Psychosomatics 41:1-4, February 2000
© 2000 The Academy of Psychosomatic Medicine
Neuropsychiatry
Constantine G. Lyketsos, M.D., M.H.S.
Received and accepted September 2, 1999. From the Neuropsychiatry Service, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, Baltimore, Maryland. Address correspondence and reprint requests to Dr. Lyketsos, Osler 320, The Johns Hopkins Hospital, Baltimore, MD 21287; e-mail: kostas{at}jhmi.edu
Key Words: Neuropsychiatry • Brain Disease
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INTRODUCTION
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Brain diseases often have psychological as well as neurological manifestations. Sometimes, as in Huntington disease, the former precedes the latter; sometimes, as in stroke, they occur almost simultaneously; sometimes, as in epilepsy, the neurological manifestations are evident long before the psychological ones. Neuropsychiatry is the discipline that seeks to understand these associations. The relationship among mental life, behavior, neurologic symptoms, and brain disease is, therefore, at the center of neuropsychiatric inquiry. As the psychiatry of the neurologically ill, neuropsychiatry sits at the interface between psychiatry and neurology and is a central aspect of consultation–liaison psychiatry. Such intersections of fields are often where the most important scientific discoveries are made. Neuropsychiatry is a "top-down" field, meaning that it begins its inquiry at the clinical level and relates this to the underlying brain disease. Also, neuropsychiatry takes a long-term, hands-on approach to patient care.
The neuropsychiatric approach has three components: 1) description, 2) explanation, and 3) treatment. Derived from a careful evaluation of the patient, description is concerned with the identification of the patient's mental and/or behavioral disturbance by applying standard psychiatric phenomenology, for example, as presented by Jaspers.1 Description is further concerned with defining the patient's brain disease and the clinical relationship between the psychiatric disturbance and brain disease.
The goal of explanation is to specify the cause of the neuropsychiatric disturbance. The methodological approach, presented by McHugh and Slavney,2 who describe four perspectives of pychiatry, is most useful to neuropsychiatric explanation. The application of perspectives reasoning is illustrated in this issue of Psychosomatics by Schwartz and Marsh,3 in their article on epilepsy. Using this approach reminds us that neuropsychiatry is an opportunity to practice psychiatry with a less familiar population, rather than a new specialty. This approach also provides an opportunity for the general psychiatrist to understand more about the brain, brain–behavior relationships, and how they apply to the practice of general psychiatry.
Most often in neuropsychiatry, the disease perspective is used to explain a neuropsychiatric disturbance as a direct result of a "broken part," caused by the patient's brain disease ("what the patient has"). In this way, the disturbance is understood to be a symptom of the primary brain disease. However, not every psychiatric disturbance in a neuropsychiatric patient is best understood by using the disease perspective. Brain damage occurs in individuals of different personalities. Also, the brain damage, at times, alters the personality. The combined premorbid and postinjury personality influence a person's ability to adapt to the consequences of brain damage. Generally speaking, neuropsychiatric patients are more vulnerable to the development of distress after provocation. This dimensional perspective explains disturbances in mental state and/or behavior after brain injury as the consequence of the right provocation affecting a vulnerable individual (who the patient is after the brain injury), using the "potential-provocation-response" logic.2
The behavior perspective is a third explanatory logic used in neuropsychiatry. Here the focus is on the patient's behavior (what the patient does), and on the balance between the forces driving and the forces opposing the expression of a behavior. This perspective is concerned with motivated behaviors—such as sleeping, eating, or sexuality—as well as with potentially driven maladaptive behaviors, such as aggression, self-injury, or pacing. Disturbances of behavior are, of course, common after brain damage. However, their explanation is complex, with many, often concurrent, etiologic factors.
Finally, the life-story perspective attempts to understand the distress of the person who has suffered brain damage by using meaningful connections.1,2 It is concerned with what the patient has encountered—the symptoms of the brain disease; the reaction of others to the symptoms (e.g., unfamiliar or unsupportive); and attempts to understand his/her distress as a psychological reaction to these experiences. While not all psychiatric symptoms are best explained by using this perspective, its narrative method allows for an empathic, therapeutic connection between the neuropsychiatrist and the patient. Demoralization that patients with brain disease experience over personal losses illustrates this perspective.3
Once the neuropsychiatric symptoms of a given patient are formulated by using these perspectives, treatment interventions flow naturally from the explanations developed. The treatment of patients with neuropsychiatric disturbances has several goals. Whenever possible, prevention or correction of the brain insult is sought. Typically, however, neuropsychiatrists treat patients who have chronic diseases, many of which are progressive, and some of which are eventually terminal. In this circumstance, the goals of treatment include the preservation of function, the augmentation of quality of life, and the prolongation of life. Symptomatic relief, comforting, and supportive care for patients are commonly used.5
Several standard psychiatric treatments have been adapted to the neuropsychiatric setting. These include pharmacotherapy; psychotherapy; behavior-modification strategies; therapeutic environments; bright-light therapy; electroconvulsive therapy; surgery; and rehabilitative interventions (e.g., occupational therapy, activity therapy, speech therapy, vocational counseling, and cognitive rehabilitation). Also, because most patients with neuropsychiatric disturbances require one or more caregivers for successful day-to-day functioning, much of the treatment is targeted to the caregiver in a systematic way.5
This issue of Psychosomatics brings the aforementioned discussion to life by illustrating the practice of neuropsychiatry as applied to stroke, epilepsy, Parkinson's disease, and basal ganglia diseases. These conditions were chosen to represent a wide range of disturbances with different etiologies, types of brain injury, brain areas involved, and prognosis. All are essentially irreversible brain conditions, some progressive and some not. While specific therapy for the primary disease is not available for any, in many cases there are available symptomatic therapies that have emerged from an understanding of the pathophysiology of the brain disease.
