Why Do We Separate Psychiatry and Neurology - Psychology Today

11/6/21, 10:26 PM Why Do We Separate Psychiatry and Neurology?
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Mark L. Ruffalo D.Psa., L.C.S.W.

From Freud to Fluoxetine
PSYCHIATRY
Why Do We Separate
Psychiatry and
Neurology?
A comparison of mental and neurological disease.
Posted December 1, 2019

Reviewed by Abigail Fagan
As advances in neurobiology and genetics reveal complex

associations between brain structure, function, and the symp‐
toms of mental illness, there have been renewed calls to re‐
position mental illness as disease of the nervous system. This
is highlighted in public statements by prominent figures in
American psychiatry, such as Thomas Insel's assertion that
mental illness is brain disease and Eric Kandel's proposal to
merge psychiatry with neurology.
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The psychiatrist and philosopher Karl Jaspers argued it is a logical error to hold
that mental disorders are reducible to diseases of the brain. US
Source: Public domain
The relationship between psychiatry and neurology has al‐

ways been a fascinating and contentious one, and these de‐
bates surrounding the relationship between mental and neu‐
rological disease are nothing new. Almost two hundred years
ago, the eminent neurologist and psychiatrist Wilhelm
Griesinger (1845) insisted that "all mental illnesses are cere‐
bral illnesses," an argument that is echoed in more recent as‐
sertions like those of Insel and Kandel.
In contrast, the psychiatrist and philosopher Karl Jaspers

(1913), writing almost a century after Greisinger, argued that
"there has been no fulfillment of the hope that clinical obser‐
vation of psychic phenomena, of the life-history and of the
outcome might yield characteristic groupings which would
subsequently be confirmed in the cerebral findings" (p. 568).
A recent paper published in the Journal of Neuropsychiatry

and Clinical Neurosciences begins, "While most organs have
one dedicated medical specialty, the brain has been histori‐
cally divided into two disciplines, neurology and psychiatry"
(Perez, Keshavan, Scharf, Boes, & Price, 2018, p. 271),
squarely positioning psychiatry as a specialty that deals with
diseases of the brain.
I argue that these proposals to reclassify mental illness as

neurological disease are based on a basic category error and
that the distinction between psychiatry and neurology is not
an arbitrary one.
This is not to deny physicalism, that is, that the mind exists
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because of the brain, and I submit that it is possible to simul‐
taneously accept that the mind is a function of the brain and
that mental disorders are not reducible to brain disorders. To
do this, let us first examine the difference between mental
and neurological illness and then evaluate the claim that
mental disorders can be reduced to the pathologies of the
brain.
Replay
Neurological diseases are, by definition, diseases of the cen‐

tral and peripheral nervous system, and they can generally
be identified on the basis of objective medical testing, such
as electroencephalography for epilepsy and magnetic reso‐
nance imaging for a brain tumor. Many neurological diseases
can be localized, meaning found to exist as a lesion in a par‐
ticular area of the brain or nervous system. While some neu‐
rological diseases can cause mental symptoms, such as
changes in mood or perception, neurological illness is not
chiefly associated with these psychological abnormalities,
and they exist secondary to the disease's deleterious effects
on the nervous system.
In contrast, mental or psychiatric illness is characterized by a

US
clinically significant disturbance in an individual's thoughts,
feelings, or behaviors. The Diagnostic and Statistical Manual
of Mental Disorders is theoretically neutral on the cause of
mental disorders, and, despite claims to the contrary by an‐
tipsychiatrists, organized American psychiatry has never offi‐
cially defined mental illness as "chemical imbalance" or brain
disease (see Pies, 2019).
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While many advances have been made in the realms of neu‐

roscience and genetics that aid our understanding of mental
illness, there remains not a single identifiable biomarker for
any mental disorder. Historically, mental disorders have been
considered functional diseases, due to their impairment of
functioning, rather than structural diseases, which are associ‐
ated with known biological abnormalities. The American
Psychiatric Association (2013) defines mental disorders this
way:
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A mental disorder is a syndrome characterized by

