Neurology Neurosurgery & Psychiatry
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Journal of Neurology, Neurosurgery, and Psychiatry 1992;55:983-985 983 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.11.983 on 1 November 1992. Downloaded from 7ournal of NEUROLOGY NEUROSURGERY & PSYCHIATRY Editorial What is neuropsychiatry?* Neuropsychiatry is a rather seductive term. It implies an of the brain. It developed from the start as a rational and amalgam between neurology and psychiatry, which in a scientific discipline, tying certain maladies to the growing sense it is. But there is a great deal more to the name and knowledge of brain function and brain organisation. to the discipline than that. If we view it too narrowly as an Still very unsure of itself, psychiatry watched from the admixture of neurology and psychiatry we miss out on the sidelines and envied this success. So the intimate tie essence of the subject as an important and developing between neurology and neuropathology became an avenue branch of psychiatry. for exploring psychiatric disorders. Many of the great So what precisely is it? The matter was debated at the German psychiatrists ofthe nineteenth century were at the summer meeting of the British Neuropsychiatry Associa- same time neuropathologists. Resounding successes were tion, held in conjunction with the sister organisation, the achieved for example, in the field of the dementias and American Neuropsychiatric Association. As a prelude to general paresis. Lesions could at last be displayed in the discussion a detailed questionnaire had been distributed to brains of certain psychiatric patients. members of both organisations. This was in a sense a heyday for neuropsychiatry, with First, it was clear that the term was seen as representing both neurology and psychiatry employing parallel approa- an approach to the study of psychiatric disorders, rather ches. Many clinical practitioners were indistinguishably than merely specifying the study of a restricted range of neurologists and psychiatrists, a true amalgam of both. conditions. Indeed some two thirds ofrespondents felt that Further developments, however, served to disrupt the all psychiatric disorders could be approached from the status quo. Chief among these was the growth of psycho- viewpoint of a possible neurological basis. The Americans dynamics, a system of thinking about mental disorder were bolder in this than the British, and neurological which had little to do with the brain. It enriched respondents more certain than psychiatrists. As for the psychiatry, but meant nothing to neurology, and it drove a subset of psychiatric disorders most directly of concern to wedge between the two disciplines. Psychiatrists were keen http://jnnp.bmj.com/ neuropsychiatry, this was variously defined as "those for to exploit these new approaches, and neurologists became which knowledge of brain structure and function is glad to leave the muddle of mental illness to others. Later indispensable", or "those with a well-defined cerebral we saw the rise of social and epidemiological psychiatry, basis". Furthermore, virtually all agreed that neuro- again largely devoid of relevance to the brain, yet still psychiatry was concerned with psychiatric aspects of providing psychiatrists with new insights into their work. neurological disorders, and that it dealt with the border- Multi-factorial approaches to mental disorder prospered. land territory between clinical neurology and clinical The neuropsychiatric view came often to be dubbed on September 30, 2021 by guest. Protected copyright. psychiatry. narrow, old fashioned, and atherapeutic. In other words neuropsychiatry is seen by these Associa- Some, however, remained loyal all through to the tions as constituting a particular approach to the under- concept of neuropsychiatry. Sir Charles Symonds, the standing of psychiatric disorder and as having relevance to doyen of British neurologists, was a fighter for the cause, a wide range of such disorders, but with its own special regretting psychiatry's drift away from neurology and field within the clinical domain. neuroscience, and making some remarkable recommen- dations. 