Neuropsychiatry

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X-ray image of deep brain stimulation, an experimental procedure used to treat disorders such as OCD and depression. Deep Brain Stimulation.jpg
X-ray image of deep brain stimulation, an experimental procedure used to treat disorders such as OCD and depression.

Neuropsychiatry is a branch of medicine that deals with psychiatry as it relates to neurology, in an effort to understand and attribute behavior to the interaction of neurobiology and social psychology factors. [1] Within neuropsychiatry, the mind is considered "as an emergent property of the brain", [2] whereas other behavioral and neurological specialties might consider the two as separate entities. [3] Those disciplines are typically practiced separately.

Contents

Currently, neuropsychiatry has become a growing subspecialty of psychiatry as it closely relates the fields of neuropsychology and behavioral neurology, and attempts to utilize this understanding to better understand autism, ADHD, Tourette's syndrome, etc.

The case for the rapprochement of neurology and psychiatry

Given the considerable overlap between these subspecialities, there has been a resurgence of interest and debate relating to neuropsychiatry in academia over the last decade. [3] [4] [5] [6] [7] Most of this work argues for a rapprochement of neurology and psychiatry, forming a specialty above and beyond a subspecialty of psychiatry. For example, Professor Joseph B. Martin, former Dean of Harvard Medical School and a neurologist by training, has summarized the argument for reunion: "the separation of the two categories is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway." [4] These points and some of the other major arguments are detailed below.

Mind/brain monism

Neurologists have focused objectively on organic nervous system pathology, especially of the brain, whereas psychiatrists have laid claim to illnesses of the mind. This antipodal distinction between brain and mind as two different entities has characterized many of the differences between the two specialties. However, it has been argued that this division is fictional; evidence from the last century of research has shown that our mental life has its roots in the brain. [4] Brain and mind have been argued not to be discrete entities but just different ways of looking at the same system. [8] It has been argued that embracing this mind/brain monism may be useful for several reasons. First, rejecting dualism implies that all mentation is biological, which provides a common research framework in which understanding and treatment of mental disorders can be advanced. Second, it mitigates widespread confusion about the legitimacy of mental illness by suggesting that all disorders should have a footprint in the brain.[ citation needed ]

In sum, a reason for the division between psychiatry and neurology was the distinction between mind or first-person experience and the brain. That this difference is taken to be artificial by proponents of mind/brain monism supports a merge between these specialties.[ citation needed ] These specialities are different but rely on each other.[ citation needed ]

Causal pluralism

One of the reasons for the divide is that neurology traditionally looks at the causes of disorders from an "inside-the-skin" perspective (neuropathology, genetics) whereas psychiatry looks at "outside-the-skin" causation (personal, interpersonal, cultural). [7] This dichotomy is argued not to be instructive and authors have argued that it is better conceptualized as two ends of a causal continuum. [7] The benefits of this position are: firstly, understanding of etiology will be enriched, in particular between brain and environment. One example is eating disorders, which have been found to have some neuropathology [9] but also show increased incidence in rural Fijian school girls after exposure to television. [10] Another example is schizophrenia, the risk for which may be considerably reduced in a healthy family environment. [11]

It is also argued that this augmented understanding of etiology will lead to better remediation and rehabilitation strategies through an understanding of the different levels in the causal process where one can intervene. It may be that non-organic interventions, like cognitive behavioral therapy (CBT), better attenuate disorders alone or in conjunction with drugs. Linden's demonstration of how psychotherapy has neurobiological commonalities with pharmacotherapy is a pertinent example of this and is encouraging from a patient perspective as the potentiality for pernicious side effects is decreased while self-efficacy is increased. [12]

In sum, the argument is that an understanding of the mental disorders must not only have a specific knowledge of brain constituents and genetics (inside-the-skin) but also the context (outside-the-skin) in which these parts operate. [13] Only by joining neurology and psychiatry, it is argued, can this nexus be used to reduce human suffering.[ citation needed ] Combining these subjects would help improve patient care and reduce stigma.[ citation needed ]

Organic basis

To further sketch psychiatry's history shows a departure from structural neuropathology, relying more upon ideology. [14] One example of this is Tourette syndrome, which Sándor Ferenczi, although never having seen a patient with Tourette syndrome, suggested was the symbolic expression of masturbation caused by sexual repression. [15] However, starting with the efficacy of neuroleptic drugs in attenuating symptoms [16] the syndrome has gained pathophysiological support [17] and is hypothesized to have a genetic basis too, based on its high inheritability. [18] This trend can be seen for many hitherto traditionally psychiatric disorders (see table) and is argued to support reuniting neurology and psychiatry because both are dealing with disorders of the same system.[ citation needed ]

