Motion and Emotion: The Neuropsychiatry of Movement Disorders and Epilepsy

By Andrea E. Cavanna

This book illustrates the clinical interface between neurology and psychiatry by focusing on neuropsychiatric conditions characterised by alterations at the level of both motor function and behaviour. The neuropsychiatric approach to movement disorders and epilepsy is of key importance in clinically assessing and treating these common and often disabling conditions. While addressing the clinical challenges posed by the behavioural aspects of movement disorders and epilepsy, it invites readers on a journey through the evolving discipline of neuropsychiatry / behavioural neurology – both in the past and today. This discipline has an illustrious history, and continues its ascending trajectory in the new millennium through the activity of long-established national organisations (British Neuropsychiatry Association, BNPA, and American Neuropsychiatric Association, ANPA) as well as newly developed strategic research initiatives (Michael Trimble Neuropsychiatry Research Group, MTNRG).

• Language: English
• Publisher: Springer
• Release date: Jul 3, 2018
• ISBN: 9783319893303

Book preview

Part IFoundations of Neuropsychiatry

© Springer International Publishing AG, part of Springer Nature 2018

Andrea E. CavannaMotion and Emotionhttps://doi.org/10.1007/978-3-319-89330-3_1

1.  Men Ought to Know…

Andrea E. Cavanna¹ 

(1)

Dept of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom

Men ought to know that from nothing else but the brain come joys, delights, laughter and sports, and sorrows, griefs, despondency, and lamentations. And by this, in an especial manner, we acquire wisdom and knowledge, and see and hear and know what are foul and what are fair, what are bad and what are good, what are sweet and what are unsavory […] And by the same organ we become mad and delirious, and fears and terrors assail us […] All these things we endure from the brain when it is not healthy […] In these ways I am of the opinion that the brain exercises the greatest power in the man

Hippocrates, On the Sacred Disease (400 BC)

Keywords

Behavioural neurologyBrainless neurologyMindless psychiatryNeuropsychiatryQuality of life

The unification of the study of the mind and the brain has a long and venerable tradition, which can be traced back to Hippocrates and the first Western philosophers. Hippocrates’ words can be read – and are still widely quoted – as a manifesto of naturalism or biological reductionism ante litteram and are echoed by the following dialogue between Socrates and Phaedrus: ‘Socrates: Now do you think one can acquire any particular knowledge of the nature of the soul without knowing the nature of the whole man? Phaedrus: If Hippocrates the Asclepiad is to be trusted, one cannot know the nature of the body, either, except in that way’. These words, written in Plato’s Phaedrus around 370 BC, suggest the existence of an uninterrupted line of thought throughout Western culture advocating the need for the convergence between neurology and psychiatry within a unified, yet multifaceted, discipline. Incidentally, this idea has even led scientists to suggest that interest in the brain as the seat of the highest human faculties might have been documented in the form of concealed neuroanatomy within artworks, at times when brain dissections were not encouraged (Fig. 1.1).

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Fig. 1.1

Concealed neuroanatomy in Gerard David’s Transfiguration of Christ (1520) (left) and Michelangelo Buonarroti’s Creation of Adam (1511) (right)? ‘Discovery consists of seeing what everybody has seen and thinking what nobody has thought’ (Albert Szent-Georgyi, 1893–1986). © https://​commons.​wikimedia.​org/​wiki/​File:​Human_​brain_​frontal_​(coronal)_​section_​description_​2.​JPG, https://​commons.​wikimedia.​org/​wiki/​File:​God2-Sistine_​Chapel.​png, https://​commons.​wikimedia.​org/​wiki/​File:​Gerard_​David.​Transfiguration_​of_​Christ02.​jpg, https://​www.​flickr.​com/​photos/​66351465@N00/​14071517001, https://​creativecommons.​org/​licenses/​by/​2.​0/​

However, the unfolding of history has shown that it is not easy to reach an univocal definition of neuropsychiatry. Intuitively, neuropsychiatry represents a clinical discipline located at the crossroads of neurology and psychiatry and deals with the interface of behavioural phenomena driven by brain dysfunction. Both clinical experience and epidemiological data suggest that behavioural symptoms are highly prevalent in patients with neurological conditions, are a major source of disability and diminished health-related quality of life , and represent the target of treatment interventions that can significantly decrease the suffering they generate.

It is widely recognised that unfortunately patients with behavioural problems originating from brain pathologies often slip through the net of healthcare services. During the second half of the twentieth century, the increasing trend towards parcellation and specialisation within medical science led to the creation of a radical – and somewhat artificial – divide between neurology and psychiatry, resulting in the unavoidable and despicable loss of the holistic perspective on the patient. In this sense, a bridge discipline like neuropsychiatry could pose as a natural remedy to the potentially dangerously extreme stances adopted by so-called ‘mindless neurology ’ (i.e. neurological approaches which neglect mental and behavioural manifestations of brain disorders) and ‘brainless psychiatry ’ (i.e. psychiatric approaches centred around psychological and social models which overlook biological explanations and interventions) (Fig. 1.2).

