- 1. Draft Horacio Page 118/10/2010CORE CURRICULUM IN
NEUROPSYCHIATRYInternational Neuropsychiatric Association
BackgroundNeuropsychiatry is an old discipline with its origins in
the mid-nineteenth century, or perhaps even earlier to the 17th
century, much before the birth of modern psychiatry. For many
decades however, neurology and psychiatry developed as separate
disciplines, leading to a dearth of dialogue between the
disciplines. Neuropsychiatry has remerged in the last two decades
as a sub-discipline which bridges the two established disciplines
of neurology and psychiatry. In its broader role, neuropsychiatry
applies the principles of neuroscience to the understanding and
treatment of emotional, behavioural and cognitive disorders. In its
narrower and more practical approach, neuropsychiatry is that
branch of psychiatry which is concerned with the diagnosis and
management of the psychiatric and behavioural consequences of
demonstrable brain disturbance, and psychiatric or behavioural
symptoms suggestive of demonstrable brain disturbance. As such, the
practice of neuropsychiatry requires skills and knowledge that in
part traverse the traditional Psychiatry / Neurology boundary.The
discipline of Neuropsychiatry (NP) must be considered in relation
to Behavioural Neurology (BN). In many respects, NP and BN are two
slightly different approaches to the same set of disorders and
conditions, with the former being biased toward traditional
Psychiatry and the latter having its route through Neurology. The
core competencies are similar, with perhaps differences in
emphasis. Since this curriculum is being developed under the aegis
of the INA, the term Neuropsychiatry will be used. An effort will
be made to identify specific areas that are particularly important
to BN so that the curriculum can be readily adapted to BN.Currently
there are few training programs worldwide that are exclusive to
neuropsychiatry and lead to a specific neuropsychiatry specialist
accreditation. In most countries, trainees who gain experience in
neuropsychiatry do so within general adult psychiatry, old age
psychiatry, child psychiatry or forensic psychiatry. This is true
even for countries in which a number of neuropsychiatry specialist
positions exist. Some countries have a dual training in Neurology
and Psychiatry, with a certification in both disciplines. While
this approach meets some of the requirements of training in NP, it
is the position of the INA that training in Neuropsychiatry
specifically, following basic training in psychiatry and neurology
is necessary to meet the requirements of specialist NP
training.Goals of a training program:The purpose of a training
program in NP is to produce specialists who will be competent in
the diagnosis and management of common neuropsychiatric disorders,
able to utilize specialized neuropsychiatric investigations in the
evaluation of these disorders, able to
2. Draft HoracioPage 218/10/2010 provide secondary and tertiary
level consultations to general physicians, psychiatrists and
neurologists, and be involved in teaching and research in relation
to these disorders. While the range of disorders included in NP is
difficult to delineate, an attempt is made in the core competencies
section of this document to define this territory, with the
acknowledgement that this is an evolving process depending upon the
knowledge base of the day.The following are the goals of the
training program:1. To develop a sound knowledge base of the
neuroscientific principles underlyingneuropsychiatric practice, in
relation to neuroanatomy, neurophysiology,neurochemistry and
neuropharmacology.2. To gain first hand experience of common
neuropsychiatric disorders and becomecompetent in their diagnosis
and management.3. To develop an expertise in the use and
interpretation of specializedneuropsychiatric investigations, in
particular neurophysiology, neuroimaging andneuropsychology.4. To
be competent in the recognition and management of common
psychiatric andneurologic disorders.5. To develop specialized
skills in the physical treatments in neuropsychiatry, butwithout
ignoring the principles of psychotherapeutic and
rehabilitativeapproaches.6. To develop skills in the critical
evaluation of research evidence in thepathophysiology,
phenomenology and treatment of neuropsychiatric disorders.7. To
conduct research to improve the empirical basis of
neuropsychiatricknowledge and practice.8. To act as advocates for
sufferers of neuropsychiatric illnesses, and to contribute tothe
development of the profession.Structure of a NP training
program:There is no one model that will suit all training programs
in NP. An attempt is made to outline the basic tenets of such a
program. i. A NP training program shall endeavour to create
specialists in NP who functionas secondary and tertiary level
specialists. They shall provide consultations togeneral
psychiatrists, neurologists and general physicians on a range
ofneuropsychiatric disorders. ii. A NP training program will
generally comprise a 2-year fellowship programwhich will focus on
the core competencies detailed below. In some situations,only a
one-year fellowship in NP maybe practicable. Full competency should
notbe assumed after one year of training. However, if the trainee
works for a furthertwo years in a largely or exclusively
neuropsychiatric service (but not specificallyas a trainee), it
would be considered likely that the training requirements wouldhave
been met in this period. iii. The NP Fellow will have previously
received training in Psychiatry and/orNeurology. In general, this
would have been a 3-year training program in a centrethat offers
training in both specialties. It is expected that the psychiatry
trainee 3. Draft HoracioPage 318/10/2010 would have received at
least 6 months training in neurology, but the neurology trainee
would have at least 1 year of training in psychiatry. If this is
not the case, the Fellowship period would be used to remedy this
with a clinical rotation in the appropriate discipline.iv. The NP
training will be in a neuropsychiatric centre with two or more
neuropsychiatrists, one or more clinical neuropsychologists, a
neurologist (part- time or fulltime), and a working relationship
with psychiatric, clinical neurology and neurosurgical services.
