Tag: Behavioural Neurology

An Overview of Neurology

Published on by Andrew Marshall2 Comments

Introduction

Neurology (from Greek: νεῦρον (neûron), “string, nerve” and the suffix -logia, “study of”) is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the nervous system, which comprises the brain, the spinal cord and the peripheral nerves. Neurological practice relies heavily on the field of neuroscience, the scientific study of the nervous system.

A neurologist is a physician specialising in neurology and trained to investigate, diagnose and treat neurological disorders. Neurologists diagnose and treat myriad neurologic conditions, including stroke, epilepsy, movement disorders such as Parkinson’s disease, brain infections, autoimmune neurologic disorders such as multiple sclerosis, sleep disorders, brain injury, headache disorders like migraine, tumours of the brain and dementias such as Alzheimer’s disease. Neurologists may also have roles in clinical research, clinical trials, and basic or translational research. Neurology is a nonsurgical specialty, its corresponding surgical specialty is neurosurgery.

Refer to neurohospitalist.

Brief History

The academic discipline began between the 15th and 16th centuries with the work and research of many neurologists such as Thomas Willis, Robert Whytt, Matthew Baillie, Charles Bell, Moritz Heinrich Romberg, Duchenne de Boulogne, William A. Hammond, Jean-Martin Charcot, C. Miller Fisher and John Hughlings Jackson. Neo-Latin neurologia appeared in various texts from 1610 denoting an anatomical focus on the nerves (variably understood as vessels), and was most notably used by Willis, who preferred Greek νευρολογία.

Training

In the United States and Canada, neurologists are physicians who have completed a postgraduate training period known as residency specialising in neurology after graduation from medical school. This additional training period typically lasts four years, with the first year devoted to training in internal medicine. On average, neurologists complete a total of eight to ten years of training. This includes four years of medical school, four years of residency and an optional one to two years of fellowship.

While neurologists may treat general neurologic conditions, some neurologists go on to receive additional training focusing on a particular subspecialty in the field of neurology. These training programs are called fellowships, and are one to two years in duration. Subspecialties in the United States include brain injury medicine, clinical neurophysiology, epilepsy, neurodevelopmental disabilities, neuromuscular medicine, pain medicine, sleep medicine, neurocritical care, vascular neurology (stroke), behavioural neurology, child neurology, headache, neuroimmunology and infectious disease, movement disorders, neuroimaging, neurooncology, and neurorehabilitation.

In Germany, a compulsory year of psychiatry must be done to complete a residency of neurology.

In the United Kingdom and Ireland, neurology is a subspecialty of general (internal) medicine. After five years of medical school and two years as a Foundation Trainee, an aspiring neurologist must pass the examination for Membership of the Royal College of Physicians (or the Irish equivalent) and complete two years of core medical training before entering specialist training in neurology. Up to the 1960s, some intending to become neurologists would also spend two years working in psychiatric units before obtaining a diploma in psychological medicine. However, that was uncommon and, now that the MRCPsych takes three years to obtain, would no longer be practical. A period of research is essential, and obtaining a higher degree aids career progression. Many found it was eased after an attachment to the Institute of Neurology at Queen Square, London. Some neurologists enter the field of rehabilitation medicine (known as physiatry in the US) to specialise in neurological rehabilitation, which may include stroke medicine, as well as traumatic brain injuries.

Physical Examination

During a neurological examination, the neurologist reviews the patient’s health history with special attention to the patient’s neurologic complaints. The patient then takes a neurological exam. Typically, the exam tests mental status, function of the cranial nerves (including vision), strength, coordination, reflexes, sensation and gait. This information helps the neurologist determine whether the problem exists in the nervous system and the clinical localization. Localisation of the pathology is the key process by which neurologists develop their differential diagnosis. Further tests may be needed to confirm a diagnosis and ultimately guide therapy and appropriate management. Useful adjunct imaging studies in neurology include CT scanning and MRI. Other tests used to assess muscle and nerve function include nerve conduction studies and electromyography.

Clinical Tasks

Neurologists examine patients who are referred to them by other physicians in both the inpatient and outpatient settings. Neurologists begin their interactions with patients by taking a comprehensive medical history, and then performing a physical examination focusing on evaluating the nervous system. Components of the neurological examination include assessment of the patient’s cognitive function, cranial nerves, motor strength, sensation, reflexes, coordination, and gait.

