Psychiatry for Neurologists - part 1 pps

ANDERSON,MD • Departments of Psychiatry and Neurology, University of Maryland Hospital, University of Maryland School of Medicine, Baltimore, MD GIANFRANCO DALLA BARBA,MD • Department of

Psychiatry for Neurologists

C U R R E N T C L I N I C A L N E U R O L O G Y

Daniel Tarsy, MD, SERIES EDITOR

Psychiatry for Neurologists,edited by Dilip V Jeste and Joseph H Friedman, 2006

Diagnostic Criteria in Neurology,edited by Alan J Lerner, 2006

Status Epilepticus: A Clinical Perspective, edited by Frank W Drislane, 2005

Thrombolytic Therapy for Acute Stroke, Second Edition, edited by Patrick D Lyden, 2005

Parkinson’s Disease and Nonmotor Dysfunction, edited by Ronald F Pfeiffer and Ivan Bodis-Wollner,

Atypical Parkinsonian Disorders: Clinical and Research Aspects, edited by Irene Litvan, 2005

Handbook of Neurocritical Care, edited by Anish Bhardwaj, Marek A Mirski, and John A Ulatowski,

2004

Handbook of Stroke Prevention in Clinical Practice, edited by Karen L Furie and Peter J Kelly, 2004

Clinical Handbook of Insomnia, edited by Hrayr P Attarian, 2004

Critical Care Neurology and Neurosurgery, edited by Jose I Suarez, 2004

Alzheimer’s Disease: A Physician’s Guide to Practical Management, edited by Ralph W Richter and Brigitte Zoeller Richter, 2004

Field of Vision: A Manual and Atlas of Perimetry, edited by Jason J S Barton and Michael Benatar, 2003

Surgical Treatment of Parkinson’s Disease and Other Movement Disorders, edited by Daniel Tarsy, Jerrold

L Vitek, and Andres M Lozano, 2003

Myasthenia Gravis and Related Disorders, edited by Henry J Kaminski, 2003

Seizures: Medical Causes and Management, edited by Norman Delanty, 2002

Clinical Evaluation and Management of Spasticity, edited by David A Gelber and Douglas R Jeffery,

2002

Early Diagnosis of Alzheimer's Disease, edited by Leonard F M Scinto and Kirk R Daffner, 2000

Psychiatry for Neurologists

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Library of Congress Cataloging-in-Publication Data

Psychiatry for neurologists / edited by Dilip V Jeste, Joseph H Friedman.

p cm (Current clinical neurology)

Includes bibliographical references and index.

ISBN 1-58829-483-8 (alk paper)

1 Neuropsychiatry 2 Psychiatry 3 Neurologists I Jeste, Dilip V.

II Friedman, Joseph H III Series.

RC341.P892 2005

616.8 dc22

2005001928

For Susie,

with love, admiration, and gratitude

for the many sacrifices,

great and small

—JHF

To Sonali, Shafali, and Neelum,

for filling my life with fun and love

—DVJ

Dedication

Series Editor’s Introduction

vii

Psychiatry for Neurologists is an ambitious volume that was recruited for the Current Clinical

Neurology series because of a perceived need to provide neurologists with a useful and convenientresource covering the areas of clinical psychiatry that impact the management of neurological disor-ders Although it may be a cliché to reiterate that the disciplines of neurology and psychiatry concernthe same organ, the fact is that long ago they unfortunately went their separate ways The reasons forthis and a description of the paths they followed are elegantly reviewed by Dr Goetz in his chapterconcerning the history of neurology and psychiatry in America Curiously, although in this countryneurology became more allied with internal medicine, it has continued to share its specialty boardwith psychiatry Somehow, this alliance managed to survive the mid-20th century era when psycho-analytic theory and practice, founded by the neurologist Sigmund Freud, held sway

Beginning in the 1950s, the arrival of effective antipsychotic drugs, antidepressants, lithium, andanxiolytic agents provided an alternative medical approach to the treatment of psychiatric disorders.The effects of these agents, many of which were originally discovered serendipitously, precipitatedenormous interest into the biochemical underpinnings of psychiatric disorders Thus, by the 1970s,the dopamine hypothesis of schizophrenia and norepinephrine and serotonin hypotheses of depres-sion were born The remarkable effects of hallucinogenic drugs gave further impetus to the field,driving a concept suggesting a possible “chemistry of the mind” that might unlock the secrets of allpsychiatric disease Although that somewhat overreaching promise has not been realized, even forthe psychotic disorders, a new generation of biological psychiatrists is actively engaged in the study

of the molecular and genetic basis of psychiatric disorders

It is no accident that the editors, Drs Jeste and Friedman, have spent much of their careers ing the neurological effects of antipsychotic drugs The striking ability of antipsychotic drugs tomimic parkinsonism, tremor, dyskinesia, and dystonia was appreciated early on as a potential win-dow into understanding the pathophysiology of organic movement disorders and paralleled theimpact these drugs had on the understanding of psychotic disorders Thus, in no small part, owing tothe psychiatric and neurological effects of antipsychotic drugs, psychiatry and neurology began toshare an area of common ground The concept of a motor and limbic striatum and proposals concern-ing parallel cortical-subcortical motor and limbic circuits helped shape the understanding of bothextrapyramidal and psychiatric disorders With the advent of effective treatments for psychotic disor-ders and Parkinson’s disease, together with their inevitable side effects (antipsychotics causemovement disorders and antiparkinson drugs cause psychosis), it became clear that psychiatrists andneurologists need each other Now other areas of mutual interest and concern are being increasinglyappreciated This volume provides the comprehensive and useful overview needed to allow neurolo-gists to feel comfortable managing the psychiatric aspects of the neurological disorders they treat

study-After all, it is the same organ!

