Knowledge of neuroanatomy also is useful and relevant if a psychiatrist wishes to understand and take advantage of the revolution in diagnostic imaging that has emerged over the past 50 years. During the vast stretch of human history, including while many of today’s senior psychiatrists were in training, the skull of a living person was a “black box” into which no one could see. Then, in the mid-1970s, computer technology applied to information from skull x-ray films made it possible to generate images of the brain itself (CT scans) for the first time. Following in succession came the development of MRI; positron emission tomography; single photon emission CT; functional MRI; imaging of amyloid deposits, tau, and other proteins; diffusion tensor imaging; and new approaches for capturing microglial activation that may provide a tool for gauging inflammation in the brain. These and other techniques serve not only to expand our diagnostic capabilities but also to open new avenues for research, including research into mental disorders.
Moreover, as the field of psychiatry evolves, biological interventions beyond ECT and psychopharmacology are becoming more widely used. Repetitive transcranial magnetic stimulation (rTMS), deep brain stimulation (DBS), and other neuromodulatory approaches to treatment are based on an understanding of neuroanatomy.
While a busy, practicing psychiatrist might opt to utilize neurology and neuropsychiatry consultants rather than expand his or her knowledge into the arena of clinical neuroscience and the relevant neuroanatomy, this knowledge is currently required of all newly graduating psychiatrists. In 2013, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Psychiatry and Neurology (ABPN) published The Psychiatry Milestone Project2 that established competency requirements to be utilized in psychiatry residency training programs. These programs must now evaluate a trainee’s competence in 22 defined domains. One of these is the “Clinical Neuroscience” domain, defined as including “knowledge of neurology, neuropsychiatry, neurodiagnostic testing, and relevant neuroscience and their application in clinical settings.”
Perhaps the best answer to the question of why a psychiatrist might want to learn neuroanatomy is that it helps with learning to think in a different way. Neuroanatomy provides an underlying matrix by which to organize our psychiatric observations and theories within a scientifically based framework.
Since the time of Paul Broca (1824-1880), an important goal of the neurological disciplines has been to map the relationship between behavior and brain. One might argue that understanding lesion localization for specific deficits such as Broca’s aphasia is not particularly relevant for a psychiatric practice given that psychiatrists tend to be most interested in more complex behavioral syndromes such as depression, autism spectrum disorder, or schizophrenia. On the other hand, the quest to localize has led to many unexpected insights into complex human behavior.
For instance, the neurological organization of language is relevant in thinking about the mental status features of many patients who might consult with a psychiatrist. Consider patients with autism spectrum disorder who are pedantic and literal; think of schizophrenic patients who are tangential or have loose associations, or who are hallucinating verbal material. Patients with learning disabilities or post-traumatic brain injuries may have trouble with a variety of different aspects of language and communication such as word retrieval or reading. An understanding of the neurological organization of language might be applied to these various disturbances, leading to insights that could be useful in formulating the patients’ difficulties.
Specifically, in the arena of language, we know that the word and grammar aspects of language are neurologically discrete from the “music” of verbal communication, called prosody. Prosody is a crucial aspect of social interaction. Prosody includes intonation, rhythm, pace, pitch, loudness, and so on; these elements communicate emotion (emotional prosody) as well as nuances of meaning (linguistic prosody). Irony, for instance, is conveyed principally through prosody. When you say something “in anger” or “with doubt” or “deceitfully,” the clues to these communications are largely prosodic.
Dr. Schildkrout is Assistant Professor of Psychiatry, Part-time, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA. She is the author of 2 books, Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders and Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems.
1. Cold Spring Harbor Laboratory. 3D Brain. 2016. https://itunes.apple.com/us/app/3d-brain/id331399332?mt=8. Accessed February 2, 2017.
2. The Accreditation Council for Graduate Medical Education, The American Board of Psychiatry and Neurology. The Psychiatry Milestone Project. July 2015. https://www.acgme.org/Portals/0/PDFs/Milestones/PsychiatryMilestones.pdf.
3. Schildkrout B. How to move beyond the Diagnostic and Statistical Manual of Mental Disorders/International Classification of Diseases. J Nerv Mental Dis. 2016;204:723-727.