Neuropsychiatry and Behavioral Neurology: Principles and Practice is a clinically-oriented textbook that aims to link rapid advances in basic, cognitive, and affective neuroscience with the care of patients struggling with losses that often involve their most cherished human capacities. The work was inspired by an annual Harvard Medical School course on the same topic that the editors and their colleagues at Brigham and Women’s Hospital initiated in 2014.
Neuropsychiatric and behavioral neurologic diseases are common, challenging, and extraordinarily fascinating. The symptoms of patients with these disorders can be puzzling to clinicians and result in individuals seeing numerous psychiatrists and neurologists before an appropriate diagnosis is made. The number of patients at risk for struggling with these disorders is rising, in part due to our increasingly aging population. At the same time, basic and translational research within the clinical neurosciences has been growing at exponential pace, which has important implications for the ways in which patients are and will be evaluated, diagnosed, treated, and followed. Given these converging trends, this is an opportune time to take stock of the field and provide guidance for understanding a rapidly expanding body of knowledge and the ways in which it can be meaningfully translated into clinical practice.
Our textbook relies on the perspective of authors who have a deep reservoir of clinical experience that helps them to synthesize and convey complex information about structural and functional neural networks most relevant to the practice of neuropsychiatry and behavioral neurology. These experts have utilized their experience caring for patients to refine their understanding of mechanisms underlying brain function and disease, and have endeavored to use their knowledge about underlying neural circuitry to inform their understanding of the emotional, cognitive, and behavioral difficulties facing their patients.
Several fundamental principles have served as guideposts for this textbook.
First, given the complexity of the subject matter, inferences drawn about cerebral organization and function should be based on converging evidence from a variety of sources. These include experimental neuroanatomy, single cell recordings in awake behaving monkeys, depth electrode studies in humans, electrophysiologic, positron emission tomography (PET), and functional magnetic resonance imaging (fMRI) activity elicited while humans are participating in cognitive/experimental tasks, structural MRI delineating the distribution of changes in cortical volume, cortical thickness, and white matter integrity, resting state functional connectivity MRI (rs-fcMRI) characterizing intrinsic networks of the brain, and information derived from patients with focal lesions that disrupt specific neural networks.
Second, given the complexity of clinical cases, a multidisciplinary approach is the most appropriate one for understanding the different contributions to the challenges facing our patients and delineating potential avenues for therapy, remediation, compensatory activity, and healing.
Third, multidisciplinary work is most likely to be successful when efforts are made to foster an abiding respect for the knowledge and perspective offered by specialists outside of our own area of expertise and to work together to integrate approaches. Over the last 25 years, leaders of our group have endeavored to create an academic community that places a very high value on the process of listening to and learning from members with different subspecialty training and expertise. In keeping with this approach, the authors of chapters in this textbook represent the core disciplines of our Center for Brain/Mind Medicine, including neuropsychiatry, behavioral neurology, geriatric psychiatry, neuropsychology, clinical psychology, social work, and physiatry. In addition, chapters have been written by colleagues from related fields with whom we have close affiliations, including psychopharmacology, neuroradiology, child psychiatry, forensic psychiatry, speech and language pathology, sleep medicine, epilepsy, immunology, women’s mental health, global health, and pain management.
Fourth, the growing subspecialization and number of topics within the purview of neuropsychiatry and behavioral neurology, coupled with the explosion of information from the disciplines of cognitive and affective neuroscience, genetics, and psychotherapeutics, to name a few, make it difficult for individuals to have comprehensive knowledge about all these relevant fields. In this context, we are susceptible to getting lost in the myriad of details that are disseminated, losing sight of the big picture. It is more critical than ever to have access to an overview that can provide user-friendly frameworks for making sense of and accommodating new information. The editors have a deep appreciation for the value of chapters that distill large bodies of complex information. From our perspective, an outstanding chapter by experts can be viewed as a kind of gift to the rest of us.
