Stuart C. Yudofsky, MD

The Special Report that starts on the next page highlights some of theimportant current issues in neuropsychiatry. The articles in this reportshould be of particular interest to clinical psychiatrists who treat patientswith psychiatric illnesses or symptoms associated with brain injury ordysfunction. The neuropsychiatric aspectsof several conditions are addressed in thearticles included in this section: Alzheimerdisease, traumatic brain injury (TBI), movementdisorders in sleep, and age-relatedcognitive impairment. In addition, electroencephalography(EEG) is discussed asan important tool that may assist cliniciansin diagnosing and treating behavioral disordersthat frequently accompany brain injuryand dementia. A few comments concerningeach of the articles included in thisspecial section follow.

Drs Boutros and Coburn provide anexcellent overview of the usefulness ofthe standard EEG (SEEG) and computeranalyzedquantified EEG (QEEG) in evaluatingselect neuropsychiatric disorders.The authors summarize 5 clinical indicationsfor use of SEEG and QEEG:acute or gradual mental status changes,unusual or atypical clinical presentations,recent personality changes, episodicaggressive behavior, and attention andlearning disorders.

Because many women may reportcognitive impairment during and aftermenopause, Drs Dumas and Newhouse andMs Salerno review a number of importantarticles that discuss whether estrogentherapy may maintain a woman's premenopausallevel of cognitive functioningand may reduce the risk of Alzheimer disease. The authors conclude that estrogenshould not routinely be used for either purpose but that more research needsto be conducted into the type of estrogen, method of administration, and timingof estrogen therapy relative to menopause for preserving cognition. They alsooutline a number of common and serious adverse effects of estrogen treatment.

Because people spend nearly a third of their lives asleep, an understandingof some of the neuropsychiatric disorders associated with sleep is important.Dr Sachdev provides a scholarly review of the various movement disorders that may occur during sleep. In some neuropsychiatric disorders, such as Parkinsondisease and Tourette syndrome, abnormal movements are present during theday but generally absent during sleep, whereas in other disorders, such as nocturnalepilepsy, parasomnias, restless legs syndrome, and periodic limb movementsof sleep, abnormal movements occur duringsleep but rarely during wakefulness. Theauthor also provides an informativesummary of the medications that may beused to treat restless legs syndrome,narcolepsy, and cataplexy.

With more than 2 million persons in theUnited States sustaining a TBI each year,the article by Dr Kim is especially relevantfor psychiatrists who will treat patientsfor various adverse sequelae of TBIs,including aggression, impulsivity, cognitivedeficits, and depression. Dr Kim alsooutlines the neurobiology of TBI anddefines mild TBI.

Drs Reichman and Shah summarize 4stages of Alzheimer disease progression-mild, moderate, severe, and terminal-andprovide a concise yet complete review ofthe medications available to treat cognitiveimpairment during disease progression.The dosages, risks, and benefits ofthe currently available cholinesteraseinhibitors-donepezil, rivastigmine, andgalantamine-and the 

-methyl D-aspartatereceptor antagonist memantine arediscussed in their article.

The 5 papers included in this SpecialReport section on neuropsychiatry providecompelling evidence for the renaissance ofneuropsychiatry as a clinical discipline. Wehave every reason to hope that this will leadto a better understanding of the complex interactions between brain and behaviorand will reduce the artificial distinction between neurology and psychiatry.

Dr Hales is Joe P. Tupin Professor and chair, department of psychiatry and behavioral sciences,University of California, Davis, School of Medicine. Dr Yudofsky is DC and Irene EllwoodProfessor and chairman, Menninger Department of Psychiatry and Behavioral Sciences, BaylorCollege of Medicine, Houston.

Special Report Chairpersons:    
  Robert E. Hales, MD, MBA  
Stuart C. Yudofsky, MD

Electroencephalography in Neuropsychiatry

The Role of Estrogen in the Development of Age-Related Cognitive Impairment and Dementia

Neuropsychiatric Dimensions of Movement Disorders in Sleep

Neuropsychiatric Aspects of Traumatic Brain Injury

Treating Cognition and Function in Patients With Alzheimer Disease

Articles

The 5 papers in this Special Report  on neuropsychiatry provide compelling evidence for the renaissance of neuropsychiatry as a clinical discipline. Wehave every reason to hope that this will lead to a better understanding of the complex interactions between brain and behavior and will reduce the artificial distinction between neurology and psychiatry.

Neuropsychiatry: A Renaissance

What is neuropsychiatry, and how does this field differ from the traditional specialties of neurology and psychiatry?

