Neurology, Psychiatry, or Just Brain Medicine?

The brain is perhaps the only organ in the body where there are two completely different medical specialties that treat patients with dysfunction in the organ. Those specialties are, of course, neurology and psychiatry.

We are perhaps so used to having these two separate specialties that we don’t often step back and think how unusual this is. If we have a lung problem, the appropriate specialty is pulmonology. If there is a need for a specialist in the heart, we go to a cardiologist. If there is a problem with our kidneys, we go to a nephrologist. But if there is a brain problem, we have neurology and psychiatry. Why is that?

Actually, neurology and psychiatry were actually unified at one time. In the 1800s, the neurologists Jean-Martin Charcot and Sigmund Freud (yes, he was a neurologist), divided brain diseases into those that could be detected by the technology of the time (which became “neurological”) and those that couldn’t be (which became “psychiatric”). That was in the 1800s, and technology has changed immensely, but doctors still practice this way.

Advances in technology are now beginning to blur the distinction between the fields. We have technology now (called transcranial magnetic stimulation, or TMS) that can modulate specific networks in the brain and improve symptoms of what traditionally are thought to be psychiatric diseases such as major depression, obsessive-compulsive disorder, and addictions.

On the other side, we are realizing that traditional neurological diseases often have significant mood, behavioral, and cognitive elements (what could be classified as “psychiatric” symptoms). In epilepsy, for example, mood problems can be more determinant of quality of life than seizure frequency. Multiple sclerosis can lead to significant mood, fatigue, and cognitive problems.

Delusions can often occur with many “neurological” diseases such as Alzheimer’s disease. Hallucinations can often occur with Lewy body dementia and Parkinson’s disease. Brain tumors (as “neurological” a disorder as we can think of) can cause behavioral changes (what we think of as “psychiatric”). Traumatic brain injury can lead to seizures (“neurological”) as well as personality changes (“psychiatric”).

So, what do we do? Luckily, the pendulum may be swinging away from the formulation of the 1800s to a more modern viewpoint. After neurology or psychiatry residencies, it is possible now for physicians to do a behavioral neurology and neuropsychiatry fellowship—this is an example of where doctors from both specialties can be trained together. Others have been pushing to combine neurology and psychiatry residencies and have a joint “brain medicine” residency.

There is a long way to go, but we may have at least started on the path to undo the schism of neurology from psychiatry. This path can lead to one specialty for the organ of the brain, just like there is one specialty for the organ of the lungs, or the heart, or the kidneys—in other words, like the rest of medicine.