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What is Neuropsychiatry?
9
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Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007
What is Neuropsychiatry?
Germán E. Berríos
1
Abstract
Introduction
: Neuropsychiatry is based on social and scientif 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 ref ned descriptive psychopathology without trying to “naturalize” these
symptoms in a simplistic way, reducing them to putative biological markers.
Conclusions
:
±requently, neurological symptoms are not psychiatric, For instance, hallucinations in severe
melancholia are only superf 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 científ 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 ref 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 superf 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.
Artículos
Artículos
Berríos G.
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Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007
The Word and its Referents
Names help or hinder in all walks of
life, particularly when they behave
as drifting signiF ers. ±or example,
since it first appeared in fin de
siècle ±rance as a double-barre-
lled word (‘neuro-psychiatrie’), the
meaning of ‘neuropsychiatry’ has
repeatedly changed. By the inter-
bellum period, and now converted
in ‘neuropsychiatrie’, it referred to
the clinical doings of medics trained
both in neurology and psychiatry.
By 1918, the word appeared in the
Anglo-Saxon to name a form of:
“Psychiatry which relates mental or
emotional disturbance to disordered
brain function”. My own deF nition
is narrower: “discipline that deals
with the psychiatric complications
of neurological disease”. On the
other hand, American usage is
broader and tantamount to “biolo-
gical psychiatry”.
Currently, and F rst and fore most
“neuropsychiatry” refers to overla-
pping clinical disciplines sha ring
the belief that mental symptoms
are produced at disorde red brain
sites. It is also used to ma ke a
professional claim vis-à-vis rival
views of mental disorder such as
psychoanalysis. Lastly, it
creates
a social and economic space whe-
rein like-minded researchers safely
congregate to usufruct their fashio-
nable ideas.
The Context
Whether there is ‘neuropsychiatry’
in a particular country, and whether
it has a broad or narrow meaning
will depend, to a large extent, upon
the structure of its health services
and on the quality of the rela-
tionship between neurology and
psychiatry.
This is interesting and ironical as
both specialisms are new. Alienism
(the original name for psychiatry)
and neurology developed by the
1830s and 1860s respectively as the
direct result of the fragmentation of
the old grand Cullean category of
‘Neurosis’, and of the broadening
of the notion of ‘lesion’ which by
the end of the century indistinctly
referred to failures and solutions of
continuity in putative ‘structural’,
‘physiological’ or ‘psychological’
domains.
In Germany and ±rance, the for-
mation of alienists included neuro-
logical training and this facilitated
the use of the term ‘neuropsychia-
trist’. In Great Britain, on the other
hand, and due to important socio-
economic reasons (which there is
no space to discuss), neurology
and psychiatry had fully diverged
by the 1880s. This means that for
more than 90 years there was little
communication between the two
and that during the 1970s ‘neurop-
sychiatry’ had to be reinvented. It is
not altogether surprising that those
What is Neuropsychiatry?
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Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007
of us who were involved in such
re-creation had both neurological
and psychiatric training. This also
explains why to this day we do not
have in the UK a uniF ed deF nition
of neuropsychiatry.
The American deF nition has become
popular and this has encouraged
psychiatrists holding a biological
orientation au outrance to call
themselves ‘neuropsychiatrists’.
Others (like myself) continue deF -
ning neuropsychiatry in a narrow
way. The former can be found in all
venues of psychiatric care, the latter
work in general hospitals and do a
great deal of ‘neuro-liaison’ work (I
introduced this term in a lecture
given in Wellington, New Zealand
some years ago).
Neuropsychiatry
in Cambridge, UK
In keeping with the above, my own
‘neuropsychiatric’ clinical service
is organize on the narrow view
that neuropsychiatry is a branch
of psychiatry that deals with the
mental complications of neurolo-
gical disease. I do not believe that
such practice should in any way be
interpreted as a statement about
the nature of mental disorders in
general. Even within the conF nes
of my narrow deF nition, it seems
clear that neurological patients who
develop delusions, hallucinations,
obsessions, sadness, anxiety, etc.,
etc. do so on account of a variety
of mechanisms. On the one hand,
there are the causal aetiologies.
As my work on musical hallu-
cinations and irritability states
in Huntington’s disease patients
showed years ago, a direct link
can be demonstrated between
symptom and brain site or CAG
repeat, respectively. On the other
hand, neurological patients have
reasons for their symptoms, that is,
neurological diseases happen to real
people and hence have semantic
contexts. This adds an entire new
layer of meaning, hermeneutics and
therapeutic response. Patients may
show behavioural copies of mental
symptoms and these do not have
the same brain representation as
the conventional symptoms.
Neuropsychiatric clinical work ge-
nerates clinical templates which
can be translated into research
paradigms. There is nothing new
in this and each university will
use a different rhetoric to sell what
they do. Some sell themselves as
top-to-bottom research institutions
(i.e. grand ideas governing action),
others, are bottom-up ones (piece-
meal, low level research converging
upwards). This is the case of the
Cambridge University Neuroscience
Campus (the largest in the UK) whi-
ch includes research institutes and
a neuroimaging suite with inter alia
12 MRI magnets. My Neuropsychia-
try Service (6 clinics) is linked with
Berríos G.
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Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007
most of the research centres in the
campus. For example, the PD Clinic
provides patients for the large pro-
jects on receptor expression, fMRI,
pharmacology, and neurosurgery.
