Psychiatry, like many other specialties within medicine, has a range of sub-specialties from which one can choose during higher training, which lead to further development of expertise in a certain area of psychiatry and a particular subset of patients.
Neuropsychiatry is one of those sub-specialties.
Simply defined, neuropsychiatry is the practice of managing mental illness in the context of an organic, neurological cause or associated lesion — depression in Parkinson’s disease, organic causes of psychosis and schizophrenia, and the psychological components of dementia are some examples of presentations that would typically be attended to by a neuropsychiatrist.
It brings together the fields of neurology and psychiatry to further our understanding and facilitate the most appropriate management of presentations that are neither purely psychiatric nor purely neurological in nature — a masterful blend of mind and matter.
My interest in neuropsychiatry first came about after my second year of medical school whilst completing a six-week lab-based summer research project on Parkinson’s disease with one of the research groups at my university.
I have always been fascinated by the brain, even before commencing my degree, and by that point was quite certain that the specialty I ended up pursuing would be one of the ones related to the nervous system.
Whilst contemplating a career in neurology, I was also simultaneously exploring psychiatry, attending the annual one-week psychiatry summer school at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN) at King’s College London.
The outcomes of these events during that summer were: 1) a change in career plans and my decision to pursue psychiatry, and 2) an infatuation with the possibility of training in both psychiatry and neurology.
This infatuation led me to discover that there, in fact, exists a neuropsychiatry sub-specialty through the psychiatry specialty training route. However, it is relatively less well-established compared to the other sub-specialties.
I also explored other, equally interesting psychiatry sub-specialties: child and adolescent, perinatal, addictions, forensic…
My interest in neuropsychiatry has recently re-emerged, and I am, once again, considering it as my sub-specialty of choice. Thus, I have carried out internet searches seeking to understand more about the training pathway and how neuropsychiatry as a discipline came to exist.
In this blog article, I will explore the origins of neuropsychiatry, dating back to ancient history, and its place now in modern medicine. I will then discuss the current training pathway for becoming a neuropsychiatrist in the United Kingdom (UK), followed by laying down my argument for why the future of neuropsychiatry training should be its evolution into dual training in both neurology and psychiatry.
“BY THE SAME ORGAN COMES JOYS, DELIGHTS…AND FEARS AND TERRORS…” — THE ORIGINS OF NEUROPSYCHIATRY
Modern neuropsychiatry is often labelled as a relatively new practice within medicine, however, this is not strictly true.
The history of neuropsychiatry can be traced back to ancient Greece, though it is slightly vague and elusive. Hippocrates, the ancient Greek physician and ‘father of medicine’, postulated his theory on the origin of epilepsy, proclaiming that:
“by the same organ (from which comes) joys, delights, laughter and sports, and sorrows, griefs, despondency and lamentations…we become mad and delirious...”
During the Renaissance and Romantic periods, neuroscience went through a number of developments.
For example, neuroanatomy underwent further exploration by the likes of Andreas Vesalius and Thomas Willis. René Descartes approached questions about mind and body and existence from a philosophical and mathematical perspective. From Descartes’ musings came his famous conclusion, “cogito ergo sum”, and his contributions to ‘substance dualism’ (‘Cartesian dualism’) — the idea that the mind and body are essentially distinct entities.
These ideas stemmed from a larger ‘mind-body problem’ discourse that a number of Enlightenment philosophers engaged with at the time, including Descartes. What relation do the mind and body have?
Immanuel Kant, a German philosopher and one of the most influential Enlightenment thinkers, formed a model of the mind that has played a central role in the development of cognitive science.
Romantic poets challenged the passive brain theory of empiricists, which had dominated theoretical neuroscience for hundreds of years — the idea that the brain solely received sensations as a receptor, which then led to a muscular response (S -> R). The theory did not explain the creativity of the mind, manifested through the arts and great literary works, which required active thinking and shaping of human experiences and the world around us.
Phrenology, now a refuted concept and dismissed as pseudoscience, was conceived by Franz Gall and Johann Spurzheim and proposed that the role of different regions of the cerebral cortex of the brain in the make-up of the mind corresponded with the size of the skull encasing the region.
Further evolutions within neuropsychiatry occurred until its split into two distinctly different specialisms, neurology and psychiatry, later in the 19th century.
Growing, singular interest in mental states and the mind, including memory and dreams and the influence of individuals such as Sigmund Feud and his founding of psychoanalysis, led to the development of psychiatry, which focussed less on neuroscience and more on the psychological processes. This left neurology and its focus on the brain and organic disorders and lesions to develop separately into what it is recognised as today.
It was not until the late 20th century that efforts were made to revive the practice of neuropsychiatry once again.
Formal neuropsychiatry organisations within the medical community were formed, such as the British Neuropsychiatric Association in 1987, the American Neuropsychiatric Association in 1988, and the International Neuropsychiatric Association in 1996.
Other developments included the discovery of the electroencephalogram (EEG) by Hans Berger and its use to extensively study the electrical discharge of seizures and its link to psychiatric presentations in patients.
NEUROPSYCHIATRY AND 21ST-CENTURY MEDICINE
Neuropsychiatry has now returned to what it once was: an equally weighted practice of both neurological and psychiatric explorations of presentations that fall into the remit of the discipline — or has it?
