The short video below introduces today’s blog:
I read a great post by Dr. George Dawson about neuroscience, which seemed to be a nice counterpoint about my rant on the same subject. Compare the tweets below:
What got this started was the JAMA Psychiatry article published March 13, “The Future of Psychiatry as Clinical Neuroscience: Why Not Now?” You can’t get the whole text unless you subscribe, which annoys me, but I pulled quotes from it and they bothered me a little. The best example is “The diseases we treat are diseases of the brain.”
OK, so I’m hung up on the broad assumption that every mental disorder or behavioral issue is a disease. That’s because when I was a resident, one of the lecture series was Perspectives in Psychiatry and it was delivered by Dr. Robert G. Robinson, MD, PhD, who was the department chair at the time. It’s based on the book by the same name, written by Paul McHugh, MD and Phillip Slavney, MD. This book was developed into another book, Systematic Psychiatric Evaluation, geared to practical application of the principles described by McHugh and Slavney.
Bob is a consummate neuropsychiatrist. He’s done a lot of research on poststroke neuropsychiatric syndromes and is a great example of a clinical neuroscientist. No one has ever referred to him as “Way Out Willie,” at least not that I know of–lately. He co-edited a book with me on consultation psychiatry.
Bob came to The University of Iowa from Johns Hopkins to lead the psychiatry department. Our new chair and epigenetics and psychiatric disorders expert, Dr. Jimmy Potash, also from Hopkins, now delivers the Perspectives in Psychiatry lectures, carrying on the tradition. This approach makes a distinction between psychiatric problems as diseases and, for example, life story issues.
That’s why I have a problem with blanket statements that sound like the proposition, “All mental disorders are brain disorders.” Maybe that’s why Bob has told me that I’ll never be a scientist, but I think that’s mainly because I’m a humorist. We both know I appreciate the importance of clinical neuroscience in psychiatry. And I don’t think either Bob or Jimmy believes that all mental disorders are brain disorders. But maybe I should ask them.
I doubt the lay public believes that either.
On the other hand, it’s clear that the influence of the neuroscience aspect of psychiatry has reached into the careers of general hospital psychiatric consultants. You can get sense of that from articles like the one published in Psychiatric Times, entitled “Brief Psychotherapy at the Bedside: Existential Neuroscience to Mobilize Assertive Coping.
However, as I read the article I get the sense that psychiatric consultants can foster more adaptive coping in the hospitalized medically ill by using supportive psychotherapy and motivational interviewing without having a diagram of the “brain circuits and signaling pathways” that underlie the interpersonal interaction. In fact, the authors of the Psychiatric Times article about existential neuroscience described doing just that in their 2005 paper, (Griffith JL, Gaby L. Brief psychotherapy at the bedside: countering demoralization from medical illness.Psychosomatics. 2005;46:109-116) on which the current article is based. The neuroscience component was added seemingly to modernize it. They otherwise send essentially the same message.
When I’m called to a Code Green (emergency situations in which violence may occur or has already occurred, often because a patient is delirious) in our emergency room or anywhere in our hospital, I’m not thinking about neurotransmitters. I’m wondering how to help ensure that everyone involved will be safe and hopefully unharmed. When I’m listening to a patient talk about her many losses after being in the hospital for weeks, sometimes months, I’m concentrating on being a witness to her suffering, not a repairman to her neuroreceptors. And I think that’s how most psychiatry residents think of their interactions with patients most of the time.
I’m not anti-neuroscience. But I can see why some chief residents in psychiatry who were surveyed about the inclusion of neuroscience topics in resident didactic lecture schedules couldn’t think of a practical application for it. Faculty have to use the ACGME Milestones to evaluate residents. I just took a quick glance at one of the latest articles on the Milestones Project in the March/April 2015 issue of Psychosomatics . This was on the Milestones for Psychosomatic Medicine; I didn’t see the word “neuroscience” in it.
It’s just happenstance that there is an article on traumatic brain injury ( and I’m not insinuating that trying to teach neuroscience to psychiatry residents is in any way traumatizing to their brains–not in the slightest, no sirree-Bob Robinson, no way, not at all) in the March 2015 issue of Psychiatric Times that mentions “hand waving,” which the author points out means “attempting to get past a moment when a difficult explanation is required.” When it comes to clinical neuroscience in psychiatry, sometimes it seems like there’s an awful lot of that going on.
1. Boland, R. J., et al. (2015). “The milestones for psychosomatic medicine subspecialty training.” Psychosomatics 56(2): 153-167.
BACKGROUND: The Accreditation Council of Graduate Medical Education Milestones project is a key element in the Next Accreditation System for graduate medical education. On completing the general psychiatry milestones in 2013, the Accreditation Council of Graduate Medical Education began the process of creating milestones for the accredited psychiatric subspecialties. METHODS: With consultation from the Academy of Psychosomatic Medicine, the Accreditation Council of Graduate Medical Education appointed a working group to create the psychosomatic medicine milestones, using the general psychiatry milestones as a starting point. RESULTS: This article represents a record of the work of this committee. It describes the history and rationale behind the milestones, the development process used by the working group, and the implications of these milestones on psychosomatic medicine fellowship training. CONCLUSIONS: The milestones, as presented in this article, will have an important influence on psychosomatic medicine training programs. The implications of these include changes in how fellowship programs will be reviewed and accredited by the Accreditation Council of Graduate Medical Education and changes in the process of assessment and feedback for fellows.