Clinical Neuroscience and Training of

Future Psychiatrists
Collection of Articles Published in the
 Editorial Board
Editor in Chief T.P. George, University of Toronto, Toronto, Ontario, Canada
M. Keshavan, Beth Israel Deaconess Medical Center and Harvard Medical S. Grover, Postgraduate Inst. of Medical Education & Research,
School, Boston, MA, USA Chandigarh, India
Coordinating Editor D.V. Jeste, University of California at San Diego (UCSD), La Jolla,
California, USA
G. Venkatasubramanian
H. Jürgen-Möller, Ludwig Maximilian Universität München, Munich,
Deputy Editors Germany
V. Eapen, University of New South Wales, Liverpool Hospital, NSW, Australia H. Li, Florida Agricultural and Mechanical University, Tallahassee, Florida,
B.N. Gangadhar USA
R. Tandon, University of Florida, Dept. of Psychiatry, Gainesville, FL, USA M. Maj, Università di Napoli, Largo Madonna delle Grazie, Naples, Italy
H.A. Nasrallah, Saint Louis University School of Medicine, St. Louis,
Asian Pearls Editors
Missouri, USA
S. Tan
M. Navasimhan, University of South Carolina School of Medicine,
M. Mizuno Columbia, South Carolina, USA
T.A. Okasha G.N. Pandey, University of Illinois at Chicago, Chicago, Illinois, USA
East Asia U. Rao, University of Texas Southwestern Medical Center, Dallas, Texas, USA
J.S. Kwon, Seoul National University (SNU), Seoul, South Korea A.V. Ravindran, University of Toronto, Toronto, Ontario, Canada
West Asia P. Ruiz, University of Texas, Houston, TX, USA
Z. Kronfol, Weill Medical College of Cornell University, Manhattan, N. Sartorius, Université de Genève, Geneva, Switzerland
New York, USA L. Seidman
M. Takeda, Osaka University Medical School, Osaka, Japan
South East Asia
J. Thirthalli, National Institute of Mental Health and Neuroscience
S.A. Chong, Institute of Mental Health, Singapore, Singapore
(NIMHANS), Bengaluru, Karnataka State, India
South Asia P. Tyrer, Imperial Coll Sci, Tech & Med, London, England, UK
A. Avasthi, Post Graduate Institute of Medical Education and Research, P. Udomratn, Prince of Songkla University, Songkhla, Thailand
Chandigarh, India M. Warrier, Elite Mission Hospital, Thrissur, India
Central Asia L.N. Yatham, University of British Columbia, Vancouver, British Columbia,
P. Morozov, Russian Federation Canada

Language Editor Advisory Board

K. Rosengarth, USA
Early Career Psychiatrists Corner Assistant Editor
J. Torous
Honorary Consulting Editor
R.F. D’Souza, Totem International Institute, Port Melbourne,
Victoria, Australia
Editorial Board
R. Belmaker, Ben Gurion University of the Negev, Beersheva, Israel
D. Bhugra, King’s College London, London, England, UK
K.N.R. Chengappa, University of Pittsburgh School of Medicine, Western
Psychiatric Institute and Clinic (WPIC), Pittsburgh, PA, USA
M.P. Deva, Suri Seri Begawan Hospital, Kuala Belait, Brunei Darussalam
H. El Kholy, Ain Shams University, Cairo, Egypt
H.S. Akiskal, University of California at San Diego (UCSD), La Jolla,
California, USA
W.T. Carpenter Jr., University of Maryland School of Medicine,
Baltimore, Maryland, USA
R. Ganguli, University of Toronto, Toronto, Ontario, Canada
S. Kanba, Kyushu University, Fukuoka, Japan
S. Kapur, University of Oslo, Oslo, Norway
V. Patel, London School of Hygiene and Tropical Medicine,
London, England, UK
M.T. Tsuang, University California San Diego, La Jolla, California, USA
G. Valliant, Massachusetts General Hospital, Charlestown, Massachusetts,
USA
J Wang, Shanghai Jiao Tong University, Mental Health Center,
Shanghai, China
A. Weizman, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
 Table of contents
Introduction from the Editors: Clinical Neuroscience and Translational Psychiatry
Rajiv Tandon, Dawn Bruijnzeel.....................................................................................................................................................................................................4

All papers were originally published in Asian Journal of Psychiatry, Volume 17 (October 2015)

Editorial: Is psychiatry in need of a course correction

Matcheri S. Keshavan, Urvakhsh M. Mehta.................................................................................................................................................................................5

A proposed solution to integrating cognitive-affective neuroscience and neuropsychiatry in psychiatry residency training: The time is now
John Torous, Adam P. Stern, Jaya L. Padmanabhan, Matcheri S. Keshavan, David L. Perez......................................................................................................7

Integrating neuroscience into psychiatric residency training

Thomas R. Insel...........................................................................................................................................................................................................................13

Psychiatry is a clinical neuroscience, but how do we move the field?

Rajiv Tandon, Babu Rankupalli, Uma Suryadevara, Joseph Thornton.......................................................................................................................................15

Bringing neuroscience to teaching rounds: Refreshing our clinical pidgin

Vinod Hiremagalur Srihari.........................................................................................................................................................................................................19

Bridging the brain–mind divide in psychiatric education: The neuro-bio-psycho-social formulation

David A. Silbersweig....................................................................................................................................................................................................................21

Remembering psychiatry’s core strengths while incorporating neuroscience

Oliver Freudenreich, Nicholas Kontos, John Querques........................................................................................................................................................... 23

‘‘The time is now’’: Integrating neuroscience into psychiatry training

David A. Ross, Melissa R. Arbuckle, Michael J. Travis................................................................................................................................................................ 25

Facing our future

Bruce H. Price..............................................................................................................................................................................................................................27

The importance of teaching neuroscience to psychiatric residents in the context of psychological formulations
Carl Salzman............................................................................................................................................................................................................................... 29

The relevance of translational neuroscience in psychiatry residency training

Commentary on ‘‘Torous et al. A proposed solution to integrating cognitive–affective neuroscience and neuropsychiatry in psychiatry residency
training: The time is now’’
Sri Mahavir Agarwal, Ganesan Venkatasubramanian................................................................................................................................................................31

Toward the era of transformational neuropsychiatry

Henry A. Nasrallah..................................................................................................................................................................................................................... 33

Neuropsychiatry: More than the sum of its parts?

John Moriarty, Anthony S. David............................................................................................................................................................................................... 35
 Asian Journal of Psychiatry
Clinical Neuroscience and
Translational Psychiatry
Rajiv Tandon, MD, and Dawn Bruijnzeel, MD
Psychiatry Service, North Florida/South Georgia Veterans Healthcare System, Department of Psychiatry, University of Florida College of Medicine,
1149 Newell Drive, L4-100, Gainesville, FL 32611, USA
tandon@ufl.edu • dawn.bruijnzeel@va.gov
The field of psychiatry is at a crossroads with the crucial decision pertaining to the approach to translational psychiatry that we must choose. Our
failure to make revolutionary advances in our understanding and treatment of major psychiatric disorders over the past several decades has led
to calls to move beyond our current nosology and knowledge base sooner rather than later and replace it with a completely new framework best
exemplified by Research Domain Criteria (RDoC) (Insel, 2010; Keshavan, 2013). The still nascent knowledge base of behavioral neuroscience and
the primordial state of its translation to human mental function have led to the alternate recommendation “not to throw the baby out with the
bathwater” and instead adopt the less anarchic strategy of retaining the more useful aspects of our current knowledge base while more rigorously
developing the neurobiological foundations of human mentation and more deliberately relating it to pathological behavior (Fulford et al., 2014;
Tandon and Maj, 2008; Tandon, 2012). These issues are expounded by experts from diverse fields in this collection of 12 articles from the Asian
Journal of Psychiatry. This collection of articles has been compiled especially for ANCIPS 2016, the theme of which is “Translational Psychiatry.”
The authors all agree that the brain is the organ of psychiatry and that clinicians need a better foundation in neuroscience to better serve their
patients and to develop the capacity to understand future developments in the field. There are different perspectives, however, as to precisely
how this goal should be pursued. All authors comment on an article by Torous and co-workers (the first article in this issue), which describes the
teaching of a “neurological” approach to psychiatric disorders.
There is justifiable excitement about the rapid progress in the tools available to basic neuroscientists and the research modalities that are now
possible. It is also true that most practicing psychiatrists do not comprehend the truly remarkable advances in neuroscience and molecular biology
that are revolutionizing our understanding of how the brain mediates the range of human behavior. It is equally true that basic neuroscientists rarely
appreciate the nature of human psychopathology or the strengths/limitations of current methods to describe it. What is even more worrisome is the
fact that neuroscientists and clinicians no longer comprehend, let alone speak, the other’s language- and neither acknowledges this deficiency!
While the informed practice of psychiatry will always involve a solid foundation in modern neuroscience, some understanding of philosophy,
anthropology, ethology, evolutionary biology, sociology and other disciplines will always be important. It is essential, however, that psychiatrists
also have a working knowledge of basic brain operations. This includes accurate knowledge of neural structures, neurodevelopment, neuronal
and glial function, synaptic development, molecular mechanisms, regulation of neuronal circuits, genetics, epigenetics and paradigms used in
neuroscience research.
At ANCIPS 2016, the CME presentations and several symposia/workshops will explore and articulate the promise of translational psychiatry. As
we consider how to better integrate the clinical with the neuroscience, it is important to recognize that the endeavor is a two-way street with both
clinicians and neuroscience researchers playing lead roles in developing the bridge! As will be evident at ANCIPS 2016, this is an exciting time for
our field, with translational psychiatry at the cutting edge. It is hoped that this collection of articles will provide a broad perspective about how we
can properly harness the enormous opportunities with which we are presented.
References
Fulford KWM, Bartolotti L, Broome M, 2014. Taking the long view: an emerging framework for translational psychiatric science. World Psychiatry
13, 110-117.
Insel TR, Wang PS, 2010. Rethinking mental illness. JAMA 303, 1970-1971.
Keshavan MS, 2013. Classification of psychotic disorders: need to move to a neuroscience-informed nosology. Asian J. Psychiatry 6, 191-192.
Tandon R, 2012. The nosology of schizophrenia: Towards DSM-5 and ICD-11. Psychiatr. Clin. North Am. 35, 557-569.
Tandon R, Maj M, 2008. Nosological status and definition of schizophrenia: some considerations for DSM-5 and ICD-11. Asian J. Psychiatry 1, 22-27.

4
 Asian Journal of Psychiatry 17 (2015) 1–2
Contents lists available at ScienceDirect
Asian Journal of Psychiatry
journal homepage: www.elsevier.com/locate/ajp
Editorial
Is psychiatry in need of a course correction?
When one of us (MSK) was fresh out of medical school and
considering a choice of specialty in the late seventies, he
remembers agonizing for quite a while between psychiatry and
neurology. On the one hand, the mysteries of the mind were
fascinating but the lack of a clear-cut framework to understand
psychiatric disorders was frustrating. It was easy then for someone
like Thomas Szasz to dismiss schizophrenia as a moral disease or
for R.D. Laing to view it as a spiritual breakthrough. Neurology on
the other hand was intellectually tidy, and offered a clear way to
understand its patients. Keshavan eventually chose the psychiatry
path because of its very challenges, as there were so many
unanswered questions. If psychiatry were then how it is now, he
feels he may not even have hesitated. It is useful to reflect why.
A large part of the initial reluctance of many aspiring
psychiatrists may well have been the lingering ambiguity in the
definition of our discipline itself. Psychiatry has for long suffered
from a lack of clear definition of its boundaries. There have been
threats to the role of psychiatry from both within and outside the
field. Challenges from outside the field have included criticism
from patient groups, low status of the field within medicine, and
within society in general, and encroachment on territories by other
disciplines (neurology, psychology, social work) (Katschnig, 2010).
Challenges within the field have been even larger. In particular,
from a sociological standpoint, a key component of being a
profession involves having a unique body of skills and knowledge
base, from which the scope and boundaries of the services, and of
the potential consumers is defined (Coady, 2009). Psychiatry has
suffered from a lack of a coherent theoretical basis, with several
camps with distinct ideologies and bodies of knowledge (Goodwin
and Geddes, 2007; Kingdon and Young, 2007). While the major
illnesses served by psychiatry have always been brain disorders,
the brain as the organ system of our specialty has not always been
acknowledged upfront; diseases such as dementias and epilepsy,
once largely within the province of psychiatry, have moved into
neurology as etiology and pathophysiology have become clearer.
Frontotemporal dementia, Rett syndrome, 22q deletion syndrome
and NMDA receptor encephalitis are recent examples. Entities
where ‘‘biological’’ or organic causation is not clear have remained
within psychiatry, making this a specialty of idiopathic disorders!
Diseases within the field have been basically defined based on
subjective reports of psychopathology and observed behaviors.
The validity of our diagnostic systems has remained questionable
http://dx.doi.org/10.1016/j.ajp.2015.10.001
1876-2018/ 2015 Published by Elsevier B.V.
(Keshavan, 2014), and few actionable biomarkers have been
identified (Prata et al., 2014).
While such criticisms against and fears of the demise of
psychiatry have been repeatedly voiced (Poole and Bhugra,
2008), the field continues to survive. There are several reasons for
optimism. First, the public health magnitude of mental health
problems is increasingly dominating the unmet needs in all of
medicine (Tomlinson et al., 2009). The need for psychiatrists
continues to grow. Second, important conceptual changes such
as research domain criteria (RDoC) are gaining traction, raising
hope for more valid approaches to organizing the translational
body of knowledge central to psychiatric disorders (Cuthbert and
Insel, 2010). Third, the neural circuits of behavioral domains such
as attention, memory executive functions, thought processes,
emotion perception and reward seeking have been increasingly
well delineated using modern imaging techniques. Fourth,
spectacular advances have been made in unraveling the genetic
basis of major neuropsychiatric disorders such as schizophrenia,
autism and bipolar disorders. Finally, major methodological
advances such as the connectome (Fan et al., 2015), optogenetics
(Deisseroth, 2015), sonogenetics (Ibsen et al., 2015) and
pluripotent stem cells (Wright et al., 2014) are making it
possible to accelerate translational discoveries of enormous
potential impact on the field. All this is clearly giving a coherent
conceptual framework for placing at least the major psychiatric
disorders, (such as schizophrenia, bipolar disorder, obsessive
compulsive disorder) on a firm footing. Cognitive and affective
neuroscience, rather than psychopathology or its theories, is
more likely to serve as the basic science for psychiatry, just as it is
for neurology.
Having a knowledge base and a cohesive conceptual foundation
will in and of itself not assure a profession its due standing. While it
is harder nowadays for anti-psychiatrist theories to seem credible
in the face of neuroscience knowledge, we are still far from
elucidating the specific pathophysiological substrates of most
mental illnesses. The theoretical framework is yet to be translated
to actionable practice, and this is where the rubber meets the road.
Although cutting edge neuroscience techniques have not yet
yielded diagnostic biomarkers yet, a ray of hope emerges from
recent genomics and neuroimaging studies that have begun to
shed light on possible prognostic biomarkers (Frank et al., 2015;
Hager and Keshavan, 2015; Sarpal et al., 2015).
5
 2 Editorial / Asian Journal of Psychiatry 17 (2015) 1–2
Nevertheless, there is a clear need for a course correction in
psychiatry. There have been repeated calls for psychiatry’s return
to its ‘‘home’’ in medicine, as evinced by the new symbol of the
Asclepian rod in the logo of the American Psychiatric Association
(Keshavan, 2015). We believe that psychiatry has always been and
will remain a branch of medicine. The bigger issue is the need for
psychiatry to have a coherent body of actionable knowledge and
skill set that its practitioners are best trained to practice. Having a
medical training provides the needed basis to acquire the needed
clinical neuroscience training. The discipline also has to battle the
stigma attached to the profession, competitions in the marketplace
from allied professions, and resource limitations to enable more
research creating a solid evidence base for diagnosis and treatment
of the most distressed and disabled individuals it serves. Most
important, the field needs to embrace its unique role in medicine –
that of treating brain disorders with behavioral manifestations.
Coming back to where we started – medical graduates at
crossroads while choosing their line of specialty are probably
better placed today to make an informed choice. It is for us to
ensure that their fascination for treating disorders of the mind is
not cut short by their reluctance to pursue an unsure science.
Incorporating a neuroscience-informed psychiatry curriculum in
medical undergraduate training can beckon more trainees to this
fascinating subject. This will enable the field of psychiatry to
invigorate itself by recruiting not just more minds, but also smarter
minds of this generation, thus complementing the suggested
paradigm shift in psychiatry residency training from the conser-
vative to the state of the art approach (Insel, 2015). Firm grounding
in neuroscience is critical for the future generation of psychiatrists,
more than ever before. It is important not to be reductionistic in
this endeavor, but to draw upon the rich tapestry of new
information constantly emerging on the social determinants of
mental health.
Yogi Berra said, ‘‘When you come to a fork in the road, take it’’.
This is good advice for the beginner in psychiatry in the 21st
6
century. As the figure suggests, there may well be a new, as yet not
well trod path in the middle of the fork for psychiatry, free of the
baggage of prior unproven theories, and one that is a clinical
neuroscience well grounded in its psychosocial and biological
foundations. It is timely that several articles in this issue including
the paper by Torous et al. (2015) address the need for introducing
more neuroscience in the early training of future psychiatrists. In
the forthcoming issue of the Asian Journal of Psychiatry, we will
feature a series of articles on teaching neuroscience for psychia-
trists.
References
Coady, M., 2009. The nature of professions: implications for psychiatry. In: Bloch, S.,
Green, S.A. (Eds.), Psychiatric Ethics. Oxford University Press, Oxford, pp. 85–98.
Cuthbert, B.N., Insel, T.R., 2010. Toward new approaches to psychotic disorders: the
NIMH Research Domain Criteria project. Schizophr. Bull. 36, 1061–1062.
Deisseroth, K., 2015. Optogenetics: 10 years of microbial opsins in neuroscience.
Nat. Neurosci. 18, 1213–1225.
Fan, Q., Witzel, T., Nummenmaa, A., Van Dijk, K.R., Van Horn, J.D., Drews, M.K.,
Somerville, L.H., Sheridan, M.A., Santillana, R.M., Snyder, J., Hedden, T., Shaw,
E.E., Hollinshead, M.O., Renvall, V., Zanzonico, R., Keil, B., Cauley, S., Polimeni,
J.R., Tisdall, D., Buckner, R.L., Wedeen, V.J., Wald, L.L., Toga, A.W., Rosen, B.R.,
2015. MGH-USC Human Connectome Project datasets with ultra-high b-value
diffusion MRI. Neuroimage.
Frank, J., Lang, M., Witt, S.H., Strohmaier, J., Rujescu, D., Cichon, S., Degenhardt, F.,
Nothen, M.M., Collier, D.A., Ripke, S., Naber, D., Rietschel, M., 2015. Identifica-
tion of increased genetic risk scores for schizophrenia in treatment-resistant
patients. Mol. Psychiatry 20, 150–151.
Goodwin, G.M., Geddes, J.R., 2007. What is the heartland of psychiatry? Br. J.
Psychiatry 191, 189–191.
Hager, B.M., Keshavan, M.S., 2015. Neuroimaging biomarkers for psychosis. Curr.
Behav. Neurosci. Rep. 2015, 1–10.
Ibsen, S., Tong, A., Schutt, C., Esener, S., Chalasani, S.H., 2015. Sonogenetics is a non-
invasive approach to activating neurons in Caenorhabditis elegans. Nat. Com-
mun. 6, 8264.
Insel, T.R., 2015. Integrating neuroscience into psychiatric residency training. Asian
J. Psychiatry 17, 133–134.
Katschnig, H., 2010. Are psychiatrists an endangered species? Observations on
internal and external challenges to the profession. World Psychiatry 9, 21–28.
Keshavan, M.S., 2014. Psychiatric classification at cross-roads. Asian J. Psychiatry 7,
1.
Keshavan, M.S., 2015. The Asclepian rod and the return of psychiatry to its home in.
medicine and neuroscience. Asian J. Psychiatry 16, 87–88.
Kingdon, D., Young, A.H., 2007. Research into putative biological mechanisms of
mental disorders has been of no value to clinical psychiatry. Br. J. Psychiatry
191, 285–290.
Poole, R., Bhugra, D., 2008. Should psychiatry exist? Int. J. Soc. Psychiatry 54, 195–
196.
Prata, D., Mechelli, A., Kapur, S., 2014. Clinically meaningful biomarkers for psy-
chosis: a systematic and quantitative review. Neurosci. Biobehav. Rev. 45, 134–
141.
Sarpal, D.K., Argyelan, M., Robinson, D.G., Szeszko, P.R., Karlsgodt, K.H., John, M.,
Weissman, N., Gallego, J.A., Kane, J.M., Lencz, T., Malhotra, A.K., 2015. Baseline
striatal functional connectivity as a predictor of response to antipsychotic drug
treatment. Am. J. Psychiatry, appiajp201514121571.
Tomlinson, M., Rudan, I., Saxena, S., Swartz, L., Tsai, A.C., Patel, V., 2009. Setting
priorities for global mental health research. Bull. World Health Organ. 87, 438–
446.
Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A
proposed solution to integrating cognitive-affective neuroscience and neuro-
psychiatry in psychiatry residency training: the time is now. Asian J. Psychiatry
17, 116–121.
Wright, R., Rethelyi, J.M., Gage, F.H., 2014. Enhancing induced pluripotent stem cell
models of schizophrenia. JAMA Psychiatry 71, 334–335.
Matcheri S. Keshavan MD*
Beth Israel Deaconess Medical Center and Harvard Medical School,
Boston, MA, United States
Urvakhsh M. Mehta MD
National Institute of Mental Health and Neurosciences,
Bangalore, India
*Corresponding author
E-mail address: keshavanms@gmail.com (M.S. Keshavan).
 Asian Journal of Psychiatry 17 (2015) 116–121

