A CONCEPTUAL ISSUE IN PSYCHIATRY
We analyzed the domains of psychiatry and neurology from the perspective of medical evolution, with the aim to logically distinguish between the two medical domains, not at the clinical level, which is quite clearly distinguished, but at the level of biological root of the neuronal populations of CNS in psychic diseases. The conclusion is that the logical and operative delimitation is to consider the diffuse affection of the specific neuronal populations which give the psychiatric symptomatology during the entire evolution of the disease or during its first half, belongs to psychiatry and the macroscopic affection of the neuronal populations and of those specifically diffuse ( like in Parkison disease) belongs to neurology.
I.INTRODUCTION (Historical perspective)
When the term of psychiatry was created by Reil, in 1801, only alienations in the psychotic sense and the retarded were described as being psycho-pathological labels on their own. All the rest were a sort of appendix to neurologic pathology. Actually, even though psychiatry only becomes a discipline around the half of 19th century, in practice, the term neuropsychiatry continued to exist up until the middle of the 20th century.
As long as the classical macroscopic and microscopic anato-pahology drew the borderline between neurologic and psychic diseases, everything was clear and controversy-free.
Knowledge evolved, however, and the pathogeny of psychic diseases is trapped today in its biological perspective at genetic and neurochemical level. It is true that the biological perspective is reductionist, which has a negative influence on the evolution of the knowledge of the whole, but it is presently the most fruitful one and it triggers the knowledge and therapeutic progress. That is the reason why it will remain, until the creation of a holistic model, the main window though which to look into the inner side of psychic diseases.
The neurochemical model, the main biological model, with all its flaws and inaccuracies, has nevertheless b l u r r e d t h e c l e a r d i s t i n c t i o n b e t w e e n t h e psychopatholoical pathogeny and neurological pathogeny. And this blur occurs in all psychiatry chapters, more obviously in dementias and psychosis, which at the time of the birth of psychiatry seemed to have nothing to do with neurology, and had a special pathology status.
Such an evolution with overstating the role of the biological aspect in „stricto sensu” in the psychic disease pathology will lead to the extremely wrong idea that psychic diseases and psychism in general are epiforms of certain neurological aspects. The science of the sane psychic, psychology is completely at a loss when confronted with this trap. As it lacks biological base, it cannot have a holistic approach of the issue.
It is clear and irrefutable that the domains of neurology and psychiatry are independent scientific domains, answering all the specific scientific criteria. So, it is not possible to merge the two specialties into a future mega-neuro-psychiatry and it would be impossible to comprise such specialty by a clinically efficient specialist. Then, what is the direction of our knowledge?
In order to answer all the possible questions that this problem poses, we should start with answering the following: how far in neuronal geography can we talk about the domain of neurology and where does the domain of psychiatry begin?
I.GENERALASPECTS OF THE ISSUE
It is necessary to consider the generality of the problem because we agree with Plotin (1), who states „ the being, the essence and the question why -is what makes them a whole”. Thus, the interrogation is implicit to any reality and interrogation must always start in generality in order to allow the contextualization of the given reality in a systemic structure.
The maximum generality of the Einstein type E=mc2 is the long held dream of most sciences. But in the everyday practice and theory generality, depending on its level, generality is characterized by a punctually concrete level of incompleteness. This incompleteness derives from and is equal to the reverse extension of the random application of generality.
With the view to accessing a more complete generality, however, there are levels to be achieved, step by step.Thinkers have learnt this only by a logical exercise. Boethius (2) said in the 13th century „… knowing the effect leads to knowing the cause. And the one who knows the superior causes and knows that their nature requires them to have another cause, led to knowing the first cause”. Well, in medicine, the last effect is the clinical symptom, so everything starts from the clinical aspect, from where, step by step ( cause by cause) we get to what we consider to be the first cause or , more accurately, a complex of first causes.
We are getting closer to our theme and comment another text of Boethius which quotes: „ the sounds of our voices are symbols of the affections of our souls, just as the letters of the alphabet are symbols of the sounds in our voices”. Eco Umberto concludes „ the affections of the soul are not mental images of things but existing modes of thinking, cognitive ways ( such as thinking, fear, joy)”
There are two plans in this interpretation: one of general modes, of patterns and one of specific shades which articulate in mental constructions, seen through generations, with origin in generalities, in patterns. The illness affects the basic levels (the „prime” ones), which change the articulations of shades in mental constructions. That is why we have to treat the basic levels which get sick. And the sane psychic exists only through the integrity of all levels ( causative cascades).
It is interesting to observe that in our case one of the basic causes is the genetic one, to which we do not have therapeutic access yet. In this respect, the illness is a system of pathogenic cascades. But, from knowing the causative cascades which finally lead to sane or pathological psychic we lack a level, the one that makes the transition between clear neurologic causes and non- neurological ones, or if we wish to call them differently, non-material causes.
That is why I consider the problem of delimitating the disciplinary domains of psychiatry and neurology as essential in the evolution of our knowledge.
I. T H E I S S U E O F D I S C I P L I N A R Y DELIMITATION
The problem of delimitating the disciplines has always existed. Thus, delimitating the area of psychic disease towards psychological suffering, a shade of normality has drifted in a direction or another throughout time. Delimitating the psychopathological behavior from some culturally imposed behavioral patterns has always aroused debate. Presently, it is necessary to clarify the space which delimitates the psychiatric and the neurologic pathology.