The centre would be part of a general teaching hospital and have
easy access to a neurophysiology service and up-to-date
neuroimaging, which would include structural MRI and functional
imaging. It would also have a research program.v. The training
program will include a research project, which would preferably be
based on empirical research.vi. The training program will have an
evaluation component, based on a formal assessment and/or a series
of informal assessments by the supervisors.vii. The program will
prepare the trainee for a life-long period of education and
professional enhancement.viii.The program will instil by example
the highest ethical standards of conduct in clinical practice and
scholarly work. 4. Draft HoracioPage 418/10/2010 A survey of
required competencies in NeuropsychiatryThe curriculum below
identifies some core competencies in the skill base, and specific
modules of specialist knowledge base. These shall be acquired over
two years. The competencies are described as modules, but they are
not necessarily independent of each other. The importance of the
Core Skills module is highlighted. The aims and objectives of this
module will normally be covered within the specific clinical
modules undertaken but should represent an additional and specific
focus of study within the individual clinical modules. The level of
expertise in each of the specific modules will vary, depending upon
the facilities available, but a basic level of competence in each
module is expected in a 2-year training program.1. Core Skills
Module1.1. Knowledge base in clinical neuroscience1.2. Clinical
skills in neuropsychiatry1.2.1.Neuropsychiatric diagnosis including
history and examination, neurophysiological investigations,
neuroimaging, neuropsychology, and other
investigations1.2.2.Treatment, including pharmacology and other
physical treatments (ECT, TMS, Surgical interventions), without
neglecting psychotherapeutic and rehabilitative interventions1.3.
Critical thinking in neuropsychiatry research and scholarship2.
Specific modules 2.1. Cognitive disorders:2.1.1.Dementias and
Pre-dementia syndromes2.1.2.Non-dementing cognitive disorders2.2.
Seizure disorders2.3. Movement disorders2.4. Traumatic brain
injury2.5. Secondary psychiatric disorders, i.e. psychosis,
depression, mania and anxiety disorders secondary to organic brain
disease2.6. Substance-induced psychiatric disorders alcohol, drugs
of abuse, etc.2.7. Attentional disorders (adult ADHD and related
syndromes)2.8. General Hospital Liaison Neuropsychiatry2.9.
Developmental Neuropsychiatry2.10.Sleep
disorders2.11.Neuropsychiatric rehabilitation2.12.Forensic
neuropsychiatry 5. Draft HoracioPage 518/10/20101. CORE SKILLS
MODULESpecific Competencies1.1 Knowledge base in Neuroscience:
Knowledge of brain structure at the macroscopic and microscopic
levels, inparticular the knowledge of neuronal networks, the limbic
system, theneuroanatomical substrates of memory and the frontal
executive system A knowledge of CNS structure-function correlations
Knowledge of neurochemistry, especially neurotransmitter and
receptorfunction. The biochemical basis of neuropsychopharmacology
The basic principles of neurophysiology The basic principles of
genetics and immunology as they apply to the CNS A basic grasp of
issues related to the mind-brain debate, the biology
ofconsciousness and other neurophilosophical issues.1.2 Clinical
skills in Neuropsychiatry 1) Undertake clinical assessment of
patients with apparent or possible neuropsychiatric problems.(i)
Take a neuropsychiatric history; this includes all of the
information routinely gathered as part of a psychiatric and medical
history, but with special emphasis on gathering information about
possible illnesses or injury to the central nervoussystem, sudden
or gradual changes in intellectualfunctioning, level of
consciousness, personality andjudgement, as well as changes in
motor and sensory functions, whichmight indicate neurological
disease.(ii)Perform a neuropsychiatric assessment. This will again
involve and encompass all of the routine skills required to carry
out a psychiatric examination, but in addition will include:
demonstration of the ability to elicit informationrelevant to
possible neuropsychiatric disorders andneurological conditions, for
example: the ability tolist the history of stepwise cognitive
decline orpsychomotor seizure activity.(iii) Perform a cognitive
examination (simple and extended). A core skill in neuropsychiatry
is the ability to carry out simple tests at the bedside to
determine a patients level of orientation, attention, 6. Draft
Horacio Page 618/10/2010 concentration, memory etc. and to do so in
the context of a psychiatric examination. A neuropsychiatrist, and
in particular one from a neurological background, would be
competent in assessing deficits in language, praxis, gnosis,
visuospatial function and other cognitive syndromes This would not
require the ability to administer formal neuropsychological tests,
but may involve carrying out paper and pencil tests and the use of
simple material such as word lists or pictures. A neuropsychiatrist
should have competency in interpreting results of such an
