Background: Neuropsychiatry and behavioural neurology are interdisciplinary fields that bridge psychiatry and neurology. However, there is no consensus about core curriculum components for training in these areas. This scoping review examines existing syllabuses to identify common course components and core themes in neuropsychiatry and behavioural neurology education. Methods: A scoping review of both peer-reviewed and grey literature was conducted to identify unique syllabuses for neuropsychiatry and behavioural neurology courses which were analysed to determine the scope of covered disorders, conceptual approaches to training, assessment and intervention components, clinical experience requirements. Results: A total of 23 unique syllabuses were identified including syllabuses from Australia, Argentina, Chile, Mexico, New Zealand, South Africa, USA, UK, and one explicitly international in scope. The analysis revealed comprehensive coverage of major neuropsychiatric conditions. Course content extended beyond the co-presentation of psychiatric and neurological disorders to include functional, behavioural, and cognitively defined disorders. Training in neuropsychiatry and behavioural neurology encompassed fundamental issues in mind and brain medicine, neuropsychology, philosophy, ethics, and social sciences. Assessment and intervention components emphasized clinical skills and knowledge relevant to both mental health and neurological services, with a particular focus on case management within social and institutional contexts. Conclusions: Neuropsychiatry and behavioural neurology training integrates a broad spectrum of knowledge and skills, is aimed at a range of professionals, and is delivered as both specialist training and as embedded components within core training. ### Competing Interest Statement VB is an unpaid member of the board of directors of the British Neuropsychiatry Association, a registered charity that runs continuous professional training and academic conferences. EJ is an unpaid coopted member of the Royal College of Psychiatrists Faculty of Neuropsychiatry Executive Committee and Chair of the Sub-Specialty Advisory Committee for education and training. SB is a board director of the American Board of Psychiatry and Neurology. All other authors have no interests to declare. ### Funding Statement This study did not receive any funding ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes This is a scoping review and so all data is referenced in the manuscript

Behavioral neurology & neuropsychiatry (BNNP) is a field that seeks to understand brain-behavior relationships, including fundamental brain organization principles and the many ways that brain structures and connectivity can be disrupted, leading to abnormalities of behavior, cognition, emotion, perception, and social cognition. In North America, BNNP has existed as an integrated subspecialty through the United Council for Neurologic Subspecialties since 2006. Nonetheless, the number of behavioral neurologists across academic medical centers and community settings is not keeping pace with increasing clinical and research demand. In this commentary, we provide a brief history of BNNP followed by an outline of the current challenges and opportunities for BNNP from the behavioral neurologist's perspective across clinical, research, and educational spheres. We provide a practical guide for promoting BNNP and addressing the shortage of behavioral neurologists to facilitate the continued growth and development of the subspecialty. We also urge a greater commitment to recruit trainees from diverse backgrounds so as to dismantle persistent obstacles that hinder inclusivity in BNNP-efforts that will further enhance the growth and impact of the subspecialty. With rapidly expanding diagnostic and therapeutic approaches across a range of conditions at the intersection of neurology and psychiatry, BNNP is well positioned to attract new trainees and expand its reach across clinical, research, and educational activities.

In the early 20th century, neurology training included more experience in psychiatry, and psychiatry training included more training in neurology than what is currently required. After World War I, the increased need for differential diagnosis of what might now be called functional neurological disorders resulted in the military encouraging combined residency training in neurology and psychiatry and the promulgation of the term "neuropsychiatry" for this specialty. Thirty-six percent of physicians certified by the American Board of Psychiatry and Neurology in its first decade (1935-1945) held certification in both neurology and psychiatry. However, the term neuropsychiatry gradually became used interchangeably with general psychiatry-to distinguish it from psychoanalysis-and lost its specificity. It is widely held that the popularity of psychoanalysis resulted in psychiatrists perceiving less need for neurological knowledge, and inclusion of neurology content in psychiatry training decreased. Dual residency training programs in neurology and psychiatry began to increase in popularity again in the 1980s as advances in neuroscience, neuroimaging, and pharmacology, paired with the growth of behavioral neurology, laid the foundation for meaningful practice of neuropsychiatry. The author surveyed 207 physicians who graduated from both a neurology and psychiatry residency and 18 current trainees in combined neuropsychiatry residency programs to collect information on their current practice, academic activity, and opinions about their training. The response rate was 64%. Respondents' attitudes toward the value of their dual neurology and psychiatry training were overwhelmingly positive. Reasons for the lack of growth of combined residency programs in neurology and psychiatry are examined.

