Acad Psychiatry 30:410-415, October 2006
doi: 10.1176/appi.ap.30.5.410
© 2006 Academic Psychiatry
A Neural Systems-Based Neurobiology and Neuropsychiatry Course: Integrating Biology, Psychodynamics, and Psychology in the Psychiatric Curriculum
Timothy Lacy, M.D. and
John D. Hughes, M.D.
Received February 18, 2006; accepted March 14, 2006. Dr. Lacy is affiliated with the Department of Psychiatry, Malcolm Grow Medical Center, Andrews Air Force Base, Maryland. Dr. Hughes is affiliated with The National Naval Medical Center, Bethesda, Maryland. Address correspondence to Dr. Lacy, 1050 W. Perimeter Road, 4A, SGOHA, Andrews Air Force Base, MD 20762; timothy.lacy{at}pentagon.af.mil (E-mail). Copyright © 2006 Academic Psychiatry.
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ABSTRACT
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OBJECTIVE: Psychotherapy and biological psychiatry remain divided in psychiatry residency curricula. Behavioral neurobiology and neuropsychiatry provide a systems-level framework that allows teachers to integrate biology, psychodynamics, and psychology. METHOD: The authors detail the underlying assumptions and outline of a neural systems-based neuroscience course they teach at the National Capital Consortium Psychiatry Residency Program. They review course assessment reports and classroom observations. RESULTS: Self-report measures and teacher observations are encouraging. By the end of the course, residents are able to discuss both neurobiological and psychodynamic/psychological concepts of distributed biological neural networks. They verbalize an understanding that psychology is biology, that any distinction is artificial, and that both are valuable. CONCLUSIONS: A neuroscience curriculum founded on the underlying principles of behavioral neurobiology and neuropsychiatry is inherently anti-reductionistic and facilitates the acquisition of detailed information as well as critical thinking and cross-disciplinary correlations with psychological theories and psychotherapy.
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Current Educational Climate
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Recent developments in neurobiology have increased the understanding of the brain and mind. Despite the scholarly, educational, and popular work to reduce this artificial division (1–9), neurobiology and psychology remain separated within psychiatric education.
The neurobiological education of psychiatry residents commonly focuses on neurons, neurotransmitters, and cellular and molecular mechanisms, all essential knowledge for the modern psychiatrist. However, in order to connect these structures and processes to mental experience and behavior, the details must be understood in the context of overall neural system functioning. An educational emphasis on details without this contextual placement sends the implicit message that the knowledge of details is sufficient to explain the biological aspects of mental experience. Residents taught in such a reductionistic fashion learn specific details but may not grasp their significance in the system as a whole. The potential outcome of this educational model is a generation of psychiatrists with limited capacity for critical neuropsychiatric thinking and whose idea of psychiatric biology is equated with the relatively narrow field of psychopharmacology.
The current iteration of the Diagnostic and Statistical Manual of Mental Disorders (10) allows psychiatrists to describe psychiatric disorders based on descriptive phenomenology and symptom checklists. These diagnostic categories are the profession’s current best effort at describing behavioral and mental phenotypes. Understandably, beginning residents, in an effort to master the material rapidly, tend to accept the diagnostic categories uncritically, an attitude that is sometimes promoted by their supervisors. Acceptance of this type promulgates an algorithmic mindset that actually halts phenomenological curiosity and diagnostic acumen. Once residents have enough data to "check off the boxes," they may assume that they have achieved the goal of diagnosis, and thereby understand the patient.
The course described in this article was specifically designed to address these concerns and was founded on the belief that a neural systems-based understanding of neurobiology goes hand-in-hand with deep psychological understanding, and that armed with this knowledge, the psychiatrist can approach diagnosis and biological and psychological treatment in a more sophisticated fashion.
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The Course
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The course described herein is titled "Neurobiology, Neuropsychopharmacology and Neuropsychiatry," a course for third-year psychiatry residents in the National Capital Consortium Military Psychiatric Residency Program. The course (Figure 1) evolved over time and reflects, as all courses do, the particular strengths and interests of the course directors. Residents also concurrently attend courses in psychodynamics and other courses on theory and psychosocial treatments.
