Neurology and psychiatry: closing the great divide

A synergetic turn in cognitive neuroscience of brain diseases

Despite significant improvements in our understanding of brain diseases, many barriers remain. Cognitive neuroscience faces four major challenges: complex structure-function associations; disease phenotype heterogeneity; the lack of transdiagnostic models; and oversimplified cognitive approaches restricted to the laboratory. Here, we propose a synergetics framework that can help to perform the necessary dimensionality reduction of complex interactions between the brain, body, and environment. The key solutions include low-dimensional spatiotemporal hierarchies for brain-structure associations, whole-brain modeling to handle phenotype diversity, model integration of shared transdiagnostic pathophysiological pathways, and naturalistic frameworks balancing experimental control and ecological validity. Creating whole-brain models with reduced manifolds combined with ecological measures can improve our understanding of brain disease and help identify novel interventions. Synergetics provides an integrated framework for future progress in clinical and cognitive neuroscience, pushing the boundaries of brain health and disease toward more mature, naturalistic approaches.

Toward a Unified Classification System for Brain-Mind Disorders: Putting Calls for Integrated Clinical Neuroscience Into Action

Dividing the brain-mind into the specialized fields of neurology and psychiatry has produced many granular advantages, but these silos have imposed barriers to comprehensively understanding and contextualizing the fundamentals governing mental life and its maladies. Scientific inquiry into these fundamentals cannot reach its full potential without interdigitating the boundaries of two specialties of the same organ for both scholarship and clinical practice. We propose that to truly integrate disorders of the brain and the mind for research and clinical care, we must carefully reexamine the classification of its disorders (nosology) as an instrument to develop a coherent pathological and psychological framework. We call on professional organizations from neurology, psychiatry, behavioral neurology, neuropsychiatry, neuropsychology, and other relevant subspecialties (eg, geriatric psychiatry) to convene a multidisciplinary task force to define the current classification principles of their subspecialties and work toward developing an integrated nosology. The effect of a shared classification system, which we acknowledge is a difficult proposition philosophically and politically, would have transformative potential across educational, clinical, scientific, programmatic, and sociocultural realms. If accomplished, this initiative would provide a definitive step toward reducing stigma (and promoting reimbursement parity) for the full spectrum of complex brain disorders (regardless of traditional neurologic vs psychiatric conceptualizations).

Frontotemporal dementia: Past, present, and future

INTRODUCTION

The history of frontotemporal dementia (FTD) is both old and new. This study explores its historical roots, dating back to the 19th century, while recognizes it as a distinct neurological entity only a few decades ago.

METHODS

This qualitative study and literature review provides an overview of FTD's historical background, birth, evolution, and future directions.

RESULTS

Recognition of FTD was hindered by rigid perceptions of dementia, the division between neurology and psychiatry, reliance on IQ-based assessment, limited neuroimaging capabilities, and lack of pathological proof. Overcoming these barriers involved revisiting early pioneers' approaches, focusing on focal impairment, establishing non-Alzheimer's disease cohorts, fostering collaboration, and developing diagnostic criteria. Current gaps include the need for biology-oriented psychiatry education, biological biomarkers, and culturally sensitive, objective clinical instruments predicting underlying pathology.

DISCUSSION

Independent multidisciplinary centers are essential. The future of FTD lies in disease-modifying therapies, presenting new opportunities for healthcare professionals and researchers.

The shared genetic risk architecture of neurological and psychiatric disorders: a genome-wide analysis

While neurological and psychiatric disorders have historically been considered to reflect distinct pathogenic entities, recent findings suggest shared pathobiological mechanisms. However, the extent to which these heritable disorders share genetic influences remains unclear. Here, we performed a comprehensive analysis of GWAS data, involving nearly 1 million cases across ten neurological diseases and ten psychiatric disorders, to compare their common genetic risk and biological underpinnings. Using complementary statistical tools, we demonstrate widespread genetic overlap across the disorders, even in the absence of genetic correlations. This indicates that a large set of common variants impact risk of multiple neurological and psychiatric disorders, but with divergent effect sizes. Furthermore, biological interrogation revealed a range of biological processes associated with neurological diseases, while psychiatric disorders consistently implicated neuronal biology. Altogether, the study indicates that neurological and psychiatric disorders share key etiological aspects, which has important implications for disease classification, precision medicine, and clinical practice.

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.

