Clinical Neuroscience and Training of Future Psychiatrists Collection of Articles Published in the Editorial Board

Editor in Chief T.P. George, University of Toronto, Toronto, Ontario, Canada M. Keshavan, Beth Israel Deaconess Medical Center and Harvard Medical S. Grover, Postgraduate Inst. of Medical Education & Research, School, Boston, MA, USA Chandigarh, India Coordinating Editor D.V. Jeste, University of California at San Diego (UCSD), La Jolla, California, USA G. Venkatasubramanian H. Jürgen-Möller, Ludwig Maximilian Universität München, Munich, Deputy Editors Germany V. Eapen, University of New South Wales, Liverpool Hospital, NSW, Australia H. Li, Florida Agricultural and Mechanical University, Tallahassee, Florida, B.N. Gangadhar USA R. Tandon, University of Florida, Dept. of Psychiatry, Gainesville, FL, USA M. Maj, Università di Napoli, Largo Madonna delle Grazie, Naples, Italy H.A. Nasrallah, Saint Louis University School of Medicine, St. Louis, Asian Pearls Editors Missouri, USA S. Tan M. Navasimhan, University of South Carolina School of Medicine, M. Mizuno Columbia, South Carolina, USA T.A. Okasha G.N. Pandey, University of Illinois at Chicago, Chicago, Illinois, USA East Asia U. Rao, University of Texas Southwestern Medical Center, Dallas, Texas, USA J.S. Kwon, Seoul National University (SNU), Seoul, South Korea A.V. Ravindran, University of Toronto, Toronto, Ontario, Canada West Asia P. Ruiz, University of Texas, Houston, TX, USA Z. Kronfol, Weill Medical College of Cornell University, Manhattan, N. Sartorius, Université de Genève, Geneva, Switzerland New York, USA L. Seidman M. Takeda, Osaka University Medical School, Osaka, Japan South East Asia J. Thirthalli, National Institute of Mental Health and Neuroscience S.A. Chong, Institute of Mental Health, Singapore, Singapore (NIMHANS), Bengaluru, Karnataka State, India South Asia P. Tyrer, Imperial Coll Sci, Tech & Med, London, England, UK A. Avasthi, Post Graduate Institute of Medical Education and Research, P. Udomratn, Prince of Songkla University, Songkhla, Thailand Chandigarh, India M. Warrier, Elite Mission Hospital, Thrissur, India Central Asia L.N. Yatham, University of British Columbia, Vancouver, British Columbia, P. Morozov, Russian Federation Canada Language Editor Advisory Board K. Rosengarth, USA H.S. Akiskal, University of California at San Diego (UCSD), La Jolla, California, USA Early Career Psychiatrists Corner Assistant Editor W.T. Carpenter Jr., University of Maryland School of Medicine, J. Torous Baltimore, Maryland, USA Honorary Consulting Editor R. Ganguli, University of Toronto, Toronto, Ontario, Canada R.F. D’Souza, Totem International Institute, Port Melbourne, S. Kanba, Kyushu University, Fukuoka, Japan Victoria, Australia S. Kapur, University of Oslo, Oslo, Norway V. Patel, London School of Hygiene and Tropical Medicine, Editorial Board London, England, UK R. Belmaker, Ben Gurion University of the Negev, Beersheva, Israel M.T. Tsuang, University California San Diego, La Jolla, California, USA D. Bhugra, King’s College London, London, England, UK G. Valliant, Massachusetts General Hospital, Charlestown, Massachusetts, K.N.R. Chengappa, University of Pittsburgh School of Medicine, Western USA Psychiatric Institute and Clinic (WPIC), Pittsburgh, PA, USA J Wang, Shanghai Jiao Tong University, Mental Health Center, M.P. Deva, Suri Seri Begawan Hospital, Kuala Belait, Brunei Darussalam Shanghai, China H. El Kholy, Ain Shams University, Cairo, Egypt A. Weizman, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel Table of contents

Introduction from the Editors: Clinical Neuroscience and Translational Psychiatry Rajiv Tandon, Dawn Bruijnzeel...... 4

All papers were originally published in Asian Journal of Psychiatry, Volume 17 (October 2015)

Editorial: Is psychiatry in need of a course correction Matcheri S. Keshavan, Urvakhsh M. Mehta...... 5

A proposed solution to integrating cognitive-affective neuroscience and neuropsychiatry in psychiatry residency training:T he time is now John Torous, Adam P. Stern, Jaya L. Padmanabhan, Matcheri S. Keshavan, David L. Perez...... 7

Integrating neuroscience into psychiatric residency training Thomas R. Insel...... 13

Psychiatry is a clinical neuroscience, but how do we move the field? Rajiv Tandon, Babu Rankupalli, Uma Suryadevara, Joseph Thornton...... 15

Bringing neuroscience to teaching rounds: Refreshing our clinical pidgin Vinod Hiremagalur Srihari...... 19

Bridging the brain–mind divide in psychiatric education: The neuro-bio-psycho-social formulation David A. Silbersweig...... 21

Remembering psychiatry’s core strengths while incorporating neuroscience Oliver Freudenreich, Nicholas Kontos, John Querques...... 23

‘‘The time is now’’: Integrating neuroscience into psychiatry training David A. Ross, Melissa R. Arbuckle, Michael J. Travis...... 25

Facing our future Bruce H. Price...... 27

The importance of teaching neuroscience to psychiatric residents in the context of psychological formulations Carl Salzman...... 29

The relevance of translational neuroscience in psychiatry residency training Commentary on ‘‘Torous et al. A proposed solution to integrating cognitive–affective neuroscience and neuropsychiatry in psychiatry residency training: The time is now’’ Sri Mahavir Agarwal, Ganesan Venkatasubramanian...... 31

Toward the era of transformational neuropsychiatry Henry A. Nasrallah...... 33

Neuropsychiatry: More than the sum of its parts? John Moriarty, Anthony S. David...... 35 Asian Journal of Psychiatry Clinical Neuroscience and Translational Psychiatry

Rajiv Tandon, MD, and Dawn Bruijnzeel, MD Psychiatry Service, North Florida/South Georgia Veterans Healthcare System, Department of Psychiatry, University of Florida College of Medicine, 1149 Newell Drive, L4-100, Gainesville, FL 32611, USA [email protected] • [email protected] The field of psychiatry is at a crossroads with the crucial decision pertaining to the approach to translational psychiatry that we must choose. Our failure to make revolutionary advances in our understanding and treatment of major psychiatric disorders over the past several decades has led to calls to move beyond our current nosology and knowledge base sooner rather than later and replace it with a completely new framework best exemplified byR esearch Domain Criteria (RDoC) (Insel, 2010; Keshavan, 2013). The still nascent knowledge base of behavioral neuroscience and the primordial state of its translation to human mental function have led to the alternate recommendation “not to throw the baby out with the bathwater” and instead adopt the less anarchic strategy of retaining the more useful aspects of our current knowledge base while more rigorously developing the neurobiological foundations of human mentation and more deliberately relating it to pathological behavior (Fulford et al., 2014; Tandon and Maj, 2008; Tandon, 2012). These issues are expounded by experts from diverse fields in this collection of 12 articles from the Asian Journal of Psychiatry. This collection of articles has been compiled especially for ANCIPS 2016, the theme of which is “Translational Psychiatry.” The authors all agree that the brain is the organ of psychiatry and that clinicians need a better foundation in neuroscience to better serve their patients and to develop the capacity to understand future developments in the field. There are different perspectives, however, as to precisely how this goal should be pursued. All authors comment on an article by Torous and co-workers (the first article in this issue), which describes the teaching of a “neurological” approach to psychiatric disorders. There is justifiable excitement about the rapid progress in the tools available to basic neuroscientists and the research modalities that are now possible. It is also true that most practicing psychiatrists do not comprehend the truly remarkable advances in neuroscience and molecular biology that are revolutionizing our understanding of how the brain mediates the range of human behavior. It is equally true that basic neuroscientists rarely appreciate the nature of human psychopathology or the strengths/limitations of current methods to describe it. What is even more worrisome is the fact that neuroscientists and clinicians no longer comprehend, let alone speak, the other’s language- and neither acknowledges this deficiency! While the informed practice of psychiatry will always involve a solid foundation in modern neuroscience, some understanding of philosophy, anthropology, ethology, evolutionary biology, sociology and other disciplines will always be important. It is essential, however, that psychiatrists also have a working knowledge of basic brain operations. This includes accurate knowledge of neural structures, neurodevelopment, neuronal and glial function, synaptic development, molecular mechanisms, regulation of neuronal circuits, genetics, epigenetics and paradigms used in neuroscience research. At ANCIPS 2016, the CME presentations and several symposia/workshops will explore and articulate the promise of translational psychiatry. As we consider how to better integrate the clinical with the neuroscience, it is important to recognize that the endeavor is a two-way street with both clinicians and neuroscience researchers playing lead roles in developing the bridge! As will be evident at ANCIPS 2016, this is an exciting time for our field, with translational psychiatry at the cutting edge.I t is hoped that this collection of articles will provide a broad perspective about how we can properly harness the enormous opportunities with which we are presented. References Fulford KWM, Bartolotti L, Broome M, 2014. Taking the long view: an emerging framework for translational psychiatric science. World Psychiatry 13, 110-117. Insel TR, Wang PS, 2010. Rethinking mental illness. JAMA 303, 1970-1971. Keshavan MS, 2013. Classification of psychotic disorders: need to move to a neuroscience-informed nosology.Asian J. Psychiatry 6, 191-192. Tandon R, 2012. The nosology of schizophrenia: Towards DSM-5 and ICD-11. Psychiatr. Clin. North Am. 35, 557-569. Tandon R, Maj M, 2008. Nosological status and definition of schizophrenia: some considerations forD SM-5 and ICD-11. Asian J. Psychiatry 1, 22-27.

Asian Journal of Psychiatry 17 (2015) 1–2

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Editorial

Is psychiatry in need of a course correction?

When one of us (MSK) was fresh out of medical school and (Keshavan, 2014), and few actionable biomarkers have been

considering a choice of specialty in the late seventies, he identiﬁed (Prata et al., 2014).

remembers agonizing for quite a while between psychiatry and While such criticisms against and fears of the demise of

neurology. On the one hand, the mysteries of the mind were psychiatry have been repeatedly voiced (Poole and Bhugra,

fascinating but the lack of a clear-cut framework to understand 2008), the ﬁeld continues to survive. There are several reasons for

psychiatric disorders was frustrating. It was easy then for someone optimism. First, the public health magnitude of mental health

like Thomas Szasz to dismiss schizophrenia as a moral disease or problems is increasingly dominating the unmet needs in all of

for R.D. Laing to view it as a spiritual breakthrough. Neurology on medicine (Tomlinson et al., 2009). The need for psychiatrists

the other hand was intellectually tidy, and offered a clear way to continues to grow. Second, important conceptual changes such

understand its patients. Keshavan eventually chose the psychiatry as research domain criteria (RDoC) are gaining traction, raising

path because of its very challenges, as there were so many hope for more valid approaches to organizing the translational

unanswered questions. If psychiatry were then how it is now, he body of knowledge central to psychiatric disorders (Cuthbert and

feels he may not even have hesitated. It is useful to reﬂect why. Insel, 2010). Third, the neural circuits of behavioral domains such

A large part of the initial reluctance of many aspiring as attention, memory executive functions, thought processes,

psychiatrists may well have been the lingering ambiguity in the emotion perception and reward seeking have been increasingly

deﬁnition of our discipline itself. Psychiatry has for long suffered well delineated using modern imaging techniques. Fourth,

from a lack of clear deﬁnition of its boundaries. There have been spectacular advances have been made in unraveling the genetic

threats to the role of psychiatry from both within and outside the basis of major neuropsychiatric disorders such as schizophrenia,

ﬁeld. Challenges from outside the ﬁeld have included criticism autism and bipolar disorders. Finally, major methodological

from patient groups, low status of the ﬁeld within medicine, and advances such as the connectome (Fan et al., 2015), optogenetics

within society in general, and encroachment on territories by other (Deisseroth, 2015), sonogenetics (Ibsen et al., 2015) and

disciplines (neurology, psychology, social work) (Katschnig, 2010). pluripotent stem cells (Wright et al., 2014) are making it

Challenges within the ﬁeld have been even larger. In particular, possible to accelerate translational discoveries of enormous

from a sociological standpoint, a key component of being a potential impact on the ﬁeld. All this is clearly giving a coherent

profession involves having a unique body of skills and knowledge conceptual framework for placing at least the major psychiatric

base, from which the scope and boundaries of the services, and of disorders, (such as schizophrenia, bipolar disorder, obsessive

the potential consumers is deﬁned (Coady, 2009). Psychiatry has compulsive disorder) on a ﬁrm footing. Cognitive and affective

suffered from a lack of a coherent theoretical basis, with several neuroscience, rather than psychopathology or its theories, is

camps with distinct ideologies and bodies of knowledge (Goodwin more likely to serve as the basic science for psychiatry, just as it is

and Geddes, 2007; Kingdon and Young, 2007). While the major for neurology.

illnesses served by psychiatry have always been brain disorders, Having a knowledge base and a cohesive conceptual foundation

the brain as the organ system of our specialty has not always been will in and of itself not assure a profession its due standing. While it

acknowledged upfront; diseases such as dementias and epilepsy, is harder nowadays for anti-psychiatrist theories to seem credible

once largely within the province of psychiatry, have moved into in the face of neuroscience knowledge, we are still far from

neurology as etiology and pathophysiology have become clearer. elucidating the speciﬁc pathophysiological substrates of most

Frontotemporal dementia, Rett syndrome, 22q deletion syndrome mental illnesses. The theoretical framework is yet to be translated

and NMDA receptor encephalitis are recent examples. Entities to actionable practice, and this is where the rubber meets the road.

where ‘‘biological’’ or organic causation is not clear have remained Although cutting edge neuroscience techniques have not yet

within psychiatry, making this a specialty of idiopathic disorders! yielded diagnostic biomarkers yet, a ray of hope emerges from

Diseases within the ﬁeld have been basically deﬁned based on recent genomics and neuroimaging studies that have begun to

subjective reports of psychopathology and observed behaviors. shed light on possible prognostic biomarkers (Frank et al., 2015;

The validity of our diagnostic systems has remained questionable Hager and Keshavan, 2015; Sarpal et al., 2015).

http://dx.doi.org/10.1016/j.ajp.2015.10.001

1876-2018/ß 2015 Published by Elsevier B.V.

2 Editorial / Asian Journal of Psychiatry 17 (2015) 1–2

century. As the ﬁgure suggests, there may well be a new, as yet not

well trod path in the middle of the fork for psychiatry, free of the

baggage of prior unproven theories, and one that is a clinical

neuroscience well grounded in its psychosocial and biological

foundations. It is timely that several articles in this issue including

the paper by Torous et al. (2015) address the need for introducing

more neuroscience in the early training of future psychiatrists. In

the forthcoming issue of the Asian Journal of Psychiatry, we will

feature a series of articles on teaching neuroscience for psychiatrists.

References

Coady, M., 2009. The nature of professions: implications for psychiatry. In: Bloch, S.,

Green, S.A. (Eds.), Psychiatric Ethics. Oxford University Press, Oxford, pp. 85–98.

Cuthbert, B.N., Insel, T.R., 2010. Toward new approaches to psychotic disorders: the

NIMH Research Domain Criteria project. Schizophr. Bull. 36, 1061–1062.

Deisseroth, K., 2015. Optogenetics: 10 years of microbial opsins in neuroscience.

Nat. Neurosci. 18, 1213–1225.

Fan, Q., Witzel, T., Nummenmaa, A., Van Dijk, K.R., Van Horn, J.D., Drews, M.K.,

Somerville, L.H., Sheridan, M.A., Santillana, R.M., Snyder, J., Hedden, T., Shaw,

E.E., Hollinshead, M.O., Renvall, V., Zanzonico, R., Keil, B., Cauley, S., Polimeni,

J.R., Tisdall, D., Buckner, R.L., Wedeen, V.J., Wald, L.L., Toga, A.W., Rosen, B.R.,

2015. MGH-USC Human Connectome Project datasets with ultra-high b-value

diffusion MRI. Neuroimage.

Frank, J., Lang, M., Witt, S.H., Strohmaier, J., Rujescu, D., Cichon, S., Degenhardt, F.,

Nothen, M.M., Collier, D.A., Ripke, S., Naber, D., Rietschel, M., 2015. Identiﬁca-

tion of increased genetic risk scores for schizophrenia in treatment-resistant

patients. Mol. Psychiatry 20, 150–151.

Goodwin, G.M., Geddes, J.R., 2007. What is the heartland of psychiatry? Br. J.

Psychiatry 191, 189–191.

Hager, B.M., Keshavan, M.S., 2015. Neuroimaging biomarkers for psychosis. Curr.

Behav. Neurosci. Rep. 2015, 1–10.

Ibsen, S., Tong, A., Schutt, C., Esener, S., Chalasani, S.H., 2015. Sonogenetics is a non-

invasive approach to activating neurons in Caenorhabditis elegans. Nat. Com-

mun. 6, 8264.

Insel, T.R., 2015. Integrating neuroscience into psychiatric residency training. Asian

J. Psychiatry 17, 133–134.

Nevertheless, there is a clear need for a course correction in

Katschnig, H., 2010. Are psychiatrists an endangered species? Observations on

psychiatry. There have been repeated calls for psychiatry’s return

internal and external challenges to the profession. World Psychiatry 9, 21–28.

to its ‘‘home’’ in medicine, as evinced by the new symbol of the Keshavan, M.S., 2014. Psychiatric classiﬁcation at cross-roads. Asian J. Psychiatry 7,

Asclepian rod in the logo of the American Psychiatric Association 1.

Keshavan, M.S., 2015. The Asclepian rod and the return of psychiatry to its home in.

(Keshavan, 2015). We believe that psychiatry has always been and

medicine and neuroscience. Asian J. Psychiatry 16, 87–88.

will remain a branch of medicine. The bigger issue is the need for Kingdon, D., Young, A.H., 2007. Research into putative biological mechanisms of

psychiatry to have a coherent body of actionable knowledge and mental disorders has been of no value to clinical psychiatry. Br. J. Psychiatry

191, 285–290.

skill set that its practitioners are best trained to practice. Having a

Poole, R., Bhugra, D., 2008. Should psychiatry exist? Int. J. Soc. Psychiatry 54, 195–

medical training provides the needed basis to acquire the needed 196.

clinical neuroscience training. The discipline also has to battle the Prata, D., Mechelli, A., Kapur, S., 2014. Clinically meaningful biomarkers for psy-

chosis: a systematic and quantitative review. Neurosci. Biobehav. Rev. 45, 134–

stigma attached to the profession, competitions in the marketplace

141.

from allied professions, and resource limitations to enable more

Sarpal, D.K., Argyelan, M., Robinson, D.G., Szeszko, P.R., Karlsgodt, K.H., John, M.,

research creating a solid evidence base for diagnosis and treatment Weissman, N., Gallego, J.A., Kane, J.M., Lencz, T., Malhotra, A.K., 2015. Baseline

striatal functional connectivity as a predictor of response to antipsychotic drug

of the most distressed and disabled individuals it serves. Most

treatment. Am. J. Psychiatry, appiajp201514121571.

important, the ﬁeld needs to embrace its unique role in medicine –

Tomlinson, M., Rudan, I., Saxena, S., Swartz, L., Tsai, A.C., Patel, V., 2009. Setting

that of treating brain disorders with behavioral manifestations. priorities for global mental health research. Bull. World Health Organ. 87, 438–

446.

