New BMJ article by White & co: Merge neurology and psychiatry

[Anne]

New article by White & co in British Medical Journal:

Analysis
Time to end the distinction between mental and neurological illnesses
http://www.bmj.com/content/344/bmj.e3454

From CAA:s Facebook page:

Published today (behind a paywall), an article by White, Rickards and Zeman titled, "Time to end the distinction between mental and neurological illnesses" that proposes psychiatric disorders be classified as disorders of the nervous system. In the text of the article, CFS is one of several conditions grouped as functional somatic syndromes, "which are neither solely physical nor solely mental but both." They also propose merging the mental, behavioral and neurology chapters of the ICD-11, a classification system used to code for insurance reimbursement and other payment systems.

Link to abstract: http://bit.ly/JMFI7u

 

[Esther12]

Thanks Anne.

This will update our classificatory system in the light of contemporary neuroscience and foster the integration of psychiatry into the mainstream of medicine, where it belongs.

Do they mean it will make the sort of quackery involved in claiming patients are 'back to normal' when they are more disabled than was needed to be classed as suffering from severe and disabling fatigue will no longer be acceptable? Or just that fewer people will distrust them when they claim to know what they're talking about.

To integrate psychiatry into the mainstream of medicine, we need to raise standards for psychiatrists. That would help rid us of people like White, and benefit everyone.

 

[SOC]

In the text of the article, CFS is one of several conditions grouped as functional somatic syndromes, "which are neither solely physical nor solely mental but both."

Oh, please! While this is a sign that the psychobabble contingent is beginning to recognize that there is indeed a physical basis for ME/CFS, it's still nothing more than a self-serving rationalization of their previous untenable, absurd, and abusive beliefs, treatments, and policies. Just a fancy-dancing, wiggle-worded attempt to cover their asses which are becoming increasingly exposed as more medical data becomes available.

Some forms of mental illness are the result of disordered thinking and not physical diseases or dysfunctions. Substantial harm can be done by all kinds of mental and physical abuse or trauma. People learn dysfunctional thinking in order to cope with the situation. Talk therapy, not neurology, is what is needed in those cases.

Schizophrenia and some forms of depression (among others) have been demonstrated to be physical illnesses which are appropriately treated with medications. They should be treated as neurological illnesses, not illnesses of the mind. It's simply a recognition of the difference between the brain and the mind.

Falsely conflating psychiatry and neurology only serves to save face for the psychobabble lobby whose claim on a number of physiological illnesses is becoming exposed as the falsehood it is.

Psychology and neurology are two distinct fields. There's nothing wrong with psychology applied correctly. What's wrong are the false "territorial" inroads psychology and psychiatry keep trying to make into other fields by claiming that genuine physical illnesses are the result of "false illness beliefs".

There is no reason that a person wouldn't need care from both fields. After all, having a serious illness, especially one that affects brain function could easily cause dysfunctional thinking as a coping mechanism. That doesn't make the two problems the same field.

Frankly, I don't think the psychiatry people belong in neurology, where they will continue to muddy the waters. Psychiatry may cease to exist as a field of specialty and the domain divided (correctly) between psychology and neurology, which would probably be a big benefit to all patients.

 

[Esther12]

I think that there are always going to be areas where what's considered psychiatry overlaps with what's considered neurology.

But there are moral problems with the way in which psychiatry treats a lot of patients.

I find a pragmatic approach to the management of human being's cognitions to be pretty repulsive, and something that could only ever be justified in the most extreme of circumstances. If psychiatry permits such an approach, then we should try to make psychiatry as small as possible, and something which will only affect as few patients as is possible - we certainly shouldn't allow it to expand to include all those with neurological problems too.

 

[floydguy]

I think that there are always going to be areas where what's considered psychiatry overlaps with what's considered neurology.

But there are moral problems with the way in which psychiatry treats a lot of patients.

I find a pragmatic approach to the management of human being's cognitions to be pretty repulsive, and something that could only ever be justified in the most extreme of circumstances. If psychiatry permits such an approach, then we should try to make psychiatry as small as possible, and something which will only affect as few patients as is possible - we certainly shouldn't allow it to expand to include all those with neurological problems too.

Please expand on where exactly you think psychiatry overlaps with neurology. I tend to look at psychiatrists as psychobabblers with prescription pads. I think healthcare would be a lot better off if there was a distinct separation where there were psychologists - sans drug dealing authority - who use talk therapy and those based in hard science, such as neurologists. Psychiatrists operate in the nebulous middle and seem to be at the root of much mischief.