clinically significant disturbance in an individual's
cognition, emotion regulation, or behavior that re‐
flects a dysfunction in the psychological, biological,
or developmental processes underlying mental
functioning. Mental disorders are usually associated
with significant distress in social, occupational, or
other important activities (p. 20).
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Research
Thus, while neurological diseases can generally be identified

via objective biological means and may present with psycho‐
logical sequelae, psychiatric diseases or mental disorders
cannot be identified biologically and are defined by their dis‐
turbances in thought, emotion, and behavior.
Another distinguishing characteristic of mental disorder is its

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relationship to environmental factors. Whereas a variety of
life circumstances and experiences are associated with the
development and course of mental disease, such as child‐
hood trauma, no significant relationship exists between envi‐
ronmental-psychological factors and the onset of neurologi‐
cal disease. While psychotherapy is a treatment for mental
illness, it makes no sense to speak of psychotherapy as a
treatment for brain cancer or stroke.
The now-abandoned Norwich State Hospital in Norwich and Preston,

Connecticut.
Source: Norwich Hospital District, used with permission.
Perhaps the best example of the difference between mental

and neurological disease is conversion disorder, now also re‐
ferred to as functional neurological symptom disorder.
Conversion disorder, previously subsumed under the broad
category of hysteria, was fundamental in Freud’s develop‐
ment of psychoanalysis. It's characterized by the presence of
neurological symptoms, such as weakness, paralysis, or
blindness, without organic (neurological) cause. Conversion
symptoms are often precipitated by psychological trauma
and are interpreted psychoanalytically as a hidden or sym‐
bolic means of communication. Unable to express them‐
selves via conventional means, patients with conversion dis‐
order resort to a symbolic protolanguage to communicate

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their psychological conflicts.
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Nevertheless, there have been recent attempts to reduce

conversion disorder to dysfunction of neurobiology, and re‐
search has shown dorsal anterior cingulate cortex structural
alterations in conversion disorder patients compared to con‐
trols (Perez et al., 2018). But the question we must ask our‐
selves is, is this where we think the locus of conversion disor‐
der is? Or is this merely a neurological correlate of a psycho‐
logical phenomenon?
I argue that the locus of mental disorder is better conceived

as the person rather than the brain. Whatever the etiology of
mental disorder—whether it is genetic, the product of gene-
environment interactions, psychological, or social—we iden‐
tify it on the basis of its disruption to the person's mental life
or relationships. This is not so with neurological or other
physical diseases, which can be identified on the basis of
structural abnormality and often presents without any disrup‐
tion at all to the person or the self.
Banner (2013) summarizes it this way:
There is much talk in the empirical literature about

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brain 'abnormalities', 'deficits' and 'alterations' asso‐
ciated with mental disorder symptoms. But concep‐
tually, what marks these differences as indicative of
disorder or dysfunction? It is the association they
bear with deviations from epistemic, evaluative,
emotional, moral and social norms of functioning, in
other words … person‐level [emphasis added] con‐
structs… (p. 512).
Conceiving of mental disorders as disorders of the person,

who has a brain as well as a complex psychosocial environ‐
ment—rather than as diseases of the brain—does not dis‐
count the many significant advances made through biological
and genetic investigation. Nor does such a conceptualization
rely on an erroneous mind-body dualism or negate the effec‐
tiveness of biological therapy. To the contrary, conceiving of
mental disorders in this way is both philosophically sound
and places us in the best position to treat them, from a uni‐
fied biopsychosocial perspective.
As psychiatrists are first and foremost medical doctors, there

is an understandable hesitation to construing mental illness in
this manner. If mental illness is not a brain disease, then what
organ is affected? Is mental illness merely a metaphor, or fake
disease as the psychiatrist Szasz argued?
A thorough analysis of the meaning of disease (dis-ease) in

the history of medicine reveals that the classification of a par‐
ticular entity as a disease requires no known, or putative, bio‐
logical cause, and the classification of all diseases, not just
mental ones, relies on a subjective determination regarding
abnormality. What is of consequence in disease classification
is the degree of suffering and incapacity rather than the pres‐
ence of a biological lesion. Thus, to accept that mental dis‐

US
ease is a disease of the person rather than a disease of the
brain is not to say that mental diseases are not diseases at
all.
Rather than attempting to reorient itself as a specialty of brain

science alongside neurology and neurosurgery, psychiatry
would be better served by orienting the rest of medicine to‐
wards itself, as a specialty that operates uniquely as a multi-
level science. Regardless of future advances in neurobiology,
psychiatry will remain the specialty that deals with the com‐
plex problems of the individual person (mental disorders),
problems that are qualitatively different from those treated by
neurologists—and it should embrace its role in this regard.
References
American Psychiatric Association. (2013). Diagnostic and statistical

manual of mental disorders (5th ed.). Washington, DC: Publisher.
Banner, N. F. (2013). Mental disorders are not brain disorders.

Journal of Evaluation in Clinical Practice, 19(3), 509-513.
Griesinger, W. (1845). Die pathologie und therapie der psychischen

krankheiten. Stuttgart, Germany: Krabbe.
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About the Author
Mark L. Ruffalo, D.Psa., L.C.S.W., is Instructor

of Psychiatry at the University of Central
Florida College of Medicine and Adjunct
Instructor of Psychiatry at Tufts University
School of Medicine.
Online: Mark L. Ruffalo, DPsa, LCSW, LinkedIn,

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11/6/21, 10:26 PM Why Do We Separate Psychiatry and Neurology?

Find a Therapist (City or Zip)

Mark L. Ruffalo D.Psa., L.C.S.W.

As advances in neurobiology and genetics reveal complex

article continues after advertisement

Source: Public domain

The relationship between psychiatry and neurology has al‐

In contrast, the psychiatrist and philosopher Karl Jaspers

A recent paper published in the Journal of Neuropsychiatry

I argue that these proposals to reclassify mental illness as

article continues after advertisement

Neurological diseases are, by definition, diseases of the cen‐

In contrast, mental or psychiatric illness is characterized by a

Find a therapist near me

While many advances have been made in the realms of neu‐

article continues after advertisement

OPEN A FREE ACCOUNT

A mental disorder is a syndrome characterized by

PSYCHIATRY ESSENTIAL READS

Meaningful Symptoms Are Still Symptoms

The New Techniques Driving Psychiatric

Thus, while neurological diseases can generally be identified

Another distinguishing characteristic of mental disorder is its

The now-abandoned Norwich State Hospital in Norwich and Preston,

Source: Norwich Hospital District, used with permission.

Perhaps the best example of the difference between mental

order resort to a symbolic protolanguage to communicate

article continues after advertisement

OPEN A FREE ACCOUNT

Nevertheless, there have been recent attempts to reduce

I argue that the locus of mental disorder is better conceived

Banner (2013) summarizes it this way:

There is much talk in the empirical literature about

Conceiving of mental disorders as disorders of the person,

As psychiatrists are first and foremost medical doctors, there

A thorough analysis of the meaning of disease (dis-ease) in

ence of a biological lesion. Thus, to accept that mental dis‐

Rather than attempting to reorient itself as a specialty of brain

American Psychiatric Association. (2013). Diagnostic and statistical

Banner, N. F. (2013). Mental disorders are not brain disorders.

Griesinger, W. (1845). Die pathologie und therapie der psychischen

About the Author

Mark L. Ruffalo, D.Psa., L.C.S.W., is Instructor

Online: Mark L. Ruffalo, DPsa, LCSW, LinkedIn,

Meaningful Symptoms Are Still Symptoms

Interpreting the Symptoms of Schizophrenia

Are you a Therapist?

About Editorial Process Privacy Terms Accessibility

Psychology Today © 2021 Sussex Publishers, LLC

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