Coming back to where we started – medical graduates at

Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A

crossroads while choosing their line of specialty are probably

proposed solution to integrating cognitive-affective neuroscience and neuro-

better placed today to make an informed choice. It is for us to psychiatry in psychiatry residency training: the time is now. Asian J. Psychiatry

ensure that their fascination for treating disorders of the mind is 17, 116–121.

Wright, R., Rethelyi, J.M., Gage, F.H., 2014. Enhancing induced pluripotent stem cell

not cut short by their reluctance to pursue an unsure science.

models of schizophrenia. JAMA Psychiatry 71, 334–335.

Incorporating a neuroscience-informed psychiatry curriculum in

medical undergraduate training can beckon more trainees to this

fascinating subject. This will enable the ﬁeld of psychiatry to

invigorate itself by recruiting not just more minds, but also smarter

Matcheri S. Keshavan MD*

minds of this generation, thus complementing the suggested

Beth Israel Deaconess Medical Center and Harvard Medical School,

paradigm shift in psychiatry residency training from the conser-

Boston, MA, United States

vative to the state of the art approach (Insel, 2015). Firm grounding

in neuroscience is critical for the future generation of psychiatrists,

Urvakhsh M. Mehta MD

more than ever before. It is important not to be reductionistic in

National Institute of Mental Health and Neurosciences,

this endeavor, but to draw upon the rich tapestry of new

Bangalore, India

information constantly emerging on the social determinants of

mental health.

*Corresponding author

Yogi Berra said, ‘‘When you come to a fork in the road, take it’’.

E-mail address: [email protected] (M.S. Keshavan).

This is good advice for the beginner in psychiatry in the 21st

Asian Journal of Psychiatry 17 (2015) 116–121

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

A proposed solution to integrating cognitive-affective neuroscience

and neuropsychiatry in psychiatry residency training: The time is now

a,b,c c,d c,e c

John Torous , Adam P. Stern , Jaya L. Padmanabhan , Matcheri S. Keshavan ,

b,f,g,

David L. Perez *

Harvard Longwood Psychiatry Residency Training Program, Boston, MA, USA

Brigham and Women’s Hospital, Department of Psychiatry, Harvard Medical School, Boston, MA, USA

Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School, Boston, MA, USA

Berenson Allen Center for Non-Invasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, USA

McLean Hospital, Department of Behavioral Neurology and Neuropsychiatry, Belmont, MA, USA

Massachusetts General Hospital, Department of Psychiatry, Harvard Medical School, Boston, MA, USA

Massachusetts General Hospital, Department of Neurology, Harvard Medical School, Boston, MA, USA

A R T I C L E I N F O A B S T R A C T

Article history: Despite increasing recognition of the importance of a strong neuroscience and neuropsychiatry

Received 12 March 2015

education in the training of psychiatry residents, achieving this competency has proven challenging. In

Accepted 5 May 2015

this perspective article, we selectively discuss the current state of these educational efforts and outline

how using brain-symptom relationships from a systems-level neural circuit approach in clinical

Keywords:

formulations may help residents value, understand, and apply cognitive-affective neuroscience based

Education

principles towards the care of psychiatric patients. To demonstrate the utility of this model, we present a

Neuroscience

case of major depressive disorder and discuss suspected abnormal neural circuits and therapeutic

Neuropsychiatry

implications. A clinical neural systems-level, symptom-based approach to conceptualize mental illness

Residency

can complement and expand residents’ existing psychiatric knowledge.

Neural circuits

1. Introduction absence of any grossly visible pathology and neurological disorders

based in the clinical-pathologic correlate (Price et al., 2000; Martin,

Modern day psychiatry and neurology have shared origins. 2002). Signiﬁcant advances in cellular-molecular and systems-

Among the most impactful examples of this shared history are the level cognitive-affective neuroscience and in vivo neuroimaging

clinical efforts performed at the La Salpeˆtrie`re Hospital in France in research across psychiatric disorders have now proven this

the late 19th century, where visionaries including Jean-Martin distinction to be misleading. As examples, post-mortem patholog-

Charcot, Sigmund Freud, Gilles de la Tourette, and Pierre Janet all ical changes in the hippocampus in schizophrenia (Harrison, 2004)

worked collaboratively in their care and study of patients with and in the anterior cingulate cortex in major depressive disorder

conditions at the interface of brain and mind (Bogousslavsky, (MDD) (Ongur et al., 1998; Cotter et al., 2001) have been well

2014). In a unifying statement Charcot wrote ‘‘the neurological tree characterized. Yet, despite signiﬁcant advances in our knowledge

has its branches; neurasthenia, hysteria, epilepsy, all the types of of the biological basis of psychiatric disorders and calls from

mental conditions, progressive paralysis, gait ataxia (Charcot, international leaders such as the Nobel Laureate Eric Kandel

1887).’’ Unfortunately, despite this shared history, a ‘‘great divide’’ (Cowan and Kandel, 2001) for increased neuroscience and

emerged throughout the 20th century with psychiatric mental clinically-relevant neurology education in psychiatry residency,

disorders being largely deﬁned by the presence of symptoms in the cognitive-affective neuroscience and neuropsychiatry remain a

challenge to integrate into clinical practice and psychiatric training

experiences.

While there has been increasing recognition for the need to

* Corresponding author at: Massachusetts General Hospital Departments of

better incorporate neuroscience and psychiatrically relevant

Neurology and Psychiatry 149 13th Street Charlestown, MA 02129, USA.

Tel.: +1 617 724 7299. neurology into the education and training of psychiatry residents

E-mail address: [email protected] (D.L. Perez). (Benjamin, 2013), successfully implementing such efforts and

http://dx.doi.org/10.1016/j.ajp.2015.05.007

J. Torous et al. / Asian Journal of Psychiatry 17 (2015) 116–121 117

achieving tangible results has remained elusive. A recent study, for (Chung and Insel, 2014). RDoC is essentially a systems-level,

example, noted that while 94% of surveyed academic chairs, dimensional research approach that conceptualizes psychiatric

practicing psychiatrists, and residents agreed on the need to illness in part as disorders of neural circuitry (Insel et al., 2010). It

further promote neuroscience education, only 13% of trainees emphasizes the association between broadly deﬁned emotional

considered themselves to have a strong neuroscience knowledge and cognitive domains (e.g., negative and positive emotional

base (Fung et al., 2015). In this article, we present the integrated valence systems) and neurobiological measures, ranging from

perspectives of a current psychiatry resident in training (JT), a genetics to physiology, in a manner agnostic to traditional

neuropsychiatry fellow with a background in neuroimaging diagnostic categories. The National Neuroscience Curriculum

research (JLP), an early career academic faculty psychiatrist with Initiative (NNCI) (http://www.nncionline.org/) has also been

a background in neuromodulation (APS), a researcher in psychiat- recently established to create, pilot, and disseminate a compre-

ric neuroscience (MSK), and a dual trained early career neurolo- hensive set of shared resources for psychiatry residents and

gist-psychiatrist and cognitive-affective neuroscientist (DLP) to already features online educational modules, resources, and

explore how trainees can bridge in real-time brain-symptom videos. Also, the Accreditation Council for Graduate Medical

relationships in psychiatry. This article outlines how psychiatry Education (ACGME) in the United States recently implemented a

residents can integrate systems-level neuroscience into their novel framework for evaluating resident performance and one of

training to conceptualize psychiatric symptom-complexes and the these evaluation metrics is that all residents must show

advance translational therapeutic efforts. An illustrative case competency in clinical neuroscience. However, the speciﬁcs

example is presented to model this approach. behind how individual residency programs implement and meet

this clinical neuroscience requirement are less well deﬁned.

2. Current challenge Beyond the evolving resources and changes discussed in this

section, the time is now for residents, educators and like-minded

Many psychiatry residents may not be aware of their potential academic psychiatrists to develop a culture of embracing cogni-

interest in a clinical psychiatric neuroscience approach to patient tive-affective neuroscience and neuropsychiatry to expedite the

care due to a lack of clinical exposure. While any patient ‘‘bench-to-bedside’’ translation of brain-symptom relationships to

presentation can, and should, inspire a comprehensive, neuros- help guide clinical thinking and future innovative therapeutic

cientiﬁcally and neurologically informed approach, trainees need interventions.

clinical exposure to cases with salient neuropsychiatric elements

to develop relevant conceptual and technical skills. High yield 4. Proposed solution

neuropsychiatric cases may include patients with prominent

emotional, perceptual and/or behavioral symptoms in the context We suggest that one potentially immediate and impactful

of neurodegenerative disease, epilepsy, cerebrovascular disease, method of increasing psychiatry residents’ awareness, interest,

traumatic brain injury, movement disorders and autoimmune expertise and clinical appreciation of clinical psychiatric neurosci-

disorders with neuropsychiatric features such as anti-NMDA ence and neuropsychiatry is to encourage real-time circuit-speciﬁc

encephalitis. However, depending on the training environment, discussions of brain-symptom relationships across the care of

some residents may be rarely exposed to such patients, as they are psychiatric patients. Akin to daily discussions occurring in

instead treated in sub-specialty clinics or other departments. neurology wards and outpatient clinics related to localizing the

A related challenge for residents in developing a strong structural lesion, we speciﬁcally propose that psychiatry residents

neuroscience and neuropsychiatric foundation may be the nature should be taught and encouraged to engage in discussions around

of the didactics available within many training programs. A recent identifying suspected abnormally functioning brain circuits (and

study of 226 adult and child/adolescent psychiatry program particular nodes within a broadly distributed network that may be

directors noted that 39% felt that a lack of neuropsychiatry faculty, linked to a patient’s particular symptoms). Given that the bio-

and 36% a lack of neuroscience faculty, were perceived barriers to psycho-social model is an integral part of psychiatric formulation

appropriately offering increased training in neuropsychiatry and (Engel, 1977) and residency educational experience, encouraging

the neurosciences respectively (Benjamin et al., 2014). Other residents to use clinically-oriented neuroscience and neuropsy-

barriers also included the lack of relevant curriculums and faculty chiatric principles to discuss the likely affected brain circuits as

availability. part of their overall case formulation offers an inexpensive and

While a long-term solution to both these issues could be to readily available translational neuroscience paradigm.

establish neuropsychiatry divisions within academic psychiatry While identifying a discrete lesion remains important in

departments, in which psychiatry residents readily care for making a neurological diagnosis, speciﬁc focal lesion localization

patients with psychiatric symptoms secondary to neurological in psychiatry has proven more difﬁcult. Rather than there being a

illnesses, an equally important solution as discussed below is for speciﬁc lesion or neuroanatomical site of damage that we can

academic psychiatry departments to place greater emphasis on a localize through examination or neuroimaging, psychiatric dis-

brain-symptom based approach in the formulation and treatment eases may be better framed as disorders of distributed, inter-

of patients experiencing idiopathic (primary) psychiatric symp- connected brain networks. To use a metaphor, these diseases can

toms. be considered like the abnormal trafﬁc ﬂow patterns in a congested

city where old and narrow roads, inefﬁcient trafﬁc lights, and

3. Evolving large-scale solutions bottlenecks at bridges create in combination a horrible trafﬁc jam

of the city’s network of streets. While no one trafﬁc light, single

Recognizing the challenges likely experienced by most resi- narrow road, or individual bridge may in itself be typically

dents in United States training programs and globally, several sufﬁcient to cause a trafﬁc jam, their effects combine to bring the

solutions have been proposed and developed at the national level. city’s trafﬁc to a halt. Furthermore, at times there is one speciﬁc

The National Institute of Mental Health (NIMH) has taken a dual bridge or intersection that receives trafﬁc from many distinct parts

approach to specifically support trainees who will define of the city and its disruption by itself can cause significant delays.

psychiatry as a ﬁeld of ‘‘clinical neurosciences’’ and encourages Likewise, psychiatric symptoms can be conceptualized as brain

neuroscience literacy through development of online modules and network problems where often times no single isolated region, or

teaching based on the Research Domain Criteria (RDoC) project lesion, of the brain is responsible for a psychiatric illness but rather

118 J. Torous et al. / Asian Journal of Psychiatry 17 (2015) 116–121

multiple disrupted brain regions within a network or across response and baseline neuroimaging patterns have also shown, for

several networks function abnormally to produce particular example, that pretreatment subgenual anterior cingulate cortex

symptom complexes. Furthermore, there may be a critical region hypermetabolism in patients with major depressive disorder is

or ‘‘hub’’ within a group of interconnected regions that if disrupted potentially linked to failure to achieve remission following SSRI

may have particularly adverse effects of brain function and medication or cognitive behavioral therapy (either alone or in

symptom expression (Bullmore and Sporns, 2009). This perspec- combination) (McGrath et al., 2014). Preliminary evidence also

tive of brain circuits, particularly at the level of prefrontal cortex- suggests that baseline insula metabolic proﬁles may serve as a

subcortical circuits was emphasized by Alexander and colleagues treatment selection biomarker to guide treatment initiation of

in the mid 1980s following their detailed descriptions of ﬁve SSRI versus cognitive behavioral therapy in untreated individu-

discrete prefrontal-subcortical brain circuits (Alexander et al., als with major depression (McGrath et al., 2013). A meta-

1986). Prefrontal regions including the dorsolateral prefrontal analysis of neuroimaging studies in depression probing func-

cortex, anterior cingulate cortex and orbitofrontal cortex each tional and structural neural biomarkers of treatment response

were shown to have discrete basal ganglia and thalamic across pharmacologic and psychological interventions showed

connections and primarily involved in higher-order cognitive or that positive treatment response was linked to baseline

affective functions. Didactic efforts by Cummings and others increased perigenual anterior cingulate cortex activations; poor

demonstrated the utility of these circuits to explain psychiatric treatment response was predicted by decreased striatal and

symptoms including linking impairments of the anterior cingulate anterior insula activations and regional atrophy in the dorsolat-

cortex-subcortical circuit to motivational deﬁcits, the orbitofrontal eral prefrontal cortex and hippocampus (Fu et al., 2013). While

cortex-subcortical circuit to disinhibited behavior, and the further prospective and multi-site research studies are neces-

dorsolateral prefrontal cortex-subcortical circuit to dysexecutive sary to validate these structural and functional proﬁles as

symptoms (Bonelli and Cummings, 2007; Mega and Cummings, possible treatment related biomarkers, an equally important

1994). Over the past two decades, these brain-symptom relation- obstacle to incorporating these and other brain science advances

ships have been reﬁned and these neural network connections is the lack of clinical proﬁciency and comfort psychiatrists have

have been implicated in the real-world clinical practice of in using and integrating brain circuit discussions in the care of

psychiatrists. For example, it was shown that treatments targeting patients. Our proposal to encourage all psychiatrists and

speciﬁc neuroanatomical locations such as repetitive transcranial psychiatry residents to engage in discussions around localizing

magnetic stimulation (rTMS) to the dorsolateral prefrontal cortex suspected abnormally functioning brain circuits provides a

in depression displayed treatment efﬁcacy (Pascual-Leone et al., necessary bridge to allow promising advances to be actually

1996). While a more detailed up-to-date discussion of the default adopted once well-validated.

mode (Zhang and Raichle, 2010), salience (Seeley et al., 2007), Interventional neurotherapeutics, which seek to optimize

attention (Corbetta et al., 2008), emotional processing (Etkin, functional activations and connectivity patterns, are an increas-

2010; LeDoux, 2007; Etkin et al., 2011), cognitive control (Badre ingly widespread treatment modality in which brain circuit

and Wagner, 2007; Ridderinkhof et al., 2004), social cognitive expertise is critical for the clinician. TMS was ﬁrst approved by the

(Lieberman, 2007; Adolphs, 2003; Bickart et al., 2012), memory Food and Drug Administration (FDA) for use in treatment-

(Eichenbaum, 2000) and visceral-somatic processing (Perez et al., resistant depression in 2008 (Stern and Cohen, 2013). While this

2015a) networks among others is beyond the scope of this device speciﬁcally targets the dorsolateral prefrontal cortex to

perspective article, they have been reviewed elsewhere (Perez modulate baseline lateral prefrontal hypoactivation in depres-

et al., 2015b,c,d). From an educational perspective, systems-level sion, a newer device capable of targeting deeper structures such as

brain-symptom discussions offer a useful mechanism to transform the anterior cingulate and the orbitofrontal cortex was approved

more abstract neuroscience concepts into clinically useful tools for in 2013 (Stern and Cohen, 2013). In addition, recent resting state

patient care. Integrating regular brain circuit discussions into analyses have linked anti-correlated dorsolateral prefrontal

diagnostic and therapeutic discussions may foster active learning cortex - subgenual anterior cingulate cortex functional connec-

and facilitates the translational process of bringing neuroscience tivity to TMS therapeutic efﬁcacy (Fox et al., 2012), which

advancements to the clinic. connects the non-invasive and invasive neuromodulation liter-

ature in MDD.

5. Therapeutic implications of a brain-based approach to Deep brain stimulation (DBS), which involves implantation of

psychiatric symptoms electrodes in strategic brain regions, is an emerging neurother-

apeutic approach which has displayed promising results in clinical

A brain-based, neuroscientiﬁcally informed understanding of research studies of treatment-resistant depression (Blomstedt

psychiatric illness is of more than academic interest to future et al., 2013; Mayberg et al., 2005; Kisely et al., 2014). Thus far, DBS

psychiatrists. It will be increasingly relevant in understanding, of the subgenual anterior cingulate cortex (Brodmann area 25),

selecting and administering psychological and biologically-in- ventral striatum, and nucleus accumbens have shown potential

formed treatments. While expert clinicians and the clinical efﬁcacy in alleviating treatment-resistant depression (Malone

interview are likely to remain the gold standard for clinical et al., 2009; Bewernick et al., 2010; Holtzheimer et al., 2012). These

diagnosis, clinicians often lack clear guidance around which targeted brain regions are particularly notable since each is a

particular treatment is most likely to be beneﬁcial for a given component of the anterior cingulate-subcortical circuit. An

patient. Adjunct structural and functional neuroimaging biomark- understanding of the neural circuits underlying these disorders

ers may serve as clinically useful biomarkers of psychopharma- is essential to the successful application of these emerging

cology and psychotherapy treatment selection (Gabrieli et al., treatments. Given the continued momentum of neurotherapeutic

2015; Pizzagalli, 2011). Neuroimaging studies investigating neural investigations in psychiatric research to modulate brain networks,

mechanisms of selective serotonin re-uptake inhibitor (SSRI) it is increasingly necessary for psychiatric trainees to understand

administration have shown decreased amygdala-hippocampal interventional neurotherapeutic approaches, including their ana-

reactivity following drug administration, while norepinephrine tomical basis, and gain mastery of their use as part of their training.

reuptake inhibitors have been demonstrated to increase dorsolat- If psychiatrists do not embrace opportunities to become specialists

eral prefrontal cortex and cingulate gyrus activations (Outhred in neuromodulation, the void could be ﬁlled by other clinical

et al., 2013). Studies evaluating associations between treatment experts in brain functioning.

