Academic Psychiatry 25:148-155, September 2001
© 2001 Academic Psychiatry
Functional Neuroanatomy of Psychiatric Disorders
A Didactic Course for Residents
Richard D. Lane, M.D., Ph.D. and
Rebecca L. Potter, M.D.
Dr. Lane is at the Department of Psychiatry, University of Arizona, Tucson, Arizona. Address reprint requests to Dr. Lane, Department of Psychiatry, University of Arizona, P.O. Box 245002; Tucson, AZ 85724-5002. e-mail: lane{at}email.arizona.edu
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ABSTRACT
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The literature on the functional neuroanatomy of psychiatric disorders is growing and is certain to expand in the future. To prepare psychiatric residents for the inevitable transformation in how psychiatric disorders are conceptualized and treated, we have created a course focusing on the functional neuroanatomy of psychiatric disorders. The four sections of the course include neuroanatomy, functional neuroimaging techniques, cognitive neuroscience, and current evidence on the neuroanatomical basis of psychiatric disorders. This article summarizes the organization and content of the course and the very favorable evaluations of the course by residents.
Key Words: Neuroanatomy • Functional Neuroimaging • New Ideas
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INTRODUCTION
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Psychiatry in the decades ahead is likely to be a very different field from the one that we know today. Currently, many diagnostic distinctions are made in DSM-IV that are not well validated. Many treatments of psychiatric disorders are nonspecific. At present, we know that psychotherapy and pharmacotherapy can be effective, but we know little about their effects on regional brain activity. In light of the enormous progress being made in the neurosciences, it is likely that new ways of conceptualizing and treating psychiatric disorders will emerge in the years ahead from a better understanding of how psychiatric disorders arise from disordered brain function. To prepare psychiatrists of the future for this transformation, we have developed a new course to teach psychiatric residents how to understand and critically evaluate new findings as they become available. To our knowledge, no course has been created previously with the focus and content of the one that we describe below.
Functional neuroanatomy may constitute the optimal domain in which the various facets of psychiatry can be integrated into a common language and conceptual structure. Psychiatric treatments broadly consist of psychotherapy in all of its modalities (individual, couples, family, group) and somatic treatments (pharmacotherapy and ECT, in particular). Factors that contribute to the etiology and treatment of psychiatric disorders exist at the molecular (genes, neurotransmitters, hormones), psychological (conditioning, learning, executive functions), and environmental (interpersonal, family, community, environmental) levels.
Although the ultimate cause(s) of certain psychiatric disorders may not be located at the level of systems neuroscience, all of the factors just listed ultimately exert their influence on mental states through their effect on activity in different regions of the brain and the interactions between these regions. Thus, functional neuroanatomy may be the single best level for integrating information about etiology and treatment in psychiatry into a coherent framework. To the extent that this is true, the potential exists to identify the morbid anatomy underlying psychiatric disorders in a way that exactly parallels the morbid anatomy that underlies the disorders in all other areas of medicine. Because of this potential, the decades ahead may well see the reintegration of psychiatry into medicine in such a way that its status in the field of medicine will never be questioned again.
In our view, the goals of residency training are twofold: to prepare residents for licensure and accreditation and to prepare them as well as possible for what the field will be 20 years in the future. This raises the question of how best to teach psychiatrists of the future about this new and exciting field as well as how to prepare them for the inevitable major discoveries that will occur in the not-too-distant future. We believe that a year-long course in the third postgraduate year (PGY-III) is the optimal approach.
One could argue that since our ultimate goal is to understand the functional neuroanatomy of psychiatric disorders, the major research findings that are currently established regarding regional brain activity in psychiatric disorders could be incorporated into existing PGY-II courses in psychopathology. For example, findings regarding abnormalities of function in the head of the caudate nucleus in obsessive–compulsive disorder (OCD; [1]) could be taught with the epidemiology, genetics, natural history, diagnostic criteria, and pharmacotherapeutic approaches to OCD.
The problem, however, is that this approach will not enable residents to understand functional neuroanatomy. Rather, a background in neuroanatomy, functional neuroimaging techniques, and cognitive neuroscience constitutes the fundamental foundation upon which functional neuroimaging results in psychiatric patients can be understood.
We believe that residents will have little hope of understanding the meaning of the results of functional neuroimaging studies of psychiatric disorders without this more extensive background. Furthermore, PGY-III residents, who are primarily working in outpatient settings and are learning to be psychotherapists, are searching for conceptual tools to help them understand how the biological and psychosocial interventions that they are practicing work together. We believe that presenting this course in the PGY-III year helps residents deal with a critical conceptual challenge that they confront on a daily basis.