Back to table of contents Previous article Next article REVIEWFull AccessGuideline Watch: Practice Guideline for the Treatment of Patients With Borderline Personality DisorderJohn M. Oldham, M.D., M.S.John M. Oldham, M.D., M.S.Published Online:1 Jul 2005https://doi.org/10.1176/foc.3.3.396AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Since the 2001 publication of APA's Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (1), more studies have been published on borderline personality disorder (BPD) than on any other personality disorder (2, 3). New analyses of the validity of the DSM-IV-TR criteria–defined construct of BPD have been published, new data on the prevalence of BPD are available, risk factors for and biological characteristics of BPD are being elucidated, and new studies on the treatment of BPD have been carried out. This guideline watch highlights the most important of these developments.Definition, diagnostic stability, and longitudinal courseDefinitionWith an eye toward DSM-V, careful examination of Axis II is occurring. This has, in part, included comparing the relative merits of categorical systems such as DSM-IV-TR and dimensional systems such as the five-factor model (4). This debate is as yet unresolved. However, recent studies have analyzed the nine DSM-IV criteria that define BPD and have concluded that, as defined, BPD appears to reflect a statistically coherent construct (5, 6). Utilization of a polythetic system requiring five out of nine criteria to make a categorical BPD diagnosis inevitably results in extensive heterogeneity within and between BPD populations being treated or studied. Increased attention is being focused on how to set the appropriate diagnostic "cutoff point" (i.e., the minimum number of criteria required to make the diagnosis). Also under discussion is whether some core criteria should be essential or whether all criteria should be weighted equally in establishing a diagnosis. New data also emphasize the importance of evaluating the degree of functional impairment in patients with BPD (7). A dimensional approach can be used to measure overall levels of dysfunction (8). Alternatively, the DSM criteria can be assessed in a dimensional fashion to capture functional impairment (9). However, even with proposed dimensional approaches, a discrete diagnostic threshold would need to be established in terms of illness severity and need for treatment (10).A number of recent studies have examined the boundaries between BPD and selected Axis I conditions. Since some patients with BPD may benefit from mood-stabilizing medications, the overlap between BPD and bipolar II disorder has been of particular interest (11–13). Although some individuals with BPD will also have a co-occurring bipolar disorder, the majority of the evidence to date supports BPD as an independent diagnosis rather than an attenuated form of a mood disorder (14–16). Similarly, though patients with BPD frequently have a history of trauma, the diagnosis is not considered a variant of posttraumatic stress disorder (PTSD) (17, 18). Of continuing interest is the identification of early precursors of BPD, such as a possible association between a history of childhood attention-deficit/hyperactivity disorder (ADHD) symptoms and diagnosis of BPD in adulthood (19).Diagnostic stability and longitudinal courseNew prospective longitudinal studies evaluating the long-term stability of BPD have been published. Results of the NIMH Collaborative Longitudinal Personality Disorders Study indicate that at 2 years after BPD diagnosis, only 44% of the patients retain the diagnosis (20). The McLean Hospital group has reported a 6-year follow-up of borderline patients, in which 74% of the patients met criteria for remission over the entire follow-up period (21). Longer term results have been published by Canadian researchers, indicating that only 8% of the total borderline patient group still met diagnostic criteria at 27-year follow-up (22, 23). High rates of remission are speculated to relate to a number of factors, such as treatment effectiveness and/or fluctuating severity of comorbid Axis I conditions. BPD has been shown to be significantly associated with major depressive disorder (MDD) and PTSD longitudinally (24). Somewhat counterintuitively, however, when BPD and MDD were followed over time, improvement in MDD was not followed by improvement in BPD; instead, improvement in MDD was more often predicted by prior improvement in BPD (25). Thus, the primary determinants of change in patients with BPD may not be related to comorbid Axis I psychopathology (26). Other suggested contributions to high rates of remission of BPD over time include diminished impulsivity with increased age (27), social learning, and stress-reducing life adjustments such as avoidance of interpersonal intimacy (22). It should be noted that the concept of remission of BPD reflects dropping below the DSM-IV-TR threshold on the continuum of criteria defining the disorder, yet significant problems relating to the personality structure and organization can continue even if the diagnostic threshold