983fullpdf - Journal of Neurology, Neurosurgery and Psychiatry

76736_7983_full.pdf JournalofNeurology,Neurosurgery,andPsychiatry1992;55:983-985

7ournalofNEUROLOGYNEUROSURGERY&PSYCHIATRY

Editorial

Whatisneuropsychiatry?*

Neuropsychiatryisaratherseductiveterm.Itimpliesanamalgambetweenneurologyandpsychiatry,whichinasenseitis.Butthereisagreatdealmoretothenameandtothedisciplinethanthat.Ifweviewittoonarrowlyasanadmixtureofneurologyandpsychiatrywemissoutontheessenceofthesubjectasanimportantanddevelopingbranchofpsychiatry.Sowhatpreciselyisit?ThematterwasdebatedatthesummermeetingoftheBritishNeuropsychiatryAssocia-tion,heldinconjunctionwiththesisterorganisation,theAmericanNeuropsychiatricAssociation.Asapreludetodiscussionadetailedquestionnairehadbeendistributedtomembersofbothorganisations.First,itwasclearthatthetermwasseenasrepresentinganapproachtothestudyofpsychiatricdisorders,ratherthanmerelyspecifyingthestudyofarestrictedrangeofconditions.Indeedsometwothirdsofrespondentsfeltthatallpsychiatricdisorderscouldbeapproachedfromtheviewpointofapossibleneurologicalbasis.TheAmericanswerebolderinthisthantheBritish,andneurologicalrespondentsmorecertainthanpsychiatrists.Asforthesubsetofpsychiatricdisordersmostdirectlyofconcerntoneuropsychiatry,thiswasvariouslydefinedas"thoseforwhichknowledgeofbrainstructureandfunctionisindispensable",or"thosewithawell-definedcerebralbasis".Furthermore,virtuallyallagreedthatneuro-psychiatrywasconcernedwithpsychiatricaspectsofneurologicaldisorders,andthatitdealtwiththeborder-landterritorybetweenclinicalneurologyandclinicalpsychiatry.InotherwordsneuropsychiatryisseenbytheseAssocia-tionsasconstitutingaparticularapproachtotheunder-standingofpsychiatricdisorderandashavingrelevancetoawiderangeofsuchdisorders,butwithitsownspecialfieldwithintheclinicaldomain.