examination in order to determine whether the patient is suffering
from a dementing illness, a confusional state or a specific
cognitive deficit as well as competency in diagnosing the range of
adult psychiatric conditions. Part of the skill would involve
placing the results of the examination in the context of the
patients educational and social background and pre-morbid level of
functioning.(iv) Perform a neurological examination. The trainee
should be able to carry out a full anddetailed neurological
examination, if necessary,with particular emphasis on the central
nervoussystem and higher cortical functioning. The trainee should
be able to demonstrate the abilityto interpret any abnormal signs
elicited and placethem in the context of the patients presentation
anda differential diagnosis. This may include elicitingsigns, which
require further specialist investigation,either within the realm of
neuropsychiatry orneurology or electrophysiology.(v)Construct a
neuropsychiatic differential diagnosis. The trainee
neuropsychiatrist should be able todemonstrate familiarity with
multi-axial forms ofclassification. S/he should be able to arrange
multiple diagnosesinto a rational hierarchy and be able to
summarisethe key elements of the history and examination,which
support that differential diagnosis. S/he should be able to
evaluate the extent to whichpatterns of psychiatric symptomatology
andpresentation may be due to underlying organic braindisease. 7.
Draft HoracioPage 718/10/2010 Be familiar with the range of organic
disorders thatmay account for particular presentations. S/he should
be able to communicate this in a clearand concise way to other
health professionals aswell as patients and their carers. 2)
Undertake and plan investigation of a patient with apparent or
possibleneuropsychiatric problems.i) Trainees should be familiar
with the relevant haematological,metabolic, bacteriological,
virological, immunological andtoxicological investigations of
relevance to neuropsychiatry. This willinclude: Demonstrating
knowledge and judgement that the relevant parameter is of central
importance to the neuropsychiatric presentation Knowing which
investigations need to be pursued with further tests, and knowing
which may be incidental or within normal limits. Interpretation of
examination of cerebro-spinal fluid, nerve, muscle and brain biopsy
will also be required, although detailed knowledge is not
necessary.ii) Unlike many other specialities within psychiatry,
neuropsychiatry requires familiarity with EEG and other
neurophysiological investigations and their interpretation. The
trainee should be able to discuss the advantages and limitations of
the routine EEG, sleep EEG and longer term EEG telemetry in
patients with possible neuropsychiatric problems. While the trainee
is not expected to be competent in reading EEGs independently, s/he
should have working knowledge of the profiles of normal and
abnormal EEGs. In addition s/he should understand the use and
application of sensory evoked potentials and nerve conduction
studies and EMG as they occur in neurological disorders with
neuropsychiatric complications, and also as a tool to exclude
neurological causes of abnormal function, which may in fact have a
psychological basis. The trainee should be familiar with the
settings in which these investigations are carried out, should be
able to query the interpretation with a consultant or 8. Draft
HoracioPage 818/10/2010experienced technician in the area and to
conveythis information to members of the multi-disciplineteam,
carers and patients alike.iii) Neuropsychiatry requires sound
understanding of the indications for,and interpretations of, the
various forms of brain imaging, bothstructural and functional,
including MRI, CT, SPECT and PET etc. The trainee should have
sufficient familiarity with these techniques to be able to describe
them to a patient and their family/carer and to be able to
interpret the results. The trainee should know when such
investigations are likely to alter management or treatment
decisions and should have some understanding of their theoretical
importance. The trainee should have sufficient first hand knowledge
of CT and MRI brain scans to be able to detect salient
abnormalities and critically assess an expert report.3) Prescribe
and oversee treatment to patients with neuropsychiatric
disorderssuch as those with psychiatric and behavioural symptoms
and co-existingneurological disorder. Be familiar with social,
psychological and biologicalinterventions for neuropsychiatric
disorders.i) The trainee should have sufficient skill to explain
the mode of action,benefits and side effects of these treatments to
fellow healthprofessionals, patients and their families. Be
familiar with the principles of treatment of majorneurological
disorders and be familiar withneuropsychiatric complications of
such treatment. The neuropsychiatrist should also be aware of
theneurological manifestations and complications ofpsychiatric
treatment and advise patients andprofessionals on evaluating the
importance of theseand in minimising their occurrence and severity.
