(upbeat music)
- Hello and welcome back to The Thought Broadcast,
the trainee focus podcast from Australasian Psychiatry.
My name is Ed Miller,
and I'm the trainee editor of Australasian Psychiatry.
Joining me today are deputy editors
of Australasian Psychiatry, Fiona Wilkes and Andrew Amos,
editorial committee member, Michael Waitman,
and psychoanalytic psychotherapist, Stephen Yates.
Welcome, everyone.
- Thanks, Ed. - Morning, Ed.
- Hi, Ed. - Hello.
- So this is the first part of two parts of this podcast,
where we will be discussing a paper
that we have all written together,
which is currently undergoing peer review for publication.
And the paper provides a conceptual overview
of neuropsychoanalytic and neuropsychiatric principles,
which we think could help to inform
a basic neuroscientific curriculum for psychiatry trainees.
We will touch on topics such as the common origins
of both neuropsychoanalysis and neuropsychiatry
in psychoanalysis, neurology, and early psychiatry,
philosophy of mind, psychoanalysis, consciousness,
and affective neuroscience for neuropsychoanalysis,
and discussing the importance of hierarchical brain network
function and scope of disorders and treatments
for neuropsychiatry.
We will also describe case vignettes
and demonstrate how these concepts could be used
to better understand specific psychiatric presentations.
Ultimately, we hope to champion psychiatrists
as expert psychotherapists,
as well as provide clinical neuroscience knowledge
for psychiatry, which could be used
in lecture material, online teaching modules,
bedside teaching, psychotherapy training for psychiatrists,
and case formulation and discussion.
So, since the 1990s, there has been an explosion
of neuroscientific and philosophical advances
in our understanding of brain and mind,
with major implications for psychiatry.
Psychiatry is increasingly considered
to be a clinical neuroscience discipline,
meaning that it deals with disorders
that stem from disrupted brain networks and systems
caused by underlying genetic, developmental,
and environmental influences.
However, the developments in neuroscience
are technically complex and are occurring at a rapid pace.
This makes them difficult to contextualize
with other psychiatry curriculum elements
that often do not progress as quickly,
such as mental health legislation,
some ethical principles, diagnostic criteria,
and nosology, and psychotherapy training.
This makes developing and refining
a robust clinical neuroscience curriculum
for psychiatry a difficult task.
Consequently, the development
of a clinical neuroscience curriculum
for psychiatry training lags behind
the neuroscientific progress,
with many training programs having no such component,
or there being a wide variation in content
when it is taught.
So, neuropsychoanalysis and neuropsychiatry
are two fields that are closely related to psychiatry,
which have already incorporated neuroscience
into their regular practice and theory.
It makes sense then that highlighting key concepts
from these fields would greatly enhance
the development of a clinical neuroscience curriculum
for basic psychiatry training.
Moreover, discoveries from neuropsychoanalysis
and neuropsychiatry could help equip psychiatrists
to become expert psychotherapists
by leveraging their unique training
in both contemporary mind and brain science.
I'll hand over to Stephen,
who will now talk a little bit about neuropsychoanalysis.
The term neuropsychoanalysis was coined by Mark Sohms,
now professor Mark Sohms from the University of Cape Town.
There's a clinical neuropsychologist
who, in work with brain-injured patients,
was initially, I think, a bit dissatisfied
with conventional psychological training's perspective
on subjectivity, on what it means to be a subject,
have an inner life.
And contemporaneous work with stroke patients,
various types of brain injuries.
Professor Sohms began to explore
how psychoanalytic phenomena manifest
in those patients with demonstrable brain deficit.
And what he found was a set of patterns
and made a series of comments and arguments
that attempted to reintegrate the substrate of the brain
into a psychoanalytic understanding,
or as they relate to psychoanalytic phenomena.
The bridge that finally allowed
a much fuller integration of the two disciplines
was actually the work of Yuck Pankset
in affective neuroscience
that happened through the 90s and early 2000s,
that by demonstrating the seven networks
of the emotion networks with their unique,
irreducible affect states,
Sohms made a series of reinterpretations,
essentially a Freudian drive theory
that later feeds into an object relations theory
that tries to do what Freud had wanted to happen
in a project for a scientific psychology,
which is to reintegrate the natural sciences into psychology.
So in this sense, they are, as you say,
an attempt to integrate psychoanalysis
into the neurosciences.
