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The Science of

Neuropsychiatry: Past,

Present, and Future

Shahar Arzy, M.D., Ph.D.

Shlomo Danziger, M.A.

The field of neuropsychiatry aims to overcome the

separation of neurology and psychiatry, which is reflected in a gap between the neurologist, searching for the underlying neuroanatomical basis of a disorder, and the psychiatrist, dipping into its phenomenology and underlying genetics. This gap becomes slighter in our day, as recent research in clinical neurosciences enables us to better investigate the neural basis of neuropsychiatric disorders. This article reviews the history and development of neuropsychiatry in the occidental world, suggesting that the science of neuropsychiatry could optimize for the diagnosis, monitoring, and treatment of behavioral, cognitive, and so-called mental disorders.(The Journal of Neuropsychiatry and Clinical

Neurosciences 2014; 26:392-395)

T he renewed clinical field of neuropsychiatry aims, as itsnameimplies,toovercometheongoingseparation of neurology and psychiatry, which solidified in the middle of the twentieth century. For over half a century, cognitive and behavioral neurology has been restricted mainly to dementias and behavioral aspects of neurolog- ical diseases, such as well-defined syndromes in stroke cases, whereas disorders of fundamental cognitive func- tions such as emotion (e.g., depression) and thought (e.g., schizophrenia)havebeen entitled"mentaldisorders"and have been investigated and treated outside the neurolog- ical milieu. Departments of psychiatry have focused on the special needs of their patients that include long hos- pitalizations; psychological, social, and complementary support; and adjustments of pharmaceutical and electro- physiological therapies. However, the psychiatrist does not necessarily share the neurologist's quest to identify the underlying neuroanatomical basis of a disorder. The gap between the two disciplines becomes conspicuous in our day, as we see how the recent technologies which enable us to better investigate the neural basis of neuro- psychiatric disorders have not yet led to significant break- throughs in the comprehension, monitoring, or treatment of psychiatric diseases. This article reviews the history and development of neuropsychiatry in the occidental world, and suggests that the science of neuropsychiatry could enable the optimization of modern technologies for the diagnosis, monitoring, and treatment of behavioral, cog-

nitive, and so-called mental disorders.Received Dec. 13, 2013; revised Feb. 15, 2014; accepted Feb. 24, 2014.

From the Neuropsychiatry Lab, Faculty of Medicine, Hadassah

Hebrew

Universit

y

Medical

School,

Jerusalem,

Israel

(SA, SD); Agnes Ginges Institute for Neurogenetics, Dept. of Neurology, Hadassah Hebrew University Medical Center, Jerusalem, Israel (SA); and Dept. of Cognitive Sciences, HebrewUniversity, Jerusalem, Israel (SA,SD). Send correspondence to Dr. Arzy; e-mail: shahar.arzy@ekmd.huji.ac.il

Copyright © 2014 American Psychiatric Association392http://neuro.psychiatryonline.orgJ Neuropsychiatry Clin Neurosci 26:4, Fall 2014

The beginning of neuropsychiatry is attributed to nine- teenth century scientists in Germany and France. In France, Étienne-Jean Georget (1795-1828), a disciple of Pinel and Esquirol, emphasized the organic etiology of mental disorders, and Antoine Laurent Bayle (1799-

1858) claimed that dementia and mental disorder were

both aspects of the same disease. 1

In Berlin, Wilhelm

Griesinger (1817-1868), professor of neurology and psy- chiatry who is considered by many the founding fa- ther of neuropsychiatry, stated,"Psychische Krankheiten sind Erkrankungen des Gehirns,"or"Mental illnesses are diseases of the brain." 2,3

In his revolutionary text-

book of psychiatry,Pathologie und Therapie der Psychischen Krankheiten(1845), Griesinger called for a change of at- titude toward the psychiatric patient from that of sinner who should be punished and isolated, to sufferer of a biological disease who requires curing. Griesinger's works influenced many European neuropsychiatrists, including Meyer, Meynert, Liepmann, Pick, Oppenheim,

Charcot, Korsakoff, von Monakow, Babinski, Janet,

Freud, Jackson, Bleuler, Kraepelin, Bonhoeffer, and

Alzheimer.

