Neuropsychiatry, Encephiatrics, and Ergasiology, Oh My!

First of all, a shout-out regarding the NICE Guidelines for Delirium update. Remember my broken links post about this in November? Well, as promised, the NICE Guidelines have been updated and we now have access to a much better organized and responsive web site which allows downloads of valuable guidance about monitoring for and managing delirium. The powerpoints and the pdfs are back and I couldn’t be more excited. You can reach the site from my link list or google it. It’s definitely worth a look.

Another shout-out is the first year anniversary of our Psychosomatic Medicine Interest Group (PMIG) and, as one participant remarked, it hardly seems possible that a year has already flown by! The trainees have made it a huge, popular success and it’s not just because of the free lunch–though pizza helps.

The subtext for the January PMIG meeting is the growing field of Neuropsychiatry. I admit I used to make fun of the neuroscience focus in psychiatry, but believe me, I’m reformed. The latest article is a piece in the December 15, 2016 issue of Psychiatric Times, which I recently tweeted.

The article led me to explore the Neuropsychiatry specialty saga even further. I can tell you it looks a lot like what happened to Consultation-Liaison (C-L) Psychiatry…Psychosomatic Medicine (PM) if you prefer to call the specialty by that name. However, the Academy of Psychosomatic Medicine (APM) is checking with the membership about changing the PM name to C-L Psychiatry if enough members vote for that. It would mean the APM might change its own name.

I commented on article; it’s the long-winded one signed “James.” I forgot to sign my full name. But it’s the really short one right above mine, written by Dr. Ronald Pies, MD, which led me to other papers that kindled my interest in the integrative movement which has been going on for many decades in so many areas of medicine. The Neuropsychiatry specialty issue is just one of several large-scale efforts to swing the field away from fragmentation toward integration. Why else would we see the development of combined specialty programs including Internal Medicine-Psychiatry, or Family Medicine-Psychiatry? And the rich and complex history of the road to specialization for C-L Psychiatry has been detailed in Dr. Don R. Lipsitt’s book, “Foundations of Consultation-Liaison Psychiatry: The Bumpy Road to Specialization.”

Recall my post about the proposal by Dr. William R. Yates, MD, who was one of my teachers, to create a specialty called Neuroscience Medicine. He envisions the core specialties as psychiatry and neurology, similar to what Schildkrout and Frankel describe for Neuropsychiatry. Notice that my comment focuses on a few of the nuts and bolts of the effort to establish the specialty–which probably betrays my skepticism. I’m such a geezer.

Then have a look at Dr. Pies’ succinct remark along with a link to an article containing his comment on the viability of combining psychiatry and neurology. It’s that one link which eventually led me to what, in my opinion, is his brilliant 2005 editorial, Why Psychiatry and Neurology Cannot Simply Merge,” (Pies, R. (2005). “Why psychiatry and neurology cannot simply merge.” J Neuropsychiatry Clin Neurosci 17(3): 304-309.). He has never said that the two disciplines can never be combined. In fact, he introduces his idea of a broader discipline called “encephiatrics.”

If you think I’m going to make fun of yet another name for a specialty which tries to integrate medicine and psychiatry–you’re right. Recall a roughly similar-sounding name, “encephalopathologist” which is what one person suggested in a letter to the editor about an article in Current Psychiatry (Current Psychiatry 2016 March;15(3):23-24.). The entire letter is below:

“We are not ‘psychiatrists’
I found Dr. Nasrallah’s editorial regarding the future developments in psychiatry interesting (Do you practice sophisticated psychiatry? 10 Proposed foundations of advanced care, From the Editor, Current Psychiatry. August 2015 p. 12-13). As a young psychiatrist in private practice, I understand why the title “psychiatrist” was initially adopted. I am sure that many of my colleagues agree that the word “psyche” is an abstract, confusing concept: How can we claim to treat something that is not part of known human anatomy?
Nevertheless, we need to clarify the specific nature of our work, namely: the diagnosis and treatment of diseases of the brain, considering other medical causes that can present or exacerbate brain nosology, while providing guidance to modify behavior, thus improving the functional, social, and overall lifestyle of our patients.