Daniel Tarsy, MD

Parkinson’s Disease & Movement Disorders Center

Beth Israel Deaconess Medical Center

Harvard Medical School

Boston, MA

Although one of the editors is trained in both psychiatry and neurology (DJ), the other, not nally interested in behavioral problems at all, has come, through long clinical practice, to be increas-ingly convinced of the broad overlap between the two disciplines This means that the lack of anappreciation and understanding of the behavioral problems that are so common in neurologicalpatients puts both the neurologist and the patient at a disadvantage in both diagnosis and treatment.And although there are texts on “neuropsychiatry” and “neurology for psychiatrists,” we envisioned

origi-a resource thorigi-at will origi-acquorigi-aint clinicorigi-al neurologists with “breorigi-ad-origi-and-butter” psychiorigi-atric issues thorigi-atthese physicians face with their neurological patients Some patients will have behavioral problems

as a result of their primary neurological problems, such as Huntington’s disease or Tourette’ssyndrome, whereas others have primary psychiatric disorders and later develop neurologicalproblems, such as persons with schizophrenia who develop seizures, strokes, Parkinson’s disease,and the like However, it becomes increasingly apparent with experience that it is the exceptionalneurological patient who does not have some behavioral component as part of the illness

In Psychiatry for Neurologists, we have focused on practical issues and mostly shied away from

the theoretical For example, we have favored the approach of describing depression and itstreatment in Parkinson’s disease rather than addressing the role of the basal ganglia in mood Wethink the available neuropsychiatry texts address these theoretical issues quite well, but that thesetexts have mainly targeted psychiatric audiences who are looking for a grounding in neurophysiologyand anatomy, seeking “hard” explanations for disorders that until recently have been considered

“functional.”

Neurology residency training only recently has mandated a rotation on the psychiatry service.This has resulted in a generation of neurologists who often have little direct experience with primarypsychiatric disorders and have no intellectual foundation on which to interpret their findings In thehospital, the liaison psychiatrists, themselves sometimes adrift in the world of neurological disorders,often prove unable to provide significant assistance in the interpretation or management of behav-

ioral problems, leaving the neurologist without a true safety net Psychiatry for Neurologists is

intended to help the clinical neurologist interpret the behavioral problems in their patients selves, not necessarily to manage the problems independently, but rather to understand the patient in

them-a lthem-arger context This will hopefully them-allow the neurologist to better interpret the psychithem-atric problemsleading to improved interactions with psychiatric consultants, when they are needed

When one editor (JHF) started working in Parkinson’s disease 20 plus years ago, it was clear tohim that it was a movement disorder, that the discussions over depression being intrinsic or reactivewere akin to wondering about the number of angels that could dance on the head of a pin Withgreater experience and increased sensitivity, he has come to realize that Parkinson’s disease is really

a “neurobehavioral disorder” defined clinically by its movement disorder The most devastatingaspects of Parkinson’s disease are, in fact, the behavioral aspects, not the movement dysfunction.There is sometimes a tendency to regard psychiatry as a “different” type of medical practice becausethe patients don’t get “sick” in the same way The stigma against mental illness needs to be combatedwith education There is an interesting “The Far Side” cartoon by Gary Larson A patient is lying on

a couch and a somewhat deranged appearing Sigmund Freud imitation is scribbling in his pad, “Justplain nuts.” It is time to move beyond this image As we learn more and more about emotionalproblems, we find “organic” explanations in genetic and physiological derangements One gene

ix

problem creates tics, a “neurological” disorder, while a closely related mutation causes compulsive disorder, a “psychiatric” disorder Why these fall into separate categories owes more to

obsessive-accidents in history (see chapters by Goetz and Boller) than anything else Alzheimer’s disease and

dementia with Lewy bodies are good examples of illnesses that fall clearly into both camps, with manysuccessful collaborations We believe that neurology and psychiatry are increasingly coming togetherafter a long period of moving apart We hope to help reduce this gap at least a little with this text

Joseph H Friedman, MD

Dilip V Jeste, MD

xi

Dedication v

Series Editor’s Introduction vii

Preface ix

Contributors xiii

Part I Introduction 1 Historical Interfaces Between American Neurology and Psychiatry 3

Christopher G Goetz 2 The Evolution of Psychiatry and Neurology: Two Disciplines Divided by a Common Goal? 11