Allostatic-Interoceptive Overload in Frontotemporal Dementia

BACKGROUND

The predictive coding theory of allostatic-interoceptive load states that brain networks mediating autonomic regulation and interoceptive-exteroceptive balance regulate the internal milieu to anticipate future needs and environmental demands. These functions seem to be distinctly compromised in behavioral variant frontotemporal dementia (bvFTD), including alterations of the allostatic-interoceptive network (AIN). Here, we hypothesize that bvFTD is typified by an allostatic-interoceptive overload.

METHODS

We assessed resting-state heartbeat evoked potential (rsHEP) modulation as well as its behavioral and multimodal neuroimaging correlates in patients with bvFTD relative to healthy control subjects and patients with Alzheimer's disease (N = 94). We measured 1) resting-state electroencephalography (to assess the rsHEP, prompted by visceral inputs and modulated by internal body sensing), 2) associations between rsHEP and its neural generators (source location), 3) cognitive disturbances (cognitive state, executive functions, facial emotion recognition), 4) brain atrophy, and 5) resting-state functional magnetic resonance imaging functional connectivity (AIN vs. control networks).

RESULTS

Relative to healthy control subjects and patients with Alzheimer's disease, patients with bvFTD presented more negative rsHEP amplitudes with sources in critical hubs of the AIN (insula, amygdala, somatosensory cortex, hippocampus, anterior cingulate cortex). This exacerbated rsHEP modulation selectively predicted the patients' cognitive profile (including cognitive decline, executive dysfunction, and emotional impairments). In addition, increased rsHEP modulation in bvFTD was associated with decreased brain volume and connectivity of the AIN. Machine learning results confirmed AIN specificity in predicting the bvFTD group.

CONCLUSIONS

Altogether, these results suggest that bvFTD may be characterized by an allostatic-interoceptive overload manifested in ongoing electrophysiological markers, brain atrophy, functional networks, and cognition.

The Neuropsychiatric Approach to the Assessment of Patients in Neurology

Neuropsychiatry is a clinical neuroscience specialty focused on the evaluation and treatment of patients who present with symptoms at the intersection of neurology and psychiatry. Neuropsychiatrists assess and manage the cognitive, affective, behavioral, and perceptual manifestations of disorders of the central nervous system. Although fellowship training in behavioral neurology-neuropsychiatry exists in the United States and several other countries internationally, the need for neuropsychiatric expertise greatly outweighs the number of specialists in practice or training. This article serves as a primer for both neurologists and psychiatrists seeking to improve or refresh their knowledge of the neuropsychiatric assessment, including detailing aspects of the history-taking, physical exam, psychometric testing, and associated diagnostic work-up. In doing so, we urge the next generation of neurologists and psychiatrists to take on both the opportunity and challenge to work at the intersection of both clinical neuroscience specialties using an integrated neuropsychiatric perspective.

Use of cognitive event-related potentials in the management of psychiatric disorders: Towards an individual follow-up and multi-component clinical approach

Relapse prevention remains a major challenge in psychiatry, thus indicating that the established treatment methods combining psychotherapy with neuropharmacological interventions are not entirely effective. In recent years, several intervention strategies have been devised that are aimed at improving psychiatric treatment by providing a complementary set of add-on tools that can be used by clinicians to improve current patient assessment. Among these, cognitive event-related potentials (ERPs) have been indexed as valuable biomarkers of the pathophysiological mechanisms of various mental illnesses. However, despite decades of research, their clinical utility is still controversial and a matter of debate. In this opinion review, I present the main arguments supporting the use of cognitive ERPs in the management of psychiatric disorders, stressing why it is currently still not the case despite the vast number of ERP studies to date. I also propose a clinically-oriented suitable way in which this technique could — in my opinion — be effectively incorporated into individual patient care by promotion of the use of individual ERP test-retest sessions and the use of a multi-component approach.

Artificial intelligence in disease diagnostics: A critical review and classification on the current state of research guiding future direction

The diagnosis of diseases is decisive for planning proper treatment and ensuring the well-being of patients. Human error hinders accurate diagnostics, as interpreting medical information is a complex and cognitively challenging task. The application of artificial intelligence (AI) can improve the level of diagnostic accuracy and efficiency. While the current literature has examined various approaches to diagnosing various diseases, an overview of fields in which AI has been applied, including their performance aiming to identify emergent digitalized healthcare services, has not yet been adequately realized in extant research. By conducting a critical review, we portray the AI landscape in diagnostics and provide a snapshot to guide future research. This paper extends academia by proposing a research agenda. Practitioners understand the extent to which AI improves diagnostics and how healthcare benefits from it. However, several issues need to be addressed before successful application of AI in disease diagnostics can be achieved.

