Psychiatry, The Brain and the Deep Blue Sea

Psychiatry, The Brain and the Deep Blue Sea

It has been said that there are still two great unexplored regions left on earth- the deep oceans and the human brain. But whilst much about how the brain functions remains unclear, there is no doubt that we are making great strides now in unlocking its secrets.

Doctors become doctors because they are interested in how the different parts of the body work, and what happens when they don't. Gastroenterologists study the workings of the gut, cardiologists the heart, haematologists the blood and so on. Two specialties focus on the brain - neurology and my own specialty, psychiatry.

The study of the brain was relatively crude until a century ago, when neurology took a great scientific leap forward with the explosion of knowledge about the nervous system. Brought about by the advent of new technologies such as microscopy and recording electrodes, this led to the discovery of the neuron, allowing the study of neurons, neurodegeneration and many other fundamental building blocks of clinical neuroscience. But during those critical years, psychiatry lagged behind. There was no equivalent to what the military would call "kit", such as the new microscopic techniques which were transforming neurology in the hands of pioneers like Alzheimer. There were certainly great minds, perhaps some of the greatest, such as Freud thinking about how why and what we think. But still the brain, rather like the deep oceans, remained hard to explore.

Now the study of the brain is going through its own explosion of discovery though. Thanks to new technologies such as neuroimaging we understand far more about the complex structural and functional abnormalities underlying psychiatric illnesses and healthy cognitive and emotional processes. Through epigenetics we are able to better explain the interactions between genes and environment that manifest as psychiatric symptoms and are likely passed down through generations. Neuroscience is already transforming the treatment of addiction, as we can now identify parts of the brain involved in getting pleasure from a drug and observe that in addiction dysregulation in this system means that the part of the brain involved in drive, motivation and habit comes to dominate. So these observations give us a more sophisticated understanding of what works when it comes to treating addiction, because scientists have been able to observe by looking at real brains how medications modulate key brain processes in addiction such as reward, motivation, impulsivity or stress.

So far, this flowering of knowledge has only just begun to change the practice of psychiatry. This is to be expected. Understanding how a system works is the start of understanding how and why it doesn't, and it is still a long journey before that in turn leads to new treatments. Nevertheless, it is more than likely that medical students and psychiatrists entering training today will be using some of the fruits of these new discoveries in their clinical practice in the future.

That is why the Royal College of Psychiatrists is acting now to get ahead of the game. Our International Congress this week sees the official launch of a new project - funded by the Wellcome Trust and the Gatsby Foundation - that will herald a major overhaul of our curriculum, to bring it up to date with these new developments and understanding of the brain. Our new trainees need to have a prepared mind to be able to recognise the potential value of new science as it arises, because as clinicians they will be in the critical place to bridge the gap between theory and practice. We want psychiatry to reflect the excitement that is bubbling through our universities, and to tell those students who see the potential for clinical neuroscience that they will find a ready home in psychiatry. After all, what could be more satisfying that being at the cusp of new developments to improve the treatment of illnesses such as the dementias, autism, bipolar disorder, major depression or schizophrenia.

But does this mean (as some predict) that psychiatry will eventually become indistinguishable from neurology, and that the two will merge? No. Because although I do strongly believe that modern neuroscience will improve, and possibly transform our understanding of the major mental illnesses, it will never provide a complete explanation. We already know just how much our thoughts and feelings influence our behavior, and vice versa. Our mind can never be solely reduced to neural circuitry. And nor can neuroscience ever replace an understanding of how we exist as human beings in society - how the social forces that surround us from cradle to grave will always play a crucial part on our health and well being. We would be failing our patients if we ignored what is going on in neuroscience, but we would be failing them equally if we ignored what is going on outside neuroscience. Our curriculum might evolve, but the essence of psychiatry - integrating the physical, psychological and social - will never change.

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