Psychiatry and neurology should marry and become one profession, said
Stuart Yudofsky, M.D., M.P.H., at last month's APA Institute on Psychiatric
Services in Chicago.
In a lecture titled "Neuropsychiatry and the Future of Psychiatry,
Neurology, and Psychiatry," Yudofsky charted a winding path of
understanding about the human brain and behavior—from the ancient Greek
conception that insanity was inflicted by the gods and treated by priests,
through Hippocrates, Plato, medieval Christianity, the Enlightenment, the
origins of psychiatry and neurology, psychoanalysis and the demedicalization
of psychiatry, up to the birth of a new subspecialty with the formation in
1988 of the American Neuropsychiatric
Stuart Yudofsky, M.D.: "I believe psychiatry and neurology should
be combined into one profession.... "It would obviate the mind-body
dualism that is the source of all stigma against mental illness, and against
us [as psychiatrists], and it would reestablish psychiatry as a medical
Credit: Ellen Dallager
He said that the logical endpoint of this journey is the merger of
psychiatry and neurology.
"I believe psychiatry and neurology should be combined into one
profession," he said. "It would obviate the mind-body dualism that
is the source of all stigma against mental illness, and against us [as
psychiatrists], and it would reestablish psychiatry as a medical
Yudofsky is the D.C. and Irene Ellwood Professor and Chair of the Menninger
Department of Psychiatry and Behavioral Sciences at Baylor College of
He cited examples of recent research that point the direction toward a
21st-century neuropsychiatry based on a genetic and neuromolecular
understanding of behavior. Among these is a remarkable study conducted at
Baylor and published in the August 8 Science demonstrating stark
differences in brain functioning among patients with borderline personality
disorder (BPD) in areas of the brain central to interpersonal trust.
The study employed an "economic exchange game" that depends on
cooperation as a proxy for studying interpersonal trust; the game involves an"
investor" and a "trustee" and a simulated stock
Cooperation occurs when the investor and trustee act in a manner that
mutually benefits both players: if an investor sends $20 to a trustee and the
trustee splits the tripled investment ($60) with the investor, both the
investor and trustee profit. The investor earns $10 more, and the trustee
earns $30 more than if the investor had sent nothing.
However, if a trustee does not repay at least the amount invested, the
investor accrues no benefit from the exchange, likely triggering smaller
subsequent investments. Thus, increased cooperation is linked with increased
money exchanged across the course of the 10-round game.
In the study, subjects diagnosed with BPD played the trustee role against
an investor without a psychiatric disorder. In early rounds of the game,
investment levels did not differ between subjects partnered with BPD trustees
and subjects partnered with healthy trustees. However, in late rounds,
investments were significantly lower for dyads with a BPD trustee than in
control dyads with a healthy trustee. This downward shift in investment levels
for dyads with BPD trustees reflects a break in cooperation.
But researchers also tested the ability of subjects to repair broken
cooperation, since breakdowns are common in interpersonal relations—for
many reasons other than broken trust—and successful social agents must
sense or even anticipate these failures and select actions to repair them.
So the researchers focused on rounds in which cooperation was
low—that is, rounds in which investments of $5 or less were made. These
typically occur late in the game in response to "untrustworthy"
returns by a trustee; such ruptures of cooperation provide the trustee an
opportunity to repair the broken cooperation by repaying a large fraction of
the tripled investment—thereby signaling their trustworthiness in the
presence of low offers—a response the researchers termed"
Remarkably, comparison of healthy trustees with BPD trustees found healthy
players to be almost twice as likely as BPD players to coax in the presence of
low offers—that is, to repay a third or more of the investment.
Brain scans of the players revealed neuroanatomical correlates to these
behaviors: activity in the anterior insula, a region known to respond to norm
violations across affective, economic, and social dimensions, strongly
differentiated healthy participants from individuals with BPD. Healthy
subjects showed a strong linear relationship between anterior insula response
and both magnitude of monetary offers received from their partners (input) and
the amount of money repaid to their partners (output).
In stark contrast, activity in the anterior insula of BPD participants was
related only to the magnitude of repayment sent back to their partner
(output), not to the magnitude of offers received (input).
"These neural and behavioral data suggest that norms used in
perception of social gestures are pathologically perturbed or missing
altogether among individuals with BPD," the researchers wrote.
Yudofsky pointed out that neurology has its own forms of"
reductionism" that need the expertise of psychiatry to correct.
He cited the example of a teenage patient who experiences an epileptic seizure
in public that leaves the individual handicapped for the rest of his or her
"The neurologist looks for the lesion and treats with an
anticonvulsant and says 'we've solved the problem,'" Yudofsky said."
But we know that kid's problems are just beginning."
An abstract of "The Rupture and Repair of Cooperation in
Borderline Personality Disorder" is posted at<www.sciencemag.org/cgi/content/abstract/321/5890/806>.▪