DNA Methylation-Dependent Dysregulation of GABAergic Interneuron Functionality in Neuropsychiatric Diseases

Neuropsychiatric diseases, such as mood disorders, schizophrenia, and autism, represent multifactorial disorders, differing in causes, disease onset, severity, and symptoms. A common feature of numerous neuropsychiatric conditions are defects in the cortical inhibitory GABAergic system. The balance of excitation and inhibition is fundamental for proper and efficient information processing in the cerebral cortex. Thus, altered inhibition is suggested to account for pathological symptoms like cognitive impairments and dysfunctional multisensory integration. While it became apparent that most of these diseases have a clear genetic component, environmental influences emerged as an impact of disease manifestation, onset, and severity. Epigenetic mechanisms of transcriptional control, such as DNA methylation, are known to be responsive to external stimuli, and are suspected to be implicated in the functional impairments of GABAergic interneurons, and hence, the pathophysiology of neuropsychiatric diseases. Here, we provide an overview about the multifaceted functional implications of DNA methylation and DNA methyltransferases in cortical interneuron development and function in health and disease. Apart from the regulation of gamma-aminobutyric acid-related genes and genes relevant for interneuron development, we discuss the role of DNA methylation-dependent regulation of synaptic transmission by the modulation of endocytosis-related genes as potential pathophysiological mechanisms underlying neuropsychiatric conditions. Deciphering the hierarchy and mechanisms of changes in epigenetic signatures is crucial to develop effective strategies for treatment and prevention.

Dopamine D1 and D2 receptors mediate analgesic and hypnotic effects of l-tetrahydropalmatine in a mouse neuropathic pain model

RATIONALE

Levo-tetrahydropalmatine (l-THP), an active ingredient of Corydalis yanhusuo, has been reported to be a partial agonist for dopamine D₁ receptors (D₁R) and an antagonist for D₂R. Although it has been safely used clinically in China for decades as an analgesic with sedative/hypnotic properties, there are few studies that address the mechanisms by which l-THP exerts its beneficial effects in chronic pain-induced sleep disturbance.

OBJECTIVES

To investigate the effects and mechanisms of l-THP on sleep disturbance in a neuropathic pain-like condition.

METHODS

A mouse model of chronic neuropathic pain induced by partial sciatic nerve ligation (PSNL) was employed. The antinociceptive and hypnotic effects of l-THP were evaluated by measurement of mechanical allodynia, thermal hyperalgesia, and electroencephalogram (EEG) recordings in PSNL mice. Pharmacological approaches and c-Fos expression were used to clarify the mechanisms of l-THP.

RESULTS

Intraperitoneal injection of l-THP at 5 and 10 mg/kg not only significantly increased the mechanical threshold by 134.4% and 174.8%, and prolonged the thermal latency by 49.4% and 69.2%, but also increased non-rapid eye movement sleep by 17.5% and 29.6%, and decreased sleep fragmentation in PSNL mice, compared with the vehicle control. Moreover, the antinociceptive effect of l-THP was prevented by D₁R antagonist SCH23390 or D₂R agonist quinpirole; meanwhile, the hypnotic effect of l-THP was blocked by quinpirole rather than by SCH23390. Immunohistochemistry demonstrated that l-THP inhibited c-Fos overexpression induced by PSNL in the cingulate cortex and the periaqueductal gray.

CONCLUSIONS

These findings indicated that l-THP exerted analgesic effects by agonism D₁R and antagonism D₂R, and the antagonism of D₂R mediated the hypnotic effect of l-THP in PSNL mice.

Psychiatric manifestations of neurologic diseases: Etiology, phenomenology, and treatment

Understanding the etiology and meaning of behavioral symptomatology in the context of neurologic disease, and choosing the most effective intervention is a vexing task. This introduction summarizes the history of our understanding of the relationship between behavioral symptoms and primary neurologic conditions, and considers the ways in which both psychiatric and neurologic disorders occurring simultaneously may inform both knowledge of etiology and treatment decisions.

