NEUROPSYCHIATRY: Past, Present and Future and into the 21st century

The 30th Anniversary Meeting of the British Neuropsychiatry Association and the Third British Symposium on the History of Neurology and Psychiatry

Held at the Royal College of Surgeons, London.

February 22nd 2017.

Edward H Reynolds* and Timothy R Nicholson**

*Department of Clinical Neurosciences, King’s College, London SE5 9PJ, UK.

**Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE5 8AF, UK.

Correspondence to EHR: reynolds@buckles.u-net.com

 

Following the first and second British Symposia  on the History of Neurology and Psychiatry held respectively in July 2014 at the Institute of Psychiatry, Psychology and Neuroscience (IOPPN),King’s College, London1 and in November 2015 at the Institute of Neurology (ION), University College, London2, a third Historical Symposium was held in conjunction with the 30th anniversary meeting of the British Neuropsychiatry Association (BNPA) at the Royal College of Surgeons, London, on February 22nd 2017 under the theme of “Neuropsychiatry: Past, Present and Future”.

The President of the BNPA, Chris Butler, welcomed 120 members and guests to discuss a theme which was central to the history and future of the Association.

 

THE FOUNDATION OF BNPA

Ted Reynolds, a founder committee member of the BNPA, described how a small group of “neuropsychiatrists” met on the initiative of Jonathan Bird on January 27th 1987 during a Royal College of Psychiatry meeting at the Royal Society of Medicine to discuss the possibility of establishing a special interest group in neuropsychiatry.  Following wider consultation a one day inaugural scientific meeting was held at the Institute of Psychiatry (IOP) on October 30th 1987 at which it was agreed to establish an Association “to encourage cross-disciplinary discussion of clinical and academic issues of common interest to people working in neurology, psychiatry and neuropsychology, including professionals in allied professions”.  A founding Committee was elected comprising: Alwyn Lishman, Chairman; Jonathan Bird, Secretary; Mary Robertson, Treasurer; Ted Reynolds,representing neurology, and Maria Wyke, neuropsychology (figure 1).   Over the succeeding year the BNPA took off with widespread support, a constitution was developed and twice yearly scientific meetings initiated.

 

 

 

 

 

 

 

 

 

 

Figure 1. Founding committee members of the BNPA. Left to right: Jonathan Bird, Mary Robertson, Alwyn Lishman and Ted Reynolds, together with Maria Ron (centre) who succeeded Alwyn Lishman.  Photograph at BNPA meeting, February 2013.

 

Sadly Maria Wyke (figure 2) died in November 2016.  Laura Goldstein, Professor of Clinical Neuropsychology at the IOPPN, presented a brief overview of Maria’s distinguished career, which began in Mexico City and Columbia, New York.  After 20 years at the National Hospital in London in the 1950’s and 1960’s she was attracted to the IOP until her retirement in 1990.  Her clinical assessments and broad range of academic studies were highly regarded by her peers and by the pioneering International Neuropsychological Symposium, of which she was a prominent member.  Maria was also admired for her elegance and style.

Figure 2: Maria Wyke, founding committee neuropsychologist.

 

THE ORIGINS OF NEUROPSYCHIATRY/BNPA

Jonathan Bird, Consultant Neuropsychiatrist to the Burdon Centre for Neuropsychiatry, Neuropsychology, and Epileptology, Bristol, reviewed the evolution of neuropsychiatry from its origins in the 19th century, through its divisions from psychodynamic psychiatry and from neurology in the early 20th century, towards its revival in the late 20th century.  In the process he highlighted UK developments and possible personality differences between psychiatrists and neurologists.  He concluded that neuropsychiatry has a long, varied and not always illustrious history.  Sometimes it has clung on by its fingernails to its very existence and sometimes it has been flavour of the month.

He conceived of the BNPA as an essential academic meeting point for all those interested in brain/behaviour relationships.   Over the last 30 years it has broadened the recognition and acceptance of the neuropsychiatric way of thinking about, researching into and managing people with some of the most complex and mysterious disorders which trouble our minds and bodies.