4

Kraepelin (1856-1926) and Alzheimer (1864-

1915), for instance, practiced psychiatry, but hoped to

discover the basis of psychiatric diseases through his- tological or neuropathological methods. 5 In North America, Benjamin Rush, a renowned Phila- delphian physician (1746-1813), claimed that mental illnesses"are moved by the same causes and subject to the same laws"as other diseases of the human body. But despite this assertion, in nineteenth century America, neurology was practiced in hospitals, whereas psychiatry was restricted to sanatoriums and asylums. 5

The Boston

Psychological Society, founded in 1880 by eight psychia- trists, began accepting neurologists as members a decade later, so that in 1901 its name was changed to the Boston Society of Neurology and Psychiatry. Neurologist James Jackson Putnam (1846-1918) and his colleagues at Har- vard are notable for their interdisciplinary cooperation, which brought together psychologists, philosophers, neurologists, and psychiatrists. 5

In the earlier 1900s, then,

neuropsychiatry was anemergingdiscipline in the German- and French-speaking world, and to a certain extent in the

United States.

Withtheriseofpsychodynamicsatthe beginningofthe

twentieth century, the interest in the relationship between psychiatric disorders and the brain was gradually aban- doned. Psychiatrists enthusiastically embraced the key that they were given to the human psyche, and this new

"mentalistic"approachconsequentlydetachedpsychiatryfrom neurology. It may be further speculated that neu-

rologists, too, accepted this dichotomy and were relieved to leave the treatment of mental illness to others. 6 It is plausible that neurologists were deterred by a combina- tion of factors, namely patients'characters and person- alities; lack of knowledge in diagnosis, pharmacotherapy, and psychotherapy; and inexperience with cognitive and emotional aspects of neuropsychiatric disorders.

In the United Kingdom, Sir Charles Symonds (1890-

1978), the doyen of British neurologists, tried to oppose

this separation, but his opinion was rejected by his colleagues. 6 An influential factor on the history of neuropsychiatry was the forced migration of German-speaking clinical neuropsychiatrists and neuroscientists after the rise of Nazism and Fascism in central Europe. As detailed in a recent study by Stahnisch, 7 of the 52,000 doctors in 1933 Germany, about 16% were of Jewish ancestry or what the Nazis defined as being Jewish. This made approximately

8,000 to 9,000 physicians when Hitler came into power.

Various clinical areas of psychiatry and neurology were rejected because they were seen as representing instances of aJewish Science. Nearly 30% of all those expulsed physicians and faculty members practiced neurology and psychiatry, and overall, more than 600 researchers and physicians in the clinical neurosciences immigrated into North America. Consequently, the relations between neurology, psychiatry, psychology, and pathology un- derwent a gradual readjustment, and clinical brain sci- ences had become a leading biomedical field in North America. Notably, many of the immigrants were influ- enced by a holistic neurology approach and by adjacent fieldssuch asphilosophy, psychology, and historyaswell as by an experimental approach. Among the prominent figures were the neurologist, psychiatrist, and psycholo- gist Kurt Goldstein (1878-1965), who with psychiatrists and psychotherapists Fritz Perls (1893-1970) and Laura Perls (1905-1990) founded Gestalt therapy; Adhémar Gelb (1887-1936), Victor Franz (1883-1950), and Walter Riese (1890-1976), who was the director of the Neuroan- atomical Institute at the Frankfurt Psychiatric Hospital.

The interchange between neurology and psychiatry,

humanity and experimental approach, is exemplified in figures like the neurologist and psychiatrist Karl Stern (1906-1975), changing from a neuropathologist in Europe to being a clinical psychiatrist and ardent university teacher in Canada; Robert Weil (1909-2002), the founding member of the Canadian Psychiatric Association (CPA), who implanted statistical methods in mental health J Neuropsychiatry Clin Neurosci 26:4, Fall 2014http://neuro.psychiatryonline.org393

ARZY and DANZIGER

research and diagnostic testing of psychopathological conditions; or the prominent Berlin neurologist Friedrich Heinrich Lewy (1885-1950) best known for the discovery of Lewy Bodies. 7

To summarize, the effects of the process

of forced-migration on modern clinical brain research and the transplantation of European concepts and methods into the North American clinical and basic neuroscience hascontributedtointerrelationsbetweentheclinicalbrain sciences of neurology, psychiatry, neuropathology, and experimental psychology, into an inter-reliant framework. After World War II, the division between neurology and psychiatry became explicit. TheArchives of Neurol- ogy and Psychiatry, first published in 1919, was separated into two journals. The American Academy of Neurology was founded in 1948 to deal with"pure"neurological issues, and separate neurology departments were estab- lished throughout the United States. 5,8

In 1965, the Resi-

dency Review Committee for Psychiatry and Neurology (RRC,nowseparatedbetweenneurologyandpsychiatry), an accrediting body separate from the American Board of Psychiatry and Neurology(ABPN), deleted psychi- atric trainingasamandatory experience for neurologists. 4 At the same time, with the introduction of neuroleptics, biological psychiatry began to emerge, contributing to the separation of neurology and psychiatry into two different disciplines. 4,8 In the 1980s, attitudes once again began leaning toward a linkage of the two disciplines. At a 1985 symposium in Paris marking the 100th anniversary of the naming of Gilles-de-la-Tourette syndrome, the American delegation presented evidence in support of an organic basis for the syndrome, while many in the French academy held that the syndrome was caused primarily by a psychopatho- logic release of repressed tendencies. 5

