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Neuropsychiatry

The long historical relationship between neurology and psychiatry impacts the area of transient traumatic head injury. This neuropsychiatric link impacts both the actual brain injury facets as well as the psychological elements. Historically, physicians interested in the central nervous system focused either globally on behavior or more specifically on demonstrated pathology of the central nervous system reflecting such terms as "post-traumatic" and "post-concussional" in the brain injury context and interpretations of etiology that were polarized. Most practitioners in the area have had very little exposure, if any, to neuropsychiatry.

Three specialties have approached the area but from rather diverse origins and conceptual frameworks. Behavioral neurologists define brain behavior relationships often through the single case study with generalizations made about the anatomical basis of the manifested behavior and specific localization of similar types of behavior. Neuropsychiatrists emphasize the phenomenology of behavioral disorders and how these correlate with diseases in neurology and the neurologic aspects of behavioral disorders (Tucker and Neppe, 1988). In head injury, the psyche as well as the brain are both recognized as interplaying with each other. Finally, neuropsychologists employ standardized and objective assessments of intellectual, cognitive and psychological functioning, emphasizing a more actuarial and statistical methodology of evaluating behavior.

While each group appears to look at different aspects of the same animal, each has identified important areas of knowledge that are missing in traditional psychiatric, psychological and neurologic training. We will focus here primarily on the comparison of behavioral neurology and neuropsychiatry and make the case for a time-based neuropsychiatric approach applied to the head injury population.

In the context of head injury, exacerbation of pre-existing conditions commonly occurs. In this context, neuropsychiatrists recognize that marked behavior disturbance may correlate with paroxysmal discharges in the temporal lobe on the electroencephalogram (Tucker and Neppe, 1994). While these patients would not be considered to have a seizure disorder by most behavioral neurologists, many neuropsychiatrists believe these patients represent a form of seizure disorder which we for non-prejudicial reasons have called "Paroxysmal Neurobehavioral Disorder" (Blumer and Neppe, in press). We have characterized the individual events as "atypical spells" (Neppe and Tucker, 1992 and 1994; Tucker and Neppe, 1991). Many of these patients respond to anticonvulsant treatment. Similarly, a patient on neuroleptic medication who develops an atypical movement disorder with neuroleptic medication different biochemically or clinically from extrapyramidal reactions may still be labelled "tardive dyskinesia" with a recommendation that the medication be stopped by the Behavioral Neurologist; the Neuropsychiatrist may be prepared to recognize such atypicality and delineate movement disorders different from those of tardive dyskinesia.

There is a need to incorporate the neuropsychiatric approach to the often misunderstood population of patients with closed head injury (Tucker and Neppe, 1991). A gap exists in the evaluation and management of patients with closed head injury primarily because of the differences in approach between neurology and neuropsychiatry. The neuropsychiatric emphasis can be a practical and helpful adjunct to the primary health care providers (neurologists and neuropsychologists) who are primarily responsible for services provided to the closed head injury population. The purpose of this chapter is to discuss the neuropsychiatric approach and offer some clinical ideas to assist health care providers in providing a more comprehensive and thorough evaluation.

 

 


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