Pippa Wysong

Editor’s Note: Jonathan Silver, MD, is Clinical Professor of Psychiatry at New York University School of Medicine, past president and fellow of the American Neuropsychiatry Association (ANPA), and certified in behavioral neurology and neuropsychiatry. Coauthor of Textbook of Traumatic Brain Injury, published by the American Psychiatric Association in 2004, his ongoing research involves studying neurobehavioral problems in traumatic brain injury. Currently Chair of the Examination Committee for the Behavioral Neurology and Neuropsychiatry accreditation program of the ANPA, Dr. Silver spoke with Medscape about neuropsychiatry as a subspecialty: What is it? Who practices it? How does it differ from the individual specialties of neurology and psychiatry? What is a superspecialty, as opposed to a subspecialty, and should neuropsychiatry be considered a superspecialty?

Medscape: Let’s start with the basics. Can you tell Medscape readers how you define neuropsychiatry?

Dr. Silver: Neuropsychiatry is a field that both explores brain behavior relationships and focuses on the assessment and treatment of patients who have neurologic disorders along with cognitive, emotional, and/or behavioral problems.

Medscape: Can you provide some examples?

Dr. Silver: Individuals with traumatic brain injury can have a multitude of physical symptoms and often may have cognitive, emotional, or behavioral problems as well. These can be as — or more — debilitating than the neurologic sequelae.

Medscape: Where did neuropsychiatry come from?

Dr. Silver: In Germany in the mid-1800s there were individuals who called themselves neuropsychiatrists. Back then, neurology and psychiatry were more or less one field, but neuropsychiatry was different from what is meant by it today. Around the early 1900s, psychiatry and neurology mostly divided territories into the emotional vs the physical.

Medscape: What about neuropsychiatry today?

Dr. Silver: Actually, there is some confusion in the field. I want to differentiate neuropsychiatry from biological psychiatry, because in some people’s minds they are the same thing — though there is some overlap. Plus, a lot of individuals and practitioners use the term “neuropsychiatry” as a way to say that they are biological psychiatrists. I outline some of this in an editorial I wrote for the Journal of Neuropsychiatry & Clinical Neurosciences.^[1]

Medscape: How is biological psychiatry defined?

Dr. Silver: Biological psychiatry involves examining the role of how the brain functions in the production of psychiatric disorders. It could be chemical (such as in depression), anatomical (such as in schizophrenia or brain trauma), or genetic.

Those things are important in neuropsychiatry too, but biological psychiatry does not focus on the treatment of those individuals with neurologic disorders. Neuropsychiatry does.

Medscape: There seems to be variation in the definition of neuropsychiatry. Can you walk through what some of those definitions are?

Dr. Silver: I can tell you some common ways that people use the term, as opposed to official definitions. An example is lawyers looking for neuropsychiatrists for certain kinds of legal cases. They might define neuropsychiatry as somebody who is certified in both neurology and psychiatry. While that is a neurologist and a psychiatrist, it is not a neuropsychiatrist. It ignores the fact that there is a specific body of knowledge and training that is necessary for the field of neuropsychiatry. You can take care of patients with stroke or patients with depression, but that does not mean that you have expertise taking care of the stroke patient who is depressed.

Medscape: So a true neuropsychiatrist is trained specifically in neuropsychiatry?

Dr. Silver: Correct.

Medscape: Another example?

Dr. Silver: The word neuropsychiatrist is sometimes mistakenly used to mean psychopharmacologist. Some departments of psychiatry are inappropriately called “neuropsychiatric” departments, though what they do is biologic treatments of psychiatric disorders. They do not have the expertise to treat neuropsychiatric sequelae of traumatic brain injury. Some people use the term neuropsychiatry as an attempt to market either themselves or their department as cutting-edge.

Medscape: Neuropsychiatry is now an accredited subspecialty. How did that come about?

