Door County Summer Institute #33

The Door County Summer Institute (DCSI) was founded by Medical College of Wisconsin Professor Carlyle H. Chan, MD.  It is held at the Landmark Lodge in Egg Harbor, Wisconsin.  Egg Harbor is one of many small towns that dot the Door County peninsula bordered on the west by Green Bay and on the east by Lake Michigan.  If you have a lake view from the Lodge, there is generally an unobstructed view of the expanse of Green Bay with a few visible islands on the horizon. The weather this time of the year is tropical for the midwest with temperatures in the 80s and the occasional thunderstorm.

The DCSI is a psychiatry conference and most of the people who attend are psychiatrists but there are also psychologists, social workers, NPs, PA-Cs and nonpsychiatrist physicians.  The programs are very eclectic with topics ranging from psychopharmacology to terrorism. In the course I have attended there have been 1 to 3 instructors.  The instructors are all generally considered to be experts in the fields they are presenting. The courses are generally 2 days in duration (mornings only) with plenty of discussion about places to see in the area that include, restaurants, art galleries, concerts, plays, and musical productions.

As I mentioned in a previous post, I attended four sessions on Practical Neuropsychiatry for Clinicians presented by Sheldon Benjamin, MD.  I consider myself to be a neuropsychiatrist.  Early in my career, I attended behavioral neurology conferences and ran an Alzheimer's Disease and Memory Disorder Clinic co-staffed by a neurologist for about 12 years. I also evaluated neuropsychiatric problems in acute care settings. My hope was to get some complementary knowledge from an expert with a different career path and I was not disappointed.

The first session was spent on an overall neuropsychiatric approach to the patient and Dr. Benjamin made the observation that neuropsychiatry is personalized medicine in that each formulation is uniquely developed for the individual and it also answers the question about what treatment will help that unique individual. On that basis, is is not a nonspecific label.  His reasoning can be extended to the psychiatric formulation in general. As previously noted on this blog, a formulation is the most unique aspect of the evaluation and it needs to be included as well as the diagnoses. Any psychiatrist knows that people with the same diagnoses are unique individuals and that the diagnosis alone does not take into account the unique conscious states of individuals any more than any other medical diagnosis.

From there most of the rest of the first day was spent on a discussion of frontal lobe function and executive function.  Rather than focus on the consensus list of neuropsychological tests thought to comprise executive function, he presented an adaptation of D. Frank Benson's schema to illustrate the basic dimensions (anticipation, monitoring) involved in goal selection and planning and the underlying behaviors.   He emphasized the assessment of frontal function as being possible without any specialized testing and illustrated the point with a humorous example (1).  Executive function was primarily a product of prefrontal cortical function but parietal cortex and cerebellar cortex were also involved on the basis of an analysis of cognitive and neuroimaging articles (2).

There was an emphasis on practical assessment frontal lobe function and more specifically the ecological validity of the tasks. In other words what do the tests mean in real life. The MoCA Test was used to illustrate that tests of frontal executive function do not require any special equipment. The trail making, clock drawing, and verbal fluency sections were highlighted as requiring frontal executive function. The MoCA Test was described as potentially problematic due to the new licensing procedure. Dr. Benjamin presented several other tests that could be added to the bedside exam that included both neurological examinations of for example anti-saccades and more complex cognitive tasks such as complex problem-solving, inferential reasoning, the script generation task, and a headline task. After the presentation there was a brief workshop where patient was presented and participants needed to pick one behavioral problem, develop a hypothesis, and suggest what tests could be used.  The ultimate goal was to consider not just a useful test, but also potential rehabilitation approaches. A total of 16 cognitive domains and 30 cognitive tasks were provided that could be used to develop specific tests.

The final section of the first two days was about traumatic brain injuries.  I have a previous post on an application from this section on classifying the severity of these injuries.  The epidemiology is striking with a prevalence equivalent to patients with severe mental illnesses.  The death rate is about 50,000 people per year and at 1 year a many as 15% of people with a mild TBI remain symptomatic.  The myth discussed is that we all grow up thinking that TBIs are relatively benign.  I see that occurring regularly in the patients I assess who have had multiple TBIs or concussions and who never saw a physician for assessment. In many cases they resumed playing the sport immediately where they were injured.  That is a very high-risk scenario.  The coupe-contre-coup injury was discussed as well as how to identify it on brain imaging studies and autopsies.  Several specific mechanisms of injury were discussed including diffuse axonal injury (DAI) and how that occurs during TBIs.  Shear forces used to be considered the main mechanism of injury but now permeability changes are thought to occur that leads to lysis of axons in the 12-24 hour window.

Second Syndrome or Second Impact Syndrome was mentioned as a complication of returning to play too soon and sustaining a second concussion with a resulting massive injury.  It apparently based on a 1984 report (3) where a football player sustained a concussion in a fight and then another concussion 4 days later playing football.  That second injury resulted in massive cerebral edema and death. The purported mechanism is a vulnerable window of decreased brain metabolism.  Concussed athletes have been examined with MR spectroscopy.  In this method, N-acetylaspartate (NAA) is a marker of neuronal viability. Following concussions, NAA is depressed to the lowest at about three days after the injury and it recovers by 30 days.  In another study, if a second injury occurred before 15 days – recover of the NAA marker did not occur until 45 days.  Some sources consider this syndrome to be controversial due to recall bias and a lack of reported cases in other literature, but the depression of brain metabolism is concerning.  Clinical symptoms of TBI may be underreported or not reported at all during this recovery phase.