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Fig. 1.2

Neuropsychiatry as a natural remedy for ‘mindless neurology’ and ‘brainless psychiatry’

Convincing attempts to prevent the radical split between neurology and psychiatry can be traced in the writings of several formidable clinicians from the last two centuries. American neurologist Stanley Cobb (1887–1968), one of the fathers of modern neuropsychiatry (Fig. 1.3), was troubled throughout his career by the attempts of medical scientists to draw clear-cut distinctions between mental and physical symptoms, between psychic and somatic causes, between functional and organic diseases, and even between psychology and physiology.

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Fig. 1.3

Stanley Cobb (1887–1968) in his office at Harvard Medical School (1922). © https://​commons.​wikimedia.​org/​wiki/​File:​Stanley_​Cobb_​at_​the_​Harvard_​Medical_​School,_​1922.​png

Back in 1943, Stanley Cobb wrote:

I solve the mind-body problem by stating that there is no such problem. There are, of course, plenty of problems concerning the ‘mind’, and the ‘body’, and all intermediate levels of integration of the nervous system. What I wish to emphasize is that there is no problem of ‘mind’ versus ‘body’, because biologically no such dichotomy can be made. The dichotomy is an artefact; there is no truth in it, and the discussion has no place in science in 1943 […] The difference between psychology and physiology is merely one of complexity. The simpler bodily processes are studied in physiological departments; the more complex ones that entail the highest levels of neural integration are studied in psychological departments. There is no biological significance to this division; it is simply an administrative affair, so that the university president will know what salary goes to which professor.

It was Stanley Cobb who first proposed the image of a pyramid-shaped diagram linking the basic sciences to clinical psychiatry and ultimately to philosophy (Fig. 1.4).

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Fig. 1.4

Stanley Cobb’s pyramid model linking basic sciences to clinical psychiatry and philosophy. © https://​commons.​wikimedia.​org/​wiki/​File:​INES_​pyramid.​jpg

The connections between the basic sciences (at the base of the pyramid) and psychiatry (at the top) were portrayed as a gap to be gradually filled in by empirical research supporting psychiatric hypotheses. In 1975, another eminent American neurologist, Norman Geschwind (1926–1984), famously wrote that ‘it must be realized that every behavior has an anatomy’. By placing an unprecedented emphasis on the structure of the brain and revealing how this extraordinary organ can be understood as the source of human behaviour and its disturbances, neuropsychiatry is gradually filling the void between basic sciences and psychiatry/philosophy in Cobb’s pyramid model, thus proving Geschwind right. ‘Nihil quod non scriptum est’, it would be tempting to conclude, based on Hippocrates’ ancient prophecy.

Suggested Reading

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Cobb S. Foundations of neuropsychiatry. 6th ed. Baltimore: Williams & Wilkins; 1958.

David A, Fleminger S, Kopelman M, Lovestone S, Mellers J. Lishman’s organic psychiatry: a textbook of neuropsychiatry. 4th ed. New York: Wiley-Blackwell; 2009.Crossref

Hurwitz TA, Lee WT, editors. Casebook of neuropsychiatry. Washington, DC: American Psychiatric Publishing; 2013.

Miyoshi K, Morimura Y, Maeda K, editors. Neuropsychiatric disorders. Tokyo: Springer; 2010.

Priller J, Rickards H, editors. Neuropsychiatry case studies. New York: Springer; 2016.

Schiffer R, Rao M, Fogel BS. Neuropsychiatry. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2003.

Yudofsky SC, Hales RE, editors. Clinical manual of neuropsychiatry. Washington, DC: American Psychiatric Publishing; 2011.

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Agrawal N, Bhattacharya R, Rickards H. Provision of neuropsychiatry services: variability and unmet need. BJPsych Bull. 2015;39:297–301.Crossref

Arambepola NMA, Rickards H, Cavanna AE. The evolving discipline and services of neuropsychiatry in the United Kingdom. Acta Neuropsychiatr. 2012;24:191–8.Crossref

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Fleminger S, Leigh E, McCarthy C. The size of demand for specialized neuropsychiatry services: rates of referrals to neuropsychiatric services in the South Thames region of the United Kingdom. J Neuropsychiatry Clin Neurosci. 2006;18:121–8.Crossref

Fogel BS, Duffy J, McNamara ME, Salloway S. Skeptics and enthusiasts in neuropsychiatry. J Neuropsychiatry Clin Neurosci. 1992;4:458–62.Crossref

