Neuroscience and psychiatry: marriage or coexistence?

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.

Dopamine, schizophrenia, mania, and depression: Toward a unified hypothesis of cortico-striatopallido-thalamic function

Considerable evidence from preclinical and clinical investigations implicates disturbances of brain dopamine (DA) function in the pathophysiology of several psychiatric and neurologic disorders. We describe a neural model that may help organize theseindependent experimental observations. Cortical regions classically associated with the limbic system interact with infracortical structures, including the nucleus accumbens, ventral pallidum, and dorsomedial nucleus of the thalamus. In our model, overactivity in forebrain DA systems results in the loss of lateral inhibitory interactions in the nucleus accumbens, causing disinhibition of pallidothalamic efferents; this in turn causes rapid changes and a loss of focused corticothalamic activity in cortical regions controlling cognitive and emotional processes. These effects might be manifested clinically by some symptoms of psychoses. Underactivity of forebrain DA results in excess lateral inhibition in the nucleus accumbens, causing tonic inhibition of pallidothalamic efferents; this perpetuates tonic corticothalamic activity and prevents the initiation of new activity in other critical cortical regions. These effects might be manifested clinically by some symptoms of depression. This model parallels existing explanations for the etiology of several movement disorders, and may lead to testable inferences regarding the neural substrates of specific psychopathologies.

Medication treatment strategies in the MTA Study: relevance to clinicians and researchers

OBJECTIVE

Clinicians have difficulty applying drug research findings to clinical practice, because research protocols use methods different from those used in daily office practice settings.

METHOD

To design a medication protocol for a multisite clinical trial involving 576 children with attention-deficit hyperactivity disorder (ADHD) while maintaining relevance to clinical practice, investigators from the NIMH Collaborative Multisite Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder (MTA study) developed novel medication strategies. These were designed to work either in a monomodal or multimodal format and to ensure standard approaches are used across diverse sites. Each child randomized to medication (projected N = 288) is individually titrated to his or her "best" methylphenidate dose and has individual ADHD symptoms monitored. Decision rules were developed to guide "best dose" selection, dose changes, medication changes, the management of side effects, and integration with psychosocial treatments.

CONCLUSIONS

The MTA study uses a controlled method to standardize the identification of each child's "best" methylphenidate dose in a national, multisite cooperative treatment program. Although the titration protocol is complex, the study's individual dosing approach and algorithms for openly managing ADHD children's medication over time will be of interest to clinicians in office practice.

Neurological diagnoses in psychiatric patients. The uncertain boundaries between neurology and psychiatry

The study highlights the high prevalence of neurological diagnoses in a population of psychiatric in-patients admitted to 16 private clinics and 6 private institutes because of their mental and behavioral disorders. Neurological diseases affected 13.05% of acute and 68.09% of chronic psychiatric patients. These results emphasize the need for specific neurological competence in the treatment of many psychiatric patients and better integration between neurological and psychiatric departments. The close relationship between neurology and psychiatry, as well as the renaissance of neuropsychiatry are discussed.

Diagnosis and treatment of personality disorders

This article touches on four current areas of controversy in the field of the personality disorders -- definition, etiology, assessment, and treatment. There is a tremendous amount of disability, personal distress, and public health expense as a result of the personality disorders. We are seeing steady progress in each of these areas. The implications of this progress are enormous, and the interest in this area is widespread, not just among psychiatric health professionals or among patients and their families and friends, but also among the public at large.

Neuroscience

Neuroscience, encouraged by the advent of approaches at the molecular level, is finally beginning to play an important part in the theoretical basis of psychiatry. Although its immediate effect on clinical practice remains limited, this too is likely to change within the near future. Psychiatrists, and Membership candidates in particular, are now expected to be au fait with everything from conduction of the nerve impulse to second messengers and linkage analysis. Unfortunately, the complexity and breadth of the underlying science is expanding at an ever-increasing rate, making it difficult to keep up to date with advances. The following are offered as readable overviews of the neuroscientific areas especially relevant to psychiatry, with an emphasis on publications or editions produced within the past three years, since the rate of progress renders most texts rapidly redundant. The broader question of how all this neuroscience is going to alter psychiatry – for better or worse – has also attracted considerable debate, if few conclusions (e.g. Pardes, 1986; Detre, 1987).

Psychobiology and psychiatric nursing: a philosophical matrix

Over the past several years, conceptualizations of the mind have been challenged by a knowledge explosion in the psychobiological sciences. Such new knowledge continues to fuel a paradigm shift in psychiatry away from traditional psychodynamic models of the mind and toward ones balanced with a psychobiological dimension. The combination of psychodynamic and psychobiological fields of knowledge offers an opportunity for a holistic perspective on the human experience. Psychiatric nursing faces the challenge of integrating this new knowledge for the enrichment of its practice. To accomplish this complex task, issues need to be addressed in many areas critical to psychiatric nursing. Three areas are discussed in this article and include philosophy, communication of philosophy, and testing of philosophy. This article concludes with a discussion of some potential mechanisms to deal with the tensions generated by a paradigm shift in psychiatric nursing.