In the section on specific frontal syndromes, Dr. Benjamin pointed out that he was pleasantly surprised by the Neurocognitive Disorders section in the DSM-5.  I agree with his observation. There is highly detailed information about making those diagnoses and what information is relevant. For the course he looked at personality changes associated with various frontal syndromes such as orbitofrontal syndrome, prefrontal syndromes, mixed frontal syndromes, ventromedial syndromes, and secondary mood disorders.

That last two days of the course were focused on memory, encephalitis lethargica, autoimmune syndromes, and the six landmark cases necessary for neuropsychiatric literacy.  I will end with a summary of the six cases because for most readers of this blog – they are readily accessible in the paper written by Benjamin, et al (4).  His discussion of the Phineas Gage case was remarkable given the amount of misinformation that exists.  He presented a detailed timeline of the injury and how Gage was treated initially by the town physician and then by the railroad physician.  New England Journal of Medicine subscribers may be surprised to learn that they have access to the full text of an 1848 account from attending physician Dr. Harlow (5).  There are 43 references in the medical literature. For anyone not familiar with the case, he sustained a penetrating wound to the brain when a 43 inch, 13.5 pound iron rod used to tamp sand and gunpowder into a hole for excavating rock was propelled through his left orbit and left frontal lobe exiting out the top of his skull.  Dr. Benjamin pointed out that there are numerous false accounts of the incident and I had read several suggesting that the rod had to be extracted from Gage's skull by the doctor in attendance. In fact, the rod blew through his head an landed about 30 feet away.  The rod had been specially designed by Gage so that one end was tapered for prying.  That is what led to the penetrating wound and is also what saved him.  The year of this injury was 1848, before antibiotics and neurosurgery.  Gage was transported to a hotel where he stayed and was able to walk up to his room on the second floor where he experienced transient delirium but he was able to recover and return home after 74 days.  There are numerous accounts of his neuropsychiatric recovery.  The commonest description is that he was "no longer Gage".  He could no longer work as a railroad foreman, but sometime later traveled to Chile where he was a stagecoach driver managing a 6-horse stagecoach. He died about 12 years after the injury from status epilepticus.  The index case of severe frontal lobe damage illustrates preservation of cognitive and motor skills with some personality changes.        

  

 In conclusion, I highly recommend Dr. Benjamin’s work and this course if you ever want to attend a DCSI.  More to the point, I highly recommend that medically oriented psychiatrists develop skills in neuropsychiatry by working these principles and skills into their practice like I have over the past 30 years.  When I say medically oriented psychiatrists, I am generally referring to acute care psychiatrists (inpatient, addiction and consultation liaison) and outpatient psychiatrists who are seeing patients as identified as having cognitive problems and possible dementias like geriatric psychiatrists or psychiatrists who specialize in treating people with complex medical and psychiatric problems. In my situation seeing inpatients with a variety of complex problems, making associated medical diagnoses, and working closely with other consultants was very effective in reaching this goal. An additional skill was reading all brain imaging and taking an early interest in EEG and QEEG.  Seeing all of the brain imaging of patients has never been easier than with the current EHR.  When we were using only paper records, I would often trace an axial section of a CT or MRI and put that in the patient’s chart but now it is right there.   I think it is also a critical factor in deciding what an ultimate practice environment must look like for psychiatrists interested in this type of practice. Th environment has to provide access to the necessary imaging, neurophysiological, and laboratory testing as well as easy access to other consultants.  Complex problems require an environment where they can be addressed.  Many current practice environments for psychiatrists do not provide access to these tools or state-of-the-art treatment modalities.  In many of these settings it is difficult to find a working blood pressure device. 

Given the appropriate medical setting, there has never been a better time to be a neuropsychiatrist and train neuropsychiatrists for the future.

George Dawson, MD, DFAPA

References:

1: Rockwood K, Chertkow H. A cellular-telephone model of assessing frontal lobe function in physicians. CMAJ. 2007 Dec 4;177(12):1533-5. PubMed PMID: 18056616. Link (full text)

2: Nowrangi MA, Lyketsos C, Rao V, Munro CA. Systematic review of neuroimaging correlates of executive functioning: converging evidence from different clinical populations. J Neuropsychiatry Clin Neurosci. 2014 Apr 1;26(2):114-25. doi: 10.1176/appi.neuropsych.12070176. Review. PubMed PMID: 24763759. Link (full text)

3: Kamins J, Giza CC. Concussion-Mild Traumatic Brain Injury: Recoverable Injury with Potential for Serious Sequelae. Neurosurg Clin N Am. 2016 Oct;27(4):441-52. doi: 10.1016/j.nec.2016.05.005. Review. PubMed PMID: 27637394; PubMed Central PMCID: PMC5899515. Full Text

4: Benjamin S, MacGillivray L, Schildkrout B, Cohen-Oram A, Lauterbach MD, Levin LL. Six Landmark Case Reports Essential for Neuropsychiatric Literacy. J Neuropsychiatry Clin Neurosci. 2018 Fall;30(4):279-290. doi: 10.1176/appi.neuropsych.18020027. Epub 2018 Aug 24. PubMed PMID: 30141725.