J. Torous et al. / Asian Journal of Psychiatry 17 (2015) 116–121 119

6. Model case illustrating a brain-symptom, systems-level Another possibility includes rTMS to the dorsolateral prefrontal

formulation cortex which can modulate medial prefrontal regions through

afferent connections. Lastly, consideration could be given to a

A 28 year-old single, employed woman with a family history of referral to a clinical trial such as for cognitive bias modiﬁcation

mood and anxiety disorders presented with 6 months of depressed (CBM; Almeida et al., 2014); the patient’s dysphoric-anxious mood

and mildly anxious mood, negatively themed rumination, de- suggests increased amygdala activation, and a positive response to

creased interest in previously enjoyed activities, low-self worth, attention bias modiﬁcation is associated with increased pre-

impaired concentration with reported forgetfulness at work, treatment amygdala activation (Britton et al., 2014). In part due to

delayed sleep onset, preserved appetite and no suicidal ideation. patient preference and resource availability, a therapeutic course

Psychiatric review of symptoms was otherwise negative. Symp- of cognitive behavioral therapy, using CBM principles, was

toms began following a romantic breakup, and psychosocial pursued.

history was notable for early-life maternal emotional abuse and

parental divorce during her teenage years. Mental status evalua- 7. Conclusions

tion revealed poor eye contact, mildly labile affect, depressed

mood and multiple negatively themed self-referential comments. In this article, we highlighted several important barriers to the

Cognitive Assessment showed slowed processing speed on incorporation of clinical psychiatric neuroscience and neuropsy-

abbreviated Trails B and serial 7s, impaired executive function chiatry in general psychiatry residency training. Our proposed

(increased perseverative errors on the Wisconsin Card Sort Test) approach integrates cognitive-affective neuroscience and neuro-

and spontaneous word recall at 5 minutes of 4/5 improving to 5/5 psychiatry into the real-time training experiences of residents in a

with categorical cues. Elemental neurological examination and clinically relevant way (Fig. 1). Several counterarguments may be

medical work-up for reversible causes of depression were within raised against our proposal. One, is the evidence for the

normal limits. She previously failed to achieve beneﬁt from an aforementioned brain-behavior relationships substantial and

adequate trial of an SSRI medication. consistent enough to introduce into a general psychiatry curricu-

A clinical psychiatric neuroscience-based formulation for this lum? The answer at this point is an unequivocal yes. Even if some

patient’s symptom complex would be as follows. The patient’s of the speciﬁc details change, it is clear that the fundamental

depressive symptoms appear to at least partially localize to the paradigm of psychiatric illness as neural circuit based disorders is

anterior cingulate cortex and related striatal-thalamic subcortical here to stay. Second, would training programs without trained

components. This individual exhibits ruminative negatively neuropsychiatrists and neuropsychiatry divisions (or similar

valenced thinking which is suggestive of impaired modulation biologically-oriented divisions such as consultation-liaison psy-

of negative mood states, which has been linked to functional chiatry) have the resources to educate their residents in this

abnormalities of the subgenual anterior cingulate cortex (Hamani approach? This is a potentially more difﬁcult challenge, but we

et al., 2011; Holtzheimer and Mayberg, 2011) and the amygdala would suggest that with some creative problem-solving, most

(Belzung et al., 2015). The patient reports anhedonia which has programs would ﬁnd it feasible to at least introduce a deeper focus

been observed to also localize to the anterior cingulate cortex- on neuroscience and neuropsychiatry into the curriculum and

subcortical circuit, particularly the ventral striatum/nucleus daily training experience. The national efforts noted earlier in this

accumbens (Epstein et al., 2006; Epstein et al., 2011; Pizzagalli

et al., 2009). The patient’s concentration deﬁcits and mild

dysexecutive syndrome is suggestive of lateral prefrontal dysfunc-

tion including the dorsolateral prefrontal cortex (Grimm et al.,

2008). Of note, the dorsolateral and anterior cingulate cortices are

reciprocally connected through cortico-cortical connections

(Hamani et al., 2011). Also, the patient’s mixed depressed-anxious

mood, a commonly encountered clinical presentation, highlights

that depression and anxiety have overlapping frontolimbic neural

substrates (Ionescu et al., 2013). From a developmental neurosci-

ence perspective, the patient‘s emotion regulation and expression

circuits (including the medial prefrontal cortex and amygdala) may

have been sensitized by childhood emotional abuse leading to

aberrant (maladaptive) neuroplastic changes (Leuner and Shors,

2013; Dannlowski et al., 2012). These neuroplastic changes may

have led to heightened reactivity (in-part from impaired top-down

prefrontal cortex regulation of limbic activity) following recent

relational stress, triggering negative ruminations and a dysphoric-

anxious mood.

From a brain-based therapeutic perspective, given that several

aspects of the patient’s symptom complex (such as emotional

dysregulation and impaired executive function) localize to medial

and lateral regulatory prefrontal and amygdalar circuits, consid-

eration was given to a possible trial of a serotonin-norepinephrine

reuptake inhibitor. Alternatively or in combination, cognitive

behavioral therapy may be beneﬁcial to treat the patient’s self- Fig. 1. A conceptual framework of the suggested central role of clinical psychiatric

neuroscience and neuropsychiatry in academic psychiatry and closely related

referential, negatively valenced rumination which localizes to the

ﬁelds. In part, these core (inter-related) disciplines can help bridge the rapidly

subgenual anterior cingulate cortex and related frontolimbic

evolving ﬁeld of systems-level, cognitive affective neuroscience to enable brain-

connections (Holtzheimer and Mayberg, 2011), and cognitive

symptom relationship discussions to more comprehensively formulate psychiatric

behavioral therapy may improve depression symptoms by symptom complexes and foster the development of validated biologically informed

modulating medial prefrontal circuits (Yoshimura et al., 2014). therapeutic interventions.

120 J. Torous et al. / Asian Journal of Psychiatry 17 (2015) 116–121

Corbetta, M., Patel, G., Shulman, G.L., 2008. The reorienting system of the human

paper also suggest a potential solution, with the promise of many

brain: from environment to theory of mind. Neuron 58, 306–324.

online educational resources.

Cotter, D., Mackay, D., Landau, S., Kerwin, R., Everall, I., 2001. Reduced glial cell

The past several decades have witnessed the impressive density and neuronal size in the anterior cingulate cortex in major depressive

disorder. Arch. Gen. Psychiatry 58, 545–553.

progress of neuroscientiﬁc research in elucidating the relation-

Cowan, W.M., Kandel, E.R., 2001. Prospects for neurology and psychiatry. J. Am.

ships between brain function and mental states. It is more

Med. Assoc. 285, 594–600.

important than ever for the next generation of psychiatrists to be Dannlowski, U., Stuhrmann, A., Beutelmann, V., Zwanzger, P., Lenzen, T., Grotegerd,

educated in a brain-based approach to psychiatric illness. Although D., Domschke, K., Hohoff, C., Ohrmann, P., Bauer, J., Lindner, C., Postert, C.,

Konrad, C., Arolt, V., Heindel, W., Suslow, T., Kugel, H., 2012. Limbic scars: long-

the examples in this article have focused on depression, the

term consequences of childhood maltreatment revealed by functional and

education model presented is applicable to any psychiatric illness structural magnetic resonance imaging. Biol. Psychiatry 71, 286–293.

including bipolar disorder (Brady et al., 2014), schizophrenia Eichenbaum, H., 2000. A cortical-hippocampal system for declarative memory. Nat.

Rev. Neurosci. 1, 41–50.

(Keshavan et al., 2008), post-traumatic stress disorder (Pitman

Engel, G.L., 1977. The need for a new medical model: a challenge for biomedicine.

et al., 2012), and functional neurological symptom disorder (Perez Science 196, 129–136.

et al., 2012, 2015e) among others. Parallel translational efforts will Epstein, J., Pan, H., Kocsis, J.H., Yang, Y., Butler, T., Chusid, J., Hochberg, H., Murrough,

J., Strohmayer, E., Stern, E., Silbersweig, D.A., 2006. Lack of ventral striatal

also look to integrate cellular-molecular biology, neurochemistry,

response to positive stimuli in depressed versus normal subjects. Am. J.

and epigenetic-genetic inﬂuences on brain-symptom relation-

Psychiatry 163, 1784–1790.

ships. Such education will ensure that psychiatrists remain at the Epstein, J., Perez, D.L., Ervin, K., Pan, H., Kocsis, J.H., Stern, E., Silbersweig, D.A., 2011.

Failure to segregate emotional processing from cognitive and sensorimotor

forefront, rather than the periphery, of advances in the diagnosis

processing in major depression. Psychiatry Res. 193, 144–150.

and treatment of mental illness in the 21st century and beyond.

Etkin, A., 2010. Functional neuroanatomy of anxiety: a neural circuit perspective.

Curr. Topics Behav. Neurosci. 2, 251–277.

Etkin, A., Egner, T., Kalisch, R., 2011. Emotional processing in anterior cingulate and

Authorship contributions

medial prefrontal cortex. Trends Cogn. Sci. 15, 85–93.

Fu, C.H., Steiner, H., Costafreda, S.G., 2013. Predictive neural biomarkers of clinical

Drs. Torous and Perez participated in the conception and design response in depression: a meta-analysis of functional and structural neuroim-

aging studies of pharmacological and psychological therapies. Neurobiol. Dis.

of this manuscript, and Drs. Torous, Perez, Stern, Padmanabhan,

52, 75–83.

and Keshavan participated in the drafting and critical review of the Fung, L.K., Akil, M., Widge, A., Roberts, L.W., Etkin, A., 2015. Attitudes toward

manuscript. All authors approved the ﬁnal version for publication. neuroscience education in psychiatry: a national multi-stakeholder survey.

Acad. Psychiatry 39, 139–146.

Fox, M.D., Buckner, R.L., White, M.P., Greicius, M.D., Pascual-Leone, A., 2012.

Disclosures/conﬂicts of interest Efﬁcacy of transcranial magnetic stimulation targets for depression is related

to intrinsic functional connectivity with the subgenual cingulate. Biol. Psy-

chiatry 72, 595–603.

The authors have no disclosures or conﬂicts of interest to report.

Gabrieli, J.D., Ghosh, S.S., Whitﬁeld-Gabrieli, S., 2015. Prediction as a humanitarian and

pragmatic contribution from human cognitive neuroscience. Neuron 85, 11–26.

References Grimm, S., Beck, J., Schuepbach, D., Boesiger, P., Bermpohl, F., Niehaus, L., Boeker, H.,

Northoff, G., 2008. Imbalance between left and right dorsolateral prefrontal

cortex in major depression is linked to negative emotional judgment: an fMRI

Adolphs, R., 2003. Cognitive neuroscience of human social behaviour. Nat. Rev.

study in severe major depressive disorder. Biol. Psychiatry 63, 369–376.

Neurosci. 4, 165–178.

Hamani, C., Mayberg, H., Stone, S., Laxton, A., Haber, S., Lozano, A.M., 2011. The

Alexander, G.E., DeLong, M.R., Strick, P.L., 1986. Parallel organization of function-

subcallosal cingulate gyrus in the context of major depression. Biol. Psychiatry

ally segregated circuits linking basal ganglia and cortex. Ann. Rev. Neurosci. 9,

69, 301–308.

357–381.

Harrison, P.J., 2004. The hippocampus in schizophrenia: a review of the neuropath-

Almeida, O.P., MacLeod, C., Ford, A., Grafton, B., Hirani, V., Glance, D., Holmes, E.,

ological evidence and its pathophysiological implications. Psychopharmacology

2014. Cognitive bias modiﬁcation to prevent depression (COPE): study protocol

(Berl) 174, 151–162.

for a randomised controlled trial. Trials 15, 282.

Holtzheimer, P.E., Mayberg, H.S., 2011. Stuck in a rut: rethinking depression and its

Badre, D., Wagner, A.D., 2007. Left ventrolateral prefrontal cortex and the cognitive

treatment. Trends Neurosci. 34, 1–9.

control of memory. Neuropsychologia 45, 28883–28901.

Holtzheimer, P.E., Kelley, M.E., Gross, R.E., Filkowski, M.M., Garlow, S.J., Barrocas, A.,

Belzung, C., Willner, P., Philippot, P., 2015. Depression: from psychopathology to

Wint, D., Craighead, M.C., Kozarsky, J., Chismar, R., Moreines, J.L., Mewes, K.,

pathophysiology. Curr. Opin. Neurobiol. 30, 24–30.

Posse, P.R., Gutman, D.A., Mayberg, H.S., 2012. Subcallosal cingulate deep brain

Benjamin, S., 2013. Educating psychiatry residents in neuropsychiatry and neuro-

stimulation for treatment-resistant unipolar and bipolar depression. Arch. Gen.

science. Int. Rev. Psychiatry 25, 265–275.

Psychiatry 69, 150–158.

Benjamin, S., Travis, M.J., Cooper, J.J., Dickey, C.C., Reardon, C.L., 2014. Neuropsy-

Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D.S., Quinn, K., Sanislow, C.,

chiatry and neuroscience education of psychiatry trainees: attitudes and bar-

Wang, P., 2010. Research domain criteria (RDoC): toward a new classiﬁcation

riers. Acad. Psychiatry 38, 135–140.

framework for research on mental disorders. Am. J. Psychiatry 167, 748–751.

Bickart, K.C., Hollenbeck, M.C., Barrett, L.F., Dickerson, B.C., 2012. Intrinsic amygda-

Ionescu, D.F., Niciu, M.J., Mathews, D.C., Richards, E.M., Zarate Jr., C.A., 2013.

la–cortical functional connectivity predicts social network size in humans. J.

Neurobiology of anxious depression: a review. Depress. Anxiety 30, 374–385.

Neurosci. 32, 14729–14741.

Keshavan, M.S., Tandon, R., Boutros, N.N., Nasrallah, H.A., 2008. Schizophrenia,just the

Brady, R., O¨ ngu¨ r, D., Keshavan, M., 2014. Neurobiology of mood-state shifts in

facts: what we know in 2008: part 3: neurobiology. Schizophr. Res. 106, 89–107.

bipolar disorder: a selective review and a hypothesis. Harv. Rev. Psychiatry 22,

Lieberman, M.D., 2007. Social cognitive neuroscience: a review of core processes.

23–30.

Ann. Rev. Psychol. 58, 259–289.

Bewernick, B.H., Hurlemann, R., Matusch, A., Kayser, S., Hadrysiewicz, B., Axmacher,

LeDoux, J., 2007. The amygdala. Curr. Biol. 17, R868–R874.

N., Cooper-Mahkorn, D., Cohen, M.X., Brockman, H., Lenartz, D., Strum, V.,

Leuner, B., Shors, T.J., 2013. Stress, anxiety, and dendritic spines: what are the

Schlaepfer, T.E., 2010. Nucleus accumbens deep brain stimulation decreases

connections? Neuroscience 251, 108–119.

ratings of depression and anxiety in treatment-resistant depression. Biol.

Kisely, S., Hall, K., Siskind, D., Frater, J., Olson, S., Crompton, D., 2014. Deep brain

Psychiatry 67, 110–116.

stimulation for obsessive-compulsive disorder: a systematic review and meta-

Bogousslavsky, J., 2014. Jean-Martin Charcot and his legacy. Front. Neurol. Neurosci.

analysis. Psychol. Med. 44, 3533–3542.

35, 44–55.

Malone Jr., D.A., Dougherty, D.D., Rezai, A.R., Carpenter, L.L., Friehs, G.M., Eskandar,

Bonelli, R.M., Cummings, J.L., 2007. Frontal-subcortical circuitry and behavior.

E.N., Rauch, S.L., Rasmussen, S.A., Machado, A.G., Kubu, C.S., Tyrka, A.R., Price,

Dialogues Clin. Neurosci. 9, 141–151.

L.H., Stypulkowski, P.H., Giftakis, J.E., Rise, M.T., Malloy, P.F., Salloway, S.P.,

Blomstedt, P., Sjoberg, R.L., Hansson, M., Bodlund, O., Hariz, M.I., 2013. Deep brain

Greenberg, B.D., 2009. Deep brain stimulation of the ventral capsule/ventral

stimulation in the treatment of obsessive-compulsive disorder. World Neuro-

striatum for treatment-resistant depression. Biol. Psychiatry 65, 267–275.

surg. 80, e245–e253.

Mayberg, H.S., Lozano, A.M., Voon, V., McNeely, H.E., Seminowicz, D., Hamani, C.,

Britton, J.C., Suway, J.G., Clementi, M.A., Fox, N.A., Pine, D.S., Bar-Haim, Y., 2014.

Schwalb, J.M., Kennedt, S.H., 2005. Deep brain stimulation for treatment-

Neural changes with attention bias modiﬁcation for anxiety: a randomized trial.

resistant depression. Neuron 45, 651–660.

Soc. Cogn. Affect. Neurosci. (pii: nsu141 Epub ahead of print).

Martin, J.B., 2002. The integration of neurology, psychiatry, and neuroscience in the

Bullmore, E., Sporns, O., 2009. Complex brain networks: graph theoretical analysis

21st century. Am. J. Psychiatry 159, 695–704.

of structural and functional systems. Nat. Rev. Neurosci. 10, 186–198.

McGrath, C.L., Kelley, M.E., Holtzheimer, P.E., Dunlop, B.W., Craighead, W.E., Franco,

Charcot, J., 1887. Lec¸ons du mardi a´ la Salpeˆtrie`re: policliniques, 1887–1888.

A.R., Craddock, R.C., Mayberg, H.S., 2013. Toward a neuroimaging treatment

Bureaux du Progra´es Maˆedical, Paris.

selection biomarker for major depressive disorder. J. Am. Med. Assoc. Psychiatry

Chung, J.Y., Insel, T.R., 2014. Mind the gap: neuroscience literacy and the next

70, 821–829.

generation of psychiatrists. Acad. Psychiatry 38, 121–123.

J. Torous et al. / Asian Journal of Psychiatry 17 (2015) 116–121 121

McGrath, C.L., Kelley, M.E., Dunlop, B.W., Holtzheimer 3rd, P.E., Craighead, W.E., nonepileptic seizures and functional movement disorders: neural functional

Mayberg, H.S., 2014. Pretreatment brain states identify likely nonresponse to unawareness. Clinical EEG and Neuroscience 46, 4–15.

standard treatments for depression. Biol. Psychiatry 76, 527–535. Perez, D.L., Barsky, A.J., Daffner, K., Silbersweig, D.A., 2012. Motor and somatosen-

Mega, M.S., Cummings, J.L., 1994. Frontal-subcortical circuits and neuropsychiatric sory conversion disorder: a functional unawareness syndrome? J. Neuropsy-

disorders. J. Neuropsychiatry Clin. Neurosci. 6, 358–370. chiatry Clin. Neurosci. 24, 141–151.