ii) Be familiar with potential drug interactions between
psychiatric andneurological medications and other treatments. This
will include the awareness of the risks associated withprescribing
psychotropic drugs to patients with neurological andneurosurgical
diseases. iii) Be familiar with non-pharmacological treatments in
neurological and neuropsychiatricdisorders. The trainee will have
competence in the assessmentfor and the administration of
electro-convulsivetherapy (ECT) in its current form. 9. Draft
Horacio Page 918/10/2010 The trainee should have some understanding
of the newer physical treatments such as transcranial magnetic
stimulation (TMS), vagus nerve stimulation (VNS), deep brain
stimulation (DBS), and other physical treatments. S/he should also
acquire knowledge of the principles of neuro-rehabilitation and
familiarity with the concepts of disability and handicap 4) To
diagnose and treat patients with medically unexplained symptoms
which present as neurological and neuropsychiatric problems, this
includes working with colleagues in other disciplines to determine
which further tests and investigations are necessary or not as the
case may be. (i) Neuropsychiatry should involve competence in
understanding thepossible social, cultural and family influences on
unexplainedneurological symptoms. (ii)The trainee should be able to
develop a grasp of the principles behindcognitive behavioural
treatments for such patients and be able to planand oversee such
treatments carried out by another professional suchas a trained
nurse or clinical psychologist. (iii) S/ he should be aware of the
relationship between neuropsychiatryand allied psychiatric
subspecialties such as old age, child and learningdisability
psychiatry and which service patients might mostappropriately be
served by.1.3Critical thinking in neuropsychiatry research and
scholarshipA specialist training in NP will equip the trainee to
think critically in the field. The trainee should be able to
critically assess the empirical evidence in support of any clinical
practice, including the ability to criticize published material.
This skill can be developed by means of journal clubs, attendance
at research meetings, research presentations, short-term courses,
etc. It is expected that in the second year of training, the
trainee will undertake a research project. This should ideally
involve all the steps in an empirical project (background review,
design of study, applying for ethics clearance, data gathering,
analysis and report preparation). However, it may take up the form
of a critical review of a current topic, or a case series. The
trainee will produce a report of a publishable standard, as judged
by the supervisors, and will be encouraged to publish in a peer-
reviewed journal. The research report will be a mandatory component
of the second year of training. 10. Draft HoracioPage 10 18/10/2010
2. SPECIFIC MODULES MODULE 2.1 Cognitive DisordersA. Specific
CompetenciesI.Dementias and pre-dementia syndromes:Be familiar with
the diagnosis and investigation of dementias resulting from: -
Alzheimers disease (AD) - Vascular Cognitive Impairment (VCI) -
Dementia with Lewy Bodies (DLB) - Fronto-temporal dementia (FTD) ,
including semantic dementia, progressive aphasia, etc. - Dementias
related to Parkinsonism+ syndromes (progressive supranuclear palsy,
corticobasal degeneration, multiple system atrophy) - Prion
diseases, esp. Creutzfeldt-Jakob disease and variant CJD -
Huntingtons disease - Dementia resulting from head injury, alcohol
use, medical conditions including HIV, brain tumours, encephalitis,
etc.II. Other cognitive disorders:a. Be familiar with the diagnosis
and investigation of specific memorydisorders (amnesic syndromes),
in particular:- Alcoholic Korsakoffs syndrome- Other causes of
thiamine deficiency- Brain infection such as herpes encephalitis or
other encephalopathies- Brain dysfunction resulting from cerebral
hypoxia e.g. carbon monoxide poisoning- Vascular disorders, such as
thalamic infarction or subarachnoid haemorrhage b. Be familiar with
the diagnosis and investigation of frontal/executive syndromes of
disinhibitory and non-spontaneous types c. Be familiar with the
diagnosis and investigation of other, more posterior cognitive
disorders:- including language disorders (anomias, and disorders of
comprehension orexpression), reading disorders (surface and deep
dyslexia), mentalcalculation (whether or not part of Gerstmanns
syndrome), disorders ofvisuo-spatial awareness, perception,
construction, and the agnosias. III. Be familiar with the diagnosis
and investigation of psychologically-basedcognitive impairments: -
Hysterical conditions, including psychogenic amnesias 11. Draft
HoracioPage 1118/10/2010-Pseudodementias, as in
depression-Cognitive impairment as part of somatisation,
factitious, or malingering syndromes IV. Be familiar with the
status and controversies regarding Mild Cognitive ImpairmentB.