Should neurologists diagnose and manage functional neurologic disorders? It is complicated

Whereas only neurologists can "rule in" functional neurologic disorders (FNDs)-using physical signs and semiologic features-their role in follow-up care remains debated. We outlined the arguments for and against a neurologist's primary role in both assessing and managing FNDs. Favorable arguments include the following: (1) FND presents neurologically, and thus, only neurologists can ascertain the etiology of new neurologic deficits appearing on follow-up, and (2) neurologic encounters facilitate acceptance of diagnosis and enhance treatment engagement. Counter arguments include the following: (1) FND is a Diagnostic and Statistical Manual of Mental Disorders, 5th Edition codified psychiatric disorder with largely psychiatric treatments, and (2) neurologists can reassess patients if new neurologic symptoms develop without playing a primary follow-up role. Although more research is needed to clarify optimal approaches, neurologic expertise could be leveraged for diagnostic and coordinating roles if the pool of neurologists, psychiatrists, psychotherapists, physical and occupational therapists, and other allied clinicians trained in the interdisciplinary care of FNDs is substantially increased.

Bridging the Great Divide: What Can Neurology Learn From Psychiatry?

Neurology and psychiatry share common historical origins and rely on similar tools to study brain disorders. Yet the practical integration of medical and scientific approaches across these clinical neurosciences remains elusive. Although much has been written about the need to incorporate emerging systems-level, cellular-molecular, and genetic-epigenetic advances into a science of mind for psychiatric disorders, less attention has been given to applying clinical neuroscience principles to conceptualize neurologic conditions with an integrated neurobio-psycho-social approach. In this perspective article, the authors briefly outline the historically interwoven and complicated relationship between neurology and psychiatry. Through a series of vignettes, the authors then illustrate how some traditional psychiatric conditions are being reconceptualized in part as disorders of neurodevelopment and awareness. They emphasize the intersection of neurology and psychiatry by highlighting conditions that cut across traditional diagnostic boundaries. The authors argue that the divide between neurology and psychiatry can be narrowed by moving from lesion-based toward circuit-based understandings of neuropsychiatric disorders, from unidirectional toward bidirectional models of brain-behavior relationships, from exclusive reliance on categorical diagnoses toward transdiagnostic dimensional perspectives, and from silo-based research and treatments toward interdisciplinary approaches. The time is ripe for neurologists and psychiatrists to implement an integrated clinical neuroscience approach to the assessment and management of brain disorders. The subspecialty of behavioral neurology & neuropsychiatry is poised to lead the next generation of clinicians to merge brain science with psychological and social-cultural factors. These efforts will catalyze translational research, revitalize training programs, and advance the development of impactful patient-centered treatments.

Schizophrenia as a psychosomatic illness: An interdisciplinary approach between Lacanian psychoanalysis and the neurosciences

According to Lacan's theory of schizophrenia (as well as other delirious forms of psychosis), under certain conditions the signifying function breaks down, thus turning the schizophrenic individual's world into one in which a number of events become enigmatic and signal him or her. The schizophrenic individual tries to deal with these signs that besiege him or her either by means of an interpretative attitude (a stable delusional mood) or by apathy. These two types of responses correspond with the stereotypical (and mood) processes by which the schizophrenic individual attempts to avoid the distress provoked by the enigmatic desire of the Other, while simultaneously corresponding with psychosomatic processes of the brain organ.

Social neuroscience: undoing the schism between neurology and psychiatry

Multiple disorders once jointly conceived as "nervous diseases" became segregated by the distinct institutional traditions forged in neurology and psychiatry. As a result, each field specialized in the study and treatment of a subset of such conditions. Here we propose new avenues for interdisciplinary interaction through a triangulation of both fields with social neuroscience. To this end, we review evidence from five relevant domains (facial emotion recognition, empathy, theory of mind, moral cognition, and social context assessment), highlighting their common disturbances across neurological and psychiatric conditions and discussing their multiple pathophysiological mechanisms. Our proposal is anchored in multidimensional evidence, including behavioral, neurocognitive, and genetic findings. From a clinical perspective, this work paves the way for dimensional and transdiagnostic approaches, new pharmacological treatments, and educational innovations rooted in a combined neuropsychiatric training. Research-wise, it fosters new models of the social brain and a novel platform to explore the interplay of cognitive and social functions. Finally, we identify new challenges for this synergistic framework.