5. Harlow JM.  Passage of an Iron Bar Through the Head. The Boston Medical and Surgical Journal. 1848 XXIX(20): 389-393.

6: Damasio H, Grabowski T, Frank R, Galaburda AM, Damasio AR. The return of Phineas Gage: clues about the brain from the skull of a famous patient. Science. 1994 May 20;264(5162):1102-5. Erratum in: Science 1994 Aug 26;265(5176):1159. PubMed PMID: 8178168.

7: Haas LF. Phineas Gage and the science of brain localisation. J Neurol Neurosurg Psychiatry. 2001 Dec;71(6):761. PubMed PMID: 11723197; PubMed Central PMCID: PMC1737620. Full Text

Supplementary 1:

Don’t forget Dr. Benjamin’s Brain Card as an excellent resource.  The nominal cots is used to fund a web site that provides free access to additional clinical resources that are available to Brain Card holders for free.

Supplementary 2:

I anticipate some complaints from psychiatrists who will say that they do not have enough time to do detailed assessments like the ones suggested in this post.  Despite the penetration of managed care and the fact that most physicians are employees, I contend that it is still possible to do detailed and intensive evaluations on patients with complex problems. My strategy for a long time was to do inpatient work where I could see people as many times a day as I needed to an I had access to resources like EEG labs and imaging studies.  The ability to meet with families for a more in depth analysis of the problem was also a plus. Choosing the correct work setting goes a long way toward allowing this kind of work.  

The Harvard Neuropsychiatry Course

I went to the Harvard Neuropsychiatry course for all of the wrong reasons.  I started going to HMS courses in Boston back in the late 1980s.  I have always seen myself as a medical psychiatrist knowledgeable in neurology, medical imaging and electroencephalography.  I have always liked seeing people with complicated problems that are associated with psychiatric diagnoses or who have psychiatric symptoms associated with their primary medical or neurological diagnoses.  That led me to the Behavioral Neurology courses through Harvard where the presentations were done by all of the experts at time including M-Marcel Mesulaum, Antonio Damasio, Hanna Damasio, Elliot Ross, and David Bear.  Their work is well represented in the text Principles of Behavioral and Cognitive Neurology.  At the time there were some older neuropsychiatry texts but learning about the field generally had to occur on a reference by reference basis.  I was working in a Memory Disorders and Geriatric Psychiatry Clinic and learning neuropsychiatry on a syndrome by syndrome basis.  I did not find out until this course that it is the largest meeting in the field and has been occurring on an annual basis for the past two years.  My motivation for coming was basically to see whether I missed anything.  I always need to answer the question: "Can a clinician working too many hours per week keep up with a technical field to an acceptable degree."  For the first time ever in my career I was spending a lot of money on a conference and travelling well outside my comfort zone to see presenters who I did not know that well.

There were about 320 people registered for the course.  The setting was a hotel built in the early 20th century but extensively remodeled to 4 star hotel status.  The conference itself took place in the main ballroom and it was densely populated with some overflow into balcony seats and a mezzanine area in the back.  The audiovisual effects worked with with a large projection screen over the speaker and large LEDs TVs lining each side of the ballroom.

The  overall format of the course was to present a lot of technical information on Day 1 and discuss more discrete diseases and syndromes on Day 2.  The detailed agenda for both days can be found at this link.  Day 1 was a focus on neuroanatomy, functional brain networks, neuroimaging,  neuropsychiatric and neuropsychological approaches to the complex patient, and a detailed approach to the complex patient.  These were not TED talks.  The first three presentations covered 81, 60, and 60 slides.  That is the way I like it.  An additional benefit is that all of the PowerPoints were available in PDF form online.  Even the most unreadable slides are easily visible in this form.  The PDF form is also allows the syllabus to be printed in black and white and used primarily for note taking.  Legibility of the slides depend on the print size and many in this syllabus were unreadable.  I think that all conferences should use this approach.  I would like it modified so that the original slides could be reused in lectures by Creative Commons licenses.

The early lecturers used a lot of subordinate clauses and very long sentences.  I could imagine that anyone unfamiliar with the jargon could get lost.  The lecturers were unapologetic and one of them suggested studying the slides and references to get up to speed.  The pace of the course was intense with brief coffee and lunch breaks in order to cover the advertised CME.  Several of the lecturers ended up accelerating their presentations as they realized that they were running out of time.  My focus in these conferences is on information transfer and not style points on the lectures.  At that level I consider it a success.  Key points were highlighted as well as references.  There were a couple of graphics that were not referenced.  The syllabus for the course is 453 pages long and could easily be worked into a text at some point.