Also, in an ideal world, we hope to train future psychiatrists to critically evaluate published findings as they become available rather than simply assume that if a paper is published in a respectable journal, it means that the findings will stand the test of time. If future psychiatrists are to acquire such critical abilities, they must develop the conceptual tools and acquire the information needed to evaluate and integrate new knowledge in this area.
Organization of the Course
The primary purpose of this course is to teach residents what is currently known about the functional neuroanatomy of psychiatric disorders. To do so, it is necessary to 1) review the fundamentals of neuroanatomy (Section I); 2) grasp the fundamentals of the major functional neuroimaging techniques, particularly positron emission tomography (PET) and functional magnetic resonance imaging (fMRI; Section II); 3) learn what is currently known about the neural substrates of basic cognitive functions (Section III); and 4) review papers dealing with functional neuroimaging of specific psychiatric disorders (Section IV).
This course is taught in three 90-minute sessions per month for the entire year (total: 37 sessions). These consist of 6 sessions in Section I, 5 sessions in Section II, 13 sessions in Section III, and 11 sessions in Section IV (Table 1). In addition, there is one initial meeting for purposes of organization and administration and a second meeting for a conceptual introduction to the course.
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TABLE 1. Overview of the four sections of the course and the topic(s) covered in each of the 90-minute sessions Note: The session number is indicated for each topic. Representative readings for each topic are shown in parentheses, as listed in Reference section. PET=positron-emission tomography; SPECT=single photon emission computed tomography; MRI=magnetic resonance imaging; fMRI=functional magnetic resonance imaging; MRS=magnetic resonance spectroscopy; OCD=obsessive–compulsive disorder; PTSD=posttraumatic stress disorder.
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The textbook for Section III is Cognitive Neuroscience: The Biology of the Mind, by Gazzaniga, Ivry, and Mangun (2). This is a beautifully illustrated text that is written at the college undergraduate level. It is notable for being accurate and readable without being oversimplified. In Section IV, overview chapters on neuroimaging studies of major psychiatric disorders, gleaned from the excellent text by Charney et al., titled Neurobiology of Mental Illness (3), are supplemented by original-data papers in psychiatric and other scientific journals. The syllabus is updated regularly and can be accessed on the internet (www.medicine.arizona.edu/psychiatry).
In addition to the textbooks on cognitive neuroscience and the neurobiology of mental illness, residents are also encouraged to purchase the new edition of a handsomely illustrated textbook of neuroanatomy written by University of Arizona faculty (4). Also, we have created a master set of readings and photocopied the set for each resident. (This procedure was in compliance with copyright laws and facilitated access to the material.) The reading list is changed regularly when new articles or chapters appear that present the latest findings in a manner that residents can understand.
We placed emphasis on the importance of attendance at the beginning of the course. To encourage attendance, we had residents sign in at each session. Attendance has also been facilitated by departmental policy, which states that attending physicians will provide coverage for residents during their seminars.
We implemented a back-up system for presentations, so that if residents needed to cancel at the last minute (because of illness or other unforeseen event) other residents could present in their place. We found that, in approximately 20% of sessions, this back-up system was needed, a percentage that was somewhat unexpected and illustrates its usefulness.
Each session is 90 minutes long. The content of each session is based on the assigned readings. In the sections on neuroanatomy and neuroimaging, the format consists of a faculty lecture, followed by a question-and-answer period. In Sections III and IV, a knowledgeable faculty member is present for all sessions, but residents take turns presenting the readings. The 90-minute sessions are roughly divided into a 30-minute presentation by the resident, who summarizes the readings, highlights areas where material is not understood, and poses questions for the group. The second 30-minute segment has the faculty discussant answering questions about the readings, highlighting the points that require greater emphasis, and putting into context aspects that have been over- or under-emphasized. The final 30-minute segment has faculty members presenting their own research or findings from other investigators that extend and amplify that which has already been discussed and/or conducting a discussion of the clinical applicability of the material just presented. The presenting resident is charged with providing a one-page summary of the main points of the session either at the time of the presentation or by the next meeting.
A final aspect of the course organization is the requirement that residents write a 10-page paper due at the end of the year. The purpose of the paper is to facilitate integration across the different sections of the course. At the beginning of the course, residents choose a particular psychiatric disorder that will be their major topic. They then approach the review of cognitive neuroscientific topics from the perspective of that particular disorder and are assigned topics for presentation that are related to their chosen disorder (e.g., attention/attention-deficit disorder; memory/ posttraumatic stress disorder).
Also, they review functional neuroanatomical findings of a particular disorder in light of what is known about how the structures in question mediate cognitive functions in healthy people. The goal is to promote development of new habits of thought aimed at understanding how psychopathology can result from an alteration of healthy mental processes.
