Department of Psychiatry

Behavioral Neurology & Neuropsychiatry Fellowship Training Program

Background of Neuropsychiatry and Behavioral Neurology

Behavioral neurology and neuropsychiatry are disciplines within the clinical neurosciences that focus on the clinical and pathological aspects of neural processes associated with cognition, emotion, and behavior. The seminal work of late 19^th and early 20^th neuroscientists such as Griesenger, Broca, Wernicke, Harlow, Charcot, Freud, Alzheimer, and Pick laid the foundation for the development of neuropsychiatry and behavioral neurology as subspecialties within the traditional medical specialties of psychiatry and neurology (1-4). Although neurology and psychiatry evolved into distinct medical specialties during the 20^th century, behavioral neurology and neuropsychiatry developed in parallel given their common roots in cognitive and behavioral neuroscience (5-7). Advances in structural and functional brain imaging, clinical electrophysiology, and experimental psychology over the last two decades nurtured a remarkable growth in the clinical neurosciences, and changed fundamentally the manner in which normal and disturbed cognition, emotion, and behavior are understood clinically. These advances fostered the development of the core knowledge base and clinical skills that define modern neuropsychiatry and behavioral neurology.

Behavioral neurologists and neuropsychiatrists regard the relationship between brain and behavior as inexorable (3,4,8,9). Reciprocal interactions between psychological factors and neuropsychiatric illness are appreciated, yet both are fundamentally understood in terms of brain function and dysfunction (3,4,8-11). Clinically, behavioral neurologists and neuropsychiatrists elicit and construct comprehensive patient histories that emphasize neurodevelopmental and environmental influences on cognitive, emotional, behavioral, and elementary neurological function. Systematic clinical assessment of these functions requires the use and interpretation of standardized, validated, and reliable metrics of cognitive, emotional, behavioral, and elementary neurological functions developed for these purposes. The use and interpretation of neuroimaging, electrophysiologic, and other laboratory measures that inform diagnosis and/or treatment planning is emphasized as an essential element of neurobehavioral and neuropsychiatric assessment. Interpreting clinical signs, symptoms, and syndromes as reflecting neural processes supercedes conventional (i.e., DSM-based) psychiatric diagnoses, and the historical dichotomization of clinical conditions into strict “psychiatric” or “neurological” types is rejected in favor of a more integrative perspective. Consequently, the clinical and scientific purview of behavioral neurology and neuropsychiatry is broad, including at least:

1) Focal neurobehavioral syndromes

- e.g., aphasias, apraxias, agnosias, aprosodias, apathy, executive dysfunction, orbitofrontal syndrome, etc.

2) Major neuropsychiatric syndromes

- e.g., delirium, the dementias, and the major primary psychiatric disorders, including those with atypical or refractory presentations

3) Neurologic conditions with cognitive, emotional, behavioral features

- e.g., dementias, movement disorders, stroke, epilepsy, multiple sclerosis, traumatic brain injury, etc.

4) Comorbid neuropsychiatric and neurologic conditions

- e.g., Down’s syndrome and Alzheimer’s disease, obsessive-compulsive disorder and Tourette’s syndrome, Huntington’s disease and alcohol abuse, etc.

Given the breadth of the clinical problems addressed by behavioral neurologists and neuropsychiatrists, expertise in pharmacological, psychosocial, behavioral, and environmental interventions, alone or in combination, is required to meet the needs of patients with these conditions and their families. This comprehensive approach to clinical assessment and treatment synthesizes key aspects of the historically distinct neurological and psychiatric examinations. It is this synthesis that distinguishes the clinical paradigm of behavioral neurology and neuropsychiatry as unique among other medical subspecialties in the clinical neurosciences.

Recognizing the essential similarities between behavioral neurology and neuropsychiatry, the American Neuropsychiatric Association (ANPA) and the Society for Behavioral and Cognitive Neurology (SBCN) concur that the body of knowledge pertaining to the phenomenology, pathophysiology, diagnosis, and treatment of cognitive, emotional, and behavioral disturbances in relation to brain dysfunction is common to both behavioral neurology and neuropsychiatry. These historically separate but parallel subdisciplines can therefore be merged into a single subspecialty area of medicine that herein will be referred to as Behavioral Neurology & Neuropsychiatry.