 

[SilverbladeTE]

"Oh please buy our insane bullsh*t, because we know we are going to be exposed as frauds and absuers and maybe even participants in genocide, so don't throw our worthless asses in jail for 30 years of evil stupid crap a 5 year old could see through and all the new research is going to do just that, so we're spewing bullshit to cover our butts!

Oh and our new book is selling for £30 a copy, suckers!"

yeah...don't let the door hit your ass ont he way out, White & Co!

 

[alex3619]

Two comments I made on this on facebook:

"This is a paper by Peter White and others. White is a major proponent of CBT/GET for CFS and ME, and the chief architect of the PACE study. It is not clear to me that the CAA is supporting this, only that they are reporting on it."

"Something else just occured to me. Psychiatry has a very poor scientific basis. Neurology has a much stronger scientific basis. If this ever groes through then psychiatry will be atttempting to reach for stronger scientific support, but dragging the scientific credibilty of neurology down with it."

If this ever goes through this will be a dark time for medical science. I forsee a justification for neurology replacing psychiatry, but not merging with it. Are psychiatrists just trying to save their profession?

Bye, Alex

 

[Snow Leopard]

Given that psychiatric disease is heavily penalised in terms of insurance codes (eg limits of 2 years of coverage!), this could (in principle) be a good thing. But the other side is that psychiatrists start to use objective neurological testing when diagnosing psychiatric illnesses. I'll believe that when I see it.

 

[Calathea]

Neurology does seem to be wandering into the field of psychiatry. I've just learned (with horror) about the existence of "functional neurology", which mainly seems to be a rebranding of "it's all in your mind, dear" in a way that they hope won't offend the patients. The whole concept is based on deceit and is extremely alarming. It shouldn't exist in any medical field at all, as far as I can tell. And yes, they include ME/CFS in this category, and I've seen a website by a functional neurologist where they define ME/CFS as any fatigue lasting for more than 6 months where there are no neurological symptoms or organic causes.

 

[Esther12]

Please expand on where exactly you think psychiatry overlaps with neurology. I tend to look at psychiatrists as psychobabblers with prescription pads. I think healthcare would be a lot better off if there was a distinct separation where there were psychologists - sans drug dealing authority - who use talk therapy and those based in hard science, such as neurologists. Psychiatrists operate in the nebulous middle and seem to be at the root of much mischief.

Even if you're starting from an assumption that conventional psychiatry is largely quackery, then there are still overlaps imo.

eg: Neurological problems can lead to anxiety, and cognitive-behavioural techniques can held patients think more clearly in response to states of anxiety induced by physical and neurological changes.

 

[Anne]

One wonders: What do the neurologists think of this?

If anyone has the possibility to follow any upcoming debate/letters in BMJ, please report.

 

[Calathea]

Even if you're starting from an assumption that conventional psychiatry is largely quackery, then there are still overlaps imo.

eg: Neurological problems can lead to anxiety, and cognitive-behavioural techniques can held patients think more clearly in response to states of anxiety induced by physical and neurological changes.

That's true of all medical conditions, though. There are doubtless people who could really use some good CBT to help them deal with the consequences of a broken leg. There will be a number of factors determining how likely a physiological condition is to have psychiatric effects, including the following:

1. How long the condition lasts.
2. How disabling it is.
3. How far it affects important aspects of life such as work and relationships.
4. How dangerous it is, particularly if there is a risk of death.
5. How predictable it is.
6. How treatable it is.
7. How far it affects a person's sense of core identity.
8. How invasive the condition and/or treatment are.
9. Whether the condition and/or treatment affect brain chemistry, or areas which have a knock-on effect on brain chemistry (e.g. sleep deprivation).

My mother ended up pretty damn traumatised by having cancer, for instance, and needed specialist counselling for cancer patients. I don't think that neurological conditions are necessarily more likely to create psychological effects. I have auditory processing disorder, for instance, and I wouldn't say that it's had any psychological effects - the odd moment of social awkwardness, yes, but nothing that actually caused distress. I reckon it's mainly down to the overall impact of the condition in your life. And of course, ME is often highly devastating in that respect. But then so are plenty of non-neurological conditions. I haven't heard anyone suggesting that AIDS should be treated as a psychiatric condition, for instance, or that it "overlaps" in that way.

One of the problems is that if you have AIDS or cancer, you will hopefully be offered counselling which focuses on how this is a bloody awful, not to mention frightening, illness to have, and how to deal with that. The illness is still seen as physical. With ME, the counselling offered as standard completely ignores that important aspect in favour of victim-blaming, telling us that it's our own fault we got ill for not having the right mindset. Completely different approach.

