Promoting Growth in Behavioral Neurology: A Path Forward.

Behavioral neurology & neuropsychiatry (BNNP) is a field that seeks to understand brain-behavior relationships, including fundamental brain organization principles and the many ways that brain structures and connectivity can be disrupted, leading to abnormalities of behavior, cognition, emotion, perception, and social cognition. In North America, BNNP has existed as an integrated subspecialty through the United Council for Neurologic Subspecialties since 2006. Nonetheless, the number of behavioral neurologists across academic medical centers and community settings is not keeping pace with increasing clinical and research demand. In this commentary, we provide a brief history of BNNP followed by an outline of the current challenges and opportunities for BNNP from the behavioral neurologist's perspective across clinical, research, and educational spheres. We provide a practical guide for promoting BNNP and addressing the shortage of behavioral neurologists to facilitate the continued growth and development of the subspecialty. We also urge a greater commitment to recruit trainees from diverse backgrounds so as to dismantle persistent obstacles that hinder inclusivity in BNNP-efforts that will further enhance the growth and impact of the subspecialty. With rapidly expanding diagnostic and therapeutic approaches across a range of conditions at the intersection of neurology and psychiatry, BNNP is well positioned to attract new trainees and expand its reach across clinical, research, and educational activities.

Dual Residency Training in Neurology and Psychiatry: History and Current Practice.

In the early 20th century, neurology training included more experience in psychiatry, and psychiatry training included more training in neurology than what is currently required. After World War I, the increased need for differential diagnosis of what might now be called functional neurological disorders resulted in the military encouraging combined residency training in neurology and psychiatry and the promulgation of the term "neuropsychiatry" for this specialty. Thirty-six percent of physicians certified by the American Board of Psychiatry and Neurology in its first decade (1935-1945) held certification in both neurology and psychiatry. However, the term neuropsychiatry gradually became used interchangeably with general psychiatry-to distinguish it from psychoanalysis-and lost its specificity. It is widely held that the popularity of psychoanalysis resulted in psychiatrists perceiving less need for neurological knowledge, and inclusion of neurology content in psychiatry training decreased. Dual residency training programs in neurology and psychiatry began to increase in popularity again in the 1980s as advances in neuroscience, neuroimaging, and pharmacology, paired with the growth of behavioral neurology, laid the foundation for meaningful practice of neuropsychiatry. The author surveyed 207 physicians who graduated from both a neurology and psychiatry residency and 18 current trainees in combined neuropsychiatry residency programs to collect information on their current practice, academic activity, and opinions about their training. The response rate was 64%. Respondents' attitudes toward the value of their dual neurology and psychiatry training were overwhelmingly positive. Reasons for the lack of growth of combined residency programs in neurology and psychiatry are examined.

Life-long deficits in social adaptation and the frontal lobes: New evidence, seventy-five years after Ackerly and Benton's landmark case report of JP.

The case of JP, reported by Ackerly and Benton in 1948 with a detailed follow-up by Ackerly in 1964, stands as the index case of developmental prefrontal damage and its impact on social adaptation. Although the 1948 case report included findings from a 1933 pneumoencephalogram and exploratory craniotomy, a definitive cause was never established for JP's prefrontal damage. Etiologies were never determined for the left-sided seizures that occurred when JP was age four, nor for the progressive anterograde amnesia that JP developed in middle age. Given Ackerly's thoroughness and long-term follow-up of his patient, it was hoped that a brain cutting would have been done, though no report of a post-mortem examination was published. The lead author of this paper (SB) set out to discover what had happened to JP after Ackerly's 1964 report and whether a brain cutting had in fact occurred. Using a variety of investigative approaches, it was discovered that a post-mortem brain examination had taken place. Those present at the brain cutting were identified, and the still-living witnesses to the brain cutting were interviewed. Previously unpublished, relevant materials were uncovered from archival sources. A film of the brain cutting, as well as photos, were located. A film of Ackerly interviewing JP prior to JP's death at age sixty-four also was found. The authors studied autopsy findings in the newly discovered video and still images. These findings were judged consistent with massive perinatal hemorrhagic damage to both frontal lobes. JP's left-sided seizures were likely due to activation of a focus from his congenital brain damage. The anterograde amnesia that was documented when JP was twenty-five and that was noted to worsen when he was forty-nine remains unexplained but may have been related to slowly progressive hydrocephalus. This paper expands what is known about the case of JP, making it the only report of a person with congenital frontal injury followed for their entire life including post-mortem brain examination.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia.

