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  3. Behavioral Neurology & Neuropsychiatry
  • Cited by 18
Publisher:
Cambridge University Press
Online publication date:
February 2013
Print publication year:
2013
Online ISBN:
9781139016919
DOI:
https://doi.org/10.1017/CBO9781139016919
Subjects:
Psychiatry and Clinical Psychology, Neurology and Clinical Neuroscience, Medicine, Psychiatry
Information

Book description

The merger of behavioral neurology and neuropsychiatry into a single medical subspecialty, Behavioral Neurology & Neuropsychiatry, requires an understanding of brain-behavior relationships and a clinical approach that transcends the traditional perspectives of neurology and psychiatry. Designed as a primer of concepts and principles, and authored by a multidisciplinary group of internationally known clinical neuroscientists, this book divides into three sections:Structural and Functional Neuroanatomy (Section I) addresses the neuroanatomy and phenomenology of cognition, emotion, and behaviorClinical Assessment (Section II) describes neuropsychiatric history taking, neurological and mental status examinations, neuropsychological assessment, and neuroimaging, electrophysiologic, and laboratory methodsTreatment (Section III) discusses environmental, behavioral, rehabilitative, psychological, social, pharmacological, and procedural interventions for cognitive, emotional, and behavioral disorders.By emphasizing the principles of Behavioral Neurology & Neuropsychiatry, this book will improve your understanding of brain-behavior relationships and inform your care of patients and families affected by neurobehavioral disorders.

Reviews

'This superb book is the most complete and comprehensive publication on this subject to date. It is essential reading for all who call themselves behavioral neurologists or neuropsychiatrists. It is also an essential reference for the care of patients who suffer from neuropsychiatric disorders.'

Source: Doody's Reviews

'This book is likely to become the standard textbook for programs offering subspecialty training in behavioural neurology and neuropsychiatry. I consider it to be an excellent volume and would strongly recommend it to psychiatrists with subspecialty interest in the interface between neurology and psychiatry.'

Source: The Canadian Journal of Psychiatry

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Contents

Page 2 of 2

Contents
  • 22 - Assessmentfor subtle neurological signs
    pp 333-343
  • View abstract

    Summary

    This chapter focuses on apraxia of the upper limbs. Hugo Liepmann described three major forms of apraxia: ideomotor apraxia, which was also called ideo-kinetic apraxia in Liepmann's terminology; ideational apraxia; and limb-kinetic apraxia, also referred to by some investigators as melokinetic or innervatory apraxia. The chapter discusses the signs and pathophysiology of the apraxic disorders but use a processing approach. The Florida Action Recall Test (FLART), developed to assess conceptual apraxia, consists of 45 line drawings of objects or scenes for which an action with a tool is required. Conceptual apraxia is reported among persons with degenerative dementias such as Alzheimer's disease (AD) and in the semantic dementia subtype of frontotemporal lobar degeneration. Limb-kinetic apraxia is characterized by a loss of dexterity or deftness such that patients with this disorder are impaired at making precise, independent but coordinated finger movements.
  • 23 - Mental status examination
    pp 344-393
  • View abstract

    Summary

    This chapter discusses the neuroanatomy underlying visuospatial function. It discusses anatomical organization of visuospatial processing, and visuospatial syndromes relevant to clinical disorders. Studies on visuospatial memory have distinguished between visuospatial working memory and memory for visuospatial information. Su and colleagues studied 37 patients with basal ganglia hemorrhage and found that visuospatial function and memory were the most affected cognitive domains. The chapter considers visuospatial impairment in common neurologic diseases such as Alzheimer's disease (AD) and Parkinson's disease (PD). Less common disorders such as Huntington's disease (HD) and Williams syndrome (WMS) are also described to emphasize the variety of etiologies that may affect the visuospatial system. Posterior cortical atrophy (PCA) is a clinically homogeneous but pathologically heterogeneous syndrome in which the onset of a progressive dementia is characterized by visual deficits. AD is the most common pathological correlate of PCA.
  • 24 - Neuropsychologicalassessment
    pp 394-405
  • View abstract

