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standing to effect change By frank discussion and guidance, the physician endeavors to demonstrate the relationship of the patient s symptoms to abnormal behavior patterns and reactions, and, by a kind of reeducation, ie, psychotherapy, to assist in bringing about an understanding of the problems and improved ways of coping with them As an intellectual enterprise, however, the psychologic method alone, although yielding interesting data concerning the patient s background and the evolution of their particular symptoms in their form and content, does not provide a complete explanation of disease The two methodologies of neurologic and psychiatric medicine are both valid but have different roles In diagnosis, one begins always with a classic medical approach, assuming every symptom to be an expression of disease This method is relevant also to a theoretical formulation of disease processes In reference to therapy and management, the psychiatric approach is sometimes the only rational (and available) methodology In other circumstances, the spheres of the two methodologies tend to overlap The two methods operate at different levels and are of principal use in different types of nervous aberrations In the diagnosis and management of dif culties in adjusting to life s circumstances and in certain disorders of personality and character, which constitute such a large and important part of medicine and psychiatry, the psychologic approach achieves maximal credence The psychiatric approach has been highly successful at focusing on the interaction between an individual s traits and his or her complex environment and is not easily framed in neurologic terms This unitary view of mental disease also allows for the possibility that changes in the environment and even in the patient s mental state can cause changes in the functioning of the brain It is fair to say that this apparent clash of views between mentalism on the one hand and on the other hand the mind as a property of the physical brain has been settled in favor of the neurologic view It is supported to some extent by the observations that every known psychiatric symptom can be reproduced by well-de ned cerebral diseases, and every major neurologic disease of the cerebrum may be attended by symptoms of psychiatric disease Every disorder of function must have a structural or physiologic basis unless one adheres to a purely psychic view in which human behavior is not considered to be a product of brain function This is the position of the mind-body problem most acceptable to neurologists This concept of disorders of mind arising in brain is also subscribed to by most modern psychiatrists (Andreasen) Admittedly, neuropsychiatric monism has not had universal acceptance Western philosophers, from Plato in ancient times through Descartes, James, and, more recently, Sherrington and Eccles, broadly speaking have been dualists, holding that body and mind are independent systems, each susceptible to its own disorders This brings us to another of the crucial problems in neurology and psychiatry that of de ning a disease of the nervous system and distinguishing it from a social or psychologic maladjustment Failure to do this has resulted in confusion as to the legitimate spheres of medical activity and has been an obstacle to research The present authors de ne a disease of the nervous system as any condition in which there is a visible, physiologic, biochemical, or other subcellular lesion or in which there is reasonable evidence of its existence on the basis of stereotypy of clinical expression and of genetic and collateral laboratory data Goodwin and Guze offer a slightly different de nition of psychiatric disease as any cluster of symptoms and signs that occur with such consistency as to permit the prediction of their outcome In contrast, an abnormal psychologic reaction is de ned as a disorder of psychic function and behavior caused by a maladjustment in social relations or a disordered response to life s dif culties not based directly on a known disease process or lesion Certain mental abnormalities have an uncertain status vis-a-vis this division and are ` subject to double interpretations, depending on one s premises For example, persistent anxiety state without obvious cause in a previously healthy adult would be viewed by some psychiatrists as a reaction of fear of some unconscious threat Others would consider it the manifestation of a genetic disease in which some biochemical disturbance, as mysterious as was hyperthyroidism a century ago, developed de novo Further challenging our current conceptions is how to interpret the co-opting of basic mechanisms of the limbic.

system by thought processes to produce affective states such as depression Is a susceptibility to trigger such mechanisms a disease, a genetic proclivity, or does it re ect a normal spectrum of activity Since the nature of the condition is unsettled, it is treated by physicians using both psychologic methods and drugs Anyone who proposes to investigate it should do so with a completely open mind and be prepared to review critically any reasonable hypothesis as to its cause When the clinical specialties of psychiatry and neurology are viewed in terms of these theories about disease and psychosocial reactions, it is obvious that they overlap Diseases such as schizophrenia and manic-depressive psychosis, which are cerebral diseases and of interest to neurologists, will for the near future remain in the province of psychiatrists The latter specialists have the training in psychotherapeutic methods and expertise in neuropharmacology that is needed in the care of such patients Examples of the intersection of interests between specialties occur regularly in dealing with diseases such as dementia, and in temporal lobe epilepsy, where behavioral and cognitive changes are equally distressing to the patient and family and where drug usage must be supplemented by guidance and explanation of the illness Finally, and of utmost importance, the psychiatrist must stand as the spokesperson for the medical position on the countless ills related to social and behavioral maladjustments in modern life

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It is dif cult to appreciate the evolution of psychiatry, particularly in America, without mentioning the impact of psychosomatic medicine on theoretical thinking Beginning in the 1930s there was great interest in a large category of disease referred to for decades by this term Included at one time or another were peptic ulcer, mucous and ulcerative colitis, hay fever, asthma, urticaria, angioneurotic edema, essential hypertension, hyperthyroidism, rheumatoid arthritis, amenorrhea, and migraine diseases in which a stressful life situation or emotional upset appeared to be associated with their development, exacerbation, or prolongation By extension, certain personality traits were thought to be prevalent in patients who later developed brain diseases, such as Parkinson disease More than 70 years have passed since these ideas were rst promulgated and expressed, an enormous literature followed, but with the establishment of pathetically few unassailable facts for each of them It became clear that the so-called psychosomatic diseases are not neuroses and, in most instances, a demonstrable pathologic basis has been discovered Even peptic ulcer, an old psychosomatic favorite, has been traced to a bacterial infection No proof of psychic causation of any of the psychosomatic diseases has been found Treatment has been concerned mainly with the relief of physical symptoms and has been directed for the most part by nonpsychiatric specialists There was never rm evidence that the therapeutic results obtained by psychiatrists were better than those of a competent internist or simply of the passage of time This extended application of the concept of psychosomatic disorders is still prevalent The current societal preoccupation with stress as a cause or trigger for all manner of medical and neurologic disease, including disordered function of the immune system (psychoneuroimmunology), is an extension of this tenuous concept Interestingly, the terms psychosomatic and psychophysiologic are not listed in the fourth edition of the American Psychiatric Association s of cial diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) A few of the disorders originally called psychosomatic now appear under the categories of somatoform disorders or psychological factors affecting physical conditions; these are discussed in subsequent chapters The reader seeking further information as to the status of psychosomatic or psychophysiologic disorders is referred to the review by Rogers, Fricchione, and Reich.

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