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

A proposed solution to integrating cognitive-affective neuroscience

and neuropsychiatry in psychiatry residency training: The time is now
John Torous a,b,c, Adam P. Stern c,d, Jaya L. Padmanabhan c,e, Matcheri S. Keshavan c,
David L. Perez b,f,g,*
a
Harvard Longwood Psychiatry Residency Training Program, Boston, MA, USA
b
Brigham and Women’s Hospital, Department of Psychiatry, Harvard Medical School, Boston, MA, USA
c
Beth Israel Deaconess Medical Center, Department of Psychiatry, Harvard Medical School, Boston, MA, USA
d
Berenson Allen Center for Non-Invasive Brain Stimulation, Beth Israel Deaconess Medical Center, Harvard Medical School, USA
e
McLean Hospital, Department of Behavioral Neurology and Neuropsychiatry, Belmont, MA, USA
f
Massachusetts General Hospital, Department of Psychiatry, Harvard Medical School, Boston, MA, USA
g
Massachusetts General Hospital, Department of Neurology, Harvard Medical School, Boston, MA, USA

A R T I C L E I N F O A B S T R A C T

Article history: Despite increasing recognition of the importance of a strong neuroscience and neuropsychiatry
Received 12 March 2015 education in the training of psychiatry residents, achieving this competency has proven challenging. In
Accepted 5 May 2015 this perspective article, we selectively discuss the current state of these educational efforts and outline
how using brain-symptom relationships from a systems-level neural circuit approach in clinical
Keywords: formulations may help residents value, understand, and apply cognitive-affective neuroscience based
Education principles towards the care of psychiatric patients. To demonstrate the utility of this model, we present a
Neuroscience
case of major depressive disorder and discuss suspected abnormal neural circuits and therapeutic
Neuropsychiatry
Residency
implications. A clinical neural systems-level, symptom-based approach to conceptualize mental illness
Neural circuits can complement and expand residents’ existing psychiatric knowledge.
 2015 Elsevier B.V. All rights reserved.

1. Introduction absence of any grossly visible pathology and neurological disorders

Modern day psychiatry and neurology have shared origins.
Among the most impactful examples of this shared history are the
clinical efforts performed at the La Salpêtrière Hospital in France in
the late 19th century, where visionaries including Jean-Martin
Charcot, Sigmund Freud, Gilles de la Tourette, and Pierre Janet all
worked collaboratively in their care and study of patients with
conditions at the interface of brain and mind (Bogousslavsky,
2014). In a unifying statement Charcot wrote ‘‘the neurological tree
has its branches; neurasthenia, hysteria, epilepsy, all the types of
mental conditions, progressive paralysis, gait ataxia (Charcot,
1887).’’ Unfortunately, despite this shared history, a ‘‘great divide’’
emerged throughout the 20th century with psychiatric mental
disorders being largely defined by the presence of symptoms in the
* Corresponding author at: Massachusetts General Hospital Departments of
Neurology and Psychiatry 149 13th Street Charlestown, MA 02129, USA.
Tel.: +1 617 724 7299.
E-mail address: dlperez@partners.org (D.L. Perez).
based in the clinical-pathologic correlate (Price et al., 2000; Martin,
2002). Significant advances in cellular-molecular and systems-
level cognitive-affective neuroscience and in vivo neuroimaging
research across psychiatric disorders have now proven this
distinction to be misleading. As examples, post-mortem patholog-
ical changes in the hippocampus in schizophrenia (Harrison, 2004)
and in the anterior cingulate cortex in major depressive disorder
(MDD) (Ongur et al., 1998; Cotter et al., 2001) have been well
characterized. Yet, despite significant advances in our knowledge
of the biological basis of psychiatric disorders and calls from
international leaders such as the Nobel Laureate Eric Kandel
(Cowan and Kandel, 2001) for increased neuroscience and
clinically-relevant neurology education in psychiatry residency,
cognitive-affective neuroscience and neuropsychiatry remain a
challenge to integrate into clinical practice and psychiatric training
experiences.
While there has been increasing recognition for the need to
better incorporate neuroscience and psychiatrically relevant
neurology into the education and training of psychiatry residents
(Benjamin, 2013), successfully implementing such efforts and

http://dx.doi.org/10.1016/j.ajp.2015.05.007
1876-2018/ 2015 Elsevier B.V. All rights reserved.

7
 J. Torous et al. / Asian Journal of Psychiatry 17 (2015) 116–121
achieving tangible results has remained elusive. A recent study, for
example, noted that while 94% of surveyed academic chairs,
practicing psychiatrists, and residents agreed on the need to
further promote neuroscience education, only 13% of trainees
considered themselves to have a strong neuroscience knowledge
base (Fung et al., 2015). In this article, we present the integrated
perspectives of a current psychiatry resident in training (JT), a
neuropsychiatry fellow with a background in neuroimaging
research (JLP), an early career academic faculty psychiatrist with
a background in neuromodulation (APS), a researcher in psychiat-
ric neuroscience (MSK), and a dual trained early career neurolo-
gist-psychiatrist and cognitive-affective neuroscientist (DLP) to
explore how trainees can bridge in real-time brain-symptom
relationships in psychiatry. This article outlines how psychiatry
residents can integrate systems-level neuroscience into their
training to conceptualize psychiatric symptom-complexes and
advance translational therapeutic efforts. An illustrative case
example is presented to model this approach.
2. Current challenge
Many psychiatry residents may not be aware of their potential
interest in a clinical psychiatric neuroscience approach to patient
care due to a lack of clinical exposure. While any patient
presentation can, and should, inspire a comprehensive, neuros-
cientifically and neurologically informed approach, trainees need
clinical exposure to cases with salient neuropsychiatric elements
to develop relevant conceptual and technical skills. High yield
neuropsychiatric cases may include patients with prominent
emotional, perceptual and/or behavioral symptoms in the context
of neurodegenerative disease, epilepsy, cerebrovascular disease,
traumatic brain injury, movement disorders and autoimmune
disorders with neuropsychiatric features such as anti-NMDA
encephalitis. However, depending on the training environment,
some residents may be rarely exposed to such patients, as they are
instead treated in sub-specialty clinics or other departments.
A related challenge for residents in developing a strong
neuroscience and neuropsychiatric foundation may be the nature
of the didactics available within many training programs. A recent
study of 226 adult and child/adolescent psychiatry program
directors noted that 39% felt that a lack of neuropsychiatry faculty,
and 36% a lack of neuroscience faculty, were perceived barriers to
appropriately offering increased training in neuropsychiatry and
the neurosciences respectively (Benjamin et al., 2014). Other
barriers also included the lack of relevant curriculums and faculty
availability.
While a long-term solution to both these issues could be to
establish neuropsychiatry divisions within academic psychiatry
departments, in which psychiatry residents readily care for
patients with psychiatric symptoms secondary to neurological
illnesses, an equally important solution as discussed below is for
academic psychiatry departments to place greater emphasis on a
brain-symptom based approach in the formulation and treatment
of patients experiencing idiopathic (primary) psychiatric symp-
toms.
3. Evolving large-scale solutions
Recognizing the challenges likely experienced by most resi-
dents in United States training programs and globally, several
solutions have been proposed and developed at the national level.
The National Institute of Mental Health (NIMH) has taken a dual
approach to specifically support trainees who will define
psychiatry as a field of ‘‘clinical neurosciences’’ and encourages
neuroscience literacy through development of online modules and
teaching based on the Research Domain Criteria (RDoC) project
8
117
(Chung and Insel, 2014). RDoC is essentially a systems-level,
dimensional research approach that conceptualizes psychiatric
illness in part as disorders of neural circuitry (Insel et al., 2010). It
emphasizes the association between broadly defined emotional
and cognitive domains (e.g., negative and positive emotional
valence systems) and neurobiological measures, ranging from
genetics to physiology, in a manner agnostic to traditional
diagnostic categories. The National Neuroscience Curriculum
Initiative (NNCI) (http://www.nncionline.org/) has also been
recently established to create, pilot, and disseminate a compre-
hensive set of shared resources for psychiatry residents and
already features online educational modules, resources, and
videos. Also, the Accreditation Council for Graduate Medical
Education (ACGME) in the United States recently implemented a
novel framework for evaluating resident performance and one of
the these evaluation metrics is that all residents must show
competency in clinical neuroscience. However, the specifics
behind how individual residency programs implement and meet
this clinical neuroscience requirement are less well defined.
Beyond the evolving resources and changes discussed in this
section, the time is now for residents, educators and like-minded
academic psychiatrists to develop a culture of embracing cogni-
tive-affective neuroscience and neuropsychiatry to expedite the
‘‘bench-to-bedside’’ translation of brain-symptom relationships to
help guide clinical thinking and future innovative therapeutic
interventions.
4. Proposed solution
We suggest that one potentially immediate and impactful
method of increasing psychiatry residents’ awareness, interest,
expertise and clinical appreciation of clinical psychiatric neurosci-
ence and neuropsychiatry is to encourage real-time circuit-specific
discussions of brain-symptom relationships across the care of
psychiatric patients. Akin to daily discussions occurring in
neurology wards and outpatient clinics related to localizing the
structural lesion, we specifically propose that psychiatry residents
should be taught and encouraged to engage in discussions around
identifying suspected abnormally functioning brain circuits (and
particular nodes within a broadly distributed network that may be
linked to a patient’s particular symptoms). Given that the bio-
psycho-social model is an integral part of psychiatric formulation
(Engel, 1977) and residency educational experience, encouraging
residents to use clinically-oriented neuroscience and neuropsy-
chiatric principles to discuss the likely affected brain circuits as
part of their overall case formulation offers an inexpensive and
readily available translational neuroscience paradigm.
While identifying a discrete lesion remains important in
making a neurological diagnosis, specific focal lesion localization
in psychiatry has proven more difficult. Rather than there being a
specific lesion or neuroanatomical site of damage that we can
localize through examination or neuroimaging, psychiatric dis-
eases may be better framed as disorders of distributed, inter-
connected brain networks. To use a metaphor, these diseases can
be considered like the abnormal traffic flow patterns in a congested
city where old and narrow roads, inefficient traffic lights, and
bottlenecks at bridges create in combination a horrible traffic jam
of the city’s network of streets. While no one traffic light, single
narrow road, or individual bridge may in itself be typically
sufficient to cause a traffic jam, their effects combine to bring the
city’s traffic to a halt. Furthermore, at times there is one specific
bridge or intersection that receives traffic from many distinct parts
of the city and its disruption by itself can cause significant delays.
Likewise, psychiatric symptoms can be conceptualized as brain
network problems where often times no single isolated region, or
lesion, of the brain is responsible for a psychiatric illness but rather
118 J. Torous et al. / Asian Journal of Psychiatry 17 (2015) 116–121
multiple disrupted brain regions within a network or across
several networks function abnormally to produce particular
symptom complexes. Furthermore, there may be a critical region
or ‘‘hub’’ within a group of interconnected regions that if disrupted
may have particularly adverse effects of brain function and
symptom expression (Bullmore and Sporns, 2009). This perspec-
tive of brain circuits, particularly at the level of prefrontal cortex-
subcortical circuits was emphasized by Alexander and colleagues
in the mid 1980s following their detailed descriptions of five
discrete prefrontal-subcortical brain circuits (Alexander et al.,
1986). Prefrontal regions including the dorsolateral prefrontal
cortex, anterior cingulate cortex and orbitofrontal cortex each
were shown to have discrete basal ganglia and thalamic
connections and primarily involved in higher-order cognitive or
affective functions. Didactic efforts by Cummings and others
demonstrated the utility of these circuits to explain psychiatric
symptoms including linking impairments of the anterior cingulate
cortex-subcortical circuit to motivational deficits, the orbitofrontal
cortex-subcortical circuit to disinhibited behavior, and the
dorsolateral prefrontal cortex-subcortical circuit to dysexecutive
symptoms (Bonelli and Cummings, 2007; Mega and Cummings,
1994). Over the past two decades, these brain-symptom relation-
ships have been refined and these neural network connections
have been implicated in the real-world clinical practice of
psychiatrists. For example, it was shown that treatments targeting
specific neuroanatomical locations such as repetitive transcranial
magnetic stimulation (rTMS) to the dorsolateral prefrontal cortex
in depression displayed treatment efficacy (Pascual-Leone et al.,
1996). While a more detailed up-to-date discussion of the default
mode (Zhang and Raichle, 2010), salience (Seeley et al., 2007),
attention (Corbetta et al., 2008), emotional processing (Etkin,
2010; LeDoux, 2007; Etkin et al., 2011), cognitive control (Badre
and Wagner, 2007; Ridderinkhof et al., 2004), social cognitive
(Lieberman, 2007; Adolphs, 2003; Bickart et al., 2012), memory
(Eichenbaum, 2000) and visceral-somatic processing (Perez et al.,
2015a) networks among others is beyond the scope of this
perspective article, they have been reviewed elsewhere (Perez
et al., 2015b,c,d). From an educational perspective, systems-level
brain-symptom discussions offer a useful mechanism to transform
more abstract neuroscience concepts into clinically useful tools for
patient care. Integrating regular brain circuit discussions into
diagnostic and therapeutic discussions may foster active learning
and facilitates the translational process of bringing neuroscience
advancements to the clinic.
5. Therapeutic implications of a brain-based approach to
psychiatric symptoms
A brain-based, neuroscientifically informed understanding of
psychiatric illness is of more than academic interest to future
psychiatrists. It will be increasingly relevant in understanding,
selecting and administering psychological and biologically-in-
formed treatments. While expert clinicians and the clinical
interview are likely to remain the gold standard for clinical
diagnosis, clinicians often lack clear guidance around which
particular treatment is most likely to be beneficial for a given
patient. Adjunct structural and functional neuroimaging biomark-
ers may serve as clinically useful biomarkers of psychopharma-
cology and psychotherapy treatment selection (Gabrieli et al.,
2015; Pizzagalli, 2011). Neuroimaging studies investigating neural
mechanisms of selective serotonin re-uptake inhibitor (SSRI)
administration have shown decreased amygdala-hippocampal
reactivity following drug administration, while norepinephrine
reuptake inhibitors have been demonstrated to increase dorsolat-
eral prefrontal cortex and cingulate gyrus activations (Outhred
et al., 2013). Studies evaluating associations between treatment
response and baseline neuroimaging patterns have also shown, for
example, that pretreatment subgenual anterior cingulate cortex
hypermetabolism in patients with major depressive disorder is
potentially linked to failure to achieve remission following SSRI
medication or cognitive behavioral therapy (either alone or in
combination) (McGrath et al., 2014). Preliminary evidence also
suggests that baseline insula metabolic profiles may serve as a
treatment selection biomarker to guide treatment initiation of
SSRI versus cognitive behavioral therapy in untreated individu-
als with major depression (McGrath et al., 2013). A meta-
analysis of neuroimaging studies in depression probing func-
tional and structural neural biomarkers of treatment response
across pharmacologic and psychological interventions showed
that positive treatment response was linked to baseline
increased perigenual anterior cingulate cortex activations; poor
treatment response was predicted by decreased striatal and
anterior insula activations and regional atrophy in the dorsolat-
eral prefrontal cortex and hippocampus (Fu et al., 2013). While
further prospective and multi-site research studies are neces-
sary to validate these structural and functional profiles as
possible treatment related biomarkers, an equally important
obstacle to incorporating these and other brain science advances
is the lack of clinical proficiency and comfort psychiatrists have
in using and integrating brain circuit discussions in the care of
patients. Our proposal to encourage all psychiatrists and
psychiatry residents to engage in discussions around localizing
suspected abnormally functioning brain circuits provides a
necessary bridge to allow promising advances to be actually
adopted once well-validated.
Interventional neurotherapeutics, which seek to optimize
functional activations and connectivity patterns, are an increas-
ingly widespread treatment modality in which brain circuit
expertise is critical for the clinician. TMS was first approved by the
Food and Drug Administration (FDA) for use in treatment-
resistant depression in 2008 (Stern and Cohen, 2013). While this
device specifically targets the dorsolateral prefrontal cortex to
modulate baseline lateral prefrontal hypoactivation in depres-
sion, a newer device capable of targeting deeper structures such as
the anterior cingulate and the orbitofrontal cortex was approved
in 2013 (Stern and Cohen, 2013). In addition, recent resting state
analyses have linked anti-correlated dorsolateral prefrontal
cortex - subgenual anterior cingulate cortex functional connec-
tivity to TMS therapeutic efficacy (Fox et al., 2012), which
connects the non-invasive and invasive neuromodulation liter-
ature in MDD.
Deep brain stimulation (DBS), which involves implantation of
electrodes in strategic brain regions, is an emerging neurother-
apeutic approach which has displayed promising results in clinical
research studies of treatment-resistant depression (Blomstedt
et al., 2013; Mayberg et al., 2005; Kisely et al., 2014). Thus far, DBS
of the subgenual anterior cingulate cortex (Brodmann area 25),
ventral striatum, and nucleus accumbens have shown potential
efficacy in alleviating treatment-resistant depression (Malone
et al., 2009; Bewernick et al., 2010; Holtzheimer et al., 2012). These
targeted brain regions are particularly notable since each is a
component of the anterior cingulate-subcortical circuit. An
understanding of the neural circuits underlying these disorders
is essential to the successful application of these emerging
treatments. Given the continued momentum of neurotherapeutic
investigations in psychiatric research to modulate brain networks,
it is increasingly necessary for psychiatric trainees to understand
interventional neurotherapeutic approaches, including their ana-
tomical basis, and gain mastery of their use as part of their training.
If psychiatrists do not embrace opportunities to become specialists
in neuromodulation, the void could be filled by other clinical
experts in brain functioning.
9
 J. Torous et al. / Asian Journal of Psychiatry 17 (2015) 116–121 119