The HD Clinic is held in the ‘Bra-
in Repair Centre’ where about 12
patients who have already received
fetal cell implants in their caudate
nuclei are followed up at 3 months
intervals. The Traumatic Brain Da-
mage clinic takes place in the ‘Oliver
Zangwill Centre’, the leading cogniti-
ve neuropsychological rehabilitation
clinic in Europe. The Sleep Disorders
Clinic works closely with the ‘Res-
piratory Unit’ at Papworth hospital
which includes the more advanced
polysomnographic set up in the UK.
The Memory Complaints Clinic ser-
vices the large complex of memory
research at the ‘Cognitive and Brain
sciences Unit’, a ‘Medical Research
Council’ facility where concepts such
as executive functions and working
memory were ± rst developed; and
my General Neuropsychiatry Clinic
is linked up with the ‘Epilepsy Neu-
rosurgical Unit’, the ‘Tinnitus Clinic’,
etc. All these clinical- basic-sciences
associations create ideal opportuni-
ties for translational research which
has traditionally been the British
way of developing new ideas.
The Findings
Whatever the clinical context, neuro-
logical disorders are often accompa-
nied by psychiatric appurtenances.
The psychiatric component of some,
like Parkinson’s disease, Multiple
Sclerosis, Huntington’s disease,
Wilson’s disease, Binswanger’s
disease, etc. has been known for a
long time, and in some cases the
severity and management of that
component is more important for
social re-entry than any motor or
sensory disorder. In other cases,
however, such as the taupathies,
mitochondriopathies, CADASIL,
X-Linked Adrenoleukodystrophy,
etc. etc., not enough research has
yet been carried out to identify
the psychiatric component. In all
situations, an intelligent practice
provides the neuropsychiatrist with
conundra whose resolution has
direct relevance to psychiatry in
general; two of such will be briefl y
discussed below.
The Implications
Diagnostic Conundrum
The neuropsychiatrist often ± nds
that there is a lack of ± t between
the clinical phenomena met with
in neuro-liaison work and the con-
ventional psychiatric categories of
ICD-10 and DSM IV. Neurological
patients exhibit a variety of men-
tal symptoms but these are often
isolated and/or fl eeting and rarely
achieve critical mass to qualify for
a ‘psychiatric diagnosis’. This raises
theoretical and practical issues.
What is Neuropsychiatry?
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Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007
The former have to do with their
nature and formation mechanisms,
the latter with their management /
therapy. In the UK psychiatric the-
rapies are currently tightly governed
by guidelines which themselves are
based on meta-analytic exercises
and health economy evaluations.
Likewise, psychiatric drugs are
licensed for speciF c disorders and
share with the guidelines the same
sets of random clinical trials.
Before the time guidelines started
to be issued, psychiatric treatments
were based on a combination of
psychopharmacological knowledge,
therapeutic imagination and spe-
ciF c negotiations between doctor
and patient. This no longer obtains
and unless a patient qualiF es for a
clear diagnosis he will not be offered
medication as this might expose the
clinician to legal action. In neurop-
sychiatry, this is particularly acute
as neurological patients have mostly
mental symptoms and only rarely
mental disorders. ±urthermore,
the expression of such symptoms
may be distorted by the presence of
cognitive, expressional or emotional
deF cits directly related to the neu-
ropathological lesions.
Behavioural Copies and the
Problem of Symptom-Formation
In view of the above, the neurop-
sychiatrist often wonders whether
the mental symptoms (and occasio-
nal mental disorders) that he/she
comes across in the context of his
specialized practice are, in fact, the
same clinical phenomena as those
seen in general psychiatry. ±or
example, are the visual hallucina-
tions of Parkinson’s disease or Lewy
body dementia the same phenome-
na as those seen by a melancholic
elderly with Cotard’s syndrome?
Is the affective disorder associated
with frontal lobe strokes the same
as the common garden depressive
illness? Is the mania triggered by
steroid treatment the same as the
mania of a bipolar disorder?
These comparisons go directly to
the core of psychopathology and call
into question the epistemic capacity
of the language of psychiatry, that
is, its discriminating value. Over the
years, these questions have been
responded in different ways. There
was a time when the answer was
that so-called organic hallucinatio-
ns were different phenomena from
psychiatric hallucinations. Curren-
tly, the predictable view is that they
are, that they must be the same
phenomena. Biological psychiatry
is ruthless in its reductionism and
efforts to impose its causal me-
chanism. Many neuropsychiatrists
with long clinical experience in
their trade, however, are no longer
that cocksure. They often wonder
about multiple aetiologies and
about the existence of mechanisms
that generate behavioural copies
of the organic symptoms; or they
Berríos G.
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Rev. Colomb. Psiquiat., vol. XXXVI, Suplemento No. 1 / 2007
postulate the hypothesis that the
expressional systems in the human
may have a narrow repertoire and
act as f nal common pathways to
a variety oF triggers, some organic,
some semantic.
Such psychopathological hypothe-
ses generate Fresh approaches to the
analysis oF mental symptoms which
can only be undertaken by trained
psychiatrists. They oFFer a natural
and privileged space For psychiatric
research. UnFortunately, it is one
space that it is being abandoned by
psychiatrists who want to become
mini-neurologists -radiologists or
-geneticists. Descriptive psychopa-
thology remains the Fons et origo
oF all others ancillary disciplines in
psychiatry, and hence such diaspo-
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
geb11@cam.ac.uk
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