Diagnostic techniques: - Clinical assessment including neurological
and clinical cognitive examination. - Be familiar with the role,
importance, and principles of neuropsychological testing. - Be
familiar with the interpretation of Occupational Therapy and Speech
and Language Therapy assessments and reports. - Be familiar with
the relevant investigations in a clinical blood screen. - Be aware
of when an EEG can be helpful or even crucial. - Be familiar with
the purpose and interpretation of CT and MRI brain scans. - Be
aware of the putative role of other forms of neuroimaging including
SPECT, PET, DTI, and fMRI.C. Be familiar with the main principles
involved in the management and treatment ofcognitive disorders and
of dementias:- The work of a multidisciplinary team- The
contribution of cognitive behaviour therapy and psychological
counselling in specific conditions- The use of cognitive enhancing
drugs including cholinesterase inhibitors and memantine- The use of
other medications in neuropsychiatry, including anti-convulsants
and anti-depressants- The management of behavioural disturbances in
dementia- The use of outreach and community support servicesD. How
taught:- Observation and modelling- Working as a team member-
Supervise clinical practice- Review of suitable texts and papers in
scientific publications, including reviewarticlesE. How assessed: -
Clinical supervision - Direct observation - Clinical log book -
Clinical audit - Case presentations, etc. 12. Draft HoracioPage
1218/10/2010 MODULE 2.2 - SEIZURE DISORDERSSpecific competencies:1.
Undertake a clinical assessment of patients with suspected epilepsy
i.Take a seizure history ii. Take a neuropsychiatric history
focusing on eliciting impact of seizuredisorder on the patient
iii.Take a history from an informant iv. Perform a neurological
examination on patients with suspected epilepsy v.Construct a
formulation with differential diagnoses for the seizure type
andsyndrome, along with discussion of aetiology 2. Assess patients
suspected of having non epileptic seizures (NEAD) i.Be familiar
with the main features differentiating epilepsy and NEAD ii. Be
familiar with the co-existence of epilepsy and NEAD iii.Be familiar
with the management of NEAD 3. Undertake investigation of patients
with suspected epilepsy i.Be familiar with EEG recording and
interpretation (including the limitations)in people with epilepsy
ii. Be familiar with the indications for and interpretation of
structural andfunctional neuroimaging in people with epilepsy 4.
Prescribe treatment to patients with coexisting neurological
disorder i.Be familiar with social and psychological interventions
for the treatment ofepilepsy including relaxation techniques and
other behavioural methods ofcontrolling/ inhibiting seizures ii. Be
familiar with the principles of the medical treatment of the
differentseizure and syndrome types 13. Draft Horacio Page
1318/10/2010iii.Be familiar with potential drug interactions
between psychiatric medicationsand anticonvulsants iv. Be aware of
the risks associated with prescribing psychotropic agents
topatients with epilepsy v.Be familiar with the surgical treatment
of epilepsy including vagal nervestimulation 5. Assess and manage
special patient groups with epilepsy i.Be familiar with the
difficulties in assessing and managing seizure disordersin children
and adolescents with epilepsy, including issues around puberty ii.
Be familiar with the difficulties in assessing and managing seizure
disordersin women with epilepsy, including catamenial epilepsy,
contraception,pregnancy, teratogenicity, polycystic ovarian
syndrome, menopause iii.Be familiar with the difficulties in
assessing and managing seizure disordersin older age patients,
including cognition and issues regarding concomitantphysical
illnesses and medication iv. Be familiar with the difficulties in
assessing and managing seizure disordersin patients with learning
disability including aetiology, difficulty eliciting ahistory,
cognitive and treatment issues6. Assess and manage psychiatric
co-morbidity in people with epilepsy: pre-ictal, ictal, post-ictal,
interictal and iatrogenic i.Be familiar with the diagnosis and
management of depression in people withepilepsy including the risk
of suicide ii. Be familiar with the diagnosis and management of
anxiety/panic attacks inpeople with epilepsy, including the
difficulties in differentiating betweenpanic attacks and ictal
panic iii.Be familiar with the diagnosis and management of
psychosis (post-ictalpsychosis, chronic interictal psychosis and
forced normalisation) in peoplewith epilepsy iv. Be familiar with
the diagnosis and management of cognitive dysfunction inpeople with
epilepsy, resulting from seizures and anticonvulsant
medication,including the role of neuropsychological assessments 14.