EvolutionBeforeproceedingfurtheritmaybeusefultoconsidertheoriginandevolutionofthesubject.Psychiatrystartedmuchearlierthanneurology,wheninthe17thcenturymedicinetookoverfromthechurcharoleinthecareoftheinsane.Fromtheverybeginningpsychiatrydealtwithaclassofpersons,namely,the"mentallyill".Itsclientswereveryheterogeneous,suffer-ingfromallmannerofconditions.Andforacoupleofcenturiespsychiatrywaswildlyadriftinitsattemptstoformulatetheoriesaboutwhatwasamisswiththem.Neurologycameintobeingmuchlaterinthefirstpartofthenineteenthcentury,takingasitspointoforigindiseasesofthebrain.Itdevelopedfromthestartasarationalandscientificdiscipline,tyingcertainmaladiestothegrowingknowledgeofbrainfunctionandbrainorganisation.Stillveryunsureofitself,psychiatrywatchedfromthesidelinesandenviedthissuccess.Sotheintimatetiebetweenneurologyandneuropathologybecameanavenueforexploringpsychiatricdisorders.ManyofthegreatGermanpsychiatristsofthenineteenthcenturywereatthesametimeneuropathologists.Resoundingsuccesseswereachievedforexample,inthefieldofthedementiasandgeneralparesis.Lesionscouldatlastbedisplayedinthebrainsofcertainpsychiatricpatients.Thiswasinasenseaheydayforneuropsychiatry,withbothneurologyandpsychiatryemployingparallelapproa-ches.Manyclinicalpractitionerswereindistinguishablyneurologistsandpsychiatrists,atrueamalgamofboth.Furtherdevelopments,however,servedtodisruptthestatusquo.Chiefamongthesewasthegrowthofpsycho-dynamics,asystemofthinkingaboutmentaldisorderwhichhadlittletodowiththebrain.Itenrichedpsychiatry,butmeantnothingtoneurology,anditdroveawedgebetweenthetwodisciplines.Psychiatristswerekeentoexploitthesenewapproaches,andneurologistsbecamegladtoleavethemuddleofmentalillnesstoothers.Laterwesawtheriseofsocialandepidemiologicalpsychiatry,againlargelydevoidofrelevancetothebrain,yetstillprovidingpsychiatristswithnewinsightsintotheirwork.Multi-factorialapproachestomentaldisorderprospered.Theneuropsychiatricviewcameoftentobedubbednarrow,oldfashioned,andatherapeutic.Some,however,remainedloyalallthroughtotheconceptofneuropsychiatry.SirCharlesSymonds,thedoyenofBritishneurologists,wasafighterforthecause,regrettingpsychiatry'sdriftawayfromneurologyandneuroscience,andmakingsomeremarkablerecommen-dations.1TowardstheendoftheSecondWorldWartheRoyalCollegeofPhysicianssetupacommitteetoconsiderpsychologicalmedicine.Symonds,withRiddoch,wroteaminorityreport,urgingthatgeneralhospitalsshouldsetupNeuropsychiatryClinicsasthefocusfortheworkofpsychiatrists,neurologistsandneurosurgeonssidebyside.Thereportnotedthewideoverlapbetweenallthreedisciplines,thecommonuseofinvestigativetechniques,andtheinterweavingofresearchinterests.Thedirectorsofsuchclinicscouldbevariouslypsychiatrists,neurologistsorneurosurgeons.Psychiatristsandneurologistsshouldhavecommonbasictrainingwithagroundingingeneralmedicine,thenthreeyearsdividedbetweenpsychiatryand983 on August 15, 2023 by guest. Protected by copyright.http://jnnp.bmj.com/J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.11.983

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Editorial

neurologyalongwiththebasicsciencesappropriatetoboth.Afinaltwoyearswouldbedevotedtooneortheotherdisciplinealone.Butthisviewdidnotprevail.Thereportwasrejectedbythephysicians,andtheAssociationofBritishNeurologistswasequallyalarmedattheprospects.Theneurologistsoverwhelminglyrefusedtoenterintoanyformalalliancewithpsychiatrists.Inthesubsequentyears,neurologistsandpsychiatristshavefollowedverydifferentpaths,withasteadyerosionofmostofthelinksintrainingrequire-ments.Thebravenewworldwhichwasbrieflyurgedinthepost-waryearssimplydidnotcomeintobeing.Sowhatisthestatusofpresentdayneuropsychiatry?Itisperhapsbesttoconsidertwoaspectsseparately;theclinical-whatneuropsychiatristsdo,andtheacademicanapproachtomentaldisorderwithresearchandphilo-sophicalimplications.

AcademicneuropsychiatryToconsiderthelatterfirst,neuropsychiatrymayberegardedasthataspectofpsychiatrywhich(likeneurol-ogy)seekstoadvanceunderstandingofclinicalproblemsthroughincreasedknowledgeofbrainstructureandfunction.Itfundamentallyinvolvestheunderstandingofbrainmechanismsinrelationtomentaldisorder.Thismaybewidelyappliedsothatschizophrenia,forexample,nowfallswellwithinitscompass.Intheserespectsneuropsychiatryisthecounterpartofneurology-thepartofpsychiatrythatstayedinleaguewithitwhenthemaincorpusofpsychiatrydidnot.Itisanapproachwhichseesneurologicalandneuropathologicalknowledgeasveryimportant.Anditseizesequallyeagerlyonthemoremoderndisciplinesofneuropsychology,neurochemistry,immunologyandmoleculargenetics.Inbrief,itprospersfromeverysciencethatcanteachusaboutthebrain.This,ifyoulike,isthebasisofneuropsychiatry.Butitmustbestressedthatitspractitionersarepsychiatristswithagraspofotherapproachesaswell.Theywillnot,orshouldnot,benarrowlyconfinedbytheirinterestinthebrain.Social,developmental,psychodynamicandinter-personalforcesmustalsobeconsideredinparallelwiththeaboveifwearetograpplesuccessfullywithsomeoftheenigmasofpsychiatricdisorder.Neuropsychiatryshouldnotbeseenasanall-exclusivedomain.Onemustalsotakeissuewiththosewhoclaimthattheneuropsychiatricapproachcanaccountforallmentaldisorder.Suchvaultingambitionisreminiscentoftheonceproudclaimsofpsychodynamictheory.Humanbeingsaremorecomplexthanthat,notleastbecauseoftheirinsistenceoninteractingwithoneanother.Insomecases,perhaps,theenvironmentwillbefoundtoholdmorepathologythandoesthebrainitself.Neuropsychiatryisbestseenasstandingshouldertoshoulderwithotherapproaches,oneperspectiveofseveral,andwithcloserapplicabilitytosomeformsofmentalillnessthanothers.