In some instances, neurologists may order additional diagnostic tests as part of the evaluation. Commonly employed tests in neurology include imaging studies such as computed axial tomography (CAT) scans, magnetic resonance imaging (MRI), and ultrasound of major blood vessels of the head and neck. Neurophysiologic studies, including electroencephalography (EEG), needle electromyography (EMG), nerve conduction studies (NCSs) and evoked potentials are also commonly ordered. Neurologists frequently perform lumbar punctures to assess characteristics of a patient’s cerebrospinal fluid. Advances in genetic testing have made genetic testing an important tool in the classification of inherited neuromuscular disease and diagnosis of many other neurogenetic diseases. The role of genetic influences on the development of acquired neurologic diseases is an active area of research.

Some of the commonly encountered conditions treated by neurologists include headaches, radiculopathy, neuropathy, stroke, dementia, seizures and epilepsy, Alzheimer’s disease, attention deficit/hyperactivity disorder, Parkinson’s disease, Tourette’s syndrome, multiple sclerosis, head trauma, sleep disorders, neuromuscular diseases, and various infections and tumours of the nervous system. Neurologists are also asked to evaluate unresponsive patients on life support to confirm brain death.

Treatment options vary depending on the neurological problem. They can include referring the patient to a physiotherapist, prescribing medications, or recommending a surgical procedure.

Some neurologists specialise in certain parts of the nervous system or in specific procedures. For example, clinical neurophysiologists specialise in the use of EEG and intraoperative monitoring to diagnose certain neurological disorders. Other neurologists specialise in the use of electrodiagnostic medicine studies – needle EMG and NCSs. In the US, physicians do not typically specialize in all the aspects of clinical neurophysiology – i.e. sleep, EEG, EMG, and NCSs. The American Board of Clinical Neurophysiology certifies US physicians in general clinical neurophysiology, epilepsy, and intraoperative monitoring. The American Board of Electrodiagnostic Medicine certifies US physicians in electrodiagnostic medicine and certifies technologists in nerve-conduction studies. Sleep medicine is a subspecialty field in the US under several medical specialties including anaesthesiology, internal medicine, family medicine, and neurology. Neurosurgery is a distinct specialty that involves a different training path and emphasizes the surgical treatment of neurological disorders.

Also, many nonmedical doctors, those with doctoral degrees (usually PhDs) in subjects such as biology and chemistry, study and research the nervous system. Working in laboratories in universities, hospitals, and private companies, these neuroscientists perform clinical and laboratory experiments and tests to learn more about the nervous system and find cures or new treatments for diseases and disorders.

A great deal of overlap occurs between neuroscience and neurology. Many neurologists work in academic training hospitals, where they conduct research as neuroscientists in addition to treating patients and teaching neurology to medical students.

General Caseload

Neurologists are responsible for the diagnosis, treatment, and management of all the conditions mentioned above. When surgical or endovascular intervention is required, the neurologist may refer the patient to a neurosurgeon or an interventional neuroradiologist. In some countries, additional legal responsibilities of a neurologist may include making a finding of brain death when it is suspected that a patient has died. Neurologists frequently care for people with hereditary (genetic) diseases when the major manifestations are neurological, as is frequently the case. Lumbar punctures are frequently performed by neurologists. Some neurologists may develop an interest in particular subfields, such as stroke, dementia, movement disorders, neurointensive care, headaches, epilepsy, sleep disorders, chronic pain management, multiple sclerosis, or neuromuscular diseases.

Overlapping Areas

Some overlap also occurs with other specialties, varying from country to country and even within a local geographic area. Acute head trauma is most often treated by neurosurgeons, whereas sequelae of head trauma may be treated by neurologists or specialists in rehabilitation medicine. Although stroke cases have been traditionally managed by internal medicine or hospitalists, the emergence of vascular neurology and interventional neuroradiology has created a demand for stroke specialists. The establishment of Joint Commission-certified stroke centres has increased the role of neurologists in stroke care in many primary, as well as tertiary, hospitals. Some cases of nervous system infectious diseases are treated by infectious disease specialists. Most cases of headache are diagnosed and treated primarily by general practitioners, at least the less severe cases. Likewise, most cases of sciatica are treated by general practitioners, though they may be referred to neurologists or surgeons (neurosurgeons or orthopaedic surgeons). Sleep disorders are also treated by pulmonologists and psychiatrists. Cerebral palsy is initially treated by paediatricians, but care may be transferred to an adult neurologist after the patient reaches a certain age. Physical medicine and rehabilitation physicians may treat patients with neuromuscular diseases with electrodiagnostic studies (needle EMG and nerve-conduction studies) and other diagnostic tools. In the United Kingdom and other countries, many of the conditions encountered by older patients such as movement disorders, including Parkinson’s disease, stroke, dementia, or gait disorders, are managed predominantly by specialists in geriatric medicine.