This rather naturally leads to a deeper exploration
of the fundamental experience of consciousness.
So if you think of psychoanalysis
as being essentially a study of the subject,
and there are other studies of subjectivity
and religion and art, but from the perspective of science,
psychoanalysis is a fairly comprehensive idea
about what it means to be a subject.
The neuroscientific picture has always been a bit complicated
because the brain is both subject and object.
You know, as one could put it as that neuroscience
and psychoanalysis have been viewed as two perspectives
of the same unknowable thing in nature,
you know, the reality behind the subjective mind
and the objective brain, which we
not necessarily try and solve, but to straddle.
So there's quite a lot of potential
for neuropsychoanalysis to bridge the theoretical gaps
in theory, particularly in psychoanalytic theory,
but probably more broadly in psychological theory,
which have tended to, for reasons a bit beyond this discussion,
become siloed and remain separate.
So the chance is there for psychoanalytic theory
to come together with the brain.
And this is a very exciting prospect.
The philosophical backbone of neuropsychoanalysis
is Bruk Spinoza's dual aspect monism,
which Spinoza's philosophy, which he articulated in the 1600s,
in ethics presaged the modern neuroscientific investigation
of essentially feelings, ethics, and emotions,
which is the field I referred to earlier,
ethic neuroscience, which did influence Freud.
So formulated by Spinoza in dual aspect monism
is response to dualism, to Descartes dualism.
And Descartes postulated that mind and brain
are separate entities, which accorded
with religious dogma at the time and notions of the soul.
The Spinoza position is counterposed to that.
For Descartes, the soul resides in the pineal gland,
which was its interface to the body,
but both were fundamentally different.
And therefore, the soul was theoretically
able to persist beyond death, so you
can accommodate for religious ideas within this.
Spinoza, though, in ethics, described
the mind and brain as being forms of a third property,
which he called substance.
And the position referred to as dual aspect monism,
because the substance, monism, has two dual aspects.
The mind and brain are neither completely representative
or it be phenomenal to the other,
but occupy opposite and interrelating aspects.
But dual aspect monism was suppressed in deference
to the religious utility of Cartesian dualism,
and only recently re-entered modern vocabulary.
Emergentism and transcendental materialism
are outgrows of dual aspect monism,
which accept that mind can be an emergent property of the brain
with the potential for immaterial properties that
are not reducible to physical matter.
So our article provides an overview
of the main mind-brain philosophies
relevant to clinical neuroscience curriculum.
And there's also an adjacent, fairly persuasive argument.
Raise five Psalms that attempt to solve
the hard problem of consciousness using
neuropsychoanalytic understanding in the human spring.
But I'll stop there.
Thanks, Stephen.
So I might move across to introducing
some of the key conceptual areas of neuropsychoanalysis.
And I'll start by talking about a few examples
of how neuroscience has been used to help explain
unconscious mental processes.
So one really good example of this
comes from the work of neuropsychiatrist Eric
Candle, who suggested that there could
be a link between some of Freud's theories,
such as his topographic and structural models,
and memory systems.
He thought this would be a fruitful area for collaboration
between psychoanalysis, biology, and neuroscience.
So for example, he thought that different layers
of the unconscious, including the pre-conscious unconscious
and the unconscious proper, might
be linked to different memory systems
and corresponding brain regions and networks,
such as the prefrontal cortex.
Another example comes from the work of Mark Solmes,
Yark Panchepp, and others in this area,
who suggested that Tolvig's concepts
of anoetic, noetic, and autonoetic consciousness
might correspond to procedural semantic and episodic memory
systems.
Again, another example, dream psychology and dream physiology
have also got thorough neuroscientific descriptions,
which can be linked back to Freud's dream theory as well.
An example of this is Solmes' demonstration
that dream imagery is instantiated
in the medial, prefrontal, and parietal areas,
rather than brainstem nuclei.
Mark Solmes also suggested that neuroscientific processes
can help us test, update, and refine Freudian theory.
For example, there is some recent neuroscientific evidence
that suggests that an inverted topographic model of the mind
may actually be closer to reality
as the psychoanalytic ego, which is the part of the psychoanalytic
self, which is most conscious, might in fact
be brainstem generated rather than cortical,
whereas affix and drives may be more
cortically placed than originally thought.