In the past, I have reviewed all of the lectures at conferences.  For this conference I am going to mention a couple of high points.  There is some confusion about what neuropsychiatry is.  Barry Fogel, MD defined it at the end of Day 1: "Neuropsychiatry is a branch of clinical neuroscience more than a mental health discipline.  It is always in the context of the brain."  Every lecturer maintained that theme reviewing key brain circuits involved in pathological states including some that were considered to be functional as well as states associated with clear brain pathology.  In some cases those formulations were associated with a new conceptualization of the disorder.  A good example, is the case of traumatic brain injuries (TBI).  Tom McAllister, MD made the point that not too long ago, nobody would have showed up for a lecture on TBI.  Those were the days when it was common to consider TBIs, especially occurring in sports to be minor events.  That has been reconceptualized from the perspective of neuropathological changes, protein markers (Tau, APP, Aβ, and others), and possible progression to dementia.  The treatment of neuropsychiatric syndromes of TBI including depression, PTSD, and other psychiatric syndromes.  I am used to seeing a lot of people with bipolar like syndromes after TBIs but that was not mentioned.  Excellent reconstructions of the brain with a map of the results of a large number of TBIs were presented with an emphasis on the circuitry affected and how that can lead to symptoms.

When I think about earth shaking information on a single slide (yes - it can happen) - the best example I can think of was a slide in the presentation: Neuropsychiatric Aspects of Frontotemporal Dementia by Brad Dickerson, MD.  For anyone who has followed it, the diagnostic approaches to this relatively common dementia have been confusing over the years (2).  In a slide FTLD (Frontotemporal lobar degeneration) clinicopathological spectrum parses the 6 major clinical  syndromes into subtypes based on biological markers.  Each category was also color coded to indicate the degree of tauopathy.  I found a modified version of this slide in an article by Irwin, et al in Frontiers in Aging Neuroscience (1).  These same authors have published a significant number of the papers in the field.  This review stood out to me because it is the clearest conceptualization of FTLD that I have seen.

The second high point of the conference was on Functional Neurological Symptom Disorder (FNSD).  This is actually a subheading under Conversion Disorder in the DSM-5 (p. 318) and the main diagnosis is the disorder known to most psychiatrists.  The disorder is one of pseudoneurological symptoms like weakness, paralysis, sensory symptoms, speech problems, or seizures with no known correlates of the medical diagnosis.  The presentation by Gaston Baslet, MD on the approach to these disorders was very informative.  Rather than take a strict DSM criteria approach, he presented the criteria and then illustrated levels of diagnostic certainty - the levels of diagnostic information that are ideal versus what is clinically available.  The example given was for Psychogenic Non-Epileptic Seizures (PNES).  The increased prevalence of these disorders in neurological practice as opposed to primary care was noted.  Most importantly, the approach to treating the disorder was discussed as well as what seems to work.  A model of predisposing, precipitating, and perpetuating factors was presented.  Like most disorders, cognitive behavioral therapy (CBT) is a useful treatment modality either as psychotherapy delivered in a  standard approach or using a self help manual.  Dr. Baslet also discussed a communication protocol on how to present the diagnosis and rationale for treatment to the patient.  Limiting factors include the low number of patients who complete treatment and there is a spontaneous improvement rate of about 20%.  A neurobiological model of PNES/FNSD was presented based on the work of van der Kruijs, et al (3).  This is important work for any psychiatrist who has not had the experience of treating PNES/FNSD on an ongoing basis with psychotherapy.  My experience is consistent with the presentation in that it takes good communication with the patient and an effective model for therapy to get results.

Forced normalization epilepsy was a term that I was unfamiliar with even though I have treated a significant number of people with seizure disorders.  It was discussed in Gaston Baslet's second presentation on the Neuropsychiatry of Epilepsy.  It is a description of a syndrome where psychotic states occur as the EEG abnormalities of the seizure disorder improve or disappear.  The neuropsychiatric symptoms that emergence when this occurs is also referred to as alternate psychosis.  There is a small but significant literature on this problem that also highlights some of the controversies.  His presentation also discussed the safety of antidepressants in epilepsy and the FDA warning on suicidality and antiepileptic drugs (AEDs).  Since I prescribed a lot of gabapentin in the treatment of addiction, anxiety, and chronic pain - that is a warning that I have to address a lot with patients.  He showed the Forest plot of odds ratios for specific AEDs and according to that reference (4) some drugs may be protective for suicidal ideation and behavior.  With the discussion of emerging and interictal psychotic symptoms an equivalent brief discussion of antipsychotic drugs in these states would also have been very useful.  Dr. Baslet also mentioned one of my favorite neuropsychiatric symptoms Alice In Wonderland Syndrome or metamorphopsia as it is sometimes known.  Like Alice, patient's experience body distortion (feeling too tall, floating, sinking into the ground) as a manifestation of infectious disease (originally Epstein Barr Virus), migraines, or epilepsy.

