Neurology, Psychiatry, and Neuroscience

To the Editor: In his overview (1), Joseph B. Martin, M.D., Ph.D., suggested that the integration of neurology and psychiatry should converge within a framework of modern neuroscience. This case is made well for diseases such as Alzheimer’s and Tourette’s, although these conditions have long been established at the interface of the two disciplines.

The greater challenge facing the successful integration of psychiatry and neurology is not those diseases in which structural pathology is known or strongly suspected but rather the neuroses. Dr. Martin referred to Charcot and Weir Mitchell as great neurological pioneers. Both also devoted substantial parts of their lives to the treatment of the neuroses of hysteria and neurasthenia, respectively. It was hysterical neurosis that provided the impetus for Freud’s abandonment of the clinicopathological model, a proposal that drove the greatest schism between the disciplines of mind and brain.

If hysteria was the battlefield in which neurology and psychiatry became estranged, it can also provide the backdrop for their reconciliation. It remains the case that as many as one-third of the patients seen by clinical neurologists have symptoms that are better explained by neurosis than by neurological disease (2). Little attention is paid to these patients in textbooks of neurology or training programs. Although neuroscience is providing some understanding of these symptoms (3), they are illnesses with important psychological and social dimensions. The great psychiatrist Adolf Meyer, when shown the brain of a patient who had committed suicide at a postmortem examination, is reported to have challenged the pathologist to tell him by looking at the brain what was in his mind when he died. Important aspects of neurosis are likely to remain out of the reach of the scanner.

Dr. Martin called for “a seamless interconnection in training and in clinical practice” (1, p. 702). Will a greater shared understanding of neuroscience mean that psychiatry will simply follow neurology in abandoning the patients who fail to fit into a reductionist paradigm? A true convergence of the disciplines will also require neurology to regain its 19th century interest in the psychological and social factors that contribute to the neuroses. Like Adolf Meyer, we suspect that a focus on neuroscience alone will be inadequate for that task.