 

MOVEMENT DISORDERS – THE PARKINSON’S NÉUROSE

Andrew Lees, Emeritus Professor of Neurology at the National Hospital, noted that Jean-Martin Charcot described ‘maladie de Parkinson’ as a névrose, a term introduced in France by Pinel to mean any nervous disorder without demonstrable organic pathology. In 1917 Tretiakoff working at L’Hopital Salpetrière demonstrated that a severe loss of pigmented nerve cells in the pars compacta of the substantia nigra was invariably present giving it a ‘solidity’ denied to many other movement disorders such as dystonia and chorea and brought the disease firmly into the fold of neurology. Since the earliest clinical descriptions it has been recognised that anxiety and depression can have a profound effect on the expression and severity of the motor symptoms of Parkinson’s diseasse and that the kinesics of chronic anxiety and psychomotor retardation bear a superficial similarity to the movement disorder that characterises Parkinson’s disease. Slowness of willed movement, an invariable feature of Parkinson’s disease, can be seen in depression and also in a rare form of obsessional compulsive disorder.

The intimate links between motion and emotion in basal ganglia disorders and the notion of Parkinson’s disease as a neuropsychiatric disorder are now widely acknowledged, but the idea that severe emotional stress could cause neurodegeneration is more controversial. In 2014 Djamshidian and Lees hypothesised that chronic stress might cause Parkinson’s disease in susceptible individuals and that many of the symptoms reported in the pre-diagnostic phase of the illness are identical to those seen in functional somatic syndromes. The clinical clues that stress might be a neglected risk factor for Parkinson’s disease were summarised in the hope of stimulating further research.

 

AFTER FREUD – THE HISTORY OF HYSTERIA, CONVERSION AND FUNCTIONAL DISORDERS IN NEUROLOGY IN THE 20TH CENTURY.

Jon Stone, Honorary Reader in Neurology at the University of Edinburgh, noted that the idea of hysteria has been around, overtly anyway, since Hippocrates. Historians of psychiatry and medicine have stressed the contributions of Charcot and Freud to hysteria although arguably there were many others in the 19th century, such as Briquet and Janet, who had even more to offer.  He examined the history of functional neurological disorders in the 20th century after Freud. This flurry of interest between the 1880s and early 1920s gave way to disinterest, scepticism and concern about misdiagnosis. This was mirrored by increasing professional and geographical divisions between neurology and psychiatry after the First World War. He explored the reasons why these doldrums may have lasted such a long time.

In the 1990s the advent of more detailed imaging and videotelemetry may have stimulated new attention to functional disorders although ultimately the diagnosis has always been a positive one based on clinical signs, not normal tests. These disorders are now once again the subject of academic and clinical interest, although still too much on the fringes of neurology and psychiatry. It remains commonplace for historians of Freud and psychoanalysis for example, to assume, incorrectly, that “hysteria” is a historical entity. Revisiting older material provides a rich source of ideas and data for today’s clinical researcher but also offers cautionary tales of theories and treatments that led to stagnation rather than advancement of the field. Patterns of treatment do have a habit of repeating themselves, for example, the current enthusiasm for transcranial magnetic stimulation mirrors the excitement about electrotherapy in the 19th century. For these reasons, an understanding of the history of functional disorders in neurology is arguably more important than it is for other areas of other neurological practice.

 

EPILEPSY – THE KEY THAT UNLOCKED NEUROPSYCHIATRY.

 Professor Michael Trimble, Emeritus Professor of Behavioural Neurology at the Institute of Neurology, indicated that epilepsy has been central to the history of neuropsychiatry since Babylonian times. In his historical tour of ideas relating epilepsy and behaviour disorders, much of his presentation focused on a new approach to neuropsychiatry ushered in by Hughlings Jackson, although this underwent an eclipse in the first half of the 20th century. The significant ideas and investigations of many people from the 1970s through to the end of the 20th century were be highlighted in order to confirm how epilepsy is a major cornerstone for the development of modern neuropsychiatry.

 

COMPUTATIONAL NEUROPSYCHIATRY.