Clinical neuropsychologists are often called upon to evaluate brain-behaviour relationships for the purpose of assisting with differential diagnosis, planning rehabilitation strategies, documenting cognitive strengths and weaknesses, and measuring change over time (e.g. for identifying abnormal ageing or tracking the progression of a dementia).

Relationship to Clinical Neurophysiology

In some countries such as the United States and Germany, neurologists may subspecialise in clinical neurophysiology, the field responsible for EEG and intraoperative monitoring, or in electrodiagnostic medicine nerve conduction studies, EMG, and evoked potentials. In other countries, this is an autonomous specialty (e.g. UK, Sweden, Spain).

Overlap with Psychiatry

Refer to neuropsychiatry.

In the past, prior to the advent of more advanced diagnostic techniques such as MRI some neurologists have considered psychiatry and neurology to overlap. Although mental illnesses are believed by many to be neurological disorders affecting the central nervous system, traditionally they are classified separately, and treated by psychiatrists. In a 2002 review article in the American Journal of Psychiatry, Professor Joseph B. Martin, Dean of Harvard Medical School and a neurologist by training, wrote:

“the separation of the two categories is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway”.

Neurological disorders often have psychiatric manifestations, such as post-stroke depression, depression and dementia associated with Parkinson’s disease, mood and cognitive dysfunctions in Alzheimer’s disease, and Huntington disease, to name a few. Hence, the sharp distinction between neurology and psychiatry is not always on a biological basis. The dominance of psychoanalytic theory in the first three-quarters of the 20th century has since then been largely replaced by a focus on pharmacology. Despite the shift to a medical model, brain science has not advanced to a point where scientists or clinicians can point to readily discernible pathological lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder.

Neurological Enhancement

The emerging field of neurological enhancement highlights the potential of therapies to improve such things as workplace efficacy, attention in school, and overall happiness in personal lives. However, this field has also given rise to questions about neuroethics.

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What is Behavioural Neurology?

Published on by Andrew MarshallLeave a comment

Introduction

Behavioural neurology is a subspecialty of neurology that studies the impact of neurological damage and disease upon behaviour, memory, and cognition, and the treatment thereof.

Refer to Behavioural Neuroscience.

Background

Two fields associated with behavioural neurology are neuropsychiatry and neuropsychology. In the United States, ‘Behavioural Neurology & Neuropsychiatry’ has been recognised as a single subspecialty by the United Council for Neurologic Subspecialties (UCNS) since 2004.

Symptoms

Syndromes and diseases commonly studied by behavioural neurology include:

  • Agraphia.
  • Agnosias.
  • Agraphesthesia.
  • Alexia (acquired dyslexia).
  • Amnesias.
  • Anosognosia.
  • Aphasias.
  • Apraxias.
  • Aprosodias.
  • Attention deficit hyperactivity disorder (ADHD).
  • Autism.
  • Dementia.
  • Dyslexia.
  • Epilepsy.
  • Hemispatial Neglect.
  • Psychosis.
  • Stroke.
  • Traumatic brain injury.

Brief History

While descriptions of behavioural syndromes go back to the ancient Greeks and Egyptians, it was during the 19th century that behavioural neurology began to arise, first with the primitive localisation theories of Franz Gall, followed in the mid 19th century by the first localisations in aphasias by Paul Broca and then Carl Wernicke. Localisationist neurology and clinical descriptions reached a peak in the late 19th and early 20th century, with work extending into the clinical descriptions of dementias by Alois Alzheimer and Arnold Pick. The work of Karl Lashley in rats for a time in the early to mid 20th century put a damper on localisation theory and lesion models of behavioural function.