Finally, this textbook was written with our colleagues and trainees in mind, who, like us, are passionate about understanding the principles and practice of neuropsychiatry and behavioral neurology. We have endeavored to provide our readers with comprehensive coverage of critical topics in the field to satisfy their (and our) thirst for knowledge and desire for improved clinical care, as well as the more pragmatic objective of preparing for the United Council of Neurologic Subspecialties (UCNS) board exam. Summary points, case vignettes, and multiple choice questions are included throughout the textbook to enhance its didactic quality.
It is very challenging to maintain uniformity in a textbook with many different authors. In an effort to enhance structural consistency and quality across chapters, each one underwent an elaborate, iterative editing and feedback process. Once a chapter was submitted by the authors, it was reviewed by at least three editors/co-editors. After each review by an editor, a version of the manuscript was returned to the authors for revisions, which upon being acceptable to that editor, was forwarded to the next editor. This elaborate system resulted in most chapters undergoing at least five revisions; some chapters had up to ten versions. We thank the authors for their patience and hard work. We believe that the process contributed to an outstanding finished product.
The textbook aims to be comprehensive, clinically relevant, and accessible to individuals with different training and academic backgrounds. Section I provides a foundation for understanding neuropsychiatry and behavioral neurology through a review of structural and functional neuroanatomy. Chapter 1, which masterfully ties together historical, phylogenetic, neurobiological and clinical perspectives, is devoted to the neuroanatomic basis of cognition, behavior, and emotion. We strongly anticipate that this chapter will serve as a definitive piece of work in our field. The following two chapters address the functional neurocircuitry of affective, behavioral and cognitive processing, and the neuropsychiatric and cognitive syndromes that arise from disruptions to these systems. Section II turns to an overview of different methods for conducting neuropsychiatric assessments. The topic is introduced with a discussion of how a thoughtful, engaging neuropsychiatric evaluation can both facilitate a more complete understanding of a patient’s difficulties and serve as a powerful therapeutic tool (Chapter 4). Subsequent chapters address office assessments (based on the active generation and testing of hypotheses) (Chapter 5), neuroimaging techniques (Chapter 6), and neuropsychological evaluations (Chapter 7). Section III provides an overview of therapeutics for treating neuropsychiatric and cognitive disorders. Individual chapters are dedicated to psychopharmacological approaches (Chapter 8), neurostimulation (Chapter 9), and psychosocial interventions, including modifications in psychotherapy when working with neuropsychiatric patients, and cognitive rehabilitation (Chapter 10).
Section IV is the most extensive one in the textbook, which is comprised of 22 chapters. The first half of this section examines neurobehavioral and neuropsychiatric syndromes, and the second half tackles the neuropsychiatric aspects of different neurological and medical diseases. Chapter 11 offers a neuropsychiatric perspective on the mechanisms underlying core psychiatric disorders involving mood, anxiety, and psychosis. Chapter 12 reviews how injury to specific anatomical networks leads to common neurobehavioral syndromes. The next set of chapters addresses the growing number of the clinical entities that neuropsychiatrists and behavioral neurologists are being called upon to assess and manage. These include functional neurological disorders (Chapter 13), addiction disorders (Chapter 14), sleep disorders (Chapter 15), ADHD and executive function disorders (Chapter 16), autism spectrum disorder (Chapter 17), intellectual development disorders (Chapter 18), and Tourette syndrome and related neuropsychiatric disorders (Chapter 19).
The purpose of Chapter 20 is to introduce a practical approach for clinicians who assess patients with neurocognitive disorders. The chapters that follow review the neuropsychiatric manifestations of a range of common neurological and medical conditions, including Alzheimer’s disease (Chapter 21), stroke (Chapter 22), Parkinson’s disease and Dementia with Lewy Bodies (Chapter 23), frontotemporal dementia (Chapter 24), delirium and catatonia (Chapter 25), immune-mediated and infectious diseases (Chapter 26), multiple sclerosis (Chapter 27), cancer (Chapter 28), epilepsy (Chapter 29), traumatic brain injury (Chapter 30), pain (Chapter 31), and headache (Chapter 32).