Ongur, D., Drevets, W.C., Price, J.L., 1998. Glial reduction in the subgenual prefrontal Pitman, R.K., Rasmusson, A.M., Koenen, K.C., Shin, L.M., Orr, S.P., Gilbertson, M.W.,

cortex in mood disorders. Proc. Natl Acad. Sci. USA 95, 13290–13295. Milad, M.R., Liberzon, I., 2012. Biological studies of post-traumatic stress

Outhred, T., Hawkshead, B.E., Wager, T.D., Das, P., Malhi, G.S., Kemp, A.H., 2013. disorder. Nat. Rev. Neurosci. 13, 769–787.

Acute neural effects of selective serotonin reuptake inhibitors versus noradren- Pizzagalli, D.A., Holmes, A.J., Dillon, D.G., Goetz, E.L., Birk, J.L., Bogdan, R., Dougherty,

aline reuptake inhibitors on emotion processing: implications for differential D.D., Iosifescu, D.V., Rauch, S.L., Fava, M., 2009. Reduced caudate and nucleus

treatment efﬁcacy. Neurosci. Biobehav. Rev. 37, 1786–1800. accumbens response to rewards in unmedicated individuals with major de-

Pascual-Leone, A., Rubio, B., Pallardo, F., Catala, M.D., 1996. Rapid-rate transcranial pressive disorder. Am. J. Psychiatry 166, 702–710.

magnetic stimulation of left dorsolateral prefrontal cortex in drug-resistant Pizzagalli, D.A., 2011. Frontocingulate dysfunction in depression: toward biomark-

depression. Lancet 348, 233–237. ers of treatment response. Neuropsychopharmacology 36, 183–206.

Perez, D.L., Barsky, A.J., Vago, D.R., Baslet, G., Silbersweig, D.A., 2015a. A neural Price, B.H., Adams, R.D., Coyle, J.T., 2000. Neurology and psychiatry: closing the great

circuit framework for somatosensory ampliﬁcation in somatoform disorders. J. divide. Neurology 54, 8–14.

Neuropsychiatry Clin. Neurosci. 27, 40–50. Ridderinkhof, K.R., Ullsperger, M., Crone, E.A., Nieuwenhuis, S., 2004. The role of the

Perez, D.L., Ortiz-Tera´ n, L., Silbersweig, D.A., 2015b. Neuroimaging in psychiatry: medial frontal cortex in cognitive control. Science 306, 443–447.

the clinical-radiographic correlate. In: Fogel, B.S., Greenberg, D.B. (Eds.), Seeley, W.W., Menon, V., Schatzberg, A.F., Keller, J., Glover, G.H., Kenna, H., Reiss,

Psychiatric Care of the Medical Patient. Oxford University Press, New York A.L., Greicius, M.D., 2007. Dissociable intrinsic connectivity networks for sa-

(In press). lience processing and executive control. J. Neurosci. 27, 2349–2356.

Perez, D.L., Murray, E.D., Price, B.H., 2015c. Depression and psychosis in neurological Stern, A.P., Cohen, D., 2013. Repetitive transcranial magnetic stimulation for treat-

practice. In: Daroff, R.B., Jankovic, J., Mazziotta, J.C., Pomeroy, S.L. (Eds.), ment resistant depression. Neuropsychiatry 3, 107–115.

Neurology in Clinical Practice. 7th Ed. Elsevier, Philadelphia (In Press). Yoshimura, S., Okamoto, Y., Onoda, K., Matsunaga, M., Okada, G., Kunisato, Y.,

Perez, D.L., Eldaief, M., Epstein, J., Stern, E., Silbersweig, D.A., 2015d. The neurobiol- Yoshino, A., Ueda, K., Suzuki, S., Yamawaki, S., 2014. Cognitive behavioral

ogy of depression: an integrated systems-level, cellular-molecular and genetic therapy for depression changes medial prefrontal and ventral anterior cingulate

overview. In: Silbersweig, D.A., Barsky, A.J. (Eds.), Depression in Medical Illness. cortex activity associated with self-referential processing. Soc. Cogn. Affect.

McGraw-Hill, New York (In press). Neurosci. 9, 487–493.

Perez, D.L., Dworetzky, B.A., Dickerson, B.C., Leung, L., Cohn, R., Baslet, G., Silbers- Zhang, D., Raichle, M.E., 2010. Disease and the brain’s dark energy. Nat. Rev. Neurol.

weig, D.A., 2015e. An integrative neurocircuit perspective on psychogenic 6, 15–28.

Asian Journal of Psychiatry 17 (2015) 133–134

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Discussion

Integrating neuroscience into psychiatric residency training

Thomas R. Insel

National Institute of Mental Health, NIH, Bethesda, MD, USA

A R T I C L E I N F O

Article history:

Received 28 August 2015

Accepted 28 August 2015

There are few areas of medicine undergoing the profound diagnostic criteria are consensus deﬁnitions of symptoms that

changes we see in psychiatry today. Over the past decade, the cluster together. While this approach offers reliability and clear

fundamental sciences underlying psychiatry have begun to shift communication, it lacks biological validity and therefore cannot

from psychology and pharmacology to neuroscience and cognitive provide the necessary precision for selecting treatments. Over the

science. As the tools of neuroscience have progressed, we can begin next ﬁve years, data from genomics, systems neuroscience, and

to understand the disorders of the mind by studying the brain. The cognitive science should help us to transform diagnostics by

two related disciplines of systems neuroscience and cognitive augmenting subjective reports with objective measures. What we

science hold particular promise for revealing how brain activity is call major depressive disorder or schizophrenia today may soon be

converted to mental activity and behavior. viewed as several distinct disorders, each requiring a different

This progress is most evident in laboratory studies. Over the past treatment. This precision medicine approach requires that we

ﬁve years, with techniques like optogenetics and chemogenetics break free of the current symptom-based categories and allow the

that permit precise manipulation of neuronal activity, neuroscien- data to direct us to a new classiﬁcation.

tists have mapped the detailed circuitry for fear, mood, reward, and The second major transformation will be in therapeutics.

social behavior in the mouse brain. The development of new optics Psychiatry for much of the past four decades has been guided by

and new tools for visualizing calcium release in individual cells now the serendipitous discoveries of medications that reduced

permit neuroscientists to watch a speciﬁc circuit in real time in a psychosis or relieved depression. Based on the efﬁcacy of these

behaving mouse. With these kinds of tools, neuroscientists are drugs, we assumed that mental disorders were ‘‘chemical

beginning to decode brain signals to read out how the brain is imbalances’’. Systems neuroscience teaches us that anatomy really

processing information nearly at the speed of thought. matters and that mental disorders can be addressed as circuit

These extraordinary laboratory tools have not yet been problems. Rather than drugs to change chemicals everywhere

translated into the clinic. But even with the less precise techniques (with unavoidable side effects), treatments can begin to focus on

of human neuroimaging and neurophysiology, we can begin to see tuning speciﬁc circuits involved in mood regulation or cognitive

how the brain is working in health and disease. Systems control. How will we tune neural circuits? Both invasive (deep

neuroscience is giving us maps of the circuitry for complex brain stimulation) and non-invasive (trans-cranial magnetic

cognition. Studies of affective bias and cognitive control are stimulation) tools have been developed for neuromodulation. It

helping us to understand some of the processes underlying mood seems likely that psychotherapy that involves learning and skill

disorders and psychosis. Neuroscience and cognitive science may building also alters regional brain function, tuning circuits through

not yet be actionable in the clinic, but they will likely have a the brain’s remarkable neuroplasticity.

transformative effect in the near future in two major areas. Residents in training today will almost certainly face a world in

First, we will see major changes in diagnosis. Psychiatric the next decade with these transformed approaches to diagnosis

diagnosis, in contrast to diagnosis in most areas of medicine, relies and treatment (Torous et al., 2015). Unfortunately, training is a

solely on observable signs and subjective symptoms. Our conservative process, largely focused on the state of the ﬁeld a

decade ago rather than preparing for the ﬁeld a decade in the

future. But we need not accept this conservative approach. If

patients are to beneﬁt from the latest science, residents need to be

E-mail address: [email protected].

http://dx.doi.org/10.1016/j.ajp.2015.08.014

1876-2018/Published by Elsevier B.V.

134 T.R. Insel / Asian Journal of Psychiatry 17 (2015) 133–134

taught the state of the art and prepared for the future. I appreciate This may be one of the most exciting times to train in psychiatry

that genomics and neuroimaging have yet to yield a biomarker or as the revolution in neuroscience begins to alter how we help

really any ﬁnding that would be essential today for clinical people with mental disorders. Just the formulation of mental

practice. But just as oncologists are learning about the genes for the disorders as brain disorders will be an important shift in perspective.

control of cell division, psychiatrists need to know the basics of When the residents of today are the seasoned clinicians of mid-

brain function and the fundamentals of cognitive science so they century, they may ﬁnd it difﬁcult to believe we ever divorced

are prepared to use the tools of the future. psychiatry from brain science. What is exciting is to realize that

Of course, few training programs in psychiatry are able to offer residents today can be the vanguard of change to create a future with

quality education in neuroscience or cognitive science. In the U.S., a a far more scientiﬁc and more effective discipline.

group of neuroscientist-psychiatrists have created a website with

lectures, videos, and discussion groups to ﬁll this gap. The National

References

Neuroscience Curriculum Initiative (www.nncionline.org) is a

useful resource for trainees anywhere who want to learn about the Ross, D.A., Arbuckle, M., Travis, M.J., 2015. ‘‘The Time is Now’’: integrating neuro-

neuroscience relevant to psychiatry (Ross et al., 2015). This online science into psychiatry training. Asian J. Psychiatry 17, 126–127.

Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A

set of teaching modules is grounded in principles of adult learning

proposed solution to integrating cognitive-affective neuroscience and neuro-

and innovative teaching methods. And it is updated regularly

psychiatry in psychiatry residency training: the time is now. Asian J. Psychiatry

based on new science and feedback from residents. 17, 116–121.

Asian Journal of Psychiatry 17 (2015) 135–137

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Discussion

Psychiatry is a clinical neuroscience, but how do we move the ﬁeld?

Rajiv Tandon *, Babu Rankupalli, Uma Suryadevara, Joseph Thornton

Psychiatry Service, North Florida/South Georgia Veterans Healthcare System, Department of Psychiatry, University of Florida College of Medicine, 1149 Newell

Drive, L4-100, Gainesville, FL 32611, USA

A R T I C L E I N F O

Article history:

Received 28 August 2015

Accepted 28 August 2015

‘‘Men ought to know that from nothing else but the brain come tree surrounded by carcasses of dogs and cats. He was experiencing

joys, delights, laughter and sports, and sorrows, grief, despon- an episode of severe depression and was dissecting the animals in

dency, and lamentations. And by this, in a special manner, we order to discover the source of black bile, which was then

acquire wisdom and knowledge, and see and hear, and know considered to cause such melancholia (‘‘melancholy’’ literally

what are foul and what are fair, what are bad and what are good, means black bile in Greek). Since Hippocrates considered

what are sweet and what are unsavory. And by the same organ depression to be caused by brain malfunction speciﬁcally due to

we become mad and delirious, and fears and terrors assail us. an excess of black bile, he considered Democritus’ behavior to be

All these things we endure from the brain when it is not essentially rational and counseled Abdera’s citizens not to worry.

healthy.’’ One common element in the two case-scenarios is the effort to

understand abnormal mental behavior in terms of speciﬁc brain

The belief that ‘mental disorders are brain disorders’ goes back

abnormality. Despite strenuous endeavors by brilliant minds from

to Hippocrates (400 BCE). The fact that the mind is a reﬂection of

around the world for over 2000 years, we ﬁnd ourselves in a

the brain’s function should be self-evident since the alternative

situation where the practice of psychiatry is substantially

would be for mental function to be based on some ethereal non-

‘‘brainless’’ or at least poorly informed by our current knowledge

earthly frame. Despite this reality, most explanations of psychiatric

of how the brain works. Just as an excess of black bile is not the

disorders are not brain-based and the practice of psychiatry

cause of melancholia, ‘‘serotonin deﬁciency’’ is not the cause of

substantially reﬂects Descartes’ mind-body dualism (Miresco and

depression either. Yet that is what many practicing psychiatrists,

Kirmayer, 2006). In their timely article, Torous et al. (2015)

as well as the preponderance of our citizens, believe is the

highlight the widening gap between recent advances in cognitive

neurobiological basis of depression today. Furthermore, most

neuroscience and the practice of psychiatry and propose a remedy

practicing psychiatrists do not comprehend the truly remarkable

illustrated with the use of a model case example.

advances in neuroscience and molecular biology that are

Going back 2400 years in time, we unearth a similar case

revolutionizing our understanding of how the brain mediates

example (Sjostrand, 2001). The citizens of the Greek city, Abdera,

the range of mental functions. What is even more worrisome is the

called upon Hippocrates to investigate the irrational behavior of

fact that this enormous gap between current knowledge and

the pre-Socratic philosopher Democritus who is now best known

clinician understanding continues to widen and that neuroscien-

for the earliest elaboration of the atomic theory of matter.

tists and clinicians no longer comprehend, let alone speak, the

Democritus, known as the ‘‘laughing philosopher’’ at the time,

other’s language.

because of periods of ‘‘excessive cheerfulness’’ was seated under a

How do we change this? While the brain is undoubtedly the

organ behind the mind, most mental functions relevant to

psychiatry (thought process, thought content, mood, emotional

* Corresponding author.

regulation, reality orientation, perception, etc.) are comprehensi-

E-mail addresses: tandon@uﬂ.edu (R. Tandon), [email protected]

ble only in their interpersonal or other social context. Furthermore,

(B. Rankupalli), [email protected] (U. Suryadevara),

[email protected] (J. Thornton). the brain is not a static organ. Just as the brain mediates mental

http://dx.doi.org/10.1016/j.ajp.2015.08.013

1876-2018/Published by Elsevier B.V.

136 R. Tandon et al. / Asian Journal of Psychiatry 17 (2015) 135–137

function, life experiences mold the brain all through life. In clearly harmful treatment modalities utilized by our ﬁeld in the

addition to philosophers (e.g. Democritus) and physicians (e.g. past, were based on poorly validated neurobiological ideas of

Hippocrates), a multitude of other professionals have appropriate- mental illness. Even today, the non-evidence based use of many

ly been involved in the effort to unravel the mysteries of mental anticonvulsants (such as gabapentin, zonisamide, topiramate,

illness. The informed practice of psychiatry will always involve pregabalin, tiagabine, levetiracetam, etc.) in a host of psychiatric

more than a solid foundation in modern neuroscience – some disorders based on some neurobiological speculation along with

understanding of philosophy, anthropology, ethology, evolution- weak anecdotal evidence is indicative of this threat. It is not

ary biology, sociology, etc. will be important. In the absence of a inconceivable that psychiatrists might begin to utilize speciﬁc

basic understanding of brain operations, however, psychiatrists rTMS or DBS for presumed ‘‘loci of depression’’ without adequate

will ﬁnd themselves increasingly incapable of providing optimal clinical trial data. In this context, the recent failure of sham-

state-of-the-art treatment to their patients. Psychiatrists must be controlled DBS studies in major depression (Dougherty et al., 2015;

able to critically evaluate emerging ﬁndings in neuroscience and Morishita et al., 2014) should sound a cautionary note.

gauge their clinical relevance. To do this, clinicians must have a If the approach proposed by Torous and colleagues is unsuitable

basic fund of accurate knowledge of neural structures, neurode- for reducing the expanding gap between rapidly advancing

velopment, neuronal and glial function, synaptic development, neuroscience and practitioner knowledge, what should we do?

molecular mechanisms, regulation of neuronal circuits, and We agree that inadequate clinical relevance and deﬁcits in

paradigms used in neuroscience research. Without the knowledge residency training are two key factors contributing to the problem.

to properly appraise neuroscience ﬁndings, the clinician will be a We also agree that we cannot wait until we have a complete

lay spectator in a speculative world. understanding of how the brain mediates mental function before

Assuming that a basic understanding of cognitive neuroscience requiring such understanding by practicing psychiatrists. How do

is essential to the practice of good psychiatry, the current lack of we better integrate the clinical with the neuroscience? We believe

such knowledge in most practitioners is disconcerting. Why this the key is recognizing that the endeavor must be a two-way street

state of affairs? Torous and co-workers attribute this to an with both clinicians and neuroscience researchers having impor-

apparent lack of clinical relevance and a deﬁcit in psychiatry tant roles to play in developing the bridge! We suggest that

residency training. Let us ﬁrst delve into the details of the neuroscientists need to better integrate ﬁndings across multiple

neuroscience-based formulation they propose. The authors differ- levels of observation, brain-behavior research needs to be more

entially localize the exemplar patient’s mood symptoms to the clinically relevant, a new generation of true translational

anterior cingulate cortex, dorsolateral prefrontal cortex, medial neuroscience-knowledgeable clinical psychiatrists fully conver-

prefrontal cortex, amygdala, and ventral striatum. They then sant with both languages is needed, overly simplistic solutions

recommend a range of speciﬁc interventions (e.g. rTMS to the should be avoided, and psychiatry educators need to carefully

dorsolateral prefrontal cortex, CBT ‘‘to treat the patient’s self- re-examine what and how they teach.

referential, negatively valenced rumination which localizes to the Hundreds of thousands of ‘‘neurobiological ﬁndings’’ and

subgenual anterior cingulate cortex’’, etc.) targeting the structures several hundred hypotheses currently ﬂourish in psychiatry (e.g.

that they implicate. Torous and co-workers recommend that such in schizophrenia; Tandon et al., 2008). With few exceptions (e.g.

case-based teaching be utilized to educate psychiatry trainees ‘‘schizophrenogenic mother’’), we have not been diligent about

‘‘because it integrates cognitive-affective neuroscience and neu- explicitly discarding ﬁndings that cannot be veriﬁed or evaluating

ropsychiatry into the real-time training experiences of residents in our ideas in a rigorous hypothesis-testing manner. We believe that

a clinically relevant way’’. Will such an approach result in an both basic neuroscientists and clinical psychiatrists need to do

adequately neuroscience-knowledgeable psychiatric practitioner? better in this regard. If there is a mound of incoherent ﬁndings,

Our answer is an unequivocal ‘‘NO’’. what do you teach? With regards to the content of neuroscience,