 Professor Ray Dolan, Professor of Neuropsychiatry and Director of the Wellcome Trust Centre for Neuroimaging, at UCL, emphasised how computational psychiatry encapsulates a set of approaches to the study of psychiatric conditions that are rooted in computer science.  Two broad approaches can be identified.  The first of these is atheoretical and with an emphasis that is data driven. This usually involves the application of machine learning methods in an attempt to refine disease classification, predict treatment response and improve treatment outcomes.  This approach can be applied to a wide class of data, including the analysis of brain imaging data. The second approach is theoretical and grounded within developments that derive from theoretical neuroscience. The focus of his talk was entirely on the latter where he provided examples of its utility in deepening our understanding of (i) adaptive learning and risk behaviour (ii) providing a quantitative basis for measuring and predicting subjective states (iii) providing neurobiologically inspired models that can be used to inform mechanistic interpretations of large scale data.  These examples served to highlight how computational psychiatry can open new avenues of investigation that provide mechanistic insights into disease processes with implications for classification and treatment. Computational psychiatry also enables an easier dialogue between advances in neuroscience and the challenges of providing a biologically informed understating of psychopathology.

 

NEUROSURGICAL INTERVENTIONS IN PSYCHIATRY.

Brian A Simpson, former consultant neurosurgeon at the University Hospital of Wales, Cardiff, reviewed the evolution of “psychosurgery”, now better referred to as Neurosurgery for Mental Disorders (NMD), in relation to historical context and attitudes. The early history is often regarded now with embarrassment and even horror. The eminent physiologist John Fulton, whose 1935 London lecture triggered the notorious epidemic of radical and relatively indiscriminate frontal lobe surgery, had serious reservations. He knew that intellectual and affective functions could be separated anatomically and was probably the first to advocate more selective procedures, to avoid the sometimes devastating side effects. However, “lobotomy” was given impetus by the eminence of its pioneers, Moniz and Freeman, and by respected neurosurgeons elsewhere, including the UK. The socio-economic benefit of the liberation from asylums of large numbers of indefinite-stay patients for whom no drug treatment was available until 1954, clearly provided great encouragement. However, Walter Freeman’s cavalier approach in the USA helped to close this first chapter.

A technically much more specific approach (“Chapter 2”) became available in 1947 when stereotactic neurosurgery for humans was introduced. Case-selection also gradually improved, moving away from treating schizophrenia and from “correcting” behaviour, towards relieving affective disorders. Anterior capsulotomy was introduced in 1951 and stereotactic cingulotomy in 1962, followed by for example subcaudate tractotomy using yttrium seeds, of which more than 1300 operations were performed in London from 1961 until the 1990s. There was still much opposition but when a US Congress Commission was convened in 1974, expecting to ban “psychosurgery”, the evidence of benefit and relative absence of harm was now so compelling that it won official approval. The more refined procedures have continued with demonstrable success but in relatively small numbers. Between 1993 and 2008, 55 patients underwent bilateral anterior capsulotomy in Cardiff, 45 for depression. The 24 for whom full datasets were available showed an overall improvement of 52%, with a 75% or more improvement in 10. There were no significant changes in executive function, attention and concentration, or immediate and delayed memory, and the adverse-effect profile showed it to be safe. However, antagonism continued to be encountered.

Deep brain stimulation for psychiatric disorders is not new but it re-emerged in 1999 as a more flexible and superficially more acceptable alternative to traditional lesioning (“Chapter 3”). The relative advantages and disadvantages were summarised.  The future for NMD (“Chapter 4”) for otherwise intractable cases should be exciting, with developments in imaging and other technologies and with increasing understanding of targeted conditions. However, the need to exercise great caution, along with issues of consent and regulation, are paramount. NMD is only one tool and its successful and continuing use depends heavily upon cultural attitudes.

 

PSYCHOPHARMACOLOGY 1952-2017.

David Healy, Professor of Psychiatry at Bangor University, stated that psychopharmacology began in 1952 in a hierarchical world. Its emergence along with the drugs like the oral contraceptives contributed hugely to the “Revolutions” of 1968. Some of these drugs were treatments for an illness that would restore people to their place in the social order but others threatened to change that order. Psychiatrists were at the centre of these issues because the drugs were available on prescription-only and they were inclined from the beginning to side with the establishment, blaming conditions like tardive dyskinesia on the underlying condition rather than the treatment.

