Revista Colombiana de Psiquiatría ISSN: 0034-7450 [email protected] Asociación Colombiana de Psiquiatría Colombia

Berríos, Germán E. What is Neuropsychiatry? Revista Colombiana de Psiquiatría, vol. XXXVI, núm. 1, 2007, pp. 9-14 Asociación Colombiana de Psiquiatría Bogotá, D.C., Colombia

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What is Neuropsychiatry?*

Germán E. Berríos1

Abstract

Introduction: Neuropsychiatry is based on social and scientifi c narratives developed since the XIX century in order to understand and deal with “mental symptoms” found in the context of neurological diseases. Objective: This is an effort to answer this question: Are mental symptoms in neurology the same ones as those found in general psychiatry? Method: Analysis of the diverse symptoms found in some diseases so that the neuropsychiatrist can develop a current and refi ned descriptive psychopathology without trying to “naturalize” these symptoms in a simplistic way, reducing them to putative biological markers. Conclusions: Frequently, neurological symptoms are not psychiatric, for instance, hallucinations in severe melancholia are only superfi cially similar to “organic” hallucinations in Parkinson’s disease. In this sense, the possibility that some symptoms are not only functional copies of other symptoms (behavioral phenocopies) should be seriously considered, since such differences could have important therapeutic implications.

Keywords: Neurology, psychiatry, psychopathology, nervous system diseases.

Título: ¿Qué es la neuropsiquiatría?

Resumen

Introducción: la neuropsiquiatría está basada en narrativas sociales y científi cas que se de- sarrollaron desde el siglo XIX para entender y manejar los “síntomas mentales” encontrados en el contexto de la enfermedad neurológica. Objetivo: intentar responder a la pregunta ¿los síntomas mentales de la neurología son los “mismos” que aquellos encontrados en la psiquia- tría general? Método: análisis de algunos de los diversos síntomas evidenciados en algunas enfermedades para que el neuropsiquiatra desarrolle una psicopatología descriptiva refi nada y actualizada sobre éstas y no trate de “naturalizar” de manera simplista los síntomas, redu- ciéndolos a marcadores biológicos putativos. Conclusión: se sugiere que con frecuencia los síntomas neurológicos no son psiquiátricos, por ejemplo, las alucinaciones de la melancolía grave son sólo superfi cialmente similares a las alucinaciones “orgánicas” de la enfermedad de Parkinson. En este sentido, la posibilidad de que algunos síntomas sean únicamente copias funcionales de otros síntomas (fenocopias conductuales) debe ser considerada seriamente, pues tales diferencias pueden tener importantes implicaciones terapéuticas.

Palabras clave: neurología, psiquiatría, psicopatología, enfermedades del sistema nervioso.

* The Editors express their gratitude to the Asociación Peruana de Déficit de Atención. 1 M. D. and philosopher of Universidad de San Marcos, Perú. Psychiatrist of Oxford Uni- versity. Teacher of Epistemology of Psychiatry in University of Cambridge and director of Neuropsychiatry, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom.

Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007 9 S Berríos G.

The Word and its Referents The Context

Names help or hinder in all walks of Whether there is ‘neuropsychiatry’ life, particularly when they behave in a particular country, and whether as drifting signifi ers. For example, it has a broad or narrow meaning since it first appeared in fin de will depend, to a large extent, upon siècle France as a double-barre- the structure of its health services lled word (‘neuro-psychiatrie’), the and on the quality of the rela- meaning of ‘neuropsychiatry’ has tionship between neurology and repeatedly changed. By the inter- psychiatry. bellum period, and now converted in ‘neuropsychiatrie’, it referred to This is interesting and ironical as the clinical doings of medics trained both specialisms are new. Alienism both in neurology and psychiatry. (the original name for psychiatry) By 1918, the word appeared in the and neurology developed by the Anglo-Saxon to name a form of: 1830s and 1860s respectively as the “Psychiatry which relates mental or direct result of the fragmentation of emotional disturbance to disordered the old grand Cullean category of brain function”. My own defi nition ‘Neurosis’, and of the broadening is narrower: “discipline that deals of the notion of ‘lesion’ which by with the psychiatric complications the end of the century indistinctly of neurological disease”. On the referred to failures and solutions of other hand, American usage is continuity in putative ‘structural’, broader and tantamount to “biolo- ‘physiological’ or ‘psychological’ gical psychiatry”. domains.