has not been met.Epidemiology, biology, and etiologyTo date, few population-based studies of personality disorders have been carried out. Torgersen (28) tabulated the results of eight epidemiological studies, including the large Norwegian study done by his own group; the mean prevalence of BPD across all studies was 1.2%. In Torgersen et al.'s study of 2,053 individuals in Norway, BPD was found to be equally prevalent among males and females (29). Although it is widely perceived that treatment populations of patients with BPD consist predominantly of females, published studies are in fact contradictory on this point (30). Prevalence of BPD in treatment populations remains much higher than in the general population, and a recent study of a primary care population reported BPD to be fourfold higher than in the general population (31).New studies are examining the multiple etiologies of BPD, based on the clear relevance of genetic, neurobiological, and psychosocial factors (32, 33). Although the magnitude of the heritability of BPD is thought to be significant (34), genetic risk factors specific to BPD have not been identified. One promising approach may be the study of underlying traits, such as novelty seeking (35) or impulsivity (36). Among the environmental contributions to the etiology of BPD, the role of childhood abuse remains prominent (37), particularly severe abuse (38) and sustained abuse (39).Deficits in cognitive functioning, such as decision making (40), conflict resolution (41), and "effortful control" (41, 42), are being reported. These deficits are thought to be mediated in the frontal lobe, although not all studies have found frontal lobe impairment in cognitive functioning (43). A number of studies have suggested reduced central nervous system serotonin levels in borderline and other patients who demonstrate impulsive-aggressive behavior, but such behavioral disinhibition may reflect dysfunction in multiple monoaminergic systems and may not be specific to BPD (44).Brain imaging studies of patients with BPD suggest irregularities in both structure and function (44–46). Limbic studies have found reduced volume in the amygdala and hippocampus (47, 48), altered amygdala activation (49, 50), and hippocampal hypometabolism (51). Frontal lobe studies suggest dysfunction of the dorsolateral and medial prefrontal cortex in connection with memories of abandonment (52), of the medial orbital frontal cortex in connection with diminished regulation of impulsive behavior (53), and of the prefrontal cortex under resting conditions (51). In addition, decreased binding of a serotonin precursor has been reported in the medial prefrontal cortex and anterior cingulate cortex in patients with BPD (54). Taken together, these studies suggest abnormalities in prefrontal, corticostriatal, and limbic networks perhaps related to lowered serotonin neurotransmission and behavioral disinhibition (55). Although findings from brain imaging studies are "not ready for prime time" to guide treatment planning for patients with BPD, these techniques may well have relevance in the future for individualized prediction of treatment outcome (46).TreatmentEvidence and opinion continue to support the recommendation of the 2001 guideline that psychotherapy represents the primary, or core, treatment for this disorder and that adjunctive, symptom-targeted pharmacotherapy can be helpful. For personality disorders in general, studies of psychotherapy report its effectiveness (56, 57). Persuasive data from randomized controlled trials (RCTs) of BPD suggest that more than one type of psychotherapy is effective, and additional studies are under way. Dialectical behavior therapy (DBT) has been shown in an RCT to be effective for borderline symptoms in patients with comorbid BPD and substance abuse, though no improvement was shown for the substance abuse itself (58). In another RCT, in patients with BPD and comorbid opiate use, DBT was compared with comprehensive validation therapy (CVT). Both types of treatment were effective. There were fewer dropouts in the CVT group, and the maintenance of gains was greater in the DBT group (59). Studies of DBT by diverse research groups are being published, including a study of female veterans with BPD that compared 6 months of DBT with treatment as usual and reported improvement in the DBT group compared with the control group (60). A study from the Netherlands that compared 12 months of outpatient DBT with treatment as usual showed better treatment retention, reduced self-mutilation, and reduced self-damaging impulsivity in the DBT group (61). An intriguing inpatient RCT that compared 3 months of inpatient DBT with treatment as usual in the community demonstrated significant gains in the DBT group compared with the control group, including reduced self-injury, dissociation, depression, and anxiety and improved interpersonal functioning and social adjustment (62).Promising new psychotherapies for BPD are being piloted in open trials. These include interpersonal therapy (63); cognitive therapy (64); cognitive analytic therapy (CAT), a fusion