François Boller and Gianfranco Dalla Barba Part II Evaluation 3 Psychiatric Evaluation of the Neurological Patient 17

Stephen Salloway, Colin Harrington, and Sandra Jacobson Part III Major Psychiatric Disorders 4 An Overview of Depression 33

Irene Hegeman Richard and Jeffrey M Lyness 5 Anxiety Disorders 43

Julie Loebach Wetherell, Ariel J Lang, and Murray B Stein 6 Schizophrenia 59

David P Folsom, Adam S Fleisher, and Colin A Depp 7 Hysteria in Neurological Practice: The Somatoform and Dissociative Disorders 67

Fred Ovsiew 8 Catatonia: Clinical Features, Differential Diagnosis, and Treatment 81

Patricia I Rosebush and Michael F Mazurek 9 Addictions 93

David W Oslin 10 Personality Disorders 105

Marc E Agronin Part IV Psychiatry of Major Neurological Disorders 11 Psychiatric Complications in Dementia 123

Daniel Weintraub and Anton P Porsteinsson 12 Psychiatric Complications of Stroke 137

Sergio E Starkstein and Robert G Robinson 13 Neuromuscular Disorders 153

Jeffrey Allen Cohen and Renee Marie Vebell

xii Contents

14 Psychiatric Aspects of Parkinson’s Disease 163

Laura Marsh and Joseph H Friedman

15 Neuropsychiatric Disorders in Multiple Sclerosis 177

David C Mohr and Darcy Cox

Karen E Anderson and Karen S Marder

19 Psychiatry of the Cerebellum 241

24 Psychopharmacology: A Pharmacodynamic Approach 313

Christian Dolder and Beatriz Luna

25 Electroconvulsive Therapy 329

Eric J Christopher and Warren D Taylor

26 Neurosurgical Treatments for Psychiatric Indications 339

Lawrence T Park, Darin D Dougherty, and Scott L Rauch

27 Psychotherapy for Psychiatric Disorders 363

John R McQuaid and Laura Campbell-Sills

28 Psychiatric Emergencies and Crisis Management in a Neurology Practice 377

Sanjay Gupta

29 Informed Consent and Competency: Legal and Ethical Issues 391

David Naimark, Laura Dunn, Ansar Haroun, and Grant Morris

Index 407

Contributors

MARC E AGRONIN,MD • Director of Mental Health Services, Miami Jewish Home & Hospitalfor the Aged; Department of Psychiatry, University of Miami School of Medicine,Miami, FL

KAREN E ANDERSON,MD • Departments of Psychiatry and Neurology, University

of Maryland Hospital, University of Maryland School of Medicine, Baltimore, MD

GIANFRANCO DALLA BARBA,MD • Department of Neurology, INSERM U549, Centre PaulBroca, Paris, France

FRANÇOIS BOLLER,MD,P h D • Department of Neurology, INSERM U549, Centre Paul Broca,Paris, France

CATHY BUDMAN,MD • Departments of Neurology and Psychiatry, North Shore UniversityMedical Center, Manhasset, NY

JOHN C M BRUST,MD • Department of Neurology, Harlem Hospital Center, ColumbiaUniversity School of Physicians and Surgeons, New York, NY

LAURA CAMPBELL-SILLS,P h D • Department of Psychiatry, University of California, San Diego,CA

ERIC J CHRISTOPHER,MD • Departments of Internal Medicine and Psychiatry, VeteransAdministration Hospital, Duke University Medical Center, Durham, NC

JEFFREY ALLEN COHEN,MD • Department of Medicine (Neurology), Dartmouth-HitchcockMedical Center, Lebanon, NH

JODY COREY-BLOOM,MD,P h D • Department of Neurology, University of California, SanDiego, CA

DARCY COX, P syD • Department of Neurology, University of California, San Francisco, CA

CHRISTOPHER CHRISTODOULOU,P h D • Department of Neurology, State of New York at StonyBrook, Stony Brook, NY

DARIN D DOUGHERTY,MD,MSC • Department of Psychiatry, Massachusetts General Hospital,Harvard Medical School, Boston, MA

COLIN A DEPP,P h D • Department of Psychiatry, University of California, San Diego, CA

CHRISTIAN DOLDER,P harm D • Wingate University School of Pharmacy, Wingate, NC

LAURA DUNN,MD • Department of Psychiatry, School of Medicine, University of California,San Diego, CA

DAVID P FOLSOM,MD • Department of Psychiatry, University of California, San Diego, CA

ADAM S FLEISHER,MD • Department of Psychiatry, University of California, San Diego, CA

JOSEPH H FRIEDMAN,MD • Parkinson’s Disease and Movement Disorders Center,

NeuroHealth, Warwick, RI; Department of Clinical Neurosciences, Brown UniversityMedical School, Providence, RI

CHRISTOPHER G GOETZ,MD • Departments of Neurological Sciences and Pharmacology,Rush University Medical Center, Chicago, IL

SANJAY GUPTA,MD • Department of Psychiatry, Olean General Hospital, Olean, NY;