6. Model case illustrating a brain-symptom, systems-level Another possibility includes rTMS to the dorsolateral prefrontal
formulation cortex which can modulate medial prefrontal regions through
afferent connections. Lastly, consideration could be given to a
A 28 year-old single, employed woman with a family history of referral to a clinical trial such as for cognitive bias modification
mood and anxiety disorders presented with 6 months of depressed (CBM; Almeida et al., 2014); the patient’s dysphoric-anxious mood
and mildly anxious mood, negatively themed rumination, de- suggests increased amygdala activation, and a positive response to
creased interest in previously enjoyed activities, low-self worth, attention bias modification is associated with increased pre-
impaired concentration with reported forgetfulness at work, treatment amygdala activation (Britton et al., 2014). In part due to
delayed sleep onset, preserved appetite and no suicidal ideation. patient preference and resource availability, a therapeutic course
Psychiatric review of symptoms was otherwise negative. Symp- of cognitive behavioral therapy, using CBM principles, was
toms began following a romantic breakup, and psychosocial pursued.
history was notable for early-life maternal emotional abuse and
parental divorce during her teenage years. Mental status evalua- 7. Conclusions
tion revealed poor eye contact, mildly labile affect, depressed
mood and multiple negatively themed self-referential comments. In this article, we highlighted several important barriers to the
Cognitive Assessment showed slowed processing speed on incorporation of clinical psychiatric neuroscience and neuropsy-
abbreviated Trails B and serial 7s, impaired executive function chiatry in general psychiatry residency training. Our proposed
(increased perseverative errors on the Wisconsin Card Sort Test) approach integrates cognitive-affective neuroscience and neuro-
and spontaneous word recall at 5 minutes of 4/5 improving to 5/5 psychiatry into the real-time training experiences of residents in a
with categorical cues. Elemental neurological examination and clinically relevant way (Fig. 1). Several counterarguments may be
medical work-up for reversible causes of depression were within raised against our proposal. One, is the evidence for the
normal limits. She previously failed to achieve benefit from an aforementioned brain-behavior relationships substantial and
adequate trial of an SSRI medication. consistent enough to introduce into a general psychiatry curricu-
A clinical psychiatric neuroscience-based formulation for this lum? The answer at this point is an unequivocal yes. Even if some
patient’s symptom complex would be as follows. The patient’s of the specific details change, it is clear that the fundamental
depressive symptoms appear to at least partially localize to the paradigm of psychiatric illness as neural circuit based disorders is
anterior cingulate cortex and related striatal-thalamic subcortical here to stay. Second, would training programs without trained
components. This individual exhibits ruminative negatively neuropsychiatrists and neuropsychiatry divisions (or similar
valenced thinking which is suggestive of impaired modulation biologically-oriented divisions such as consultation-liaison psy-
of negative mood states, which has been linked to functional chiatry) have the resources to educate their residents in this
abnormalities of the subgenual anterior cingulate cortex (Hamani approach? This is a potentially more difficult challenge, but we
et al., 2011; Holtzheimer and Mayberg, 2011) and the amygdala would suggest that with some creative problem-solving, most
(Belzung et al., 2015). The patient reports anhedonia which has programs would find it feasible to at least introduce a deeper focus
been observed to also localize to the anterior cingulate cortex- on neuroscience and neuropsychiatry into the curriculum and
subcortical circuit, particularly the ventral striatum/nucleus daily training experience. The national efforts noted earlier in this
accumbens (Epstein et al., 2006; Epstein et al., 2011; Pizzagalli
et al., 2009). The patient’s concentration deficits and mild
dysexecutive syndrome is suggestive of lateral prefrontal dysfunc-
tion including the dorsolateral prefrontal cortex (Grimm et al.,
2008). Of note, the dorsolateral and anterior cingulate cortices are
reciprocally connected through cortico-cortical connections
(Hamani et al., 2011). Also, the patient’s mixed depressed-anxious
mood, a commonly encountered clinical presentation, highlights
that depression and anxiety have overlapping frontolimbic neural
substrates (Ionescu et al., 2013). From a developmental neurosci-
ence perspective, the patient‘s emotion regulation and expression
circuits (including the medial prefrontal cortex and amygdala) may
have been sensitized by childhood emotional abuse leading to
aberrant (maladaptive) neuroplastic changes (Leuner and Shors,
2013; Dannlowski et al., 2012). These neuroplastic changes may
have led to heightened reactivity (in-part from impaired top-down
prefrontal cortex regulation of limbic activity) following recent
relational stress, triggering negative ruminations and a dysphoric-
anxious mood.
From a brain-based therapeutic perspective, given that several
aspects of the patient’s symptom complex (such as emotional
dysregulation and impaired executive function) localize to medial
and lateral regulatory prefrontal and amygdalar circuits, consid-
eration was given to a possible trial of a serotonin-norepinephrine
reuptake inhibitor. Alternatively or in combination, cognitive
behavioral therapy may be beneficial to treat the patient’s self- Fig. 1. A conceptual framework of the suggested central role of clinical psychiatric
referential, negatively valenced rumination which localizes to the neuroscience and neuropsychiatry in academic psychiatry and closely related
fields. In part, these core (inter-related) disciplines can help bridge the rapidly
subgenual anterior cingulate cortex and related frontolimbic
evolving field of systems-level, cognitive affective neuroscience to enable brain-
connections (Holtzheimer and Mayberg, 2011), and cognitive symptom relationship discussions to more comprehensively formulate psychiatric
behavioral therapy may improve depression symptoms by symptom complexes and foster the development of validated biologically informed
modulating medial prefrontal circuits (Yoshimura et al., 2014). therapeutic interventions.

10
120 J. Torous et al. / Asian Journal of Psychiatry 17 (2015) 116–121
paper also suggest a potential solution, with the promise of many
online educational resources.
The past several decades have witnessed the impressive
progress of neuroscientific research in elucidating the relation-
ships between brain function and mental states. It is more
important than ever for the next generation of psychiatrists to be
educated in a brain-based approach to psychiatric illness. Although
the examples in this article have focused on depression, the
education model presented is applicable to any psychiatric illness
including bipolar disorder (Brady et al., 2014), schizophrenia
(Keshavan et al., 2008), post-traumatic stress disorder (Pitman
et al., 2012), and functional neurological symptom disorder (Perez
et al., 2012, 2015e) among others. Parallel translational efforts will
also look to integrate cellular-molecular biology, neurochemistry,
and epigenetic-genetic influences on brain-symptom relation-
ships. Such education will ensure that psychiatrists remain at the
forefront, rather than the periphery, of advances in the diagnosis
and treatment of mental illness in the 21st century and beyond.
Authorship contributions
Drs. Torous and Perez participated in the conception and design
of this manuscript, and Drs. Torous, Perez, Stern, Padmanabhan,
and Keshavan participated in the drafting and critical review of the
manuscript. All authors approved the final version for publication.
Disclosures/conflicts of interest
The authors have no disclosures or conflicts of interest to report.
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 Asian Journal of Psychiatry 17 (2015) 133–134
Contents lists available at ScienceDirect
Asian Journal of Psychiatry
journal homepage: www.elsevier.com/locate/ajp
Discussion
Integrating neuroscience into psychiatric residency training
Thomas R. Insel
National Institute of Mental Health, NIH, Bethesda, MD, USA
A R T I C L E I N F O
Article history:
Received 28 August 2015
Accepted 28 August 2015
There are few areas of medicine undergoing the profound
changes we see in psychiatry today. Over the past decade, the
fundamental sciences underlying psychiatry have begun to shift
from psychology and pharmacology to neuroscience and cognitive
science. As the tools of neuroscience have progressed, we can begin
to understand the disorders of the mind by studying the brain. The
two related disciplines of systems neuroscience and cognitive
science hold particular promise for revealing how brain activity is
converted to mental activity and behavior.
This progress is most evident in laboratory studies. Over the past
five years, with techniques like optogenetics and chemogenetics
that permit precise manipulation of neuronal activity, neuroscien-
tists have mapped the detailed circuitry for fear, mood, reward, and
social behavior in the mouse brain. The development of new optics
and new tools for visualizing calcium release in individual cells now
permit neuroscientists to watch a specific circuit in real time in a
behaving mouse. With these kinds of tools, neuroscientists are
beginning to decode brain signals to read out how the brain is
processing information nearly at the speed of thought.
These extraordinary laboratory tools have not yet been
translated into the clinic. But even with the less precise techniques
of human neuroimaging and neurophysiology, we can begin to see
how the brain is working in health and disease. Systems
neuroscience is giving us maps of the circuitry for complex
cognition. Studies of affective bias and cognitive control are
helping us to understand some of the processes underlying mood
disorders and psychosis. Neuroscience and cognitive science may
not yet be actionable in the clinic, but they will likely have a
transformative effect in the near future in two major areas.
First, we will see major changes in diagnosis. Psychiatric
diagnosis, in contrast to diagnosis in most areas of medicine, relies
solely on observable signs and subjective symptoms. Our
E-mail address: tinsel@mail.nih.gov.
http://dx.doi.org/10.1016/j.ajp.2015.08.014
1876-2018/Published by Elsevier B.V.
diagnostic criteria are consensus definitions of symptoms that
cluster together. While this approach offers reliability and clear
communication, it lacks biological validity and therefore cannot
provide the necessary precision for selecting treatments. Over the
next five years, data from genomics, systems neuroscience, and
cognitive science should help us to transform diagnostics by
augmenting subjective reports with objective measures. What we
call major depressive disorder or schizophrenia today may soon be
viewed as several distinct disorders, each requiring a different
treatment. This precision medicine approach requires that we
break free of the current symptom-based categories and allow the
data to direct us to a new classification.
The second major transformation will be in therapeutics.
Psychiatry for much of the past four decades has been guided by
the serendipitous discoveries of medications that reduced
psychosis or relieved depression. Based on the efficacy of these
drugs, we assumed that mental disorders were ‘‘chemical
imbalances’’. Systems neuroscience teaches us that anatomy really
matters and that mental disorders can be addressed as circuit
problems. Rather than drugs to change chemicals everywhere
(with unavoidable side effects), treatments can begin to focus on
tuning specific circuits involved in mood regulation or cognitive
control. How will we tune neural circuits? Both invasive (deep
brain stimulation) and non-invasive (trans-cranial magnetic
stimulation) tools have been developed for neuromodulation. It
seems likely that psychotherapy that involves learning and skill
building also alters regional brain function, tuning circuits through
the brain’s remarkable neuroplasticity.
Residents in training today will almost certainly face a world in
the next decade with these transformed approaches to diagnosis
and treatment (Torous et al., 2015). Unfortunately, training is a
conservative process, largely focused on the state of the field a
decade ago rather than preparing for the field a decade in the
future. But we need not accept this conservative approach. If
patients are to benefit from the latest science, residents need to be
13
 134 T.R. Insel / Asian Journal of Psychiatry 17 (2015) 133–134
taught the state of the art and prepared for the future. I appreciate
that genomics and neuroimaging have yet to yield a biomarker or
really any finding that would be essential today for clinical
practice. But just as oncologists are learning about the genes for the
control of cell division, psychiatrists need to know the basics of
brain function and the fundamentals of cognitive science so they
are prepared to use the tools of the future.
Of course, few training programs in psychiatry are able to offer
quality education in neuroscience or cognitive science. In the U.S., a
group of neuroscientist-psychiatrists have created a website with
lectures, videos, and discussion groups to fill this gap. The National
Neuroscience Curriculum Initiative (www.nncionline.org) is a
useful resource for trainees anywhere who want to learn about the
neuroscience relevant to psychiatry (Ross et al., 2015). This online
set of teaching modules is grounded in principles of adult learning
and innovative teaching methods. And it is updated regularly
based on new science and feedback from residents.
14
This may be one of the most exciting times to train in psychiatry
as the revolution in neuroscience begins to alter how we help
people with mental disorders. Just the formulation of mental
disorders as brain disorders will be an important shift in perspective.
When the residents of today are the seasoned clinicians of mid-
century, they may find it difficult to believe we ever divorced
psychiatry from brain science. What is exciting is to realize that
residents today can be the vanguard of change to create a future with
a far more scientific and more effective discipline.
References
Ross, D.A., Arbuckle, M., Travis, M.J., 2015. ‘‘The Time is Now’’: integrating neuro-
science into psychiatry training. Asian J. Psychiatry 17, 126–127.
Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A
proposed solution to integrating cognitive-affective neuroscience and neuro-
psychiatry in psychiatry residency training: the time is now. Asian J. Psychiatry
17, 116–121.
 Asian Journal of Psychiatry 17 (2015) 135–137