Draft Horacio Page 14 18/10/2010 v.Be familiar with the diagnosis
and management of sexual dysfunction inpeople with epilepsy vi. Be
familiar with the diagnosis and management of disorders of
impulsecontrol (anger/irritability, drug/alcohol problems) in
people with epilepsy vii.Be familiar with quality of life issues in
people with epilepsy, such as stigma,locus of control,
employment/relationship difficulties.7. Be aware of the issues
involved in the medico-legal aspects of epilepsy i.Be aware of the
driving license implications of having epilepsy ii. Be familiar
with the concept of automatisms when used as a defence in court.8.
Liaison with Epilepsy Surgery Program:In centres affiliated with
Epilepsy Surgery programs, the trainee should becomefamiliar with
the psychiatric issues involved in the assessment of candidates
forepilepsy surgery, and be able to provide pre-operative
consultations and post-operative follow-up to such patients. B. How
taught / clinical settingsC. How assessed 15. Draft HoracioPage
1518/10/2010 Module 2.3 Movement DisordersSpecific Competenciesi.
Clinical assessment 1) Take a history of movement disorder 2)
Assess psychiatric history 3) Assess neurological history 4)
Perform psychiatric examination 5) Perform neurological examination
6) Construct differential diagnosis of movement disorderii.
Investigation 1) Review previous neurological examinations 2)
Review previous neurological treatment 3) Review previous
psychiatric treatment 4) Order further relevant investigationsiii.
Treatment 1) Review previous psychiatric treatment 2) Review
previous neurological treatment 3) Recommend alterations to current
treatment 4) Prescribe new appropriate treatment 5) Review effects
of treatmentSuggested learning methods 1) Attend movement disorders
clinic 2) Discuss neurological treatment of movement disorders with
neurologistSuggested assessment method clinic logbook 1) Parkinsons
disease 2) Tourettes syndrome tics 3) Tremor 4) Dystonia 5)
Catatonia 6) Neuroleptic induced movement disorders tardive
dyskinesia, tardive dystonia, akathisia, NMS, drug-induced
parkinsonism, etc. 7) Hysterical conversion/somatisation disorders
16. Draft HoracioPage 16 18/10/2010 Module 2.4 Traumatic Brain
injuryClinical settings: i. Emergency services, with patient
presenting with psychiatric disturbancefollowing head injury ii.
Medical or surgical ward, involving patients with neuropsychiatric
disturbancefollowing head injury iii. Outpatient clinics iv.
Neurorehabilitation settings v. Medicolegal settingsSpecific
competencies: i. To take a competent trauma history, including the
assessment of PTA, administration of GCS, etc.ii. To assess
psychiatric morbidity related to head injuryiii. To assess the
relative contributions of brain injury, post-traumatic epilepsy,
physical disability, personality, psychosocial and medicolegal
factors contributing to neuropsychiatric presentationsiv. To be
able to assess cognitive disturbances following head injury,
including the interpretation of neuropsychological assessmentsv. To
be able to manage neuropsychiatric disturbances in head injured
patients using drug treatment, cognitive and behavioural
interventions. Suggested learning methods: i. Participate in
emergency, medical and surgical consultations with supervisorii.
Assess patients in outpatient clinics and follow-up these
patientsiii. Attend rehabilitation rounds and participate in
consultations. 17. Draft HoracioPage 1718/10/2010 Module 2.5
Secondary psychiatric syndromes and deliriumClinical settings:i.
Psychiatric wards ii. Neuropsychiatric outpatient clinics iii.
Medical and surgical wardsSpecific competencies:i. Familiarity with
common presentations of delirium and secondary
psychiatricsyndromes, including secondary delusional disorder,
secondary hallucinosis,secondary depression or mania, secondary
anxiety disorder, secondary OCD, andorganic personality disorders.
ii. Knowledge of the common causes of these syndromes iii.
Competency in the investigation of the aetiology of secondary
syndromes, and theinterpretation of the results of the
investigations. iv. Experience in the treatment of such syndromes,
including the use of psychotropicand neurotherapeutic drugs. v.
Knowledge of the pathophysiological mechanisms underlying the
development ofsecondary syndromes.Suggested learning methods:i.
Review of published material ii.Neuropsychiatric clinic attendance
iii. Consultations on psychiatric, medical and surgical wards
iv.Case discussions 18. Draft Horacio Page 18 18/10/2010 Module
2.6Substance-induced neuropsychiatric psychiatric syndromesClinical
settings:i. Drug-dependence clinic ii.Psychiatric wards iii.
