I just finished re-reading Valenstein and Heilman's text on neuropsychology
(bedtime reading; I'm fascinated by anything having to do with the brain).
I also have a number of friends in the area, and my wife will probably do
a Ph.D. in it in the next few years; she finds speech-language pathology
a rather unsatisfying grab-bag of a discipline.  In any case, I've gotten
a rather strong impression of the future of the brain-oriented clinical
disciplines, and I wanted to check it out with our net.neurologists, since
that is one discipline I don't have friends in.

It seems to me that the boundaries among the various disciplines are
shifting, as follows:

Neurologists will be oriented more toward peripheral neuropathies, and
the organic origins of CNS disorders, and less toward the diagnosis and
localization of lesions following, e.g., a stroke or closed-head injury.

Neuropsychologists, who do not get M.D.'s, will specialize in diagnosis
and treatment of the deficits caused by brain injury and by neurochemical
imbalances.  They will be the experts on agnosias, aphasias, apraxias,
and the like.  They will (at least they should) take over the aphasias
from the speech people, but this will be a real turf battle.

The disputed territory between neuropsychology and neurology will shift
to somewhere between the thalamus and the medulla oblongata :-).
Neuropsychologists will seek, and probably will get, the right to
prescribe some medications with M.D. approval.

As the neurochemical origins of psychiatric diseases become clearer,
psychologists will take over their diagnosis and treatment, with M.D.
oversight for prescriptions.  There will be an intense turf battle,
as psychiatrists try to preserve their discipline.  However, the need
to tell distinguish causes of, for example, depression, which causes may
include brain tumours and strokes, will favor the sort of broad CNS
specialist that a neuropsychologist should be over the more narrow
training of a psychiatrist.

The driving force for all of this is that the body of knowledge regarding
CNS disorders is growing too unwieldy for a standard medical education;
something has to give, and for the detailed diagnosis of CNS disorders,
that will be the standard early medical education.  Already, I know my
wife prepares much longer diagnoses of her stroke patients than the
neurologists do (actually, she _did_ during her year at the Buffalo VA);
they would say "Broca's aphasia with limited anomia," she would say
"Syntax without subordinate clauses, anomia for small common objects,
(and so forth)."

Mark
--
Mark A. Fulk                    University of Rochester

My wife *is* a neuropsychologist, and I assure you she knows a heck
of a lot more about the brain and cortical specialization than the
large majority of phycicians; I learn things from her all the time.
There are indeed a handful of behavioural neurologists who may have
similar levels of knowledge, but they are few and far between.  When
it comes to research on memory, perception, attention, etc., and thier
correlations with brain structure, Neuropsychologists are second to none.
But no, I do not think they should be able to prescribe {*filter*}.  (My wife
agrees with this -- she has no special training in pharmacology, and has
no desire to face a malpractice suit for prescribing {*filter*} she knows
little about).

Ken

                                     ^^^^^^^^

I am in complete agreement with you.  Perhaps you overlooked the word
"clinical" in my original post.

===================================================================
This is patently absurd; but whoever wishes to become a philosopher
must learn not to be frightened by absurdities. -- Bertrand Russell

===================================================================

So why do Tourette's patients go to neurologists?

This may be the best argument for an M.D., but I'm not sure it really
establishes the case.  Why must behavi{*filter*}neurologists diagnose these
things?  Aren't they usually ruled out by the referring physician?

I didn't advocate psychologists prescribing on their own; they would need
appropriate training and supervision.

I get the feeling from Klawans that he doesn't have a lot of respect
for the psychiatric specialty.  When one considers the kinds of
abuse that psychiatrists have historically been responsible for,
abuse which IMHO was not defensible as the product of necessary
ignorance, one tends to agree.  (I have in mind Kanner's treatment
of parents of autistic children; psychosurgery; the over-use of ECT;
sex hormones for {*filter*}ity; and the like.  You may say that all
these things are in the past, but Kanner only admitted error in 1972;
the failings in the past may be the only acknowledged ones.  As a matter
of fact, I found out that a friend of mine has a (now {*filter*}) autistic
child yesterday, at lunch.  The child had been diagnosed (correctly)
by Kanner in 1970; Kanner told my friend and his wife that they were
"classic refrigerator parents."  As of lunch yesterday, my friend had
not heard about Kanner's retraction; when I told him about it, he
nearly exploded.  For 21 years, nobody had bothered to tell him that
the accepted explanation for his son's problems had changed.)

                         ^^^^^^^

No they aren't, at least not in the hospitals that Tina has worked in.
The heads of the speech department at the Buffalo VA and at Shands
Hospital in Florida both reported to the hospital administrator.
Both, BTW, had Ph.D.'s in speech-language pathology.  There was no
medical supervision; consults were sent by neurology, ENT, and the
social work department.  A lot of Tina's work in Shands was with
laryngectomies, teaching the use of the tracheo-esophageal valve.
They were all ENT referrals.  Incidentally, speech could refuse a
referral; this was politically a terrible idea, but the possibility
was theoretically there.

I'm suggesting that the disciplinary lines be drawn in different places,
not that the training devoted to diagnosis and treatment of brain
disorders (including "mental" ones) be reduced.
--
Mark A. Fulk                    University of Rochester

What do you base this on?  I have read the same book, and certainly
found nothing in there to indicate that, nor does Ken Heilman advocate
anything like this.  I know many neuropsychologists, very few of
which are interested in being doctors and taking care of patients.
Most of them do not do any sort of therapy at all, but mainly
do research and perform testing services.
They are very interested in studying patients that we send them,
but have little interest in either their acute or chronic management,
for which they have *no* training.  Management of acute stroke
and head injury is extremely medically intensive and I can't imagine
any type of psychologist having the slightest interest in doing it.
As for following stable chronic aphasics, I suspect psychologists
could do so, but what would be the interest in it for them?  After
a year or two, there is no further evolution in the way the brain
adapts to the injury and any medical care revolves around helping
the caregiver (usually the spouse) cope and preventing any further
strokes by the use of anticoagulants.  The main issues in using
anticoagulants are preventing drug interactions and watching for
inadvertant bleeding, neither of which psychologists have any
training whatever.  I can also tell you, that there is absolutely
no way that neurologists are going to give up taking care of
patients with disease of the brain, neither are other physicians
going to refer their patients directly to neuropsychologists.

I suspect my observations here will also apply to psychiatrists
vis-a-vis other types of psychologists.  The training of the
neuropsychologist is the one that is narrow, not the training
of the psychiatrist, which is much broader.  The neuropsychologist
knows a small field in great depth, whereas the psychiatrist is
trained a little bit in a lot of different things.  

Neuropsychologists are very important members of the team,
but they are not going to replace doctors, for *any* type
of patient, even those with very specific lesions.

--
----------------------------------------------------------------------------
Gordon Banks  N3JXP      | "Skepticism is the chastity of the intellect, and

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

Because they have a movement disorder.

Often not.  Actually never in the cases I see, since the internist
wouldn't send the patient on to me if he already knew that the
neurologic symptoms had an underlying medical cause.  I make the
diagnosis of hypopthyroidism about once a month, usually on patients who
have recently been seen by an internist or family practitioner.  A
neurologist may be better versed in the medical conditions that cause an
unusual neurologic symptom than the internist is, particularly when that
symptom is uncommon in patients with that disorder.

===================================================================
This is patently absurd; but whoever wishes to become a philosopher
must learn not to be frightened by absurdities. -- Bertrand Russell

===================================================================

I don't believe it was always thought so.  I don't have my copy of _The
Man Who Mistook His Wife for a Hat_ handy, but I recall that, in "Witty
Ticcy Ray," Sacks was pretty acerbic about the treatment Tourette's
patients had received at the hands of various psychotherapists.

I can understand that kind of confusion.  One day at the Marshall
Chess Club in Manhattan, I (normally a patzer myself) found myself
in a game with one of the worst players I'd ever met.  Even down
two rooks and a bishop, this fellow kept giggling and muttering to
himself, giving the impression that he had some astounding plan in
mind.  He never resigned until actually checkmated, and I wasn't
good enough to mate him quickly; he always found a last-ditch escape
by sacrificing even more major pieces.

This was in 1978 or so; I thought the guy was pretty weird, and dismissed
him from active memory for several years.  Then I read "Witty Ticcy Ray,"
and remembered this character.  Not only did he mutter and giggle, but
he was constantly shifting around in his chair and moving, sometimes
flicking, his hands about.  It was terribly distracting, and, had I had
the slightest excuse, I would have gone off to play with someone else.
Now I'm a little ashamed of how I treated the guy, and what I thought of
him at the time.  He might have been a better chess player if he could
have found some opponents.  It is very clear to me that most people
would have thought he was crazy; I certainly did.

This long aside over, it isn't clear to me that you can make a clear
distinction between behavi{*filter*}and movement disorders, and confusion
in that respect has had negative effects in the past.

Do you think internists are any better than family practitioners in this
respect?  I tend to prefer internists, myself, even though one of our
closest friends is a family practitioner; I'd rather have a strong
diagnostician than family therapy, and I know my internist will call
our pediatrician, or vice versa, if the occasion warrants it.  I know
that she (the internist) always asks me what's happening with the kids,
and I assume that she is not just being friendly.

I'll add another item to your list of medical conditions with obscure
neurological consequences, from Klawans.  Evidently there are a number
of types of thoracic tumor that produce hormones with powerful effects
on the CNS.  Klawans was particularly proud of diagnosing one patient
who jumped powerfully straight up in response to sudden loud sounds.
The origin of the noise-induced myoclonus was a lung tumor producing
some hormone.  This was one of the cases in which Klawans showed some
disdain for psychiatrists; his patient had been variously misdiagnosed
by one or more before getting to him.  The story is in _Newton's Madness_.

Back to the original argument.  A few straw men have been attacked, although
I have to take the blame for not being clear enough.  Part of the problem is
that my own thoughts aren't that amazingly clear anyway.

I never disputed that people working on brain disorders had to able to
recognize a lot of illnesses that did not originate in the brain, but
presented initially as neurological illness.  I'm not sure how many such
things there are, but there are certainly at least a dozen examples.
Just so you understand: I don't think that current training in neuro-
psychology is adequate to the role I see for the field.  The training
will definitely have to be expanded, in particular, in the directions
that you and Gordon have pointed out.

I also don't think that psychologists have any role in the management of
the acute stroke or head injury patient.  There, the primary issues are
clearly medical: managing swelling, preventing further damage.  MDs are
also needed in the management of the causes: keeping cholesterol down,
for example.  But I think that Gordon is too dismissive of the role of
continuing therapy.  If the speech-language pathologists he sees are
typical of the field, I'm can certainly understand the attitude; they
are grossly underpaid and undertrained, and I imagine that damned few
of them are really very helpful to their patients.  (Fortunately, most
of the worst confine themselves to working in the schools, where the
problems are a bit more tractable.)  Furthermore, it seems to me that
the notion that slp's can treat aphasia independently of memory problems,
apraxia, and the like is horribly mistaken; it was this realization
(of my wife's) that first set me thinking about the problem of disciplinary
lines in brain disease therapy.

It seems to me that the line between psychiatry and neurology is similarly
vague, and that, far too often, major advances in the treatment of once
"psychiatric" disorders like Tourette's and autism have been achieved by
moving them to the "neurological" side of the line.  I know of no examples
of the reverse of this phenomenon.

One thing that I didn't make clear early on is very important: I'd like to
see a remedy for the prevalence of essentially unscientific, ideologically
motivated quack fields of psychotherapy.  Many of the practitioners of these
fields are psychiatrists, like the [expletive deleted] Freudians who caused
so much grief to parents of autistic kids.  Others are psychologists; they
owe their credibility to clinical psychology programs that are little better
than diploma mills.  It is this group of people that are responsible for
the current fad in {*filter*} abuse therapy.  Judging from some sources, there
must be several billion personalities occupying the 250 million or so
bodies in the USA.  There is a character here in Rochester, a doctor of
psychology, who diagnoses all kids with ADD.  His differential diagnosis
seems to go:  Anything other than ADD, even being reasonably normal, is
ruled out by presence in his office.  Less than five bounces off the wall
in ten minutes = ADD without hyperactivity, more than five bounces, ADHD.
I know many people who've been to see this guy, and he has never done
anything for any of them except diagnose ADD and prescribe Ritalin.  The
trouble is that many of the local pediatricians believe in this joker,
and prescribe Ritalin whenever he says to.  (Fortunately, our pediatrician
is not a believer.)  There seem to be a lot of psychologists who fit this
one-diagnosis-johnny pattern.

Not that all psychologists are bad; Tina has a weekly teacher's group meeting
with one in the suburbs here who is very broadly knowledgable of the problems
besetting young kids; attendance has been a real education for her, and she
has seen him get some terrific results and call quite a number of shots
right on target.  He has even made a few medical referrals, with excellent
results.  This guy does a hell of a lot of good.

So what is my solution?  Really, the creation of a new specialty, one in
which Oliver Sacks might feel very comfortable, and that a good psychologist
could qualify without another lifetime of training.  This specialty is
directed at the functional aspects of brain disorders, and specifically
disavows the distinctions between "neurological," "psychological," and
"psychiatric" disorders.  Its central philosophy is, in fact, functionalism,
as the term is generally meant by the cognitive science community.  Training
in this field would necessarily include all of the following:

1) Neuropharmacology, although not all of pharmacology.

2) Non-CNS causes of apparent brain dysfunction.  This training would have
   to include plenty of clinical observation.

3) Much of classical neurology.  However, medical management of diseases
   like the demyelinating diseases and dystrophy would be omitted or
   lightly covered.  Similarly, peripheral neuropathies would be
   omitted.

4) The useful parts of psychiatry.  If it isn't apparent, I tend to be
   skeptical that there are a lot of these.

5) The useful parts of clinical psychology; with a hearty ditto.

6) All of the stuff that is arising from modern cognitive psychology,
   psychophysics, and neuroscience.  It is the incredible growth in
   this knowledge that makes me think that all this PLUS an MD is too much.

6) How to work in teams with MDs.

I don't expect that anyone could qualify in this field with less than
about eight years of post-baccalaureate training.  If they had to get
an MD and medical license as well, I expect the training would run for
about twelve years.  The eight-year program would include three years
of basic neuroscience and psychology, two years of clinical observation,
and three years of internship in hospital and clinic settings.

The creation and expansion of this field will have to be accompanied with
a great deal of pressure on licensing boards and professional societies.
This pressure will be to get them to recognize that noone with anything
less than equivalent training should be practicing any kind ...

read more »

Psychiatry is not "defined by out of date notions of etiology" -
psychiatry is not defined.  Like all medical specialties, it has arisen
in response to problems people have, problems which happen to range
from the trival to the catastrophic, problems which happen to be
extremely prevalent (like schizophrenia or  depression).  The abuses of
psychiatry in the past and present have a great deal to do with the
high prevalence and seriousness of psychiatric disorders; having to do
something, psychiatrists did insulin coma "therapy", and other
ineffective things.  However, psychiatry is not going away.  In fact,
the field of psychiatry is doing rather well from a research and
therpeutic innovation standpoint.

Psychiatry invented the double blind trial.  Psychiatric research
methodology now equals or exceeds that of any other medical specialty
or psychology.  Psychiatric disorders is a big enough field to
graze herds of neuropsychologists and tenure many dozens of
social scientists and molecular biologists.  But don't anybody think
for a minute that psychiatry as a medical specialty is going the
way of the buffalo.  

=================================================================

suny health science center, syracuse    voice: (315) 422-1050
================ courtesy of syracuse university ================

The borders are largely historical.  Both neurologists and psychiatrists
see Tourette's patients, who have obsessive compulsive behavior as
well as the movement disorder.  PD is rarely seen by psychiatrists,
however unless they also have depression or something else.

The medical training is not that irrelevant.  The problem is that
{*filter*} are *dangerous* and in order to prescribe them you need
to be able to recognize and handle the problems you might create.
The problem with psychiatrists is often that they don't have enough
medical skill to handle the problems they create.  Having psychologists
with even less medical skill prescribe dangerous {*filter*} will simply
make things worse.

--
----------------------------------------------------------------------------
Gordon Banks  N3JXP      | "Skepticism is the chastity of the intellect, and

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

Because they have a movement disorder.

Often not.  

Most of them that I know have no interest in prescribing.  Therefore,
such training programs are unlikely to develop.  Doubly so since they
can't be licensed to prescribe.

Harold (not Herbert), like most of us, knows that psychiatry has
more than its share of incompetents, but there are many really good
psychiatrists who know their stuff.  I don't think Klawans is
indicting the whole idea of psychiatry when he repeats some of
the jokes we all tell about psychiatrists, or at least he doesn't
mean to.  I suppose that were I a psychiatrist I would resent such
jokes as sort of like ethnic stereotypes.  Did you read this stuff
in Klawans' books on neuropharmacology or in his {*filter*} mysteries
or in his medical history books?

--
----------------------------------------------------------------------------
Gordon Banks  N3JXP      | "Skepticism is the chastity of the intellect, and

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

Thanks for the clarification re Tourette's.  This, I think, strengthens
the point I was trying to make.  Sacks was referring to psychiatrists
who tried to treat Tourette's with shock, inappropriate {*filter*}, and
psychoanalysis.

I wasn't as clear in that reply as I should have been.  I don't think
that psychologists (or whatever you choose to call them) should be
prescribing {*filter*} alone.  Obviously, no drug _just_ affects the brain,
and any prescription will have to be reviewed by someone familiar with
the case and with the non-brain problems that might arise.  In practice,
I think that a kind of modus vivendi will arise, in which the psychologists
and medical people work out a set of boundaries together.  Some decisions
will be easy, others will require close collaboration.  And I don't think
that psychologists should have any _less_ medical skill than most
psychiatrists; from what I've seen of psychiatrists, they should have
much more.

Why do I think a major training boundary should lie between the brain and
the rest of the body?  Certainly not because they can be neatly separated!

It is just that the brain is at least as complex as the rest of the body,
and, with the growth of neuroscience and the better parts of psychology,
the medically relevant knowledge of the brain will soon (in one decade or
two) equal the extent of medically relevant knowledge of the rest of the
body.  Clearly there would have to be some overlap in training, and a
strong degree of cooperation between the specialties.  To have a clearer
idea, read the post where I describe how to go about setting up a program.

Redrawing the lines could resolve a number of problems, for example:

The historical separation between neurology and psychiatry has, in my view,
seriously hurt psychiatry.  As you point out, psychiatrists are often unable
to deal with the problems they create; they also, with a few exceptions,
seem to have a weak appreciation of scientific approaches.  Erasing the
distinction, in effect forcing the psychiatrists to learn neurology, would
help undo that harm.

There are too many clinical psychology programs that don't demand nearly
enough in the way of neuroscience and neurological knowledge.  I've never
seen any figures, but I wonder how many patients with neurological problems
have been lost, having spent too much time with some psychologist, when
they had a symptom pattern that you, Gordon, would spot rather quickly.
The only clinical psychologist I've met with anything approaching a broad
brain knowledge is{*filter*} Arnold, here in Rochester; I know that he went
way out of his way to get that knowledge, and I've heard of it paying
off on a number of occasions (Tina used to meet with him biweekly to
discuss nursery school kids).

The main sources of new knowledge about the brain are in psychology
departments and neuroscience departments.  Establishment of a ``brain''
discipline, with formal ties to those departments, would help the flow
of information both ways.  However, I'm not aware of any major problems
with information flow now, so this is a rather weak argument.

I would also point out that the brain field would rather quickly develop
specialties.  It is just that the lines among those specialties should
make more sense than the traditional lines.  We'd see age group specialists
(child, {*filter*}, aged), specialists in management of particular disorders,
maybe even anatomically based specialists.  (Did you see the new pinealist?
He's not only unparallelled, he's unpaired!)
--
Mark A. Fulk                    University of Rochester

I've answered this elsewhere.  It isn't so clear what this means, Gordon.
It is sufficiently unclear that Tourette's patients historically saw
psychiatrists.  Source: Sacks, Witty Ticcy Ray.

I've granted this point elsewhere.  Clearly anyone seeing patients for
apparently brain-related complaints should be prepared to recognize
other kinds of organic cause.  Please don't jump to the conclusion that
I don't think causes in the brain aren't organic; of course they are.
I'm just distinguishing between problems that originate in the brain
and those that originate, at least partially, elsewhere.

Most clinical psychologists I know (and that is actually quite a few)
should not even be practicing psychology.  They don't want to prescribe
because they don't want to be sued, and they are unhappy at raising the
professional level of their field, because they might have to take a
hard course sometime.  (Not that they'd admit this.  I'm guessing from
their inability to follow an article in, say, Scientific American.
This is not a high intellectual standard.)

I'm sure there are a lot of good clinical psychologists; I even know a few;
but they seem to exist despite the traditions and training of their field,
not because of it.  I think that this is very much the case in psychiatry
as well, and very much not the case in most other fields of medicine.

I don't doubt it.  Very few fields are entirely crud, and very few are
made of saints.  I've had the good fortune not to need psychiatric help,
but I have gotten to know a few psychiatrists.  My unscientific sample
is not very complementary to the field.

Medical history and "clinical tales."  The story about the girl with the
lung-tumor-induced myoclonus is in "Newton's Madness."

It isn't clear what you mean by the "idea" of psychiatry.  Clearly, mental
illness ought to be treated as best as anyone can.  On the other hand,
giving people a few years of medical school, then sticking them in the
psych wards for most of a residency, seems counterproductive.  I know
one very good physician who found it so dispiriting that he quit, and
went into OB/GYN instead.
--
Mark A. Fulk                    University of Rochester

Yes, for a long time some psychiatrists thought it was a mental
disorder.  There is obsessive compulsive behavior that goes with
the syndrome, incidentally.  You find OCs in the family even when
they don't have the tic.

In general, yes, but there are very good FP and very bad internists.

As far as I know, there is no movement to expand it.

I'm not dismissive of continuing therapy.  It is just that the neuro-
psychologists I know don't do it and don't want to.  Speech therapists,
Occupational therapists, physical therapists and physiatrists do.

Our speech therapists are very well trained in neuropsychology, by the way.
Neuropsychology is primarily a research and testing field, not a therapy
field.  You'd be better off giving the speech therapists more training
in other cognitive areas and making them "cognitive therapists" although
that name is already taken by a completely different field.

Yes, I know Pat Kelly.  He did some work on computer stuff a while back
didn't he?  What does he think of your idea?

Frankly, it isn't going to happen, or at least not in the near future.
Neurologists like the brain too much.  Probably 50% of them went into
neurology just for that reason.  No way are we going to let neuropsychologists
take over for us.  Ken Heilman would kill you if he heard you say such
a thing.
--
----------------------------------------------------------------------------
Gordon Banks  N3JXP      | "Skepticism is the chastity of the intellect, and

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

I don't quite understand your purpose in throwing out these theories,
but I'll humor you and tell you why I think your theory unlikely.

Paranoia is not limited to people who hear voices.  All people who
hear voices are not paranoids.  Paranoids do hear voices directed
at them.  If paranoia was a disorder of auditory (Heschl's gyrus)
perception, one would expect that all paranoids heard voices.
Paranoia is found in a large variety of diseases, including dementia.
I would characterize your theory as one purporting that paranoia was
a positive phenomenon, but the appearance of paranoia at a stage of
dementia might make it more likely that it was a release of higher
controls over some area, and thus a negative one.  The idea that
paranoia might have a semantic origin is more reasonable (Wernicke's
area) since paranoia involves a misinterpretation of environmental
phenomena.  Patients with Wernicke lesions initially can appear
paranoid and irascible, (as if they believed people were deliberately
refusing to communicate with them) but they usually get over this
in short order and paranoia is not a usual feature of patients with
lesions in either Wernicke's or Heshcl's gyrus.  As far as I know,
patients with focal epilepsy from tumors in these regions do not
particularly demonstrate paranoid behavior.  Thus, I see no real
evidence to support such a hypothesis, and some evidence that the
hypothesis is false since it limits the scope of paranoia unreasonably.
I'm sure Mark K. can do better.
(Incidentally, my great aunt was a classic paranoid, and never
heard any voices, or at least never admitted to hearing any.  She
did have classic delusions, but never any hallucinations.)
--
----------------------------------------------------------------------------
Gordon Banks  N3JXP      | "Skepticism is the chastity of the intellect, and

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

Psychiatrists have 4 years of medical school.  How many years do you
want psychologists to take?  And if they do, why not call them MDs?

I agree that psychiatry needs to be put on a more rigorous regimen. At
our institution, psychiatry is quite strong scientifically.  I realize
that this isn't universally true, but it can and should be.  There is
no need for a new specialty, just improving the old ones.
--
----------------------------------------------------------------------------
Gordon Banks  N3JXP      | "Skepticism is the chastity of the intellect, and

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