ClinicalneuropsychiatryWithregardtoclinicalpracticetheemphasiswillclearlybemoreoncertaindisordersthanothersasbehovesaninterestinthebrain.Inlargepartthereforeneuro-psychiatristswilldealwiththosementaldisorderswhichcanbedemonstratedtoowetheiroriginstobrainmalfunctionofaclearlyidentifiablenature.Aroundthistherewillbevariousimportantpenumbras.Thusinsomecasesthebrainmalfunctionwillbelessthanimmediatelyobvious,andtheneuropsychiatristwillbecalledontoadjudicate.Sometimesitwillbequiteunclearwhetherthepatientfallsintotheorganicorthenon-organiccamp,hencetheimportanceofathoroughTableDiagnosticcategoriesamongpatientswithknownorganicpsycho-syndromesreferredtotheMaudsleyneuropsychiatricclinic

Dementia,presenileandsenile34Sequelaeofheadinjury31Alcoholism(Korsakoff'ssyndrome,dementia,psychoses)18Memorydisorders15Braindevelopmentalabnormalities13Epilepsy10Sequelaeofencephalitis9Confusionalstates6Toxicdisorders(additionaltoalcohol)4Cerebralanoxia2Others(generalparesis,sarcoidofCNS,etc)4

acquaintancewithallformsofmentaldisorder.Andbecausetheneuropsychiatristworkscloselyalongsideneurologicalcolleaguesheorshewillseethemanifoldemotionalandothercomplicationsthatcanariseinneurologicalpatients.Bywayofillustration,thelast300patientsreferredtotheMaudsleyneuropsychiatricclinichavebeenanalysed.Almosthalf(49%)weresufferingfromclearorganicpsychosyndromes,referredforcloserdiagnosis,treatment,oradvice.Theconditionsresponsibleareshownindecreasingorderofnumbersinthetable.EpilepsyfeaturesrelativelyrarelybecauseofthecoexistenceattheMaudsleyofaspecialisedclinicforpatientswithepilepsy.Nextinfrequency(22%)werepatientswithestablishedpsychiatricillnesses(schizophrenic,affectiveorneurotic)inwhomsomereasonhadarisentosuspectbrainmalfunction.Thismostlyderivedfromthementalstate(impairedcognition,abnormalitiesofspeech,visualhallu-cinations),orfromabnormalresultsonneuroimagingorelectroencephalography.Failuresoftreatmentresponsewerequiteoftenthereasonforreferral,likewiseabnor-malitiesonphysicalexamination,mostlymotordisorder.Thirdinfrequency(20%)wereagroupofpatientswhosesymptomsgaverisetouncertaintyaboutorganicornon-organicdisorder-patientswithpossiblepseudode-mentia,pseudoseizuresorsuspectedhystericalconversiondisorder.Sleepabnormalitiesincludedhypersomnia,insomniaandhallucinatorystates.Speechdisordersincludedmutismanduncertaintiesbetweendysphasiaandschizophrenicspeechdisorder.Theremaining10%ofpatientswerereferredfromneurologicalcolleagues(suchas,patientswithParkinson'sdisease,multiplesclerosis,cerebrovascularaccidents)withtheexpectedrangeofcognitiveimpairments,depressionandanxiety.Occasionalpatientshadshownpsychoticdevelopments.Thisrepresentsthepracticeofoneneuropsychiatryclinic.Itillustratestherange,andthebreadth,ofdiag-nosticpossibilitieswhichmustoftenbekeptinmind.