    Summary

    This chapter reviews conceptual issues and definitions of the executive function. It is argued that executive function is a multidimensional construct and it is suggested that subspecialists in Behavioral neurology (BN) & Neuropsychiatry (NP) regard executive function principally as a cognitive domain. Executive function requires the integrated actions of the frontal-subcortical circuits, open-loop connections to other neocortical areas, limbic and paralimbic structures, thalamic nuclei, pontocerebellar networks, modulatory neurochemical projections from mesencephalic and ventral forebrain structures, and the white matter connections within and between all of these areas. As such, executive dysfunction is more accurately understood as dysfunction within or across these networks. The distributed structural and functional anatomy of executive function renders it vulnerable to disruption by many conditions affecting the brain. Finally, the chapter briefly discusses neuropsychological tests and bedside assessments of executive function.
  • 25 - Forensicassessment
    pp 406-414
  • View abstract

    Summary

    Comportment can be understood through analysis of its individual components: insight, judgment, self-awareness, social adaptation, and empathy. The case of Phineas Gage has served as the guiding compass towards our understanding of the prefrontal cortex as a region critical for comportment. Modern neuroimaging using the skull of Gage has shown bihemispheric prefrontal lesions involving the orbitofrontal cortex, the medial frontal cortex, and the anterior cingulate gyrus. A variety of diseases that preferentially affect the prefrontal cortex and that result in increased aggression, loss of empathy, and disinhibition have provided neurologists with insight into the brain structures responsible for comportment. This chapter discusses the pathogenesis of developmental disorders such as autism and Asperger's Syndrome (AS), degenerative processes such as frontotemporal dementia (FTD), physical injury to the prefrontal cortex, and schizophrenia as well as relevant functional neuroimaging studies.
  • 26 - Structuralneuroimaging
    pp 415-429
  • View abstract

    Summary

    Emotions and emotional feelings arise through the integrated processing of bodily sensations, environmental events, thoughts and recollections, and they shape new learning, facilitate decision-making, and guide behavior. Mood and affect have been defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) according to the durations of the emotions and emotional feelings comprising them. The development of functionally impairing pervasive and sustained disturbances of emotion and emotional feelings suggests a mood disorder such as major depression, dysthymia, mania, hypomania, or cyclothymia. Functionally impairing moment-to-moment disturbances of emotional expression and experience are disorders of affect. This category of clinical conditions includes disorders of affective excess such as pathological laughing and crying, pathological euphoria, essential crying, witzelsucht, and affective lability. The phenomenologies of emotional generation, expression, experience, and control reflect their putative neurobiologies. MacLean applied the principles of evolutionary neurobiology to the description of the limbic system and its function.
  • 27 - Advancedneuroimaging
    pp 430-441
  • View abstract

    Summary

    This chapter illustrates the complexity of personality by the exploration of its neurobiology, including neurochemistry, and neuroanatomy via the temperament and character dimensional model and its relationship to psychiatric and neurological disorders. Thomas and Chess conceptualized temperament as the stylistic component of behavior, as differentiated from the motivation and content of behavior. Character is influenced by socio-cultural learning and matures in progressive steps throughout life. Character can be measured in three dimensions: self-directedness, cooperativeness, and self-transcendence. Personality dimensions involve complex adaptive systems of multiple genetic and environmental variables. Both gene-gene and gene-environment interactions are expected for understanding quantitative developmental phenomena and these have been abundantly confirmed for personality. Gene-environment interaction has also been demonstrated for novelty seeking and for harm avoidance in prospective population-based studies. Twin studies show that human personality traits are roughly equally influenced by genetic and by environmental influences.
  • 28 - Electroencephalography
    pp 442-458
  • View abstract

    Summary

    The genetic contribution to many neuropsychiatric disorders is disclosed by obtaining a family history. Patients with dissociative and conversion disorders often present to subspecialists in Behavioral Neurology & Neuropsychiatry (BN&NP). BN&NP remains a bastion of bedside medicine in an increasingly technological medical world. The clinician should screen for other symptoms when a dissociative or conversion disorder diagnosis is under consideration. Clinicians should routinely ask about nocturnal sleep timing and duration, sleep quality, and excessive daytime sleepiness. Many patients presenting with psychiatric symptoms have a remote history of traumatic brain injury (TBI), and a screening question about TBI should be routine in the psychiatric evaluation. Patients with many cerebral diseases, including incipient degenerative disease, cerebrovascular disease, multiple sclerosis, and past mild TBI, experience cognitive problems that are distressing and noticeable to others but not of a severity sufficient to warrant a diagnosis of dementia.
  • 30 - Neurotoxicology
    pp 474-484
  • View abstract

