ATLANTA— Neuropsychiatry is a continuously evolving concept. Although widespread disagreement persists regarding what neuropsychiatry should encompass, the intertwining of brain and thought and of mind and body is central to any definition, according to Stuart C. Yudofsky, MD.

“First of all, neuropsychiatry is firmly rooted in medicine, with primary attention given to the role of the brain in dysfunctions of mood, behavior, impulse, and cognition,” he said. “The focus is on prevention, assessment, and treatment of psychiatric illnesses and symptoms associated with brain lesions and dysfunctions. Neuropsychiatrists care for patients with psychiatric symptoms associated with neurological disorders, and a significant percentage of the disabling symptoms associated with neurologic disorders involve symptoms and dysfunctions that are conventionally considered psychiatric. These are conditions that often fall through the cracks between the specialties of neurology and psychiatry.” Referring to symptoms that lie in the gray zone between psychiatry and neurology, Dr. Yudofsky added, “Often these symptoms are unrecognized and, therefore, untreated and include dysfunctions of attention, alertness, perception, memory, language and speech, intelligence, cognition, motivation.”

Dr. Yudofsky believes that neuropsychiatry has enjoyed a rebirth within the past decade or so. “Neuropsychiatry has taken the lead in directing where the field of psychiatry is going,” he said. “Specifically in the application of brain imaging, basic science technologies, and medical genetics in demonstrating a primary role of the brain in the etiology and pathophysiology of most major psychiatric disorders such as schizophrenia, manic depression, and personality disorders.” Dr. Yudofsky is the D.C. and Irene Ellwood Professor and Chairman of the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, and Chief of Psychiatry Service at Methodist Hospital in Houston. He addressed the 158th Annual Meeting of the American Psychiatric Association, where he delivered the 2005 Distinguished Psychiatrist Lecture.

HISTORIC CONCEPTUALIZATIONS OF INSANITY AND MENTAL ILLNESS

Every culture since the beginning of time has had people who experience dysfunctions of mood, thinking, perception, and behavior. Over the millennia, different cultures have conceptualized these conditions of disparate ways. In about 2000 bc, the ancient Greeks believed that gods—good and evil—controlled all of man’s actions and destiny. Treatment consisted of priests mediating between gods and man through rituals, purification, and prayers, as insanity was imposed from outside of man as divine punishment. “This history comprises one of the origins of the stigmatization of people with mental illness being conceptualized by the ancient Greeks as manifestations of man’s being evil,” said Dr. Yudofsky. “The Greeks believed that epilepsy was a form of ‘insanity,’ and, only recently, after we developed EEG technology that indicated that the motoric and behavioral abnormalities associated with epilepsy are brain-based phenomena, did the stigma associated with seizure disorders decline.”

About 1,500 years later, Hippocrates became the first prominent physician to associate the brain with mental function and dysfunction. Writing about epilepsy—and this was heresy at the time, said Dr. Yudofsky—Hippocrates maintained, “Men ought to know that from the brain and the brain alone arise our pleasure, joy, laughter, just as well as our sorrow, pain, grief, and tears—that through it, the brain, we think, hear, see, and distinguish the ugly from the beautiful, the bad from the good, the pleasant from the unpleasant.” Hippocrates concluded that the “body affects the brain, with the imbalance of specific humors being responsible for mental illnesses,” said Dr. Yudofsky. Shortly thereafter, Plato, who was influenced by Hippocrates, believed not only that the body affected the mind, but also that the mind affected the body in ways that caused “psychosomatic” illnesses.

In the first through fourth centuries, medieval Christianity viewed mental illness as arising from the devil and other demons, conspiring “to influence our moment to moment struggle by taking possession of our mind and soul,” said Dr. Yudofsky. The European medical historian Ackernecht documented that hallucinations, delusions, and aberrant behavior were thought by the Church to be signs of demonic possessions and man’s spiritual decline…. Religious faith replaced Greek rationalism and skeptical empiricism. The mentally ill themselves were considered to be evil; otherwise they would not be possessed or sick. People with mental illness were also considered to be ‘contagious,’ as they could influence others in the ways of the devil. This belief put the mentally ill at great risk for punishment and even execution.”

