The word and its referents
Names help or hinder in all walks of life, particularly when they behave as drifting signifiers. For example, since it first appeared in fin de siècle France as a double-barrelled word (‘neuro-psychiatrie’), the meaning of ‘neuropsychiatry’ has repeatedly changed. By the interbellum period, and now converted in ‘neuropsychiatrie’, it referred to the clinical doings of medics trained both in neurology and psychiatry. By 1918, the word appeared in the Anglo-Saxon to name a form of: “Psychiatry which relates mental or emotional disturbance to disordered brain function”. My own definition is narrower: “discipline that deals with the psychiatric complications of neurological disease”. On the other hand, American usage is broader and tantamount to “biological psychiatry”.

Currently, and first and foremost “neuropsychiatry” refers to overlapping clinical disciplines sharing the belief that mental symptoms are produced at disordered brain sites. It is also used to make a professional claim vis-à-vis rival views of mental disorder such as psychoanalysis. Lastly, it creates a social and economic space wherein like-minded researchers safely congregate to usufruct their fashionable ideas.

The context
Whether there is ‘neuropsychiatry’ in a particular country, and whether it has a broad or narrow meaning will depend, to a large extent, upon the structure of its health services and on the quality of the relationship between neurology and psychiatry.

Neuropsychiatry in Cambridge, UK
In keeping with the above, my own ‘neuropsychiatric’ clinical service is organize on the narrow view that neuropsychiatry is a branch of psychiatry that deals with the mental complications of neurological disease. I do not believe that such practice should in any way be interpreted as a statement about the nature of mental disorders in general. Even within the confines of my narrow definition, it seems clear that neurological patients who develop delusions, hallucinations, obsessions, sadness, anxiety, etc., etc. do so on account of a variety of mechanisms. On the one hand, there are the causal aetiologies. As my work on musical hallucinations and irritability states in Huntington’s disease patients showed years ago, a direct link can be demonstrated between symptom and brain site or CAG repeat, respectively. On the other hand, neurological patients have reasons for their symptoms, that is, neurological diseases happen to real people and hence have semantic contexts. This adds an entire new layer of meaning, hermeneutics and therapeutic response. Patients may show behavioural copies of mental symptoms and these do not have the same brain representation as the conventional symptoms.

Neuropsychiatric clinical work generates clinical templates which can be translated into research paradigms. There is nothing new in this and each university will use a different rhetoric to sell what they do. Some sell themselves as top-to-bottom research institutions (i.e. grand ideas governing action), others, are bottom-up ones (piecemeal, low level research converging upwards). This is the case of the Cambridge University Neuroscience Campus (the largest in the UK) which includes research institutes and a neuroimaging suite with inter alia 12 MRI magnets. My Neuropsychiatry Service (6 clinics) is linked with most of the research centres in the campus. For example, the PD Clinic provides patients for the large projects on receptor expression, fMRI, pharmacology, and neurosurgery. The HD Clinic is held in the ‘Brain Repair Centre’ where about 12 patients who have already received fetal cell implants in their caudate nuclei are followed up at 3 months intervals. The Traumatic Brain Damage clinic takes place in the ‘Oliver Zangwill Centre’, the leading cognitive neuropsychological rehabilitation clinic in Europe. The Sleep Disorders Clinic works closely with the ‘Respiratory Unit’ at Papworth hospital which includes the more advanced polysomnographic set up in the UK. The Memory Complaints Clinic services the large complex of memory research at the ‘Cognitive and Brain sciences Unit’, a ‘Medical Research Council’ facility where concepts such as executive functions and working memory were first developed; and my General Neuropsychiatry Clinic is linked up with the ‘Epilepsy Neurosurgical Unit’, the ‘Tinnitus Clinic’, etc. All these clinical- basic-sciences associations create ideal opportunities for translational research which has traditionally been the British way of developing new ideas.

The findings
Whatever the clinical context, neurological disorders are often accompanied by psychiatric appurtenances. The psychiatric component of some, like Parkinson’s disease, Multiple Sclerosis, Huntington’s disease, Wilson’s disease, Binswanger’s disease, etc., etc. has been known for a long time, and in some cases the severity and management of that component is more important for social re-entry than any motor or sensory disorder. In other cases, however, such as the taupathies, mitochondriopathies, CADASIL, X-Linked Adrenoleukodystrophy, etc. etc., not enough research has yet been carried out to identify the psychiatric component. In all situations, an intelligent practice provides the neuropsychiatrist with conundra whose resolution has direct relevance to psychiatry in general; two of such will be briefly discussed below.

The implications

Diagnostic conundrum
The neuropsychiatrist often finds that there is a lack of fit between the clinical phenomena met with in neuro-liaison work and the conventional psychiatric categories of ICD-10 and DSM IV. Neurological patients exhibit a variety of mental symptoms but these are often isolated and/or fleeting and rarely achieve critical mass to qualify for a ‘psychiatric diagnosis’. This raises theoretical and practical issues. The former have to do with their nature and formation mechanisms, the latter with their management / therapy. In the UK psychiatric therapies are currently tightly governed by guidelines which themselves are based on meta-analytic exercises and health economy evaluations. Likewise, psychiatric drugs are licensed for specific disorders and share with the guidelines the same sets of random clinical trials. Before the time guidelines started to be issued, psychiatric treatments were based on a combination of psychopharmacological knowledge, therapeutic imagination and specific negotiations between doctor and patient. This no longer obtains and unless a patient qualifies for a clear diagnosis he will not be offered medication as this might expose the clinician to legal action. In neuropsychiatry, this is particularly acute as neurological patients have mostly mental symptoms and only rarely mental disorders. Furthermore, the expression of such symptoms may be distorted by the presence of cognitive, expressional or emotional deficits directly related to the neuropathological lesions.

Behavioural copies and the problem of symptom-formation
In view of the above, the neuropsychiatrist often wonders whether the mental symptoms (and occasional mental disorders) that he/she comes across in the context of his specialized practice are, in fact, the same clinical phenomena as those seen in general psychiatry. For example, are the visual hallucinations of Parkinson’s disease or Lewy body dementia the same phenomena as those seen by a melancholic elderly with Cotard’s syndrome? Is the affective disorder associated with frontal lobe strokes the same as the common garden depressive illness? Is the mania triggered by steroid treatment the same as the mania of a bipolar disorder?

Prof. G.E. Berrios
BA (Oxford); DPhilSci (Oxford); MD; FRCPsych; FBPsS; FMedSci
Dr. Med. honoris causa [Heidelberg; San Marcos]
Consultant Neuropsychiatrist, Head Neuropsychiatry Service;
Reader in the Epistemology of Psychiatry, University of Cambridge
Addenbrooke's Hospital (Box 189) Hills Road, Cambridge, UK, CB2 2QQ
Voice: 44 (0)1223-336965; Fax 44 (0)1223 336968; email: geb11@cam.ac.uk