NeuropsychiatryinrelationtoothersubspecialtiesFinally,onemayconsiderthelinkswithothersub-specialities-biologicalpsychiatry,liaisonpsychiatry,andbehaviouralneurology.Allhavetheirchampionsandtheirownpeculiarhistories.Itisdifficulttodisentanglethethreads.

Biologicalpsychiatryseemstohavegrownfromthestartwithbiologicallyorientedtreatmentstrategies.Certainlyfromthe1950sonwardspharmacologicaldiscoveriesbegantotransformpsychiatricpractice,andtheirsuc-cessesledontoanintensivefocusonbrainbiochemistry.Discoveriesinneuroendocrinologywerefurtherappended,knowledgeofcellmechanismsgrew,andfinallywehavewitnessedtheachievementsofmoleculargenetics.Biologicalpsychiatryexploitsthisnewknowledgetoadvanceunderstandingofmentalillness.Butitdiffersfromneuropsychiatryintwoimportantrespects.First,itis984 on August 15, 2023 by guest. Protected by copyright.http://jnnp.bmj.com/J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.11.983

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Editorial

concernedwitheventspredominantlyatthemicroscopicorcellularlevel.Thebiologicalpsychiatristcanprosperwhileknowinglittleaboutbrainorganisationmorebroadly,andwhilehavinglittleinterestinneurologyorneuropsychology.Thatisfarfromtrueoftheneuro-psychiatristwhoremainsfascinatedbyneuralsystems,brainorganisation,thefunctionsofdifferentpartsofthebrainandtheirrelationshipswithoneanother.Putverybaldly,thefundamentalsciencesforneuropsychiatry(andneurology)areneuroanatomyandneurophysiology;thoseforbiologicalpsychiatrycentreonthecellanditschemicalprocesses.Aseconddifferencederivesfromtheabove.Theneuropsychiatristshavetheirclinicalbase,aterritorywithinpsychiatryinwhichheorsheisacknowledgedtoexcel.Thebiologicalpsychiatristdoesnothavethiscircumscribedclinicalfield.Biologicalpsychiatryisessen-tiallyanacademicapproach,appliedwidelytoallfieldsofpsychiatricdisorder;theneuroses,thepsychosesandthepersonalitydisordersallcomewithinitsremit.Thetwoareofcourseinterwoven.Neuropsychiatrists(andneurologists)arealsointerestedinthecellandinchemicalprocesses.Theytooemploypharmacologicaltreatments.Soonewonderswhythenewterm"biologicalpsychiatry"wascoined?Perhapsitwasinreactiontothecloselinksbetweenneuropsychiatryandneurology-areflectionofthenewpsychiatry'sproudindependence.Orperhapsitwasfeltthattraditionalneuropsychiatrywastendingtolagbehindinitsappreciationofthesignificanceofthenewneurochemicalandotherdiscoveries.Atthemomentneuropsychiatryandbiologicalpsy-chiatrystandinasomewhatuneasyrelationshipwithoneanother.Oneevenwonderswhethertheonewillcometosubsumetheother.Thequestionnairementionedearliersoughttoaddressthisissue,onequestionstatingthatbiologicalpsychiatryincludedneuropsychiatry,theotherstatingthereverse.Overall,thereplieswereremarkablyevenlybalanced,butdifferencesemergedbetweentheUKandtheUSA.TheUKpsychiatristsfavouredtheascend-ancyofbiologicalpsychiatryoverneuropsychiatrytoastatisticallysignificantextent(eventhoughtheyhadjoinedtheBritishNeuropsychiatryAssociation!).TheUSApsy-chiatristsweremoreresoluteinchampioningneuro-psychiatryoverbiologicalpsychiatry.Neurologistsfrombothcountriesalsotendedtoseeneuropsychiatryasencompassingbiologicalpsychiatry.However,asub-stantial10%ofrespondentsadmitteduncertainty.Thesituationisclearlyinastateofflux.