    Summary

    This chapter presents a practical clinical approach to the neurological examination in Behavioral Neurology & Neuropsychiatry (BN&NP). The upper body examination during a complete physical usually ends with auscultation of the heart and lungs. Assessment of the olfactory nerves is especially important in the evaluation of persons with traumatic brain injury as well as neurodegenerative disorders involving medial temporal structures and/or cholinergic dysfunction. Funduscopic examination, testing of visual fields, and visual acuity testing are used to assess the optic nerves. The examiner looks for muscle fasciculations and atrophy throughout the examination. Tone, reflexes, strength, sensation, and coordination in the arms must also be examined. The heel-knee-shin test is the most common assessment of coordination in the lower extremities. The Romberg test is begun by asking the patient to stand erect with his feet together, eyes open, and arms down.
  • 31 - Neuropathologicalassessment
    pp 485-497
  • View abstract

    Summary

    This chapter focuses on subtle neurological signs (SNS) in schizophrenia and illustrates the principles of their assessment and interpretation among persons with neuropsychiatric disorders more generally. Growing appreciation of the role of SNS has led to the development of multiple, structured instruments to assess neurological impairment. These instruments differ markedly in the specific neurological signs assessed and in their psychometric properties. The most commonly employed neurological scales (The Woods Scale, The Heidelberger Scale, The Modified Quantified Neurological Scale, The Cambridge Neurological Inventory, and The Neurological Evaluation Scale (NES)) and their characteristics are described. NES is among the most widely used SNS scales in schizophrenia research. Schizophrenia and other psychoses are characterized by the presence of psychotic symptoms, which are frequently divided into positive symptoms and negative symptoms. Research on neurological signs provides strong evidence supporting the conceptualization of neurological signs as a trait feature of schizophrenia.
  • Section III - Treatments in Behavioral Neurology & Neuropsychiatry
    pp 498-648
  • View abstract

    Summary

    This chapter presents an overview of the mental status examination, its core elements, and its most commonly used methods. The mental status examination focuses on cognitive, emotional, behavioral, and related sensorimotor functions and their disturbances - i.e., neuropsychiatric symptoms, signs, and syndromes. Through observation, interview, and testing, the mental status examination identifies the symptoms and signs of structural and/or functional disturbances of the brain. Neuropsychiatric symptoms and signs are sometimes categorized as positive or negative. Atypical clinical presentations sometimes are neurological condition-specific variants of typical neuropsychiatric syndromes. The observational components of the mental status examination are undertaken at the first moment of any form of contact with a patient and continue throughout the entire clinical encounter. Observation continues throughout the clinical interview, during which the examiner attends to the patient's appearance, behavior, statements, manner of communicating, and interpersonal interactions with examiner.
  • 33 - Rehabilitation and pharmacotherapy ofcognitive impairments
    pp 511-542
  • View abstract

    Summary

    Neuropsychological assessment is an important component of the comprehensive neurodiagnostic evaluation of many patients with suspected or known brain dysfunction. Neuropsychological evaluations are covered by most major insurance carriers using the American Medical Association's Current Procedural Terminology (CPT) codes for the procedures. A clinical interview with the patient, focusing upon the presenting complaint and history of potential central nervous system (CNS) risk factors or other demographic and background characteristics, might contribute to symptoms or impact current test performance. The neuropsychological evaluation typically begins with a review of the referral question and available medical records. Neuropsychological tests vary in terms of their available normative comparison groups, although some represent large databases comprised of representative samples of the general population. Neuropsychological reports vary widely depending upon the practitioner, his or her background and current setting, the nature and extent of the evaluation, and the referral base of the neuropsychologist's practice.
  • 34 - Pharmacotherapyof emotional disturbances
    pp 543-565
  • View abstract