The clinician-investigator interface in psychiatry I--Values and problems

The two following papers describe some of the benefits and problems involved in integrating clinical and investigative work. It is stressed that there are a number of advantages to such integration. Researchers especially benefit from the proximity to patients and clinicians. Education can be significantly enhanced when researchers and clinicians are in one setting and this can benefit residents, medical students and non-medical health personnel. There are a number of problems to such clinical research in psychiatry. These are discussed especially as they relate to senior faculty and their resistances to research. The shortage of clinician scientists in teaching positions means that most residents are not involved with such people as mentors early in their training and do not consider this as a career option after their residency training. Reductionistic thinking on the part of some researchers and when researchers are not first-rate clinicians both contribute to residents not becoming involved in clinical investigation. Funding policies as well as chairmen's hiring policies also play a role here.

Psychiatry: mindless or brainless, both or neither?

After a period marked by one-sided emphasis on psychodynamics and social issues, or what could be called "brainless" psychiatry on account of its relative neglect of cerebral processes, we are witnessing an opposite trend towards extreme biologism or "mindless" psychiatry. The pendulum has swung periodically from one to the other of these reductionistic positions throughout the history of psychiatry. The author argues that neither brainless nor mindless psychiatry can do justice to the complexity of mental illness and to the treatment of patients. Psychiatry's distinguishing feature as a clinical discipline is its equal concern with subjective experience, or the mind, and with the body, including brain function, which together constitute a person, a psychiatrist's proper focus of inquiry and intervention. Moreover, a person, viewed as a mindbody complex, is in constant interaction with the environment. It follows that both study of mental illness and clinical practice need to take into account the psychological, the biological and the social aspects. These three aspects are not mutually reducible and are indispensable for the understanding and treatment of the individual patient. Such a comprehensive, biopsychosocial approach provides an antithesis to the reductionistic viewpoints and, in the writer's opinion, is both practically and theoretically most satisfying.

Implications of altered limbic-hypothalamic-pituitary-adrenocortical (LHPA)-function for neurobiology of depression

The current article suggests that the neuroendocrine system constitutes a bidirectional link between the brain and humoral homeostasis in the periphery. Any change of neuronal activity in the brain--regardless whether induced by external stimuli or endogenous errors of metabolism--may result in altered composition of gene products. Among these are peptides which directly or indirectly alter endocrine activity and may concomitantly induce a variety of behavioral effects. This has been experimentally demonstrated by neuropeptidergic manipulation of sleep-electroencephalographic (EEG) measures and behavioral studies in animals. An integral part of the neuroendocrine communication are effects of peripheral hormones upon brain structures and their interactions with the immune system. Within this framework all hormones of the limbic-hypothalamic- pituitary-adrenocortical (LHPA)-axis play a dominant role, because: (1) corticotropin-releasing hormone (CRH) was shown to integrate centrally behavioral and metabolic responses to stress; and (2) corticosteroids exert a host of neurochemical changes within the CNS which by far exceed their primary endocrine feedback action. As a corollary, hyperexposure to corticosteroids induces widespread changes of neuronal cell biology which are of clinical significance for depression research (e.g. neuronal cell loss in the hippocampus, down-regulation of glucocorticoid receptors within monoaminergic neurons). Clinical neuroendocrine research over the past years focussed upon evaluation of pathophysiology underlying dexamethasone resistant cortisol levels or hypercortisolism linked to depression and utilized advanced methods for multihormonal analysis and newly synthesized neuropeptides (e.g. CRH) for challenge studies in combination with neurophysiological assessments.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychoanalysis today

Psychoanalysis as a theory has permeated Western culture in a way that often no longer is conscious. Psychoanalysis as a practice has had a more visible and stormy progress. A similar fate has befallen behavioural, biological, cognitive and social psychology, and it is argued that the attractiveness of reductionism acts to prevent critical appraisal of psychoanalysis and of the other paradigms.

The interface of psychiatry and medicine: towards integrated health care

Establishment of closer links with medicine in clinical work, research and teaching represents a major achievement of psychiatry in this century. Development of general hospital psychiatry has played a key role in this regard. Numerous studies quoted in this article have documented a large overlap between psychiatric and physical morbidity in the community and in all health care settings. These findings argue most strongly in favour of continued efforts to expand all activities at the interface of psychiatry and medicine, with truly integrated health care as the ultimate goal.