The course begins with an overview of behavioral neuroanatomy using the multilayered structure of the brain described by Yakovlev (11) and MacLean (12) as the template. The principles of evolution and comparative ethology are key components of psychiatric neurobiology that are traditionally given little emphasis. In the opening section, we discuss these concepts and their relationship to brain structure and function, drawing principally on the works of MacLean and Panksepp (13). This is followed by an introduction to sensory processing in which we trace the pathways from sensation to cognition, affect, and autonomic/visceral reaction in what we term a "sensory walking tour" through the brain.
Upon this foundation, we teach detailed anatomy in a series of individual lectures. The emphasis of the anatomy lectures is on the place each structure holds in the distributed networks that make the brain a "system of systems." The guiding theme in these lectures is that behavioral function and dysfunction arise from the activity of several distributed systems of the brain and that these individual systems are composed of dauntingly complex arrays of interacting neuroanatomical structures from the brainstem, through the diencephalon, to the cortex (14).
We integrate concepts from neural network theory, cognitive psychology, and related fields to provide what we refer to as a "representational framework" for approaching all psychological processes (15). This is based on the fundamental assumption that all behavior is the function of information-processing systems of the brain. All psychological processes are manifestations of the activation and manipulation of information represented in the brain in a distributed fashion. We present a description of various cognitive systems on the basis of this common framework. All psychiatric symptoms and related psychological processes are subsequently conceptualized in this fashion. This whole-brain representational emphasis is inherently anti-reductionistic and fosters deductive as well as inductive reasoning.
There are a few published reports of innovative teaching techniques in neurobiology and neuropsychiatry. Matthews et al. (16) describe a creative interdisciplinary "neurobehavior rounds" approach which integrates the concepts in a clinical setting. Green et al. (17) describe an intriguing brain-cutting approach to teaching functional neuroanatomy. But of the reported curricular approaches, our course is most similar to the course described by Lane and Potter (18). There are some significant differences between the two courses that warrant discussion.
All course directors must find a way to parse the limited time they have in ways that invariably reflect the bias and interests of the educators as well as available resources and faculty expertise. Along these lines, Lane and Potter’s series of neuroanatomy lectures are limited to a few topics thought to be most germane to behavior while we have a greater number of neuroanatomy lectures and follow a more traditional organization of neuroanatomy texts. Our approach differs from standard neuroanatomy texts, however, in our emphasis on function as a complement to structural or anatomical connections, especially as function relates to emotion, cognition, and its relevance to neuropsychiatric dysfunction. We assign readings from Nolte (19), which we chose for their clear prose and striking illustrations, but our "neuroanatomy" lectures rely much more heavily on theories and data from the behavioral neuroscience literature, with supplemental neuropsychiatric case discussions and psychological and psychotherapeutic principles.
Unlike Lane and Potter, who hold five lectures on neuroimaging, we devote only one lecture specific to the topic. This may be perceived as a weakness of our course because of the prominence of neuroimaging in modern psychiatry. However, we believe a strong foundation in behavioral neuroscience is required in order to analyze critically the significance of functional imaging. Therefore, rather than focus on imaging, we chose to emphasize the anatomy and neural systems content and to illustrate this at various points throughout the course with data from a variety of sources, including neuroimaging. There have been exciting developments in functional imaging techniques over the past couple of decades. Unfortunately, many believe that simply understanding the activation patterns measured with functional magnetic resonance imaging (fMRI) or positron emission tomography (PET) is equivalent to an understanding of the neurobiology of cognitive functions and neuropsychiatric disorders. The reality is far more complicated than the images suggest. We emphasize that the information from these studies must be assessed critically in conjunction with the data from other methodologies and that this can only be properly done with a strong foundation in systems-level behavioral neuroscience. We encourage our residents to challenge us as well as the interpretations of authors when discussing functional imaging studies.