The best answer to these questions is that neuropsychiatry is a concept that has undergone continuous evolution over the past 150 years. Over these years the term has had widely disparate meanings--both to medical professionals and to the general public. During the first 75 years of the 20th century, critics of psychiatry contended that the field had become a "brainless profession" that had abandoned its roots in neurobiology and in evidence-based medicine, while neurologists had become less sensitive and prepared to treat the omnipresent psychosocial aspects of brain-based conditions under their purview (Martin, 2002; Sabshin, 1990; Yudofsky and Hales, 2002). During that era, many medical professionals and the general public considered neuropsychiatry to be almost synonymous with biological psychiatry. Fortunately, by the turn of the 21st century, research discoveries about the brain bases of many psychiatric conditions coupled with the revolutionary successes of somatic treatments for people with severe and persistent mental disorders helped return psychiatry to mainstream medicine.

Today, most regard neuropsychiatry as a subspecialty of psychiatry that focuses on caring for the behavioral, cognitive and emotional symptoms of patients who suffer from what are conventionally regarded as neurological disorders, such as Parkinson's disease, stroke, traumatic brain injury and multiple sclerosis. Neuropsychiatry also focuses on symptoms that "fall between the cracks" in the porous boundaries between neurology and psychiatry, such as dysfunctions of attention, alertness, perception, memory, cognition, language, intelligence and motivation. Nonetheless, fundamental to any conceptualization of neuropsychiatry is "the indelible inseparability of brain and thought, of mind and body, and of mental and physical" (Yudofsky and Hales, 1989).

In this special report, two excellent review articles, "Brain Imaging Data of ADHD" and "Utilization of MRS to Identify Neurochemical Abnormalities in Patients With Bipolar Disorder," document how advances in the functional imaging of the living brain are shedding new light on our understanding of the pathogenesis, pathophysiology and treatment of two prevalent and disabling psychiatric conditions in children and adults. A third review article, "Applications of Transcranial Magnetic Stimulation to Therapy in Psychiatry," is exemplary in examining how brain-technology interfaces hold promise for innovative treatments of a broad range of psychiatric illnesses. As a group, these three papers comprise representative samplings of the avalanche of opportunity brought about by contemporary basic and clinical neuroscience discovery in the more sensitive and valid diagnosis and effective treatment of people who suffer from mental illnesses.

The fourth article found in this section, "Educational Issues in Neuropsychiatry," seeks to answer the question "what is neuropsychiatry?" by reviewing how clinicians who currently define themselves as neuropsychiatrists or behavioral neurologists receive their training in these subspecialty areas. The article reviews the core curricula developed jointly by the American Neuropsychiatric Association and the Society for Behavioral and Cognitive Neurology, the two most prominent U.S. organizations representing neuropsychiatry and behavioral neurology, respectively, and concludes that the absence of a formal board certification process has restrained the growth and, by implication, the consensual definition of the two subspecialties.

Remarkably, on June 30, the United Council for Neurologic Subspecialties (UCNS), whose parent organizations are the American Academy of Neurology, American Neurological Association, Association of University Professors of Neurology, Child Neurology Society and Professors of Child Neurology, wrote to the presidents of the American Neuropsychiatric Association and the Society for Behavioral and Cognitive Neurology to inform them that their joint application for a neurological subspecialty area had been approved! Formal accreditation processes for fellowships and certification processes for neuropsychiatry and behavioral neurology will be established through the auspices of the UCNS. We believe that this is a major step in understanding and caring for the many patients with devastating symptoms and syndromes that fall through the arbitrary and confusing boundaries between neurology and psychiatry.

acknowledges Stuart C. Yudofsky, M.D., and Robert E. Hales, M.D., for their work in planning and reviewing this special report.

Dr. Yudofsky is D.C. and Irene Ellwood Professor and chairperson of the Menninger Department of Psychiatry and Behavioral Sciences at the Baylor College of Medicine.

Dr. Hales is Joe Tupin Professor and chairperson of the department of psychiatry and behavioral sciences at the University of California, Davis, School of Medicine.

 Martin JB (2002), The integration of neurology, psychiatry, and neuroscience in the 21st century. Am J Psychiatry 159(5):695-704.
 

 Sabshin M (1990), Turning points in twentieth-century American psychiatry. Am J Psychiatry 147(10):1267-1274.
 

 Yudofsky SC, Hales RE (1989), The reemergence of neuropsychiatry: definition and direction. J Neuropsychiatry Clin Neurosci 1(1):1-6.
 

 Yudofsky SC, Hales RE (2002), Neuropsychiatry and the future of psychiatry and neurology. Am J Psychiatry 159(8):1261-1264.

In their introduction to the neuropsychiatry special report, Drs. Yudofsky and Hales recapitulate the evolution of neuropsychiatry over the past 150 years, offering up an answer to the question: "What is neuropsychiatry and how does it differ from the traditional specialties of neurology and psychiatry?"

Stuart C. Yudofsky, MD

Articles

Neuropsychiatry: A Renaissance

The Indelible Inseparability of Brain and Thought, of Mind and Body