Neuropsychiatric outpatient clinics iv.Medical and surgical
wardsSpecific competencies:i. Familiarity with common presentations
of alcohol and substance relatedneuropsychiatric syndromes ii.
Competency in the investigation of these syndromes, including
biological andpsychosocial investigations iii. Experience in the
treatment of such syndromes, including the use of psychotropicdrugs
and psychosocial and rehabilitative interventions iv. Knowledge of
the pathophysiological mechanisms underlying the development
ofthese syndromes.Suggested learning methods:i. Review of published
material ii.Clinic attendance iii. Consultations on psychiatric,
medical and surgical wards iv.Case discussions 19. Draft
HoracioPage 1918/10/2010 Module 2.7 Attentional and dysexecutive
syndromes (including Adult ADHD)Clinical settings: i. Specialised
Adult ADHD Clinicii. Psychiatric wardsiii. Neuropsychiatric
outpatient clinicsSpecific competencies: i. Familiarity with common
presentations of ADHD in adultsii. Competency in the investigation
of attentional and frontal dysexecutive syndromes, including
biological and psychosocial investigationsiii. Experience in the
treatment of such syndromes, including the use of psychotropic
drugs and psychosocial and rehabilitative interventionsiv.
Knowledge of the pathophysiological mechanisms underlying the
development of these syndromes.Suggested learning methods:i. Review
of published material ii.Clinic attendance iii. Consultations on
psychiatric, medical and surgical wards iv.Case discussions 20.
Draft HoracioPage 2018/10/2010 MODULE 2.8 - GENERAL HOSPITAL
LIAISON NEUROPSYCHIATRYKey competencies.1. Undertake assessment of
patients with unexplained neurological symptoms i)Take an
appropriate neuropsychiatric historyii) Interpret previously
performed investigationsiii)Perform examination of mental and
physical statusiv) Assess the patients function in the context of
their disabilityv)Understand the concepts of conversion,
somatisation and dissociation in aneurological context.vi)
Formulate appropriate management plansvii)Communicate information
to the neurological teamLearning and assessment methods;1i Take an
appropriate neuropsychiatric history (see other sections)1ii
Interpret previously performed investigations Suggested learning
methods Suggested assessment methods Observation/modellingValidated
self-assessment Supervised clinical practice Clinical Supervision
Specific teaching from relevant health Case presentation
professionals (e.g. radiologist)1iii Perform examination of
physical and mental status (see other sections)1iv Assess patients
function in the context of their disability Suggested learning
methodsSuggested assessment methods Observation/modelling Validated
self-assessment Supervised clinical practiceClinical supervision
Specific teaching from relevant healthClinical log-book
professionals (e.g. occupational therapist) Case presentation1v
Understand the concepts of conversion, somatisation and
dissociation Suggested learning methods Suggested assessment
methods Supervised clinical practice Clinical supervision Reading
relevant texts Clinical log book Peer group discussionCase
presentation1vi Formulate appropriate management plans (see other
sections)1vii Communicate information to neurology team Suggested
learning methods Suggested assessment methods Obervation/modelling
Clinical supervision 21. Draft HoracioPage 21 18/10/2010 Supervised
clinical practiceDirect observation 2) Undertake assessment of
patients with delirium. i)Take a relevant clinical history from
patient and informantsii) Gather information from clinical
staffiii)Perform examination of physical and mental statusiv)
Construct an appropriate differential diagnosis (delirium vs.