A  final brief point was noted in the presentation on neuropsychology by Aaron Nelson, PhD.  It is useful at a time when I think there is a lot of controversy about these assessments and what they show.  The commonest reason I see patients getting a neuropsychological assessment these days is Attention Deficit-Hyperactivity Disorder.  It is generally presented to me as proof of the disorder and proof that a person needs stimulant medications.  The patient generally reports that they were "tested" for ADHD and found to have it despite a normal development history, normal and typically good academic performance, and good vocational achievement.  I have previously posted that Russell Barkley, PhD one of the leading authorities on ADHD has stated that neuropsychological testing is neither necessary or sufficient to make a diagnosis of ADHD and as it is based on clinical criteria.  Of course the main reason for neuropsychological testing of individuals suspected of having ADHD is to test for any associated learning disorders and in the adult patients I see - very few people recall any information of that sort.  Dr. Nelson points out that intraindividual variation in neuropsychological test performance is common with 66% or participants in his study (6) producing maximal discrepancies that exceeded 3 standard deviations on test performance.  His conclusion is that score variability alone is not enough to base diagnostic inferences on.  Dr. Nelson also called for a show of hands to see if any clinicians had access to neuropsychological testing in a time frame of less than 3 months.  There were few if any hands raised.            

Those were a few of my favorite highlights from this conference.  There are many more, but I am trying to keep this post contained to the highlights and overall focus.  This is an intense conference but a good one.  In the follow up assessment, they asked if the course should be three days rather than two and I endorsed that approach.  I think that the inflammatory section of neuropsychiatric disorders could be reinforced by having any of the psychiatrists who write the sections in Lahita's text on Systemic Lupus Erythematosus present on that topic. If your priorities in conferences are similar to mine (information transfer, non-experiential, and a direct comparison of your skills to the experts are a priority) - you might want to attend this conference next year.  The course organizers did have question and answer sessions regularly throughout the program and questions were actively solicited by course staff and read and answered by the lecturers.

And it turns out my approach to self-study has paid off.  There were several points where I could have stood up and given the lecture.  That may seem immodest if you believe that practicing psychiatrists need to be constantly tested and reassessed by some higher authority to prove that they are competent.   I don't and never have.  It turns out all you have to do is practice medicine, think a lot about what you are doing and try to keep up on the literature.  At one point the lecturers asked about how many people in the audience were psychiatrists and then how many have treated people with frontotemporal dementia.  Most of the people were psychiatrists and most of them have assessed and treated frontotemporal dementia, despite the fact that the diagnostic classification has been in a state of flux for the past 20 years.  Thinking about that, there was a tremendous amount of knowledge about neuropsychiatric disorders in that room.  I can't imagine that this disorder or the general importance cerebral atrophy on imaging  is well recognized in primary care settings.  That is just one of the reasons why neuropsychiatrists are needed out there and why these concepts need to be taught and understood in residency training.



George Dawson, MD, DFAPA
 
 

References:

1:  Irwin DJ, Trojanowski JQ, Grossman M. Cerebrospinal fluid biomarkers for differentiation of frontotemporal lobar degeneration from Alzheimer's disease. Front Aging Neurosci. 2013 Feb 21;5:6. doi: 10.3389/fnagi.2013.00006. PubMed PMID: 23440936; PubMed Central PMCID: PMC3578350.

2:  Kertesz A, Munoz DG.  Frontotemporal Dementia; in:  Alzheimer Disease. RD Torrey, R Katzman, KL Bick, SS Sisodia (eds); Lippincott Williams and Wilkins; New York; 1999; pp 133-145.

3:  van der Kruijs SJ, Bodde NM, Vaessen MJ, Lazeron RH, Vonck K, Boon P, HofmanPA, Backes WH, Aldenkamp AP, Jansen JF. Functional connectivity of dissociation in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry. 2012 Mar;83(3):239-47. doi: 10.1136/jnnp-2011-300776. PubMed PMID: 22056967.   JNNP has a collection of Neuropsychiatry articles up until 2015.

4:  Hesdorffer DC, Kanner AM. The FDA alert on suicidality and antiepilepticdrugs: Fire or false alarm? Epilepsia. 2009 May;50(5):978-86. doi: 10.1111/j.1528-1167.2009.02012.x. Review. PubMed PMID: 19496806.

5: Hesdorffer DC, Berg AT, Kanner AM. An update on antiepileptic drugs andsuicide: are there definitive answers yet? Epilepsy Curr. 2010 Nov;10(6):137-45. doi: 10.1111/j.1535-7511.2010.01382.x. PubMed PMID: 21157540.   

6: Schretlen DJ, Munro CA, Anthony JC, Pearlson GD. Examining the range of normal intraindividual variability in neuropsychological test performance. J Int Neuropsychol Soc. 2003 Sep;9(6):864-70. PubMed PMID: 14632245.



Attribution:

The graphic at the top of this post is the cover of my syllabus for this course.  I have no affiliation with the course or Harvard Medical School, I just paid the fee to take the course like everybody else.  The graphic is included here is to provide information about the course that I reviewed in this post.

The NIMH Director and the RDoC - The Politics and The Science

from: Insel TR, Cuthbert BN. Medicine. Brain disorders? Precisely. 

Science. 2015 May1;348(6234):499-500.

