Neuropsychiatry: An Introductory Approach

Arciniegas and Beresford's new text, Neuropsychiatry: An Introductory Approach, is an admirable effort to create a compact, approachable, and coherent introductory text on neuropsychiatry. Its authors intend it “as a primer of concepts and methods” for use by residents, medical students, and others with an interest in the field of neuropsychiatry. In three sections, the book covers fundamental concepts in neuropsychiatry, a neuropsychiatric approach to evaluating the patient, and a neuropsychiatric approach to the management of several common disorders.

The introductory chapter describes the authors' conception of neuropsychiatry, both in the context of ancient philosophical arguments about the mind/body problem and in the context of modern specialty turf wars. The next six chapters then lay the groundwork for the remaining text. Early chapters on essential behavioral neuroanatomy and basic cognition feel somewhat rushed, with the latter chapter doing little more than cataloguing clinical aphasia, amnesia, apraxia, and agnosia syndromes. However, with the chapter on complex cognition, the authors hit their stride and make a truly valuable contribution to the teaching of the basic neuroscience of complex mental processes.

Here they outline a model that becomes the organizing concept for much of the rest of the book, demonstrating how complex cognitive functions such as executive function, social intelligence, and motivation are all subserved by parallel frontal-subcortical circuits built on the same underlying architecture. For each major complex function, the authors outline, using diagrams coded both neuroanatomically and neurochemically, circuits linking the frontal cortex to key mesencephalic, thalamic, and striatal structures. The recurring theme, introduced in the chapter on complex cognition, and extended throughout the book, is one of cortical activation by ascending excitatory pathways from mesencephalic dopaminergic structures (such as the ventral tegmental area) and by glutamatergic projections from the thalamus, with reciprocal feedback from the cortex by means of descending glutamatergic projections interfacing through the striatum. In thus highlighting the role of subcortical structures in mediating higher mental functioning, the authors create implicit parallels between disorders of emotion and behavior and the motor syndromes with which subcortical dysfunction is classically associated. Their model has a great deal of explanatory power, not only to explain symptoms associated with various forms of frontal or subcortical dysfunction but also to predict a number of the side effects of psychotropic medications (such as SSRI-induced apathy) in a manner more coherent than traditional psychopharmacology texts.

The remaining chapters of the introductory section, covering emotion, personality, and psychological adaptation, attempt to follow in the same vein as the chapter on complex cognition, but they meet with less success. This problem stems more from the limited neurobiological research base on these phenomena compared with the large amount of work in the area of complex cognition than from any deficiency on the authors' part. As a consequence, these chapters have a more speculative aspect, particularly in the authors' attempts to demonstrate a continuum between dimensions of personality and psychopathology and to map psychological defense mechanisms onto specific domains of brain functioning.

The second section of the book covers the basic features of a “neuropsychiatric approach” to evaluating a patient. For the most part, these chapters review a standard approach to appropriate psychiatric history taking, the neurological exam, and the mental status examination. These well-organized chapters would likely be of great use to a medical student doing a rotation in a neuropsychiatric discipline. A simple introduction to neuroimaging and a chapter on basic electrophysiology are also provided. These chapters are clear and well written and would likely be of interest to psychiatric residents and psychiatrists, although they might seem too superficial to readers with extensive neurological training.

The third and final section of the book explores a neuropsychiatric approach to the understanding and management of selected clinical conditions. Some of these (e.g., Parkinson's disease and dementia) have traditionally been the purview of neurology, whereas others (e.g., obsessive-compulsive disorder and alcoholism) are more traditionally considered “psychiatric.” At its best, this section integrates the mechanistic perspectives on cognition and emotion presented in part 1 and delivers on the book's promise of an integrative neuropsychiatric approach to these clinical phenomena.

Chapters on delirium and dementia represent conventional approaches to the diagnosis and management of these staples of neurology and consultation-liaison psychiatry. The value of the authors' neuropsychiatric approach starts to become evident, however, in the subsequent chapters on obsessive-compulsive disorder (OCD) and apathy syndromes. The authors put OCD in the context of the model of parallel cortical-subcortical circuits laid out in their chapter on complex cognition. They illustrate how OCD symptoms can be understood in terms of unopposed overactivity of the orbitofrontal-subcortical circuit and its interaction with parallel circuits, such as the dorsolateral prefrontal circuit. An understanding of the common neurobiological targets of seemingly disparate therapeutic approaches (such as SSRI treatment, cognitive-behavioral therapy, and gamma-knife capsulotomy) follows logically from the model presented.

In the chapter on diminished motivation and apathy, the authors focus on a group of symptoms often underrecognized and undertreated by clinicians operating from within the limited boundaries of DSM-IV nosology. Understanding apathy as a dysfunction of one or more subcircuits of the “extended amygdala” and ventral striatopallidum has implications for treatment (e.g., with prodopaminergic agents) that may not be considered by clinicians who consider apathy only as a symptom of depression or schizophrenia.

Chapters on Parkinson's disease, alcohol dependence, and traumatic brain injury (TBI) are somewhat less successful in marrying clinical material to the book's neurocircuit models but are still valuable summaries of a neuropsychiatric approach to these illnesses. In particular, the material on Parkinson's disease explores the emotional dysregulation associated with the disease in greater depth than it is usually considered. The chapter on TBI is superb and notable for its treatment of the physics of brain injury.

At its best, Neuropsychiatry: An Introductory Approach is able to meet the goal set out in its epigram to make the complexities of neurocircuitry “as simple as possible, but not simpler.” The model of parallel cortical-subcortical circuits presented in the book's introductory chapters can indeed at times shine new light on common brain functions and dysfunctions. However, at other times the authors' reach exceeds their grasp, and the treatment of certain topics is uncomfortably stretched to fit the book's theoretical framework. The book also suffers from its mandate to serve as an introductory text for medical students, residents, and others interested in the field of psychiatry. As a consequence of this broad vision, the book veers between relatively advanced material (e.g., in its treatment of neurocircuitry) to rather rudimentary material (e.g., in the area of diagnosis and management). Taken as a whole, the book's strengths outweigh its weaknesses, and it represents a valuable contribution to the teaching of the neurobiology of human behavior and brain disease.

Dr. Jaffe is a Research Fellow in Psychiatry at the Nathan S. Kline Institute for Psychiatric Research, Orangeburg, NY.