biopsychosocial formulation on every patient. It is apparent that some programs are not preparing residents to bring the mind and the brain together.

Addiction psychiatry is a field that could logically integrate the mind/brain issue. Unfortunately, according to Dr. Levin, this has not been the case. Developments in the biological measurement and analysis of brains of persons who are addicted to substances or who are intoxicated or dependent upon substances are countered by a tradition of clinical work that is psychological and spiritual. She noted that there is even some resistance to the use of medications in substance abuse treatment programs, perhaps because those programs are led by nonphysicians. This has implications for the mind/brain dichotomy because trainees in our fellowship programs are not learning the modalities that are used in the “real world.” A real challenge for educators in the substance abuse arena is how to develop a curriculum that integrates the most current research with established modalities, especially when the practitioners do not read the same journals that psychiatrists do.

For Dr. Strain, the body, “subsumed as Axis III,” was an area inappropriately omitted from psychiatry’s mind/brain dichotomy. The body deserves consideration in any psychiatric education that is comprehensive and integrated. Thus, he argued, the field should recognize both biologic and psychologic aspects of psychopathology, but not necessarily compacted under one intellectual frame. Why, he asked, should trainees in psychiatry not be expected to master many different topics? Should not physicians with their 11 billion neurons be able to do the same for intrapsychic conflict, biologic concepts, psychologic concepts, and end organ dysfunction?

Thus Dr. Strain agreed with Dr. Yudofsky that there is a need for integration, but he proposed many approaches. Otherwise, he averred, we are babying trainees. A good psychoanalyst, in this manner, recognizes ECT as a great treatment. In his view educators should increase attention to the body, medical comorbidity, pharmacokinetics, dynamics, and drug-drug interactions until every candidate for the board understands the implication of the fact that the brilliant musician George Gershwin died of an intracranial tumor after being put on the couch for two years.

In answer to a question about genetics, Dr. Strain noted that the topic reminds us that while we cannot know everything, we need to figure out what are the minimums for a psychiatric education. Some genetic disorders can be very complicated. Psychiatrists should know about them and how to navigate them much like one learns Mendeleyev’s system rather than the facts of each atom individually. The same goes for drug-drug or p450 interactions. Training directors, he argued, need to teach us what to know and how to access it, but not to remember it all. To this, Dr. Yudofsky noted, “I can agree with that.”

What aspects of the mind, brain, and body should be taught to psychiatry residents? It is clear from this workshop that the answers hinge, to a great degree, on how one views the current state of the profession and where he or she would like it to go. These four experts offer different assessments; it is hoped that we can all think together on where to go from here. ▪