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NEUROPSYCHIATRY & BEHAVIORAL NEUROLOGY | HISTORICAL LANDMARKS OF USA | NEUROPSYCHOLOGY AND NEUROPSYCHIATRY |

Neuropsychiatry: the Interface Area of Psychiatry and Neurology

What is Neuropsychiatry and Behavioral Neurology?

Neuropsychiatry involves the interface area of psychiatry and neurology. This is a specialist medical discipline involving the behavioral or psychological difficulties associated with known or suspected neurological conditions such as epilepsy, head injury, attention deficit disorder, dementia, tardive dyskinesia, atypical spells, irritability and any organic mental disorder. Technically, Neuropsychiatry concentrates on the abnormalities in those areas of higher brain function such as the cerebral cortex and limbic system. Sometimes difficult to treat psychological or psychiatric conditions, including problems relating to medication. are related to these areas.

The subspecialty of neuropsychiatry is the "neurological aspects of psychiatry and the psychiatric aspects of neurology." All neuropsychiatric patients invariably have a psychiatric aspect as well as a higher brain neurological facet.

Neuropsychiatry, now used synonymously with Behavioral Neurology, is the medical subspecialty dealing with the evaluation and management of higher brain functions (cerebral cortex and limbic system).

Although Neuropsychiatry and Behavioral Neurology are regarded as the same specialty,  the primary initial specialty directions may be different. (Neuropsychiatrists may come to this specialty through psychiatry, Behavioral Neurologists through Neurology).  Because of the highly specialized nature of this specialty, there was technically no board certification in this area until late 2006. This changed when the  United Council for Neurologic Subspecialties (UCNS) introduced Subspecialty Certification of Behavioral Neurology and Neuropsychiatry. (BPNP). These two specialties by so doing merged into one. psychiatrists specialize in these behavioral facets as do behavioral neurologists whose discipline is similar. The term Neuropsychiatrist and Behavioral Neurologist should be restricted to those with psychiatric training and special background training in the psychopathology of the cerebral cortex.

A training in Neurology and in Psychiatry alone does not make one a neuropsychiatrist / behavioral neurologist.

One method of training today would be a full four year residency in one or both of Psychiatry or Neurology and then an added Fellowship program e.g. of two years.

Historical Landmarks in Neuropsychiatry in the USA

Dr Vernon M. Neppe MD, PhD, founded  the first Division of Neuropsychiatry in a Department of Psychiatry in the USA in 1986 (at the University of Washington (UW), Seattle, WA). He directed this division till 1992, offering also specialized medical student, residency and fellowship rotations in Neuropsychiatry. Dr Neppe was recruited from overseas (South Africa)  by the then Chairman of Psychiatry, Gary J. Tucker MD,   after a national search had failed. Dr Neppe had previously effectively done what may have been the first unofficial "Fellowship"  in Neuropsychiatry and Behavioral Neurology (1982-1983) at Cornell University Medical Center (White Plains, and Manhattan, NY).

Dr. Neppe  then founded the Pacific Neuropsychiatric Institute in 1992  (pni.org). This became the first private institute dealing with the area of Neuropsychiatry specifically. The PNI was developed as a model neuropsychiatric and behavioral neurological institute,  clinically involving extremely detailed sequential consultations and testing plus detailed analyses of psychopharmacogical elements. The PNI focuses, as well,  on research (with the development of numerous questionnaires and tests) and education. Amongst the most important for this subdiscipline are the BROCAS SCAN, the SOBIN and the INSET, which are tests that Dr Neppe has developed and modified over the past two decades and are still in the process of research. The BROCAS SCAN is an examination of higher brain function, the SOBIN and the INSET are structured closed ended and with amplification open ended historical measures of current and past symptoms and signs of neuropsychiatric relevance.

The American Neuropsychiatric Association was established in 1988. It is an organization of professionals in neuropsychiatry and clinical neurosciences (not necessarily MDs) dedicated to understanding the links between neuroscience and behavior, and to developing effective diagnosis and treatment for patients with neuropsychiatric disorders. The ANPA members work together in a collegial and interdisciplinary fashion to: advance knowledge of brain-behavior relations; provide a forum for learning; and promote excellent, scientific and compassionate patient care. The interdisciplinary nature of the membership encourages collaborations in research presentations, symposia, workshops and/or continuing education courses. The Journal of Neuropsychiatry and Clinical Neurosciences is the official publication of the organization, and is a benefit of membership. ANPA was the brainchild of two neuropsychiatrists, Barry Fogel, M.D., and Randolph B. Schiffer, M.D. 

