Crossing and recrossing the boundary of neurology and psychiatry in the USA


Yale University School of Medicine, New Haven, CT, USA


This talk will discuss the evolution of the links between neurology and psychiatry in the USA. The inextricable link between neurology and psychiatry in the USA was reflected in the earlier part of this century by Adolf Meyer, Professor of Psychiatry at the Johns Hopkins Medical School from 1910-1941 who came from the Swiss tradition of neuropathology and neuroanatomy. He brought psychiatry into the hospital setting and targeted the physical causes of mental illness ; however, he also recognized the importance of the role of the community and family as the contextual basis of mental disorders. However, during the latter half of this century, psychiatry grew independent of neurology as psychoanalysis assumed a major role in the theoretical formulation and treatment of psychiatric illness. Likewise, the community psychiatry movement with its sole focus on social causation of mental illness became detached from mainstream medicine.

The past "Decade of the Brain" in the USA has been associated with a dramatic increase in the use of the term "neuropsychiatry", reflecting an increased focus on neural mechanisms for the major psychiatric disorders. This trend has emerged primarily from within psychiatry as the tools of neuroimaging and genetics have become more widely available, as well as through the families of the mentally ill who have developed powerful lobbying organizations for the medicalization and hopefully, destigmatization of mental illness. Schizophrenia and bipolar disorder have been legislated as "biologically based brain disorders'' leading to increased reimbursement by health insurance and funding of research on the biological roots of mental disorders. Increasing success with medical treatment of mental illness led individuals and families as well as informed clinicians to reject psychoanalysis as the sole etiologic and treatment model of major illness. Likewise, the failure of community psychiatry through forced "re-integration" of mentally ill to the community spurred some of the serious social problems of the last decade as exemplified by homelessness and secondary drug abuse disorders, which has even been given the new categorization of "dual diagnosis".

Despite the intentions of the recent movement toward neuropsychiatry, true integration of neurology and psychiatry has yet to occur. Few psychiatrists have received sufficient training in neurology, as reflected by the recent elimination of the oral neurologic examination as part of Board Certification for Psychiatry. Likewise, few neurologists in the USA receive adequate training in psychiatry, nor are there a sufficient number who receive specialty training in each discipline. Although Behavioral Neurology has been an important subspecialty of neurology, the disorders of interest tend to be aphasia and dementia. with little focus on emotion and cognition. True integration in the spirit of Adolf Meyer is a likely outcome of the next decade, as the pendulum swings back to provide a true balance between the tools of neurology and psychiatry in studying the etiology and treatment of mental illness in the USA.


Plenary 4   (Adolph Meyer Lecture)
Thursday, 16 September 1999

The Neurosciences and Psychiatry: Crossing the Boundaries

Joint Congress of the European Association for the History of Psychiatry (EAHP), the European Club for the History of Neurology (ECHN), and the International Society for the History of the Neurosciences (ISHN)

Zurich and Lausanne, Switzerland, 13-18 September 1999