I caught this article about the RDoC criteria for classifying mental illnesses based on various non descriptive parameters and neuroscience in the journal Science a couple of weeks ago.  As any reader of this blog can attest, there is no stronger advocate for the role of neuroscience in current psychiatric practice and the future of psychiatry than me.  There has been media controversy on this subject and it is always difficult to determine how much real controversy exists and how much of it is just made up for the sake of media self promotion like much of the DSM-5 controversy was.  Reading through the article by Thomas Insel and Bruce Cuthbert  there are statements that can be taken at face value.  I think these statements are consistent with the position that clinicians in general are not very scientific and are also outright clueless in some areas.  This is a bias that I have certainly heard from other scientists and it does not serve the cause of science very well, especially if the goal is to advance neuroscience and bring everyone up to speed on that discipline.  Dr. Insel has presented his view that all of the trainees in the clinical neurosciences of psychiatry, neurology, and neurosurgery should rotate through a year or two of a shared neuroscience.  When I first heard him present it five years ago I thought it was a great idea.  In the time since and especially after getting a response from him, I think it is less clear.  It would be great if every department of psychiatry had neuroscientists on staff to teach neuroscience.  But they don't and there is also the problem of neuroscientists being focused on research rather than teaching.  On the other hand, there are plenty of bright people in those departments who know a lot about the brain.  It is a question of reconciling these two points to come up with the necessary infrastructure yet in this article the authors make it seem as if large clinical problems are not addressed and that clinicians are fumbling around with very crude assessment methods.

They list three articles as examples of the RDoC.  The most interesting of these articles is one from the American Journal of Psychiatry that proposes that computer abstracted data from hospital notes that is converted to RDoC criteria are better predictors of hospital length of stay (LOS) than DSM criteria.  Just considering that method my first impression was that there was a lot wrong with that picture.  First of all,  LOS data is tremendously skewed based on non-clinical practices.  All it takes is hospital case managers with some success in intimidating physicians to skew the data in favor of business rather than actual medical or psychiatric discharge decisions.  Second, the quality of data from inpatient settings is incredibly bad due to the toxic combination of electronic health records and government billing and coding regulations.  As a reviewer, I have seen thousands of inpatient records, some of them hundreds of pages in length and I have found EHR records are notoriously poor in information content.  And finally, I thought the RDoC was a new system designed to be dependent more on neuroscience than the DSM-5?  How does methodology that looks at this DSM biased, sketchy clinical data result in a RDoC diagnosis?  Looking at the graphic from the Science article at the top of this post, it is pretty clear that 3 out 5 data dimensions under "Integrated Data" are basically clinical data.  There is a smugness displayed in the report similar to what might be seen in a rant by an antipsychiatrist: "For now clinicians might be best advised simply to be aware of the usefulness of dimensional models to capture psychopathology."  and "This result should provide some reassurance to clinicians that their notes do contain relevant detail for deriving dimensional measures of illness; like Molière’s Bourgeois Gentlemen speaking prose without knowing it, clinicians may already speak some RDoC."

Really?

The average person I see has chronic insomnia and has had possible sleep terrors and nightmares in childhood along with social phobia.  At some point they developed either severe anxiety or depression, but they can't recall the sequence of events and they currently have both.   They typically think that they have had "manic episodes" and may have been diagnosed with bipolar disorder even though they don't know what a manic episode is.  All they know is that their symptoms have persisted usually without remission for the past 10 to 15 years.  Of course that is complicated by the fact that they have been using marijuana, alcohol, and opioids in excessive amounts since then,  they may not have a significant family history of psychiatric and addiction problems, and they have the expected childhood adversity and adult markers of psychological trauma and abuse.  Further, I know from talking to the same people in repeated initial evaluations over the years that they don't give the same history twice and rarely remember much about their medications or psychotherapy treatment.  Should I use a "placeholder diagnosis" (pejorative term from reference 4) or should I assume that I am dealing with the social phobia that the patient may have had in childhood?  The idea that an RDoC diagnosis is going to give me an answer to that question any better than a DSM-5 diagnosis is pure folly if you ask me.  At least until we get the promised neuroscientific markers promised by the NIMH.  In fact, the description of the RDoC in these articles is reminiscent of another technology that was supposed to diagnose mental illness and that was quantitative EEG or QEEG.  I know quite a lot about QEEG, because I purchased a machine in the 1980s after a promising article on the technology came out in the journal Science.  I researched it using highly skilled EEG techs and an expert in neurophysiology to run the protocols, and concluded the diagnoses that came from the computerized analysis of the tracing were no better than chance in terms of what patients presented with.  Like RDoC diagnoses, the computerized analysis of QEEG data was highly dependent on the input of clinical data collected by the clinician.  It allowed the clinician to add and subtract clinical variables and look at how the diagnosis varied.  

The staff and researchers at the NIMH need to decide if a superior and critical attitude toward physicians who use current clinical approaches and are successful with them is the best one.  It should be obvious from the above analysis that many of us are not as naive or as ignorant about science as they expect. My proposed solution would be a more collaborative approach including the following:

1.  Recruit and train neuroscience teachers - most of them are already out there.  For example much of what I teach to trainees interested in addiction and addiction medicine is neuroscience.  It is also much more realistic than waiting for every department to have access to neuroscience researchers and then expecting those researchers to teach in addition to doing research.  My guess is that every Psychiatry department already has faculty that teach neuroanatomy, pharmacology, brain science and neuroscience already and that most of them are not officially scientists.

2.  Make the reading list available online - the article refers to over 1,000 published articles that focus on the RDoC criteria.  These should be available though the National Library of Medicine web site along with other neuroscience articles of interest to psychiatrists.  An added bonus would be CME activity available for self study.