Course Content
The readings for the course are listed in Table 1. In the orientation section, we discuss important articles by Kandel (5) and Andreasen (6). The article by Kandel helps trainees to understand how mental processes are assumed to be brain processes and how brain function provides an integrative framework for phenomena ranging from genetic to societal influences. The article by Andreasen points out that we are currently living in an era in which Freud's dream of linking mental states with brain function (7) can now be realized. This article discusses the usefulness of a cognitive–neuroscientific approach to psychiatry and provides multiple illustrations of how findings from cognitive neuroscience and psychopathology may be related to one another.
The neuroanatomy section is taught with the understanding that PGY-III residents have had extensive training in neuroanatomy and neurology. Our aim in this section is to encourage the residents to think in neuroanatomical and systems terms again. The brain overview includes a brain-cutting as well as an introduction (for future reference) to a computer program that enables 3-D visualization of brain systems (8).
We then discuss neuroanatomical systems that are particularly relevant to psychiatry and cognitive neuroscience. The chemical neuroanatomy lecture discusses the topography of ascending neurotransmitter systems, including dopamine, serotonin, norepinephrine, and acetylcholine. Thalamo-cortical relationships are discussed to illustrate fundamental features of subcortical and cortical organization, as well as the beauty and precision of neuroanatomical connections. The visual system is arguably the best understood brain system and is the system used most often to explore the neural substrates of consciousness (9,10). The motor system is directly implicated in disorders such as OCD. More generally, the motor system is the setting for the procedural learning of maladaptive behavior patterns that are often the basis for clinical intervention (11). A single session on the limbic system provides a foundation for further discussion of the neural substrates of emotion in Section III.
The section on neuroimaging focuses on PET and fMRI, the premier functional neuroimaging techniques in cognitive neuroscience today. We believe that it is also important for residents to develop some familiarity with other techniques that either have been used in the past or will be used increasingly in the future. Single photon emission computed tomography (SPECT) is closely related to PET and is taught in conjunction with it. Similarly, fMRI and magnetic resonance spectroscopy require an understanding of many of the same principles. We also spend some time on magneto-encephalography and transcranial magnetic stimulation. The latter holds particular promise as a possible alternative to electroconvulsive therapy in the future (12).
The cognitive neuroscience section focuses on the readings in the Gazzaniga et al. textbook. This section begins with a session on plasticity (2), undoubtedly the neural basis for interaction between genetic and environmental influences, as well as the neural basis for therapeutic change. We then discuss selected topics in cognitive neuroscience from the same source (2), including vision, perception (in general), attention, memory, language, hemispheric asymmetry, emotion (13,14), frontal lobe function, and consciousness (2). This section concludes with an integrative overview of cognitive neuroscience by Mesulam (15).
The readings in this section summarize both the experimental paradigms and the major findings to date regarding the neural substrates of various mental functions. Each session begins with a brief discussion of the relevance of the given mental function to psychiatric disorders. More time is spent on those mental functions that have particular relevance to psychiatry, such as emotion and executive (frontal lobe) function. These topics were selected because they are thought to be the minimum needed to understand the functional neuroimaging findings in Section IV.
In Section IV, we discuss major psychiatric disorders. We have attempted to include both seminal original reports as well as overview articles, such as those published in journals such as CNS Spectrums. We have found that residents more easily digest papers that review research findings than original reports. The focus in this section is the brain circuitry putatively involved in the pathophysiology of these disorders. We make an attempt to be comprehensive in the topics covered, rather than exhaustive on any one topic. In this section, efforts are made to link fundamental mental operations discussed in Section III with the particular disorder under discussion in Section IV.
Course Ratings
Final ratings of the course by residents who took it in its first and second year are presented in Table 2. It is clear that the course was highly rated each year.
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TABLE 2. Final ratings of the course by six psychiatric residents who took it during the first year it was taught (Year 1) and by five psychiatric residents who took it during the second year it was taught (Year 2)
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A major concern in designing this course was the possibility that the residents might not find the content relevant because it was not always directly applicable to their clinical work. In fact, although considerable progress has been made, the neuroanatomical basis of every psychiatric disorder (with the possible exception of Alzheimer's disease) is unknown at this time. However, residents discovered that the findings discussed in this course significantly enhanced their understanding of each disorder. They also appreciated and found very valuable the opportunity to understand the interplay between biology and environment in shaping human behavior. Residents enjoyed the format of the course and found that doing presentations with a faculty member is an extremely effective way to learn the material.
The content of the course in the second year of presentation (Table 1) reflects changes suggested by the residents who took the course in the first year. In general, it was difficult for residents, with their busy clinical and seminar duties, to do a great deal of reading. Thus, each reading assignment listed in Table 1 was broken down into those sections that are required and those that are recommended. For certain topics, the syllabus contained additional recommended readings.