The definition of chapters of human diseases and their classification (4) is mainly dictated by the organ ( heart, eye… diseases) and by causality ( infectious, tumoral etc.). As for neurology and psychiatry, they have an intersecting definition dictated by the organ. Neurology expresses by its notion a series of diseases of the nervous system. Psychiatry deals with diseases which do not necessarily affect the CNS, a part of nervous system, but which cannot be considered in their biological insertion outside the central nervous system, some a lot, others a little or at all.
The definition of diseases, not of chapters, is clinical. (5) Historically, as they have been known, the diseases have been and will probably always be clinically defined, which is syptomatologically. From this point of view, neurology and psychiatry are essentially different. One refers to the quantitative affection of the motor and sensorial functions and the other refers to flows of the psychic. One refers to „palpable” symptoms and signs while the other refers to subjective signs and symptoms (thoughts, feelings, sensations etc.)
However, if we analyze the insertion into the biologic aspect at the level of present knowledge, more exactly, that part of causative roots of the psychic diseases, then the two groups of diseases are close, up to the point of claiming their borders, and more deeply, from the genetic aspect, they have large areas of common pathogenic vulnerabilities.
Let us take dementias, for instance. There are approx. 77 neurological diseases which have a demential syndrome in their clinical description. The demential syndrome is the expression of sufferings by global collapse of the psychism. (6). But, apart Alzheimer disease which does not have neurological symptoms in its first third of evolution, all the other diseases, including Alzheimer in its last two thirds of evolution, have psychopathological symptoms of dementia as well as neurological symptoms. So, these diseases have double categorization. But only the Alzheimer and mixed vascular Alzheimer dementias have specific causative treatment. For the remaining set, the intervention of the psychiatrist is still unnecessary and inefficient. (7). In case of Alzheimer disease, however, the therapeutic intervention of the neurologist is unnecessary, any psychiatrist can monitor the evolution of the disease according to his knowledge.
In case of psychosis, be them of schizophrenic or affective type (8), we deal with neuroplasticity phenomena, up to anatomic modifications (third ventricle and the surrounding formations). Nevertheless, although we have anatomic modifications, we do not have neurological symptoms.
All these aspects pose the problem of interference between the two specializations, of the delimitation between them in pathogenity, which automatically imply therapeutic competence.
The problem has four logical solutions. The first one is the one in which the diffuse affection of the neuronal populations – like the one in psychosis, Alzheimer disease, alcoholic dementias, dementias caused by other intoxications and dementias from minor and repeated cerebral strokes, which only give psychic modifications- to be considered as belonging to psychiatry in the depth of pathogeny. The second solution would be that all demential diseases to be considered, from the depth of pathogeny to symptomatology, as psychic diseases. The third one would be that all the diseases which affected the brain not just macroscopically but microscopically, as well, to be considered neurological diseases. The fourth solution would be that all these diseases to be considered diseases which involve both the psychiatrist and the neurologist.
The first solution makes a sufficiently clear disjunction (9), derived from the definitions of the diseases, but pathogenic as well. The diffuse affection of the brain, meaning the lessening of the neuronal population in a diffuse way, initially affects only the psychic functions, like in psychosis. On the way, depending on the intensity of the neuronal depopulation, there can be neurologic symptoms as well, like in Alzheimer disease. These should be then considered psychic diseases. The complete therapeutic range of these diseases, which comprise biological, psycho-therapeutic, behavioral recuperating treatments, apart the biological ones, are outside the neurologist’s expertise. The second solution would extend the first one by comprising all the diseases which give dementias and would confront the psychiatrist with a neurological symptomatology and pathology for which he has no expertise. The third solution would force the neurologist to deal with non- neurological diseases, like playing the role of a GP when confronted with them. The fourth solution, the one which implies team work, would be the most realistic one, if these teams are complex and made up of a psychiatrist, a neurologist, a psychologist, a psychotherapist, a social worker, in clinics as well. But this solution is not possible in many countries due to financial and organizational issues. That is why the most logical and realistic solution is at present the one which proposes that the diseases with roots in the suffering of the central neuronal masses, which affect diffusely the neuronal populations and which give from onset to offset or just in the first half of their evolution only psychopathological sufferings, to be considered psychic diseases, as it is the case empirically – except Alzheimer disease- in certain geographical areas.
The disjunction between the domain of psychiatry and neurology, in the depth of the pathogeny of neuronal populations must, clinically and logically, be considered presently at a level of diffuse affection which generates psychiatric pathology versus the macroscopic affection of the brain, which, with certain exceptions dictated by the clinical picture of the disease that confirm the rule (10), such as the Parkinson disease, affect the motor functions and quantitatively the sensorial ones.
1.Plotin. Opere III. Bucharest: Humanitas, 2010, 38, VI 7,5.
2.Boetius of Dacia. Despre viaţa filosofului. Bucharest: Polirom, 2005, 29.
3.Eco U. De la arbore spre labirint. Bucharest: Polirom, 2009, 172.
4.World Health Organizațion. International Classification of Diseases. (10-th Edition – Romanian). Bucharest: Ministry of Health, 1993.
5.Ey H, Bernard P, Brisset C. Manuel de Psychiatrie. Masson et Cie, 1974.
6.American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed. TR). Arlington, VA: American Psychiatric Publishing, 2000.
7.Lăzărescu M. Bazele Psihopatologiei Clinice. Bucharest: Editura Academiei Române, 2010.
8.Gauthier S. Clinical Diagnosis And Management Of Alzheimer’s Disease. Martin Dunitz: 2nd, 1999.
9.Kasper S, Papadimitrion GN. Schizophrenia. Informa, 2009.
10.Raden J. The Philosophy Of Psychiatry. Oxford University Press, 2004.
11. Osler W. The Evolution Of Modern Medicine. Yale University Press, 1921