3.  Post a list of neuroscience modules and build on that list -  In a previous post, I posted two links to neuroscience modules through the NIMH.  I would put up two lists, one containing a growing list of modules and the second with a list of the neuroscience concepts that need to be illustrated.  This would be useful for psychiatrists, psychiatrists in training, and medical school professors hoping to make their basic science lectures more relevant, since many clinicians still seem to have difficulty understanding how neuroscience is important in psychiatry.

4.  Better graphics - make high resolution graphs that illustrate detailed brain anatomy and basic science available online for teachers.  Pulling this material together is often the most difficult part of the teaching job and it requires an intensive effort to not run afoul of copyright laws.   It would be easier to recruit neuroscience teachers if there are high quality teaching materials available.

5.  A neuroscience teaching blog - In addition to the NIMH staff posting the references, concepts and modules, an open teaching blog should also be available.  I would encourage it to be a platform for discussing concepts and how to present them to trainees.  Ideally, it would be a place for active dialogue about the concepts and teaching them.

I think that all of these measures would be helpful in building an infrastructure of neuroscience teachers, neuroscience teaching, and a mechanism for the widespread dissemination of this material in residency programs and in educational programs for practicing psychiatrists.  If the RDoC is in fact worthwhile, there is plenty of brainpower outside of the NIMH to figure that out.

It is the brainpower that is currently focused on coming up with solutions and resolving problems of incredible clinical complexity.  And that happens every day.

I plan to send these recommendation to Director Insel and see what he thinks.



George Dawson, MD, DFAPA

1: Insel TR, Cuthbert BN. Medicine. Brain disorders? Precisely. Science. 2015 May 1;348(6234):499-500. doi: 10.1126/science.aab2358. PubMed PMID: 25931539.

2: Casey BJ, Craddock N, Cuthbert BN, Hyman SE, Lee FS, Ressler KJ. DSM-5 and RDoC: progress in psychiatry research? Nat Rev Neurosci. 2013 Nov;14(11):810-4. doi: 10.1038/nrn3621. Review. PubMed PMID: 24135697.

3:  NIMH.  Research Domain Criteria

4:  McCoy TH, Castro VM, Rosenfield HR, Cagan A, Kohane IS, Perlis RH. A clinical perspective on the relevance of research domain criteria in electronic health records. Am J Psychiatry. 2015 Apr;172(4):316-20. doi: 10.1176/appi.ajp.2014.14091177. PubMed PMID: 25827030.

Supplementary 1:

The above figure is licensed through the American Association for the Advancement of Science - license number 3637270124183.

Will The Real Neuropsychiatrists Please Stand Up?

Recent dilemma - one of several people around the state who consult with me on tough cases called looking for a neuropsychiatrist.  He had called earlier and I advised him what he might discuss with the patient's primary care physicians that might be relevant.  I suggested a test that turned up positive and in and of itself could account for the subacute cognitive and behavioral changes being observed by many people who know the patient well.  I got a call back today requesting referral to a neuropsychiatrist and responded that I don't really know of any.  I consider myself to be a neuropsychiatrist but do not know of other psychiatrists who practice in the same way.   There is one neuropsychiatrist who practices at the state hospital and is restricted to seeing those inpatients.  There is one who sees primarily developmentally disabled persons with significant psychiatric comorbidity.  There are several who practice strictly geriatric psychiatry.  One of the purposes of this post is to see if there are any neuropsychiatrists in Minnesota.  My current employment situation precludes me from seeing any neuropsychiatry referrals.

Neuropsychiatry is a frequently used term that is the subject of books and papers.  Several prominent psychiatrists were identified as neuropsychiatrists.  I went back to an anniversary celebration for the University of Wisconsin Department of Psychiatry and learned that early on it was a department of neuropsychiatry.  It turns out that the Department of Neuropsychiatry was established in 1925 and in 1956 it was divided into separate departments of Psychiatry and Neurology.  One of the key questions is whether neuropsychiatry is an historical term or whether it has applications today.  The literature of the field would suggest that there is applicability with several texts using the term in their titles, but many don't even mention the word psychiatry.  As an example, a partial stack from my library:

A Google Search shows hits for Neuropsychiatry and basically flat during a time when Neuroscience has taken off.  Both of them are dwarfed by Psychoanalysis, but much of the psychoanalytical writing has nothing to do with psychiatry or medicine.

What does it mean to practice neuropsychiatry?  Neuropsychiatrists practice in a number of settings.  For years I ran a Geriatric Psychiatry and Memory Disorder Clinic.  Inpatient psychiatry in both acute care and long term hospitals can also be practice settings for neuropsychiatrists.  The critical factor in any setting is whether there are systems in place that allow for the comprehensive assessment and treatment of patients.   By comprehensive assessment,  I mean a physician who is interested and capable of finding out what is wrong with a person's brain.  In today's managed care world a patient could present with seizures, acute mental status changes, delirium, and acute psychiatric symptoms and find that they are treated for an acute problem and discharged in a few days - often without seeing a neurologist or a psychiatrist.  There may be no good explanations for what happened.  The discharge plan may be that the patient is supposed to follow up in an outpatient setting to get those answers.  That certainly is possible, but a significant number of people fall through the cracks.  There are also a significant number of people who never get an answer and a significant number who should never had been discharged in the first place.