So there's a huge potential for the use of neuroimaging methods
to help unmask unconscious processes
in other psychoanalytic concepts, such as mourning
or psychoanalytic perspectives on confabulation.
That's a really exciting area of research.
Another core insight that arises from linking
the psychoanalytic unconscious to neuroscience
is the free energy principle.
So the free energy principle has been described
as the new royal road in the dialogue between neuroscience
and psychoanalysis, the bridge between the mind
and the brain.
This free energy principle was introduced
by Carl Friston in the 1990s in his brain imaging work.
The free energy principle analogizes the mind-brain system
to any other biological system that
requires adaptation to its environment to survive.
It considers the brain as a hierarchically constructed
inferential machine containing many interconnected large scale
networks.
These hierarchical networks optimize the prediction,
representation, and construction of increasingly complex lower
order mental and sensory information
to more accurately interpret and predict
the meaning of both the internal and external environments.
So the way this works is that it minimizes
the amount of free energy, which can
be thought of as statistical uncertainty or surprise.
It minimizes the amount of that available in the mind and brain,
thus reducing prediction error, which
can also be understood as reducing
the statistical complexity of the information contained
in the brain.
This means that the mind-brain can never
know the world directly, but only perceive it
by predicting what it could be like and then testing it
against new information.
The mind-brain always tries to predict reality
as accurately as possible, which is important for survival.
Sufficiently poor predictions could
result in psychopathology-like hallucinations.
Another way to put it would be that the mind-brain
tries to continuously learn about the world
to feel safe, to adapt, and to survive.
This basic model, intriguingly, is
similar to Freud's original topographic model
of primary and secondary processes.
The primary process generates unconscious fantasies,
wishes, and desires generated by the id, which
is an example of bottom-up processing.
And these are countered by the top-down egos, affinity,
for contrasting these impulses against the incoming sensory
information and the reality of the external world.
According to Jim Hopkins, a psychoanalyst,
the free energy principle overlaps
with psychoanalysis in understanding
emotional conflict and trauma, understanding
the function of memory consolidation
and reconciliation in dreaming, and identifying
the role played by the mind-brain's tendency
to predict reality in order to reduce statistical complexity
and buffer against excessive statistical surprise
in the origins of a range of mental disorders,
such as schizophrenia.
Thanks, Michael.
I'm now going to talk about the neurobiology of infancy,
development, and affective neuroscience.
So the neuroscientific investigation
of memory sleep and dreaming and consciousness
can also be linked to the psychoanalytic focus
on early life development.
Both Freudian and Bionian descriptions
of mind elucidate a developmental process
that explains how the registration of bodily sensory
and affective experience creates, shapes,
and is represented in thought.
This longitudinal buildup of unconscious representations
of visceral states and their representations in thought
has been linked to activity in the posterior and middle
insular and the default mode-neck work.
Kandel discussed this buildup in terms
of psychological determinancy, causality,
and development, including the role of early life experience
and predisposition in the development of psychopathology
and linked this to Freudian constructs
like signal anxiety.
Johannes Lehtonen suggested that neurobiological
and proto-psychological processes
during the perinatal period can be linked to psychoanalysis.
So for example, the impact of early attachment
and caregiving relationships can be mapped
to specific biochemical processes
and the molecular genetic mechanisms
of neuronal synapse formation.
So these processes are formative
for the early organization of the mind
and also create preconditions for nonverbal,
unconscious communication, and therapeutic interplay.
Furthermore, neuroscientific evidence also suggests
that the psychoanalytic concept of the ego
may be present from birth, which provides an example
of how neuroscience can help to answer
key psychoanalytic questions.
Yark-Panchepp's description of mammalian effective systems
has been described by Psalms as a translation
of Freudian drive theory based on more precise research.
Panchepp described nested brain-mind hierarchies
where primary process emotion systems,
genetically endowed effects
in the deep subcortical regions of the brain,
become shaped and molded by learning
and conditioning in the midbrain
before being represented in symbolic
and tertiary-level thought in the neocortex.
So this bottom-up process is then regulated
by top-down neocortex inputs in what is referred to
as a two-way or circular causation process
of representation and learning.
Panchepp argues that the seat of consciousness, the self,
as it relates to an intertwined with affect and drives,
is now increasingly established to be subcortical
rather than cortical.