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Discussion

Psychiatry is a clinical neuroscience, but how do we move the field?

Rajiv Tandon *, Babu Rankupalli, Uma Suryadevara, Joseph Thornton
Psychiatry Service, North Florida/South Georgia Veterans Healthcare System, Department of Psychiatry, University of Florida College of Medicine, 1149 Newell
Drive, L4-100, Gainesville, FL 32611, USA

A R T I C L E I N F O

Article history:
Received 28 August 2015
Accepted 28 August 2015

‘‘Men ought to know that from nothing else but the brain come
joys, delights, laughter and sports, and sorrows, grief, despon-
dency, and lamentations. And by this, in a special manner, we
acquire wisdom and knowledge, and see and hear, and know
what are foul and what are fair, what are bad and what are good,
what are sweet and what are unsavory. And by the same organ
we become mad and delirious, and fears and terrors assail us.
All these things we endure from the brain when it is not
healthy.’’
The belief that ‘mental disorders are brain disorders’ goes back
to Hippocrates (400 BCE). The fact that the mind is a reflection of
the brain’s function should be self-evident since the alternative
would be for mental function to be based on some ethereal non-
earthly frame. Despite this reality, most explanations of psychiatric
disorders are not brain-based and the practice of psychiatry
substantially reflects Descartes’ mind-body dualism (Miresco and
Kirmayer, 2006). In their timely article, Torous et al. (2015)
highlight the widening gap between recent advances in cognitive
neuroscience and the practice of psychiatry and propose a remedy
illustrated with the use of a model case example.
Going back 2400 years in time, we unearth a similar case
example (Sjostrand, 2001). The citizens of the Greek city, Abdera,
called upon Hippocrates to investigate the irrational behavior of
the pre-Socratic philosopher Democritus who is now best known
for the earliest elaboration of the atomic theory of matter.
Democritus, known as the ‘‘laughing philosopher’’ at the time,
because of periods of ‘‘excessive cheerfulness’’ was seated under a
* Corresponding author.
E-mail addresses: tandon@ufl.edu (R. Tandon), babu.rankupalli@va.gov
(B. Rankupalli), uma.suryadevara@va.gov (U. Suryadevara),
joseph.thornton@va.gov (J. Thornton).
tree surrounded by carcasses of dogs and cats. He was experiencing
an episode of severe depression and was dissecting the animals in
order to discover the source of black bile, which was then
considered to cause such melancholia (‘‘melancholy’’ literally
means black bile in Greek). Since Hippocrates considered
depression to be caused by brain malfunction specifically due to
an excess of black bile, he considered Democritus’ behavior to be
essentially rational and counseled Abdera’s citizens not to worry.
One common element in the two case-scenarios is the effort to
understand abnormal mental behavior in terms of specific brain
abnormality. Despite strenuous endeavors by brilliant minds from
around the world for over 2000 years, we find ourselves in a
situation where the practice of psychiatry is substantially
‘‘brainless’’ or at least poorly informed by our current knowledge
of how the brain works. Just as an excess of black bile is not the
cause of melancholia, ‘‘serotonin deficiency’’ is not the cause of
depression either. Yet that is what many practicing psychiatrists,
as well as the preponderance of our citizens, believe is the
neurobiological basis of depression today. Furthermore, most
practicing psychiatrists do not comprehend the truly remarkable
advances in neuroscience and molecular biology that are
revolutionizing our understanding of how the brain mediates
the range of mental functions. What is even more worrisome is the
fact that this enormous gap between current knowledge and
clinician understanding continues to widen and that neuroscien-
tists and clinicians no longer comprehend, let alone speak, the
other’s language.
How do we change this? While the brain is undoubtedly the
organ behind the mind, most mental functions relevant to
psychiatry (thought process, thought content, mood, emotional
regulation, reality orientation, perception, etc.) are comprehensi-
ble only in their interpersonal or other social context. Furthermore,
the brain is not a static organ. Just as the brain mediates mental

http://dx.doi.org/10.1016/j.ajp.2015.08.013
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 136 R. Tandon et al. / Asian Journal of Psychiatry 17 (2015) 135–137
function, life experiences mold the brain all through life. In
addition to philosophers (e.g. Democritus) and physicians (e.g.
Hippocrates), a multitude of other professionals have appropriate-
ly been involved in the effort to unravel the mysteries of mental
illness. The informed practice of psychiatry will always involve
more than a solid foundation in modern neuroscience – some
understanding of philosophy, anthropology, ethology, evolution-
ary biology, sociology, etc. will be important. In the absence of a
basic understanding of brain operations, however, psychiatrists
will find themselves increasingly incapable of providing optimal
state-of-the-art treatment to their patients. Psychiatrists must be
able to critically evaluate emerging findings in neuroscience and
gauge their clinical relevance. To do this, clinicians must have a
basic fund of accurate knowledge of neural structures, neurode-
velopment, neuronal and glial function, synaptic development,
molecular mechanisms, regulation of neuronal circuits, and
paradigms used in neuroscience research. Without the knowledge
to properly appraise neuroscience findings, the clinician will be a
lay spectator in a speculative world.
Assuming that a basic understanding of cognitive neuroscience
is essential to the practice of good psychiatry, the current lack of
such knowledge in most practitioners is disconcerting. Why this
state of affairs? Torous and co-workers attribute this to an
apparent lack of clinical relevance and a deficit in psychiatry
residency training. Let us first delve into the details of the
neuroscience-based formulation they propose. The authors differ-
entially localize the exemplar patient’s mood symptoms to the
anterior cingulate cortex, dorsolateral prefrontal cortex, medial
prefrontal cortex, amygdala, and ventral striatum. They then
recommend a range of specific interventions (e.g. rTMS to the
dorsolateral prefrontal cortex, CBT ‘‘to treat the patient’s self-
referential, negatively valenced rumination which localizes to the
subgenual anterior cingulate cortex’’, etc.) targeting the structures
that they implicate. Torous and co-workers recommend that such
case-based teaching be utilized to educate psychiatry trainees
‘‘because it integrates cognitive-affective neuroscience and neu-
ropsychiatry into the real-time training experiences of residents in
a clinically relevant way’’. Will such an approach result in an
adequately neuroscience-knowledgeable psychiatric practitioner?
Our answer is an unequivocal ‘‘NO’’.
First, the anatomical localization model put forward by Torous
and co-workers represents only a small part of our current
understanding of neuro-circuitry. Specific mental functions are not
localized in specific brain regions as the authors’ model appears to
suggest. While the approach of anatomic localization or ‘‘topo-
graphic diagnosis’’ is the principal first step currently utilized by
clinical neurologists (Arciniegas et al., 2013; Ropper et al., 2014), it
is not a ‘‘systems-level neural circuit approach’’ that the authors
suggest it is. Clinical neurology itself is moving on from a classic
‘‘area localization’’ approach to one that is more circuit- and
system-based and also incorporates single-neuron actions and
interactions (Cash and Hochberg, 2015).
Second, one needs to avoid oversimplification, particularly if it
superficially appears to be clinically relevant. Four decades ago, a
generation of psychiatrists was taught that monoamine deficiency
underlies depression and that dopamine excess is the basis of
schizophrenia which explains why antidepressant medications
and antipsychotic medications, respectively, are effective agents in
their treatment. Despite a plethora of studies documenting these
assertions to be untrue, the ‘‘chemical imbalance’’ explanation of
most mental illnesses prevails. Teaching on the basis of the model
proposed by Torous et al. would likely lead to a similar fixed
inaccurate template for another generation.
Third, there are real dangers associated with propagating
poorly substantiated theories of the neurobiological underpin-
nings of mental illness. Insulin shock and prefrontal lobotomy,
16
clearly harmful treatment modalities utilized by our field in the
past, were based on poorly validated neurobiological ideas of
mental illness. Even today, the non-evidence based use of many
anticonvulsants (such as gabapentin, zonisamide, topiramate,
pregabalin, tiagabine, levetiracetam, etc.) in a host of psychiatric
disorders based on some neurobiological speculation along with
weak anecdotal evidence is indicative of this threat. It is not
inconceivable that psychiatrists might begin to utilize specific
rTMS or DBS for presumed ‘‘loci of depression’’ without adequate
clinical trial data. In this context, the recent failure of sham-
controlled DBS studies in major depression (Dougherty et al., 2015;
Morishita et al., 2014) should sound a cautionary note.
If the approach proposed by Torous and colleagues is unsuitable
for reducing the expanding gap between rapidly advancing
neuroscience and practitioner knowledge, what should we do?
We agree that inadequate clinical relevance and deficits in
residency training are two key factors contributing to the problem.
We also agree that we cannot wait until we have a complete
understanding of how the brain mediates mental function before
requiring such understanding by practicing psychiatrists. How do
we better integrate the clinical with the neuroscience? We believe
the key is recognizing that the endeavor must be a two-way street
with both clinicians and neuroscience researchers having impor-
tant roles to play in developing the bridge! We suggest that
neuroscientists need to better integrate findings across multiple
levels of observation, brain-behavior research needs to be more
clinically relevant, a new generation of true translational
neuroscience-knowledgeable clinical psychiatrists fully conver-
sant with both languages is needed, overly simplistic solutions
should be avoided, and psychiatry educators need to carefully
re-examine what and how they teach.
Hundreds of thousands of ‘‘neurobiological findings’’ and
several hundred hypotheses currently flourish in psychiatry (e.g.
in schizophrenia; Tandon et al., 2008). With few exceptions (e.g.
‘‘schizophrenogenic mother’’), we have not been diligent about
explicitly discarding findings that cannot be verified or evaluating
our ideas in a rigorous hypothesis-testing manner. We believe that
both basic neuroscientists and clinical psychiatrists need to do
better in this regard. If there is a mound of incoherent findings,
what do you teach? With regards to the content of neuroscience,
we believe that greater emphasis should be placed on teaching
basic principles of neurobiology rather than insufficiently validat-
ed neurobiological models of psychiatric diseases (Weisberg et al.,
2008). Given the fact that our current psychiatric nosology does
not line up with biology, such teaching is even less useful or
relevant.
What gives us hope? First, initiatives such as RDoC (Insel and
Wang, 2010; Insel and Cuthbert, 2015) have the potential to map
brain circuitry that underlies mental functions and malfunctions –
here, it is critical that a testing of clearly articulated refutable
hypotheses and rigor in examining each link characterize this process.
Second, recent changes in DSM-5 with the introduction of
dimensional assessments that have the potential to align with
endophenotypes and RDoC circuits (e.g. Barch et al., 2013; Tandon
et al., 2013) and early diagnosis (e.g. Tsuang et al., 2013) provide a
better bridge to a future etio-pathophysiological nosology – here, it
is essential that clinicians utilize DSM-5 rigorously. Both basic
neuroscientists and clinicians have an important role to play in
building a valid nosological bi-directional bridge (Keshavan, 2013;
Krishnan, 2015; Tandon, 2012). Third, there are a number of
current efforts to develop model neuroscience curricula for
trainees in psychiatry (Coverdale et al., 2014) – here, emphasis
should be placed on teaching enduring methods and principles,
avoiding cookie-cutter oversimplifications, and deleting less useful
materials (Lunn, 2015). Fourth, advances in cognitive neuroscience,
brain imaging, psychiatric genetics and genomics are progressing
 R. Tandon et al. / Asian Journal of Psychiatry 17 (2015) 135–137
so rapidly that their proper clinical application is inevitable – here,
meaningful two-way translation is imperative.
We agree that meaningful incorporation of current neurosci-
ence knowledge into the training of psychiatrists (at all stages in
their career) is vital and that ‘‘the time is now’’ (Ross et al., 2015).
But what we teach should be carefully considered and the
curriculum developed accordingly.
References
Arciniegas, D.B., Anderson, C.A., Filley, C.M., 2013. Behavioral Neurology and
Neuropsychiatry. Cambridge University Press, New York.
Barch, D., Bustillo, J., Gaebel, W., et al., 2013. Logic and justification for dimensional
assessment of symptoms and related clinical phenomena in psychosis:
relevance to DSM-5. Schizophr. Res. 150, 15–20.
Cash, S.S., Hochberg, L.R., 2015. The emergence of single neurons in clinical
neurology. Neuron 86, 79–91.
Coverdale, J., Balon, R., Beresin, E.V., et al., 2014. Teaching clinical neuroscience to
psychiatry residents: model curricula. Acad. Psychiatry 38, 111–115.
Dougherty, D.D., Rezai, A.R., Carpenter, L.L., et al., 2015. A randomized sham-
controlled trial of deep brain stimulation of the ventral capsule/ventral striatum
for chronic treatment-resistant depression. Biol. Psychiatry 78, 240–248.
Hippocrates (c.460-c370 B.C.). In Hippocratic Corpus, On the Sacred Disease.
Translated by Francis Adams.
Insel, T.R., Cuthbert, B.N., 2015. Brain disorders? Precisely. Science 348, 499–500.
Insel, T.R., Wang, P.S., 2010. Rethinking mental illness. JAMA 303, 1970–1971.
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Keshavan, M.S., 2013. Classification of psychotic disorders: need to move to a
neuroscience-informed nosology. Asian J. Psychiatry 6, 191–192.
Krishnan, R.R., 2015. A knowledge network for a dynamic taxonomy of psychiatric
disease. Dialogues Clin. Neurosci. 17, 79–87.
Lunn, B., 2015. Education in psychiatry. Int. Encycl. Soc. Behav. Sci. 7, 185–193.
Miresco, M.J., Kirmayer, L.J., 2006. The persistence of mind-brain dualism
in psychiatric reasoning about clinical scenarios. Am. J. Psychiatry 163,
913–918.
Morishita, T., Fayad, S.M., Higuchi, M.A., et al., 2014. Deep brain stimulation for
treatment resistant depression: systematic review of clinical outcomes. Neu-
rotherapeutics 11, 475–484.
Ropper, A.H., Samuels, M.A., Klein, J.P., 2014. Adams and Victor’s Principles of
Neurology, 10th ed. McGraw-Hill Education, New York.
Ross, D.A., Travis, M.J., Arbuckle, M.R., 2015. The future of psychiatry as a clinical
neuroscience: why not now? JAMA Psychiatry 72, 413–414.
Sjostrand, L., 2001. Hippocrates’ evaluation of the madness of Democritus. Sven.
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Tandon, R., 2012. The nosology of schizophrenia: towards DSM-5 and ICD-11.
Psychiatr. Clin. North Am. 35, 557–569.
Tandon, R., Keshavan, M.S., Nasrallah, H.A., 2008. Schizophrenia, ‘‘Just the facts’’ 1.
What we know in 2008. Schizophr. Res. 100, 1–18.
Tandon, R., Gaebel, W., Barch, D.M., et al., 2013. Definition and description of
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Torous, J., Stern, A.P., Padmanabhan, J.L., et al., 2015. A proposed solution to
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17
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 Asian Journal of Psychiatry 17 (2015) 138–139
Contents lists available at ScienceDirect
Asian Journal of Psychiatry
journal homepage: www.elsevier.com/locate/ajp
Commentary
Bringing neuroscience to teaching rounds: Refreshing
our clinical pidgin
Vinod Hiremagalur Srihari
Yale University, Department of Psychiatry, 34 Park Street, Rm 273A, Connecticut Mental Health Center, New Haven, CT 06519, United States
A R T I C L E I N F O
Article history:
Received 30 June 2015
Accepted 27 August 2015
Torous et al. offer a compelling proposal to ‘‘encourage all
psychiatrists and psychiatry residents to engage in discussions
around localizing suspected abnormally functioning brain cir-
cuits.’’ This timely paper offers a practical approach and echoes
concerns (Bullmore et al., 2009; Kontos et al., 2006) about the
pedagogical fallout of the current state of psychiatric practice. To
put it more bluntly – are current workplaces inadequate learning
environments for future psychiatrists? Will they transmit a style
of practice that excludes emerging knowledge about the
neurobiology of mental illness? Torous et al. offer several clinical
examples, and are speaking as physicians, educators and
scientists who are engaged in the real world of practice. The
proposal thus evokes a familiar and central scene at the clinical
coalface: the trainee and supervisor leaning in to their interaction
with the patient. This is a triad in which the rubber of all our
curricular aspirations meets the proverbial road of the clinical
encounter where, for better and worse, habits of practice (and
learning) are acquired. As with many practical initiatives, the
authors acknowledge that there is much work to be done, e.g. to
develop curricular resources, train faculty and address the limits
of our knowledge. The effort itself, however, fits well within a
long-standing pluralist tradition in medicine. Psychiatry has
been a leading exemplar of such pluralism and can indeed
welcome and integrate ‘Cognitive-Affective Neuroscience’ and
‘Neuropsychiatry’.
Swales provided an illuminating and entertaining history of
three old, and often battling, ‘cultures’ in medicine (Swales, 2000).
While cutting-edge physiological theory (e.g. bleeding to target
inflammation from excessive blood volume) had to sometimes
yield to empirical evidence (patients with typhoid did not fare
E-mail address: vinod.srihari@yale.edu.
http://dx.doi.org/10.1016/j.ajp.2015.08.011
1876-2018/ 2015 Elsevier B.V. All rights reserved.
better when bled), the latter approach was derided by distin-
guished 19th century physiologists like Claude Bernard. For him,
the control of disease required experimentation in the laboratory
to discover the determinism or mechanisms of disease. In this view,
clinical observations on whole patients were tantamount to
‘‘analyzing what was going on in a house by counting how many
people went in, or how much smoke came out of the chimney.’’
This tension between the imaginative leaps of physiological theory
(biological psychiatry) and the discipline of checking outcomes in
whole human subjects (clinical epidemiology) has been formative
for modern medicine. Both belong within the broader effort to
refine the causal stories we have of illnesses, and have existed side
by side with another strong vein in medicine. That is, the tradition
of honoring the patient’s story, as a narrator of their own life and
their intersection with illness, rather than merely a subject of
impersonal mechanisms.
These old tensions between distinct insights from the study of
disease mechanisms, population-based studies and patient narra-
tives (Greenhalgh, 1999) can enrich any clinical encounter when
considered together, but risk caricature when used in isolation.
Psychiatry led other medical specialties in articulating remedies
for such false choices. For Jaspers it was indistinguishing and
honoring the domains of Erkalaren (Explanation) and Verstehen
(Understanding). We can simultaneously seek to explain the causal
impact of physiologic processes, temperamental dispositions,
behavioral distortions or adversities while we must also seek to
understand its meaning for an individual patient. McHugh and
Slavney have advocated taking distinct perspectives on each case –
akin to looking through different lenses – of Disease, Disposition,
Behavior and Narrative (McHugh and Slavney, 2012). While Engel’s
biopsychosocial framework listed the different levels from which
to consider the patients’ predicament, the challenge for the
clinician (and indeed the clinical scientist) is often to wager limited
19
 V.H. Srihari / Asian Journal of Psychiatry 17 (2015) 138–139
resources on the few levels most likely to leverage results
(Heninger, personal communication). A principled pluralism
(Ghaemi and McHugh, 2007) must then choose which perspective
to emphasize, while remaining open to constraints from the others.
For a particular case, formulating a detailed narrative (normal
grief) can be the key element of treatment, while in others,
knowledge of the relevant pathophysiological process (Alzheimer’s
disease) can organize a holistic plan of care.
We need to train multi-lingual psychiatrists (Srihari, 2008).
The metaphor of language points to the challenges and rewards
of such learning. The ‘‘circuit talk’’ (my inelegant phrase)
exemplified by Torous et al., is a welcome addition to this
mix. Indeed, as a relatively recent entrant to the already noisy
clinical encounter, it might need more nurturing and attention
from clinical educators. The case presented by the authors
vividly illustrates both the promise and the challenge: while the
young woman with depression provides a pedagogically live
opportunity to discuss circuit dysfunction (and to keep the spirit
of Claude Bernard alive in the clinic), the treatments currently
available (an SNRI and CBT) can be adequately applied without
this discussion. Indeed, the clinical encounter is the province of
many disciplines that vie for a voice – ethics, philosophy,
statistics, history, literature. Biological psychiatry itself has
domains such as genetics, imaging and electrophysiology that,
like the other disciplines, have developed distinct technical
languages. These are languages that the clinician needs to at
least work with if not fully understand. And how must all of this
be communicated to our patients?
The study of trade between distinct cultures can offer optimism
to the beleaguered clinician educator. Anthropologists have
20
139
described ‘contact languages’ that develop to allow basic
communication (Cooper, 2014). The first product of such efforts
are often pidgins which, lacking a grammar or written text, cannot
sustain much more than a basic coordination of efforts. However,
when the young grow up speaking the pidgin as natives, full-
fledged languages – creoles – can develop and sustain a deeper
engagement. So, while we follow Torous et al. in their quest
to bring ‘circuit talk’ into the pidgin that thoughtful clinicians are
constructing everyday, we can hope that what proves useful will
then become part of the language of ordinary practice.
Conflicts of interest
None.
References
Bullmore, E., Fletcher, P., Jones, P.B., 2009. Why Psychiatry Can’t Afford to be
Neurophobic.
Cooper, R., 2014. Psychiatry and Philosophy of Science. Routledge.
Ghaemi, S.N., McHugh, P.R., 2007. The Concepts of Psychiatry: A Pluralistic Ap-
proach to the Mind and Mental Illness.
Greenhalgh, T., 1999. Narrative based medicine: narrative based medicine in an
evidence based world. BMJ 318, 323–325.
Kontos, N.N., Querques, J.J., Freudenreich, O.O., 2006. The problem of the psycho-
pharmacologist. Acad. Psychiatry 30, 218–226, http://dx.doi.org/10.1176/
appi.ap.30.3.218.
McHugh, P.R., Slavney, P.R., 2012. Mental illness – comprehensive evaluation
or checklist? N. Engl. J. Med. 366, 1853–1855, http://dx.doi.org/10.1056/
NEJMp1202555.
Srihari, V., 2008. Evidence-based medicine in the education of psychiatrists. Acad.
Psychiatry 32, 463–469, http://dx.doi.org/10.1176/appi.ap.32.6.463.
Swales, J., 2000. The troublesome search for evidence: three cultures in need of
integration. J. R. Soc. Med. 93, 402–407.
 Asian Journal of Psychiatry 17 (2015) 122–123