(Reprinted with permission from The American Journal of Psychiatry 2020; 177:868-872).

Reduction in apathy following epilepsy surgery.

INTRODUCTION: Surgical treatment for patients with epilepsy who do not respond to antiepileptic medication can lead to changes in behavior, including new onset of neuropsychiatric symptoms such as depression and anxiety. In other cases, neuropsychiatric symptoms present before surgery may be alleviated. Because application of diagnostic criteria for primary psychiatric disorders may not be valid in assessing behavior in epilepsy populations, we sought to determine the feasibility of measuring behaviors associated with frontal-subcortical dysfunction using the Frontal Systems Behavior Scale (FrSBe) in patients who had received surgical intervention for medically refractory epilepsy. MATERIALS AND METHODS: Twenty-three patients who had previously undergone epilepsy surgery and their family member informants completed the FrSBe. The FrSBe includes separate forms for patients and informants to rate symptoms associated with three frontal lobe syndromes - executive dysfunction, disinhibition, and apathy - prior to and following a neurological condition. Patients and informants were asked to rate frontal lobe behaviors before and after epilepsy surgery using the FrSBe. RESULTS: Informants rated patients as showing a significantly greater reduction in apathy on the FrSBe compared to either disinhibition or executive dysfunction subscales. A trend in reduction of apathy following right hemisphere resection was found. CONCLUSIONS: Patients who have undergone epilepsy surgery show a reduction in apathy but it is unclear whether this behavioral change is directly related to the surgical intervention. We suggest that these preliminary findings support the utility of implementing dimensional scales such as the FrSBe to study behavioral changes following epilepsy surgery.

Six Landmark Case Reports Essential for Neuropsychiatric Literacy.

Well-described clinical case reports have been a core component of the neuropsychiatry literature and have led to: a deepened understanding of brain-behavior relationships and neuropsychiatric phenomenology, new paths for research, and compelling material for physicians who are studying neurology and psychiatry. Six landmark neuropsychiatry cases were selected for being well described, paradigmatic, and illuminating of brain-behavior correlations: Phineas Gage, Louis Victor Leborgne ("Tan"), Auguste Deter, Solomon Shereshevsky ("S"), "JP," and Henry Gustav Molaison ("HM"). Each case and its neuropsychiatric lessons are summarized from primary sources, highlighting some less appreciated aspects. Case reports continue to be a valuable resource for neuropsychiatric education. Yet only four of the 10 highest impact factor psychiatry journals accept case reports for publication.

The neurological examination adapted for neuropsychiatry.

The neuropsychiatric examination includes standard neurological and cognitive examination techniques with several additional observations and tasks designed to capture abnormalities common among patients with neuropsychiatric disorders or neurocognitive complaints. Although useful as a screening tool, a single standardized rating scale such as the Mini Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA) is insufficient to establish a neuropsychiatric diagnosis. Extra attention is paid to findings commonly seen in the setting of psychiatric disorders, dementias, movement disorders, or dysfunction of cortical or subcortical structures. Dysmorphic features, dermatologic findings, neurodevelopmental signs, signs of embellishment, and expanded neurocognitive testing are included. The neuropsychiatric clinician utilizes the techniques described in this article to adapt the examination to each patient's situation, choosing the most appropriate techniques to supplement the basic neurological and psychiatric examinations in support of diagnostic hypotheses being considered. The added examination techniques facilitate diagnosis of neurocognitive disorders and enable neuropsychiatric formulation.

The Differential Diagnosis and Treatment of Catatonia in Children and Adolescents.