of cognitive and psychodynamic therapy (65, 66); and systems training for emotional predictability and problem solving (STEPPS), a cognitive-behavioral systems–based form of time-limited group treatment for patients with BPD (67). In an ongoing study comparing transference-focused psychotherapy (TFP) with DBT and supportive psychotherapy, TFP appeared to be beneficial (68), although the comparative analysis of the other two treatments has yet to be completed. The efficacy of TFP is also being assessed in a large multicenter study comparing TFP with schema therapy for patients with BPD (69).A number of recent studies have focused on the benefits of pharmacotherapy for patients with BPD. An RCT that compared a group treated with fluvoxamine and a control group showed robust, long-lasting reduction in rapid mood shifts only in the treatment group (70). Another RCT that compared olanzapine with placebo in borderline patients showed improvement in global functioning in the medication group compared with the placebo group (71). Another RCT studied three groups of BPD patients—one group receiving fluoxetine, a second group receiving olanzapine, and a third receiving a combination of both; all three interventions led to substantial improvement, though a significantly greater rate of improvement in clinician-rated depression and impulsive aggression was seen in the olanzapine and the combination groups (72). Also, double-blind placebo-controlled trials demonstrated benefit of divalproex sodium for patients with BPD (73) and for patients with Cluster B personality disorders who demonstrate impulsive aggression (74). A number of case reports and noncontrolled medication trials have also been published (75–81).All in all, the database is growing, and further evidence is accumulating that BPD is a condition that can be effectively treated by a combination of psychotherapy and symptom-targeted pharmacotherapy. Further research is needed to validate the approach taken by the 2001 guideline to select one of three different medication algorithms on the basis of the predominance of cognitive-perceptual symptoms, affective dysregulation symptoms, or impulse dyscontrol symptoms. One retrospective report from the NIMH Collaborative Longitudinal Personality Disorders Study produced mixed results on this question (82).The American Psychiatric Association's (APA's) practice guidelines are developed by expert work groups using an explicit methodology that includes rigorous review of available evidence, broad peer review of iterative drafts, and formal approval by the APA Assembly and Board of Trustees. APA practice guidelines are intended to assist psychiatrists in clinical decision making. They are not intended to be a standard of care. The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. Guideline watches summarize significant developments in practice that have occured since publication of an APA practice guideline. 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The case of JP, reported by Ackerly and Benton in 1948 with a detailed follow-up by Ackerly in 1964, stands as the index case of developmental prefrontal damage and its impact on social adaptation. Although the 1948 case report included findings from a 1933 pneumoencephalogram and exploratory craniotomy, a definitive cause was never established for JP's prefrontal damage. Etiologies were never determined for the left-sided seizures that occurred when JP was age four, nor for the progressive anterograde amnesia that JP developed in middle age. Given Ackerly's thoroughness and long-term follow-up of his patient, it was hoped that a brain cutting would have been done, though no report of a post-mortem examination was published. The lead author of this paper (SB) set out to discover what had happened to JP after Ackerly's 1964 report and whether a brain cutting had in fact occurred. Using a variety of investigative approaches, it was discovered that a post-mortem brain examination had taken place. Those present at the brain cutting were identified, and the still-living witnesses to the brain cutting were interviewed. Previously unpublished, relevant materials were uncovered from archival sources. A film of the brain cutting, as well as photos, were located. A film of Ackerly interviewing JP prior to JP's death at age sixty-four also was found. The authors studied autopsy findings in the newly discovered video and still images. These findings were judged consistent with massive perinatal hemorrhagic damage to both frontal lobes. JP's left-sided seizures were likely due to activation of a focus from his congenital brain damage. The anterograde amnesia that was documented when JP was twenty-five and that was noted to worsen when he was forty-nine remains unexplained but may have been related to slowly progressive hydrocephalus. This paper expands what is known about the case of JP, making it the only report of a person with congenital frontal injury followed for their entire life including post-mortem brain examination.

(Reprinted with permission from The American Journal of Psychiatry 2020; 177:868-872).