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Discussion

Bridging the brain–mind divide in psychiatric education:

The neuro-bio-psycho-social formulation
David A. Silbersweig
Brigham and Women’s Hospital, Harvard Medical School, United States

A R T I C L E I N F O A B S T R A C T

Article history: Psychiatrists of the future need to have a strong working knowledge of the organ they work with—the
Received 28 August 2015 brain. Neuropsychiatry is now more than a paradigm. Systems-level behavioral neuroscience, while still
Accepted 28 August 2015 evolving, is mature enough to provide circuit-based foundation. Cellular and molecular neuroscience is
starting to yield further mechanistic understanding. It is important to integrate such approaches into an
Keywords: evidence-based, bio-psycho-social formulation, with increasing implications for disease taxonomy,
Neuropsychiatry diagnosis and treatment.
Behavioral neuroscience
 2015 Published by Elsevier B.V.
Psychiatric education

The brain is the organ of the mind. While traditionally defined
psychiatric disorders have not been associated with macroscopic
brain lesions, the advent of functional neuroimaging has demon-
strated neuropsychological/neuropsychiatric structure–function–
symptom–syndrome relationships (Silbersweig and Stern, 1997).
An examination of the perceptual, cognitive, emotional and
behavioral effects of neurologic lesions and brain stimulation
provide convergent evidence of such relationships (Butler et al.,
2012). Final common pathways of clinical behavioral expression
are being defined, upon which various pathophysiologies, from
numerous etiologies, as well as various therapeutic modalities, act
(Epstein and Silbersweig, 2015). As systems-level neuroscience is
integrated with cellular and molecular science (Deisseroth et al.,
2015), and a clinical relevance starts to grow, it is time for a more
updated, integrated and effective approach to neuropsychiatric
education for the next generation of our field.
Torous et al. (2015) have described an excellent method for
linking clinical case formulation with models of brain circuit
dysfunction. Such case-based, interactive approaches have practi-
cal and pedagogical benefits, with active learning of salient
material. They also help to transform the clinical educational
culture, compared with didactic approaches that are not woven
into the everyday work flow.
The authors address key issues, such as whether the scientific
evidence is mature enough, whether there is direct clinical
relevance, and whether local expertise would exist in most
institutions. As they point out, there certainly is a robust literature
supporting a circuit-based conceptualization of major psychiatric
disorders (Ressler and Mayberg, 2007). It is moving beyond
simplistic localization toward a model of distributed modular
functions integrated through structural and functional connectiv-
ity (Bastos-Leite et al., 2015). The paper points to clinical relevance
in the context of therapeutics, rightly citing evolving invasive and
non-invasive brain stimulation techniques, and neural imaging
correlates and predictors of response to pharmacotherapy and
psychotherapy (Dunlop and Mayberg, 2014). For many less
severely affected and non-refractory patients, and since we are
not yet at the age of clinically useful functional neuroimaging, the
relevance of circuit models to individual patients and discussions
may remain more theoretical than practical but not necessarily
premature. Regarding local expertise, it is the case that many
centers do not yet have a depth of neuropsychiatric expertise, but
as suggested by the authors, web-based modules could be very
helpful. This might suggest that rather than this being part of the
formulation for every case, it might still be performed regularly,
but reserved for specific teaching cases or conferences. This would
also be appropriate, as there are not that many main nodes and
circuits to learn, though there are many subtleties and levels that
could be incorporated in places with local expertise in neuropsy-
chiatry (not just biological psychiatry). A circuit-based approach
will ultimately blossom as neuroimaging biomarkers are developed
that stratify patient populations, defining mechanism-based sub-
groups, with diagnostic, therapeutic and prognostic implications
(Dunlop and Mayberg, 2014). Indeed, the foundation for a new
biologically-based taxonomy for psychiatric disorders, crossing
traditional DSM categories, is being developed (Insel, 2014).
Essentially, one could advocate the explicit addition of neural
circuitry to the classic bio-psycho-social formulation, creating a

