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.