 

[Esther12]

That's true of all medical conditions, though.

Yeah - to some extent that's true.

But neurological problems can very directly lead to certain emotional responses, without requiring a cognitive mechanism. eg: changes in hormone levels need not cognitively concern a patient before leading to a type of anxiety (assuming that 'anxiety' is not defined in a way that requires cognitive response... the semantics of all this seem to get complicated quickly and easily, as so many psychiatric concepts have disputed definitions. There was some recent study about inducing anxiety without the cognitions of anxiety... I think that different patients responded to it in different ways).

This is also true for certain non-neurological conditions which can have a direct affect upon hormones, etc.

There was something on the radio recently about a patient whose brain tumour led to paedophilia, and a sexual pursuit of his step daughter. When the tumour was removed he stopped feeling (or acting upon) those desires. 6 months later and he started to feel attracted to children again, so went back to the doctors and they found that some of the tumour had regrown, so another surgery was required. I've no idea if that story is true, but such occurrences would certainly seem to be possible.

Also, our cognitions are the result of our neurological make up and responses. The trauma your mother felt as a result of her cancer would have been a result of, and impacted up, the operation of her brain.

Psychological and neurological responses are a vital part of every aspect of all individual's lives. That's why we need to take such care when medicalising these areas, and placing certain groups of people in positions of power and authority over others. Without effective systems of regulation and accountability, they will easily become manipulative and abusive (as we've seen with CFS). There are also important moral and political concerns around these issues, and particularly around the way in which certain people are viewed as dysfunctional. The emphasis upon the cognitive and behavioural aspects of many mental health conditions has done a lot to stigmatise those with these diagnoses, and promoted a misleading view as to their nature and how to effectively treat them. I also think that the way in which the biopsychosocial approach to medicine is used to medicalise the cognitions of those in positions of weakness, according to standards that are not applied to those in positions of power, is really disturbing.

(I realise that I've not been clear enough... sorry about that.)

 

[Calathea]

The joys of one person with brain fog trying to explain something to another person with brain fog, eh. I'm a bit dopey today, so I think I will look at your last paragraph again later. It looks good to me from what I've been able to take in so far.

Also, our cognitions are the result of our neurological make up and responses. The trauma your mother felt as a result of her cancer would have been a result of, and impacted up, the operation of her brain.

But then surely this proves my point that if you're going to look at it that way, everything involves the brain/neurology, so it becomes a pointless distinction? You can't have a working body without a brain, and all aspects of how your body functions will impact upon your life in a highly complex fashion. My mother's being traumatised by cancer didn't happen because the cancer had a direct effect on her brain (it wasn't brain cancer, for the record), it was because she knew that the cancer could kill her, and was going through a host of unpleasant, invasive medical procedures to boot.

Another point - merely being in hospital will usually raise anxiety levels, whether it's a little or a lot. This effect will happen whatever the reason for being in hospital, although of course if you combine it with certain other factors, such as fear of death, that will heighten the response. It's one of the reasons why many people prefer home births. It's also particularly true of dentistry. In many cases, it will even affect a visitor to the hospital who is not actually a patient.

I have multiple medical conditions by now, some due to the ME, some not. Some are neurological, some aren't. They all impact upon my life in different ways, and some will cause more of a psychological response than others. There does not appear to be any correlation between neurological conditions and psychological effect for me, however. Indeed, the neurological conditions tend to be less that way, if anyway. There's the APD which I mentioned above. Migraine is usually considered to be a neurological condition, and that one has minimal psychological effects on me. Dizziness - annoying but not exactly emotional. If I go through extended periods of being unable or barely able to use my hands, however (purely physical causes there), I start climbing the walls. So when I am unable to use one arm for a month at a time due to having a calcium deposit problem in the shoulder tendon, are you saying that this isn't orthopaedics, it's neurology?

I'm starting to feel as if I'm swimming in circles here, and also that we may actually be arguing the same point!

 

[Esther12]

Even without CFS, I think that can be a difficult topic to talk clearly about!

But then surely this proves my point that if you're going to look at it that way, everything involves the brain/neurology, so it becomes a pointless distinction? You can't have a working body without a brain, and all aspects of how your body functions will impact upon your life in a highly complex fashion.

Yes... and some try to use this as a justification for a biopsychosocial approach which medicalises the cognitions of patients regardless of whether cognitive distortions have been identified. I don't think that our developing understanding of how mind and body interact does anything to legitimise this sort of political and moral action.