First, the anatomical localization model put forward by Torous we believe that greater emphasis should be placed on teaching

and co-workers represents only a small part of our current basic principles of neurobiology rather than insufﬁciently validat-

understanding of neuro-circuitry. Speciﬁc mental functions are not ed neurobiological models of psychiatric diseases (Weisberg et al.,

localized in speciﬁc brain regions as the authors’ model appears to 2008). Given the fact that our current psychiatric nosology does

suggest. While the approach of anatomic localization or ‘‘topo- not line up with biology, such teaching is even less useful or

graphic diagnosis’’ is the principal ﬁrst step currently utilized by relevant.

clinical neurologists (Arciniegas et al., 2013; Ropper et al., 2014), it What gives us hope? First, initiatives such as RDoC (Insel and

is not a ‘‘systems-level neural circuit approach’’ that the authors Wang, 2010; Insel and Cuthbert, 2015) have the potential to map

suggest it is. Clinical neurology itself is moving on from a classic brain circuitry that underlies mental functions and malfunctions –

‘‘area localization’’ approach to one that is more circuit- and here, it is critical that a testing of clearly articulated refutable

system-based and also incorporates single-neuron actions and hypotheses and rigor in examining each link characterize this process.

interactions (Cash and Hochberg, 2015). Second, recent changes in DSM-5 with the introduction of

Second, one needs to avoid oversimpliﬁcation, particularly if it dimensional assessments that have the potential to align with

superﬁcially appears to be clinically relevant. Four decades ago, a endophenotypes and RDoC circuits (e.g. Barch et al., 2013; Tandon

generation of psychiatrists was taught that monoamine deﬁciency et al., 2013) and early diagnosis (e.g. Tsuang et al., 2013) provide a

underlies depression and that dopamine excess is the basis of better bridge to a future etio-pathophysiological nosology – here, it

schizophrenia which explains why antidepressant medications is essential that clinicians utilize DSM-5 rigorously. Both basic

and antipsychotic medications, respectively, are effective agents in neuroscientists and clinicians have an important role to play in

their treatment. Despite a plethora of studies documenting these building a valid nosological bi-directional bridge (Keshavan, 2013;

assertions to be untrue, the ‘‘chemical imbalance’’ explanation of Krishnan, 2015; Tandon, 2012). Third, there are a number of

most mental illnesses prevails. Teaching on the basis of the model current efforts to develop model neuroscience curricula for

proposed by Torous et al. would likely lead to a similar ﬁxed trainees in psychiatry (Coverdale et al., 2014) – here, emphasis

inaccurate template for another generation. should be placed on teaching enduring methods and principles,

Third, there are real dangers associated with propagating avoiding cookie-cutter oversimpliﬁcations, and deleting less useful

poorly substantiated theories of the neurobiological underpin- materials (Lunn, 2015). Fourth, advances in cognitive neuroscience,

nings of mental illness. Insulin shock and prefrontal lobotomy, brain imaging, psychiatric genetics and genomics are progressing

R. Tandon et al. / Asian Journal of Psychiatry 17 (2015) 135–137 137

Keshavan, M.S., 2013. Classiﬁcation of psychotic disorders: need to move to a

so rapidly that their proper clinical application is inevitable – here,

neuroscience-informed nosology. Asian J. Psychiatry 6, 191–192.

meaningful two-way translation is imperative.

Krishnan, R.R., 2015. A knowledge network for a dynamic taxonomy of psychiatric

We agree that meaningful incorporation of current neurosci- disease. Dialogues Clin. Neurosci. 17, 79–87.

Lunn, B., 2015. Education in psychiatry. Int. Encycl. Soc. Behav. Sci. 7, 185–193.

ence knowledge into the training of psychiatrists (at all stages in

Miresco, M.J., Kirmayer, L.J., 2006. The persistence of mind-brain dualism

their career) is vital and that ‘‘the time is now’’ (Ross et al., 2015).

in psychiatric reasoning about clinical scenarios. Am. J. Psychiatry 163,

But what we teach should be carefully considered and the 913–918.

curriculum developed accordingly. Morishita, T., Fayad, S.M., Higuchi, M.A., et al., 2014. Deep brain stimulation for

treatment resistant depression: systematic review of clinical outcomes. Neu-

rotherapeutics 11, 475–484.

Ropper, A.H., Samuels, M.A., Klein, J.P., 2014. Adams and Victor’s Principles of

References Neurology, 10th ed. McGraw-Hill Education, New York.

Ross, D.A., Travis, M.J., Arbuckle, M.R., 2015. The future of psychiatry as a clinical

neuroscience: why not now? JAMA Psychiatry 72, 413–414.

Arciniegas, D.B., Anderson, C.A., Filley, C.M., 2013. Behavioral Neurology and

Sjostrand, L., 2001. Hippocrates’ evaluation of the madness of Democritus. Sven.

Neuropsychiatry. Cambridge University Press, New York.

Med. Tidskr. 5, 117–130.

Barch, D., Bustillo, J., Gaebel, W., et al., 2013. Logic and justiﬁcation for dimensional

Tandon, R., 2012. The nosology of schizophrenia: towards DSM-5 and ICD-11.

assessment of symptoms and related clinical phenomena in psychosis:

Psychiatr. Clin. North Am. 35, 557–569.

relevance to DSM-5. Schizophr. Res. 150, 15–20.

Tandon, R., Keshavan, M.S., Nasrallah, H.A., 2008. Schizophrenia, ‘‘Just the facts’’ 1.

Cash, S.S., Hochberg, L.R., 2015. The emergence of single neurons in clinical

What we know in 2008. Schizophr. Res. 100, 1–18.

neurology. Neuron 86, 79–91.

Tandon, R., Gaebel, W., Barch, D.M., et al., 2013. Deﬁnition and description of

Coverdale, J., Balon, R., Beresin, E.V., et al., 2014. Teaching clinical neuroscience to

schizophrenia in DSM-5. Schizophr. Res. 150, 3–10.

psychiatry residents: model curricula. Acad. Psychiatry 38, 111–115.

Torous, J., Stern, A.P., Padmanabhan, J.L., et al., 2015. A proposed solution to

Dougherty, D.D., Rezai, A.R., Carpenter, L.L., et al., 2015. A randomized sham-

integrating cognitive-affective neuroscience and neuropsychiatry in psychiatry

controlled trial of deep brain stimulation of the ventral capsule/ventral striatum

residency training: the time is now. Asian J. Psychiatry 17, 116–121.

for chronic treatment-resistant depression. Biol. Psychiatry 78, 240–248.

Tsuang, M.T., van Os, J., Tandon, R., 2013. Attenuated psychosis syndrome in DSM-5.

Hippocrates (c.460-c370 B.C.). In Hippocratic Corpus, On the Sacred Disease.

Schizophr. Res. 150, 31–35.

Translated by Francis Adams.

Weisberg, D.S., Keil, F.C., Goodstein, J., et al., 2008. The seductive allure of

Insel, T.R., Cuthbert, B.N., 2015. Brain disorders? Precisely. Science 348, 499–500.

neuroscience explanations. J. Cogn. Neurosci. 20, 470–477.

Insel, T.R., Wang, P.S., 2010. Rethinking mental illness. JAMA 303, 1970–1971.

17 How to get published What distinguishes a good manuscript from a bad one?

For more information visit www.publishingcampus.com

Asian Journal of Psychiatry 17 (2015) 138–139

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Commentary

Bringing neuroscience to teaching rounds: Refreshing

our clinical pidgin

Vinod Hiremagalur Srihari

Yale University, Department of Psychiatry, 34 Park Street, Rm 273A, Connecticut Mental Health Center, New Haven, CT 06519, United States

A R T I C L E I N F O

Article history:

Received 30 June 2015

Accepted 27 August 2015

Torous et al. offer a compelling proposal to ‘‘encourage all better when bled), the latter approach was derided by distin-

psychiatrists and psychiatry residents to engage in discussions guished 19th century physiologists like Claude Bernard. For him,

around localizing suspected abnormally functioning brain cir- the control of disease required experimentation in the laboratory

cuits.’’ This timely paper offers a practical approach and echoes to discover the determinism or mechanisms of disease. In this view,

concerns (Bullmore et al., 2009; Kontos et al., 2006) about the clinical observations on whole patients were tantamount to

pedagogical fallout of the current state of psychiatric practice. To ‘‘analyzing what was going on in a house by counting how many

put it more bluntly – are current workplaces inadequate learning people went in, or how much smoke came out of the chimney.’’

environments for future psychiatrists? Will they transmit a style This tension between the imaginative leaps of physiological theory

of practice that excludes emerging knowledge about the (biological psychiatry) and the discipline of checking outcomes in

neurobiology of mental illness? Torous et al. offer several clinical whole human subjects (clinical epidemiology) has been formative

examples, and are speaking as physicians, educators and for modern medicine. Both belong within the broader effort to

scientists who are engaged in the real world of practice. The reﬁne the causal stories we have of illnesses, and have existed side

proposal thus evokes a familiar and central scene at the clinical by side with another strong vein in medicine. That is, the tradition

coalface: the trainee and supervisor leaning in to their interaction of honoring the patient’s story, as a narrator of their own life and

with the patient. This is a triad in which the rubber of all our their intersection with illness, rather than merely a subject of

curricular aspirations meets the proverbial road of the clinical impersonal mechanisms.

encounter where, for better and worse, habits of practice (and These old tensions between distinct insights from the study of

learning) are acquired. As with many practical initiatives, the disease mechanisms, population-based studies and patient narra-

authors acknowledge that there is much work to be done, e.g. to tives (Greenhalgh, 1999) can enrich any clinical encounter when

develop curricular resources, train faculty and address the limits considered together, but risk caricature when used in isolation.

of our knowledge. The effort itself, however, ﬁts well within a Psychiatry led other medical specialties in articulating remedies

long-standing pluralist tradition in medicine. Psychiatry has for such false choices. For Jaspers it was indistinguishing and

been a leading exemplar of such pluralism and can indeed honoring the domains of Erkalaren (Explanation) and Verstehen

welcome and integrate ‘Cognitive-Affective Neuroscience’ and (Understanding). We can simultaneously seek to explain the causal

‘Neuropsychiatry’. impact of physiologic processes, temperamental dispositions,

Swales provided an illuminating and entertaining history of behavioral distortions or adversities while we must also seek to

three old, and often battling, ‘cultures’ in medicine (Swales, 2000). understand its meaning for an individual patient. McHugh and

While cutting-edge physiological theory (e.g. bleeding to target Slavney have advocated taking distinct perspectives on each case –

inﬂammation from excessive blood volume) had to sometimes akin to looking through different lenses – of Disease, Disposition,

yield to empirical evidence (patients with typhoid did not fare Behavior and Narrative (McHugh and Slavney, 2012). While Engel’s

biopsychosocial framework listed the different levels from which

to consider the patients’ predicament, the challenge for the

E-mail address: [email protected]. clinician (and indeed the clinical scientist) is often to wager limited

http://dx.doi.org/10.1016/j.ajp.2015.08.011

V.H. Srihari / Asian Journal of Psychiatry 17 (2015) 138–139 139

resources on the few levels most likely to leverage results described ‘contact languages’ that develop to allow basic

(Heninger, personal communication). A principled pluralism communication (Cooper, 2014). The ﬁrst product of such efforts

(Ghaemi and McHugh, 2007) must then choose which perspective are often pidgins which, lacking a grammar or written text, cannot

to emphasize, while remaining open to constraints from the others. sustain much more than a basic coordination of efforts. However,

For a particular case, formulating a detailed narrative (normal when the young grow up speaking the pidgin as natives, full-

grief) can be the key element of treatment, while in others, ﬂedged languages – creoles – can develop and sustain a deeper

knowledge of the relevant pathophysiological process (Alzheimer’s engagement. So, while we follow Torous et al. in their quest

disease) can organize a holistic plan of care. to bring ‘circuit talk’ into the pidgin that thoughtful clinicians are

We need to train multi-lingual psychiatrists (Srihari, 2008). constructing everyday, we can hope that what proves useful will

The metaphor of language points to the challenges and rewards then become part of the language of ordinary practice.

of such learning. The ‘‘circuit talk’’ (my inelegant phrase)

exempliﬁed by Torous et al., is a welcome addition to this Conﬂicts of interest

mix. Indeed, as a relatively recent entrant to the already noisy

clinical encounter, it might need more nurturing and attention None.

from clinical educators. The case presented by the authors

vividly illustrates both the promise and the challenge: while the References

young woman with depression provides a pedagogically live

Bullmore, E., Fletcher, P., Jones, P.B., 2009. Why Psychiatry Can’t Afford to be

opportunity to discuss circuit dysfunction (and to keep the spirit

Neurophobic.

of Claude Bernard alive in the clinic), the treatments currently

Cooper, R., 2014. Psychiatry and Philosophy of Science. Routledge.

available (an SNRI and CBT) can be adequately applied without Ghaemi, S.N., McHugh, P.R., 2007. The Concepts of Psychiatry: A Pluralistic Ap-

proach to the Mind and Mental Illness.

this discussion. Indeed, the clinical encounter is the province of

Greenhalgh, T., 1999. Narrative based medicine: narrative based medicine in an

many disciplines that vie for a voice – ethics, philosophy,

evidence based world. BMJ 318, 323–325.

statistics, history, literature. Biological psychiatry itself has Kontos, N.N., Querques, J.J., Freudenreich, O.O., 2006. The problem of the psycho-

pharmacologist. Acad. Psychiatry 30, 218–226, http://dx.doi.org/10.1176/

domains such as genetics, imaging and electrophysiology that,

appi.ap.30.3.218.

like the other disciplines, have developed distinct technical

McHugh, P.R., Slavney, P.R., 2012. Mental illness – comprehensive evaluation

languages. These are languages that the clinician needs to at or checklist? N. Engl. J. Med. 366, 1853–1855, http://dx.doi.org/10.1056/

least work with if not fully understand. And how must all of this NEJMp1202555.

Srihari, V., 2008. Evidence-based medicine in the education of psychiatrists. Acad.

be communicated to our patients?

Psychiatry 32, 463–469, http://dx.doi.org/10.1176/appi.ap.32.6.463.

The study of trade between distinct cultures can offer optimism Swales, J., 2000. The troublesome search for evidence: three cultures in need of

to the beleaguered clinician educator. Anthropologists have integration. J. R. Soc. Med. 93, 402–407.

Asian Journal of Psychiatry 17 (2015) 122–123

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Discussion

Bridging the brain–mind divide in psychiatric education:

The neuro-bio-psycho-social formulation

David A. Silbersweig

Brigham and Women’s Hospital, Harvard Medical School, United States

A R T I C L E I N F O A B S T R A C T

Article history: Psychiatrists of the future need to have a strong working knowledge of the organ they work with—the

Received 28 August 2015

brain. Neuropsychiatry is now more than a paradigm. Systems-level behavioral neuroscience, while still

Accepted 28 August 2015

evolving, is mature enough to provide circuit-based foundation. Cellular and molecular neuroscience is

starting to yield further mechanistic understanding. It is important to integrate such approaches into an

Keywords:

evidence-based, bio-psycho-social formulation, with increasing implications for disease taxonomy,

Neuropsychiatry

diagnosis and treatment.

Behavioral neuroscience

ß 2015 Published by Elsevier B.V.

Psychiatric education

The brain is the organ of the mind. While traditionally deﬁned simplistic localization toward a model of distributed modular

psychiatric disorders have not been associated with macroscopic functions integrated through structural and functional connectiv-

brain lesions, the advent of functional neuroimaging has demon- ity (Bastos-Leite et al., 2015). The paper points to clinical relevance

strated neuropsychological/neuropsychiatric structure–function– in the context of therapeutics, rightly citing evolving invasive and

symptom–syndrome relationships (Silbersweig and Stern, 1997). non-invasive brain stimulation techniques, and neural imaging

An examination of the perceptual, cognitive, emotional and correlates and predictors of response to pharmacotherapy and

behavioral effects of neurologic lesions and brain stimulation psychotherapy (Dunlop and Mayberg, 2014). For many less

provide convergent evidence of such relationships (Butler et al., severely affected and non-refractory patients, and since we are

2012). Final common pathways of clinical behavioral expression not yet at the age of clinically useful functional neuroimaging, the

are being deﬁned, upon which various pathophysiologies, from relevance of circuit models to individual patients and discussions

numerous etiologies, as well as various therapeutic modalities, act may remain more theoretical than practical but not necessarily

(Epstein and Silbersweig, 2015). As systems-level neuroscience is premature. Regarding local expertise, it is the case that many

integrated with cellular and molecular science (Deisseroth et al., centers do not yet have a depth of neuropsychiatric expertise, but

2015), and a clinical relevance starts to grow, it is time for a more as suggested by the authors, web-based modules could be very

updated, integrated and effective approach to neuropsychiatric helpful. This might suggest that rather than this being part of the

education for the next generation of our ﬁeld. formulation for every case, it might still be performed regularly,

Torous et al. (2015) have described an excellent method for but reserved for speciﬁc teaching cases or conferences. This would

linking clinical case formulation with models of brain circuit also be appropriate, as there are not that many main nodes and

dysfunction. Such case-based, interactive approaches have practi- circuits to learn, though there are many subtleties and levels that

cal and pedagogical beneﬁts, with active learning of salient could be incorporated in places with local expertise in neuropsy-

material. They also help to transform the clinical educational chiatry (not just biological psychiatry). A circuit-based approach

culture, compared with didactic approaches that are not woven will ultimately blossom as neuroimaging biomarkers are developed

into the everyday work ﬂow. that stratify patient populations, deﬁning mechanism-based sub-

The authors address key issues, such as whether the scientiﬁc groups, with diagnostic, therapeutic and prognostic implications

evidence is mature enough, whether there is direct clinical (Dunlop and Mayberg, 2014). Indeed, the foundation for a new

relevance, and whether local expertise would exist in most biologically-based taxonomy for psychiatric disorders, crossing

institutions. As they point out, there certainly is a robust literature traditional DSM categories, is being developed (Insel, 2014).

supporting a circuit-based conceptualization of major psychiatric Essentially, one could advocate the explicit addition of neural

disorders (Ressler and Mayberg, 2007). It is moving beyond circuitry to the classic bio-psycho-social formulation, creating a

http://dx.doi.org/10.1016/j.ajp.2015.08.020

1876-2018/ß 2015 Published by Elsevier B.V.

D.A. Silbersweig / Asian Journal of Psychiatry 17 (2015) 122–123 123

new neuro-bio-psycho-social formulation. To be meaningful, the attitudes and outcomes. The neuro-bio-psycho-social formulation

different arms of the formulation need to be not only listed but also should have to withstand such a test. That said, such a formulation

integrated. This is where the incorporation of neuroscience can be can be helpful with required neuroscience milestones (Benjamin,

critical. Neural plasticity and epigenetics provide mechanisms that 2013), as noted by the authors. In a related fashion, and most

mediate organism–environment interactions in the context of importantly, it can be important in helping our brain–mind

neurodevelopment (Klengel and Binder, 2015). The authors doctors-in-training to become the contemporary and future

describe this approach nicely in their clinical example. A more specialists that our suffering patients so deserve.

complete formulation could start to address risk and resilience

factors, as well as implications for trajectory-altering, earlier

interventions, or ultimately prevention (Charney and Manji, 2004). References

But is therapeutics the only main area for clinical relevance of a

Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A

neuro-bio-psycho-social formulation? The other major clinical

proposed solution to integrating cognitive-affective neuroscience and neuro-

domain that the authors might have discussed is diagnostics. Even psychiatry in psychiatry residency training: The time is now. Asian J. Psychiatr..

before the hopefully coming age of clinical scanning in psychiatry, [Epub ahead of print] PubMed PMID: 26054985.