University of Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY

ANSAR HAROUN,MD • Departments of Psychiatry and Pediatrics, School of Medicine,

University of California, San Diego; University of San Diego School of Law; SuperiorCourt of San Diego, San Diego, CA

COLIN HARRINGTON,MD • Department of Psychiatry, Rhode Island Hospital, Department

of Psychiatry and Human Behavior, Brown Medical School, Providence, RI

xiv Contributors

SANDRA JACOBSON,MD • Department of Psychiatry, The Miriam Hospital and Department

of Psychiatry and Human Behavior, Brown Medical School, Providence, RI

DILIP V JESTE,MD • Departments of Psychiatry and Neurosciences, University of California,San Diego, and VA San Diego Healthcare System, San Diego, CA

ANDRES M KANNER,MD • Department of Neurosciences, Rush-Presbyterian-St Luke’sMedical Center, Chicago, IL

LAUREN B KRUPP,MD • Department of Neurology, State of New York at Stony Brook, StonyBrook, NY

ROGER KURLAN,MD • Department of Neurology, University of Rochester School of Medicineand Dentistry, Rochester, NY

W CURT LAFRANCE, JR.,MD • Rhode Island Hospital, Division of Neuropsychiatry,

Departments of Psychiatry and Neurology, Brown University Medical School,

Providence, RI

ARIEL J LANG,P h D • Department of Psychiatry, VA San Diego Healthcare System, University

of California, San Diego, CA

BEATRIZ LUNA,P harm D • Wingate University School of Pharmacy, Wingate, NC

JEFFREY LYNESS,MD • Department of Psychiatry, Strong Memorial Hospital, University

of Rochester School of Medicine and Dentistry, Rochester, NY

WILLIAM S MACALLISTER,P h D • Department of Neurology, State of New York at StonyBrook, Stony Brook, NY

KAREN MARDER,MD,MPH • Department of Neurology, Neurological Institute of New York,Columbia University College of Physicians and Surgeons, New York, NY

RUSSELL L MARGOLIS,MD • Departments of Psychiatry and Neurology, Johns HopkinsHospital, Johns Hopkins University School of Medicine, Baltimore, MD

LAURA MARSH,MD • Departments of Psychiatry and Neurology, Johns Hopkins MedicalCenter, The Johns Hopkins University School of Medicine, Baltimore, MD

MICHAEL F MAZUREK,MD • Department of Neurology, McMaster University Hospital,McMaster University Medical School, Hamilton, Ontario, Canada

JOHN R MCQUAID,P h D• Psychology Service, VA San Diego Healthcare System;

Department of Psychiatry, University of California, San Diego, CA

DAVID C MOHR,P h D• Departments of Neurology and Psychiatry, VA Medical Center,University of California, San Francisco, CA

GRANT MORRIS,JD,LLM • University of San Diego School of Law; Department of Psychiatry,University of San Diego School of Medicine, San Diego, CA

DAVID NAIMARK,MD • Department of Psychiatry, School of Medicine, University of California,San Diego; Superior Court of San Diego, CA

DAVID W OSLIN,MD • Department of Psychiatry, Philadelphia VA Medical Center,

University of Pennsylvania, Philadelphia, PA

FRED OVSIEW,MD • Department of Psychiatry, University of Chicago Hospitals, University

of Chicago School Pritzker School of Medicine, Chicago, IL

LAWRENCE T PARK,MD • Department of Psychiatry, Massachusetts General Hospital,

Harvard Medical School, Boston, MA

ANTON P PORSTEINSSON,MD • Department of Psychiatry, Strong Memorial Hospital,

University of Rochester School of Medicine and Dentistry, Rochester, NY

SCOTT L RAUCH,MD • Department of Psychiatry, Massachusetts General Hospital, HarvardMedical School, Boston, MA

IRENE HEGEMAN RICHARD,MD • Departments of Neurology and Psychiatry, Strong MemorialHospital, University of Rochester School of Medicine and Dentistry, Rochester, NY

ROBERT G ROBINSON,MD • Department of Psychiatry, University of Western Australia andFremantle Hospital School of Psychiatry and Clinical Neurosciences, Fremantle,Australia

PATRICIA I ROSEBUSH,MD • Department of Psychiatry, McMaster University Hospital,McMaster University Medical School, Hamilton, Ontario, Canada

STEPHEN SALLOWAY,MD,MS • Department of Neurology, Butler Hospital and Departments

of Clinical Neurosciences and Psychology and Human Behavior, Brown MedicalSchool, Providence, RI

SERGIO E STARKSTEIN,MD • School of Psychiatry and Clinical Neurosciences, FremantleHospital, University of Western Australia, Fremantle, Australia

MURRAY B STEIN,MD,MPH • Department of Psychiatry, VA San Diego Healthcare System,University of California, San Diego, CA

DOROTHY E STUBBE,MD • Department of Child and Adolescent Psychiatry, Yale Child StudyCenter, Yale–New Haven Hospital, Yale University School of Medicine, New Haven, CT

WARREN D TAYLOR,MD • Department of Psychiatry, Duke University Medical Center,Durham, NC