Linking traditional psychiatric symptoms or disorders to brain structures and genetic abnormalities.
(This table is in not exhaustive but provides some psychodynamic and neurological bases to psychiatric symptoms.)
Psychiatric symptoms Psychodynamic explanationNeural correlates
Depression Overwhelming aggression turned inward, guilt [19] Limbic-cortical dysregulation, monoamine imbalance [20]
Mania Avoidance of pain of the reality principle [21] Prefrontal cortex and hippocampus, anterior cingulate, amygdala [22] [23]
Schizophrenia Projection of inner fantasies outwards due to ego disintegration [24] [25] NMDA receptor activation in the human prefrontal cortex [26]
Visual hallucination Projection, cold distant mother causing a weak ego[ citation needed ]Retinogeniculocalcarine tract, ascending brainstem modulatory structures [27]
Auditory hallucination Projection, cold distant mother causing a weak ego[ citation needed ]Frontotemporal functional connectivity [28]
Obsessive-compulsive disorder Shame regarding a pleasurable childhood experience [29] Frontal-subcortical circuitry, right caudate activity [30] [31]
Eating disorder Attempted control of internal anxiety[ citation needed ]Atypical serotonin system, right frontal and temporal lobe dysfunction, changes to mesolimbic dopamine pathways [9] [32]

Improved patient care

Further, it is argued[ by whom? ] that this nexus will allow a more refined nosology of mental illness to emerge thus helping to improve remediation and rehabilitation strategies beyond current ones that lump together ranges of symptoms. However, it cuts both ways: traditionally neurological disorders, like Parkinson's disease, are being recognized for their high incidence of traditionally psychiatric symptoms, like psychosis and depression. [33] These symptoms, which are largely ignored in neurology, [3] can be addressed by neuropsychiatry and lead to improved patient care. In sum, it is argued that patients from both traditional psychiatry and neurology departments will see their care improved following a reuniting of the specialties.

Better management model

Psychiatrist Randolph B. Schiffer, pediatrician Daniel L. Hurst, neuropsychiatrtist Walter Lajara-Nanson, and psychiatrrist Russell C. Packard argue that there are good management and financial reasons for rapprochement. [34] [ clarification needed ]

Theory and focus

Clinical methods and research

Treatment

History

US institutions

"Behavioral Neurology & Neuropsychiatry" fellowships are accredited by the United Council for Neurologic Subspecialties (UCNS; www.ucns.org), in a manner analogous to the accreditation of psychiatry and neurology residencies in the United States by the American Board of Psychiatry and Neurology (ABPN).

The American Neuropsychiatric Association (ANPA) was established in 1988 and is the American medical subspecialty society for neuropsychiatrists. ANPA holds an annual meeting and offers other forums for education and professional networking amongst subspecialists in behavioral neurology and neuropsychiatry as well as clinicians, scientists, and educators in related fields. American Psychiatric Publishing, Inc. publishes the peer-reviewed Journal of Neuropsychiatry and Clinical Neurosciences , which is the official journal of ANPA.

International organizations

The International Neuropsychiatric Association was established in 1996. [35] INA holds congresses biennially in countries around the world and partners with regional neuropsychiatric associations around the world to support regional neuropsychiatric conferences and to facilitate the development of neuropsychiatry in the countries/regions where those conferences are held. Prof. Robert Haim Belmaker [36] is the current president of the organization whereas Prof. Ennapadam S Krishnamoorthy [37] serves as President-Elect with Dr. Gilberto Brofman as Secretary-Treasurer. [38]

The British NeuroPsychiatry Association (BNPA) was founded in 1987 [39] and is the leading academic and professional body for medical practitioners and professionals allied to medicine in the UK working at the interface of the clinical and cognitive neurosciences and psychiatry.

In 2011, a non-profit professional society named Neuropsychiatric Forum (NPF) was founded. NPF aims to support effective communication and interdisciplinary collaboration, develop education schemes and research projects, organize neuropsychiatric conferences and seminars.

Criticism

Fernando Vidal and Francisco Ortega argue that neuropsychiatry strengthens the conception of mental suffering as a product of individual irresponsibility. [40] In his book Capitalist Realism , academic Mark Fisher in turn states that when depression is made to be a consequence of individual biochemial imbalance, social causation is ruled out. [41]

Historian Edward Shorter argues that the view that depression is a brain disorder to be corrected with medication is a product of the pharmaceutical advertising rather than a scientific understanding of depression. [42]

The efficacy of neuropsychiatric treatment has been questioned. This is particularly in regard to psychiatric drugs, of which the success of and mechanism of treatment is mixed and largely unknown respectively, [43] and the use of current neuroimaging technology for diagnostic and treatment purposes, which according to neuropsychiatrist Helen S. Mayberg is "without medical or scientific support,” [44] as results do not clarify causality. [45]

See also

Related Research Articles

<span class="mw-page-title-main">Catatonia</span> Psychiatric behavioural syndrome

Catatonia is a complex syndrome, most commonly seen in people with underlying mood or psychotic disorders. People with catatonia have abnormal movement and behaviors, which vary from person to person and fluctuate in intensity within a single episode. People with catatonia appear withdrawn, meaning that they do not interact with the outside world and have difficulty processing information. They may be nearly motionless for days on end or perform repetitive purposeless movements. Two people may exhibit very different sets of behaviors and both still be diagnosed with catatonia. Treatment with benzodiazepines or ECT are most effective and lead to remission of symptoms in most cases.

