Strange Bedfellows: Pathology and Psychiatry

What do pathology and psychiatry have in common? Both are complex specialties – and both are often overlooked or underrated in terms of their clinical significance. It is perhaps because of their similarities that the interface between these two specialties fascinates me.

Our medical textbooks define what schizophrenia is, how to diagnose it, and how to treat the illness – but they don’t explain why a person with schizophrenia has hallucinations. When it comes to the pathogenesis of mental illness, we’re told that there is a chemical imbalance in the brain. A few handpicked neurotransmitters may be mentioned. But this leaves questions not only in the minds of clinicians, but also patients. What are the mechanics of the disease in the brain circuitry? With our textbooks full of neuroanatomy, why don’t we learn the details of neurological biomarkers in psychiatric illness?

I vividly remember a patient I encountered in medical school – a young female recently diagnosed with schizophrenia. Neither she nor her family could make sense of what was going on and, after a long course of treatment with faith healers, she ultimately ended up in our hospital, the only tertiary care facility in the region. A team of psychiatrists and medical students interviewed her, investigating her symptoms and attempting to fit her into one of the categories of mental health disorders. As I watched, I wondered what was actually going on in her mind – how and why she was responding to treatment. The experience was food for thought. Is it necessary for a disease to be physically present to be diagnosed? How much does our understanding of an illness increase once we are cognizant of its underlying pathophysiology?

Unfortunately, we often believe that a disease must be tangible for it to be “real.” With mental illnesses, the symptoms may be subtle and less visible. The dearth of pathological explanations for these illnesses may lead us to question their authenticity. It was well said by psychiatrist Thomas Szasz in 1987 that “… ever since the earliest days of psychiatry, psychiatrists have claimed that mental diseases are brain diseases… [but] pathologists have never been able to confirm these claims… psychiatrists ought to convince pathologists that schizophrenia is a brain disease before they take it upon themselves to tell the public that it is such a disease (1).”

The fewer symptoms you see as a clinician, the more you need to understand the pathophysiology of the disease. Just explaining schizophrenia as “hallucinations, delusions, and disorganized speech” isn’t enough; far more valuable would be a detailed explanation of the disease mechanics. Humans tend to believe more in things we can understand, be it the complexities of nature or the diagnosis of disease. Pathology plays an important role in the recognition and treatment of mental illnesses by providing the explanations we need.

Where does unusual behavior end and a mental disorder begin? The boundaries are fuzzy – but pathology can make the distinction easier. When I worked with mental illness, my patients and students frequently asked me questions like this, and my inability to answer made me curious. It is a great feat to treat and cure a patient’s disease, but if a person with bipolar disorder asks how their brain is wired differently, most psychiatrists are unable to answer – and that’s where a relationship with pathology would stand them in good stead. Psychiatrists are in frequent communication with other specialists – so why not pathologists?

A collaboration between pathology and psychiatry could result in a greater understanding and appreciation of both specialties. A path not easily found by medical students might be highlighted by discussing the pathologies of mental illnesses, potentially increasing interest in both pathology and psychiatry. Research collaborations between pioneers in both specialties could yield a greater understanding of mental illness, with better diagnosis and treatment for patients with severely disabling conditions. Let’s bring pathology and psychiatry together – and shine a light on the mysteries of the mind.