In the United States, the work of Norman Geschwind led to a renaissance of behavioural neurology. He is famous for his work on disconnection syndromes, aphasia, and behavioural syndromes of limbic epilepsy, also called Geschwind syndrome. Having trained generations of behavioural neurologists (e.g. Antonio Damasio), Geschwind is considered the father of behavioural neurology.

The advent of in vivo neuroimaging starting in the 1980s led to a further strengthening of interest in the cognitive neurosciences and provided a tool that allowed for lesion, structural, and functional correlations with behavioural dysfunction in living people.

What is Neuropsychiatry?

Published on by Andrew Marshall8 Comments

Introduction

Neuropsychiatry or Organic Psychiatry is a branch of medicine that deals with mental disorders attributable to diseases of the nervous system.

It preceded the current disciplines of psychiatry and neurology, which had common training, however, psychiatry and neurology have subsequently split apart and are typically practiced separately. Nevertheless, neuropsychiatry has become a growing subspecialty of psychiatry and it is also closely related to the fields of neuropsychology and behavioural neurology.

The Case for the Rapprochement of Neurology and Psychiatry

Given the considerable overlap between these subspecialities, there has been a resurgence of interest and debate relating to neuropsychiatry in academia over the last decade. Most of this work argues for a rapprochement of neurology and psychiatry, forming a specialty above and beyond a subspecialty of psychiatry. For example, Professor Joseph B. Martin, former Dean of Harvard Medical School and a neurologist by training, has summarized the argument for reunion: “the separation of the two categories is arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain and mind are one makes the separation artificial anyway.” These points and some of the other major arguments are detailed below.

Mind/brain Monism

Neurologists have focused objectively on organic nervous system pathology, especially of the brain, whereas psychiatrists have laid claim to illnesses of the mind. This antipodal distinction between brain and mind as two different entities has characterised many of the differences between the two specialties. However, it has been argued that this division is fictional; evidence from the last century of research has shown that our mental life has its roots in the brain. Brain and mind have been argued not to be discrete entities but just different ways of looking at the same system (Marr, 1982). It has been argued that embracing this mind/brain monism may be useful for several reasons. First, rejecting dualism implies that all mentation is biological, which provides a common research framework in which understanding and treatment of mental disorders can be advanced. Second, it mitigates widespread confusion about the legitimacy of mental illness by suggesting that all disorders should have a footprint in the brain.

In sum, a reason for the division between psychiatry and neurology was the distinction between mind or first-person experience and the brain. That this difference is taken to be artificial by proponents of mind/brain monism supports a merge between these specialties.

Causal Pluralism

One of the reasons for the divide is that neurology traditionally looks at the causes of disorders from an “inside-the-skin” perspective (neuropathology, genetics) whereas psychiatry looks at “outside-the-skin” causation (personal, interpersonal, cultural). This dichotomy is argued not to be instructive and authors have argued that it is better conceptualized as two ends of a causal continuum. The benefits of this position are: firstly, understanding of aetiology will be enriched, in particular between brain and environment. One example is eating disorders, which have been found to have some neuropathology (Uher and Treasure, 2005) but also show increased incidence in rural Fijian school girls after exposure to television (Becker, 2004). Another example is schizophrenia, the risk for which may be considerably reduced in a healthy family environment (Tienari et al., 2004).

It is also argued that this augmented understanding of aetiology will lead to better remediation and rehabilitation strategies through an understanding of the different levels in the causal process where one can intervene. It may be that non-organic interventions, like cognitive behavioural therapy (CBT), better attenuate disorders alone or in conjunction with drugs. Linden’s (2006) demonstration of how psychotherapy has neurobiological commonalities with pharmacotherapy is a pertinent example of this and is encouraging from a patient perspective as the potentiality for pernicious side effects is decreased while self-efficacy is increased.

In sum, the argument is that an understanding of the mental disorders must not only have a specific knowledge of brain constituents and genetics (inside-the-skin) but also the context (outside-the-skin) in which these parts operate (Koch and Laurent, 1999). Only by joining neurology and psychiatry, it is argued, can this nexus be used to reduce human suffering.