RENEE MARIE VEBELL,RN,MA Department of Nursing, Colby-Sawyer College, New London,NH

DANIEL WEINTRAUB,MD • Departments of Psychiatry and Neurology, Philadelphia VAMedical Center, University of Pennsylvania School of Medicine, Philadelphia, PA

JULIE LOEBACH WETHERELL,P h D• Department of Psychiatry, VA San Diego HealthcareSystem, University of California, San Diego, CA

I

1

Historical Interfaces Between American

Neurology and Psychiatry

Christopher G Goetz

INTRODUCTION

Medical specialization evolved out of the burgeoning scientific advances of the 19th century ( 1 ).This movement was an international one, but most pronounced in France, where the celebrated

Faculté de Médecine in Paris developed numerous professorial chairs to honor and prioritize advances

in selective medical fields ( 2 ) Other countries echoed this movement, adapting the concept of

spe-cialization to their own medical cultures and working with the experts available in their universities.Some specialties related primarily to the emerging laboratory disciplines, such as microbiology,pathology, pharmacology, and physiology In most instances, however, clinical specialties were basedanatomically, dividing the human body by organ systems and leading to divisions like pulmonology,dermatology, cardiology, and others Because each organ system was distinct, these specialties werelargely autonomous from one another, integrating with each other only through their original base ofinternal medicine

The brain posed a unique anatomical problem for specialization in being the organ system of focusfor two very different evolving specialties, neurology and psychiatry This chapter examines the earlyhistorical interfaces between these two specialties with an emphasis on 19th-century United States

As the author is a neurologist, the perspective admittedly focuses primarily on the history of Americanneurology and its relationship to psychiatry, rather than the reverse As an introductory chapter to abook that emphasizes the currently close interface between the two disciplines, this chapter selects

a number of topics to trace the origins of an often uneasy relationship that has been marked at times

by elitism, controversy, and overt antagonism It is not a comprehensive history, but rather a focusedview of several early themes that became the historical infrastructure for the unstable, changing flux

of relationship between the two disciplines during the 20th century Whereas the two fields times deferentially honored each other, they more frequently emphasized their differences with themost far-reaching polarization occurring during the mid-1900s when American psychiatry waslargely dominated by psychoanalytic theory As the 21st century opens, the emergence of a psychi-atric emphasis on molecular biology and neurochemistry, as well as the increasing consciousness

some-by neurologists of the impact on disability and impairment in neurological function some-by psychiatricco-morbidities, have helped to dissipate much of the dissonance that began in the 19th century These

From: Current Clinical Neurology: Psychiatry for Neurologists

Edited by: D.V Jeste and J.H Friedman © Humana Press Inc., Totowa, NJ

new-found realizations are the anchors of the positive co-dependence between these two specialtiesthat is the core of this current textbook.

AMERICAN NEUROLOGY’S ORIGINAL DUAL ALLIANCES

WITH INTERNAL MEDICINE AND PSYCHIATRY

With no patronization, it is fair to state that American medicine largely modeled itself on century European models Most prominent physicians of the 19th century studied in Europe, traveledextensively, and thereafter brought back to the United States the images of the large and well-

19th-established medical services in Vienna, Paris, London, and Berlin ( 3 ). Europe, however, was not ically homogenous In defining neurology in the second half of the 1800s, American physicians anduniversities faced two very different paradigms, the first anchored in France and the second in the

med-Germanic medical centers of Austria and Prussia ( 4 ) In France, psychiatry was an early medical

spe-cialty, and the term “alienists” designated physicians dealing with psychiatric problems of psychosis,delirium, insanity, and retardation Because of their disruptive behaviors, psychiatric patients wereusually housed in asylums that largely isolated them from general medical settings As a result, med-ical specialties, including neurology, arose out of administrative subdivisions and specialty unitswithin the major medical hospitals without a strong vying influence of psychiatric concerns As themost salient example, the celebrated neurologist, Jean-Martin Charcot (1825–1893) developed hisinterest in neurology within the general medical wards of the large Parisian hospice of the Salpêtrièrewhere the patient population was largely dominated by geriatric patients with chronic medical illness.Charcot’s academic career started with studies of arthritic, hepatic, pulmonary, and renal diseases, but

as specialty divisions in Paris drew these patients to other hospital units, the chronically disabled andlargely unclassified neurological patients remained under his direct care Out of this administrativeshifting, Charcot developed a neurological wing of wide research proportions and in 1882 receivedthe first European professorial chair of clinical diseases of the nervous system His contact with othermedical specialties remained close, but he had almost no association with alienists whose workoccurred in entirely different administrative divisions In the late 1880s, when Charcot reached thezenith of his influence, his neurological unit included a division of research psychology headed by

Janet, but there were no alienists as psychiatric specialists on his staff ( 5 ).