Ginn SR, Lorusso L. Brain, mind, and body: interactions with art in Renaissance Italy. J History Neurosci. 2008;17:295–313.Crossref

Hesdorffer DC. Comorbidity between neurological illness and psychiatric disorders. CNS Spectr. 2016;21:230–8.Crossref

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Lyketsos CG. Lessons from neuropsychiatry. J Neuropsychiatry Clin Neurosci. 2006;18:445–9.Crossref

Lyketsos CG, Kozauer N, Rabins PV. Psychiatric manifestations of neurologic disease: where are we headed? Dialogues Clin Neurosci. 2007;9:111–24.PubMedPubMedCentral

Meshberger FL. An interpretation of Michelangelo’s creation of Adam based on neuroanatomy. JAMA. 1990;264:1837–41.Crossref

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© Springer International Publishing AG, part of Springer Nature 2018

Andrea E. CavannaMotion and Emotionhttps://doi.org/10.1007/978-3-319-89330-3_2

2. Between (or Beyond) Neurology and Psychiatry

Andrea E. Cavanna¹ 

(1)

Dept of Neuropsychiatry, University of Birmingham, Birmingham, United Kingdom

Neuropsychiatry implies that its practitioners—neuropsychiatrists—are very familiar not only with the above-cited clinical skills ad methods of investigation but also with the signs and symptoms of a range of central nervous system disorders and the psychology of human motivation and desire

Michael Trimble, The Intentional Brain (2016)

Keywords

Behavioural neurologyBrain diseaseBridge disciplinesNeuropsychiatryTraining programme

What about the current dichotomy between neurology and psychiatry, which characterises most healthcare systems in the developed world? In a chapter on the neuropsychiatry of Tourette syndrome within the aptly titled book Neurology and Psychiatry: A Meeting of Minds (edited by Jonathan Mueller in 1989), British neurologist and writer Oliver Sacks beautifully summarised the bidirectional relationship between neurology and psychiatry: ‘This new orientation […] did not involve merely combining neurological and psychiatric knowledge, but conjoining them, seeing them as inseparable, seeing how psychiatric phenomena might emerge from the physiological, or how, conversely, they might be transformed into it’. Such bidirectional exchange appears to be a mandatory requirement for the development of a clinical discipline that aims to carve nature at its joints and provide patients with the best possible level of care.

The recent Renaissance of ‘bridge disciplines ’ such as neuropsychiatry and behavioural neurology marked an important milestone in the gradual process of psychiatry and neurology edging closer together in the effort to understand the brain bases of behaviour. The boundaries between neuropsychiatry and behavioural neurology are labile and can only be understood by appreciating the fact that historically most neuropsychiatrists first trained in psychiatry, whereas most behavioural neurologists first trained in neurology. Neuropsychiatry has traditionally been seen as a subfield of psychiatry, partly due to its ‘top-down’ approach, starting with productive (positive) mental and behavioural manifestations (e.g. affective symptoms, anxiety, psychosis) that occur in patients with overt brain disease and linking them to the underlying brain bases. Incidentally, the same process applies to biological psychiatry, where the underlying brain disease is explored more often with psychopharmacological modulation, genetic testing, and functional neuroimaging, than with structural neuroimaging or neuropathology techniques. Conversely, behavioural neurology has traditionally been seen as a subfield of neurology, partly due to its ‘bottom-up’ approach, starting with overt brain disease and focusing on the resulting deficiency (negative) syndromes (e.g. amnesia, aphasia, apraxia). These syndromes are currently classed as (neuro)cognitive disorders and can be thoroughly assessed by skilled clinical neuropsychologists. By taking a longitudinal perspective, it can be appreciated that few of these labels have stood the test of time. In fact, it has been argued that the boundaries between neuropsychiatry and behavioural neurology are artificial, without historical justification, and inapplicable to current research and clinical practice. Specifically, the classification of behavioural disturbances into positive manifestations (in which new abnormal behaviours occur) and negative syndromes (in which specific mental functions are lost) can be subject to criticism. This distinction dates back to nineteenth-century British neurologist John Hughlings Jackson and reflects more the zeitgeist of the era than current knowledge of neuropsychiatric syndromes, which often present with a mixture of productive symptoms and deficit syndromes. Moreover, it is apparent that eminent progenitors of behavioural neurology, including Norman Geschwind, had clinical interests that included productive symptoms (e.g. behavioural alterations and personality changes in patients with epilepsy) in addition to deficit syndromes (e.g. disconnection syndromes), thus incorporating neuropsychiatry within the conceptual framework of behavioural neurology from the very inception of the discipline.

