How the Conflict between American Psychiatry and Neurology Delayed the Appreciation of Cognitive Dysfunction in Multiple Sclerosis

Abstract

Whereas cognitive deficits in multiple sclerosis (MS) were documented in the original clinicopathological description by Charcot, the extent and nature of cognitive dysfunction was poorly understood in the U.S. until over a century later. Our objective was to discern reasons for this misunderstanding and to examine forces shifting this topic to center stage of research and increased awareness in clinical practice. We hypothesized that during the 19th century, conflict between psychiatrists and neurologists over control of treatment of the mentally ill fueled a misunderstanding of the nature of MS which led neurologists to treat diseases of the body, and psychiatrists, diseases of the mind. The importance of cognitive deficits in MS was thus minimized until scientific breakthroughs could once again bring them to light. As the rift between disciplines peaked, awareness of cognitive deficits diminished, and vice versa. This may have been one contributing factor affecting how MS was mistakenly conceptualized for a century.

Focus or Neglect on Cognitive Impairment Following the History of Multiple Sclerosis

“…A possible explanation of the neglect into which cognitive disorders in MS fell lies in the separation between neurology and psychiatry that occurred between the end of the 19th and the beginning of the 20th century. This explanation is most likely valid for North America (see Butler et al [ 35 ]). Possible reasons for this separation include the supposed dichotomy between body and mind, the spread of the psychoanalytic approach, and the relative lesser importance, as a discipline, of neurology when compared to psychiatry.…”

“…In the years following the end of the First World War, greater attention to cognitive impairments in MS seemed to emerge: Jeliffe [ 45 ] identified frequent difficulties in formulating thought, attentional processes, and memory; Sachs and Friedman [ 46 ] established, using a statistical approach, that 15.6% of a sample of 141 cases had mental changes. As highlighted by Butler et al [ 35 ], the vagueness of the term “mental changes”, together with other limitations, did not allow for any generalizations. Brown and Davis [ 47 ] believed that cognitive impairments (mental deterioration) may or may not have occurred and were, for the most part, mild; they believed that these impairments would progress to varying degrees from case to case and, even in the advanced stages of the disease, severe deterioration was occasional.…”

“…However, Clymer’s report could have had a scarce diffusion; the uncertain place of mental disorders caused by diseases such as MS, of proven “organic” origin [ 35 ] in the American medical world, could also have had a role. Another pioneer of the recognition of MS as a specific disease in the USA was Edward Seguin (1878), who is also credited with the first use of the name “multiple sclerosis” [ 36 , 37 ].…”

“…Moreover, as reported by Butler et al [ 35 ], various prominent English clinicians, such as Wilks [ 38 ], Gowers [ 39 ], and Bury [ 40 ], in a period of about 30 years, placed the mental disorders of MS in a secondary position.…”

Focus or Neglect on Cognitive Impairment Following the History of Multiple Sclerosis

“…A possible explanation of the neglect into which cognitive disorders in MS fell lies in the separation between neurology and psychiatry that occurred between the end of the 19th and the beginning of the 20th century. This explanation is most likely valid for North America (see Butler et al [ 35 ]). Possible reasons for this separation include the supposed dichotomy between body and mind, the spread of the psychoanalytic approach, and the relative lesser importance, as a discipline, of neurology when compared to psychiatry.…”

“…In the years following the end of the First World War, greater attention to cognitive impairments in MS seemed to emerge: Jeliffe [ 45 ] identified frequent difficulties in formulating thought, attentional processes, and memory; Sachs and Friedman [ 46 ] established, using a statistical approach, that 15.6% of a sample of 141 cases had mental changes. As highlighted by Butler et al [ 35 ], the vagueness of the term “mental changes”, together with other limitations, did not allow for any generalizations. Brown and Davis [ 47 ] believed that cognitive impairments (mental deterioration) may or may not have occurred and were, for the most part, mild; they believed that these impairments would progress to varying degrees from case to case and, even in the advanced stages of the disease, severe deterioration was occasional.…”

“…However, Clymer’s report could have had a scarce diffusion; the uncertain place of mental disorders caused by diseases such as MS, of proven “organic” origin [ 35 ] in the American medical world, could also have had a role. Another pioneer of the recognition of MS as a specific disease in the USA was Edward Seguin (1878), who is also credited with the first use of the name “multiple sclerosis” [ 36 , 37 ].…”

“…Moreover, as reported by Butler et al [ 35 ], various prominent English clinicians, such as Wilks [ 38 ], Gowers [ 39 ], and Bury [ 40 ], in a period of about 30 years, placed the mental disorders of MS in a secondary position.…”