Neuropsychoanalysis uniquely integrates
clinical and technical psychoanalytic concepts
with neuroscience research,
providing novel explanations for how psychotherapy works,
uncovering additional neuroscience findings
that may relate to clinical practice
and helping clinicians develop deeper formulations.
Multiple studies have researched the neuroscience
of psychoanalytic concepts,
including transference and counter-transference,
defense systems, free association and dreaming and trauma.
Indeed, transference and counter-transference
are regarded as cornerstones of psychoanalytic
and psychotherapeutic psychotherapies,
as well as having broad applicability
across a range of psychotherapeutic modalities.
Transference in particular has been defined as a tendency
in which representational aspects
of important and formative relationships,
such as with parents and siblings,
can be both consciously experienced
and/or unconsciously observed to other relationships.
In the context of a psychoanalysis,
this is a spontaneous development of representation
of in behaviour and in unconsciously determined utterance
of early life experience.
In this sense, transference relates
to the implicit relational schema
and dynamic pattern matching of a patient invoked in therapy
based on a priori learning and memory formation.
Activation of these a priori emotional processes
of therapy is key to psychic change,
part of which involves activation and remodelling
of declarative and procedural memory networks
with associated neural correlates
in the superior and inferior frontal gyra and in the putamen.
In other words, transference is a premature automatisation
of which interpretation helps to render into working memory.
Understanding the neuroscience
of similar therapeutic processes,
such as automatic mirroring and reflective functioning,
helps to explain clinical phenomena
such as therapeutic alliance and change,
since the neural motor networks of psychotherapy patients
may automatically mirror the motor movements of the therapist,
which then may in part effects on the neuronal systems
in the brain of the patient,
including through the function of the motor neurons.
Researching the effects of psychotherapy on patients
with no neurological disorders
may further elicited its neuroscientific basis.
Psychoanalysts themselves could be used as research subjects
for individual case studies
by being given different neuropeptides
and being asked to psychoanalytically interpret the changes
to their own phenomenology.
This approach could be used in areas
such as psychedelic-assisted psychotherapy,
whereby small doses of psychedelic medication
are administered to a patient
to assist with a psychotherapeutic process.
Reviews suggest that psychotherapy
has measurable effects on brain structures.
One mechanism of action for this
may be that psychotherapy causes changes
to the serotonin-driven neuronal networks
in the brain of subjects with depression.
Jeremy Holmes hypothesizes
that some psychotherapeutic interventions,
such as analytic psychotherapy
and mentalisation-based treatments,
work because of their propensity to bind free energy.
That is, reduce unpredictability
or minimise prediction error,
which in turn enhances Bayesian inference
and allow experience and feeling states
to be metabolised and assimilated.
Thanks, Stephen.
I'm now going to look at some critiques
for and against neuropsychoanalysis.
So, despite these advances in collaboration
between psychoanalysis and neuroscience,
some are concerned that neuropsychoanalysis
have abandoned dual-aspect modism,
particularly the need to bridge the gap
between mind and brain
by becoming biologically reductionistic.
A valid neuropsychoanalysis requires a balance
between subjective and objective factors
in psychoanalysis and neuroscience.
It risks becoming a token appropriation of neuroscience.
Another concern is that psychotherapists
who incorporate neuroscience
may unconsciously use biological models
when they encounter resistance.
A simple example is the issue of whether or not
to tell a patient that, from a neuroscientific perspective,
the recollection of birth trauma memory is impossible.
Should the analyst focus on the symbolic meaning
for the patient, or should they use the knowledge
of neuroscience to directly challenge a false claim?
Similarly, the prescription of psychotropic medication
could be made as a counter-transferential defence
against the anxiety of resistance,
or it could treat that anxiety
directly through a biological mechanism.
And I was just wondering, Steven,
could you talk a little bit about your personal experience
with this issue, I guess,
as a medically trained psychoanalytic psychotherapist?
How do you or do you employ neuroscience
in your psychoanalytic practice?
- This is a really interesting question.
There is an intuition that a neuropsychoanalytic formulation
in a clinical case leads to a better outcome.
What exactly those outcomes are very much open questions.
There's another PhD student who's researching this.
I know that there are plans to do studies
which could address this question,
but it's far, far from being answered.
My experience as an analyst
with offering neuropsychoanalytic understandings
comes, I think, in several forms.