<span class="mw-page-title-main">Schizophrenia</span> Mental disorder with psychotic symptoms

Schizophrenia is a mental disorder characterized variously by hallucinations, delusions, disorganized thinking and behavior, and flat or inappropriate affect. Symptoms develop gradually and typically begin during young adulthood and are never resolved. There is no objective diagnostic test; diagnosis is based on observed behavior, a psychiatric history that includes the person's reported experiences, and reports of others familiar with the person. For a diagnosis of schizophrenia, the described symptoms need to have been present for at least six months or one month. Many people with schizophrenia have other mental disorders, especially mood disorders, anxiety disorders, and obsessive–compulsive disorder.

<span class="mw-page-title-main">Apathy</span> State of indifference, or the suppression of emotions

Apathy, also referred to as indifference, is a lack of feeling, emotion, interest, or concern about something. It is a state of indifference, or the suppression of emotions such as concern, excitement, motivation, or passion. An apathetic individual has an absence of interest in or concern about emotional, social, spiritual, philosophical, virtual, or physical life and the world. Apathy can also be defined as a person's lack of goal orientation. Apathy falls in the less extreme spectrum of diminished motivation, with abulia in the middle and akinetic mutism being more extreme than both apathy and abulia.

Clinical lycanthropy is a rare psychiatric syndrome that involves a delusion that the affected person can transform into, has transformed into, or is a non-human animal. Its name is associated with the mythical condition of lycanthropy, a supernatural affliction in which humans are said to physically shapeshift into wolves. The term is used by researchers mostly in the broader sense of transformation into animals in general, that, strictly speaking, is described as zoanthropy.

Biological psychiatry or biopsychiatry is an approach to psychiatry that aims to understand mental disorder in terms of the biological function of the nervous system. It is interdisciplinary in its approach and draws on sciences such as neuroscience, psychopharmacology, biochemistry, genetics, epigenetics and physiology to investigate the biological bases of behavior and psychopathology. Biopsychiatry is the branch of medicine which deals with the study of the biological function of the nervous system in mental disorders.

Clouding of consciousness, also called brain fog or mental fog, occurs when a person is slightly less wakeful or aware than normal. They are less aware of time and their surroundings, and find it difficult to pay attention. People describe this subjective sensation as their mind being "foggy".

The obsessive–compulsive spectrum is a model of medical classification where various psychiatric, neurological and/or medical conditions are described as existing on a spectrum of conditions related to obsessive–compulsive disorder (OCD). "The disorders are thought to lie on a spectrum from impulsive to compulsive where impulsivity is said to persist due to deficits in the ability to inhibit repetitive behavior with known negative consequences, while compulsivity persists as a consequence of deficits in recognizing completion of tasks." OCD is a mental disorder characterized by obsessions and/or compulsions. An obsession is defined as "a recurring thought, image, or urge that the individual cannot control". Compulsion can be described as a "ritualistic behavior that the person feels compelled to perform". The model suggests that many conditions overlap with OCD in symptomatic profile, demographics, family history, neurobiology, comorbidity, clinical course and response to various pharmacotherapies. Conditions described as being on the spectrum are sometimes referred to as obsessive–compulsive spectrum disorders.

<span class="mw-page-title-main">History of Tourette syndrome</span>

Tourette syndrome (TS) is an inherited neurological disorder that begins in childhood or adolescence, characterized by the presence of multiple physical (motor) tics and at least one vocal (phonic) tic.

Child and adolescent psychiatry is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families. It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the pediatric population.

Geriatric psychiatry, also known as geropsychiatry, psychogeriatrics or psychiatry of old age, is a branch of medicine and a subspecialty of psychiatry dealing with the study, prevention, and treatment of neurodegenerative, cognitive impairment, and mental disorders in people of old age. Geriatric psychiatry as a subspecialty has significant overlap with the specialties of geriatric medicine, behavioural neurology, neuropsychiatry, neurology, and general psychiatry. Geriatric psychiatry has become an official subspecialty of psychiatry with a defined curriculum of study and core competencies.

