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
roots and to regain its neuroscientific identity. Prior to the Freudian
theory that dominated psychiatry for many decades in the 20th
century, psychiatry and neurology were integrated in one
department with combined training in neuropsychiatry. It is
ironic that Freud, who is a neurologist, by inventing and
propagating a theoretical psychoanalytic model for mental
functions, contributed to the rupture of the productive unity of
neurology and psychiatry. By the 1950s, psychiatry had become
de-medicalized and de-neurologized due to the abstract, non-
evidence-based psychoanalytic constructs, along with its entirely
non-medical jargon. No wonder neurologists decided to break up
from psychiatry to form their own associations and to establish
separate journals. This estrangement exacerbated the fallacious
artificial dichotomization of brain and mind, endowing neurology
with a robust medical identity and casting psychiatry as just a
philosophy of behavior with no clear medical identity and no
recognizable physical findings or neurological basis for its
disorder.
Alas, both specialties suffered from the rupture of their long-
standing union: psychiatry became brainless and neurology
became mindless. With rare exceptions, across all medical schools,
the departments of neurology and psychiatry currently exist and
function as independent silos, with rare academic interactions. The
separate training of psychiatrists and neurologists institutional-
ized the faulty brain–mind dualism: neurological disorders were
considered ‘‘organic’’ with tangible sensory/motor impairments,
while psychiatric disorders were erroneously conceptualized as
‘‘functional’’, i.e. phenotypic alterations of mood, thoughts and
behavior, with no ‘‘tangible’’ neurological localizing signs. Despite
the tremendous advances in neuropsychiatry and behavioral
* Tel.: +1 314 977 4824.
E-mail address: hnasral@SLU.edu
http://dx.doi.org/10.1016/j.ajp.2015.08.010
1876-2018/ß 2015 Elsevier B.V. All rights reserved.
neurology, this disastrous myth and misconception about psychi-
atry persists in the public arena, and has contributed to the unfair
stigma attached to mental illness and to the completely unjustified
disparagement of psychiatry.
The article by Torous et al. in this issue is an enlightened call to
action to correct and reverse the longstanding ‘‘anosognosia’’ of the
neurological correlates of psychiatric symptoms in psychiatric
training, which perpetuates brainless psychiatry. It is true that the
psychopharmacology revolution has given birth to biological
psychiatry and contributed to the wilting of psychoanalysis
(although psychodynamics remain a useful clinical psychothera-
peutic model). However, biological psychiatry needs to transcend
pharmacology and transform itself into a full-fledged clinical
neuroscience. One of the impediments is the inertia of the current
diagnostic system that focuses on arbitrary arrays of clinical
symptoms that overlook the rapid advances in how psychiatric
symptoms can be generated from disturbed neural circuits,
preventing trainees from evolving into neuropsychiatrists.
The absurdly short requirement of two months of neurology
in the four years of psychiatric training is rendered less useful by
failing to incorporate the psychiatric implications of every
neurological lesion during the rotation. Currently, neurology
supervisors are generally as naive about detecting psychopa-
thology as psychiatry supervisors are in identifying neurological
pathology.
To transform psychiatry into a clinical neuroscience specialty,
the neurology rotation must expand into a full year with intensive
neuropsychiatric training. This is a tall order because of the serious
current dearth of neuropsychiatrists or behavioral neurologists to
serve as supervisors.
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
well as site visiting and accrediting training programs in the U.S., I
am cognizant of the Herculean challenge of modifying the training
 H.A. Nasrallah / Asian Journal of Psychiatry 17 (2015) 140–141
requirements in psychiatry. There has to be a strong support and
consensus among RRC committees for changes to be drafted and
distributed to multiple constituencies for feedback, concurrence or
rejection.
The field of psychiatry currently lacks a critical mass of
neuropsychiatrists and many academic departments do not even
have a single qualified neuropsychiatrist. Thus, it will be difficult to
adopt and implement the commendable model proposed by Torous
et al. The most practical strategy for psychiatry to recapture its
neurological foundations is to establish neuropsychiatry fellowships
in as many departments as possible. This will gradually produce the
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next generation of neurologically minded psychiatric supervisors
who will expedite the neuroscientification of psychiatry.
Finally, better medical care can be provided to patients with brain
disorders if the neurology trainees receive adequate psychiatric
supervision to consistently recognize the mood, thought, cognitive
and behavioral consequences of various neurological disorders.
Behavioral Neurology fellowships should also be developed and
emphasized. Perhaps the re-integration of psychiatry and neurology
will be more likely when disorders affecting both the brain and its
mind are routinely assessed and managed by members of both
specialties. Our neuropsychiatric patients deserve no less.