Firstly, there is a specific supervision technique
developed by Psalms to understand
what is the main feeling that the patient is suffering from.
And you see, you can understand through the content
of the analytic session,
what is it that the main problem for this particular person?
And these relate to the seven ASHA2 systems
that are described in effective neurofines.
So panic, grief, care, rage, lust, fear, seeking, and so on.
By establishing this is actually quite a big deviation
from other ways of supervising a case psychoanalytically.
In my experience,
sort of what needs to happen in an analytic encounter
is to sort of make contact with something,
with the patient, and turn it from, you know,
an undigested, affective experience into thought.
This is very much a sort of, be only an idea
that it moves through a process of sort of phylogenetic
development into something more sophisticated,
which of course takes a lot of time.
And this requires affective contact
between the analyst and the patient.
Neuropsychoanalysis, or discoveries introduced
from neuropsychoanalysis,
I think give you a firmer grounding
for what exactly it is that you're doing.
You're involved in an affective experience with the patient
for the purposes of thinking something new,
by rendering it into working memory
and developing understanding.
- Well, can I ask one follow-up question, Steven?
Is a challenge that's generated
by a neuroscientific understanding any different
from a challenge generated
by any other aspect of experience?
- I suppose it's only the risk that to be with a patient
requires you to engage with your subjectivity.
I guess if you look at, I think it's Anne Alvarez,
she thought that part of what's developed in analysis
is sort of observing yourself whilst being yourself.
I call it sort of one foot in the river
and one foot on the bank.
And this is not solved.
You don't ultimately become more in the river
or more on the bank.
The whole process of psychic maturation
is to have an emotional experience
whilst being able to observe it
without being unduly dissociated from the feeling.
- I mean, my interpretation would be that
in many other situations,
you're looking at relationships
like the authority of a parent.
This is different in the sense
this is the authority of science.
And people are often very confronted by a science
because they know that they don't understand it.
So it might be more confronting,
but I think the dynamics probably are very similar.
When you challenge someone with an idea
that their parent hates them, for example,
you probably wouldn't do that with a very fragile patient,
but they then need to process that
and experience that, learn to deal with that,
as you say, while observing themselves.
I think the authority of science is different,
but the dynamic of processing that response is the same.
- I've probably only been able to address this
by metaphor or reasoning by analogy.
I'm sure that neuropsychoanalysis
will lead to the design of better psychotherapies
in the same way that flight
and the science of flight
and the science of aerodynamics
leads to the design of better planes.
I don't think we're at all clear on
in what way it improves the performance of the pilot.
You know that that is...
- I love the idea that there are gonna be
many plane crashes in the development
of neuropsychoanalysis.
- Well, I mean, we know that evolution addressed flight
in birds, but we refined the science of how it's understood.
- Bernoulli and so on.
And I think pilots...
I mean, I had a little bit of experience
flying light planes, not heaps,
but a lot of it is about feel.
And there is something analogous
to an analytic development of yourself as an individual
because you are two subjects coming together.
I think the neuropsychoanalytic understanding
has this sort of mental presence
that I'm still engaged in a scientific experience.
There is something scientific about it
without reducing the fact
that it might be exceedingly meaningful to both people
and of course oriented towards the development in the patient.
That's how I put it.
I think probably other people are gonna put it much better
than that in the fullness of time, but...
- One thing that I've sort of very briefly reflected
on that issue is that neuroscience might not help
to make the way forward clear for psychoanalysis,
but it can tell you when you're going really off track.
- Yeah.
- Potentially, so you can have one simple kind of study
or neuroscientific solution to let you know,
okay, it's definitely not down that way.
And so you can potentially reduce harm
or make something relatively straightforward,
but the way forward still isn't necessarily clear.
- That's a very good point.
That was really well demonstrated
with some of the theoretical assertions
that Francis Tufton made around autistic spectrum disorders
that were to do with early memory,
and neuroscience sort of answered the question about that.
And I think that's a really good point.
- Like analyzing people with schizophrenia, for example,
like a schizophrenic mother or something,
whereas we know it's much more complicated than that.
We don't know what it is exactly,
but we know it's not just that one kind of simple explanation.
- Yeah, yeah, I agree, I agree.
- Other authors also highlight that neuropsychoanalysis
often ignores other psychoanalytic theories,
such as Lacanian in favor of Freudian theory,
despite the development of multitudinous psychoanalytic
schools that either extend or diverge
from Freud's original work.