Observations about the mentally ill were not included in early medical textbooks, but rather in handbooks and protocols of witch hunters and exorcists, noted Dr. Yudofsky. In 1692 in Salem, Massachusetts, alleged witches were burned at the stake. In the 1700s, one European report estimated that more than 100,000 mentally ill men, women, and children were executed in Germany alone, with similar numbers occurring in France. “By the 18th century, [the mentally ill] were not only considered evil and dangerous but those who were not killed were in prison, chained to the floors of crowded cells where they were tortured,” said Dr. Yudofsky. “Meanwhile, physicians were consulted only in cases of physical ailments. Describing this period, Emil Kraepelin said, ‘Rivaling chains in popularity was the lash.… Thrashing was almost a part of the daily routine.… Physicians were consulted only in the case of physical ailments.’”

At roughly the same time, efforts were underway in Europe to treat mental disorders as a medical issue, thus opening the door to psychiatry. In the mid-19th century, Moritz Heinrich Romberg of the University of Berlin wrote the first systematic textbook of neurology and helped to establish neurology as a separate medical specialty. Shortly afterward, Wilhelm Griesinger, Professor of Psychiatry and Neurology at the University of Berlin, helped psychiatry move from the institution to the university, and advanced the concept of neuropsychiatry, said Dr. Yudofsky. “Griesinger paved the way for a new generation of neuropsychiatrists, including Theodore Meynert, Jean-Martin Charcot, Carl Wernicke, Alois Alzheimer, Arnold Pick, Emil Kraepeline, Sigmund Freud, Eugen Bleuler, and Adolf Meyer.”

20TH-CENTURY PSYCHIATRY

The development of psychoanalysis was one of the turning points in 20th-century American psychiatry, according to Dr. Yudofsky: “Melvin Sabshin, psychoanalyst and former Medical Director of the American Psychiatric Association, wrote, ‘psychoanalysis developed enormous academic and institutional power. Psychoanalysis altered the boundaries of psychiatry radically in terms of implicit definitions of psychopathology and implicit concepts of what psychiatrists should do and not do. The predominant interest of psychoanalysis and psychiatry shifted away from the severely ill patient. And the overwhelming majority of psychoanalysts demonstrated minimal interests in exploring the relationship between intrapsychic processes and new biological concepts. During the late 1960s, a confluence of trends began to take shape. The combination of psychiatry’s expanding boundaries, the predominance of ideology over science, and the field’s de-medicalization began to produce a vulnerability. Many decision makers became skeptical about psychiatrists’ capacity to diagnose and treat patients.’” Commenting on Dr. Sabshin’s words, Dr. Yudofsky stated, “If the brain and medicine are removed from the concept of mental illness, stigma is the inevitable result. And not only are patients stigmatized when this occurs, but those of us who were devoted to take care of patients are also stigmatized.”

Dr. Yudofsky quoted a 1988 survey by the National Alliance of the Mentally Ill of public perceptions of mental illness. About 71% of respondents said mental illness was due to emotional weakness; 65% said it was due to bad parenting (“shaming, blaming, defaming the family,”); 35% said that it was “incurable;” while only 10% thought that mental illness had a biologic basis involving the brain. Many viewed the illness as being the victims’ fault, that “they can pull themselves up by their bootstraps,” he said. “When my patients say that, I say, ‘Certainly you have to participate actively in overcoming your mental illness, but I also believe you should accept psychotherapy and medications. I don’t believe patients with hypothyroidism can raise thyroid levels by pulling themselves up by their bootstraps.” Dr. Yudofsky also referenced a study summarized this year in Psychiatric News in which people were asked to rate their feelings toward psychiatrists. About a third felt “very positive to somewhat positive.” When asked if they would speak to someone regarding an emotional or mental health concern, about 80% would talk to a family member or consult a primary care physician and two thirds would speak to a minister. However, fewer than 60% would seek a psychiatrist, and even fewer a psychologist.