Dr. Silver: First, the ANPA tried going through the American Board of Psychiatry and Neurology (ABPN), but they were not interested in considering any additional subspecialties. Then, in 2003, a new organization, the United Council for Neurological Subspecialties (UCNS), was formed by all of the major neurologic organizations. It was founded to establish accreditation and certification of individuals and training programs in neurologic subspecialties that were not yet large enough for the ABPN.

The UCNS has now approved 8 neurologic-related subspecialties. Ours was the first and is the behavioral neurology and neuropsychiatry subspecialty.^[2] We have developed guidelines for fellowship training, and UCNS has accredited 17 training programs throughout the country.

Medscape: Overall, how many people have been certified by the UCNS for neuropsychiatric subspecialties?

Dr. Silver: Approximately 150 individuals. UCNS is not going to administer the examination in 2009, and the last examination for individuals who have not completed a fellowship will be given in 2010. After 2010, in order to sit for the examination you have to complete an accredited fellowship. Some of the fellowships differ in emphasis, but no matter what a fellowship emphasizes, people have to be trained in a number of specific areas as well. You need to know about not only anatomy and how to interpret magnetic resonance images (MRIs), electroencephalograms (EEGs), and functional imaging, but you also need to know the role of medication in treating these disorders. You have to be board-certified in neurology or psychiatry and then [complete] the fellowship.

Medscape: Why would psychiatrists want to enter this area?

Dr. Silver: There is an ever-increasing number of people who would benefit from our expertise. For instance, there is the aging population with age-related cognitive problems, as well as increasing recognition of how common traumatic brain injury is.

Medscape: How good is the evidence for treatment in neuropsychiatry?

Dr. Silver: More research is needed. It is a maturing field.

Medscape: Some people say neuropsychiatry should be a superspecialty as opposed to a subspecialty. What does that mean?

Dr. Silver: Some individuals, such as Stuart Yudofsky [MD; D.C. and Irene Ellwood Professor and Chairman, The Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Chairman, Psychiatry Department, Methodist Hospital; Houston, Texas], propose that there should not be separate departments of psychiatry and neurology. They argue that there should be a department of neuropsychiatry, and that individuals who train in psychiatry and neurology should have identical first or second years of training. After that initial training, it is argued that they should then zero-in on areas of specialty. They say to study the brain first, then go on to do either sensory-motor problems or cognitive-emotional problems.

Medscape: What philosophical difference is there in the argument for neuropsychiatry as a super- vs a subspecialty?

Dr. Silver: There is a philosophy of “all psychiatry is neuropsychiatry,” which essentially means that “all psychiatry is biological psychiatry.” Obviously, the brain is involved in all psychiatry. But we know that environment, your upbringing, and genetics all affect your brain function. But that is different from the subspecialty of neuropsychiatry, which focuses on the treatment of a specific group of patients.

Medscape: It sounds like there are a lot of ways of looking at these issues in patients.

Dr. Silver: You can look at psychiatric problems though different lenses. You can have a neuropsychiatric approach to classic psychiatric disorders, just as you can have a psychoanalytic approach to psychiatric disorders. The neuropsychiatric approach to depression looks at the influence of different brain regions on depression and the effects of stimulation of different brain areas. You could look at neuropsychiatric techniques, but that does not mean that depression is a neuropsychiatric disorder.

Medscape: It appears that over time the definition of neuropsychiatry is becoming more focused and refined, especially now that there is an accredited program and certified specialists. Thank you for talking with Medscape readers about all of this.

References

1. Silver JS. Behavioral neurology and neuropsychiatry is a subspecialty. J Neuropsychiatry Clin Neurosci. 2006;18:146-148. Available at: neuro.psychiatryonline.org/cgi/content/full/18/2/146 Accessed April 29, 2009.
   
2. United Council for Neurologic Subspecialties (UCNS). Behavioral neurology and neuropsychiatry. Available at: www.ucns.org/go/subspecialty/behavioral Accessed April 29, 2009.