Our series of lectures on cognitive systems is similar to Lane and Potter’s cognitive neuroscience series. However, as mentioned above, we have developed a "representational framework" which borrows heavily from neural network or parallel distributed processing theory, from which we discuss each topic. This anchors our students to a common qualitative perspective of how complex cognitive phenomena, such as declarative memory, delusions, or specific emotions, "emerge" from the combined function of distributed ensembles of neurons. From our perspective, a neural network/parallel distributed processing level of analysis is what really binds the cellular/subcellular level of traditional "biological psychiatry" and psychopharmacology with the macroscopic level addressed in traditional methodologies, such as lesion analysis and functional imaging.
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Method of Instruction
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We present topics in lecture format with discussion and inquiry encouraged and actively sought. We require the purchase of three books and supplement these with our own lecture notes when appropriate (e.g., the lectures on "representational systems" and on the biology of psychotherapy). Educators must find a text that meets the time constraints and needs of their particular curriculum. We provide a short list (Appendix 1) of the texts that we use as well as some other books potentially useful to teachers, depending on the goals and length of their course.
Using Case Material
Psychiatric phenomenology, psychodynamics, psychotherapeutics, regional brain functioning, and psychopharmacology are integrated in our course with neuroanatomy and cognitive behavior neurobiology. Focusing on patterns of human experience (cognitive, emotional, and visceral/autonomic) further facilitates the teaching of the neurobiological foundations of development, psychological models, and psychotherapeutic approaches (20). To illustrate these principles and to draw upon a variety of behavioral and mental patterns, case examples for the lectures are drawn from both staff and resident experience and include not only the usual neuropsychiatric cases, such as dementia and stroke, but also examples from disturbances in normal development as well as psychotherapeutic experiences. As mentioned earlier, our residents study various psychotherapeutic approaches during the time frame of this course. This parallel instruction encourages the use of illustrative psychosocial and psychotherapeutic cases.
Course Evaluation
For several years, the course has received excellent evaluations from residents. However, in order to gather more specific resident feedback, we prepared a seven-question post-course survey of residents’ perceived level of knowledge. The survey rated responses on a Likert scale from 1 to 4, with 1 meaning "strongly disagree" and 4 meaning "strongly agree." The survey included an evaluation of teaching techniques as well as learner confidence in the understanding of regional brain function, mental status examination, the biology of emotion and cognition, the biology of psychiatric disorders, the relationship between psychopharmacology and whole-brain function, and the biological underpinnings of psychotherapy. It was administered at the completion of the course for 2 academic years (N=24). All items averaged a score between 3.0 and 3.6, reflecting a perception of adequate knowledge in all areas covered. This subjective survey is flawed in that learner perception of learning is not necessarily accurate. However, our survey was designed to obtain resident feedback in order to shape curricular changes and was not empirically validated or designed to be an accurate measure of learning. A pre-test and/or post-test of objective measures would undoubtedly give a more accurate assessment of learner outcome. Unfortunately, standard examinations, such as anatomy Shelf exams or the neurology section of the Psychiatry Resident-In-Training Examination (PRITE), do not require integration of various systems nor their application to the biological and psychological aspects of psychiatry and behavioral neurology. Ideally, an adequate examination would test not only a factual knowledge base but also a grasp of higher level concepts, such as systems interactions and brain-behavior correlates, and skills, such as a sophisticated ability to perform a neuropsychiatric mental status examination. The development of a rigorous but brief examination administered at the beginning and end of the course would yield more reliable results.
Classroom Observations
Subjective assessment of classroom discussions suggests that many of our residents successfully integrate psychodynamic, cognitive, developmental, and neurobiological concepts. One of our primary aims is to teach a biological language that serves as a framework for thinking about and discussing psychiatric diagnosis and treatment, including psychotherapeutic ideas and interventions as we discuss elsewhere (20). Toward the end of the course, resident discussions freely flow between biological and psychological concepts. They are able to make a "linguistic crosswalk" between neurobiological and psychological vocabularies, which are simply discipline-specific attempts to describe the underlying biological processes.
