Should Neurologists Manage Psychiatric Symptoms?

Andrew N. Wilner, MD

Disclosures

September 03, 2010

Question:

What Is the role of the neurologist in addressing psychiatric illness/symptoms in their patients?

Response from Andrew N. Wilner, MD
Neurohospitalist, Department of Neurology, Lawrence and Memorial Hospital, New London, Connecticut

The neurologist's task is to identify pathologic abnormalities in the brain, spinal cord, and peripheral nervous system and recommend a course of treatment. Psychiatrists tend to restrict their practice to disorders of the brain and, more specifically, the mind.

According to the online Merriam Webster dictionary, the mind is the "element or complex of elements in an individual that feels, perceives, thinks, wills, and especially reasons." The brain is defined as the "portion of the vertebrate central nervous system enclosed in the skull and continuous with the spinal cord through the foramen magnum that is composed of neurons and supporting and nutritive structures (as glia) and that integrates sensory information from inside and outside the body in controlling autonomic function (as heartbeat and respiration), in coordinating and directing correlated motor response, and in the process of learning."

So, you say "tomato" and I say "tomato." Both definitions employ very different language, but the constructs of "mind" and "brain" overlap considerably. The fact that neurologists and psychiatrists share a certifying organization, the American Board of Psychiatry and Neurology, attests to the historical appreciation of the common characteristics binding these 2 specialties. From a neurologist's and psychiatrist's perspective, problems of the brain and mind differ primarily in the strategy of investigation and management.

A Case Study to Clear the Air

A clinical case study may assist in responding to the question of how the neurologist addresses psychiatric illness or symptoms. A 27-year-old woman presents to the neurologist and reports visual hallucinations: "I think I'm going crazy. I keep seeing things that aren't there." A careful history elicits a temporal relationship between the patient's menses and the troublesome images, which tend to hover in the left visual field. Further, most of the time, the hallucinations are followed by a pounding headache, accompanied by nausea, vomiting, photophobia, phonophobia, and irritability. When asked to draw what she sees, the patient sketches a reasonable facsimile of fortification spectra. She has migraine with aura. A complete neurologic examination is normal. Because the patient insists, she undergoes magnetic resonance imaging (MRI), the results of which are normal. A course of treatment is prescribed.

If the same patient presented with auditory hallucinations that commanded her to jump out the window, followed by a headache, migraine with aura would be less likely. The neurologist would still perform a neurologic examination, order an MRI to rule out a frontal lobe tumor, and possibly record an electroencephalogram to explore the remote possibility of epileptic seizures. For psychiatrists to work effectively with patients, they need to know that pathologic lesions that can be treated medically or surgically have been "ruled out." It is the neurologist's job to determine whether there are any autoimmune, endocrine, infectious, metabolic, paraneoplastic, structural, or other "medical" problems responsible for this patient's auditory hallucinations and headache before categorizing the problem as psychiatric. After this process of elimination, the neurologist can refer the patient to a psychiatrist for the symptoms suggestive of schizophrenia.

One can argue that diseases such as depression and schizophrenia are primarily neurologic, in that they appear to result from neurotransmitter imbalances that can be treated medically. Historically, these illnesses have resided in the psychiatric domain. With respect to our 2 cases above, migraine would usually be managed by a neurologist, and schizophrenia by a psychiatrist. The extent to which neurologists care for patients with psychiatric disorders depends on the physician's level of interest and expertise and the availability of psychiatric support. Ideally, when symptoms are "nonneurologic" and suggestive of psychiatric illness, patients should be cared for by psychiatrists, who are trained to deal proficiently with diseases of the "mind" rather than the "brain."

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