Organic Basis

To further sketch psychiatry’s history shows a departure from structural neuropathology, relying more upon ideology (Sabshin, 1990). A good example of this is Tourette syndrome, which Ferenczi (1921), although never having seen a patient with Tourette syndrome, suggested was the symbolic expression of masturbation caused by sexual repression. However, starting with the efficacy of neuroleptic drugs in attenuating symptoms (Shapiro, Shapiro and Wayne, 1973) the syndrome has gained pathophysiological support (e.g. Singer, 1997) and is hypothesized to have a genetic basis too, based on its high inheritability (Robertson, 2000). This trend can be seen for many hitherto traditionally psychiatric disorders (see table) and is argued to support reuniting neurology and psychiatry because both are dealing with disorders of the same system.

Table: Linking Traditional Psychiatric Symptoms or Disorders to Brain Structures and Genetic Abnormalities.

Psychiatric SymptomsPsychodynamic ExplanationNeural CorrelatesSource
DepressionAnger turned inwardLimbic-cortical dysregulation, monoamine imbalanceMayberg (1997)
Bipolar Disorder (Mania)NarcissisticPrefrontal cortex and hippocampus, anterior cingulate, amygdalaBarrett et al. (2003), Vawter, Freed, & Kleinman (2000)
SchizophreniaNarcissistic/escapismNMDA receptor activation in the human prefrontal cortexRoss et al. (2006)
Visual HallucinationProjection, cold distant mother causing a weak egoRetinogeniculocalcarine tract, ascending brainstem modulatory structuresMocellin, Walterfang, Velakoulis, (2006)
Auditory HallucinationProjection, cold distant mother causing a weak egoFrontotemporal functional connectivityShergill et al., 2000
Obsessive Compulsive DisorderHarsh parenting leading to love-hate conflictFrontal-subcortical circuitry, right caudate activitySaxena et al. (1998), Gamazo-Garran, Soutullo and Ortuno (2002)
Eating DisorderAttempted control of internal anxietyAtypical serotonin system, right frontal and temporal lobe dysfunction, changes to mesolimbic dopamine pathwaysKaye et al. (2005), Uher and Treasure (2005), Olsen (2011), Slochower (1987)

This table is in not exhaustive but provides some neurological bases to psychiatric symptoms.

Improved Patient Care

Further, it is argued that this nexus will allow a more refined nosology of mental illness to emerge thus helping to improve remediation and rehabilitation strategies beyond current ones that lump together ranges of symptoms. However, it cuts both ways: traditionally neurological disorders, like Parkinson’s disease, are being recognized for their high incidence of traditionally psychiatric symptoms, like psychosis and depression (Lerner and Whitehouse, 2002). These symptoms, which are largely ignored in neurology, can be addressed by neuropsychiatry and lead to improved patient care. In sum, it is argued that patients from both traditional psychiatry and neurology departments will see their care improved following a reuniting of the specialties.

Better Management Model

Schiffer et al. (2004) argue that there are good management and financial reasons for rapprochement.

US Institutions

Behavioural Neurology & Neuropsychiatry fellowships are accredited by the United Council for Neurologic Subspecialties (UCNS; http://www.ucns.org), in a manner analogous to the accreditation of psychiatry and neurology residencies in the United States by the American Board of Psychiatry and Neurology (ABPN).

The American Neuropsychiatric Association (ANPA) was established in 1988 and is the American medical subspecialty society for neuropsychiatrists. ANPA holds an annual meeting and offers other forums for education and professional networking amongst subspecialists in behavioural neurology & neuropsychiatry as well as clinicians, scientists, and educators in related fields. American Psychiatric Publishing, Inc. publishes the peer-reviewed Journal of Neuropsychiatry and Clinical Neurosciences, which is the official journal of ANPA.

International Organisations

The International Neuropsychiatric Association was established in 1996. INA holds congresses biennially in countries around the world and partners with regional neuropsychiatric associations around the world to support regional neuropsychiatric conferences and to facilitate the development of neuropsychiatry in the countries/regions where those conferences are held.

The British NeuroPsychiatry Association (BNPA) was founded in 1987 and is the leading academic and professional body for medical practitioners and professionals allied to medicine in the UK working at the interface of the clinical and cognitive neurosciences and psychiatry.

Recently, a new non-profit professional society named Neuropsychiatric Forum (NPF) was founded. NPF aims to support effective communication and interdisciplinary collaboration, develop education schemes and research projects, organise neuropsychiatric conferences and seminars.