<span class="mw-page-title-main">Grandiose delusions</span> Subtype of delusion

Grandiose delusions (GDs), also known as delusions of grandeur or expansive delusions, are a subtype of delusion characterized by the extraordinary belief that one is famous, omnipotent, wealthy, or otherwise very powerful or of a high status. Grandiose delusions often have a religious, science fictional, or supernatural theme. Examples include the extraordinary belief that one is a deity or celebrity, or that one possesses fantastical talents, accomplishments, or superpowers.

<span class="mw-page-title-main">Psychiatry</span> Branch of medicine devoted to mental disorders

Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions. These include various matters related to mood, behaviour, cognition, perceptions, and emotions.

The Semel Institute for Neuroscience and Human Behavior is a research institute of the University of California Los Angeles (UCLA). It includes a number of centers, including the "Center for Neurobehavioral Genetics", which uses DNA sequencing, gene expression studies, bioinformatics, and the genetic manipulation of model organisms to understand brain and behavioral phenotypes.

<span class="mw-page-title-main">Differential diagnoses of depression</span> Differential diagnoses

Depression, one of the most commonly diagnosed psychiatric disorders, is being diagnosed in increasing numbers in various segments of the population worldwide. Depression in the United States alone affects 17.6 million Americans each year or 1 in 6 people. Depressed patients are at increased risk of type 2 diabetes, cardiovascular disease and suicide. Within the next twenty years depression is expected to become the second leading cause of disability worldwide and the leading cause in high-income nations, including the United States. In approximately 75% of suicides, the individuals had seen a physician within the prior year before their death, 45–66% within the prior month. About a third of those who died by suicide had contact with mental health services in the prior year, a fifth within the preceding month.

Clinical neuroscience is a branch of neuroscience that focuses on the scientific study of fundamental mechanisms that underlie diseases and disorders of the brain and central nervous system. It seeks to develop new ways of conceptualizing and diagnosing such disorders and ultimately of developing novel treatments.

Perminder Sachdev is an Indian neuropsychiatrist based in Australia. He is a professor of neuropsychiatry at the University of New South Wales (UNSW), co-director of the UNSW Centre for Healthy Brain Aging, and clinical director of the Neuropsychiatric Institute at the Prince of Wales Hospital, Sydney. He is considered a trailblazer in the field of neuropsychiatry. Sachdev's research interests include ageing, vascular cognitive disorders such as vascular dementia, and psychiatric disorders.

The American Neuropsychiatric Association (ANPA) is a non-profit organization of professionals in neuropsychiatry, behavioral neurology and the clinical neurosciences, with over 700 members from around the world. Established in 1988, its mission is to improve the lives of people with disorders at the interface of psychiatry and neurology, with the vision of transforming recognition, understanding and treatment of neuropsychiatric disorders. It founded in 1988 by two academic physicians doubly certified in neurology and psychiatry, Barry S. Fogel and Randolph Schiffer.

<span class="mw-page-title-main">Andrew J. Gerber</span>

Andrew J. Gerber is an American psychoanalyst and the current president and medical director of Silver Hill Hospital in New Canaan, Connecticut. His principal interests and research lie in studying the neurobiological bases of social cognition, particularly in relation to autism spectrum disorders and change in response to psychotherapy. He is a member of the American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, American Psychoanalytic Association and the Psychoanalytic Psychodynamic Research Society.

<span class="mw-page-title-main">Barry S. Fogel</span>

Barry S. Fogel is an American neuropsychiatrist, behavioral neurologist, medical writer, medical educator and inventor. He is the senior author of a standard text in neuropsychiatry and medical psychiatry, and a founder of the American Neuropsychiatric Association and the International Neuropsychiatric Association.

Charles L. Raison is an American psychiatrist and professor of psychiatry at the University of Wisconsin-Madison School of Medicine and Public Health as well as the Mary Sue and Mike Shannon Chair for Healthy Minds, Children & Families and Professor with the School of Human Ecology in Madison, Wisconsin.

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  43. ↑ Penn, Elizabeth; Tracy, Derek K. (October 2012). "The drugs don't work? antidepressants and the current and future pharmacological management of depression". Therapeutic Advances in Psychopharmacology. 2 (5): 179–188. doi:10.1177/2045125312445469. ISSN   2045-1253. PMC   3736946 . PMID   23983973.
  44. ↑ Akhigbe, A. O.; Akhigbe, K. O. (2015). "Neuroimaging in Psychiatry: A Review of the Background and Current Trends" (PDF). Nigerian Journal of Psychiatry. 13 (1).
  45. ↑ Rose, Nikolas S.; Abi-Rached, Joelle M. (2013). Neuro: the new brain sciences and the management of the mind. Princeton, N.J: Princeton University Press. ISBN   978-0-691-14960-8.

Journals

International/national organizations

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