1 Evolution Towards the end of the Second World War the Royal Before proceeding further it may be useful to consider the College of Physicians set up a committee to consider origin and evolution of the subject. psychological medicine. Symonds, with Riddoch, wrote a Psychiatry started much earlier than neurology, when in minority report, urging that general hospitals should set up the 17th century medicine took over from the church a role Neuropsychiatry Clinics as the focus for the work of in the care of the insane. From the very beginning psychiatrists, neurologists and neurosurgeons side by side. psychiatry dealt with a class of persons, namely, the The report noted the wide overlap between all three "mentally ill". Its clients were very heterogeneous, suffer- disciplines, the common use of investigative techniques, ing from all manner of conditions. And for a couple of and the interweaving of research interests. The directors of centuries psychiatry was wildly adrift in its attempts to such clinics could be variously psychiatrists, neurologists formulate theories about what was amiss with them. or neurosurgeons. Psychiatrists and neurologists should Neurology came into being much later in the first part of have common basic training with a grounding in general the nineteenth century, taking as its point oforigin diseases medicine, then three years divided between psychiatry and 984 Editorial J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.55.11.983 on 1 November 1992. Downloaded from neurology along with the basic sciences appropriate to Table Diagnostic categories among patients with known organic psycho- both. A final two years would be devoted to one or the syndromes referred to the Maudsley neuropsychiatric clinic other discipline alone. Dementia, presenile and senile 34 But this view did not prevail. The report was rejected by Sequelae of head injury 31 Alcoholism (Korsakoff's syndrome, dementia, psychoses) 18 the physicians, and the Association of British Neurologists Memory disorders 15 was equally alarmed at the prospects. The neurologists Brain developmental abnormalities 13 Epilepsy 10 overwhelmingly refused to enter into any formal alliance Sequelae of encephalitis 9 with psychiatrists. In the subsequent years, neurologists Confusional states 6 Toxic disorders (additional to alcohol) 4 and psychiatrists have followed very different paths, with a Cerebral anoxia 2 steady erosion of most of the links in training require- Others (general paresis, sarcoid of CNS, etc) 4 ments. The brave new world which was briefly urged in the post-war years simply did not come into being. So what is the status of present day neuropsychiatry? It is perhaps best to consider two aspects separately; the acquaintance with all forms of mental disorder. And clinical - what neuropsychiatrists do, and the academic because the neuropsychiatrist works closely alongside an approach to mental disorder with research and philo- neurological colleagues he or she will see the manifold sophical implications. emotional and other complications that can arise in neurological patients. Academic neuropsychiatry By way of illustration, the last 300 patients referred to To consider the latter first, neuropsychiatry may be the Maudsley neuropsychiatric clinic have been analysed. regarded as that aspect of psychiatry which (like neurol- Almost half (49%) were suffering from clear organic ogy) seeks to advance understanding of clinical problems psychosyndromes, referred for closer diagnosis, treatment, through increased knowledge of brain structure and or advice. The conditions responsible are shown in function. It fundamentally involves the understanding of decreasing order of numbers in the table. Epilepsy features brain mechanisms in relation to mental disorder. This may relatively rarely because ofthe coexistence at the Maudsley be widely applied so that schizophrenia, for example, now of a specialised clinic for patients with epilepsy. falls well within its compass. Next in frequency (22%) were patients with established In these respects neuropsychiatry is the counterpart of psychiatric illnesses (schizophrenic, affective or neurotic) neurology - the part of psychiatry that stayed in league in whom some reason had arisen to suspect brain with it when the main corpus ofpsychiatry did not. It is an malfunction. This mostly derived from the mental state approach which sees neurological and neuropathological (impaired cognition, abnormalities of speech, visual hallu- knowledge as very important. And it seizes equally eagerly cinations), or from abnormal results on neuroimaging or on the more modern disciplines of neuropsychology, electroencephalography. Failures of treatment response neurochemistry, immunology and molecular genetics. In were quite often the reason for referral, likewise abnor- brief, it prospers from every science that can teach us malities on physical examination, mostly motor disorder. about the brain. Third in frequency (20%) were a group of patients This, if you like, is the basis of neuropsychiatry. But it whose symptoms gave rise to uncertainty about organic or must be stressed that its practitioners are psychiatrists with non-organic disorder - patients with possible pseudode- a grasp of other approaches as well. They will not, or mentia, pseudoseizures or suspected hysterical conversion should not, be narrowly confined by their interest in the disorder. Sleep