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Asian Journal of Psychiatry 17 (2015) 140–141

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Asian Journal of Psychiatry


journal homepage: www.elsevier.com/locate/ajp

Discussion

Toward the era of transformational neuropsychiatry


Henry A. Nasrallah *
Department of Neurology and Psychiatry, Saint Louis University School of Medicine, 1438 South Grand Boulevard, St. Louis, MO 63104, United States

A R T I C L E I N F O

Article history:
Received 27 August 2015
Accepted 27 August 2015

The time has come for psychiatry to reclaim its neurological neurology, this disastrous myth and misconception about psychi-
roots and to regain its neuroscientific identity. Prior to the Freudian atry persists in the public arena, and has contributed to the unfair
theory that dominated psychiatry for many decades in the 20th stigma attached to mental illness and to the completely unjustified
century, psychiatry and neurology were integrated in one disparagement of psychiatry.
department with combined training in neuropsychiatry. It is The article by Torous et al. in this issue is an enlightened call to
ironic that Freud, who is a neurologist, by inventing and action to correct and reverse the longstanding ‘‘anosognosia’’ of the
propagating a theoretical psychoanalytic model for mental neurological correlates of psychiatric symptoms in psychiatric
functions, contributed to the rupture of the productive unity of training, which perpetuates brainless psychiatry. It is true that the
neurology and psychiatry. By the 1950s, psychiatry had become psychopharmacology revolution has given birth to biological
de-medicalized and de-neurologized due to the abstract, non- psychiatry and contributed to the wilting of psychoanalysis
evidence-based psychoanalytic constructs, along with its entirely (although psychodynamics remain a useful clinical psychothera-
non-medical jargon. No wonder neurologists decided to break up peutic model). However, biological psychiatry needs to transcend
from psychiatry to form their own associations and to establish pharmacology and transform itself into a full-fledged clinical
separate journals. This estrangement exacerbated the fallacious neuroscience. One of the impediments is the inertia of the current
artificial dichotomization of brain and mind, endowing neurology diagnostic system that focuses on arbitrary arrays of clinical
with a robust medical identity and casting psychiatry as just a symptoms that overlook the rapid advances in how psychiatric
philosophy of behavior with no clear medical identity and no symptoms can be generated from disturbed neural circuits,
recognizable physical findings or neurological basis for its preventing trainees from evolving into neuropsychiatrists.
disorder. The absurdly short requirement of two months of neurology
Alas, both specialties suffered from the rupture of their long- in the four years of psychiatric training is rendered less useful by
standing union: psychiatry became brainless and neurology failing to incorporate the psychiatric implications of every
became mindless. With rare exceptions, across all medical schools, neurological lesion during the rotation. Currently, neurology
the departments of neurology and psychiatry currently exist and supervisors are generally as naive about detecting psychopa-
function as independent silos, with rare academic interactions. The thology as psychiatry supervisors are in identifying neurological
separate training of psychiatrists and neurologists institutional- pathology.
ized the faulty brain–mind dualism: neurological disorders were To transform psychiatry into a clinical neuroscience specialty,
considered ‘‘organic’’ with tangible sensory/motor impairments, the neurology rotation must expand into a full year with intensive
while psychiatric disorders were erroneously conceptualized as neuropsychiatric training. This is a tall order because of the serious
‘‘functional’’, i.e. phenotypic alterations of mood, thoughts and current dearth of neuropsychiatrists or behavioral neurologists to
behavior, with no ‘‘tangible’’ neurological localizing signs. Despite serve as supervisors.
the tremendous advances in neuropsychiatry and behavioral Having served for several years on the ACGME committee in
charge of designing the didactic curriculum and clinical rotations
of psychiatric trainees (Residency Review Committee or RRC), as
* Tel.: +1 314 977 4824. well as site visiting and accrediting training programs in the U.S., I
E-mail address: hnasral@SLU.edu am cognizant of the Herculean challenge of modifying the training

http://dx.doi.org/10.1016/j.ajp.2015.08.010
1876-2018/ß 2015 Elsevier B.V. All rights reserved.
H.A. Nasrallah / Asian Journal of Psychiatry 17 (2015) 140–141 141

requirements in psychiatry. There has to be a strong support and next generation of neurologically minded psychiatric supervisors
consensus among RRC committees for changes to be drafted and who will expedite the neuroscientification of psychiatry.
distributed to multiple constituencies for feedback, concurrence or Finally, better medical care can be provided to patients with brain
rejection. disorders if the neurology trainees receive adequate psychiatric
The field of psychiatry currently lacks a critical mass of supervision to consistently recognize the mood, thought, cognitive
neuropsychiatrists and many academic departments do not even and behavioral consequences of various neurological disorders.
have a single qualified neuropsychiatrist. Thus, it will be difficult to Behavioral Neurology fellowships should also be developed and
adopt and implement the commendable model proposed by Torous emphasized. Perhaps the re-integration of psychiatry and neurology
et al. The most practical strategy for psychiatry to recapture its will be more likely when disorders affecting both the brain and its
neurological foundations is to establish neuropsychiatry fellowships mind are routinely assessed and managed by members of both
in as many departments as possible. This will gradually produce the specialties. Our neuropsychiatric patients deserve no less.