http://dx.doi.org/10.1016/j.ajp.2015.08.020
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 D.A. Silbersweig / Asian Journal of Psychiatry 17 (2015) 122–123
new neuro-bio-psycho-social formulation. To be meaningful, the
different arms of the formulation need to be not only listed but also
integrated. This is where the incorporation of neuroscience can be
critical. Neural plasticity and epigenetics provide mechanisms that
mediate organism–environment interactions in the context of
neurodevelopment (Klengel and Binder, 2015). The authors
describe this approach nicely in their clinical example. A more
complete formulation could start to address risk and resilience
factors, as well as implications for trajectory-altering, earlier
interventions, or ultimately prevention (Charney and Manji, 2004).
But is therapeutics the only main area for clinical relevance of a
neuro-bio-psycho-social formulation? The other major clinical
domain that the authors might have discussed is diagnostics. Even
before the hopefully coming age of clinical scanning in psychiatry,
every clinician is faced with the challenge of differential diagnosis.
While most cases may be more straightforward, a not insignificant
(and under-recognized) number of cases raise issues where a
knowledge of neuropsychiatric circuits is very relevant. Should this
patient with this presentation get a brain scan (if so, what kind), an
EEG, a lumbar puncture (looking for what)? A knowledge of the key
brain circuits underlying major psychiatric phenomenology,
combined with a knowledge of the ways in which various
syndromes and pathophysiologies present, is essential here (Mega
and Cummings, 1994). While the psychiatrist can still refer
patients for neurological evaluation, the referring physician needs
to determine the timing and threshold, if not the reason, for such
consultation and work-up. In fact, the neurologist also needs to be
more familiar with the emotional and behavioral sequelae of
specific neurologic lesions and conditions (Tekin and Cummings,
2002). Perhaps this neurobehavioral formulation could be
promulgated within neurology training programs as well.
Torous et al. (2015) bring up the inevitable issue of when and
how more basic scientific knowledge might be integrated with
clinical case formulations. While it may be best to start with the
systems-level, for the reasons discussed, the advent of clinically
meaningful genetic, metabolomic, proteomic, lipidomic and other
omic biomarkers is probably just a matter of time (Huang and Lin,
2015). Evidence base and common sense will determine when and
how to best incorporate such material. In the meantime, some of
the known connections between human neural circuit function
and functional genetic polymorphisms and basic neuroscientific
translational animal studies can be integrated into case formula-
tion discussions (Cao et al., 2014).
Another thing that should determine when and how educa-
tional innovations are incorporated, not mentioned in this paper, is
evidence. Increasingly, educational research, with rigorous study
designs, methods and metrics, is the means of determining
whether a new curricular or experiential element is effective
(Verduin et al., 2013). This can guide how ever-limited time and
resources should be allocated to advance knowledge, skills,
22
123
attitudes and outcomes. The neuro-bio-psycho-social formulation
should have to withstand such a test. That said, such a formulation
can be helpful with required neuroscience milestones (Benjamin,
2013), as noted by the authors. In a related fashion, and most
importantly, it can be important in helping our brain–mind
doctors-in-training to become the contemporary and future
specialists that our suffering patients so deserve.
References
Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A
proposed solution to integrating cognitive-affective neuroscience and neuro-
psychiatry in psychiatry residency training: The time is now. Asian J. Psychiatr..
[Epub ahead of print] PubMed PMID: 26054985.
Bastos-Leite, A.J., Ridgway, G.R., Silveira, C., Norton, A., Reis, S., Friston, K.J., 2015.
Dysconnectivity within the default mode in first-episode schizophrenia: a
stochastic dynamic causal modeling study with functional magnetic resonance
imaging. Schizophr. Bull. 41 (1), 144–153, http://dx.doi.org/10.1093/schbul/
sbu080.
Benjamin, S., 2013. Educating psychiatry residents in neuropsychiatry and neuro-
science. Int. Rev. Psychiatry 25 (3), 265–275, http://dx.doi.org/10.3109/
09540261.2013.786689.
Butler, T., Weisholtz, D., Isenberg, N., Harding, E., Epstein, J., Stern, E., Silbersweig, D.,
2012. Neuroimaging of frontal-limbic dysfunction in schizophrenia and epilep-
sy-related psychosis: toward a convergent neurobiology. Epilepsy Behav. 23 (2),
113–122, http://dx.doi.org/10.1016/j.yebeh.2011.11.004.
Cao, H., Duan, J., Lin, D., Shugart, Y.Y., Calhoun, V., Wang, Y.P., 2014. Sparse
representation based biomarker selection for schizophrenia with integrated
analysis of fMRI and SNPs. Neuroimage 102 (PART 1), 220–228, http://
dx.doi.org/10.1016/j.neuroimage.2014.01.021.
Charney, D.S., Manji, H.K., 2004. Life stress, genes, and depression: multiple path-
ways lead to increased risk and new opportunities for intervention. Sci STKE
2004 (225), re5, http://dx.doi.org/10.1126/stke.2252004re5.
Deisseroth, K., Etkin, A., Malenka, R.C., 2015. Optogenetics and the circuit dynamics
of psychiatric disease. JAMA 313 (20), 2019–2020, http://dx.doi.org/10.1001/
jama.2015.2544.
Dunlop, B.W., Mayberg, H.S., 2014. Neuroimaging-based biomarkers for treatment
selection in major depressive disorder. Dialogues Clin. Neurosci. 16 (4), 479–490.
Epstein, J., Silbersweig, D., 2015. The neuropsychiatric spectrum of motivational
disorders. J. Neuropsychiatry Clin. Neurosci. 27 (1), 7–18, http://dx.doi.org/
10.1176/appi.neuropsych.13120370.
Huang, T.L., Lin, C.C., 2015. Advances in biomarkers of major depressive disorder.
Adv. Clin. Chem. 68, 177–204, http://dx.doi.org/10.1016/bs.acc.2014.11.003.
Insel, T.R., 2014. The NIMH Research Domain Criteria (RDoC) Project: precision
medicine for psychiatry. Am. J. Psychiatry 171 (4), 395–397, http://dx.doi.org/
10.1176/appi.ajp.2014.14020138.
Klengel, T., Binder, E.B., 2015. Epigenetics of stress-related psychiatric disorders and
gene  environment interactions. Neuron 86 (6), 1343–1357, http://dx.doi.org/
10.1016/j.neuron.2015.05.036.
Mega, M.S., Cummings, J.L., 1994. Frontal-subcortical circuits and neuropsychiatric
disorders. J. Neuropsychiatry Clin. Neurosci. 6 (4), 358–370.
Ressler, K.J., Mayberg, H.S., 2007. Targeting abnormal neural circuits in mood
and anxiety disorders: from the laboratory to the clinic. Nat. Neurosci. 10
(9), 1116–1124, http://dx.doi.org/10.1038/nn1944.
Silbersweig, D.A., Stern, E., 1997. Symptom localization in neuropsychiatry. A
functional neuroimaging approach. Ann. NY Acad. Sci. 835, 410–420.
Tekin, S., Cummings, J.L., 2002. Frontal-subcortical neuronal circuits and clinical
neuropsychiatry: an update. J. Psychosom. Res. 53 (2), 647–654.
Verduin, M.L., Boland, R.J., Guthrie, T.M., 2013. New directions in medical education
related to psychiatry. Int. Rev. Psychiatry 25 (3), 338–346, http://dx.doi.org/
10.3109/09540261.2013.784958.
 Asian Journal of Psychiatry 17 (2015) 124–125
Contents lists available at ScienceDirect
Asian Journal of Psychiatry
journal homepage: www.elsevier.com/locate/ajp
Discussion
Remembering psychiatry’s core strengths while incorporating
neuroscience
Oliver Freudenreich a,c,*, Nicholas Kontos b,c, John Querques b,c
a
Schizophrenia Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
b
Division of Psychiatry and Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
c
Harvard Medical School, Boston, MA, United States
A R T I C L E I N F O
Article history:
Received 28 August 2015
Accepted 28 August 2015
Despite decades-long efforts to integrate psychiatry and
neuroscience, successive generations have failed to craft a
neuroscience-informed psychiatry that contributes to patient care
meaningfully. Perhaps a clear reappraisal of psychiatry’s core
strength as a clinical discipline can provide the framework for a
successful union of bench and bedside that neither sells the
discoveries of neuroscience short nor exaggerates their promises.
We agree in principle with Torous and colleagues (Torous et al.,
2015) that psychiatry can become a specialty that truly uses
knowledge about our organ of interest, the brain, in caring for our
patients. To that end, Torous et al. urge psychiatry to integrate
training in cognitive-affective neuroscience and neuropsychiatry
into residency training. They argue that we have reached the point
where patient discussions can be informed by circuit-based
neuropsychiatric analysis, comparable to the lesion-based model
in neurology. Including neuroscientific knowledge in the herme-
neutic function of clinical psychiatry will not only serve patients
but also help the field to remain at the forefront of enthusiasm over
medical progress. Torous et al.’s proposal is timely as evidenced by
a recent viewpoint in JAMA Psychiatry entitled, ‘‘The future of
psychiatry as clinical neuroscience. Why not now?’’ that similarly
argues for the need to examine our identity and future critically
(Ross et al., 2015).
However, if we want to be successful this time, we need to step
back and answer the question: What is taking so long and why is it
so difficult? After all, the seminal article by Alexander et al. (1986)
* Corresponding author at: Erich Lindemann Mental Health Center, 25 Staniford
Street, Boston, MA 02114, United States. Tel.: +1 617 912 7800.
E-mail address: Freudenreich.Oliver@mgh.harvard.edu (O. Freudenreich).
http://dx.doi.org/10.1016/j.ajp.2015.08.019
1876-2018/ 2015 Elsevier B.V. All rights reserved.
that Torous et al. rightly highlight as foundational for circuit-based
understanding of psychiatric illness was published almost three
decades ago. Several obstacles come to mind, none of them trivial.
For one, perhaps only now have we developed tools such as
optogenetics (Deisseroth et al., 2015) to probe psychiatrically
relevant neurocircuits meaningfully enough to move beyond very
crude ideas (e.g., that the amygdala is related to fear). Second,
Kraepelin’s enduring model of discrete, natural disease entities
(natüerliche Krankheitseinheiten, in German) might be wrong for
major disorders like depression and schizophrenia. Dysfunctions in
widely distributed and dynamic neuronal networks might not lend
themselves to the rigid bounds of purportedly naturally occurring
diseases carved out of phenomenologic and longitudinal observa-
tion of clinical signs and symptoms. It is no accident, and speaks to
these conceptual difficulties, that we have basically failed to
incorporate any findings from decades of neuroscience research
into the most recent revision of the Diagnostic and Statistical
Manual of Mental Disorders (DSM) (Keshavan, 2013). Indeed, the
National Institute of Mental Health has felt compelled to propose a
parallel classification system for research purposes (i.e., the
Research Domain Criteria) that does not map onto DSM clinical
categories but instead tries to understand cross-diagnostic
constructs such as systems for social processes (Insel et al.,
2010). Is it then surprising that determining what to teach
residents about neuroscience has proven difficult? Last and most
importantly, psychiatry as a clinical endeavor is more than
neuroscience; much needs to be taught that has to do with actual
patient care. The skills of observing and eliciting psychological
signs and symptoms and choosing among myriad options within
and between treatment modalities remain at the core of
psychiatric practice and beyond the reach of contemporary
23
 O. Freudenreich et al. / Asian Journal of Psychiatry 17 (2015) 124–125
neuroscience. In addition to diagnosis and treatment, issues of
suffering, coping with illness, and adherence require knowledge
about the human condition.
These challenges aside, we agree with the authors that the time
is now to begin seriously the task of developing curricula and
teachers to satisfy the unmet needs for understanding and
applying neurobiology and brain function.
Without training in neuroscience, clinicians are unable to
separate the hype from the promise. Our patients expect us to be
up on recent scientific developments, but we also need to be able to
synthesize and translate research findings and put them into a
patient’s individual context in order to give reasoned advice. Are
antipsychotics causing gray matter changes? Is psychosis stress-
induced? Are my amygdalae overactive? All are questions that
patients might ask. Also, new technologies (e.g., transcranial
magnetic stimulation [TMS] or direct brain stimulation [DBS]) that
target brain circuits need to be understood so patients can be
referred appropriately if other treatments fail.
On a more abstract level, one needs to be able to field
statements (often spun directly from psychiatry’s efforts to reduce
stigma) from patients about mental illnesses, as mechanical
invocations of ‘‘chemical imbalances’’ may no longer suffice.
Further, as neurobiological correlates of complex human qualities
such as morality, decision-making, and attachment reveal
themselves, psychiatrists face complex ethical questions about
autonomy, responsibility, the boundaries of psychopathology, and
enhancement therapies. Personal opinions and affiliations with
psychiatric ‘‘schools of thought’’ are no longer sufficient for
navigating these new waters in medical ethics (i.e., ‘‘neuroethics’’).
An informed, contemporary understanding of brain functioning is
needed in order to inform responsible, moral medical activity
when issues of autonomy, for example, are raised.
While Torous et al.’s proposal is urgent, it is not an emergency.
As a start, we might simply need to better teach residents that
there are differences between clinically discrete lesion-based
pathology (e.g., post-stroke depression), limited circuit-based
pathology (e.g., frontal network syndromes as seen in patients
with dementias and traumatic brain injuries), and widely
distributed network-based dysfunctions with significant dynamic
aspects and pathologies in the coordinated activities of neuronal
assemblies (e.g., those targeted by TMS and DBS) (Uhlhaas, 2015).
Teaching those differences (with the help of neurology as a partner
24
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in interdisciplinary learning) to get to a neuroscience-informed
psychiatry seems an achievable goal for resident education, with
incremental progress as opposed to a revolution. As Torous and
colleagues note, exposure to clinical cases is critical and can
probably not be accomplished without meaningful, as opposed to
pro forma, training in neurology.
Emphasizing neuropsychiatry and neuroscience need not fashion
the mindless, brain-based psychiatry feared by some (Eisenberg,
1986). Nor does it abrogate the need to know about the human side
of medicine, including irresponsibility, deception, and other ‘‘dirty’’
parts of human nature encountered in patient care (Freudenreich et
al., 2010). On the contrary, to place neuroscientific findings in their
real-world context, we will need to be informed by anthropology,
philosophy, and sociology. Trained in the medical model, psychia-
trists qua physicians think in terms of diagnosis, differential
diagnosis, treatment, and prognosis. As a result, we should expect
ourselves, and teach our trainees, to identify the demonstrably
‘‘organic’’ contributions to brain dysfunction, which will increasing-
ly include circuit-based concepts, and to recognize when more
existential, psychological (e.g., fear, despair, loss), and environmen-
tal factors (i.e., the social determinants of health) predominate.
References
Alexander, G.E., DeLong, M.R., Strick, P.L., 1986. Parallel organization of functionally
segregated circuits linking basal ganglia and cortex. Annu. Rev. Neurosci. 9,
357–381.
Deisseroth, K., Etkin, A., Malenka, R.C., 2015. Optogenetics and the circuit dynamics
of psychiatric disease. JAMA 313, 2019–2020.
Eisenberg, L., 1986. Mindlessness and brainlessness in psychiatry. Br. J. Psychiatry
148, 497–508.
Freudenreich, O., Kontos, N., Querques, J., 2010. The muddles of medicine: a
practical, clinical addendum to the biopsychosocial model. Psychosomatics
51, 365–369.
Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D.S., Quinn, K., Sanislow, C.,
Wang, P., 2010. Research domain criteria (RDoC): toward a new classification
framework for research on mental disorders. Am. J. Psychiatry 167, 748–751.
Keshavan, M.S., 2013. Nosology of psychoses in DSM-5: inches ahead but miles to
go. Schizophr. Res. 150, 40–41.
Ross, D.A., Travis, M.J., Arbuckle, M.R., 2015. The future of psychiatry as clinical
neuroscience: why not now? JAMA Psychiatry 72, 413–414.
Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A
proposed solution to integrating cognitive-affective neuroscience and neuro-
psychiatry in psychiaty residency training: the time is now. Asian J. Psychiatry
17, 116–121.
Uhlhaas, P.J., 2015. Neural dynamics in mental disorders. World Psychiatry 14,
116–118.
 Asian Journal of Psychiatry 17 (2015) 126–127
Contents lists available at ScienceDirect
Asian Journal of Psychiatry
journal homepage: www.elsevier.com/locate/ajp
Commentary
‘‘The time is now’’: Integrating neuroscience into psychiatry training
David A. Ross a,*, Melissa R. Arbuckle b, Michael J. Travis c
a
Department of Psychiatry, Yale School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, United States
b
Department of Psychiatry, Columbia University College of Physicians and Surgeons, United States
c
Department of Psychiatry, University of Pittsburgh Medical Center, United States
A R T I C L E I N F O
Article history:
Received 28 August 2015
Accepted 28 August 2015
This is an extraordinary time for psychiatry, as new research in
neuroscience is re-defining the essence of how we conceptualize
psychiatric illness. In this issue, Torous et al. (2015) have written a
significant paper that captures at once the excitement of new work
in the field and the importance of meaningfully incorporating this
perspective into both clinical and educational settings. The authors
also review some of the many challenges to doing so effectively.
The authors’ work comes at a time when many academics are
wrestling with this same question and the authors refer to various
ongoing efforts seeking to address this practice gap. One such
program is the National Neuroscience Curriculum Initiative (Ross
et al., 2015; www.NNCIonline.org). The NNCI was formally
launched in March of 2014 with the overarching goal of creating
a set of open resources that will help improve the teaching of
neuroscience in psychiatry. Similar to Torous et al.’s goal of helping
trainees ‘‘bridge, in real-time, brain-symptom relationships in
psychiatry’’, the NNCI sets as a central objective that ‘‘residents will
incorporate a modern neuroscience perspective as a core compo-
nent of every formulation and treatment plan.’’ Additional learning
objectives relate to relevant knowledge, attitudes towards
neuroscience, and specific behavioral skills – including that
residents will be able to serve as Ambassadors of Neuroscience
who can thoughtfully communicate findings from the field to different
audiences.
The core work of the NNCI has been the creation of educational
resources that can be used as in-class teaching and learning
activities for residency programs. The guiding principles for these
resources are: to maintain an integrative, patient centered
approach; to teach well, by applying adult learning theory; and
* Corresponding author.
E-mail address: a.ross@yale.edu">david.?a.ross@yale.edu (D.A. Ross).
http://dx.doi.org/10.1016/j.ajp.2015.08.018
1876-2018/ 2015 Elsevier B.V. All rights reserved.
to create an adaptable frame that can be easily implemented by
anyone, anywhere. To this end, each course has a comprehensive
Facilitator’s Guide that includes detailed instructions for imple-
mentation, sample scripts that can be used in class, additional
background readings, and, in many cases, videos of a neuroscience
and/or education expert teaching that exact session.
To date, the NNCI has developed six separate teaching ‘‘modules’’,
each of which reflects one potential paradigm by which one could
teach neuroscience effectively. Each module is designed to offer a
structure through which a wide range of content can be taught as
individual sessions. Critically, the course frame also enables
materials to be flexibly updated as content continues to evolve.
While much of the NNCI effort has so far been aimed at
facilitating in-class teaching and learning for psychiatry residents,
we are mindful of the value the initiative may have for other
populations (including medical students and community clinicians).
To this end, all NNCI resources are freely available via a website,
including a rapidly expanding set of self-study materials. We are also
developing teaching resources that are designed to engage more
diverse audiences with the critical process of incorporating specific
neuroscience findings directly into clinical practice.
Importantly, the NNCI reflects a collaborative effort. The core
leadership team is comprised of clinician educators from four large
university programs. This effort would not be possible without the
financial support of the NIMH. We have also established relation-
ships with the American Association of Directors of Psychiatric
Residency Training, the American Psychiatric Association Council on
Medical Education and Lifelong Learning, the Society of Biological
Psychiatry, and the American College of Neuropsychopharmacology.
We continue to seek partnership from other individuals and
organizations that share a common interest and vision.
In the year since its formal launch, the NNCI has been met with
warmth and approval from the academic community. We believe
25
 D.A. Ross et al. / Asian Journal of Psychiatry 17 (2015) 126–127
this speaks to training directors’ belief in the importance of the
mission (Benjamin et al., 2014) and also their motivation to update
their curricula (in line with the various recent data reviewed by
Torous et al., in the introduction to their paper). More than
30 residency programs have already incorporated NNCI resources
into their curricula and more than 200 individuals have signed up
as members of the NNCI Learning Collaborative. We have also
received more than 50 submissions of new content that we are
actively reviewing and editing.
Torous et al. write: ‘‘the time is now for residents, educators and
like-minded academic psychiatrists to develop a culture of
embracing cognitive-affective neuroscience and neuropsychiatry
to expedite the ‘‘bench-to-bedside’’ translation of brain-symptom
relationships to help guide clinical thinking and future innovative
therapeutic interventions.’’
26
127
We agree wholeheartedly and hope that key stakeholders will
continue to explore collaborative approaches for addressing this
critical mission.
References
Benjamin, S., Travis, M.J., Cooper, J.J., Dickey, C.C., Reardon, C.L., 2014. Neuropsy-
chiatry and neuroscience education of psychiatry trainees: attitudes and bar-
riers. Acad. Psychiatry 38 (2), 135–140.
National Neuroscience Curriculum Initiative. Available at: www.NNCIonline.org.
Ross, D.A., Travis, M.J., Arbuckle, M.R., 2015. The future of psychiatry as clinical
neuroscience: why not now? JAMA Psychiatry 72, 413–414.
Torous, J., Stern, A.P., Padmanabhan, J.L., Keshavan, M.S., Perez, D.L., 2015. A
proposed solution to integrating cognitive-affective neuroscience and neuro-
psychiatry in psychiatry residency training: the time is now. Asian J. Psychiatry
17, 116–121.
 Asian Journal of Psychiatry 17 (2015) 128–129
Contents lists available at ScienceDirect
Asian Journal of Psychiatry
journal homepage: www.elsevier.com/locate/ajp
Discussion
Facing our future
Bruce H. Price a,b,c,*
a
Department of Neurology, McLean Hospital, United States
b
Massachusetts General Hospital, United States
c
Harvard Medical School, United States
A R T I C L E I N F O
Article history:
Received 28 August 2015
Accepted 28 August 2015
I welcome this thoughtful, forward-thinking article on three
counts. The authors represent the present and future of
neuropsychiatry. They highlight that a firm understanding of the
neural structures and core networks which mediate emotions,
behavior, and cognition is foundational. And they propose
solutions for psychiatry training programs.
Over the last several decades, outmoded views have gradually
given way to more modern neuroscientific thinking (Price et al.,
2000). Instead of ‘‘nature versus nurture,’’ we now understand that
although brain regions are not dedicated to a specific function,
there are core networks based on intrinsic mechanisms which are
influenced by extrinsic, environmental factors. Thus, it becomes a
magnificent interplay between nature and nurture, genetics and
epigenetics. The old notion of ‘‘mind over matter’’ has now shifted
given our knowledge that mental forces can transform brain
matter. For instance, cognitive behavioral therapy can change
brain patterns to the benefit of patients with obsessive–compul-
sive and depressive disorders (Yoshimura et al., 2014). Another
American adage ‘‘sticks and stones may break my bones but words
will never hurt me’’ has been replaced by our understanding that
childhood abuse, including bullying, as well as acute and chronic
stress may have a permanent impact upon brain organization and
behavior (Pitman et al., 2012). We are closing the gap between
psychiatry and neurology, joined by the shared foundation of basic
and clinical neuroscience. There is clearly ‘‘a psychiatry of
neurology’’ and ‘‘a neurology of psychiatry.’’ We should abandon
the term ‘‘organic brain syndrome’’ as a relic of history which has
separated neurology and psychiatry. This article serves as a clarion
call to close ranks in a more collaborative fashion.
* Correspondence to: Department of Neurology, McLean Hospital, Belmont, MA
02478, United States.
E-mail address: keshavanms@gmail.com
http://dx.doi.org/10.1016/j.ajp.2015.08.017
1876-2018/ 2015 Published by Elsevier B.V.
Further refinements based on the author’s recommendations
follow. Given the core network anatomic approach, psychiatrists
should become familiar with the interpretation of structural and
functional MRI scans. Mental status and cognitive examinations
should be anchored in neuroanatomy. Further focus on the
prediction, prevention, rehabilitation, and recovery of psychiatric
disorders should occur. Academic neuropsychology needs to help
us refine more precise brain–behavior relationships. Investigations
should also be fostered regarding pain and suffering. The autopsy
remains a central teaching and research tool in modern medicine.
In academic centers with brain banks, the procurement of brain
autopsies for current and future research purposes should be
encouraged (Schmitt et al., 2008).
Let me raise several cautions. We must avoid reductionism and
oversimplification, that ‘‘behind every crooked thought lies a
crooked molecule.’’ Addiction is a prime example. There is no quick
biological fix for such a complex problem. There is a core network
dysfunction but it must be understood in the broader context of
social determinants. The interplay is inseparable and we must not
remain aloof from environmental forces. In fact, we should join all
efforts to combat addiction. We need to further explore and exploit
the therapeutic relationships between doctors, patients, and
families. This need has never been more apparent despite the
current erosion of the allotted patient/doctor time where
education, trust, hope, faith, and optimism are nurtured. Psycho-
therapy remains critically important and research into it deserves
more support. This also means that our fields must interrelate
more and more with philosophy, ethics, law and the humanities.
As a practical suggestion, after a patient has been presented at
rounds, the following questions should be asked: What brain
circuit/symptom relationships have been disrupted? What do we
know that directly applies to the patient and what do we need to
know but do not? What research questions can be asked and
possibly answered to close this gap?
27
 B.H. Price / Asian Journal of Psychiatry 17 (2015) 128–129
Finally, we must be wary of overpromise in medicine. We have
made enormous gains in neuroscience, yet it is astonishing at times
how little we know about brain–behavior relationships. Humility
combined with passion, dedication, and creativity remains the
most adaptive approach.
This article calls for conceptual and institutional shifts in both
psychiatry, and, in my opinion, neurology, letting go of outmoded
ways while welcoming new, more biologically informed para-
digms and interventions. Scientific discovery and brain science
have never been more promising. The times are ripe for change.
The challenge for us is to muster our forces and introduce the
necessary changes by example (Cunningham et al., 2006; Perez
et al., 2015). Psychiatry and neurology should move forward
together. One of the many salutary effects may be that increasing
numbers of medical students will be drawn to our vibrant
disciplines, creating new leadership and more fundamental
knowledge.
28
129
References
Price, B.H., Adams, R.D., Coyle, J.T., 2000. Neurology and psychiatry: closing the great
divide. Neurology 54, 8–14.
Yoshimura, S., Okamoto, Y., Onoda, K., Matsunga, M., Okada, G., Kunisato, Y.,
Yoshino, A., Ueda, K., Susuki, S., Yamawaki, S., 2014. Cognitive behavioral
therapy for depression changes medial prefrontal and ventral anterior cingulate
cortex activity associated with self-referential processing. Soc. Cognit. Affect.
Neurosci. 9 (4), 487–498.
Pitman, R.K., Rasmusson, A.M., Koenen, K.C., Shin, L.M., Orr, S.P., Gilbertson, M.W.,
Milad, M.R., Liberzon, I., 2012. Biological studies of post-traumatic stress
disorder. Nat. Rev. Neurosci. 13, 769–787.
Schmitt, A., Parlapani, E., Bauer, M., Heinsen, H., Falkai, P., 2008. Is brain banking
of psychiatric cases valuable for neurobiological research? Clinics 63 (2),
255–266.
Cunningham, M.G., Goldstein, M., Katz, D., O’Neill, S.Q., Joseph, A.B., Price, B.H., 2006.
Coalescence of psychiatry, neurology, and neuropsychology. From theory to
practice. Harv. Rev. Psychiatry 127–140.
Perez, D., Murray, E.D., Price, B.H., 2015. Depression and psychosis in neurological
practice. In: Bradley, W.G., Daroff, R.B., Fenichel, G.M., Jankovic, J. (Eds.),
Neurology in Clinical Practice. 7th ed. Butterworth Heinemann.
 Asian Journal of Psychiatry 17 (2015) 130
Contents lists available at ScienceDirect
Asian Journal of Psychiatry
journal homepage: www.elsevier.com/locate/ajp
Discussion
The importance of teaching neuroscience to psychiatric residents in
the context of psychological formulations
Carl Salzman
Professor of Psychiatry, Harvard Medical School, United States
A R T I C L E I N F O
Article history:
Received 28 August 2015
Accepted 28 August 2015
Drs. Torous, Stern, Padmanabhan, Keshavan and Perez are to be
congratulated for defining and describing a psychiatric resident
training program to encourage neuroscience learning. As these
authors eloquently describe, specific knowledge of brain function
is beginning to clarify our understanding of some, if not many,
psychiatric disorders. The authors are careful to point out that our
expanding neuroscience information base has not yet yielded
reliable and always reproducible clinical treatment results, but the
emerging data are encouraging. As the authors indicate, we now
understand specific functions of many brain anatomical sites, their
inter-site circuitry, their genetic origin, as well as the micro-
circuitry that is necessary for the extraordinary communication
between neuronal pathways throughout the brain. The authors
then provide a clinical example of neuroscience teaching using a
clinical example: the neurological basis of symptoms of a
depressed patient and the application of this information to
suggest new and more specific therapeutic approaches.
I was particularly taken by the analogy of impaired brain
circuitry with an urban traffic jam that may have many causes:
dysfunctional traffic signals (circuit nodes), street and highway
construction (pathways), impaired road materials (neurotrans-
mitters), and planning (genes). Together, dysfunction in these
areas can bring traffic to a standstill, somewhat like some
psychiatric disorders. Other traffic problems may contribute to
broken restraints and traffic guidelines leading to wild and
disorganized driving and potential mayhem. But here is where
the analogy may become simplistic and potentially misleading, as
is, I believe, the forecast of neuroscience based treatment that will
finally bring about development of more effective psychiatric
treatments. Automobile traffic may be halted by many different
E-mail address: keshavanms@gmail.com.
http://dx.doi.org/10.1016/j.ajp.2015.08.016
1876-2018/ 2015 Published by Elsevier B.V.
dysfunctions of the transportation system, but the resulting
symptoms are the same: no traffic moves. Similarly, psychiatric
disorders may share a final symptomatic picture (e.g. psychosis,
depression, anxiety) but the root causes of the symptoms may be
many and varied. Not all psychiatric disorders are the result of the
same neurobiologic dysfunction. Medicine is filled with similar
heterogeneous disorders with similar symptoms: a fever or cough
or pain may have many different causes, but the patient’s
symptoms are similar. In psychiatry, we need to know more than
which brain function is aberrant in which neuropsychiatric system.
Psychiatric disorders are usually mixtures of psychological as well
as neurobiological disturbance. Automobile traffic dysfunction is a
symptom of heterogeneous disturbances, not an illness with a
single etiology. I am concerned that growing emphasis on the
neuroscience basis of psychiatric disorders is beginning to ignore
the personal, interpersonal, family, society context of the
symptoms. Not all unhappiness is depression, not all enthusiasm
is mania, not all worry is anxiety, not all memory dysfunction is
dementia or ADD. As suggested two articles recently published in
the NY Times in July 2015 (Richard Friedman; Mindy Fullilove), we
must continue to acknowledge that brain dysfunctions are a
critical component of mental disturbance, but not the only factors
that produce symptom formation.
What to do? I believe that this article points the way toward
future teaching of psychiatry, one that I shall call (for better or
worse), ‘‘enlightened neuroscience’’. As we learn about the brain,
we do not reject the 100 years of psychological observations and
clinical experience. Rather, we integrate our emerging neurosci-
ence knowledge with what we already know about human
development, behavior, emotion, cognition and relationships. As
the authors of this wonderful article suggest, neuroscience can
stimulate new forms of treatment, but also enhance our
understanding and application of current treatments such as the
various psychotherapies.
This marriage of neuroscience, psychology, and clinical wisdom
is truly exciting. I congratulate the authors and look forward to
putting some of their ideas into our own teaching programs.
29
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 Asian Journal of Psychiatry 17 (2015) 131–132