The Psychoanalytic Concept of Jouissance and the Kindling Hypothesis

This article aims to define the conceptual field of jouissance in Lacanian theory, and put forth the hypothesis of a relationship between certain neurophysiological mechanisms and specific clinical phenomena where jouissance is “kindled” and outside the control of the symbolic process. First, the author briefly introduces Lacan's notion of jouissance and the way it draws on Freud's theorization, and describes the preliminary stages of this conceptual field in Lacan's work. Then, the jouissance related to two other concepts: repetition, with its Freudian and Lacanian nuances, as well as the—exclusively—Lacanian concept of the object petit a. Lacan's later conceptualization of language as jouissance (the notion of lalangue) is then discussed in relation to Freud's early ideas (“Letter 52”) on the different kinds of inscriptions that help form the mental apparatus. Finally, the author tries to formulate a hypothesis regarding specific neurophysiological mechanisms, based on clinical situations where jouissance becomes “kindled” and escapes the control of the symbolic processes through the neurophysiological mechanisms of conditioning, “kindling-sensitization” and “excitotoxicity.” In these cases, jouissance can have a destructive effect on the body and can affect, among others organs, the brain—a process the author has previously described heuristically as the “psychosomatic diseases of the brain.” This would be a special mechanism of automatism that would be triggered under the specific conditions of the fragility of the signifying chain (foreclosure of the Name-of-the-Father or solidification of the signifying chain) in combination with biological factors, including genetic factors. In this process, signifiers are reduced to signals, which in turn may be reduced to stimuli, with a tendency toward self-perpetuation, while affects are reduced to emotions and moods. Thus, conditioning and kindling-sensitization could also be understood in terms of a “semiotic reduction.” Can we therefore consider that certain phenomena of automatism and certain deficits (delusional moods, schizophrenic apathy, etc.) could be seen as psychosomatic disorders of the brain? The phenomena in question might also serve—albeit at random—as a kind of shield to mitigate excessive jouissance.

Identification of candidate genes for familial early-onset essential tremor

Essential tremor (ET) is one of the most common causes of tremor in humans. Despite its high heritability and prevalence, few susceptibility genes for ET have been identified. To identify ET genes, whole-exome sequencing was performed in 37 early-onset ET families with an autosomal-dominant inheritance pattern. We identified candidate genes for follow-up functional studies in five ET families. In two independent families, we identified variants predicted to affect function in the nitric oxide (NO) synthase 3 gene (NOS3) that cosegregated with disease. NOS3 is highly expressed in the central nervous system (including cerebellum), neurons and endothelial cells, and is one of three enzymes that converts l-arginine to the neurotransmitter NO. In one family, a heterozygous variant, c.46G>A (p.(Gly16Ser)), in NOS3, was identified in three affected ET cases and was absent in an unaffected family member; and in a second family, a heterozygous variant, c.164C>T (p.(Pro55Leu)), was identified in three affected ET cases (dizygotic twins and their mother). Both variants result in amino-acid substitutions of highly conserved amino-acid residues that are predicted to be deleterious and damaging by in silico analysis. In three independent families, variants predicted to affect function were also identified in other genes, including KCNS2 (KV9.2), HAPLN4 (BRAL2) and USP46. These genes are highly expressed in the cerebellum and Purkinje cells, and influence function of the gamma-amino butyric acid (GABA)-ergic system. This is in concordance with recent evidence that the pathophysiological process in ET involves cerebellar dysfunction and possibly cerebellar degeneration with a reduction in Purkinje cells, and a decrease in GABA-ergic tone.

Paeoniflorin exerts analgesic and hypnotic effects via adenosine A1 receptors in a mouse neuropathic pain model

RATIONAL

Neuropathic pain is frequently comorbid with sleep disturbances. Paeoniflorin, a main active compound of total glucosides of paeony, has been well documented to exhibit neuroprotective bioactivity.

OBJECTIVE

The present study evaluated effects of paeoniflorin on neuropathic pain and associated insomnia and the mechanisms involved.

METHODS

The analgesic and hypnotic effects of paeoniflorin were measured by mechanical threshold and thermal latency, electroencephalogram (EEG) and electromyogram, and c-Fos expression in a neuropathic pain insomnia model.