Who are the people who might benefit from neuropsychiatric assessment?  Anyone with a complex behavioral disorder that has resulted from a neurological illness or injury.  That can include people with a previous severe psychiatric disability who have acquired the neurological illness.  It can also include people with congenital neurological illnesses or injuries.  One of the key questions early on in some of these processes is whether they are potentially reversible and what can be done in the interim.  Some of the best examples I can think of involve neuropsychiatrists who have remained available to these patients over time to provide ongoing consultation and treatment recommendations.  In some cases they have assumed care in order to prevent the patient from receiving unnecessary care form other treatment providers.  Aggression is a problem of interest in many people with neurological illness because it often leads to destabilization of housing options and results in a person being placed in very suboptimal housing.  Treatment can often reverse that trend or result in a trained and informed staff that can design non-medical interventions to reduce aggression.

What is a reasonable definition?  According to the American Neuropsychiatric Association neuropsychiatry is "the integrated study of psychiatric and neurologic disorders".   Their definition goes on to point out that specific training is not necessary, that there is a significant overlap with behavioral neurology and that neuropsychiatry can be practiced if one seeks "understanding of the neurological bases of psychiatric disorders, the psychiatric manifestations of neurological disorders, and/or the evaluation and care of persons with neurologically based behavioral disturbances."  That is both a reasonable definition and a central problem.  In clinical psychiatry for example, if a patient with bipolar disorder has a significant stroke what happens to their overall plan of care from a psychiatric perspective? In many if not most cases, the treatment for bipolar disorder is disrupted leading to a prolonged period of disability and destabilization.  Neuropsychiatrists and behavioral neurologists practice at the margins of clinical practice.  That is not predicated on the importance of the area, but the business aspects of medicine today.  If psychiatry and neurology departments are established around a specific encounter and code, frequent outliers are not easily tolerated.  Patients with either neuropsychiatric problems or problems in behavioral neurology can quickly become outliers due to the need to order and review larger volumes of tests, collect greater amounts of collateral information, and analyze separate problems.  In any managed clinic, the average visit is typically focused on one problem.  Neuropsychiatric patients often have associated communication, movement, cognitive and gross neurological problems.  Some of these problems may need to be addressed on an acute or semi-acute basis.

Where are they in the state?  Neuropsychiatrists are probably located in areas outside of typical clinics.  By typical clinics I mean those that are outside of the HMO and managed care sphere.   They can be identified as clinics that are managed by physicians rather than MBAs.  The three largest that come to mind are the Mayo Clinic, the Cleveland Clinic, and the Marshfield Clinic.  Apart from those clinics there are many free standing neurology and fewer free standing neuropsychiatric clinics.  Speciality designations in geriatric psychiatry or neurology, dementias, developmental disorders, and other conditions that overlap psychiatry and neurology are good signs.  There will also be psychiatrists in institutional and correctional settings with a lot of experience in treating difficult to treat neuropsychiatric problems.  There may be a way to commoditize this knowledge and get it out to a broader audience.  Since starting this blog I have pointed out the innovative pan in place thought the University of Wisconsin and the Wisconsin Alzheimer's Institute (WAI) network of clinics.  They have impressive coverage throughout the state and provide a model for how at least one aspect of neuropsychiatry can be made widely available through collaboration with an academic program.      

What should the profession be doing about it?  The American Psychiatric Association (APA) and just about every other medical professional organization has been captive to "cost effective" rhetoric.  IN psychiatry  that comes down to access to 20 minutes of "medication management" versus comprehensive assessment of a physician who knows the neurology and medicine and how it affects the brain.  The new hype about collaborative care takes the psychiatrist out of the loop entirely.  The WAI protocol specifies the time and resource commitment necessary to run a clinic that does neuropsychiatric assessments.  I have first hand experience with the cost effective argument because my clinic was shut down for that reason.  We adhered to the WAI protocol.

What the APA and other medical professional organizations seems to not get is that if you teach people competencies in training, it is basically a futile exercise unless they can translate that into a practice setting.  The WAI protocol provides evidence of the time and resource commitment necessary to support neuropsychiatrists.   It is time to take a stand and point out that a psychiatric assessment, especially if it has a neuropsychiatric  component takes more than a 5 minute checklist and treatment based on a score.  A closely related concept is that total time spent does not necessarily equate with the correct or a useful diagnosis.  I have assessed and treated people who have had 4 hours of neuropsychological testing and that did not result in a correct diagnosis.

If those changes occurred, I might be able to advise people who ask that there are more than two neuropsychiatrists in the state.

George Dawson, MD, DFAPA

1: Benjamin S, Travis MJ, Cooper JJ, Dickey CC, Reardon CL. Neuropsychiatry and neuroscience education of psychiatry trainees: attitudes and barriers. Acad Psychiatry. 2014 Apr;38(2):135-40. doi: 10.1007/s40596-014-0051-9. Epub 2014 Mar 19. PubMed PMID: 24643397.