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Discussion

The relevance of translational neuroscience in psychiatry residency

training
Commentary on ‘‘Torous et al. A proposed solution to integrating
cognitive–affective neuroscience and neuropsychiatry in psychiatry
residency training: The time is now’’
Sri Mahavir Agarwal, Ganesan Venkatasubramanian *
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India

A R T I C L E I N F O

Article history:
Received 28 August 2015
Accepted 28 August 2015

Keywords:
Psychiatry
Training
Translational neuroscience
Brain stimulation

1. Commentary perception. The average resident in psychiatry is therefore less

In psychiatry, the critical influence of residency training in
shaping one’s outlook toward the specialty cannot be overstated. It
determines, to a large extent, conceptualization of mental
phenomena/related disorders as well as formulation of specific
treatment approaches. The psychiatry–neurology dualism that
pervades most residency programs across the world has had an
adverse impact on psychiatry training. This distinction between
specialties largely stemmed from the fact that the pathophysio-
logical processes that led to psychiatric symptoms were unknown
at that point in time making them ‘‘functional’’. However, passage of
time and lack of concerted attempts toward updating this
understanding has resulted in the hitherto unknown being
misunderstood as eternally unknowable or non-existent. This
has led to cementing of psychiatric disorders as disorders of the
‘‘mind’’, clearly distinct from disorders of the ‘‘brain’’; so much so
that several decades of dedicated and fruitful research into the
biological basis of symptoms has largely failed to change this
* Corresponding author at: Department of Psychiatry, National Institute of
Mental Health and Neurosciences (NIMHANS), Bangalore 560029, India.
E-mail address: venkat.nimhans@yahoo.com (G. Venkatasubramanian).
likely to explore brain based explanations of psychiatric symptoms
because they are prejudged to be functional. This is at odds with
the current level of knowledge where several concrete examples
exist neatly tying region or circuit level activity, or lack thereof, to
clinical symptoms. Hence, advances in understanding are slow to
permeate through an uninitiated audience; application of this
knowledge in routine patient care is slower still. On one hand, this
projects psychiatry as a branch not in tune with times, while on the
other it exposes it to attacks which question its very basis as a
medical branch since it appears not to be rooted firmly in biology.
It is in this context that the article by Tourus et al. in the current
issue assumes significance. The authors impress upon the reader
the need for psychiatric residency to be informed by cognitive–
affective neuroscience and neuropsychiatry. With regards to the
barriers that impede psychiatry residents from being trained
suitably in neurosciences and neuropsychiatry, the authors point
to the absence of suitable faculty as a core problem. This again, in
our opinion, is a manifestation of the mold psychiatry has cast itself
in over the last few decades. Absence of focus on neurosciences has
resulted in faculty who are themselves not suitably trained to
impart the necessary skills to residents, starting a vicious circle
that needs to be broken urgently. The inclusion of brain circuits and
anatomical regions related discussions in routine case discussion is

http://dx.doi.org/10.1016/j.ajp.2015.08.015
1876-2018/ 2015 Elsevier B.V. All rights reserved.