I don't think that the distinction between psychology and neurology is completely pointless, but it is impossible to pretend that there is a clear boundary between the two (depending upon how either is defined... it probably is possible to come up with an understanding of psychiatry which is more distinct from neurology than is currently the case, but the way in which the boundaries of psychiatry are currently defined seems like a complete joke resulting from cultural and historical accident).

I was going to make another point, but just got something to eat, and have not forgotten what I was saying.

 

[Calathea]

Yay for food!

I can't remember where, possibly the Trigger Point Therapy Workbook which I looked through a while back, but I read someone who pointed out that doctors are far more likely to ascribe a psychological cause to something involving the head than they are with something involving another part of the body (e.g. migraine vs. leg cramps). And then there's a well-known gender bias in this areas too. Plus the most obvious point, which is, "if we don't understand it, it must be all in the patient's mind". A huge number of medical conditions have passed through that stage, and many have come out again the other side once enough was known about how the condition worked. Epilepsy, stomach ulcers, and dyslexia, for example.

 

[Esther12]

Yeah - there are loads of problems with the way in which psychiatry is applied, and relatively little concern about it or calls for responsibility, perhaps because it's thought that those who need psychiatric help are less deserving?

 

[user9876]

Even if you're starting from an assumption that conventional psychiatry is largely quackery, then there are still overlaps imo.

eg: Neurological problems can lead to anxiety, and cognitive-behavioural techniques can held patients think more clearly in response to states of anxiety induced by physical and neurological changes.

psyological problems can be caused by various illnesses or as a result of certain drugs. For example there are some antibiotics that can cause confusion as a side effect. But treating the psycological symptoms is not the answer the causes need to be treated.

The problem with psychiatry is that they have such a broad definition of symptoms and illnesses that they can claim many people with physical illnesses have psycological problems. To me this comes from their lack of causal models (which would be developed as part of a real science) - that is they talk of symptoms and correlations with events that have happened to people and treatments such as CBT but they have no structural model that explains how the mind works and hence how an event or treatment could cause an effect. Unfortunately psyciatrists seem to lack any rigour in the way they reason and hence confuse corrolation and causeation.

To form theories of psyciatry I would have thought they would first need theories of how we think and how that maps onto neurons. This is cognitive science which I believe is still in its infancy and as far as I can tell has no connection to psychiatry. It seems to me before psyciatry can become a proper medical science we need cognitive science to mature so that the medical theories can be built on the pychological theories of how the mind works.

To me neurology is dealing with the physical failures of nerve cells and perhaps chemical inbalences in the brain (or is this a neuroendocronologist).

 

[Calathea]

psyological problems can be caused by various illnesses or as a result of certain drugs. For example there are some antibiotics that can cause confusion as a side effect. But treating the psycological symptoms is not the answer the causes need to be treated.

Daftest example of this sort of problem that I have heard of, from a friend's sister.

Patient: Could you have a look at my baby, please? She's crying nonstop, I think it may be something to do with her stomach.
Doctor 1 [completely ignoring baby]: Hmm, you don't look well. How are you feeling?
Patient: Well, I'm not getting any sleep because my baby is crying all night. Could you examine her?
Doctor 1: I think you are depressed. Here is a prescription for some antidepressants.

---------------------------

Patient: Please please please look at my baby, she won't stop crying, she's ill.
Doctor 2 [examines baby]: She's got reflux, no wonder the poor thing is so unhappy. Here's the treatment for her. Why on earth didn't you bring her in earlier?
Patient: !!!

 

[SOC]

Even if you're starting from an assumption that conventional psychiatry is largely quackery, then there are still overlaps imo.

eg: Neurological problems can lead to anxiety, and cognitive-behavioural techniques can held patients think more clearly in response to states of anxiety induced by physical and neurological changes.

Yes, and as I mentioned earlier, such a condition would be appropriately treated by a neurologist for the physiological component and separately by a psychologist to teach more functional coping skills.

This type of thing is done routinely with cancer patients, patients with acknowledged chronic illness, and so on. This is not a new concept.

The only difference is that currently plenty of psychiatrists and their minions are keeping a certain class of physical illness under their domain by calling it a mental illness and insisting that patients have mental control over the physical illness and can therefore think themselves healthy. It's a gross form of discrimination.

Because we allow them to hijack some diseases/disorders of the brain, we have given them the feeling that they can also hijack other neurological or currently explained physical illness.