Bastos-Leite, A.J., Ridgway, G.R., Silveira, C., Norton, A., Reis, S., Friston, K.J., 2015.

every clinician is faced with the challenge of differential diagnosis.

Dysconnectivity within the default mode in ﬁrst-episode schizophrenia: a

While most cases may be more straightforward, a not insigniﬁcant

stochastic dynamic causal modeling study with functional magnetic resonance

(and under-recognized) number of cases raise issues where a imaging. Schizophr. Bull. 41 (1), 144–153, http://dx.doi.org/10.1093/schbul/

sbu080.

knowledge of neuropsychiatric circuits is very relevant. Should this

Benjamin, S., 2013. Educating psychiatry residents in neuropsychiatry and neuro-

patient with this presentation get a brain scan (if so, what kind), an

science. Int. Rev. Psychiatry 25 (3), 265–275, http://dx.doi.org/10.3109/

EEG, a lumbar puncture (looking for what)? A knowledge of the key 09540261.2013.786689.

Butler, T., Weisholtz, D., Isenberg, N., Harding, E., Epstein, J., Stern, E., Silbersweig, D.,

brain circuits underlying major psychiatric phenomenology,

2012. Neuroimaging of frontal-limbic dysfunction in schizophrenia and epilep-

combined with a knowledge of the ways in which various

sy-related psychosis: toward a convergent neurobiology. Epilepsy Behav. 23 (2),

syndromes and pathophysiologies present, is essential here (Mega 113–122, http://dx.doi.org/10.1016/j.yebeh.2011.11.004.

and Cummings, 1994). While the psychiatrist can still refer Cao, H., Duan, J., Lin, D., Shugart, Y.Y., Calhoun, V., Wang, Y.P., 2014. Sparse

representation based biomarker selection for schizophrenia with integrated

patients for neurological evaluation, the referring physician needs

analysis of fMRI and SNPs. Neuroimage 102 (PART 1), 220–228, http://

to determine the timing and threshold, if not the reason, for such dx.doi.org/10.1016/j.neuroimage.2014.01.021.

consultation and work-up. In fact, the neurologist also needs to be Charney, D.S., Manji, H.K., 2004. Life stress, genes, and depression: multiple path-

ways lead to increased risk and new opportunities for intervention. Sci STKE

more familiar with the emotional and behavioral sequelae of

2004 (225), re5, http://dx.doi.org/10.1126/stke.2252004re5.

speciﬁc neurologic lesions and conditions (Tekin and Cummings,

Deisseroth, K., Etkin, A., Malenka, R.C., 2015. Optogenetics and the circuit dynamics

2002). Perhaps this neurobehavioral formulation could be of psychiatric disease. JAMA 313 (20), 2019–2020, http://dx.doi.org/10.1001/

jama.2015.2544.

promulgated within neurology training programs as well.

Dunlop, B.W., Mayberg, H.S., 2014. Neuroimaging-based biomarkers for treatment

Torous et al. (2015) bring up the inevitable issue of when and

selection in major depressive disorder. Dialogues Clin. Neurosci. 16 (4), 479–490.

how more basic scientiﬁc knowledge might be integrated with Epstein, J., Silbersweig, D., 2015. The neuropsychiatric spectrum of motivational

disorders. J. Neuropsychiatry Clin. Neurosci. 27 (1), 7–18, http://dx.doi.org/

clinical case formulations. While it may be best to start with the

10.1176/appi.neuropsych.13120370.

systems-level, for the reasons discussed, the advent of clinically

Huang, T.L., Lin, C.C., 2015. Advances in biomarkers of major depressive disorder.

meaningful genetic, metabolomic, proteomic, lipidomic and other Adv. Clin. Chem. 68, 177–204, http://dx.doi.org/10.1016/bs.acc.2014.11.003.

Insel, T.R., 2014. The NIMH Research Domain Criteria (RDoC) Project: precision

omic biomarkers is probably just a matter of time (Huang and Lin,

medicine for psychiatry. Am. J. Psychiatry 171 (4), 395–397, http://dx.doi.org/

2015). Evidence base and common sense will determine when and 10.1176/appi.ajp.2014.14020138.

how to best incorporate such material. In the meantime, some of Klengel, T., Binder, E.B., 2015. Epigenetics of stress-related psychiatric disorders and

gene environment interactions. Neuron 86 (6), 1343–1357, http://dx.doi.org/ the known connections between human neural circuit function Â

10.1016/j.neuron.2015.05.036.

and functional genetic polymorphisms and basic neuroscientiﬁc

Mega, M.S., Cummings, J.L., 1994. Frontal-subcortical circuits and neuropsychiatric

translational animal studies can be integrated into case formula- disorders. J. Neuropsychiatry Clin. Neurosci. 6 (4), 358–370.

tion discussions (Cao et al., 2014). Ressler, K.J., Mayberg, H.S., 2007. Targeting abnormal neural circuits in mood

and anxiety disorders: from the laboratory to the clinic. Nat. Neurosci. 10

Another thing that should determine when and how educa-

(9), 1116–1124, http://dx.doi.org/10.1038/nn1944.

tional innovations are incorporated, not mentioned in this paper, is Silbersweig, D.A., Stern, E., 1997. Symptom localization in neuropsychiatry. A

evidence. Increasingly, educational research, with rigorous study functional neuroimaging approach. Ann. NY Acad. Sci. 835, 410–420.

Tekin, S., Cummings, J.L., 2002. Frontal-subcortical neuronal circuits and clinical

designs, methods and metrics, is the means of determining

neuropsychiatry: an update. J. Psychosom. Res. 53 (2), 647–654.

whether a new curricular or experiential element is effective

Verduin, M.L., Boland, R.J., Guthrie, T.M., 2013. New directions in medical education

(Verduin et al., 2013). This can guide how ever-limited time and related to psychiatry. Int. Rev. Psychiatry 25 (3), 338–346, http://dx.doi.org/

10.3109/09540261.2013.784958.

resources should be allocated to advance knowledge, skills,

Asian Journal of Psychiatry 17 (2015) 124–125

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Discussion

Remembering psychiatry’s core strengths while incorporating neuroscience

a,c, b,c b,c

Oliver Freudenreich *, Nicholas Kontos , John Querques

Schizophrenia Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States

Division of Psychiatry and Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States

Harvard Medical School, Boston, MA, United States

A R T I C L E I N F O

Article history:

Received 28 August 2015

Accepted 28 August 2015

Despite decades-long efforts to integrate psychiatry and that Torous et al. rightly highlight as foundational for circuit-based

neuroscience, successive generations have failed to craft a understanding of psychiatric illness was published almost three

neuroscience-informed psychiatry that contributes to patient care decades ago. Several obstacles come to mind, none of them trivial.

meaningfully. Perhaps a clear reappraisal of psychiatry’s core For one, perhaps only now have we developed tools such as

strength as a clinical discipline can provide the framework for a optogenetics (Deisseroth et al., 2015) to probe psychiatrically

successful union of bench and bedside that neither sells the relevant neurocircuits meaningfully enough to move beyond very

discoveries of neuroscience short nor exaggerates their promises. crude ideas (e.g., that the amygdala is related to fear). Second,

We agree in principle with Torous and colleagues (Torous et al., Kraepelin’s enduring model of discrete, natural disease entities

2015) that psychiatry can become a specialty that truly uses (natu¨ erliche Krankheitseinheiten, in German) might be wrong for

knowledge about our organ of interest, the brain, in caring for our major disorders like depression and schizophrenia. Dysfunctions in

patients. To that end, Torous et al. urge psychiatry to integrate widely distributed and dynamic neuronal networks might not lend

training in cognitive-affective neuroscience and neuropsychiatry themselves to the rigid bounds of purportedly naturally occurring

into residency training. They argue that we have reached the point diseases carved out of phenomenologic and longitudinal observa-

where patient discussions can be informed by circuit-based tion of clinical signs and symptoms. It is no accident, and speaks to

neuropsychiatric analysis, comparable to the lesion-based model these conceptual difﬁculties, that we have basically failed to

in neurology. Including neuroscientiﬁc knowledge in the herme- incorporate any ﬁndings from decades of neuroscience research

neutic function of clinical psychiatry will not only serve patients into the most recent revision of the Diagnostic and Statistical

but also help the ﬁeld to remain at the forefront of enthusiasm over Manual of Mental Disorders (DSM) (Keshavan, 2013). Indeed, the

medical progress. Torous et al.’s proposal is timely as evidenced by National Institute of Mental Health has felt compelled to propose a

a recent viewpoint in JAMA Psychiatry entitled, ‘‘The future of parallel classiﬁcation system for research purposes (i.e., the

psychiatry as clinical neuroscience. Why not now?’’ that similarly Research Domain Criteria) that does not map onto DSM clinical

argues for the need to examine our identity and future critically categories but instead tries to understand cross-diagnostic

(Ross et al., 2015). constructs such as systems for social processes (Insel et al.,

However, if we want to be successful this time, we need to step 2010). Is it then surprising that determining what to teach

back and answer the question: What is taking so long and why is it residents about neuroscience has proven difﬁcult? Last and most

so difﬁcult? After all, the seminal article by Alexander et al. (1986) importantly, psychiatry as a clinical endeavor is more than

neuroscience; much needs to be taught that has to do with actual

patient care. The skills of observing and eliciting psychological

signs and symptoms and choosing among myriad options within

* Corresponding author at: Erich Lindemann Mental Health Center, 25 Staniford

Street, Boston, MA 02114, United States. Tel.: +1 617 912 7800. and between treatment modalities remain at the core of

E-mail address: [email protected] (O. Freudenreich). psychiatric practice and beyond the reach of contemporary

http://dx.doi.org/10.1016/j.ajp.2015.08.019

O. Freudenreich et al. / Asian Journal of Psychiatry 17 (2015) 124–125 125

neuroscience. In addition to diagnosis and treatment, issues of in interdisciplinary learning) to get to a neuroscience-informed

suffering, coping with illness, and adherence require knowledge psychiatry seems an achievable goal for resident education, with

about the human condition. incremental progress as opposed to a revolution. As Torous and

These challenges aside, we agree with the authors that the time colleagues note, exposure to clinical cases is critical and can

is now to begin seriously the task of developing curricula and probably not be accomplished without meaningful, as opposed to

teachers to satisfy the unmet needs for understanding and pro forma, training in neurology.

applying neurobiology and brain function. Emphasizing neuropsychiatry andneuroscience need not fashion

Without training in neuroscience, clinicians are unable to the mindless, brain-based psychiatry feared by some (Eisenberg,

separate the hype from the promise. Our patients expect us to be 1986). Nor does it abrogate the need to know about the human side

up on recent scientiﬁc developments, but we also need to be able to of medicine, including irresponsibility, deception, and other ‘‘dirty’’

synthesize and translate research ﬁndings and put them into a parts of human nature encountered in patient care (Freudenreich et

patient’s individual context in order to give reasoned advice. Are al., 2010). On the contrary, to place neuroscientiﬁc ﬁndings in their

antipsychotics causing gray matter changes? Is psychosis stress- real-world context, we will need to be informed by anthropology,

induced? Are my amygdalae overactive? All are questions that philosophy, and sociology. Trained in the medical model, psychia-

patients might ask. Also, new technologies (e.g., transcranial trists qua physicians think in terms of diagnosis, differential

magnetic stimulation [TMS] or direct brain stimulation [DBS]) that diagnosis, treatment, and prognosis. As a result, we should expect

target brain circuits need to be understood so patients can be ourselves, and teach our trainees, to identify the demonstrably

referred appropriately if other treatments fail. ‘‘organic’’ contributions to brain dysfunction, which will increasing-

On a more abstract level, one needs to be able to ﬁeld ly include circuit-based concepts, and to recognize when more

statements (often spun directly from psychiatry’s efforts to reduce existential, psychological (e.g., fear, despair, loss), and environmen-

stigma) from patients about mental illnesses, as mechanical tal factors (i.e., the social determinants of health) predominate.

invocations of ‘‘chemical imbalances’’ may no longer sufﬁce.

Further, as neurobiological correlates of complex human qualities

References

such as morality, decision-making, and attachment reveal

themselves, psychiatrists face complex ethical questions about

Alexander, G.E., DeLong, M.R., Strick, P.L., 1986. Parallel organization of functionally

autonomy, responsibility, the boundaries of psychopathology, and segregated circuits linking basal ganglia and cortex. Annu. Rev. Neurosci. 9,

357–381.

enhancement therapies. Personal opinions and afﬁliations with

Deisseroth, K., Etkin, A., Malenka, R.C., 2015. Optogenetics and the circuit dynamics

psychiatric ‘‘schools of thought’’ are no longer sufﬁcient for

of psychiatric disease. JAMA 313, 2019–2020.

navigating these new waters in medical ethics (i.e., ‘‘neuroethics’’). Eisenberg, L., 1986. Mindlessness and brainlessness in psychiatry. Br. J. Psychiatry

An informed, contemporary understanding of brain functioning is 148, 497–508.

Freudenreich, O., Kontos, N., Querques, J., 2010. The muddles of medicine: a

needed in order to inform responsible, moral medical activity

practical, clinical addendum to the biopsychosocial model. Psychosomatics

when issues of autonomy, for example, are raised. 51, 365–369.

While Torous et al.’s proposal is urgent, it is not an emergency. Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D.S., Quinn, K., Sanislow, C.,

Wang, P., 2010. Research domain criteria (RDoC): toward a new classiﬁcation

As a start, we might simply need to better teach residents that

framework for research on mental disorders. Am. J. Psychiatry 167, 748–751.

there are differences between clinically discrete lesion-based Keshavan, M.S., 2013. Nosology of psychoses in DSM-5: inches ahead but miles to

pathology (e.g., post-stroke depression), limited circuit-based go. Schizophr. Res. 150, 40–41.

Ross, D.A., Travis, M.J., Arbuckle, M.R., 2015. The future of psychiatry as clinical

pathology (e.g., frontal network syndromes as seen in patients

neuroscience: why not now? JAMA Psychiatry 72, 413–414.

with dementias and traumatic brain injuries), and widely

Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A

distributed network-based dysfunctions with signiﬁcant dynamic proposed solution to integrating cognitive-affective neuroscience and neuro-

psychiatry in psychiaty residency training: the time is now. Asian J. Psychiatry

aspects and pathologies in the coordinated activities of neuronal

17, 116–121.

assemblies (e.g., those targeted by TMS and DBS) (Uhlhaas, 2015).

Uhlhaas, P.J., 2015. Neural dynamics in mental disorders. World Psychiatry 14,

Teaching those differences (with the help of neurology as a partner 116–118.

Asian Journal of Psychiatry 17 (2015) 126–127

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Commentary

‘‘The time is now’’: Integrating neuroscience into psychiatry training

a, b c

David A. Ross *, Melissa R. Arbuckle , Michael J. Travis

Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States

Department of Psychiatry, Columbia University College of Physicians and Surgeons, United States

Department of Psychiatry, University of Pittsburgh Medical Center, United States

A R T I C L E I N F O

Article history:

Received 28 August 2015

Accepted 28 August 2015

This is an extraordinary time for psychiatry, as new research in to create an adaptable frame that can be easily implemented by

neuroscience is re-deﬁning the essence of how we conceptualize anyone, anywhere. To this end, each course has a comprehensive

psychiatric illness. In this issue, Torous et al. (2015) have written a Facilitator’s Guide that includes detailed instructions for imple-

signiﬁcant paper that captures at once the excitement of new work mentation, sample scripts that can be used in class, additional

in the ﬁeld and the importance of meaningfully incorporating this background readings, and, in many cases, videos of a neuroscience

perspective into both clinical and educational settings. The authors and/or education expert teaching that exact session.

also review some of the many challenges to doing so effectively. To date, the NNCI has developed six separate teaching ‘‘modules’’,

The authors’ work comes at a time when many academics are each of which reﬂects one potential paradigm by which one could

wrestling with this same question and the authors refer to various teach neuroscience effectively. Each module is designed to offer a

ongoing efforts seeking to address this practice gap. One such structure through which a wide range of content can be taught as

program is the National Neuroscience Curriculum Initiative (Ross individual sessions. Critically, the course frame also enables

et al., 2015; www.NNCIonline.org). The NNCI was formally materials to be ﬂexibly updated as content continues to evolve.

launched in March of 2014 with the overarching goal of creating While much of the NNCI effort has so far been aimed at

a set of open resources that will help improve the teaching of facilitating in-class teaching and learning for psychiatry residents,

neuroscience in psychiatry. Similar to Torous et al.’s goal of helping we are mindful of the value the initiative may have for other

trainees ‘‘bridge, in real-time, brain-symptom relationships in populations (including medical students and community clinicians).

psychiatry’’, the NNCI sets as a central objective that ‘‘residents will To this end, all NNCI resources are freely available via a website,

incorporate a modern neuroscience perspective as a core compo- including a rapidly expanding set of self-study materials. We are also

nent of every formulation and treatment plan.’’ Additional learning developing teaching resources that are designed to engage more

objectives relate to relevant knowledge, attitudes towards diverse audiences with the critical process of incorporating speciﬁc

neuroscience, and speciﬁc behavioral skills – including that neuroscience ﬁndings directly into clinical practice.

residents will be able to serve as Ambassadors of Neuroscience Importantly, the NNCI reﬂects a collaborative effort. The core

who can thoughtfully communicate ﬁndings from the ﬁeld to different leadership team is comprised of clinician educators from four large

audiences. university programs. This effort would not be possible without the

The core work of the NNCI has been the creation of educational ﬁnancial support of the NIMH. We have also established relation-

resources that can be used as in-class teaching and learning ships with the American Association of Directors of Psychiatric

activities for residency programs. The guiding principles for these Residency Training, the American Psychiatric Association Council on

resources are: to maintain an integrative, patient centered Medical Education and Lifelong Learning, the Society of Biological

approach; to teach well, by applying adult learning theory; and Psychiatry, and the American College of Neuropsychopharmacology.

We continue to seek partnership from other individuals and

organizations that share a common interest and vision.

In the year since its formal launch, the NNCI has been met with

* Corresponding author.

warmth and approval from the academic community. We believe

E-mail address: [email protected]">[email protected] (D.A. Ross).

http://dx.doi.org/10.1016/j.ajp.2015.08.018

D.A. Ross et al. / Asian Journal of Psychiatry 17 (2015) 126–127 127

this speaks to training directors’ belief in the importance of the We agree wholeheartedly and hope that key stakeholders will

mission (Benjamin et al., 2014) and also their motivation to update continue to explore collaborative approaches for addressing this

their curricula (in line with the various recent data reviewed by critical mission.