We have observed that this approach not only increases resident enthusiasm for learning neurobiology, but also increases their appreciation for human suffering and their empathy for patients. Residents learn that psychodynamic phenomena are "emergent properties" of distributed biological neural networks and that psychology is biology, that any distinction is artificial, and that both are valuable. When our residents genuinely grasp the biological reality of a patient’s internal world, they sometimes describe an increased capacity to deal with strong emotional reactions to challenging patients who behave in manipulative, sadistic, seductive, or aggressive ways. It is as if understanding the neural nature of psychological phenomena (i.e., that they are as "real" as neurotransmitters) helps residents to respond to these intense encounters more calmly and compassionately. Instead of perceiving patients as "purposefully" attacking them, they begin to see that patients are acting out of the only reality they have stored in their perceptual association cortices (with the associated representations within different neural systems—limbic, thalamic, basal ganglia, brainstem, etc.) and are limited by their various biological regulatory capacities.
The progression of topics in the course moves from anatomical substrate to normal function of the anatomical systems, and finally to clinical applications (Figure 2). We find that moving from complex topics to clinical topics facilitates resident compliance with reading assignments as the busy academic year proceeds. Furthermore, as we approach clinical applications toward the end of the course, residents discuss diagnostic categories with a more substantial understanding of the biological underpinnings of the phenomenology and of both the value and the limitations of categorical diagnostic labels.
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Developing Your Own Course
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Each course director has a limited and unique set of local resources and expertise. Clearly, our interests and expertise shaped our course. Likewise, Lane and Potter’s (18) course takes advantage of their interest and expertise, as do the courses described by Green et al. (17) and Matthews et al. (16). There is no perfect or ideal course. Needless to say, all courses will change over time as faculty come and go and neurobiology evolves.
Many, perhaps most, residency programs do not have large pools of neurobehavioral experts to draw from. This is an unfortunate reality but does not prevent one from developing a basic course built on these principles. Some teachers may choose to simply read a text, such as one of those listed in Appendix 1, or a popular book, such as those by Damasio (8, 9) or LeDoux (6), with their residents in a mutual learning activity using a seminar-discussion series model. They may then correlate these readings with clinical phenomena and therapeutics. Also helpful is pairing teachers together, especially teachers from different backgrounds, such as neurologists with psychiatrists, "biological" psychiatrists with psychotherapists, etc. We are constantly learning from each other as well as from guest lecturers and attempt to model an inquisitive and open-minded perspective. One university uses some of our neurobiology handouts along with readings from Panksepp (13) and others in a psychotherapy course taught by an experienced psychodynamic therapist (21).
Regardless of the pedagogical approach, we suggest that the conceptual foundation for behavioral neurobiology should consist of a solid grounding in functional neuroanatomy and neural systems. We suggest that the details of psychiatric phenomenology, mental experience, biological treatment, and psychosocial treatment can be successfully built upon this foundation in a fashion that takes advantage of the strengths of the teachers, meets the needs of learners, and emphasizes the role of individual functional and anatomical components within a larger system of systems.
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Conclusions
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In this day of growing neurobiological knowledge, there is a continuing divide between biological and psychological approaches to psychiatry. Furthermore, neurobiology is often taught in a reductionistic fashion that emphasizes only certain aspects of the complex neural system functioning that results in normal and pathological mental functioning. This situation is slowly dissipating as leading scientists publish more about the neurological underpinnings of mental life. At this time in the evolution of psychiatry, the integration of "mind and brain" is essential if we are to prevent our specialty from becoming too narrowly focused and if future psychiatrists are to become critical neuropsychiatric thinkers rather than simply "psychopharmacologists" whose only job is to use chemicals to treat complex neural system dysfunction. An approach to teaching neurobiology that is founded on the accepted principles of cognitive neuroscience, neuropsychiatry, and behavioral neurology allows one to teach the details of neurobiology and psychopharmacology within the systems context of whole-brain functioning. We contend that in order to be clinically relevant, psychiatric neurobiology education must emphasize mental experience, emotion, and patterns of behavior. An understanding of these phenomena is not found merely in the details of receptor subtypes, neurotransmitters, and the like but in how these detailed systems interact within the neural system as a whole to create human mental experience and behavior. An emphasis on distributed neural systems allows one to teach the details of the brain without losing the essence of the human mind.
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ACKNOWLEDGMENTS
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The views expressed in the paper are those of the authors and do not reflect the views or policies of the Department of Defense or the U.S. Government.
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ABSTRACT
Current Educational Climate