In 2016, Michael Trimble published a book titled The Intentional Brain: Motion, Emotion, and the Development of Modern Neuropsychiatry . Looking back on a career of over 40 years, he reflected that ‘neuropsychiatry is concerned not only with descriptions of clinical abnormalities that relate to our understanding of brain-behaviour relationships but also with the meaning of abnormal behavior’. This approach requires consideration of content as well as form, and the various life contingencies that impinge on patients which may influence the expression of their signs and symptoms, together with a propensity to tolerate diagnostic uncertainty. Trimble argued that ‘neuropsychiatry is not simply an offshoot of psychiatry. It is a discipline that has arisen out of a clinical need for patients who have fallen badly between the cracks endangered by the developments of the clinical neurosciences in the XX Century’. He added that ‘without an intimate acquaintance in particular with neuroanatomy and neuropsychology, simply struggling with the names of various neuroreceptors and transmitters and knowing enough psychopharmacology to adequately prescribe psychotropic agents does not add up to being a neuropsychiatrist’.

Although the necessity for establishing comprehensive training programmes for neuropsychiatry seems to have been widely accepted, ad hoc curricula have yet to be developed in the vast majority of countries. In fact, in several Western countries, neuropsychiatry as a formally recognised clinical discipline currently exists only for the developmental age (child neuropsychiatry). Moreover, there is a wide variability in the clinical conditions which fall within the remit of neuropsychiatry across different countries. For example, the large field of dementias (including Alzheimer disease and fronto-temporal dementia) is an essential part of neuropsychiatry in the United States, whereas it is often split between old-age psychiatry and cognitive neurology in the United Kingdom. Another example of such variability is the Melbourne Neuropsychiatry Centre , an academic unit which has established an international reputation in the areas of cognition and neuroimaging in schizophrenia – research areas which would be classed as part of biological psychiatry rather than neuropsychiatry in both the United States and the United Kingdom.

The United States played a groundbreaking role in the official establishment of neuropsychiatry practice in the contemporary era. As a result of a joint effort from the American Neuropsychiatric Association (ANPA) and the Society for Behavioral and Cognitive Neurology (SBCN) , behavioural neurology and neuropsychiatry was approved as a subspecialty area by the United Council for Neurologic Subspecialties (UCNS) in 2004. A number of excellent fellowship programmes have since been developed in the main clinical and academic institutions of the United States, which have been approved for accreditation. Behavioural neurology and neuropsychiatry is defined by the UCNS as a medical subspecialty committed to better understanding links between neuroscience and behaviour and to the care of individuals with neurologically based behavioural disturbances. Training in behavioural neurology and neuropsychiatry entails the acquisition of knowledge regarding the clinical and pathological aspects of neural processes associated with cognition, emotion, behaviour, and elementary neurological functioning, the mastery of the clinical skills required to evaluate and treat persons with such problems, and the development of a level of professionalism, interpersonal and communication skills, and practice- and systems-based competencies required for the practice of this medical subspecialty. The full curriculum for the Behavioral Neurology and Neuropsychiatry Fellowship was developed by the Joint Advisory Committee on Subspecialty Certification of the ANPA and the SBCN and was published in 2006 in the Journal of Neuropsychiatry and Clinical Neurosciences, the official journal of the ANPA.

In the United Kingdom, there are currently only two postgraduate courses in clinical neuropsychiatry. The MSc/PG Dip/PG Cert course in Clinical Neuropsychiatry at the University of Birmingham has been successfully running for over 10 years. This interdisciplinary programme aims to advance the theory and practical knowledge of experienced professionals working with people with neuropsychiatric disorders associated with neurodegeneration, brain injury, and other neurological conditions (principally doctors, neurologists, psychiatrists, psychiatric nurses, clinical psychologists, and psychologists intending to become clinical psychologists). Bringing together people employed in health, education, and social services, it is also open to psychology and other neuroscience graduates who wish to develop their academic and clinical skills.

The recently developed MSc course in clinical neuropsychiatry at King’s College London aims to allow students to develop the skills and knowledge required to specialise in neuropsychiatry as clinicians and/or academics. This programme welcomes biomedical and psychology graduates, as well as psychiatrists, neurologists, psychologists, and other health professionals onto the course.

As it is customary in course programmes, this introductory section presents the conceptual and methodological foundations of neuropsychiatry. It is clear that modern neuropsychiatry entails a combination of scientific innovation and ancient wisdom, as it becomes apparent in the following chapters, which trace the development of the scientific and philosophical thought focusing on the relationship between the brain and behaviour. A brief outline of the theoretical approaches to neuropsychiatry (borrowing basic concepts from philosophy of science and philosophy of mind) is followed by an overview of the fundamental aspects of brain anatomy and treatment modalities that are most relevant