Torous et al., in the introduction to their paper). More than

30 residency programs have already incorporated NNCI resources References

into their curricula and more than 200 individuals have signed up

as members of the NNCI Learning Collaborative. We have also Benjamin, S., Travis, M.J., Cooper, J.J., Dickey, C.C., Reardon, C.L., 2014. Neuropsy-

received more than 50 submissions of new content that we are chiatry and neuroscience education of psychiatry trainees: attitudes and bar-

riers. Acad. Psychiatry 38 (2), 135–140.

actively reviewing and editing.

National Neuroscience Curriculum Initiative. Available at: www.NNCIonline.org.

Torous et al. write: ‘‘the time is now for residents, educators and Ross, D.A., Travis, M.J., Arbuckle, M.R., 2015. The future of psychiatry as clinical

like-minded academic psychiatrists to develop a culture of neuroscience: why not now? JAMA Psychiatry 72, 413–414.

Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A

embracing cognitive-affective neuroscience and neuropsychiatry

proposed solution to integrating cognitive-affective neuroscience and neuro-

to expedite the ‘‘bench-to-bedside’’ translation of brain-symptom psychiatry in psychiatry residency training: the time is now. Asian J. Psychiatry

relationships to help guide clinical thinking and future innovative 17, 116–121.

therapeutic interventions.’’

Asian Journal of Psychiatry 17 (2015) 128–129

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Discussion

Facing our future

a,b,c,

Bruce H. Price *

Department of Neurology, McLean Hospital, United States

Massachusetts General Hospital, United States

Harvard Medical School, United States

A R T I C L E I N F O

Article history:

Received 28 August 2015

Accepted 28 August 2015

I welcome this thoughtful, forward-thinking article on three Further reﬁnements based on the author’s recommendations

counts. The authors represent the present and future of follow. Given the core network anatomic approach, psychiatrists

neuropsychiatry. They highlight that a ﬁrm understanding of the should become familiar with the interpretation of structural and

neural structures and core networks which mediate emotions, functional MRI scans. Mental status and cognitive examinations

behavior, and cognition is foundational. And they propose should be anchored in neuroanatomy. Further focus on the

solutions for psychiatry training programs. prediction, prevention, rehabilitation, and recovery of psychiatric

Over the last several decades, outmoded views have gradually disorders should occur. Academic neuropsychology needs to help

given way to more modern neuroscientiﬁc thinking (Price et al., us reﬁne more precise brain–behavior relationships. Investigations

2000). Instead of ‘‘nature versus nurture,’’ we now understand that should also be fostered regarding pain and suffering. The autopsy

although brain regions are not dedicated to a speciﬁc function, remains a central teaching and research tool in modern medicine.

there are core networks based on intrinsic mechanisms which are In academic centers with brain banks, the procurement of brain

inﬂuenced by extrinsic, environmental factors. Thus, it becomes a autopsies for current and future research purposes should be

magniﬁcent interplay between nature and nurture, genetics and encouraged (Schmitt et al., 2008).

epigenetics. The old notion of ‘‘mind over matter’’ has now shifted Let me raise several cautions. We must avoid reductionism and

given our knowledge that mental forces can transform brain oversimpliﬁcation, that ‘‘behind every crooked thought lies a

matter. For instance, cognitive behavioral therapy can change crooked molecule.’’ Addiction is a prime example. There is no quick

brain patterns to the beneﬁt of patients with obsessive–compul- biological ﬁx for such a complex problem. There is a core network

sive and depressive disorders (Yoshimura et al., 2014). Another dysfunction but it must be understood in the broader context of

American adage ‘‘sticks and stones may break my bones but words social determinants. The interplay is inseparable and we must not

will never hurt me’’ has been replaced by our understanding that remain aloof from environmental forces. In fact, we should join all

childhood abuse, including bullying, as well as acute and chronic efforts to combat addiction. We need to further explore and exploit

stress may have a permanent impact upon brain organization and the therapeutic relationships between doctors, patients, and

behavior (Pitman et al., 2012). We are closing the gap between families. This need has never been more apparent despite the

psychiatry and neurology, joined by the shared foundation of basic current erosion of the allotted patient/doctor time where

and clinical neuroscience. There is clearly ‘‘a psychiatry of education, trust, hope, faith, and optimism are nurtured. Psycho-

neurology’’ and ‘‘a neurology of psychiatry.’’ We should abandon therapy remains critically important and research into it deserves

the term ‘‘organic brain syndrome’’ as a relic of history which has more support. This also means that our ﬁelds must interrelate

separated neurology and psychiatry. This article serves as a clarion more and more with philosophy, ethics, law and the humanities.

call to close ranks in a more collaborative fashion. As a practical suggestion, after a patient has been presented at

rounds, the following questions should be asked: What brain

circuit/symptom relationships have been disrupted? What do we

know that directly applies to the patient and what do we need to

* Correspondence to: Department of Neurology, McLean Hospital, Belmont, MA

know but do not? What research questions can be asked and

02478, United States.

E-mail address: [email protected] possibly answered to close this gap?

http://dx.doi.org/10.1016/j.ajp.2015.08.017

1876-2018/ß 2015 Published by Elsevier B.V.

B.H. Price / Asian Journal of Psychiatry 17 (2015) 128–129 129

References

Finally, we must be wary of overpromise in medicine. We have

made enormous gains in neuroscience, yet it is astonishing at times

Price, B.H., Adams, R.D., Coyle, J.T., 2000. Neurology and psychiatry: closing the great

how little we know about brain–behavior relationships. Humility

divide. Neurology 54, 8–14.

combined with passion, dedication, and creativity remains the Yoshimura, S., Okamoto, Y., Onoda, K., Matsunga, M., Okada, G., Kunisato, Y.,

Yoshino, A., Ueda, K., Susuki, S., Yamawaki, S., 2014. Cognitive behavioral

most adaptive approach.

therapy for depression changes medial prefrontal and ventral anterior cingulate

This article calls for conceptual and institutional shifts in both

cortex activity associated with self-referential processing. Soc. Cognit. Affect.

psychiatry, and, in my opinion, neurology, letting go of outmoded Neurosci. 9 (4), 487–498.

ways while welcoming new, more biologically informed para- Pitman, R.K., Rasmusson, A.M., Koenen, K.C., Shin, L.M., Orr, S.P., Gilbertson, M.W.,

Milad, M.R., Liberzon, I., 2012. Biological studies of post-traumatic stress

digms and interventions. Scientiﬁc discovery and brain science

disorder. Nat. Rev. Neurosci. 13, 769–787.

have never been more promising. The times are ripe for change. Schmitt, A., Parlapani, E., Bauer, M., Heinsen, H., Falkai, P., 2008. Is brain banking

The challenge for us is to muster our forces and introduce the of psychiatric cases valuable for neurobiological research? Clinics 63 (2),

255–266.

necessary changes by example (Cunningham et al., 2006; Perez

Cunningham, M.G., Goldstein, M., Katz, D., O’Neill, S.Q., Joseph, A.B., Price, B.H., 2006.

et al., 2015). Psychiatry and neurology should move forward Coalescence of psychiatry, neurology, and neuropsychology. From theory to

together. One of the many salutary effects may be that increasing practice. Harv. Rev. Psychiatry 127–140.

Perez, D., Murray, E.D., Price, B.H., 2015. Depression and psychosis in neurological

numbers of medical students will be drawn to our vibrant

practice. In: Bradley, W.G., Daroff, R.B., Fenichel, G.M., Jankovic, J. (Eds.),

disciplines, creating new leadership and more fundamental

Neurology in Clinical Practice. 7th ed. Butterworth Heinemann. knowledge.

Asian Journal of Psychiatry 17 (2015) 130

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Discussion

The importance of teaching neuroscience to psychiatric residents in

the context of psychological formulations

Carl Salzman

Professor of Psychiatry, Harvard Medical School, United States

A R T I C L E I N F O

dysfunctions of the transportation system, but the resulting

Article history:

symptoms are the same: no trafﬁc moves. Similarly, psychiatric

Received 28 August 2015

disorders may share a ﬁnal symptomatic picture (e.g. psychosis,

Accepted 28 August 2015

depression, anxiety) but the root causes of the symptoms may be

many and varied. Not all psychiatric disorders are the result of the

same neurobiologic dysfunction. Medicine is ﬁlled with similar

heterogeneous disorders with similar symptoms: a fever or cough

Drs. Torous, Stern, Padmanabhan, Keshavan and Perez are to be or pain may have many different causes, but the patient’s

congratulated for deﬁning and describing a psychiatric resident symptoms are similar. In psychiatry, we need to know more than

training program to encourage neuroscience learning. As these which brain function is aberrant in which neuropsychiatric system.

authors eloquently describe, speciﬁc knowledge of brain function Psychiatric disorders are usually mixtures of psychological as well

is beginning to clarify our understanding of some, if not many, as neurobiological disturbance. Automobile trafﬁc dysfunction is a

psychiatric disorders. The authors are careful to point out that our symptom of heterogeneous disturbances, not an illness with a

expanding neuroscience information base has not yet yielded single etiology. I am concerned that growing emphasis on the

reliable and always reproducible clinical treatment results, but the neuroscience basis of psychiatric disorders is beginning to ignore

emerging data are encouraging. As the authors indicate, we now the personal, interpersonal, family, society context of the

understand speciﬁc functions of many brain anatomical sites, their symptoms. Not all unhappiness is depression, not all enthusiasm

inter-site circuitry, their genetic origin, as well as the micro- is mania, not all worry is anxiety, not all memory dysfunction is

circuitry that is necessary for the extraordinary communication dementia or ADD. As suggested two articles recently published in

between neuronal pathways throughout the brain. The authors the NY Times in July 2015 (Richard Friedman; Mindy Fullilove), we

then provide a clinical example of neuroscience teaching using a must continue to acknowledge that brain dysfunctions are a

clinical example: the neurological basis of symptoms of a critical component of mental disturbance, but not the only factors

depressed patient and the application of this information to that produce symptom formation.

suggest new and more speciﬁc therapeutic approaches. What to do? I believe that this article points the way toward

I was particularly taken by the analogy of impaired brain future teaching of psychiatry, one that I shall call (for better or

circuitry with an urban trafﬁc jam that may have many causes: worse), ‘‘enlightened neuroscience’’. As we learn about the brain,

dysfunctional trafﬁc signals (circuit nodes), street and highway we do not reject the 100 years of psychological observations and

construction (pathways), impaired road materials (neurotrans- clinical experience. Rather, we integrate our emerging neurosci-

mitters), and planning (genes). Together, dysfunction in these ence knowledge with what we already know about human

areas can bring trafﬁc to a standstill, somewhat like some development, behavior, emotion, cognition and relationships. As

psychiatric disorders. Other trafﬁc problems may contribute to the authors of this wonderful article suggest, neuroscience can

broken restraints and trafﬁc guidelines leading to wild and stimulate new forms of treatment, but also enhance our

disorganized driving and potential mayhem. But here is where understanding and application of current treatments such as the

the analogy may become simplistic and potentially misleading, as various psychotherapies.

is, I believe, the forecast of neuroscience based treatment that will This marriage of neuroscience, psychology, and clinical wisdom

ﬁnally bring about development of more effective psychiatric is truly exciting. I congratulate the authors and look forward to

treatments. Automobile trafﬁc may be halted by many different putting some of their ideas into our own teaching programs.

E-mail address: [email protected].

http://dx.doi.org/10.1016/j.ajp.2015.08.016

1876-2018/ß 2015 Published by Elsevier B.V.

29 如何获得出版如何区分优质文稿和劣质文稿？

优质的文稿图表示意 ...包含以下图表示意至关重要，因为... 调查elsevier.com上的所有可选期刊，了解：它们的目标和范围图片和表格是展现研究结果最有效的方式它们接收的文章类型研究成果是出版的驱动力它们的读者群通过浏览近期出版文章的摘要，了解它们当前的热门一图胜千言话题 Sue Hanauer (1968) 图表的文字说明和解释必须足够详尽，以使图表符合逻 ...遵守出版道德辑，一目了然不得剽窃他人作品不要在正文或其他图表示例中重复陈述研究结果同一作品不得重复发表，亦不得在同一时期向不同期刊投递正确引用他人作品，并标明出处使用正确的写作语言只有对作品有主要贡献的人才能够被列为合著者确保语言准确是作者的责任，而不是出版商的义务。

...遵循《作者指南》在投稿前，请向英语是母语的人士请教，或使用语言润色请严格遵循《作者指南》，不要让编辑把时间浪费在粗服务来改进您的论文糙的稿件上蹩脚的英文表达会让编辑和审稿人员难以理解您的文章，从而增加退稿风险您可以在elsevier.com的期刊主页上找到《作者指南》。警惕常见错误：  句子结构  时态错误  语法错误  语言混杂文稿通篇应使用英文，包括其中的图表和图片

您准备好投稿了吗？有大约35%的投稿在同行评审之前被拒掉。投稿前,请您仔细校正核对避免错误。文章结构您的研究成果能否促进（人们）对某个研究领域的认知？您的作品是否能引起期刊读者的兴趣？您的文稿结构是否合理？标题您的研究结果是否能正确推导出您的结论？摘要您的引用文献是否可全球范围浏览？关键字您的图表格式是否正确？您的语法和拼写错误是否已经纠正？ (IMRAD) 引言 - Introduction 方法 - Methods 请充分准备后投稿！结果 - Results 请尽量使文章简明扼要以及 - And 讨论 - Discussions

结论致谢引用 Discover访问我们免费的网络广播： our free training webcasts at 补充数据 www.publishingcampus.comwww.elsevier.com/trainingwebcasts publishingcampus.com

Asian Journal of Psychiatry 17 (2015) 131–132

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Discussion

The relevance of translational neuroscience in psychiatry residency

training

Commentary on ‘‘Torous et al. A proposed solution to integrating

cognitive–affective neuroscience and neuropsychiatry in psychiatry

residency training: The time is now’’

Sri Mahavir Agarwal, Ganesan Venkatasubramanian *

Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India

A R T I C L E I N F O

Article history:

Received 28 August 2015

Accepted 28 August 2015

Keywords: Psychiatry Training

Translational neuroscience

Brain stimulation

1. Commentary perception. The average resident in psychiatry is therefore less

likely to explore brain based explanations of psychiatric symptoms

In psychiatry, the critical inﬂuence of residency training in because they are prejudged to be functional. This is at odds with

shaping one’s outlook toward the specialty cannot be overstated. It the current level of knowledge where several concrete examples

determines, to a large extent, conceptualization of mental exist neatly tying region or circuit level activity, or lack thereof, to

phenomena/related disorders as well as formulation of speciﬁc clinical symptoms. Hence, advances in understanding are slow to

treatment approaches. The psychiatry–neurology dualism that permeate through an uninitiated audience; application of this

pervades most residency programs across the world has had an knowledge in routine patient care is slower still. On one hand, this

adverse impact on psychiatry training. This distinction between projects psychiatry as a branch not in tune with times, while on the

specialties largely stemmed from the fact that the pathophysio- other it exposes it to attacks which question its very basis as a

logical processes that led to psychiatric symptoms were unknown medical branch since it appears not to be rooted ﬁrmly in biology.

at that point in time making them ‘‘functional’’. However, passage of It is in this context that the article by Tourus et al. in the current

time and lack of concerted attempts toward updating this issue assumes signiﬁcance. The authors impress upon the reader

understanding has resulted in the hitherto unknown being the need for psychiatric residency to be informed by cognitive–

misunderstood as eternally unknowable or non-existent. This affective neuroscience and neuropsychiatry. With regards to the

has led to cementing of psychiatric disorders as disorders of the barriers that impede psychiatry residents from being trained

‘‘mind’’, clearly distinct from disorders of the ‘‘brain’’; so much so suitably in neurosciences and neuropsychiatry, the authors point

that several decades of dedicated and fruitful research into the to the absence of suitable faculty as a core problem. This again, in

biological basis of symptoms has largely failed to change this our opinion, is a manifestation of the mold psychiatry has cast itself

in over the last few decades. Absence of focus on neurosciences has

resulted in faculty who are themselves not suitably trained to

impart the necessary skills to residents, starting a vicious circle

* Corresponding author at: Department of Psychiatry, National Institute of

that needs to be broken urgently. The inclusion of brain circuits and

Mental Health and Neurosciences (NIMHANS), Bangalore 560029, India.

E-mail address: [email protected] (G. Venkatasubramanian). anatomical regions related discussions in routine case discussion is

http://dx.doi.org/10.1016/j.ajp.2015.08.015

132 S.M. Agarwal, G. Venkatasubramanian / Asian Journal of Psychiatry 17 (2015) 131–132

a novel idea with signiﬁcant advantages. This approach introduces opportunities to become specialists in neuromodulation, the void

the concept of neuroscience based causality as well as promotes could be ﬁlled by other clinical experts in brain functioning.’’

thinking toward targeted, logical, evidence based strategies that Constant updating of ‘‘knowledge’’ and converting this into

reverse the identiﬁed neuropsychiatric deﬁcit. Moreover, such an ‘‘wisdom’’ that facilitates application is a prerequisite for any

approach brings the robustness of identifying anatomical and scientiﬁc ﬁeld. It is therefore necessary for young psychiatrists to

functional neural correlates to the discussion which complements learn to assimilate and apply the knowledge that progress in

the richness of personalized and phenomenology based approach translational neuroscience makes available to them. That is

that is so unique to psychiatry. While similar views have been unlikely to happen unless they are well trained in the nuts and

expressed earlier (Benjamin, 2013; Coverdale et al., 2014), the bolts of brain based approach to psychiatry. It is quite possible that

article’s merit lies in proposing a solution which is ready to work out in the coming years our understanding might improve further

of the box and which merges seamlessly into the mores and routine paving the way for identiﬁcation of psychiatric disease processes at

of clinical residency. For instance, the description of case study in the the level of individual neurons and synapses. If psychiatrists are to

article is illustrative of how useful such an approach can be toward stay relevant in this ever changing scheme of translational

both increasing a resident’s understanding of brain processes behind neuroscience, the time to overhaul our training is, as the article

symptoms and facilitating a more informed approach to the by Tourus et al. puts it, right now!

management of psychiatric disorders. Moreover, such a method

of discussion is likely to encourage residents to learn more about

how current modalities of treatment work and help them become References

more receptive to the latest advances in neurotherapeutics. It will

Agarwal, S.M., Shivakumar, V., Bose, A., Subramaniam, A., Nawani, H., Chhabra, H.,

also help them recognize and stay alert to new techniques in future

Kalmady, S.V., Narayanaswamy, J.C., Venkatasubramanian, G., 2013. Transcra-

that may potentially improve symptoms. nial direct current stimulation in schizophrenia. Clin. Psychopharmacol. Neu-

The emergence of various invasive and non-invasive brain rosci. 11, 118–125.