RESULTS

The data revealed that paeoniflorin (50 or 100 mg/kg, i.p.) significantly increased the mechanical threshold and prolonged the thermal latency in partial sciatic nerve ligation (PSNL) mice. Meanwhile, paeoniflorin increased non-rapid eye movement (NREM) sleep amount and concomitantly decreased wakefulness time. However, pretreatment with l,3-dimethy-8-cyclopenthylxanthine, an adenosine A1 receptor (R, A1R) antagonist, abolished the analgesic and hypnotic effects of paeoniflorin. Moreover, paeoniflorin at 100 mg/kg failed to change mechanical threshold and thermal latency and NREM sleep in A1R knockout PSNL mice. Immunohistochemical study showed that paeoniflorin inhibited c-Fos overexpression induced by PSNL in the anterior cingulate cortex and ventrolateral periaqueductal gray.

CONCLUSIONS

The present findings indicated that paeoniflorin exerted analgesic and hypnotic effects via adenosine A1Rs and might be of potential use in the treatment of neuropathic pain and associated insomnia.

A proposed solution to integrating cognitive-affective neuroscience and neuropsychiatry in psychiatry residency training: The time is now

Despite increasing recognition of the importance of a strong neuroscience and neuropsychiatry education in the training of psychiatry residents, achieving this competency has proven challenging. In this perspective article, we selectively discuss the current state of these educational efforts and outline how using brain-symptom relationships from a systems-level neural circuit approach in clinical formulations may help residents value, understand, and apply cognitive-affective neuroscience based principles towards the care of psychiatric patients. To demonstrate the utility of this model, we present a case of major depressive disorder and discuss suspected abnormal neural circuits and therapeutic implications. A clinical neural systems-level, symptom-based approach to conceptualize mental illness can complement and expand residents' existing psychiatric knowledge.

The bodily self and its disorders: neurological, psychological and social aspects

PURPOSE OF REVIEW

The experience of ourselves as an embodied agent with a first-person perspective is referred to as 'bodily self'. We present a selective overview of relevant clinical and experimental studies.

RECENT FINDINGS

Sharing multisensory body space with others can be observed in patients with structurally altered bodies (amputations, congenital absence of limbs), with altered functionality after hemiplegia, such as denial of limb ownership (somatoparaphrenia) and with alterations in bodily self-consciousness on the level of the entire body (e.g. in autoscopic phenomena). In healthy participants, the mechanisms underpinning body ownership and observer perspective are empirically investigated by multisensory stimulation paradigms to alter the bodily self. The resulting illusions have promoted the understanding of complex disturbances of the bodily self, such as out-of-body experiences. We discuss the role of interoception in differentiating between self and others and review current advances in the study of body integrity identity disorder, a condition shaped as much by neurological as by social-psychological factors.

SUMMARY

We advocate a social neuroscience approach to the bodily self that takes into account the interactions between body, mind and society and might help close the divide between neurology and psychiatry.

Beyond neural cubism: promoting a multidimensional view of brain disorders by enhancing the integration of neurology and psychiatry in education

Cubism was an influential early-20th-century art movement characterized by angular, disjointed imagery. The two-dimensional appearance of Cubist figures and objects is created through juxtaposition of angles. The authors posit that the constrained perspectives found in Cubism may also be found in the clinical classification of brain disorders. Neurological disorders are often separated from psychiatric disorders as if they stemmed from different organ systems. Maintaining two isolated clinical disciplines fractionalizes the brain in the same way that Pablo Picasso fractionalized figures and objects in his Cubist art. This Neural Cubism perpetuates a clinical divide that does not reflect the scope and depth of neuroscience. All brain disorders are complex and multidimensional, with aberrant circuitry and resultant psychopharmacology manifesting as altered behavior, affect, mood, or cognition. Trainees should receive a multidimensional education based on modern neuroscience, not a partial education based on clinical precedent. The authors briefly outline the rationale for increasing the integration of neurology and psychiatry and discuss a nested model with which clinical neuroscientists (neurologists and psychiatrists) can approach and treat brain disorders.