This concern is symbolically reflected
in the choice of neuropsychoanalysis
as the name of the discipline.
Galget has highlighted a view that neuropsychoanalysis
does not truly represent psychoanalysis,
because psychoanalysis is the study of persons,
not so-called mind brains,
and is primarily interested in meanings,
including symbolic, pre-symbolic, and unconscious,
which are argued to have little relevance to neuroscience.
Blassen-Camelli argued that the central task
of psychoanalysis is the hermeneutic investigation
of the unconscious,
as opposed to superficial neuroscientific investigations.
However, some have argued that this attitude stems
from the fact that many analytic institutes
have become siloed and dogmatic,
with the reluctance to collaborate with other research groups
or engage in interdisciplinary study,
and that this is an outdated epistemological position.
Psychiatric practitioners are also in a truly unique position
to integrate clinical neuroscience with the psychotherapies,
including traditional psychoanalytic psychotherapy.
This is because a good clinical neuroscience curriculum
still has the opportunity to address
the more subjective elements of human experience,
such as affects, emotions, and their phenomenology and experience.
These concepts could then be linked to learning processes,
theory of change,
and eventually in relation to the clinical practice
of psychotherapy or psychoanalysis.
Moreover, as scientific knowledge about the brain is acquired,
fundamental psychotherapy skills
become increasingly important for psychiatrists,
skills such as being with, as opposed to doing to,
tolerating and bearing uncertainty,
and the acknowledgement of psychic reality and subjectivity
when utilizing interpersonal processes,
such as reflective function and mentalisation.
Similarly, key psychoanalytic clinical and technical principles,
such as free association, transference, and counter-transference,
can be further aligned with neuroscience research
and emotional experience.
In this vein, within a psychiatric clinical neuroscience curriculum,
there are calls for a parallel focus on humanistic psychiatry
as a fundamental aspect of any psychotherapeutic process,
which includes existential and ontological perspectives.
These include acknowledging the differences
between psychological constructs or theories
and lived human experience,
and that knowledge is enhanced through double descriptions,
scientific and humanistic,
in the same way that three-dimensional vision is produced
by comparing differing information streams from the two eyes.
That brings us on nicely to talking a bit more about neuropsychiatry.
The Russian psychologist Alexander Lyria
made some key advances in brain science here,
underpinning the emergence of neuropsychiatry.
Lyria began his career in the 1920s
with a deep interest in psychoanalysis,
entering into correspondence with Freud in 1922
and founding a psychoanalytic society.
But by the end of his career in the late 1970s,
he'd formulated mind and brain as hierarchical functions
with a complex structure and genesis,
and subserving overlined psychological functions,
which, unlike neurology, could not be precisely localised,
except for some key elementary components.
Lyria's interest in psychoanalysis
influenced him to link personal experience and development
with mind and brain function,
leading to the emergence of the field of neuropsychiatry in the 1980s.
A 1985 symposium in Paris,
marking the 100th anniversary of Guy de la Tourette's syndrome,
is cited as a turning point in the acceptance
that a disorder could have both biological and psychological components,
rather than being exclusively either neuroanatomical or functional.
With increased recognition of neurological etiologies of psychiatric conditions,
the British Neurosychiatry Association was established in 1987,
and the American Neurosychiatric Association was established in 1989.
Neurosychiatry is now often classified as a hybrid discipline
on the border between psychiatry and neurology.
It's sometimes seen as a psychiatry of brain disorders,
i.e., that neurosychiatrists work with mental disorders,
which in most cases originate from a brain malfunction.
Broadly, it's said to emphasise cognitive functions,
such as episodic memory, visual attention, executive control,
and visually-guided action.
This parallels an interest in neuroimaging and the omics,
genomics, proteomics, metabolomics, lupidomics, epigenomics,
transcatomics and neuronomics,
particularly regarding their association with potential endophenotypes
than biomarkers for disease.
Neurosychiatry remains at present a subspecialty of psychiatry,
and unlike neuropsychoanalysis has its own training and qualification pathway
in many psychiatric postgraduate colleges.
It's a systemic/dynamic specialty.
Given neuropsychiatry is focused on broad cognitive domains,
Georg Nortov suggests that neuropsychiatry should focus
on a systemic/dynamic localisation.