LiaisonpsychiatryisanimportantandthrustingforceinBritishpsychiatry.Itsplaceisclearertodiscern.Liaisonpsychiatristsworkingeneralhospitals,andseereferralsfromtheirmedicalandsurgicalcolleagues.Theydealofcoursewithneuropsychiatrytotheextentthattheyworkalongsideneurologistsandneurosurgeons.Buttheirbriefisbroadandtheirfieldheterogeneous-somespecialiseinliaisonreferralsfromrenalunits,gastroenterologists,oncologists,orinrelationtoobstetricsandgynaecology.Liaisonpsychiatryisapracticalclinicaldiscipline,ratherthanaspecialisedtheoreticalapproach.

BehaviouralneurologyhashadwiderdevelopmentinAmericathantheUKandhasgrownessentiallyfromneurology.ItsemergencemayhavereflecteddissatisfactionwithanearliereraofpsychiatricpracticeintheUSA.Behaviouralneurologylooksatabnormalbehaviourthroughtheeyesoftheneurologist,usingneurologicalknowledgeinattemptsatexplanation.Thefocusisondefinedareasofabnormalbehaviourorexperience,ratherthanonbroadsegmentsofmentaldisorder.Modelsarederivedfromlesionstudiesandknowledgeofbrainorganisation,oftenresultingintheoriesofgreatinterest.Forexample,wehavemodelsofpersonalitydysfunctionbasedontemporo-limbichyperconnection,andofobses-sionalneurosisbasedonstriate-frontalimbalance.Analo-giesaredrawnbetweendepressivepsychomotorretarda-tionandsubcorticaldementia.Itwouldseem,however,thatbehaviouralneurologytendstogiveanincompletepicture,sinceitsviewofbehaviourisboundtobenarrow.Theotherformsofexplanationavailabletopsychiatristsareinthemainleftoutofaccount.Thequestionnaireaskedwhetherneuropsychiatrywassynonymouswithbehaviouralneurologyanddrewamarkedlynegativeresponse.Itwas,however,twiceasoftenendorsedbyneurologistsasbypsychiatristsbothintheUKandtheUSA,withpositivescoresof29%and15%respectively.Inconclusion,thesevarioussubspecialitiesmaybeviewedasacomplexamalgam,adynamicfieldofinterrelationshipsbetweenvariousviewpointsandareasofknowledge.Itshouldnotbesurprisingthatthepresentmultifariousstatehasevolved,inourattemptstounravelsomethingascomplexashumanmentaldisorderinrelationtobrainmalfunction.Neuropsychiatryitselfhasobviouslyhadalongandcomplexhistory.Itappearstosurviveverywellasavigorousbranchofpsychiatrydespitethedivisionsofopinionthatithasgeneratedalongtheway.Fortunatelythepractitionersofneuropsychiatryhavestrongalliesintheircolleaguesinneurology,neuropsychologyandneu-ropathology,andintheirlinkswithworkersinthelaboratoryneurosciences.WALISHMANInstituteofPsychiatry,DeCrespignyPark,DenmarkHill,London,UK

*BasedonalecturegivenattheBritishNeuropsychiatryAssociationSummerMeeting,StCatherine'sCollege,Oxford,12-14July1992.

1SymondsCP.TriaJunctainUno.TheSixthSirHughCairnsMemorialLecture.AddressedtoTheSocietyofBritishNeurologicalSurgeons,25Sep-tember1970.Oxford:SeacourtPress:Oxford,1970.985 on August 15, 2023 by guest. Protected by copyright.http://jnnp.bmj.com/J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.11.983

on 1 November 1992. Downloaded from