The new treatments gave rise to Big Neuroscience, and later a Corporate Psychiatry, developments that brought onto the professional radar critical issues like conflict of interest and replaced a “psychobabble” in the wider culture with a “biobabble”. The treatments also gave rise to randomised controlled trials (RCT’s) and Evidence Based Medicine. The apparent efficacy of treatment in RCTs, along with the rating scales with which they were linked, created a new healthcare focused on Risk. The operational thinking embodied in trials and scales has spread throughout clinical practice and training and contributes significantly to the current shape of healthcare and mental healthcare in ways that at present look unfortunate.

 

BRAIN READING.

David Linden, Professor of Translational Neuroscience, Cardiff University, suggested that the techniques of brain imaging and neurophysiology, both invasive and non-invasive, hold considerable promise for the understanding of human mental processes. One branch of neurophysiology and cognitive neuroscience research is concerned with the inference of particular mental states from neural activation patterns. One of the aims of this research is to identify intentions in patients with severe communication disorders, for example the “locked-in” state.  Another proposed application is in the distinction between disorders of consciousness and disorders of communication. Recent advances in the analysis of functional brain images that allow for the classification of mental states also raise the question whether these techniques can be used to underpin psychiatric diagnoses, possibly even support or refute patients’ claim about their own mental states. He discussed the clinical promise and also the technical and ethical limitations of these approaches in the context of the history and future of neuropsychiatry.

 

THE FUTURE OF NEUROPSYCHIATRY.

The final session of the day was dedicated to reviewing current training in the core disciplines of the BNPA, with a particular focus on the opportunities to sub-specialise in areas of overlap with the other disciplines, specifically neuropsychiatry, neuropsychology and cognitive or behavioural neurology.    Eileen Joyce, Professor of Neuropsychiatry at the ION, University College London and Chair of the Faculty of Neuropsychiatry at the Royal College of Psychiatrists described UK neuropsychiatry training programmes and the Faculty’s proposals for a training curriculum and set of competencies with the wider aim of achieving accreditation, i.e. a neuropsychiatry “credential” via the General Medical Council. Gus Baker, Professor of Clinical Neuropsychology at Liverpool University and training lead for the Division of Neuropsychology at the British Psychological Society, discussed Neuropsychology training, emphasising how long this is and how this is not a ‘protected title’ and therefore technically anyone can call themselves a neuropsychologist.  Adam Zeman, Professor of Cognitive and Behavioural Neurology at Exeter University then highlighted the scarcity of current training opportunities in cognitive or behavioural neurology but showed evidence from a recent survey of neurology trainees of an appetite for training experiences in psychiatry and psychology that bodes well for the future.

In a subsequent panel discussion Sir Simon Wessely, Regius Professor of Psychological Medicine at King’s College London and President of the Royal College of Psychiatrists reiterated his support for the development of neuropsychiatry as a speciality, but also initiatives to increase training in the neurosciences as part of the general psychiatry training curriculum such as The Gatsby Foundation and Wellcome Trust Neuroscience Project.  Katherine Carpenter, Chair of the Division of Neuropsychology of the British Psychological Society proposed greater integration of training in all three specialities. Tom Hughes, Consultant Neurologist in Cardiff and Chair of the Neurology Specialist Advisory Committee for Neurology, was supportive of training in psychiatry and psychology for neurologists but outlined how finding the time and space for this to happen in an already tight training schedule is only set to get harder with the “Shape of Training” report proposing Neurology trainees have an additional year of general medical training and join on-call rotas.  Although all seemed in agreement that more inter-disciplinary training in these key overlapping areas was both important and desirable, the challenges of overcoming pressures for shorter and narrower training were also recognized.

The foundation of the BNPA in 1987 appears to have been the first step in the renewal of institutional neuropsychiatry in the late 20th century.  The American Neuropsychiatry Association (ANPA) was inaugurated in January 1990 and the BNPA and ANPA held their first joint meeting at St. Catherine’s College, Oxford in July 1992.  The BNPA and ANPA are now active members of a growing International Neuropsychiatry Association, a movement with deep historical roots, perhaps the subject of future BNPA historical events.

REFERENCES

  1. Reynolds EH. The historical evolution and future of neurology and psychiatry. J Neurol Neurosurg Psychiatr 2015; 86: 1386-8.
  2. Reynolds EH. The London contribution to neurology and psychiatry: the second British symposium on the history of neurology and psychiatry. J Neurol Neurosurg Psychiatr 2017; 88: 608-11.

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