The geographic

roles were now swapped, with the English speaking coun- tries now leading the re-alliance of neurology and psy- chiatry. In 1989, the American NeuropsychiatricAssociation (the ANA, and now ANPA) was established. In the United Kingdom, neuropsychiatric services evolved at a few re- gional and national centers such as the National Hospital for Neurology and Neurosurgery in London, the Institute of Neurology (ION), and the Institute of Psychiatry (IOP); and the British NeuroPsychiatry Association (BNPA) was established in 1987. In recent years, several attempts have been made to define the scope of neuropsychiatry. The suggested definitions may be divided into two main categories - minimal and maximal. The minimal approach puts neu-

ropsychiatry in the borderland between neurology andpsychiatry, and sees its subject matter as"disorders that

cross the boundary between the two disciplines" 9 ,as well as neurological aspects of psychiatric disorders and psychiatric aspects of neurological disorders. 10 The maximal approach includes the full range of central nervous system diseases (occurring'above the foramen magnum'), as well as most of the psychiatric disorders, within the scope of neuropsychiatry. For example, in a paper aiming to define the curriculum for subspecialty in behavioral neurology and neuropsychiatry, 11 the authors defined the scope of neuropsychiatry to include "at minimum": classical syndromes of behavioral neurol- ogy (e.g., aphasias, apraxias, agnosias); delirium; demen- tias, the major primary psychiatric disorders; neurological conditions with cognitive, emotional, or behavioral features, including movement disorders, stroke, epilepsy, multiple sclerosis, traumatic brain injury; and comorbid neuropsychiatric andneurologicalconditions.Rather than refer to specific disorders, the definition of neuropsychi- atry may be generalized in adherence to scientific advancement, regarding neuropsychiatry"as that aspect of psychiatry which, like neurology, seeks to advance understanding of clinical problems through increased knowledge of brain structure and function," 6 or"under- standing the neurological basis of psychiatric conditions." 10 However, despite developments in the pharmacologi- cal treatment of major psychiatric disorders such as psychosis and depression, biological psychiatry is still considered inferior to behavioral psychiatry. Thus, a dichotomy still exists between psychiatry and the clinical neurosciences. In the near future, major aspects of the clinical neurosciences may be reintroduced into traditional psychiatry with the application of advanced neuroimaging methods and genetic analyses as biological markers for diagnosis, monitoring, and treatment in psychiatric dis- orders. These are further empowered by the computational revolution of the recent years, enabling the application of sophisticated algorithms on"big-clinical-data"to enable better understanding and management of the individ- ual patient based on the patient's own disease history, brain processes, and genetic profiles. Potential new med- ical treatments, such as electrical and magnetic neuro- stimulation,arealreadyusedinpsychiatricdisorders,and chemical and optical neuromodulation and gene therapy are expected in the more distant future. Computer sciences supply new algorithms and analyses methods as well as powerful interconnected devices to process the patient's informationinreal-time.Inthefieldofneuro-immunology, a number of syndromes characterized by psychiatric

394http://neuro.psychiatryonline.orgJ Neuropsychiatry Clin Neurosci 26:4, Fall 2014

THE SCIENCE OF NEUROPSYCHIATRY

changes have been found to result from autoimmune dysfunction, at times with autoantibodies that guide both diagnosis and treatment, demonstrating how abnormal autoimmune processes can result in profound neuropsy- chiatric symptoms, 12,13 further stressing the loose border between the neurological and psychiatric worlds. In conclusion, the conceptual scopes of neuropsychia- try have varied over time. At the onset of the clinical neurosciences, neurology and psychiatry were merged. Later, as the specialties developed, the two domains went off in different directions, splitting into two separate sciences. With our current scientific understanding of the cerebral basis of psychiatric disorders, the era of the

computational, data, and genomic revolutions once againmerges the domains of neurology and psychiatry for

a neuroscientific-based diagnosis, monitoring, and treat- ment of neuropsychiatric diseases. The authors report no financial relationships with commer- cial interests. The authors thank Shira Kramer-Danziger for her wise advice and assistance in text editing, and to Drs. Oded Abramsky, Tamir Ben-Hur, and Renana Eitan for their helpful comments on the manuscript. The study was supported by the German-Israeli Foundation for Scientific Research and Development (GIF) and the Marie Curie Intra-European Fellowship within the framework of the

EU-FP7 program.

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ARZY and DANZIGER

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