    Summary

    Forensic practice is a peculiar niche of medicine, often requiring a different approach and thought process than that routinely utilized in clinical practice. The forensic evaluator must inform the subject under examination of the exact nature and purpose of the evaluation, and make clear that a typical doctor-patient relationship is not being established. Competency is a broad area of forensic practice, with important applications to routine clinical medicine as well as criminal and civil law. Competency to proceed to trial is a major source of forensic psychiatric evaluations. Tort law covers an expansive range of legal issues, only some of which are likely to involve the use of neuropsychiatric experts. The neuropsychiatrist who accepts a forensic role also assumes tremendous responsibilities involving up-to-date medical knowledge, familiarity with pertinent law, and ethical duties particular to the medical expert role.
  • 35 - Pharmacotherapyof behavioral disturbances
    pp 566-586
  • View abstract

    Summary

    This chapter focuses on the basic principles of computed tomography (CT) and magnetic resonance imaging (MRI) used for imaging the brain structure. Indications for brain imaging in Behavioral Neurology & Neuropsychiatry (BN&NP) patients include: poison or toxin exposures, dementia or cognitive decline of unknown etiology, delirium, brain injuries of any type with ongoing symptoms, new-onset psychiatric symptoms, abnormal neurological findings suggesting brain pathology, and new-onset atypical psychosis. Imaging of the brain with MRI depends on the polar characteristics of the water molecule and its unique behavior within a strong magnetic field. Factors important to consider when choosing an imaging modality include type of suspected pathology, acuity of the illness, and desired planes of section. Doppler ultrasound (US) evaluation has been used successfully in clinical neurology as a screening tool to evaluate internal carotid artery (ICA) disease.
  • 36 - Psychotherapy
    pp 587-603
  • View abstract

    Summary

    This chapter focuses on the principles of advanced neuroimaging and their current clinical applications and limitations. Xenon enhanced computed tomography imaging (Xe-CT) is used for the quantification of cerebral blood flow (CBF). Advanced magnetic resonance imaging (MRI) techniques enhance the evaluation of brain structure and/or function. Magnetic resonance angiography (MRA) is used for assessment of the integrity of arteries and veins in the human body. Magnetic resonance spectroscopy data are used to evaluate the composition and metabolic activity of the brain. Diffusion tensor imaging (DTI) is a special form of diffusion-weighted MRI that allows the assessment and visualization of white matter and its constituents on a millimeter-level scale. Arterial spin labeling allows for the characterization and direct visualization of blood low within brain tissue. Information derived from positron emission tomography (PET) data may prove useful in correlating functional and structural abnormalities, and identifying pathophysiological disturbances despite apparently normal brain structure.
  • 37 - Environmentaland behavioral interventions
    pp 604-626
  • View abstract

    Summary

    This chapter focuses on the principles of conventional Electroencephalography (EEG) recording and interpretation and the typical applications of EEG to the assessment of persons with neurological and psychiatric conditions. The electrical activity measured at the scalp with EEG is generated by cerebral cortical neurons underlying the scalp where the recording electrodes are placed. The electrical activity recorded during EEG by pairs of electrodes (channels) is displayed by arranging those channels into specific sets. The two main categories of EEG abnormalities are: slowing or the presence of slower frequency waveforms than what should be present, and epileptiform discharges, or specific EEG waveforms that signify cortical hyper-irritability and an increased risk for clinical seizures. The EEG is commonly used in clinical assessment of Behavioral Neurology & Neuropsychiatry (BN&NP) patients. Triphasic waves usually arise from a diffusely abnormally slow background, and are a classic EEG abnormality associated with metabolic encephalopathy.
  • 38 - Proceduralinterventions
    pp 627-648
  • View abstract

    Summary

    Magnetoencephalography (MEG) systems use superconducting electronics and magnetic shielding to detect the magnetic fields generated by synaptic neuronal activity. This chapter focuses on two types of quantitative analyses of human electrophysiological data: spectral analysis methods and evoked potentials. Spectral analysis of Electroencephalography (EEG) and MEG signals across multiple sensor locations reveals clear spatial patterns. EEG and MEG activity can be subdivided into three major subdivisions: spontaneous activity, evoked responses, and induced responses. Evoked responses are time domain averages across multiple trials of a repeating stimulus or response. Electroencephalographic and MEG methods based on time-frequency transformation are usually concerned with capturing changes in the brain's oscillatory phenomena produced by stimuli, mental events, or responses. A valid measure of connectivity between regions of the brain engaged in the same cognitive process or behavior is among the most highly prized uses of EEG and MEG data.

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