Expertise and clinical competence in Behavioral Neurology & Neuropsychiatry requires the development of a combination of knowledge and skills that are beyond the scope of those required for the practice of either general neurology or general psychiatry alone. The knowledge base and clinical skills of behavioral neurologists and neuropsychiatrists builds on the foundation established by primary training in either neurology or psychiatry by adding additional and specialized training in the evaluation, differential diagnosis, prognosis, pharmacological treatment, psychosocial management, and neurorehabilitation of persons with complex neuropsychiatric and neurobehavioral conditions (2-4,7-9,12-17). Because the body of knowledge and the clinical skills circumscribed by Behavioral Neurology & Neuropsychiatry are additive to those of general psychiatry and general neurology, and also distinct from the other subdisciplines of either of these medical specialties, training specific to Behavioral Neurology & Neuropsychiatry is required to achieve competence to practice in this area of medicine.

Goals and Objectives for Training in Behavioral Neurology & Neuropsychiatry

Until recently, training programs in Behavioral Neurology or Neuropsychiatry throughout the United States and Canada developed practitioners in only one of these areas. Although the goals and objectives for training in Behavioral Neurology and Neuropsychiatry overlapped substantially, the core curriculum used varied from program to program. In the service of standardizing fellowship training in these areas, the ANPA promulgated Standards for Fellowship Training in 2001 (19). The content of this document was integrated with the Core Curriculum for Training in Behavioral Neurology developed by the Section on Behavioral Neurology of the American Academy of Neurology in the service of developing the Core Curriculum and the Program Requirements for the new subspecialty, Behavioral Neurology & Neuropsychiatry.

The Goals and Objectives for training in Behavioral Neurology & Neuropsychiatry include:

Developing clinical expertise in care of patients with brain dysfunction including understanding of diagnostic skills, neurologic and mental status examinations, cognitive testing, electrophysiological testing, neuroimaging, differential diagnosis, crisis intervention, application of time-limited psychotherapy, and referral for rehabilitative therapies.
Gaining broad knowledge in the field through extensive exposure to the core literature in neuropsychiatry, neuropsychology, and behavioral neurology. Neuroanatomy and neurochemistry of cognition, emotion, and behavior must be emphasized.
Understanding the principles and practice of neuropsychopharmacology, with special emphasis on psychostimulants and other catecholaminergically active agents, cholinesterase inhibitors, NMDA receptor antagonists, anticonvulsants, atypical antipsychotics, antidepressants, and emerging neuropharmacologic agents, as well as the interactions of such agents with other medications on central nervous system function.
Participating in a structured educational curriculum that complements clinical and self-study experiences, usually consisting of rounds, case conferences, individual supervision, didactic lectures, and other courses or seminars relevant to training in Behavioral Neurology Neuropsychiatry.
Developing an understanding of research methodology in Behavioral Neurology & Neuropsychiatry.
It is not the objective of this document to specify the manner in which these educational goals and objectives are met in an individual training program or the methods by which competence in Behavioral Neurology & Neuropsychiatry are achieved or evaluated. The curriculum (i.e., the educational content in this field of study) and the methods of training (i.e., clinical experience, didactic experience, independent study) are interconnected but separate elements of an educational program. Consequently, this document offers only an outline of the core curricular content that training programs in Behavioral Neurology & Neuropsychiatry are expected to include. Programs may differ in the emphases placed on the various elements of the training curriculum described herein. A complementary set of training objectives developed for use in residency programs are offered elsewhere (7), and may be of service to both fellowship and/or residency training directors as they design their specific training programs.

The methods by which this knowledge and performance skills are taught during the course of training are considered separately from the core curricular content and are described in the document entitled "Behavioral Neurology & Neuropsychiatry Program Requirements."