Brain Dysfunctions, Psychopathologies, and Body Image Distortions

The major features in eating disorders are a preoccupation with food and its consumption and body dissatisfaction. Diagnostic manuals provide clusters of criteria according to which affected individuals can be categorized into one or other group of eating disorder. Yet, when considering the high proportion of comorbidities and ignoring the content of the symptoms (food, body), the major features seem to yield obsessional-compulsive, addictive, and impulsive qualities. In the present article, we review studies from the neuroscientific literature (mainly lesion studies) on eating disorder, obsessive-compulsive disorder, impulse control disorder, and addiction to investigate the possibility of a wider phenotype that can be related to a common brain network. The literature localizes this network to the right frontal lobe and its connectivities. This network, when dysfunctional, might result in a behavior that favors the preoccupation with particular thoughts, behaviors, anxieties, and uncontrollable urges that are accompanied by little scope for ongoing behavioral adjustments (e.g., impulse control). We reason that this network may turn out to be equally involved in understudied mental conditions of dysfunctional body processing such as muscle dysmorphia, body dysmorphic disorder (including esthetic surgery), and xelomelia. We finally consider previous notions of a wider phenotype approach to current diagnostic practice (using DSM), such as the possibility of a model with a reduced number of diagnostic categories and primary and secondary factors, and to etiological models of mental health conditions.

Neuropsychiatric genetics in developing countries: Current challenges

Neuropsychiatric disorders (NPDs) constitute a heavy burden on public health systems around the world and studies have demonstrated that the negative impact of NPDs is larger in Low and Middle Income Countries (LMICs). In recent decades, several studies have come to the understanding that genetic factors play a major role in the risk for a large number of NPDs. However, few neuropsychiatric genetics studies have been published from LMICs. In this Editorial, we discuss important issues impinging on advances in neuropsychiatric genetics research in LMICs. It is essential that scientists educate policymakers and officials of funding agencies on the importance of providing adequate funding for research in these areas. Development of local well-supported research programs focused on NPD genetics should be an important asset to develop; it would facilitate the establishment of sustainable research efforts that could lead to appropriate diagnosis and specific, affordable and feasible interventions in LMICs. It is important to point out that research into the biological basis of human NPDs is not only an academic effort reserved for a few elite institutions in economically developed countries, but it is vitally important for the mental health of people around the world.

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.

Educating psychiatry residents in neuropsychiatry and neuroscience

Neuropsychiatry and psychiatric neuroscience should be part of the general psychiatry curriculum so that graduate psychiatrists will be able to allow their patients the benefit of neuroscientifically informed diagnosis and treatment. Current neurology and neuroscience educational requirements for US psychiatry training are reviewed. The draft milestone requirements for clinical neuroscience training as part of the US Accreditation Council for Graduate Medical Education's Next Accreditation System are also provided. Suggestions for the neuropsychiatric and neuroscience content of psychiatry residency training are made, along with a description of pedagogic methods and resources. Survey data are reviewed indicating agreement by programme directors with the importance of neuroscience training and an increase in the amount of time devoted to this area. Faculty staff development in neuropsychiatry and neuroscience literacy will be needed to provide high quality training in these areas.

Neuropsychiatric symptoms in Alzheimer's disease: past progress and anticipation of the future

Neuropsychiatric symptoms (NPS) in Alzheimer's disease (AD) are widespread and disabling. This has been known since Dr. Alois Alzheimer's first case, Frau Auguste D., presented with emotional distress and delusions of infidelity/excessive jealousy, followed by cognitive symptoms. Being cognizant of this, in 2010 the Alzheimer's Association convened a research roundtable on the topic of NPS in AD. A major outcome of the roundtable was the founding of a Professional Interest Area (PIA) within the International Society to Advance Alzheimer's Research and Treatment (ISTAART). The NPS-PIA has prepared a series of documents that are intended to summarize the literature and provide more detailed specific recommendations for NPS research. This overview paper is the first of these living documents that will be updated periodically as the science advances. The overview is followed by syndrome-specific synthetic reviews and recommendations prepared by NPS-PIA workgroups on depression, apathy, sleep, agitation, and psychosis.

Synaptosomal-associated protein 25 mutation induces immaturity of the dentate granule cells of adult mice

BACKGROUND

Synaptosomal-associated protein, 25 kDa (SNAP-25) regulates the exocytosis of neurotransmitters. Growing evidence suggests that SNAP-25 is involved in neuropsychiatric disorders, such as schizophrenia, attention-deficit/hyperactivity disorder, and epilepsy. Recently, increases in anxiety-related behaviors and epilepsy have been observed in SNAP-25 knock-in (KI) mice, which have a single amino acid substitution of Ala for Ser187. However, the molecular and cellular mechanisms underlying the abnormalities in this mutant remain unknown.