We need to change our title to what we really are—encephalopathologists, not psychiatrists!
Marios Efstathiou, MD
Psychiatrist, Private Practice
Member, Cyprus Psychiatric Association
Cyprus”

That sent me on a tangent this spring about alternative names for doctors who believe that we ultimately can’t separate the brain from the body. How about Ergasiology? Love ergasiology!

Can I learn to love “encephatrics”? Maybe. But it’s probably more important to pay attention to why Dr. Pies believes it would be difficult for psychiatry and neurology to simply merge. I’m not smart enough to restate it in my own words and, besides, he says it better:

Still, we have other reasons to believe that the discourse of psychiatry differs fundamentally from that of neurology, notwithstanding the common substrate of these two disciplines (i.e., the human brain). The discourse of psychiatry, notwithstanding its burgeoning interest in neuroscience, remains grounded in human subjectivity and existential concerns. This applies not only to psychotherapy but to psychiatry as a whole. Psychiatry has always been, and essentially remains, a discourse of interlacing and multilayered meanings. Neurology is fundamentally a discourse of neuroanatomical and neurophysiological relationships.

The emphasis on what has been called “narrative-experiential listening” and the existential meaning of life experience might be specific to psychiatrists’ definition of what they do. Maybe neurology’s raison d’etre is more along the lines of emphasizing neuroanatomical relationships. I don’t think that belittles neurology, especially when you consider Schildkrout and colleagues’ vision of Neuropsychiatry (Schildkrout, B., et al. (2016). “Integrating Neuroscience Knowledge and Neuropsychiatric Skills Into Psychiatry: The Way Forward.” Acad Med 91(5): 650-656.). As they point out:

Psychiatry has traditionally concerned itself with what is individual and personal—namely, life experiences and the construction of meaning. Brain function is also an important aspect of individuality. In this era of rapidly advancing scientific information about the brain, it is now possible for psychiatrists to integrate knowledge of neuroscience into their understanding of the whole person by asking, What person has this brain? How does this brain make this person unique? How does this brain make this disorder unique? What treatment will help this disorder in this person with this brain?

That sound a lot like “It’s far more important to know what person the disease has than what disease the person has.”  – Hippocrates of Cos (c. 460 BC – c. 370 BC).

Happy holidays!

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Comments

  1. Hi Ron, I can’t begin to tell you how absorbed I was by your essays on encephiatrics and the merging (or not) of psychiatry and neurology. Your debate with the neurologist on the topic in 2010 and which was also published in Psychiatric Times was fascinating. I always thought of “sanity” as a legal term rather than a psychiatric one, referring to your opponent’s position, opposing the merging of the two specialties.

    I’ve shared your excellent essays along with those of Dr. Schildkrout and colleagues with the resident and faculty members of our new Psychosomatic Medicine Interest Group (PMIG) as part of preparation for our one year anniversary meeting next month. I wish you could be our guest!

    Have a happy New Year,

    Jim Amos, MD

    Like

    • Ronald Pies MD says:

      Many thanks again, Jim! Actually, the debate I had was with one of my residency teachers and supervisors, Bob Daly–who is a brilliant philosopher-cum-psychiatrist. We were each assigned a “side” in the debate, though I think I was less comfortable with my position than Bob was with his! I really do think there is plenty of room for some kind of creative “fusion” of these fields. Take care and keep up the great postings…

      Ron

      Liked by 1 person

  2. Ronald Pies MD says:

    Greetings, Jim–Thanks for the interesting piece on integrating psychiatry and neurology, and for the kind call-out to some of my scribbling on the subject! I was also happy to see Dr. Don Lipsitt’s work mentioned, since Don was one of my most learned supervisors, some years ago.

    In the service of integrating psychology and biology–or psychiatry and neurology–I’ll also mention Nobel Prize laureate Dr. Eric Kandel’s excellent book, “Psychiatry, Psychoanalysis, and the New Biology of Mind.”

    I was never that happy with my term, “encephiatrics”; and Meyer’s term, “ergasiology,” sounds like a condition you’d treat with simethicone! Someday, we’ll find the right Latin, Greek or Esperanto term for the very important integrative work we do in this field.

    Thanks again, and best wishes for the New Year,
    Ron

    Ronald Pies MD

    Liked by 1 person

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