It wasn’t until the mid-1970s and into the 1980s that emotional prosody was mapped to the right hemisphere, including regions for prosodic expression and prosodic comprehension, mirroring the left hemisphere organization long known as Broca’s area and Wernicke’s. Patients who have autistic spectrum disorder or right hemisphere learning disabilities may have trouble with understanding prosody. Patients with schizophrenia have deficits in expression of prosody. Language functions are also involved in hallucinatory experiences, whether experienced by the patient as “inner speech” or as coming from “outside.”
But, these are just the beginning outlines of the complex neurological underpinnings of language. For example, frontal lobe executive functions are crucial in organizing a narrative, sticking to the point, keeping the goal of the conversation in mind, and in monitoring whether the listener is “getting it.” Also involved in effective discourse are neurological systems that subserve empathy, that appraise and adjust to social circumstances, and that can comprehend another person’s inner experience and point of view.
Thinking about the difficulties a patient might have (with verbal communication or in other domains of behavior) in the context of a neuroanatomical scaffolding would be an important theoretical shift for psychiatry. The quest to localize has had far-reaching consequences, including providing insights into the underlying neurological parsing of complex behaviors that can lead us to think in a more scientific way about clinical phenomena. As psychiatrists, it makes sense to explore new ways to organize our clinical observations now that we are aware that DMS diagnostic categories are not homogenous and are not etiologically based.3 While “thinking in DSM” may still guide our clinical interventions, it is now possible, given what we have learned about the brain, to think about neuropsychiatric signs and symptoms in a way that is more neurologically sound. Conceptualizing observations of patients’ deficits into categories that are known to have particular neuroanatomical bases is an important goal and can contribute to an ongoing expansion of our understanding of biological contributions to mental disorders.
In order to do this, a psychiatrist does not need to master neuroanatomy or to learn neuroanatomy first. Learning this material can be an iterative process in which one starts with learning the insights neuroscience has discovered about memory, language, social cognition, executive functioning, attention, and so on. Then, hopefully spurred on by fascination, you might find that you want to look up the relevant neuroanatomy. Motivation, clinical relevance, narrative meaning—these mark the road to making neuroanatomy memorable.
In synergy with the genetic and technology revolutions, today there is arguably no more exciting area of exploration in all of medicine than neuroscience. As psychiatrists, we are experts in mind and meaning, deeply familiar with varieties of psychopathology and the breadth of human experience. Psychiatrists are standing at the doorway to the exciting world of the brain. Yet, for some practitioners, neuroanatomy is blocking them from getting through.
MORE ABOUT Barbara Schildkrout, MD
The physicist Steven Weinberg said, “. . . when I want to learn about something, I volunteer to teach a course on the subject.” For me, writing is a way to learn. My first project was to write about medical conditions that can masquerade as psychiatric DSM diagnoses. That led me to want to understand more about the complex process by which doctors make a diagnosis. Also, I had found that there was an active, scientific reconceptualization of many neurological diseases taking place, and I wanted to follow developments in this area.
The brain during life was no longer a black box. I began to use writing as a process by which to integrate new findings from the world of neuroscience into my psychiatric thinking. How does any particular discovery affect my long-held theoretical notions? What questions are raised by this new information? What are the implications of this new idea for my work with patients? While many readers might imagine that writing is a lonely endeavor, I find it more akin to an intense and engaging conversation about fascinating ideas.
I count myself lucky to have found a steady source of grist for my writing mill in the weekly clinical rounds of the Cognitive Neurology Unit (CNU) at Beth Israel Deaconess Medical Center in Boston. In parallel with the world of psychiatry, the field of behavioral neurology also has been grappling with how to conceptualize behavioral disturbances. Technological innovations in neuroscience have fueled research and led to new paradigms for understanding the brain and mental disease. I am grateful to have found academic settings and professional organizations such as the American Neuropsychiatric Association (ANPA) and the Group for Advancement of Psychiatry (GAP) that foster engagement with colleagues who share my curiosity and my excitement about these emerging concepts.
As a clinician, I find that intellectual stimulation helps me to bring new ideas and renewed energy to my work with patients. I turn to writing as a way to wrestle with scientific discoveries, to bring clarity to my thinking and, finally, to share my ideas with others.
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.