LEARNING OBJECTIVES: After participating in this activity, learners should be better able to:• Assess the etiologies associated with catatonia in children and adolescents• Evaluate the differential diagnosis of pediatric catatonia• Interpret the literature regarding the treatment of children and adolescents with catatonia OBJECTIVE: Pediatric catatonia is associated with many medical and psychiatric conditions. Mortality is high, and proper treatment can be lifesaving. Catatonia is increasingly recognized in pediatric populations, in which about 20% of cases are related to underlying medical conditions. To minimize morbidity, clinicians must rule out underlying disorders while simultaneously managing symptoms and causes. In our review we discuss (1) recommendations to aid rapid decision making, both diagnostic and therapeutic, (2) emergent conditions and management, (3) disorders associated with pediatric catatonia, including developmental, acquired, idiopathic, and iatrogenic etiologies, (4) available treatments, and (5) medicolegal considerations. METHODS: Initial PubMed search without date constraints using MeSH terms related to pediatric catatonia, with subsequent searches on pertinent subtopics using PubMed and Google Scholar. RESULTS: Pediatric catatonia is a dangerous but treatable neuropsychiatric condition. Psychiatrists need to be aware of differential diagnoses and to be able determine appropriate treatment within a short time frame. With prompt diagnosis and treatment, outcomes can be optimized. CONCLUSION: Pediatric catatonia is underdiagnosed and requires rapid evaluation and management.

Assessing Cultural Psychiatry Milestones Through an Objective Structured Clinical Examination.

OBJECTIVE: Culturally appropriate tools for patient assessment are needed to train psychiatric residents. An objective structured clinical examination (OSCE) can be a helpful tool for evaluating trainees in the psychiatry milestones pertaining to cultural competency. METHODS: Seventeen psychiatry residents and fellows at the University of Massachusetts participated in two small-group OSCE exercises to learn cultural interviewing using the DSM-5 Cultural Formulation Interview. Trainee groups presented a cultural formulation and received feedback. Participants were surveyed about their comfort with cultural interviewing before and after the exercise. RESULTS: Paired t tests (N = 16) showed that mean level of comfort with the Cultural Formulation Interview increased by a mean of 0.5 points after training (t = 3.16, df = 15, p < 01 95 % CI = 163-837). DISCUSSION: The UMass culturally appropriate assessment OSCE enhanced psychiatric trainees' comfort with culturally appropriate interviewing using the Cultural Formulation Interview.

Integrating Neuroscience Knowledge and Neuropsychiatric Skills Into Psychiatry: The Way Forward.

Increasing the integration of neuroscience knowledge and neuropsychiatric skills into general psychiatric practice would facilitate expanded approaches to diagnosis, formulation, and treatment while positioning practitioners to utilize findings from emerging brain research. There is growing consensus that the field of psychiatry would benefit from more familiarity with neuroscience and neuropsychiatry. Yet there remain numerous factors impeding the integration of these domains of knowledge into general psychiatry.The authors make recommendations to move the field forward, focusing on the need for advocacy by psychiatry and medical organizations and changes in psychiatry education at all levels. For individual psychiatrists, the recommendations target obstacles to attaining expanded neuroscience and neuropsychiatry education and barriers stemming from widely held, often unspoken beliefs. For the system of psychiatric care, recommendations address the conceptual and physical separation of psychiatry from medicine, overemphasis on the Diagnostic and Statistical Manual of Mental Disorders and on psychopharmacology, and different systems in medicine and psychiatry for handling reimbursement and patient records. For psychiatry residency training, recommendations focus on expanding neuroscience/neuropsychiatry faculty and integrating neuroscience education throughout the curriculum.Psychiatry traditionally concerns itself with helping individuals construct meaningful life narratives. Brain function is one of the fundamental determinants of individuality. It is now possible for psychiatrists to integrate knowledge of neuroscience into understanding the whole person by asking, What person has this brain? How does this brain make this person unique? How does this brain make this disorder unique? What treatment will help this disorder in this person with this brain?

Neuropsychiatry and neural cubism.