This means that phenotypic function is attributed
to a network of hierarchical interconnections,
which contribute to pluripotential functional or phenotypic systems
rather than to just anatomy.
This network may incorporate resonator-oscillator circuits
associated with the degree of neuronal integration.
An example is the association
between subthalamic beta-binactivity and Parkinson's disease,
which we worked out a few years ago now.
Nortov describes neuronal integration as the coordination
and adjustment of neuronal activity across multiple brain regions,
which is considered necessary for a complex functional curve,
such as emotion or cognition.
Similarly, Friston and Price have distinguished
between functional connectivity,
the outcome of remote neurophysiological events,
including the way they are mediated by other factors,
and effective connectivity,
which describes the direct influence that one neural system
exerts over another, either at a synaptic or population level.
On a microscale, connectivity may be impacted by the number
of synapses, dendrites, or neurotransmitter factors.
While on a mesoscale, there may be columns of local connections,
and on a macroscale, there may be links between neuronal populations
by pathways from different regions of the brain.
Combinations and degrees of interaction between all three levels
can then give rise to their respective functional connectivity.
Nortov has described how these processes
may relate to traditional psychiatric and neuropsychiatric disorders,
such as top-down modulation and its role in post-traumatic stress disorder,
reciprocal modulation in depression,
modulation by reversal infobias,
and modulation by functional unity in catatonia.
Neurosychiatry addresses multiple disorders
where cognitive, behavioral, or affective disturbances
result directly from brain changes.
There's a reasonably well-defined set of treatments,
including neurostimulation, neuromodulation,
neuropsychiatric rehabilitation, including measures to enhance neuroplasticity,
which is really cool, and pharmacotherapy.
Electroconvulsive therapy remains the main neurostimulation modality,
but it's been joined by vagus nerve stimulation,
transcranial direct-current stimulation,
and transcranial magnetic stimulation.
Deep brain stimulation is another important modality of treatment
for neuropsychiatric conditions,
particularly for Tourette syndrome, obsessive-compulsive disorder,
and depression, much more commonly in other countries than in Australia.
In the future, other psychiatric treatments,
such as gene therapy, stem cell use, and brain implants,
may involve direct brain intervention
and could be regarded as neuropsychiatric.
Neurosychiatric rehabilitation is a relatively new field
that originated in the treatment of traumatic brain injury,
but has been researched to treat a range of disorders
with neurocognitive effects,
such as the dementias and schizophrenia,
by addressing dysfunctions of neuroplasticity and neurogenesis.
Similarly, cognitive stimulation and training,
such as executive exercises and memory training,
have been researched as a means to improve cognitive function,
particularly in the prevention of dementia.
Moreover, a large focus of neuropsychiatric research
is in the field of biomarkers and other omics discoveries mentioned earlier.
Much of this work involves researching endophenotypes
as intermediaries of underlying biological causes,
rather than relying on clinical phenotypes or syndromes,
with an example being mismatch negativity,
which is a test of how a brain responds to an unexpected stimulus
in a repetitive sequence,
as an intermediary marker in schizophrenia,
through relating glutamate and NMTAR receptor dysfunction
and auditory hallucinations.
So that's all the time we have for part one of this podcast.
So we'll bring part one to a close.
Part two of this podcast will cover a range of different case vignettes,
which will hopefully highlight the range of perspectives
and topics discussed here in the clinical context,
which will hopefully sort of bring them to life a little bit more
and make them a little bit more practical and have some clinical utility.
I'd like to thank Andrew, Fiona, Michael and Stephen
for coming on today and having such a rich and interesting discussion.
Thanks to you all.
Thanks, Ed.
Thanks, Ed. It was fascinating.
We'd also like to acknowledge David Bill and Nishta Kumar from the college,
who give us so much support in producing and editing the show.
We are also thankful to Australasian Psychiatry for the opportunity
to make these podcasts, as well as Sidoni Prentice for our artwork
and Shady Day for our music.
We encourage our listeners to rate the podcast
on whichever app you have accessed it,
as well as promoting it to other registrars or supervisors.
We always love getting feedback or suggestions for further episodes,
including volunteers interested in being a guest.
Please get in touch by email at
[email protected].
That's all for now. My name is Ed Miller.
Thanks for listening and we'll catch you next time.
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