Currently, and fi rst and fore most In Germany and France, the for- “neuropsychiatry” refers to overla- mation of alienists included neuro- pping clinical disciplines sha ring logical training and this facilitated the belief that mental symptoms the use of the term ‘neuropsychia- are produced at disorde red brain trist’. In Great Britain, on the other sites. It is also used to make a hand, and due to important socio- professional claim vis-à-vis rival economic reasons (which there is views of mental disorder such as no space to discuss), neurology psychoanalysis. Lastly, it creates and psychiatry had fully diverged a social and economic space whe- by the 1880s. This means that for rein like-minded researchers safely more than 90 years there was little congregate to usufruct their fashio- communication between the two nable ideas. and that during the 1970s ‘neurop- sychiatry’ had to be reinvented. It is not altogether surprising that those

10 S Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007 What is Neuropsychiatry? of us who were involved in such etc. do so on account of a variety re-creation had both neurological of mechanisms. On the one hand, and psychiatric training. This also there are the causal aetiologies. explains why to this day we do not have in the UK a unifi ed defi nition As my work on musical hallu- of neuropsychiatry. cinations and irritability states in Huntington’s disease patients The American defi nition has become showed years ago, a direct link popular and this has encouraged can be demonstrated between psychiatrists holding a biological symptom and brain site or CAG orientation au outrance to call repeat, respectively. On the other themselves ‘neuropsychiatrists’. hand, neurological patients have Others (like myself) continue defi - reasons for their symptoms, that is, ning neuropsychiatry in a narrow neurological diseases happen to real way. The former can be found in all people and hence have semantic venues of psychiatric care, the latter contexts. This adds an entire new work in general hospitals and do a layer of meaning, hermeneutics and great deal of ‘neuro-liaison’ work (I therapeutic response. Patients may introduced this term in a lecture show behavioural copies of mental given in Wellington, New Zealand symptoms and these do not have some years ago). the same brain representation as the conventional symptoms.

Neuropsychiatry Neuropsychiatric clinical work ge- in Cambridge, UK nerates clinical templates which can be translated into research In keeping with the above, my own paradigms. There is nothing new ‘neuropsychiatric’ clinical service in this and each university will is organize on the narrow view use a different rhetoric to sell what that neuropsychiatry is a branch they do. Some sell themselves as of psychiatry that deals with the top-to-bottom research institutions mental complications of neurolo- (i.e. grand ideas governing action), gical disease. I do not believe that others, are bottom-up ones (piece- such practice should in any way be meal, low level research converging interpreted as a statement about upwards). This is the case of the the nature of mental disorders in Cambridge University Neuroscience general. Even within the confi nes Campus (the largest in the UK) whi- of my narrow defi nition, it seems ch includes research institutes and clear that neurological patients who a neuroimaging suite with inter alia develop delusions, hallucinations, 12 MRI magnets. My Neuropsychia- obsessions, sadness, anxiety, etc., try Service (6 clinics) is linked with

Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007 11 S Berríos G. most of the research centres in the nied by psychiatric appurtenances. campus. For example, the PD Clinic The psychiatric component of some, provides patients for the large pro- like Parkinson’s disease, Multiple jects on receptor expression, fMRI, Sclerosis, Huntington’s disease, pharmacology, and neurosurgery. Wilson’s disease, Binswanger’s disease, etc. has been known for a The HD Clinic is held in the ‘Bra- long time, and in some cases the in Repair Centre’ where about 12 severity and management of that patients who have already received component is more important for fetal cell implants in their caudate social re-entry than any motor or nuclei are followed up at 3 months sensory disorder. In other cases, intervals. The Traumatic Brain Da- however, such as the taupathies, mage clinic takes place in the ‘Oliver mitochondriopathies, CADASIL, Zangwill Centre’, the leading cogniti- X-Linked Adrenoleukodystrophy, ve neuropsychological rehabilitation etc. etc., not enough research has clinic in Europe. The Sleep Disorders yet been carried out to identify Clinic works closely with the ‘Res- the psychiatric component. In all piratory Unit’ at Papworth hospital situations, an intelligent practice which includes the more advanced provides the neuropsychiatrist with polysomnographic set up in the UK. conundra whose resolution has The Memory Complaints Clinic ser- direct relevance to psychiatry in vices the large complex of memory general; two of such will be briefl y research at the ‘Cognitive and Brain discussed below. sciences Unit’, a ‘Medical Research Council’ facility where concepts such as executive functions and working The Implications memory were fi rst developed; and my General Neuropsychiatry Clinic Diagnostic Conundrum is linked up with the ‘Epilepsy Neu- rosurgical Unit’, the ‘Tinnitus Clinic’, The neuropsychiatrist often fi nds etc. All these clinical- basic-sciences that there is a lack of fi t between associations create ideal opportuni- the clinical phenomena met with ties for translational research which in neuro-liaison work and the con- has traditionally been the British ventional psychiatric categories of way of developing new ideas. ICD-10 and DSM IV. Neurological patients exhibit a variety of men- tal symptoms but these are often The Findings isolated and/or fl eeting and rarely achieve critical mass to qualify for Whatever the clinical context, neuro- a ‘psychiatric diagnosis’. This raises logical disorders are often accompa- theoretical and practical issues.

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The former have to do with their nal mental disorders) that he/she nature and formation mechanisms, comes across in the context of his the latter with their management / specialized practice are, in fact, the therapy. In the UK psychiatric the- same clinical phenomena as those rapies are currently tightly governed seen in general psychiatry. For by guidelines which themselves are example, are the visual hallucina- based on meta-analytic exercises tions of Parkinson’s disease or Lewy and health economy evaluations. body dementia the same phenome- Likewise, psychiatric drugs are na as those seen by a melancholic licensed for specifi c disorders and elderly with Cotard’s syndrome? share with the guidelines the same Is the affective disorder associated sets of random clinical trials. with frontal lobe strokes the same as the common garden depressive Before the time guidelines started illness? Is the mania triggered by to be issued, psychiatric treatments steroid treatment the same as the were based on a combination of mania of a bipolar disorder? psychopharmacological knowledge, therapeutic imagination and spe- These comparisons go directly to cifi c negotiations between doctor the core of psychopathology and call and patient. This no longer obtains into question the epistemic capacity and unless a patient qualifi es for a of the language of psychiatry, that clear diagnosis he will not be offered is, its discriminating value. Over the medication as this might expose the years, these questions have been clinician to legal action. In neurop- responded in different ways. There sychiatry, this is particularly acute was a time when the answer was as neurological patients have mostly that so-called organic hallucinatio- mental symptoms and only rarely ns were different phenomena from mental disorders. Furthermore, psychiatric hallucinations. Curren- the expression of such symptoms tly, the predictable view is that they may be distorted by the presence of are, that they must be the same cognitive, expressional or emotional phenomena. Biological psychiatry defi cits directly related to the neu- is ruthless in its reductionism and ropathological lesions. efforts to impose its causal me- chanism. Many neuropsychiatrists with long clinical experience in Behavioural Copies and the their trade, however, are no longer Problem of Symptom-Formation that cocksure. They often wonder about multiple aetiologies and In view of the above, the neurop- about the existence of mechanisms sychiatrist often wonders whether that generate behavioural copies the mental symptoms (and occasio- of the organic symptoms; or they

Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007 13 S Berríos G. postulate the hypothesis that the psychiatrists. They offer a natural expressional systems in the human and privileged space for psychiatric may have a narrow repertoire and research. Unfortunately, it is one act as fi nal common pathways to space that it is being abandoned by a variety of triggers, some organic, psychiatrists who want to become some semantic. mini-neurologists -radiologists or -geneticists. Descriptive psychopa- Such psychopathological hypothe- thology remains the fons et origo ses generate fresh approaches to the of all others ancillary disciplines in analysis of mental symptoms which psychiatry, and hence such diaspo- can only be undertaken by trained ra must be deeply regretted.

Recibido para evaluación: 2 de junio de 2007 Aceptado para publicación: 12 de julio de 2007

Correspondencia Germán E. Berríos Addenbrooke’s Hospital Cambridge University Hospitals NHS Foundation Trust, Hills Rd, Cambridge CB2 0QQ, United Kingdom [email protected]

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