In appreciating the neuropsychiatry of these four diseases, four common themes emerge. First, the initial descriptive neuropsychiatry of these conditions has been completed, to a greater or lesser extent. Each disease has associated with it its own particular neuropsychiatric nosology. While familiar psychiatric syndromes (e.g., dementia, delirium, major depression, anxiety disorder, mania, psychosis), defined by using the DSM-IV classification, occur in relation to these brain diseases, these syndromes are in most cases secondary to the brain damage caused by these diseases. These are variants of the DSM-IV conditions (e.g., major depressive disorder vs. poststroke depression) that differ slightly from their DSM-IV counterpart, likely because they have a different etiology, even though similar brain areas appear to be involved.
In addition, there are nosologic entities that are not well captured by DSM-IV. Some of these occur across the spectrum of these diseases (e.g., apathy, irritability). Others are specific to individual diseases, as illustrated by the postconcussion syndrome of traumatic brain injury. This difficulty in classfication requires the future development of a new nosology for neuropsychiatry, taking into account the clinical phenomena and the underlying disease. For example, how should we best classify what we now call "apathy," "emotional lability," "irritability," "frontal lobe syndrome," "organic personality disorder," and "cognitive disorder not otherwise specified?" This special series of papers in Psychosomatics is, among other things, an effort to begin discussion about such a nosology.
The second theme that should be apparent is that these neuropsychiatric disturbances are common accompaniments of brain disease. In fact, it is difficult to think of most brain diseases without thinking of their neuropsychiatric manifestations. In the clinical setting, neuropsychiatric symptoms are a major source of disability for patients. Further, they worsen prognosis and lead to dangerous outcomes involving aggression, violence, or self-harm. Given that there are several interventions for neuropsychiatric symptoms, these interventions should be applied for the benefit of patients and their caregivers. However, many patients with neuropsychiatric illness go unevaluated and untreated by neuropsychiatrists.
In part, this shortcoming reflects the third theme: the lack of adequate scientific knowledge about how to treat these neuropsychiatric conditions. For example, what is the proper clinical management of major depression occurring after brain damage? Do the same antidepressants work as for major depressive disorder? What about nonpharmacologic interventions, such as psychotherapy, electroconvulsive therapy, or bright light therapy? Similarly, how should "psychosis" in Parkinson's disease be treated? Why does it in some cases respond to ondansetron? This part of the field is wide open. The proper definition and targeting of therapies in neuropsychiatric disorders requires extensive study. In addition to the effects of treatment on the neuropsychiatric symptoms, it is essential to study the effects of treatments on a range of other outcomes, for example, functioning, quality of life, survival, and health care utilization.
The final theme is the knowledge that the study of neuropsychiatric disorders brings to the rest of psychiatry. All these conditions are experiments of nature that are occurring in the setting of damage to the brain. As brain diseases are being increasingly understood, and as understanding of the associated neuropsychiatric phenomena is developed, greater insight into brain–behavior relationships will emerge. In addition to the neuropsychiatric approach, this study relies upon the methods of disciplines such as epidemiology, brain imaging, neuroscience, genetics, and pharmacology. Already, the study of stroke, Parkinson's disease, and Huntington's disease has provided insights into the role of the basal ganglia and frontal lobes in depression and anxiety. Moreover, from the study of epilepsy we have a better understanding of the role of the temporal lobes in psychosis. Study of the cerebellar degenerations and white matter diseases, such as multiple sclerosis, will further expand this insight. This knowledge will begin to come together over the next decade as new research is being conducted in individual disorders, and as information from different diseases is compared systematically.
As we approach the twenty-first century, neuropsychiatry is poised for continued rapid growth in clinical care, research, and education. The field will likely emerge as one of the most central areas of contemporary psychiatry. The Decade of the Brain, which will soon come to its end, has created essential new methods, technologies, and knowledge regarding the brain, which will now be applied to neuropsychiatric inquiry in tandem with time-tested psychiatric methods, such as phenomenology and psychopharmacology. The result is likely to be substantial growth of the field, coupled with broad scientific advance.
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ACKNOWLEDGMENTS
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The author thanks Drs. Paul McHugh, Phillip Slavney, Peter Rabins, Glenn Treisman, Laura Marsh, and Thomas Wise, whose ideas have greatly influenced this editorial.
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REFERENCES
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- Jaspers K: General Psychopathology (translation). Baltimore, MD, The Johns Hopkins University Press, 1997
- McHugh PR, Slavney PR: The Perspectives of Psychiatry, 2nd Edition. Baltimore, MD, The Johns Hopkins University Press, 1998
- Schwartz J, Marsh L: The psychiatric perspectives of epilepsy. Psychosomatics 2000; 41:31–38[Abstract/Free Full Text]
- Slavney PR: Diagnosing demoralization in consultation psychiatry. Psychosomatics 1999; 40:325–329[Abstract/Free Full Text]
- Rabins PV, Lyketsos CG, Steele CD: Practical Dementia Care. New York, Oxford University Press, 1999, p 1
This article has been cited by other articles:
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C. G. Lyketsos
Lessons From Neuropsychiatry
J Neuropsychiatry Clin Neurosci,
November 1, 2006;
18(4):
445 - 449.
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