The art movement known as Cubism did not represent a failure of perspective but, rather, was a movement aimed at advancing art by juxtaposing different perspectives. In this issue, Taylor and colleagues describe the current approach by neurologists and psychiatrists to patients with brain disorders as "Neural Cubism" because of the competing angles of these specialists' perspectives about these disorders. They advocate both integrated training for all residents in the two fields and a system of "nested hierarchies" to reclassify brain disorders according to their effect on levels of brain function. The unspoken premise of their article is that it is time for psychiatry and neurology to reunite.This Commentary takes the view that reuniting the long-separated specialties of neurology and psychiatry would not necessarily create better care for all patients with brain disorders but that trainees in both fields would benefit from increased training in the complementary specialty. The new Accreditation Council for Graduate Medical Education clinical neuroscience milestones for psychiatry training and psychiatry milestones for neurology training are steps in the right direction. Increasing opportunities for combined neurology-psychiatry training will help create a cadre of specialists equipped to efficiently care for complex patients within emerging accountable care organizations. Drawing from two fields in the service of understanding brain-behavior interactions increases the potential for innovation at their interface. The author concludes that the time has come to increase the neurological and neuroscience content of psychiatry training but not to unite the two fields.

Neuropsychiatry and neuroscience education of psychiatry trainees: attitudes and barriers.

OBJECTIVE: The American Association of Directors of Psychiatric Residency Training (AADPRT) Task Force on Neuropsychiatry and Neuroscience Education of Psychiatry Residents was established in 2011 with the charge to seek information about what the field of psychiatry considers the core topics in neuropsychiatry and neuroscience to which psychiatry residents should be exposed; whether there are any "competencies" in this area on which the field agrees; whether psychiatry departments have the internal capacity to teach these topics if they are desirable; and what the reception would be for "portable curricula" in neuroscience. METHODS: The task force reviewed the literature and developed a survey instrument to be administered nationwide to all psychiatry residency program directors. The AADPRT Executive Committee assisted with the survey review, and their feedback was incorporated into the final instrument. RESULTS: In 2011-2012, 226 adult and child and adolescent psychiatry residency program directors responded to the survey, representing over half of all US adult and child psychiatry training directors. About three quarters indicated that faculty resources were available in their departments but 39% felt the lack of neuropsychiatry faculty and 36% felt the absence of neuroscience faculty to be significant barriers. Respectively, 64 and 60% felt that neuropsychiatry and psychiatric neuroscience knowledge were very important or critically important to the provision of excellent care. Ninety-two percent were interested in access to portable neuroscience curricula. CONCLUSIONS: There is widespread agreement among training directors on the importance of neuropsychiatry and neuroscience knowledge to general psychiatrists but barriers to training exist, including some programs that lack faculty resources and a dearth of portable curricula in these areas.

A DSM-5 to-do list for adult psychiatry residency directors.

A small study within the author's department, comparing resident and faculty attitudes toward the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), revealed that the DSM-5 transition process is starting from a point in which neither faculty nor residents are optimistic that the new DSM will result in improved diagnosis or treatment. However, the publication of DSM-5 presents training directors with opportunities to engage trainees in the study of the evolution of psychiatric nosology and the evidence for core psychiatric diagnoses. Residents should be encouraged to become familiar with both DSM-5 and National Institute of Mental Health Research Domain Criteria (NIMH RDoC) categories in their study of the neurobiology of psychiatric disorders. Department chairs are encouraged to establish timelines for the DSM-5 transition for faculty, residents, medical student teaching, medical record keeping, and billing for services. Training directors should be aware that national examinations for trainees will transition gradually between 2014 and 2017, so comparisons should be made whenever possible between DSM-IV-TR and DSM-5. To minimize trainee confusion, departments should attend to the coherence of transition timelines among faculty, resident, and medical student training.

Congenital and acquired disorders presenting as psychosis in children and young adults.

A review of the published literature found 60 congenital and acquired disorders with symptoms that include psychosis in youth. The prevalence, workup, genetics, and associated neuropsychiatric features of each disorder are described. Eighteen disorders (30%) have distinct phenotypes (doorway diagnoses); 18 disorders (30%) are associated with intellectual disability; and 43 disorders (72%) have prominent neurologic signs. Thirty-one disorders (52%) can present without such distinct characteristics, and are thus more easily overlooked. A systematic and cost-effective differential diagnostic approach based on estimated prevalence and most prominent associated signs is recommended.