Residents also felt that the original 60-minute format afforded too little time for discussion and requested a 90-minute format so that the material could be covered more adequately. A 90-minute format has now been successfully adopted. Devoting this amount of time to one course clearly requires approval at the departmental level.
In summary, residents were unanimous in finding this course valuable. Residents also consistently indicated that the material was important and very relevant to their future careers as psychiatrists. This course directly affected their thought processes as clinicians by giving them a framework for integrating all aspects of the clinical work that they were doing. It therefore helped them to feel more grounded. They gained a better appreciation of the pathophysiology of the disorders that they encountered, and reported that this increased understanding enabled them to better explain specific disorders to their patients. Residents also felt that, with this background, they would be better able to evaluate emerging findings on the neuroanatomical basis of psychiatric disorders.
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DISCUSSION
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The fundamental resources required for implementing this course consist primarily of a psychiatrist who is interested in the topic and is willing to read all of the material and attend all of the sessions. The quality of the course is facilitated if faculty members from other departments can either present lectures or serve as discussants for particular topics.
At the University of Arizona, we are fortunate to have neuroanatomists with both considerable expertise and a willingness to teach psychiatric residents. The ideal neuroanatomy lecture in this setting is one that focuses on neuroanatomical systems and the patterns of interconnection between structures, supplemented by clinical illustrations of the consequences of lesions in different sites.
The section on functional neuroimaging requires a seminar leader familiar with neuroimaging techniques, so that both fundamental principles and technical issues can be explained in simple terms. It is challenging to teach brain-imaging concepts at a level understandable to residents. This is particularly true because most written summaries of these complex modalities have not been written at a level of sophistication and understandability appropriate for residents. Covering six modalities in five sessions is challenging but can be accomplished with the 90-minute format.
Teaching in Section III was greatly enhanced by a very strong cognitive neuroscience program at the University of Arizona and excellent relations between the Departments of Psychology and Psychiatry. The guest discussants were able to use their extensive knowledge of each topic to explain complex phenomena in succinct and cogent terms.
The papers and chapters in Section IV ideally should be discussed by a faculty member familiar with the disorder in question. Also, familiarity with findings regarding the neural substrates of relevant basic mental operations in healthy subjects facilitates an understanding of the abnormalities observed in psychiatric patients.
There were numerous examples in which residents were able to correlate findings in cognitive neuroscience with observations in their patients. A fundamental distinction in cognitive neuroscience is that between implicit, unconscious processes and explicit, conscious processes. This distinction is important because distinct neural substrates exist for conscious and unconscious processes (2). One resident commented that this material helped her appreciate that an unconscious really does exist (albeit quite different from the unconscious as it is understood in the psychodynamic tradition).
In the session on memory, residents learned that the accuracy of memories is often quite unreliable even when subjects are confident that their recollections are accurate. This finding has implications for the process of taking histories in any medical setting and raises questions about the nature of "truth" when relying on memory. The material on frontal lobe functioning was highly relevant to processes such as impulse control, the role of emotion in decision-making, and adapting behavior to social circumstances.
Another example of a clinical application of a cognitive neuroscience principle is the procedural (implicit) organization of emotion as described by Clyman (11), which has implications for understanding the persistent nature of emotional learning that occurs automatically and without conscious thought.
It was clear that in each topic area, the assigned readings only scratched the surface. Supplementary readings helped presenters expand their presentations, provided material for the 10-page papers, and served as a resource for those who wanted to get a more in-depth understanding of any given topic.
Kandel (5) points out that psychiatry has a unique vantage point on human behavior, and has much to offer neuroscience by highlighting phenomena that are worthy of further research. To the extent that psychiatrists become familiar with this body of work, it will not only enhance their clinical sensitivity and acumen but can also facilitate communication between researchers and clinicians. In this way, those at the forefront of treating patients, the arena in which research findings will ultimately be implemented, can have an important influence on the process of discovering the neural underpinnings of clinically relevant phenomena.
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ACKNOWLEDGMENTS
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This article is dedicated to the memory of Charles M. Kerr, M.D., a valued faculty colleague who attended the course in its entirety during its first year, provided unwavering encouragement, and made valuable comments and suggestions.
This work was presented at the Annual Meeting of the American Association of Directors of Psychiatric Residency Training, Santa Monica, CA, March 11–15, 1999, and the Annual Meeting of the Society for Neuroscience, Miami Beach, Florida, October 23–28, 1999.
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T. Lacy and J. D. Hughes
A Neural Systems-Based Neurobiology and Neuropsychiatry Course: Integrating Biology, Psychodynamics, and Psychology in the Psychiatric Curriculum
Acad Psychiatry,
October 1, 2006;
30(5):
410 - 415.
[Abstract]
[Full Text]
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ABSTRACT
INTRODUCTION