Linda Mah Joan Swearer Catherine A Phillips Sheldon Benjamin 1Rotman Research Institute, Baycrest, Toronto, Canada; 2Department of Psychiatry, Baycrest Health Sciences, Toronto, Canada; 3Department of Psychiatry, Division of Geriatric Psychiatry, University of Toronto, Toronto, Canada; 4Department of Neurology, University of Massachusetts Medical School, Worcester, MA, USA; 5Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA Introduction: Surgical treatment for patients with epilepsy who do not respond to antiepileptic medication can lead to changes in behavior, including new onset of neuropsychiatric symptoms such as depression and anxiety. In other cases, neuropsychiatric symptoms present before surgery may be alleviated. Because application of diagnostic criteria for primary psychiatric disorders may not be valid in assessing behavior in epilepsy populations, we sought to determine the feasibility of measuring behaviors associated with frontalsubcortical dysfunction using the Frontal Systems Behavior Scale (FrSBe) in patients who had received surgical intervention for medically refractory epilepsy. Materials and methods: Twenty-three patients who had previously undergone epilepsy surgery and their family member informants completed the FrSBe. The FrSBe includes separate forms for patients and informants to rate symptoms associated with three frontal lobe syndromes – executive dysfunction, disinhibition, and apathy – prior to and following a neurological condition. Patients and informants were asked to rate frontal lobe behaviors before and after epilepsy surgery using the FrSBe. Results: Informants rated patients as showing a significantly greater reduction in apathy on the FrSBe compared to either disinhibition or executive dysfunction subscales. A trend in reduction of apathy following right hemisphere resection was found. Conclusions: Patients who have undergone epilepsy surgery show a reduction in apathy but it is unclear whether this behavioral change is directly related to the surgical intervention. We suggest that these preliminary findings support the utility of implementing dimensional scales such as the FrSBe to study behavioral changes following epilepsy surgery.

INTRODUCTION:Surgical treatment for patients with epilepsy who do not respond to antiepileptic medication can lead to changes in behavior, including new onset of neuropsychiatric symptoms such as depression and anxiety. In other cases, neuropsychiatric symptoms present before surgery may be alleviated. Because application of diagnostic criteria for primary psychiatric disorders may not be valid in assessing behavior in epilepsy populations, we sought to determine the feasibility of measuring behaviors associated with frontal-subcortical dysfunction using the Frontal Systems Behavior Scale (FrSBe) in patients who had received surgical intervention for medically refractory epilepsy.MATERIALS AND METHODS:Twenty-three patients who had previously undergone epilepsy surgery and their family member informants completed the FrSBe. The FrSBe includes separate forms for patients and informants to rate symptoms associated with three frontal lobe syndromes - executive dysfunction, disinhibition, and apathy - prior to and following a neurological condition. Patients and informants were asked to rate frontal lobe behaviors before and after epilepsy surgery using the FrSBe.RESULTS:Informants rated patients as showing a significantly greater reduction in apathy on the FrSBe compared to either disinhibition or executive dysfunction subscales. A trend in reduction of apathy following right hemisphere resection was found.CONCLUSIONS:Patients who have undergone epilepsy surgery show a reduction in apathy but it is unclear whether this behavioral change is directly related to the surgical intervention. We suggest that these preliminary findings support the utility of implementing dimensional scales such as the FrSBe to study behavioral changes following epilepsy surgery.

The neuropsychiatric examination includes standard neurological and cognitive examination techniques with several additional observations and tasks designed to capture abnormalities common among patients with neuropsychiatric disorders or neurocognitive complaints. Although useful as a screening tool, a single standardized rating scale such as the Mini Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA) is insufficient to establish a neuropsychiatric diagnosis. Extra attention is paid to findings commonly seen in the setting of psychiatric disorders, dementias, movement disorders, or dysfunction of cortical or subcortical structures. Dysmorphic features, dermatologic findings, neurodevelopmental signs, signs of embellishment, and expanded neurocognitive testing are included. The neuropsychiatric clinician utilizes the techniques described in this article to adapt the examination to each patient’s situation, choosing the most appropriate techniques to supplement the basic neurological and psychiatric examinations in support of diagnostic hypotheses being considered. The added examination techniques facilitate diagnosis of neurocognitive disorders and enable neuropsychiatric formulation.

Well-described clinical case reports have been a core component of the neuropsychiatry literature and have led to: a deepened understanding of brain-behavior relationships and neuropsychiatric phenomenology, new paths for research, and compelling material for physicians who are studying neurology and psychiatry. Six landmark neuropsychiatry cases were selected for being well described, paradigmatic, and illuminating of brain-behavior correlations: Phineas Gage, Louis Victor Leborgne ("Tan"), Auguste Deter, Solomon Shereshevsky ("S"), "JP," and Henry Gustav Molaison ("HM"). Each case and its neuropsychiatric lessons are summarized from primary sources, highlighting some less appreciated aspects. Case reports continue to be a valuable resource for neuropsychiatric education. Yet only four of the 10 highest impact factor psychiatry journals accept case reports for publication.