Neuropsychiatry, what is it?

A short introduction to the history of neuropsychiatry and how it influences medicine today.

A story of twins separated at birth

Neuropsychiatry was a medical speciality for many years. It can be considered the forerunner of two major medical specialities: neurology and psychiatry. At the end of the 19th century and the beginning of the 20th century, great doctors who contributed to neurology also contributed to psychiatry. These doctors were to be found in the centre of Europe, especially between France, Germany and Switzerland. One of the great doctors of these years was Jean-Martin Charcot (1). A French neurologist who is considered one of the fathers of modern neurology, he contributed greatly to the development of neurology through the discovery of cerebral aneurysms and the study of aphasia, but he also played an essential role in psychiatry, not only through his support and development of hypnosis but also through the great influence he had on Sigmund Freud (2). Freud worked with Charcot at his clinic in France and began to develop his theories on the psyche, consciousness and the subconscious. While Charcot sought a functional origin for neuropsychiatric diseases and disorders, Freud, based on hypnosis, tried to find a psychological origin for the same disorders. It may be from this encounter between these two great personalities that neurology and psychiatry followed different paths.

Freud was considered a "Nervenarzt". Nervenarzt was the name given to psychiatrists and neurologists before there was a clear distinction between the two specialities. Even today, in the specialised training of both psychiatrists and neurologists in German-speaking countries (Switzerland, Germany, Austria...), each aspirant has to have trained for at least 12 months in the other speciality before they can take the exam.

Neuropsychiatry therefore brings together knowledge from both specialities, neurology and psychiatry. But it would be very reductive to say that neuropsychiatry is the speciality that lies at the intersection of neurology and psychiatry. Neuropsychiatry is much more than that, it's more than a speciality, it's what allows doctors to understand the person in front of them. It doesn't dissociate the body from the mind, the material from the immaterial, reason from being, considering the person with their physical, mental and psychological characteristics. These characteristics are inseparable and can influence each other. Looking at one of these characteristics and neglecting the rest prevents us from having a complete and comprehensive view of the person.

This image is possibly too reductive of the true reality of neuropsychiatry.

Neuropsychiatry has also been of great interest to neurosurgeons, who have long been intrigued by the link between mental illness and brain damage. In fact, some of the first treatments for mental illness were actually surgical procedures. For example, at the end of the 19th century, the psychiatrist Gottlieb Burkhardt performed a procedure called frontal leucotomy (from which Egas Moniz would later draw inspiration for his work), which involved cutting the connections between the frontal lobe and other parts of the brain. (3)

Although these early treatments may seem barbaric by today's standards, they paved the way for important advances in our understanding of mental illness. In recent years, there has been a renewed interest in neuropsychiatry, as researchers have begun to unravel the mysteries of the brain. (4)

Neuropsychiatry takes a global approach to neurological and psychiatric pathologies, understanding that brain lesions cause psychiatric problems and psychiatric pathologies stem from chemical and formological brain disorders

A story of "marriage" and "divorce"

With all the evolution that has taken place in the history of medicine, especially in the 19th and 20th centuries, there have been situations of "marriage" and "divorce" between the two specialities. The speciality of psychiatry has existed in Portugal since 1911. Epileptic disorders were considered psychiatric until recently.

In April 1949, the Portuguese Society of Neurology and Psychiatry (SPNP) was created. Both neurology and psychiatry had a single society and held their congresses, sessions and meetings together. And for 20 years the two visions lived and coexisted together. With the passage of time, it was thought to remodelling the two sections, separating Psychiatry and Neurology, but still being part of the same society.

In 1973, the SPNP split into two classes, but until then the boundary that existed between the different pathologies and problems that each speciality dealt with was very blurred. But with the introduction of psychotherapeutic currents, the excision became evident.

Despite the differences, the two specialities were closely linked, to the extent that psychiatrists called themselves neuropsychiatrists. These same psychiatrists would put this designation on the door of their offices, so that patients who consulted them, even if they had a psychosis or other problem, could always tell their family that they had been to see the neurologist. Many Portuguese neurologists, including Egas Moniz (5), practised psychiatry (Egas Moniz was even shot by one of his psychiatric patients). (6)

Even in the 20th century, there was no neurology in the Portuguese army, only neuropsychiatry.

In 1979, the SPNP was finally split into the Portuguese Society of Psychiatry and the Portuguese Society of Neurology. The initiative to propose this split came from psychiatrists. Evil tongues have it that it was under great pressure from Prof António Fernandes da Fonseca that it was proposed to create the Portuguese Society of Psychiatry and Mental Health. In this way, this society could belong to an international society of Portuguese-speaking psychiatrists with its own statutes and Fernandes da Fonseca himself would be the director of this international society.
But in reality, the differences were already too great and separation was the right course of action.

Neuropsychiatry tries to solve the puzzle that is our brain in the different neurological and psychiatric pathologies from a comprehensive point of view.

An organ of the body, different specialities and knowledge

The truth is that the brain is the part of our body that has the most "specialists" in charge of it... We have neurologists, neurosurgeons, psychiatrists, psychologists, neuropsychologists (isn't that a pleonasm?), neuropsychiatrists, neuroradiologists and more professions have sprung up around this mysterious organ... neurobiologists, neuroscientists, neurolinguists... and so many others related to the brain. (7)

It's clear that the brain is a mystery, that we still have a lot to learn about it and that's why there are more and more sciences, university courses and professions "born" from the study of this marvellous and complex organ.

Of course, all these disciplines are connected, but each one is special and has its own peculiarities. Each has its own reason for being "separate" and following its own path. But in reality they are not separate and each will "drink" from the knowledge and new discoveries made by the other. That's why in medicine you can't want to treat one organ and leave out the rest, and even worse is wanting to treat the brain or brain disease only from a neurological point of view and not think about the psychiatric or psychological and social consequences.

And it's from this point of view, in which treatment has to be comprehensive and encompass a range of knowledge and consequences, that the figure of the neuropsychiatrist makes sense and will become increasingly important in the future.