As previously mentioned, neuropsychiatry is a sub-specialty within psychiatry. Therefore, doctors going down the neurology training route with an interest in the psychiatric aspect of presentations they might encounter may not come across neuropsychiatry as a career option or may find themselves having to retrain to pursue that path.
To add to the complexity of the situation, neuropsychiatry higher training is not as straightforward as the others.
It is not a sub-specialty that is formally recognised by the General Medical Council (GMC), the regulatory body of medical training and practice in the UK. Therefore, aspiring neuropsychiatrists tend to have to carve out their own training pathways to meet the competency requirements to become a consultant.
CV-building activities, such as completing a master’s in Clinical Neuropsychiatry, are useful pursuits in the training process.
Currently, there are plans by the Faculty of Neuropsychiatry of the Royal College of Psychiatrists (RCPsych) to make training in the sub-specialty more structured by providing a curriculum and syllabus, which will hopefully lead to its formal endorsement by the GMC.
But could we go one step further?
After thinking about the dilemma the current situation poses for doctors keen on both specialties, I believe the best next step for the evolution and future of the discipline is the implementation of dual training in both neurology and psychiatry.
THE BEST OF BOTH WORLDS
Dual training in neurology and psychiatry is not a new concept.
For example, it already exists in the United States (US), such as the programme offered by New York University. Residents (registrars) dual train in neurology and psychiatry for six years, an extra two years than the four-year singular neurology and psychiatry residencies.
The curriculum is created by the American Board of Psychiatry and Neurology (ABPN), which oversees neurology, psychiatry, and dual neurology and psychiatry training in the US.
The fact that the curriculum and certification of the individual neurology and psychiatry residencies is provided by the same board sets an example in emphasising that neurology and psychiatry are not dichotomous disciplines and should be housed by the same training body.
To put things into perspective, having separate specialty boards represent neurology and psychiatry would be analogous to having obstetrics and gynaecology represented by two separate boards.
It sounds absurd and goes against the norm we have accepted for obstetrics and gynaecology training to be joint — after all, they are both related to the female reproductive system.
Yet that absurd situation is exactly what exists for neurology and psychiatry training in the UK: neurology is overseen by the Royal College of Physicians (RCP) as a ‘medical’ specialty and psychiatry by the RCPsych.
But why? After all, they are both related to the nervous system.
Psychiatrists and neurologists should be trained in both specialties to achieve the higher level of competence and holistic training their patients deserve.
You wouldn’t expect an obstetrician to not have the sound understanding and knowledge of gynaecological conditions required to enable them to manage gynaecological presentations, and vice versa. This is even most likely virtually impossible because of the design of their training programme.
Therefore, we should expect the same when it comes to neurologists’ and psychiatrists’ understanding of the other specialty.
Even if a doctor decides not to pursue neuropsychiatry as a career by the end of the dual training and chooses either neurology or psychiatry instead, they are knowledgeable in both areas and would be equipped to spot and manage presentations that fall into either category, or both, were a patient requiring this care to walk into their consultation room.
The neuropsychiatric complications studied in patients who have had the coronavirus disease 19 (COVID-19) have recently highlighted the necessity for neurologists and psychiatrists to be competent in both disciplines.
Dual training would mean patients would no longer need to see their neurologist for their Parkinson’s disease and have a separate appointment with a psychiatrist for their associated depression.
This would allow for better continuity of care and a deeper doctor-patient rapport to be built, more efficient healthcare provision and resource management, and fewer appointments for patients to keep track of.
In medicine, we are spoiled for choice — sometimes both a blessing and a curse. For those interested in neurology and psychiatry, dual training eliminates the need to choose between them early in the specialty training stage. It would open the doors to three potential career paths: neurology; psychiatry; and neuropsychiatry.
Since ancient civilisation, neurology and psychiatry have been studied together, explored and attempted to be mastered as one unified discipline. To focus on one without the other is to only see half of the full picture.
Moving forward, we must have a greater appreciation of their shared organ system and strive to achieve a clearer vision of all that sits within the frames of neuropsychiatric disorders.
Special note from the editors: This is the seventh blog of our new series, The future of mental health as seen by the future leaders in mental health, written by the 2020 ‘Psych Stars.’ Selected by The Royal College of Psychiatrists, Psych Star ambassadors are a group of final year medical students awarded for their particular interest and commitment to psychiatry. During the year-long scheme as Psych Stars, students are nurtured in their interest in psychiatry through the assignment of mentors, by gaining access to learning resources and events, and by becoming part of a network of like-minded students. More information on the Psych Stars scheme can be read here. We have decided to invite each of the Psych Stars to write a blog on how they envision the future of mental health by choosing an area in which they are passionate. We have decided to run the series as a celebration of these student’s success and to provide an outlook for each of the awardees to share their passion. With a new blog published each Friday, the series will run over the next few months.
If you enjoyed today’s blog by Bibire, be sure to head over to check out the previous blogs in our Psych Star series covering topics such as compassion, the mind-body interaction, the future of child & adolescent psychiatry, gender inequality, global health, and male mental health.