Changing definitions of euphoria in multiple sclerosis: A short report

“…13 However, Cottrell and Wilson, in particular, were also not without fault, and their characterisation of the majority of their MS patients as lacking cognitive impairment has been severely criticised. 1,14 Thus, their definition of euphoria may, too, contain incorrect elements and lack construct validity. This leaves us still questioning which definition truly captures what it means to be euphoric, and leaves us unable to reliably compare the results of the various authors.…”

Focus or Neglect on Cognitive Impairment Following the History of Multiple Sclerosis

“…A possible explanation of the neglect into which cognitive disorders in MS fell lies in the separation between neurology and psychiatry that occurred between the end of the 19th and the beginning of the 20th century. This explanation is most likely valid for North America (see Butler et al [ 35 ]). Possible reasons for this separation include the supposed dichotomy between body and mind, the spread of the psychoanalytic approach, and the relative lesser importance, as a discipline, of neurology when compared to psychiatry.…”

“…In the years following the end of the First World War, greater attention to cognitive impairments in MS seemed to emerge: Jeliffe [ 45 ] identified frequent difficulties in formulating thought, attentional processes, and memory; Sachs and Friedman [ 46 ] established, using a statistical approach, that 15.6% of a sample of 141 cases had mental changes. As highlighted by Butler et al [ 35 ], the vagueness of the term “mental changes”, together with other limitations, did not allow for any generalizations. Brown and Davis [ 47 ] believed that cognitive impairments (mental deterioration) may or may not have occurred and were, for the most part, mild; they believed that these impairments would progress to varying degrees from case to case and, even in the advanced stages of the disease, severe deterioration was occasional.…”

“…However, Clymer’s report could have had a scarce diffusion; the uncertain place of mental disorders caused by diseases such as MS, of proven “organic” origin [ 35 ] in the American medical world, could also have had a role. Another pioneer of the recognition of MS as a specific disease in the USA was Edward Seguin (1878), who is also credited with the first use of the name “multiple sclerosis” [ 36 , 37 ].…”

“…Moreover, as reported by Butler et al [ 35 ], various prominent English clinicians, such as Wilks [ 38 ], Gowers [ 39 ], and Bury [ 40 ], in a period of about 30 years, placed the mental disorders of MS in a secondary position.…”

Changing definitions of euphoria in multiple sclerosis: A short report

“…13 However, Cottrell and Wilson, in particular, were also not without fault, and their characterisation of the majority of their MS patients as lacking cognitive impairment has been severely criticised. 1,14 Thus, their definition of euphoria may, too, contain incorrect elements and lack construct validity. This leaves us still questioning which definition truly captures what it means to be euphoric, and leaves us unable to reliably compare the results of the various authors.…”

Focus or Neglect on Cognitive Impairment Following the History of Multiple Sclerosis

“…A possible explanation of the neglect into which cognitive disorders in MS fell lies in the separation between neurology and psychiatry that occurred between the end of the 19th and the beginning of the 20th century. This explanation is most likely valid for North America (see Butler et al [ 35 ]). Possible reasons for this separation include the supposed dichotomy between body and mind, the spread of the psychoanalytic approach, and the relative lesser importance, as a discipline, of neurology when compared to psychiatry.…”

“…In the years following the end of the First World War, greater attention to cognitive impairments in MS seemed to emerge: Jeliffe [ 45 ] identified frequent difficulties in formulating thought, attentional processes, and memory; Sachs and Friedman [ 46 ] established, using a statistical approach, that 15.6% of a sample of 141 cases had mental changes. As highlighted by Butler et al [ 35 ], the vagueness of the term “mental changes”, together with other limitations, did not allow for any generalizations. Brown and Davis [ 47 ] believed that cognitive impairments (mental deterioration) may or may not have occurred and were, for the most part, mild; they believed that these impairments would progress to varying degrees from case to case and, even in the advanced stages of the disease, severe deterioration was occasional.…”

“…However, Clymer’s report could have had a scarce diffusion; the uncertain place of mental disorders caused by diseases such as MS, of proven “organic” origin [ 35 ] in the American medical world, could also have had a role. Another pioneer of the recognition of MS as a specific disease in the USA was Edward Seguin (1878), who is also credited with the first use of the name “multiple sclerosis” [ 36 , 37 ].…”

“…Moreover, as reported by Butler et al [ 35 ], various prominent English clinicians, such as Wilks [ 38 ], Gowers [ 39 ], and Bury [ 40 ], in a period of about 30 years, placed the mental disorders of MS in a secondary position.…”

Changing definitions of euphoria in multiple sclerosis: A short report

“…13 However, Cottrell and Wilson, in particular, were also not without fault, and their characterisation of the majority of their MS patients as lacking cognitive impairment has been severely criticised. 1,14 Thus, their definition of euphoria may, too, contain incorrect elements and lack construct validity. This leaves us still questioning which definition truly captures what it means to be euphoric, and leaves us unable to reliably compare the results of the various authors.…”