September 2009, Volume 59, Issue 9

Editorial

For the sake of your patients, talk to each other!

Haider Ali Naqvi  ( Department of Psychiatry,Aga Khan University,Stadium Road, Karachi, Pakistan. )
Ayeesha Kamran Kamal  ( Section of Neurology, Department of Medicine,Aga Khan University, Stadium Road, Karachi, Pakistan. )

References

1.Naqvi H, Khan M. Post-stroke depression. Pak J Neurological Sci 2006; 1:18-24. 
2.Katon W, Ciechanowski P. Impact of major depression on chronic medical illness. J Psychosom Res 2002; 53: 859-63.
3.Akil M, Brewer GJ. Psychiatry and behavioral abnormalities in Wilson's disease. Adv Neurol 1995; 65: 171-8.
4.Marsden CD. Hysteria - a neurologist's view. Psychol Med 1986; 16: 277-88. 
5.Kanner AM. When did neurologists and psychiatrists stop talking to each other? Epilepsy Behav 2003; 4: 597-601. 
6.Berc EA. A simple objective test for measuring flexibility in thinking. J Gen Psychol 1948; 39: 15-22.

Psychiatry and Neurology are disciplines which have quite an overlap. At least, the illness, so far have not started distinguishing themselves in sections and departments. Depression is a complication of stroke, much as it is co morbidity with other chronic diseases.1,2 Epilepsy has the same stigma attached to itself as Schizophrenia; both have supernatural grounds attributed to it. Evil spirits or possession by spirits impairs help-seeking, leading to social isolation and exclusion. Similarly presentation of certain neurological conditions can be very confusing, albeit mimicking psychiatric disorders. It would not be wrong in stating that conditions like Wilson's disease and Huntington's chorea have neuropsychiatric manifestations in the early part of their course.3 Astute neurologists are always mindful of these perfidious presentations.
Then there are those conditions which bring neurologists and psychiatrics face to face. The turf between the two specialties might not be that clear cut when it comes to conversion disorder. Literature gives a high probability of conversion disorder in patients with known epilepsy.4 We are told that diagnosis of epilepsy is primarily based on clinical history or description of seizure episode. A high false positive rate of EEG doesn't help either. With a patient lying on the couch, neurologist on one side and psychiatrist on the other side, arguing that the jerks were tonic-clonic, or otherwise, the debate continues.  
The curtain has been drawn on this conflict since a long time at the cost of embarrassment to medical professionals and compromised patients' care. We decided to examine this issue, which is not specific to any setting, initiating a dialogue between the two and asking for their opinion on these differences.5
Psychiatrists generally feel that neurologists are too dependent on technology. Some might say that they have lost the finesse to talk to patients since the departure of Sigmund Freud, who happened to be a neurologist by training. They find comfort in the concreteness of neuro-anatomy and brain pathways; if anatomy is the destiny then it leaves no room for fluid states like Ego, Superego or Id.   By the default of their training, they would hang on to their hammer and whatever it may elicit (from Babinski's sign to an exaggerated knee jerk), they might take the pain of doing lumber puncture but would not sit with him to talk about what is worrying him. Similarly they would look in to the black and grey of an MRI Scan but would not trust Rorschach's ink blot test.6 However one would also confess that some Neurologist's listening skills are as good as any Psychotherapist's. 
Neurologists on the other hand think that psychiatrists are secretive about their management principles, handing them down the generation of trainees. They think that there is a secret recipe, an insight in to the avenues of unconscious mind which psychiatrists guard obtrusively. Half life of a psychiatrist is another matter of debate; the more years one spends, dealing with patients of unsound mind, the greater the impact on one's own mental equilibrium. Individuals become disagreeable, cranky insisting on their own way to the point of being obsessive. Some resort to paranoid distrustfulness, taking offense when none was intended, sensitive to criticism and disagreement. Some neurologists would go to this extent that they proclaim that psychiatrists are failed doctors. Though there is no objective evidence to claim such impressions which may have stemmed from the stigma attached with the mental illnesses and health professionals. In fact some of the Psychiatrists have been at the forefront of social reforms and movements for a civil society (M. Scott Peck, 1936- 2005). 
Contradiction in the professionals is even reflected in day to day practice. One may treat the extra-pyramidal symptoms in Parkinsonism while the other may induce them through dopamine blockers. Psychiatrists give dopamine blockers while neurologists might use their agonists. One may treat epilepsy while other may induce it through medications which lower the seizure threshold. To add fuel to fire they don't talk to each other.
Neurologists might feel more at ease with Neurosurgeons or Neuroradiologists who may share the flare for technology.  On the same ground psychiatrist may feel more at ease with psychologists or sociologists who may share their passion for abstractions. In essence all are part and parcel of one discipline, which can be best described as Neurosciences. The sooner they are able to recognize it the better it is; there are research issues at the interface of these disciplines which can never be resolved unless one takes a multidisciplinary approach. Science has no boundaries, no drawing room clichés. It is ruthlessly honest, demanding integrity, collaboration and teamwork. Though it may not be focused on proving the truth, it does focus on falsifying the falseness of evidence or a hypothesis.
Analogy can be drawn between a good patient care and a relay race; one person does his bit of running and passes on the baton to the next person. In patient-management, a team of physicians becomes important; it is reliance on other person's expert judgment that can be a decisive factor. Decisions need to be made on the spur of the moment. This can be a life and death issue for a patient. If the person on the other side drops the baton, or comes up with excuses of one sort or another, then one looses the sense of connectivity. Ultimately it is the 'team' that looses. This applies to most disciplines in Medicine as they have to work together in order to deliver comprehensive care. The various subspecialties in Medicine, Maternal and Child health, neurosciences, Radiology and Pathology have to work in close liaison in order to deliver complete care.
The practice of Neuroscience is ultimately geared towards saving the brain — in doing this we restore functional ability and return people to the roles that they perform in life; in other fields of medicine the loss of functionality is not as profound as the disorders of the Brain. A young son at age 18 may start hearing voices and never fulfill the dreams that his mother envisions for him, or a mother may have her first seizure and forever become unsure of giving her baby a bath. In contradistinction, a heart attack is merely a 'troponitis' — it does not take away who you are. It is imperative that those imbued with the responsibility of restoring these persons — communicate, because their ultimate goal, after all, is the same.
Since neurologists and psychiatrists work closely, differences crop up frequently. Relationships become stale, and level of trust decreases. A few centers have joint peer-review meetings or case-conferences, giving an opportunity to discuss these issues. Such meetings should be held on regular basis in order to facilitate the discussion.      
The differences in approach can be due to, a different Medical world view. Both, neurologists and psychiatrists have a common goal i.e. patients well being. The approach can be different. One is focused on the whole while the other might be looking at the obvious piece. It is just like lateralization; the left brain and right brain might have different specializations though one may not be superior to the other. These might be complementary, a whole brain which can reason logically, communicate coherently and be able to appreciate the abstractness of clinical presentations. This is akin to understanding the prosody inherent in the work of Mozart or appreciation of the emotional infliction in Di Vinci's work.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: