Many people are
fascinated by the interplay between psychiatry and neurology.
Should the specialties be separate, or should it be ‘same organ,
same speciality’? What about the emerging interface speciality,
neuropsychiatry? What do neuropsychiatrists do and what skills
might they have? And, close to the heart of foundation trainees
with an interest in both minds and brains, which speciality could
you imagine yourself doing?
During foundation year
one I was fortunate enough to spend two days with Dr Jon Stone,
Consultant Neurologist in Edinburgh, sitting in his clinics and
reviewing ward referrals. We saw a range of general neurology and
patients with ‘functional’ neurological symptoms. Functional
neurology is Dr Stone’s area of expertise. Although he is not a
neuropsychiatrist by training, his clinical practice is very much
at the interface between neurology and psychiatry.
Functional symptoms refer
to neurological symptoms without identifiable structural cause.
They are also called conversion symptoms, dissociative symptoms,
psychogenic symptoms and non-organic symptoms. It doesn’t refer to
symptoms made up by patients, or to a last ditch diagnosis when
‘nothing else can be found’. In fact, a functional diagnosis should
ideally be made on the basis of positive signs or symptoms. One
sign which really impressed me was ‘Hoover’s sign’, where a patient
can only weakly extend their hip when it is the primary movement
asked for, but can synergistically extend it strongly when asked to
flex the contralateral hip against resistance. This demonstrates
that the muscle and its peripheral nerve supply is intact, but
control of it is not. This sign tends to surprise patients too, but
pointing it out doesn’t take the it away.
We saw many patients with
functional symptoms, ranging from transient arm paralysis through
to dissociative pseudoseizures, persisting even while intubated.
Although the symptoms can seem quite disparate, many may be part of
a symptom constellation with different emphasis in different
patients, similar to the way angina can cause mainly chest pain in
some but shortness of breath in others. This concept was really
brought home to me when a patient presented with functional arm
weakness, without any complaints of leg weakness, but was Hoover’s
sign positive on the affected side - demonstrating evidence of
previously unnoticed lower limb involvement.
I was privileged to
observe a number of patients being introduced to the idea of having
a functional disorder. This is a very challenging explanation and
advice scenario. Some patients were initially suspicious, fearing
that they were going to be told that their symptoms were “all in
their mind” which they took to be the same as made-up. However,
with reassurance that their symptoms were still real, important,
and treatable, most patients were receptive to the
diagnosis.
Being a neuropsychiatrist
or neurologist with an interest in functional neurological symptoms
requires a diverse skill set. Firstly, you need excellent
neurological knowledge and skills to ensure you are able to
securely recognise/exclude ‘structurally identifiable’ neurological
disease as well as functional problems. Secondly, you require high
quality communication skills to enable you to explain a difficult
disease concept and negotiate any stigma. Thirdly, an ability to
establish rapport and elicit psychological symptoms and social
stressors is important. Many patients with functional neurological
symptoms don’t suffer from affective disorders, anxiety disorders
or adverse childhood experiences, but the proportion is higher than
in the general population and it helps to be able to recognise it
when they do.
I learnt a lot from my
taster, but there are other aspects of neuropsychiatry too. For
example, some neuropsychiatrists specialise in dementia, a widely
accepted example of a ‘mind’ problem with a ‘brain’ origin. Others
work on psychiatric sequelae of brain injury, or on diagnosing
comorbid psychiatric and neurological disorders. I would highly
recommend learning more about neuropsychiatry to anyone interested
in neurology, psychiatry, or their interface. Which speciality you
choose in the end depends on your personality and skills, but
learning more about this fascinating area will stand you in good
stead whichever path you take in medicine.
Katie Marwick, foundation year two doctor,
South-East Scotland
Further Reading
Dr Stone’s excellent
website, where you can read his thoughts on functional neurology
rather than my interpretation: http://www.neurosymptoms.org/
The British Neuropsychiatry Association, who
hold annual meetings: http://www.bnpa.org.uk/
The bare essentials:
Functional symptoms in neurology. Stone J. Practical Neurology.
2009 Jun; 9(3):179-89. A very clear review article.
Page last updated on 22 May
by E Baker-Glenn