Benjamin, S., 2013. Educating psychiatry residents in neuropsychiatry and neuro-

stimulation modalities for treating psychiatric disorders over the

science. Int. Rev. Psychiatry 25, 265–275.

last few years highlights the challenge in front of us. Application of

Coverdale, J., Balon, R., Beresin, E.V., Louie, A.K., Tait, G.R., Goldsmith, M., Roberts,

these techniques assumes thorough understanding of the anatom- L.W., 2014. Teaching clinical neuroscience to psychiatry residents: model

curricula. Acad. Psychiatry 38, 111–115.

ical and functional basis of effects produced and the brain circuits

Lefaucheur, J.P., Andre-Obadia, N., Antal, A., Ayache, S.S., Baeken, C., Benninger, D.H.,

or regions they act upon. Evidence for the efﬁcacy of techniques

Cantello, R.M., Cincotta, M., de Carvalho, M., De Ridder, D., Devanne, H., Di

like transcranial magnetic stimulation (TMS) (Lefaucheur et al., Lazzaro, V., Filipovic, S.R., Hummel, F.C., Jaaskelainen, S.K., Kimiskidis, V.K.,

Koch, G., Langguth, B., Nyffeler, T., Oliviero, A., Padberg, F., Poulet, E., Rossi, S.,

2014) and transcranial direct current stimulation (tDCS) (Agarwal

Rossini, P.M., Rothwell, J.C., Schonfeldt-Lecuona, C., Siebner, H.R., Slotema, C.W.,

et al., 2013; Tortella et al., 2015) in treating psychiatric disorders is

Stagg, C.J., Valls-Sole, J., Ziemann, U., Paulus, W., Garcia-Larrea, L., 2014. Evi-

fast accumulating. Given the efﬁcacy, safety proﬁle and the interest dence-based guidelines on the therapeutic use of repetitive transcranial mag-

these techniques have generated in the scientiﬁc community, it is netic stimulation (rTMS). Clin. Neurophysiol. 125, 2150–2206.

Tortella, G., Casati, R., Aparicio, L.V., Mantovani, A., Senco, N., D’Urso, G.,

likely that they will gradually become commonplace and a

Brunelin, J., Guarienti, F., Selingardi, P.M., Muszkat, D., Junior Bde, S.,

psychiatrist will be expected to, at the very least, understand Valiengo, L., Moffa, A.H., Simis, M., Borrione, L., Brunoni, A.R., 2015.

how they work. The authors highlight this in their article and Transcranial direct current stimulation in psychiatric disorders. World J.

Psychiatry 5, 88–102.

sound a timely warning in saying: ‘‘If psychiatrists do not embrace

Asian Journal of Psychiatry 17 (2015) 140–141

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Discussion

Toward the era of transformational neuropsychiatry

Henry A. Nasrallah *

Department of Neurology and Psychiatry, Saint Louis University School of Medicine, 1438 South Grand Boulevard, St. Louis, MO 63104, United States

A R T I C L E I N F O

Article history:

Received 27 August 2015

Accepted 27 August 2015

The time has come for psychiatry to reclaim its neurological neurology, this disastrous myth and misconception about psychi-

roots and to regain its neuroscientiﬁc identity. Prior to the Freudian atry persists in the public arena, and has contributed to the unfair

theory that dominated psychiatry for many decades in the 20th stigma attached to mental illness and to the completely unjustiﬁed

century, psychiatry and neurology were integrated in one disparagement of psychiatry.

department with combined training in neuropsychiatry. It is The article by Torous et al. in this issue is an enlightened call to

ironic that Freud, who is a neurologist, by inventing and action to correct and reverse the longstanding ‘‘anosognosia’’ of the

propagating a theoretical psychoanalytic model for mental neurological correlates of psychiatric symptoms in psychiatric

functions, contributed to the rupture of the productive unity of training, which perpetuates brainless psychiatry. It is true that the

neurology and psychiatry. By the 1950s, psychiatry had become psychopharmacology revolution has given birth to biological

de-medicalized and de-neurologized due to the abstract, non- psychiatry and contributed to the wilting of psychoanalysis

evidence-based psychoanalytic constructs, along with its entirely (although psychodynamics remain a useful clinical psychothera-

non-medical jargon. No wonder neurologists decided to break up peutic model). However, biological psychiatry needs to transcend

from psychiatry to form their own associations and to establish pharmacology and transform itself into a full-ﬂedged clinical

separate journals. This estrangement exacerbated the fallacious neuroscience. One of the impediments is the inertia of the current

artiﬁcial dichotomization of brain and mind, endowing neurology diagnostic system that focuses on arbitrary arrays of clinical

with a robust medical identity and casting psychiatry as just a symptoms that overlook the rapid advances in how psychiatric

philosophy of behavior with no clear medical identity and no symptoms can be generated from disturbed neural circuits,

recognizable physical ﬁndings or neurological basis for its preventing trainees from evolving into neuropsychiatrists.

disorder. The absurdly short requirement of two months of neurology

Alas, both specialties suffered from the rupture of their long- in the four years of psychiatric training is rendered less useful by

standing union: psychiatry became brainless and neurology failing to incorporate the psychiatric implications of every

became mindless. With rare exceptions, across all medical schools, neurological lesion during the rotation. Currently, neurology

the departments of neurology and psychiatry currently exist and supervisors are generally as naive about detecting psychopa-

function as independent silos, with rare academic interactions. The thology as psychiatry supervisors are in identifying neurological

separate training of psychiatrists and neurologists institutional- pathology.

ized the faulty brain–mind dualism: neurological disorders were To transform psychiatry into a clinical neuroscience specialty,

considered ‘‘organic’’ with tangible sensory/motor impairments, the neurology rotation must expand into a full year with intensive

while psychiatric disorders were erroneously conceptualized as neuropsychiatric training. This is a tall order because of the serious

‘‘functional’’, i.e. phenotypic alterations of mood, thoughts and current dearth of neuropsychiatrists or behavioral neurologists to

behavior, with no ‘‘tangible’’ neurological localizing signs. Despite serve as supervisors.

the tremendous advances in neuropsychiatry and behavioral Having served for several years on the ACGME committee in

charge of designing the didactic curriculum and clinical rotations

of psychiatric trainees (Residency Review Committee or RRC), as

well as site visiting and accrediting training programs in the U.S., I

* Tel.: +1 314 977 4824.

E-mail address: [email protected] am cognizant of the Herculean challenge of modifying the training

http://dx.doi.org/10.1016/j.ajp.2015.08.010

H.A. Nasrallah / Asian Journal of Psychiatry 17 (2015) 140–141 141

requirements in psychiatry. There has to be a strong support and next generation of neurologically minded psychiatric supervisors

consensus among RRC committees for changes to be drafted and who will expedite the neuroscientiﬁcation of psychiatry.

distributed to multiple constituencies for feedback, concurrence or Finally, better medical care can be provided to patients with brain

rejection. disorders if the neurology trainees receive adequate psychiatric

The ﬁeld of psychiatry currently lacks a critical mass of supervision to consistently recognize the mood, thought, cognitive

neuropsychiatrists and many academic departments do not even and behavioral consequences of various neurological disorders.

have a single qualiﬁed neuropsychiatrist. Thus, it will be difﬁcult to Behavioral Neurology fellowships should also be developed and

adopt and implement the commendable model proposed by Torous emphasized. Perhaps the re-integration of psychiatry and neurology

et al. The most practical strategy for psychiatry to recapture its will be more likely when disorders affecting both the brain and its

neurological foundations is to establish neuropsychiatry fellowships mind are routinely assessed and managed by members of both

in as many departments as possible. This will gradually produce the specialties. Our neuropsychiatric patients deserve no less.

Asian Journal of Psychiatry 17 (2015) 142–143

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

jo urnal homepage: www.elsevier.com/locate/ajp

Commentary

Neuropsychiatry: More than the sum of its parts?

a b,

John Moriarty , Anthony S. David *

South London & Maudsley NHS Foundation Trust, London SE5 8AZ, UK

Institute of Psychiatry, Psychology & Neuroscience, King’s College London, PO Box 68, London SE5 8AF, UK

A R T I C L E I N F O

Article history:

Received 20 July 2015

Accepted 27 August 2015

Thank you for asking us to comment on the article by Torous provoked debate in the UK (Reilly, 2015; Fitzgerald, 2015). There is

and colleagues (this issue): ‘‘A Proposed Solution to Integrating also a political context that the medical or purely biological

Cognitive-Affective Neuroscience and Neuropsychiatry in Psychi- approach to human cognition, affect, perception, etc., has been

atry Residency Training: The Time Is Now’’. We do so from the seen as ‘reductionist’ and limiting, by a range of commentators

perspective of clinical academics who have worked predominantly outside medicine – including those few who identify themselves

in the UK and who have a keen interest in the training of ideologically with ‘antipsychiatry’, which has been difﬁcult for

psychiatrists in general and in the ﬁeld of neuropsychiatry in psychiatrists to endure.

particular. There have been many recent articles which begin by The deﬁnition in the target article of ‘‘psychiatric mental

lamenting the divide which exists between psychiatry and disorders being largely deﬁned by the presence of symptoms in the

neurology (White et al., 2012). Many of these suggest, like this absence of any grossly visible pathology’’ does ‘work’ for day to day

one, that the division is based on clinicians within psychiatry practice. What the deﬁnition lacks is the more positive aspects that

treating those patients with diseases which have no obvious make psychiatry somewhat unique. According to McHugh and

neurology while those within neurology treat those patients that Slavney (1983):

do. However, this may be a bit simplistic and it is likely that the

In the everyday world of the clinic, psychiatrists are distin-

two disciplines have evolved and diverged initially because of a

guished from other medical specialists not because they are

primary interest in different disorders and this has become

concerned with ‘‘minds’’ rather than ‘‘bodies,’’ but because they

reinforced by different languages and treatment interests. The

focus on complaints appearing in people’s thoughts, percep-

inﬂuence of psychology, psychoanalysis and systems thinking has

tions, moods, and behaviours rather than their skins, bones,

been much more profound in psychiatry than in neurology.

muscles and viscera . . .. Psychiatric concerns thus extend from

There are at least two forces which may additionally contribute

the ultrastructure of the body to the relationship of groups of

to the call for psychiatry to embrace neurological thinking more –

minds within a social context.p4

one is the perceived growth in our understanding of the basic

neuroscience of psychiatric disorders (which is the one made most The most important consideration in our view, on reading the

of by Torous and co-authors) and the other is the fear (if that is a example given of the cognitive neuroscience formulation of the

fair description of it) that the development and promotion of case of depression, would be to ask: what the effect of such a

psychological treatment models may marginalise medical psy- formulation might be on, (a) doctors in training in psychiatry, (b)

chiatrists within their own discipline as non-medically trained patients and (c) other professionals and non-psychiatric doctors? It

therapists may lead the way in the development of acceptable and might well appeal to many and if it caught on it would certainly

effective treatments for many mental illnesses. This has recently change the perception of the preoccupations of the typical

psychiatrist. However, we fear it might alienate even more. We

suspect many doctors in training are drawn to psychiatry because

of a genuine interest in the mentally ill and their experiences but

* Corresponding author.

often a motivation to help in ways which go beyond the model of

E-mail addresses: [email protected] (J. Moriarty),

[email protected] (A.S. David). diagnosis and biological treatment. To them, and to many patients

http://dx.doi.org/10.1016/j.ajp.2015.08.012

J. Moriarty, A.S. David / Asian Journal of Psychiatry 17 (2015) 142–143 143

or non-medics involved in the assessment and care of people with would certainly be nice if psychiatrists were as knowledgeable and

mental illness, the example of the formulation given might be ﬂuent in these areas as they can be in terms of speculative

experienced as almost a caricature of a reductionist interpretation psychological, pharmacological or psychodynamic aspects of

of research ﬁndings which largely report between group differ- formulation. One of the unique skills of the practicing psychiatrist

ences in biomarkers or imaging markers and cannot be applied and neuropsychiatrist is understanding the limits of scientiﬁc

sensibly in an individual case and at worst, reduce the range and knowledge and accepting that, even if in the future when some of

complexity of individual patients’ experiences to some dysregula- the ﬁndings from genetics and neuroimaging, etc., go beyond

tion of neural circuits. group descriptions but are actually applicable at the individual

We have seen this historically in terms of the upregulation and level, as envisaged by the recent RDoC NIMH initiative, there will

downregulation of transmitter systems and the modest global be instances where biology does not help us understand the

structural differences between the brains of groups with and person’s predicament and that we have to then appreciate the

without diagnosis of mental illness. We certainly now have a more power of beliefs, desires, and the inﬂuence of society and culture

complex and detailed understanding of some of these systems but of on people’s behaviour and mental life.

course such models remain rather crude. Such descriptions (not We would end by quoting the views of the doyen of UK

enough serotonin, too much dopamine; functional connectivity; neuropsychiatry, Alwyn Lishman summarised in the introduction

fronto-limbic dysregulation) are in many ways almost as meta- to the 4th edition of his ‘Organic Psychiatry’ (David et al., 2009):

phorical as talking about trafﬁc congestion in relation to the brain.

‘Neuropsychiatry ‘‘must capitalize on all that psychiatry has to

Turning to the UK training approach – certainly neuroscience

offer’’ including psychodynamic, social and cultural aspects,

remains a part of the curriculum and is tested in mandatory

and . . . ‘‘neuropsychiatric practice requires a widening not a

examinations. There is no mandatory overlap of training of

narrowing of psychiatric skills and interests’’’. P3

neurologists and psychiatrists, unlike in many European countries

where a shared curriculum is the norm. In terms of competencies a

good deal of emphasis is put on the systematic assessment of cases Acknowledgements

using standard diagnostic processes and categories and there is a

requirement to have at least basic competencies in pharmacologi-

The authors are supported by the UK National Institute of

cal and psychological (both cognitive and psychodynamic usually) Health Research (NIHR) Biomedical Research Centre at the South

treatment strategies.

London & Maudsley NHS Foundation Trust and Institute of

Neuropsychiatry as such is not a formally recognised subspe- Psychiatry, Psychology & Neuroscience, King’s College London.

cialty within the UK and there is no clear shared understanding of

its borders. It tends to include that part of consultation-liaison

psychiatry which works with neurology but also encompasses References

aspects of neurodegeneration, neurorehabilitation and develop-

David, A.S., Fleminger, S., Kopelman, M., Lovestone, S., Mellers, J. (Eds.), 2009.

mental psychiatry. Each of these areas would have their own

Lishman’s Organic Psychiatry: A Textbook of Neuropsychiatry. Revised 4th

curricula, which could be stated in terms of both knowledge and ed. Wiley-Blackwell.

skills. There is however a fairly persistent push to recognise Fitzgerald, M., 2015. Do psychiatry and neurology need a close partnership or

a merger? Br. J. Psychiatry Bull. 39, 105–107, http://dx.doi.org/10.1192/

neuropsychiatry or the neuropsychiatry perspective in current

pb.bp.113.046227.

clinical psychiatric practice. McHugh, P.R., Slavney, P.R., 1983. The Perspectives of Psychiatry. Johns Hopkins

Returning to Torous et al.’s ‘formulation’. We admire this and University Press.

Reilly, T.J., 2015. The neurology-psychiatry divide: a thought experiment. Br.

would like to move towards a more general aim of getting all

J. Psychiatry Bull. 39, 134–135, http://dx.doi.org/10.1192/pb.bp.113.045740.

trainees to practice formulating a case using sophisticated

White, P.D., Rickards, H., Zeman, A.Z., 2012. Time to end the distinction between

biological or behavioural neurological language and concepts. It mental and neurological illnesses. Br. Med. J. 344, e3454.

36 論文の発表に向けた心得良い原稿と悪い原稿の分かれ目

良い原稿とは... イラスト

. . .ジャーナルに適していること以下の理由により、イラストは重要です。エルゼビアのホームページ（elsevier.com）で候補となりうるすべて ■ 図と表は結果を最も効率的に提示する方法です。方法です。のジャーナルについて調べましょう。 ■ 結果は論文の原動力となる重要な要素です。です。 ■ 目的と範囲（Aims and Scope） ■ 論文の種類 ■ 読者層一枚の絵は一千語に匹敵する。 ■ 最近発表された論文の抄録に目を通し、注目されている話題を Sue Hanauer (1968) 知る ■ 図や表を見ただけで内容を理解できるように、詳しいるよように、詳しいキャプキャプシショョ ...出版倫理を順守していることンや凡例を記載します。 ■ 他者の論文を盗用しない。 ■ 文中や他の図表に同じ結果を重複して記載記載してはいけません。してはいけません。 ■ 同じ研究に関して複数の論文を出版しない、同じ原稿を一度に複数のジャーナルに投稿しない。 ■ 他者の論文を適切に引用する。適切な言語を使いましょう。

■ 大きな貢献を果たした共著者のみを示す。出版社は言語の修正は行いません。言語については著者の責任です。

...投稿規定（Guide for Authors）に従うこと ■ 論文を投稿する前にネイティブ・スピーカーに依頼するか英文校投稿規定を順守して、原稿を準備してください。編集者は完成度の正サービスを利用して英語の質を高めてください。低い原稿に時間を浪費することを嫌います。 ■ 英語がうまく書かれていないと、編集者も査読者も論文の内容を理解するのに苦労し、結果的に論文は却下されることになってし elsevier.comにある各ジャーナルのホームページで投稿規定を確認まいます。することができます。 ■ よくある誤りに注意してください。ｘ不適切な構文ｘ時制の誤りｘ不正確な文法ｘ複数言語の混在 ■ 図、グラフおよび写真を含む原稿全体で英語を使用してください。

投稿する準備は整いましたか？

投稿された原稿の約35％が査読前の段階で却下されています。投稿する前に、原稿の内容を必ず見直してください。

■ あなたの発見は、特定の研究分野における理解に貢献論文の構造するものですか？ ■ あなたの論文は、読者の関心を引くものですか？ ■ 原稿は適切な構造に則って作成されていますか？ Title（タイトル） ■ 達した結論は結果で裏付けられていますか？ Abstract（抄録） Keywords（キーワード） ■ 参考文献は地域的な偏りがなく、入手可能ですか？ ■ 図表の形式は適切ですか？ (IMRAD) ■ 文法およびスペルの誤りをすべて修正しましたか？ Introduction（序文） Methods（方法）原稿はできる限り準備を万全に整えてください！ Results（結果）簡潔に書きましょう And Discussions（考察）

Conclusions（結論） Acknowledgements（謝辞） References（参考文献） Discover ourour free free training training webcasts webcasts at at Supplementary data（補助データ） www.publishingcampus.comwww.elsevier.com/trainingwebcasts publishingcampus.com 36 Notes Training. Advice. Discussion. Networking.

Free online lectures, training and advice covering: • Introduction to scholarly publishing • How to get published in a journal • Book publishing • Peer review • Publishing ethics • Grant writing • Getting your paper noticed

Helping you on your way to publishing a world-class book or journal article publishingcampus.com

Get recognition CAMPUS CERTIFICATES for courses taken www.asianjournalofpsychiatry.com

Join the conversation

/elsevierpsychiatry @els_psychiatry