In contrast, the Germanic medical model emphasized the fusion of neurology and psychiatry,

largely based on the influential leadership of Wilhelm Griesinger ( 6 ) Writing of the Prussian concept

of approaching the study of brain disorders, Griesinger articulated: “Psychiatry and neurology are notlike closely connected fields, they are one field, ruled by the same laws, where everyone speaks the

same language” ( 7 ) As such, when Griesinger gained his professorial chair in Berlin (1865), the title

was Professor of Psychiatry and Nervous Disease Likewise, Wernicke, the celebrated clinician entist whose name is linked to fluent aphasias, led both the psychiatric service and the polyclinic fornervous diseases in Breslau The Prussian model anchored itself in laboratory studies and pathology,bringing substantive advances to organic concepts of dementias and psychosis

sci-Against this historical backdrop, the development of American specialties varied by region and timeperiod, and, in the case of neurology and psychiatry, the models drew from both the French andGermanic traditions The result was an ambiguous hybrid and uneasy peace between neurologyand psychiatry in the 19th century that took a full century to stabilize Studying early university pro-fessorships, 19th-century specialty journals, and local as well as national professional societies unveilsseveral dimensions of the uncomfortable and unresolved relationship that embodied early Americanneurology and psychiatry

EARLY UNIVERSITY PROFESSORSHIPS

Harvard Medical School was the first in the United States to conceptualize a professorship in

neuro-logical science ( 8 ) In 1864, the dean initiated recruitment of CE Brown-Séquard under the title of

Historical Interfaces 5

Professor of Physiology and Pathology of the Nervous System The professorship was short-lived andunsuccessful, primarily because of Brown-Séquard’s own indecisiveness and unreliable behavior AfterBrown-Séquard left Harvard to return to Europe, the university turned to its own Department ofClinical Medicine for neurological staff J Putnam lectured on diseases of the nervous system in the1870s and eventually was awarded a professorship designated exclusively to diseases of the nervoussystem This chair was largely based on the French model of neurology as a division of internal med-icine The heritage of linkage between neurology and medicine remained instilled in the Boston pro-gram through the 20th century with a tradition of recruitment of neurology trainees who were alreadygraduates of internal medicine programs

In New York, the Bellevue Hospital Medical School developed a model much closer to the Prussiantradition After the American Civil War, William Hammond, who would become one of the most dis-tinguished American neurologists of the 19th century, moved to New York and joined the staff of themedical school Hammond had been the surgeon general and was largely responsible for the organi-

zation of military hospitals for the Union campaign ( 9 ) The combat style, weaponry, and grueling

exposure that characterized the Civil War led to a vast medical experience with neurological and chiatric diagnoses related to war trauma The medical school post that he occupied was titled “lec-turer of Diseases of the Mind and Nervous System,” thereby fusing the responsibility for psychiatricand neurological teaching Hammond’s “Nerve Clinic” incorporated both psychiatric and neurologi-cal patients in the same service In 1866, when the medical school awarded him a professorship, thetitle of Professor of Diseases of the Mind and Nervous System reflected this double responsibility.Hammond’s introductory lecture, “The Proper Use of the Mind,” drew upon examples of dementia,

psy-psychotic behaviors, and motor or sensory symptoms with equal emphasis ( 4 ).

Both Brown-Séquard and Hammond had difficult and alienating personalities that caused cant disruption in the smooth administrative acceptance of neurology in American medical schools.From an administrative perspective, Hammond’s demanding and antagonistic postures were as prob-lematic as Brown-Séquard’s restlessness, because both led to very short-lived neurological profes-sorship that required full revamping After a rift with the administration and faculty at Bellevue,Hammond resigned, and the medical school administration dissolved the chair altogether The reor-ganization involved the naming of two separate chairs, one for diseases of the nervous system and theother for psychological medicine Whether this solution was selected to limit the power of one manover too wide a discipline or to recognize inherent differences between neurology and psychiatry, thedivision of work was clearly stated as a departure from the earlier Prussian model and reinforced theseparation of the two disciplines academically

signifi-To search for a more clear understanding of issues between early neurology and psychiatry in century America without the confounding problems of troublesome personalities, the most respected

19th-of American neurologists should be studied Although never a university pr19th-ofessor, the Philadelphian,S.W Mitchell was undoubtedly the most revered and senior of early American specialists dealing withneurological and psychiatric conditions A celebrated clinician with national and international tiesthroughout the medical world, Mitchell trained in general medicine and was world renown for his stud-ies of toxins, neuropathies, hysteria, and malingering His detailed studies of nerve injuries, his exten-sive analyses of rattlesnake venom, and his interest in rehabilitation therapies in Sydenham’s choreastand along side his internationally respected rest therapy used for the treatment of hysteria and otherbehavioral impairments Nonetheless, he was short tempered with psychiatric patients and harsh withpsychiatric colleagues, establishing an American tradition, even in the early years of neurology thatlegitimized an attitude of condescendence by neurologists toward psychiatrists and psychiatric patients

As one example of patient treatment, his student, B Tucker described Mitchell’s assessment of awoman whose illness inexplicably precluded her from walking As the team of doctors entered thehall after Mitchell examined the patient, Tucker recalled:

“Will she ever be able to walk?” asked one of the doctors “Yes, in a moment,” said Dr Mitchell Then the door of the room flew open and the paralyzed patient in her nightgown rushed out and down

the hall Smoke exuded from the room “What on earth is the matter?” asked someone “I set the bedclothes on fire,” said Dr Mitchell (10,p 343)

Mitchell publicly drew the lines between the two specialties in 1894 when he accepted an tion to speak at a meeting of the American Medico-Psychological Association Although a guest ofhis psychiatric colleagues, he vehemently criticized the lackluster progress in psychiatric research,the isolation of psychiatry from the rest of medicine, the lack of resident physicians in asylums, andthe customs, bureaucracy, and politics that hampered research efforts The shocking and alienatingpresentation led to defensive responses that set a new tone within American medicine and crystallized

invita-a tension thinvita-at hinvita-ad been linvita-argely uninvita-articulinvita-ated before ( 4 ) Neurologists rallied to the criticism, and the

American Neurological Association (ANA) developed official position papers on the development ofspecial neurological centers and the removal of neurological patients from the state and local asylumswhere they were deemed under inadequate expert care The rift categorically fostered the placement

of American neurology beside internal medicine and not beside psychiatry, although the reality of ashared patient population necessitated continuing interactions

direction, and the Journal of Nervous and Mental Disease was prioritizing psychiatric issues,

specif-ically psychoanalysis, under the editorship of S.E Jelliffe The journal has survived these swings intothe present, but did not maintain its premier status, being replaced by specialty journals in neurologyand psychiatry Even in the 20th century, when the AMA developed its specialties journals, it used the

same tradition and started the Archives of Neurology and Psychiatry, but this effort was short-lived and the Archives of Neurology and Archives of General Psychiatry became separate journals ( 4 ).

Other journals developed in the 19th century that capitalized on a readership with presumed shared

interests in topics to cover neurological and psychiatric domains The Alienist and Neurologist started

in 1880 and remained in circulation for 40 years, offering readers a pragmatic venue for reading aboutnew therapies The journal title honored both fields in slightly different ways Although it listed psy-chiatry first, the choice of alienist to describe psychiatric specialists was a marginally archaic desig-nation even in the late 1880s In contrast, neurologist was a very modern term, and its use is among

the first in official settings The American Journal of Neurology and Psychiatry developed in 1882,

and although its title honors the two fields, the journal distinguished itself primarily as a venue forarticles on the interface between neurology and internal medicine rather than between neurology and

psychiatry ( 4 ).

In distinctive ways, each journal adopted strategies to defining a proper niche of readership,although these efforts increasingly honored differences over similarities The term “neuropsychiatrist”

grew primarily out of administrative organizational documents during World War I and was not a

well-formed 19th-century concept ( 12 ) In parallel to the movement among neurologists to define their own

journals, specialty journals devoted more specifically to psychiatry developed, including the American

Journal of Insanity (1844) and the American Journal of Mental Deficiency (1876), among others.

Efforts to realign the two fields in shared publication efforts would await the movement of détentethat surrounded the development of a unified American Board of Psychiatry and Neurology for cer-tification efforts in the 1930s The panels and colloquia linked to this effort to save both specialties

as distinct medical entities fostered co-authorships and collective writing efforts that had not been seenfor decades Although these efforts did not specifically lead to new journals, a re-appreciation of sharedinterests between neurology and psychiatry developed and led to several joint position papers andpublications that helped in the establishment of government bodies including the National Institutes

of Health

PROFESSIONAL SOCIETIES

The ANA was founded in 1875 and is the oldest national neurological organization in the world

( 4 , 12 ) Its original mission clearly included the establishing and fostering of an intellectual and

struc-tural forum for neurologists as distinct from other physicians The argumentative William Hammondwas the primary energy source behind the founding effort, and a transparent battle with the superin-tendents of mental asylums brewed even in the beginning meetings of the new organization The ANAwas very socially proactive in its early years, publishing position papers on public health issues andsimilar to Mitchell’s 1894 edict, specifically attacked the mental asylum administrative systems Inthis way, without ambiguity, the ANA positioned itself as an organization for neurologists, not psy-chiatrists, and although the qualifications and credentials of these two fields remained vague in the19th century, a spirit of separatism was clearly articulated at an official level Some neurological his-torians have suggested that the ANA’s elitism was based as a reaction against the pre-existing exclu-siveness of the American Association of Asylum Superintendents, but such arguments of precedenceare less important than the reality of bipartisan antagonism

An important distinction however merits emphasis in this growing polarization at an administrativelevel, because the alienation did not occur along diagnostic or disease lines As only one example, George