In Section V, other critical issues involving our field are addressed. The topics examined include women’s neuropsychiatry (Chapter 33), forensic neuropsychiatry (Chapter 34), a holistic and sustainable approach to caring for complex neuropsychiatric patients (Chapter 35), the integration of neuropsychiatric care in other medical settings like primary care (Chapter 36), a discussion of patient individuality as it pertains to neuropsychiatry and psychotherapy (Chapter 37), and the role of neuropsychiatry in global health (Chapter 38). The final chapter considers future directions for the fields of neuropsychiatry and behavioral neurology.
A major goal of this textbook is to help clinicians 1) link alterations in emotion, cognition, and behavior to their neurobiological origins, 2) place the unique aspects of a patient’s illness within a broader context that emphasizes the role of underlying neurocircuitry, 3) develop informed differential diagnoses, and 4) plan and implement the most effective treatment strategies. At the same time, the textbook provides an opportunity for researchers to gain a more textured appreciation of clinical behavioral neuroscience and the different ways in which dysfunction of various neural networks impact the lives of patients. We hope to expand a common vocabulary across related disciplines to enhance communication and a greater sense of shared purpose between clinicians from different disciplines and with colleagues who primarily serve as investigators.
Given the breadth and complexity of the material, editing a textbook on neuropsychiatry and behavioral neurology is a daunting task. We are extremely grateful to the authors of each of the chapters. We set high standards and required more work than is typically asked of individuals preparing chapters for a textbook. Authors were remarkably receptive to the questions raised and feedback provided. All of us learned a lot in the process. Editors and authors alike feel indebted to our patients who help us refine our understanding of brain function and the impact of various interventions. We hope that one way to show our gratitude to patients is by promulgating information about neuropsychiatry and behavioral neurology that can improve clinical care.
We would like to thank our colleagues Gaston Baslet, Scott McGinnis, and Shreya Raj, who provided help in reviewing early drafts of several chapters. We would like to acknowledge the invaluable assistance we received from McGraw-Hill and its editorial staff, especially Andrew Moyer (senior editor) and Ishan Chaudhary (project manager). We are also thankful for the superb administrative help provided by Eva Maynard, Jayme Paynter, and Brittany McFeeley at Brigham and Women’s Hospital.
The editors feel indebted to our mentors, who inspired us to enter the field and profoundly influenced our ways of thinking about it. In this context, Kirk Daffner offers special thanks to Marsel Mesulam, Sandra Weintraub, Martin Samuels, David Dawson, Michael Ronthal, Bruce Price, Kenneth Heilman, and the late Norman Geschwind. Laura Safar extends her appreciation to Jacinto Armando as a representative of her mentors in Buenos Aires; Boris Astrachan, Ovidio De Leon, and Laura Miller, as representatives of many mentors in Chicago; and Ben Liptzin, David Silbersweig and Kirk Daffner, as representatives of the many colleagues in Massachusetts who have further nurtured her love for clinical work and academic medicine. David Silbersweig acknowledges the important role that Fred Plum, Jerome Posner, Robert Michels, Jack Barchas, Richard Frackowiak, and Chris Frith played in the development of his career. In addition, we acknowledge the tremendous impact that our trainees have had on our approach to synthesizing and conveying the most essential components of neuropsychiatry, behavioral neurology, and neuropsychology. We also would like to thank our families for their ongoing support and wisdom, including Lise Bliss, Jesse Daffner, Molly Daffner-Deming, and Adam Daffner-Deming, Gregg Daffner, and the late Joseph and Adele Daffner (Dr. Daffner), Juana Martinez, Chase H. Harrison, Hugo Safar, Silvia Safar, Diego Safar, and the late Hector Safar (Dr. Safar), and Emily Stern, Arielle Silbersweig, Joshua Silbersweig, Martin Silbersweig, Jean Silbersweig, Susan Riedel, and Laurie Silbersweig. Finally, all of us recognize that given the rapid pace of change in our fields, some of the information in the textbook will not be fully up to date even as it is published. However, we hope that although components will require updating, the basic framework provided will endure, and continue to offer a guide for clinicians caring for patients with neuropsychiatric and behavioral neurologic symptoms. We look forward to the opportunity of revising the material in future editions of the textbook.
David A. Silbersweig
Laura T. Safar
Kirk R. Daffner
Brigham and Women’s Hospital
Harvard Medical School