RESULTS

In this study, we found that a significant number of dentate gyrus (DG) granule cells was histologically and electrophysiologically similar to immature DG neurons in the dentate gyrus of the adult mutants, a phenomenon termed the "immature DG" (iDG). SNAP-25 KI mice and other mice possessing the iDG phenotype, i.e., alpha-calcium/calmodulin-dependent protein kinase II heterozygous mice, Schnurri-2 knockout mice, and mice treated with the antidepressant fluoxetine, showed similar molecular expression patterns, with over 100 genes similarly altered. A working memory deficit was also identified in mutant mice during a spontaneous forced alternation task using a modified T-maze, a behavioral task known to be dependent on hippocampal function. Chronic treatments with the antiepileptic drug valproate abolished the iDG phenotype and the working memory deficit in mutants.

CONCLUSIONS

These findings suggest that the substitution of Ala for Ser187 in SNAP-25 induces the iDG phenotype, which can also be caused by epilepsy, and led to a severe working memory deficit. In addition, the iDG phenotype in adulthood is likely an endophenotype for at least a part of some common psychiatric disorders.

Diagnosis and treatment of sleep disorders: a brief review for clinicians

Sleep disorders encompass a wide spectrum of diseases with significant individual health consequences and high economic costs to society. To facilitate the diagnosis and treatment of sleep disorders, this review provides a framework using the International Classification of Sleep Disorders, Primary and secondary insomnia are differentiated, and pharmacological and nonpharmacological treatments are discussed. Common circadian rhythm disorders are described in conjunction with interventions, including chronotherapy and light therapy. The diagnosis and treatment of restless legs syndrome/periodic limb movement disorder is addressed. Attention is focused on obstructive sleep apnea and upper airway resistance syndrome, and their treatment. The constellation of symptoms and findings in narcolepsy are reviewed together with diagnostic testing and therapy, Parasomnias, including sleep terrors, somnambulism, and rapid eye movement (REM) behavior sleep disorders are described, together with associated laboratory testing results and treatment.

Posterior cortical atrophy: an exemplar for renovating diagnostic formulation in neuropsychiatry

Neurodegenerative dementias represent among the most clinically and pathologically complex syndromes in neuropsychiatry. Phenomenologically protean, and often initially presenting with subtle subsyndromal characteristics, neurodegenerative behavioral syndromes can manifest with an assortment of cognitive, mood, personality, and comportmental changes, often alloyed with elementary neurologic (e.g., motor) signs. A range of pathogenic mechanisms (e.g., amyloid plaques, Pick bodies, etc) typically underlie corresponding clinical syndromes. However, overlap in both clinical expression and histopathologic comorbidities frequently exist among cortical and subcortical neurodegenerative disorders. Moreover, secondary central nervous system pathologies (e.g., cerebrovascular disease) commonly coexist with neurodegenerative processes, further complicating clinical phenomenology-based nosologic categorization. Evolving insight into the etiologic mechanisms of neurodegenerative dementias, and correspondingly improving potential for intervention, require more precise differentiation among dementia subtypes and comprehensive identification of contemporaneous neurodegenerative processes. Increasing appreciation of this diagnostic complexity is prompting the need for renovation of existing diagnostic schemas. We address these issues by reviewing the atypical dementia type known as posterior cortical atrophy. We then use posterior cortical atrophy as an exemplar for renovating neuropsychiatric diagnostic classification to better account for the layered complexity of clinical and pathologic domains needing to be characterized to accurately and completely diagnose neuropsychiatric disturbances.

Endophenotypes and the diagnosis of personality disorders

It has been suggested that psychiatric diagnosis should come to depend on endophenotypes, in order to define more precisely the mechanisms behind mental disorders. This construct is associated with the assumption that mental processes can be reduced to activity at a neuronal level. The approach has had a strong influence on the conceptual basis of proposals for DSM-5, but could be consistent either with categorical or dimensional diagnosis. However, application of endophenotypes to personality disorders is unlikely for the foreseeable future, given an insufficient knowledge of etiology and pathogenesis.

Neuropathic pain: mind-body considerations

Emerging research in neuroscience is bridging the gap between mind and body. Thought is brain based and influences brain function. The continuum and bidirectionality of mind and body, thought and brain, emotions and physiology forms the basis of understanding neuropathic pain, a neuropsychiatric condition with myriad clinical manifestations.