Beard, a prominent New York physician, was the first elected member of the ANA ( 13 ) As part of the

entry criteria, each new member presented a paper, and his presentation was on neurasthenia, a nosis he had studied extensively, and, as a result, was known internationally as Beard’s disease Althoughhis contemporaries argued whether neurasthenia was a stress-related emotional condition without focalneurological signs, Beard nonetheless entered the ANA on the credibility of his work in this researcharea His example emphasizes that although neurology and psychiatry evolved as separate fields, thedistinction between a neurologist and psychiatrist remained poorly defined and, in a practice environ-ment outside asylums, the two terms in fact largely embodied the same specialist

diag-At the local level within the United States, administrative antagonisms were less marked, and thereality of a limited number of colleagues interested in brain disorders forced more collegiality A vari-ety of different models were used for gathering physicians with neurological, psychiatric, or sharedinterests In Boston, the original venue was the Boston Medico-Psychological Society, and this name

was changed in 1901 to the Boston Society of Psychiatry and Neurology ( 14 ) This local group

gath-ered for case presentations and discussion, but was also important in steering social and governmentpolicies, especially in dealing with the rights of intellectually deficient patients The Chicago Neuro-logical Society, founded in 1898, may have sounded exclusive in its title, but was openly receptive to

members and presentations from ophthalmology, psychiatry, surgery, and internal medicine ( 15 ) The

Philadelphia Neurological Society held a more neurological focus on the rules for membership, butregularly had combined or joint-sponsored meetings with psychiatric colleagues, usually in the form

of partnership with the Medical Jurisprudence Society of Philadelphia, a group that focused on

medico-legal aspects of insanity and mental deficiency ( 16 ).

THE FRUITS AND PRICES OF DISTINCTION

The rise of specialism allowed the development of intellectual distinction and research focus at thescientific level, personal and financial independence for practitioners at the professional level, andadministrative autonomy at university and government levels With all these motivations, however,19th-century American physicians who identified themselves by an interest in nervous system disor-ders did not have the advantage of a unified, systematic educational model for career development.The disjointed and volatile atmosphere that surrounded the budding areas of neurology and psychia-try created marked disparities in training credentials throughout the United States in the 19th and early20th centuries Against the threat of neurology’s absorption into internal medicine in the 1920s andthe reality of highly varying training programs across the United States in both neurology and psy-chiatry, the visionaries who formulated the American Board of Psychiatry and Neurology in 1934sought to reduce the alienation of the past and work together to establish basic credentials in both fields

( 17 ) The recognition of needed shared expertise and complementary educational guidelines allowed

the first major step toward simultaneously honoring both fields and dissipating prior antagonism Morethan any other administrative body, this board has fostered a liaison between the two fields that neverexisted in the 19th century and has stabilized a relationship to the mutual benefit of both fields

In the author’s view, however, the major source of reconciliation between neurology and try has been the evolution in scientific discoveries and the on-going reality that the distinction between

psychia-a ppsychia-atient with psychipsychia-atric disepsychia-ase psychia-and neurologicpsychia-al disepsychia-ase rempsychia-ains unequivocpsychia-ally difficult to define.The discoveries of genetic patterns in psychotic disorders, the specificity of dopamine receptor antag-onists to the treatment of schizophrenia, and the increasing literature on the biochemistry of depres-sion parallel similar axes of research in such neurological diagnosis as primary epilepsies andParkinson’s disease Just as many of the techniques applied to neurological research have been adopted

by psychiatric teams, pharmacogenomics, a field largely driven by psychiatrists in the past to definegroups of patients most likely to respond to different medications, is increasingly being applied within

neurology ( 18 ) With the advent of medications that selectively treat psychiatric illness, neurological

side effects, primarily in the form of movement disorders, have brought neurologists and psychiatristsinto cross-consultation relationships These interfaces are equally crucial to the care of subjects withdementias, chronic epilepsy, and conditions that have both motor and behavioral elements such asHuntington’s disease and Gilles de la Tourette syndrome Perhaps most importantly, the psychogenicneurological disorders, still a vague class of diagnoses, require an interface of combined specialties

for accurate delineation and management ( 19 ) New studies that demonstrate objective clinical

neuro-logical improvements during placebo treatments underscore the interface, overlap, and likely sharedbiochemical mechanisms between phenomena traditionally segregated with comfort into neurology

or psychiatry ( 20 ) These scientific and patient-based realizations by both neurologists and

psychia-trists bridge a gap that was formulated very early in the fields’ histories and could not be fully ciled by administrators or official credentialing bodies As such, the preparation of this volume isfounded in medical science and justifies itself on a shared, mutually beneficial current working rela-tionship between psychiatrists and neurologists It is tempting to consider the historical antagonismand discomfort between American neurology and psychiatry as dissipated with these developments,but in the author’s view, old traditions tend to show their residual effects in continuing although subtleways This chapter therefore is written not only as an historical backdrop for the other chapters of thisvolume but is offered so that neither the past is forgotten nor its traditions minimized

recon-REFERENCES

1 Rosen G The Specialization of Medicine New York, NY: Arno Press; 1972.

2 Ackerknecht IH Medicine at the Paris Hospital 1794–1848 Baltimore: Johns Hopkins University Press; 1967.

3 Gardner AK Old Wine in New Bottles: Or Spare Hours of a Student in Paris New York: Francis Company; 1848.

4 Goetz CG History of the American Neurological Association in celebration of the 125th anniversary: tempus et hora: time and the hour Ann Neurol 2003;53(Suppl 4):S1–S45.