NEUROSCIENCE RESEARCH

The field of neuropsychiatry is poised to take greater leaps forward as neuroscience research moves further into the 21st century. Dr. Yudofsky expects breakthroughs to occur in molecular biology, genetics, and brain imaging, as well as overall technology. Researchers around the world have been making inroads in a number of those areas. For example, scientists have used single-photon emission CT to observe enlarged ventricles and decreasing brain mass in the brains of patients with Alzheimer’s disease. Investigators at Baylor College of Medicine led by Ron Davis, PhD, have examined the brains of fruit flies through photon microscopy, due to the flies’ well-investigated and documented conditioning model of learning and memory, noted Dr. Yudofsky. These and other researchers have shown that mushroom bodies play a key role in the fruit fly in learning and the formation and storage of memories.” Certain Drosophila mutants, which have been discovered through classical conditioning models to have impaired learning and memory, have been bred and studied. One of the Drosophila mutants was identified by Dr. Davis and colleagues to have impaired short-term olfactory memory.

In recent research regarding personality disorders conducted at Baylor College of Medicine in the Brown Human Neuroimaging Laboratory, researchers have used a technique called hyperscanning to observe the brain functioning of two people while they are interacting. The brains of two people are scanned while they participate in interactive games. People with personality disorders or with conditions that affect their capacity for social interaction, such as autism, can be observed while they attempt to interact with healthy subjects. In research at Baylor College of Medicine led by neuroscientist Read Montague, PhD, investigators have looked at how trust is formulated in the brain. Using a game involving economic exchange, they found that reciprocity expressed by one player strongly predicted future trust expressed by his or her partner, a finding that was mirrored by neural responses in the dorsal striatum. The investigators believe that the hyperscanning technique can shed light on disorders such as autism and personality disorders. “Experiments utilizing the social exchange game are currently being conducted at Baylor College of Medicine with patients who have borderline personality disorder,” said Dr. Yudofsky. “Most people with borderline personality disorder have difficulties with both trust and relationships. Scientists at Baylor have identified specific differences in their brains (from control groups) as they make the decisions.”

A NEUROPSYCHIATRIC PERSPECTIVE

“The reemergence of the neuropsychiatric paradigm has helped, along with progress in psychopharmacology, to reestablish psychiatry as a medical specialty,” asserted Dr. Yudofsky. Nonetheless, public confusion still exists about the differences among clinical psychologists, psychiatric social workers, and psychiatrists. The more that mental illness is associated with the brain, the less the stigma that results, stressed Dr. Yudofsky. “Mental illness as a label will go away. We won’t be using this vague term too much longer; it will become obsolete some day, just like the outdated terms, ‘lunacy’ and ‘insanity.’ We will denote people with so-called mental illnesses as having specific neurobiological functions—such as a person with abnormal down-regulation of the 5-HT-2 receptor.” Dr. Yudofsky believes that “in many academic centers, training in psychiatry does not sufficiently encompass basic neuroscience, neurobiology, neuroanatomy, neuropathology, and neurology. Training neurologists should also improve with more emphasis on psychodynamics, psychotherapeutics, cognitive behavioral therapies, and psychopharmacology.”

Neuropsychiatry also accommodates the enlarging gray zone between neurology and psychiatry, said Dr. Yudofsky. As the population ages, the risk of neuropsychiatric disorders such as Alzheimer’s disease, Parkinson’s disease, and stroke becomes greater. Dr. Yudofsky considers these conditions to be “neuropsychiatric, because, in addition to cognitive, sensory and motor dysfunctions, people with these conditions experience anxiety, depression, psychosis, confusion, agitation, irritability, and apathy. In addition, neuroscience discovery relentlessly uncovers more associations between brain and psychopathology.” Dr. Yudofsky believes that the difference between neuropsychiatry and psychiatry is shrinking, and that soon “neuropsychiatry will become mainstream psychiatry.”

—Colby Stong

Suggested Reading
Yudofsky SC, Hales RE. Neuropsychiatry and the future of psychiatry and neurology. Am J Psychiatry. 2002;159:1261-1264.
King-Casas B, Tomlin D, Anen C, et al. Getting to know you: reputation and trust in a two-person economic exchange. Science. 2005;308:78-83.

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