An official sanctioning of the subspecialty of or special interest in  Neuropsychiatry in the early 1990s with the publication based on peer review of the book Best Doctors in America  {Woodward White publishers)  ·(e.g.  1st ed., 1992) This publication was later discontinued. However, another nationally peer reviewed publication, Castle Connolly's  Americas Top Doctors (annual editions since 2001) then became available.  However only a handful or two (depending on listing) of  Neuropsychiatrists per issue achieved such national prominence (Dr Neppe apparently has been the only one listed in all editions of both these books and also became the first physician dually listed under Neuropsychiatry and Behavioral Neurology [as well as Psychopharmacology and Forensic Psychiatry or later Neuropsychiatry}).  These publications gave further legitimacy to  Neuropsychiatry as a specialized subspecialty. However, Neuropsychiatry was variably classified  as involving special expertise within Psychiatry (e.g. Dr Neppe) or Neurology (e.g. Dr Cummings) and not necessarily therefore as a subspecialty.

There was an indirect label of Neuropsychiatrist previously through the AMA: In late 2003,  the AMA recognized Neuropsychiatry as an  official subspecialty of Psychiatry.  Apparently the first MD so listed was Dr Vernon Neppe.

Over the past few years we are seeing an increasing number of Fellowships in Neuropsychiatry/ Behavioral Neurology which the UCNS are certifying. An early Fellowship program was offered at the University of Washington in the Division of Neuropsychiatry.

In 2006, the People to People Ambassador program had the first delegation in Neuropsychiatry (and Psychopharmacology).
This was a very successful delegation to China. This delegation was led by Dr Vernon Neppe.

"Behavioral Neurology and Neuropsychiatry" (BN&NP) taken together is now a recognized official subspecialty certified by the United Council for Neurologic Subspecialties. (UCNS). The first examination was administered in Sept 2006.
This certification allows an official subspecialty board certification label. The criteria for admission to this examination are rather stringent and the examination  requires a high level of specialized knowledge.  The first graduating group of about fifty (including Dr Neppe) can use the official abbreviation for this subcertification, namely  BN&NP.  A major advance is this recognition of BN&NP as a subspecialty of Neurology.

The criteria for admission to this examination are rather stringent and the examination requires a high level of specialized knowledge.

The difference between Neuropsychiatrists and Neuropsychologists

Neuropsychiatrists also called Behavioral Neurologists
• are MDs: They are physicians, who are medically trained at medical schools and have thereafter specialized in an extremely complex area.
• are an unusual, highly educated medical subspecialty.
• their background is in psychiatry and neurology
• they specialize in pathology of the higher brain at the clinical neurological and psychiatric levels
• they are clinicians who focus on managing difficulties, assessing prognosis and prescribing medications
• usually perform specialized neuropsychiatric evaluations
• use detailed structured history taking questionnaires which are amplified clinically and also use tests that are standardized for a particular population and will commonly find areas of abnormality which may or may not be clinically relevant and also 
• neuropsychiatric evaluations involve assessments of higher cerebral cortical functions, integration of brain symptomatology such as temporal lobe phenomena, correlations with neurological and psychiatric diagnoses and appropriate prescriptions, and several clinically relevant neuropsychiatric tests.
• also rely on neuropsychological tests and such measures as ambulatory electroencephalography.
• neuropsychiatrists are often the "captains" of the treating team for neurological conditions with associated psychiatric disorders or psychiatric conditions with neurological disorders.
typical patients with neuropsychiatric conditions include patients who suffer from

• seizures with behavioral, emotional or thinking difficulties • traumatic head injuries with personality or other changes including post-traumatic stress disorders
• headaches or migraines with mood changes, depression or anxiety
• movement disorders such as tardive dyskinesia with associated medication or psychiatric elements
• brain injuries or disturbances
• temporal lobe disease


Neuropsychologists
• are not physicians.
• generally have PhDs in psychology.
• have subspecialized in the psychological assessment and management of higher brain function.
• cannot prescribe
• usually perform specialized neuropsychological evaluations such as personality, intelligence and specific brain disorder evaluations. 
• these tests are standardized and will commonly find areas of abnormality which may or may not be clinically relevant.

 


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