31
 132 S.M. Agarwal, G. Venkatasubramanian / Asian Journal of Psychiatry 17 (2015) 131–132
a novel idea with significant advantages. This approach introduces
the concept of neuroscience based causality as well as promotes
thinking toward targeted, logical, evidence based strategies that
reverse the identified neuropsychiatric deficit. Moreover, such an
approach brings the robustness of identifying anatomical and
functional neural correlates to the discussion which complements
the richness of personalized and phenomenology based approach
that is so unique to psychiatry. While similar views have been
expressed earlier (Benjamin, 2013; Coverdale et al., 2014), the
article’s merit lies in proposing a solution which is ready to work out
of the box and which merges seamlessly into the mores and routine
of clinical residency. For instance, the description of case study in the
article is illustrative of how useful such an approach can be toward
both increasing a resident’s understanding of brain processes behind
symptoms and facilitating a more informed approach to the
management of psychiatric disorders. Moreover, such a method
of discussion is likely to encourage residents to learn more about
how current modalities of treatment work and help them become
more receptive to the latest advances in neurotherapeutics. It will
also help them recognize and stay alert to new techniques in future
that may potentially improve symptoms.
The emergence of various invasive and non-invasive brain
stimulation modalities for treating psychiatric disorders over the
last few years highlights the challenge in front of us. Application of
these techniques assumes thorough understanding of the anatom-
ical and functional basis of effects produced and the brain circuits
or regions they act upon. Evidence for the efficacy of techniques
like transcranial magnetic stimulation (TMS) (Lefaucheur et al.,
2014) and transcranial direct current stimulation (tDCS) (Agarwal
et al., 2013; Tortella et al., 2015) in treating psychiatric disorders is
fast accumulating. Given the efficacy, safety profile and the interest
these techniques have generated in the scientific community, it is
likely that they will gradually become commonplace and a
psychiatrist will be expected to, at the very least, understand
how they work. The authors highlight this in their article and
sound a timely warning in saying: ‘‘If psychiatrists do not embrace
32
opportunities to become specialists in neuromodulation, the void
could be filled by other clinical experts in brain functioning.’’
Constant updating of ‘‘knowledge’’ and converting this into
‘‘wisdom’’ that facilitates application is a prerequisite for any
scientific field. It is therefore necessary for young psychiatrists to
learn to assimilate and apply the knowledge that progress in
translational neuroscience makes available to them. That is
unlikely to happen unless they are well trained in the nuts and
bolts of brain based approach to psychiatry. It is quite possible that
in the coming years our understanding might improve further
paving the way for identification of psychiatric disease processes at
the level of individual neurons and synapses. If psychiatrists are to
stay relevant in this ever changing scheme of translational
neuroscience, the time to overhaul our training is, as the article
by Tourus et al. puts it, right now!
References
Agarwal, S.M., Shivakumar, V., Bose, A., Subramaniam, A., Nawani, H., Chhabra, H.,
Kalmady, S.V., Narayanaswamy, J.C., Venkatasubramanian, G., 2013. Transcra-
nial direct current stimulation in schizophrenia. Clin. Psychopharmacol. Neu-
rosci. 11, 118–125.
Benjamin, S., 2013. Educating psychiatry residents in neuropsychiatry and neuro-
science. Int. Rev. Psychiatry 25, 265–275.
Coverdale, J., Balon, R., Beresin, E.V., Louie, A.K., Tait, G.R., Goldsmith, M., Roberts,
L.W., 2014. Teaching clinical neuroscience to psychiatry residents: model
curricula. Acad. Psychiatry 38, 111–115.
Lefaucheur, J.P., Andre-Obadia, N., Antal, A., Ayache, S.S., Baeken, C., Benninger, D.H.,
Cantello, R.M., Cincotta, M., de Carvalho, M., De Ridder, D., Devanne, H., Di
Lazzaro, V., Filipovic, S.R., Hummel, F.C., Jaaskelainen, S.K., Kimiskidis, V.K.,
Koch, G., Langguth, B., Nyffeler, T., Oliviero, A., Padberg, F., Poulet, E., Rossi, S.,
Rossini, P.M., Rothwell, J.C., Schonfeldt-Lecuona, C., Siebner, H.R., Slotema, C.W.,
Stagg, C.J., Valls-Sole, J., Ziemann, U., Paulus, W., Garcia-Larrea, L., 2014. Evi-
dence-based guidelines on the therapeutic use of repetitive transcranial mag-
netic stimulation (rTMS). Clin. Neurophysiol. 125, 2150–2206.
Tortella, G., Casati, R., Aparicio, L.V., Mantovani, A., Senco, N., D’Urso, G.,
Brunelin, J., Guarienti, F., Selingardi, P.M., Muszkat, D., Junior Bde, S.,
Valiengo, L., Moffa, A.H., Simis, M., Borrione, L., Brunoni, A.R., 2015.
Transcranial direct current stimulation in psychiatric disorders. World J.
Psychiatry 5, 88–102.
 Asian Journal of Psychiatry 17 (2015) 140–141
Contents lists available at ScienceDirect
Asian Journal of Psychiatry
journal homepage: www.elsevier.com/locate/ajp
Discussion
Toward the era of transformational neuropsychiatry
Henry A. Nasrallah *
Department of Neurology and Psychiatry, Saint Louis University School of Medicine, 1438 South Grand Boulevard, St. Louis, MO 63104, United States
A R T I C L E I N F O
Article history:
Received 27 August 2015
Accepted 27 August 2015
The time has come for psychiatry to reclaim its neurological
roots and to regain its neuroscientific identity. Prior to the Freudian
theory that dominated psychiatry for many decades in the 20th
century, psychiatry and neurology were integrated in one
department with combined training in neuropsychiatry. It is
ironic that Freud, who is a neurologist, by inventing and
propagating a theoretical psychoanalytic model for mental
functions, contributed to the rupture of the productive unity of
neurology and psychiatry. By the 1950s, psychiatry had become
de-medicalized and de-neurologized due to the abstract, non-
evidence-based psychoanalytic constructs, along with its entirely
non-medical jargon. No wonder neurologists decided to break up
from psychiatry to form their own associations and to establish
separate journals. This estrangement exacerbated the fallacious
artificial dichotomization of brain and mind, endowing neurology
with a robust medical identity and casting psychiatry as just a
philosophy of behavior with no clear medical identity and no
recognizable physical findings or neurological basis for its
disorder.
Alas, both specialties suffered from the rupture of their long-
standing union: psychiatry became brainless and neurology
became mindless. With rare exceptions, across all medical schools,
the departments of neurology and psychiatry currently exist and
function as independent silos, with rare academic interactions. The
separate training of psychiatrists and neurologists institutional-
ized the faulty brain–mind dualism: neurological disorders were
considered ‘‘organic’’ with tangible sensory/motor impairments,
while psychiatric disorders were erroneously conceptualized as
‘‘functional’’, i.e. phenotypic alterations of mood, thoughts and
behavior, with no ‘‘tangible’’ neurological localizing signs. Despite
the tremendous advances in neuropsychiatry and behavioral
* Tel.: +1 314 977 4824.
E-mail address: hnasral@SLU.edu
http://dx.doi.org/10.1016/j.ajp.2015.08.010
1876-2018/ 2015 Elsevier B.V. All rights reserved.
neurology, this disastrous myth and misconception about psychi-
atry persists in the public arena, and has contributed to the unfair
stigma attached to mental illness and to the completely unjustified
disparagement of psychiatry.
The article by Torous et al. in this issue is an enlightened call to
action to correct and reverse the longstanding ‘‘anosognosia’’ of the
neurological correlates of psychiatric symptoms in psychiatric
training, which perpetuates brainless psychiatry. It is true that the
psychopharmacology revolution has given birth to biological
psychiatry and contributed to the wilting of psychoanalysis
(although psychodynamics remain a useful clinical psychothera-
peutic model). However, biological psychiatry needs to transcend
pharmacology and transform itself into a full-fledged clinical
neuroscience. One of the impediments is the inertia of the current
diagnostic system that focuses on arbitrary arrays of clinical
symptoms that overlook the rapid advances in how psychiatric
symptoms can be generated from disturbed neural circuits,
preventing trainees from evolving into neuropsychiatrists.
The absurdly short requirement of two months of neurology
in the four years of psychiatric training is rendered less useful by
failing to incorporate the psychiatric implications of every
neurological lesion during the rotation. Currently, neurology
supervisors are generally as naive about detecting psychopa-
thology as psychiatry supervisors are in identifying neurological
pathology.
To transform psychiatry into a clinical neuroscience specialty,
the neurology rotation must expand into a full year with intensive
neuropsychiatric training. This is a tall order because of the serious
current dearth of neuropsychiatrists or behavioral neurologists to
serve as supervisors.
Having served for several years on the ACGME committee in
charge of designing the didactic curriculum and clinical rotations
of psychiatric trainees (Residency Review Committee or RRC), as
well as site visiting and accrediting training programs in the U.S., I
am cognizant of the Herculean challenge of modifying the training
33
 H.A. Nasrallah / Asian Journal of Psychiatry 17 (2015) 140–141
requirements in psychiatry. There has to be a strong support and
consensus among RRC committees for changes to be drafted and
distributed to multiple constituencies for feedback, concurrence or
rejection.
The field of psychiatry currently lacks a critical mass of
neuropsychiatrists and many academic departments do not even
have a single qualified neuropsychiatrist. Thus, it will be difficult to
adopt and implement the commendable model proposed by Torous
et al. The most practical strategy for psychiatry to recapture its
neurological foundations is to establish neuropsychiatry fellowships
in as many departments as possible. This will gradually produce the
34
141
next generation of neurologically minded psychiatric supervisors
who will expedite the neuroscientification of psychiatry.
Finally, better medical care can be provided to patients with brain
disorders if the neurology trainees receive adequate psychiatric
supervision to consistently recognize the mood, thought, cognitive
and behavioral consequences of various neurological disorders.
Behavioral Neurology fellowships should also be developed and
emphasized. Perhaps the re-integration of psychiatry and neurology
will be more likely when disorders affecting both the brain and its
mind are routinely assessed and managed by members of both
specialties. Our neuropsychiatric patients deserve no less.
 Asian Journal of Psychiatry 17 (2015) 142–143

Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Commentary

Neuropsychiatry: More than the sum of its parts?

John Moriarty a, Anthony S. David b,*
a
South London & Maudsley NHS Foundation Trust, London SE5 8AZ, UK
b
Institute of Psychiatry, Psychology & Neuroscience, King’s College London, PO Box 68, London SE5 8AF, UK

A R T I C L E I N F O

Article history:
Received 20 July 2015
Accepted 27 August 2015

Thank you for asking us to comment on the article by Torous
and colleagues (this issue): ‘‘A Proposed Solution to Integrating
Cognitive-Affective Neuroscience and Neuropsychiatry in Psychi-
atry Residency Training: The Time Is Now’’. We do so from the
perspective of clinical academics who have worked predominantly
in the UK and who have a keen interest in the training of
psychiatrists in general and in the field of neuropsychiatry in
particular. There have been many recent articles which begin by
lamenting the divide which exists between psychiatry and
neurology (White et al., 2012). Many of these suggest, like this
one, that the division is based on clinicians within psychiatry
treating those patients with diseases which have no obvious
neurology while those within neurology treat those patients that
do. However, this may be a bit simplistic and it is likely that the
two disciplines have evolved and diverged initially because of a
primary interest in different disorders and this has become
reinforced by different languages and treatment interests. The
influence of psychology, psychoanalysis and systems thinking has
been much more profound in psychiatry than in neurology.
There are at least two forces which may additionally contribute
to the call for psychiatry to embrace neurological thinking more –
one is the perceived growth in our understanding of the basic
neuroscience of psychiatric disorders (which is the one made most
of by Torous and co-authors) and the other is the fear (if that is a
fair description of it) that the development and promotion of
psychological treatment models may marginalise medical psy-
chiatrists within their own discipline as non-medically trained
therapists may lead the way in the development of acceptable and
effective treatments for many mental illnesses. This has recently
* Corresponding author.
E-mail addresses: john.moriarty@slam.nhs.uk (J. Moriarty),
anthony.david@kcl.ac.uk (A.S. David).
provoked debate in the UK (Reilly, 2015; Fitzgerald, 2015). There is
also a political context that the medical or purely biological
approach to human cognition, affect, perception, etc., has been
seen as ‘reductionist’ and limiting, by a range of commentators
outside medicine – including those few who identify themselves
ideologically with ‘antipsychiatry’, which has been difficult for
psychiatrists to endure.
The definition in the target article of ‘‘psychiatric mental
disorders being largely defined by the presence of symptoms in the
absence of any grossly visible pathology’’ does ‘work’ for day to day
practice. What the definition lacks is the more positive aspects that
make psychiatry somewhat unique. According to McHugh and
Slavney (1983):
In the everyday world of the clinic, psychiatrists are distin-
guished from other medical specialists not because they are
concerned with ‘‘minds’’ rather than ‘‘bodies,’’ but because they
focus on complaints appearing in people’s thoughts, percep-
tions, moods, and behaviours rather than their skins, bones,
muscles and viscera . . .. Psychiatric concerns thus extend from
the ultrastructure of the body to the relationship of groups of
minds within a social context.p4
The most important consideration in our view, on reading the
example given of the cognitive neuroscience formulation of the
case of depression, would be to ask: what the effect of such a
formulation might be on, (a) doctors in training in psychiatry, (b)
patients and (c) other professionals and non-psychiatric doctors? It
might well appeal to many and if it caught on it would certainly
change the perception of the preoccupations of the typical
psychiatrist. However, we fear it might alienate even more. We
suspect many doctors in training are drawn to psychiatry because
of a genuine interest in the mentally ill and their experiences but
often a motivation to help in ways which go beyond the model of
diagnosis and biological treatment. To them, and to many patients

http://dx.doi.org/10.1016/j.ajp.2015.08.012
1876-2018/ 2015 Elsevier B.V. All rights reserved.

35
 J. Moriarty, A.S. David / Asian Journal of Psychiatry 17 (2015) 142–143
or non-medics involved in the assessment and care of people with
mental illness, the example of the formulation given might be
experienced as almost a caricature of a reductionist interpretation
of research findings which largely report between group differ-
ences in biomarkers or imaging markers and cannot be applied
sensibly in an individual case and at worst, reduce the range and
complexity of individual patients’ experiences to some dysregula-
tion of neural circuits.
We have seen this historically in terms of the upregulation and
downregulation of transmitter systems and the modest global
structural differences between the brains of groups with and
without diagnosis of mental illness. We certainly now have a more
complex and detailed understanding of some of these systems but of
course such models remain rather crude. Such descriptions (not
enough serotonin, too much dopamine; functional connectivity;
fronto-limbic dysregulation) are in many ways almost as meta-
phorical as talking about traffic congestion in relation to the brain.
Turning to the UK training approach – certainly neuroscience
remains a part of the curriculum and is tested in mandatory
examinations. There is no mandatory overlap of training of
neurologists and psychiatrists, unlike in many European countries
where a shared curriculum is the norm. In terms of competencies a
good deal of emphasis is put on the systematic assessment of cases
using standard diagnostic processes and categories and there is a
requirement to have at least basic competencies in pharmacologi-
cal and psychological (both cognitive and psychodynamic usually)
treatment strategies.
Neuropsychiatry as such is not a formally recognised subspe-
cialty within the UK and there is no clear shared understanding of
its borders. It tends to include that part of consultation-liaison
psychiatry which works with neurology but also encompasses
aspects of neurodegeneration, neurorehabilitation and develop-
mental psychiatry. Each of these areas would have their own
curricula, which could be stated in terms of both knowledge and
skills. There is however a fairly persistent push to recognise
neuropsychiatry or the neuropsychiatry perspective in current
clinical psychiatric practice.
Returning to Torous et al.’s ‘formulation’. We admire this and
would like to move towards a more general aim of getting all
trainees to practice formulating a case using sophisticated
biological or behavioural neurological language and concepts. It
36
143
would certainly be nice if psychiatrists were as knowledgeable and
fluent in these areas as they can be in terms of speculative
psychological, pharmacological or psychodynamic aspects of
formulation. One of the unique skills of the practicing psychiatrist
and neuropsychiatrist is understanding the limits of scientific
knowledge and accepting that, even if in the future when some of
the findings from genetics and neuroimaging, etc., go beyond
group descriptions but are actually applicable at the individual
level, as envisaged by the recent RDoC NIMH initiative, there will
be instances where biology does not help us understand the
person’s predicament and that we have to then appreciate the
power of beliefs, desires, and the influence of society and culture
on people’s behaviour and mental life.
We would end by quoting the views of the doyen of UK
neuropsychiatry, Alwyn Lishman summarised in the introduction
to the 4th edition of his ‘Organic Psychiatry’ (David et al., 2009):
‘Neuropsychiatry ‘‘must capitalize on all that psychiatry has to
offer’’ including psychodynamic, social and cultural aspects,
and . . . ‘‘neuropsychiatric practice requires a widening not a
narrowing of psychiatric skills and interests’’’. P3
Acknowledgements
The authors are supported by the UK National Institute of
Health Research (NIHR) Biomedical Research Centre at the South
London & Maudsley NHS Foundation Trust and Institute of
Psychiatry, Psychology & Neuroscience, King’s College London.
References
David, A.S., Fleminger, S., Kopelman, M., Lovestone, S., Mellers, J. (Eds.), 2009.
Lishman’s Organic Psychiatry: A Textbook of Neuropsychiatry. Revised 4th
ed. Wiley-Blackwell.
Fitzgerald, M., 2015. Do psychiatry and neurology need a close partnership or
a merger? Br. J. Psychiatry Bull. 39, 105–107, http://dx.doi.org/10.1192/
pb.bp.113.046227.
McHugh, P.R., Slavney, P.R., 1983. The Perspectives of Psychiatry. Johns Hopkins
University Press.
Reilly, T.J., 2015. The neurology-psychiatry divide: a thought experiment. Br.
J. Psychiatry Bull. 39, 134–135, http://dx.doi.org/10.1192/pb.bp.113.045740.
White, P.D., Rickards, H., Zeman, A.Z., 2012. Time to end the distinction between
mental and neurological illnesses. Br. Med. J. 344, e3454.
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