depression vs.dementia)v)Perform investigation to ascertain
aetiologyvi) Initiate and monitor treatment where
appropriateLearning and assessment methods 2i Take a relevant
clinical history from patients and informants (see other sections)
2ii Gather information form clinical staffSuggested learning
methods Suggested assessment methodsObservation/modellingClinical
supervisionSupervised clinical practice Direct observationWorking
as a team member 2iii Perform examination of physical and mental
status (see other sections) 2iv Construct an appropriate
differential diagnosis (e.g. delirium vs. depression
vs.dementia)Suggested learning methods Suggested assessment
methodsSupervised clinical practice Clinical supervisionAppropriate
readingCase presentation Clinical log book Validated
self-assessment 2v Perform investigation to ascertain
aetiologySuggested learning methods Suggested assessment
methodsSupervised clinical practice Clinical supervisionAppropriate
readingCase presentationSpecific teaching from other healthClinical
log bookprofessionalsValidated self-assessment2vi Initiate and
monitor treatment where appropriate (see other sections) 22. Draft
HoracioPage 22 18/10/2010 MODULE 2.9 : DEVELOPMENTAL
NEUROPSYCHIATRYPreamble:Developmental neuropsychiatry is that
branch of psychiatry concerned with the diagnosis and management of
emotional, behavioural and learning disorders that are associated
with demonstrable or suspected organic brain dysfunction, and which
manifest during childhood. Because these disorders are primarily
disruptive to normal developmental attainments or adjustment, they
are known as neurodevelopmental disorders. The practice of
developmental neuropsychiatry requires skills and knowledge that
encompass not only child psychiatry, in broad terms, but also
paediatric neurology and learning disabilities.Currently, there is
no formal training programme leading to a specific accreditation in
developmental neuropsychiatry. In this respect, the sub-specialty
is in the same category as adult neuropsychiatry. Few child
psychiatric training programmes explicitly include training in
developmental neuropsychiatry. However, it is arguable that within
the clinical field of child psychiatry, neurodevelopmental
disorders are now the predominant reason for specialist
referral.The competencies outlined below describe the minimum range
of skills in developmental neuropsychiatry that ought to be
acquired by consultant child psychiatrists in training. We
recommend that all trainees have at least one year of experience in
this specialty, but that those who intend to become specialists in
this area may choose to spend additional time gaining particular
skills. Skills in developmental neuropsychiatrySpecific
competencies: 1. Undertake clinical assessment of patients with
apparent neurodevelopmental disorders, a. Take a developmental
neuropsychiatric history b. Perform a neurobehavioural assessment
c. Arrange for, and interpret a neurocognitive examination d.
Perform a neurological examination, and interpret signs e.
Construct a neurodevelopmental differential diagnosis 2. Undertake
investigation of patients with apparent developmental
neuropsychiatric disordersa. Be familiar with relevant
haematological and metabolic investigationsb. Be familiar with EEG
recording and interpretationc. Be familiar with indications for and
interpretation of structural neuroimaging 23. Draft Horacio Page
2318/10/20103. Prescribe treatment to patients on basis of clinical
assessmenta. Be familiar with the evidence for the effectiveness of
specificpharmacological treatments of common neurodevelopmental
disordersb. Be familiar with the constraints on prescribing
psychotropic medicationsto children, the indications, approval
status and potential side effectsc. Be familiar with the need to
undertake appropriate investigations beforeprescription, and the
need for monitoring of treatments prescribed, in orderto minimise
side-effects and complications.d. Be familiar with indications for
non-medical treatments including:behavioural management techniques,
educational interventions, skills-training (e.g. motor, social,
speech and language). 1a. Taking a developmental neuropsychiatric
history: Suggested learning methods Suggested assessment methods
Observation/modelling Validated self assessment Working as a team
member In-training assessment Supervised clinical practice Clinical
supervision Focused training courses Direct observation of clinical
work Peer review Clinical logbook Clinical audit Case presentations
Review of case notes and other records Chart-stimulated recall 24.
Draft Horacio Page 2418/10/2010 3) Work collaboratively with
neuroscience colleagues i)Obtain relevant information about
patients behaviour from neuroscience staffii) Advise neuroscience
ward staff about interpretation and management ofabnormal mental
states and behavioursiii)Work collaboratively with neuroscience
clinicians to establish correctdiagnoses and treatment plansiv)
Develop academic links within the neuroscience communityLearning
and assessment methods3i Obtain relevant information about patients
behaviour from neuroscience staff Suggested learning
methodsSuggested assessment methods Observation/modelling Clinical
supervision Supervised clinical practiceDirect observation3ii
Advise staff about the interpretation and management of abnormal
mental states and behaviours Suggested learning methodsSuggested
assessment methods Observation/modelling Clinical supervision
Supervised clinical practiceDirect observation3iii Work
collaboratively with neuroscience colleagues to establish correct
diagnosis and treatment plans Suggested learning methodsSuggested
assessment methods Observation/modelling Clinical supervision
Supervised clinical practiceDirect observation3iv Develop academic
links with the neuroscience community Suggested learning
methodsSuggested assessment methods Observation/modelling Clinical
supervision Supervised clinical practiceCase presentation 4) Assess
critically ill patients in a neuroscience setting i)Assess the
mental states of patients who are in the post-operative period or
ina neuro critical care settingii) Produce a differential diagnosis
and formulation for patients with mentaldisorder in this
settingiii)Make assessments of capacity in critically ill
patientsiv) Advise on the management of disturbed behaviour in
critically ill patients 25. Draft Horacio Page 2518/10/2010
Learning and assessment methods4i Assess mental states of patients
who are in the post operative period or in a neuro critical care
setting Suggested learning methods Suggested assessment methods
Observation/modellingClinical supervision Working as a team member
Direct observation Supervised clinical practice Clinical
logbookCase presentation4ii Produce a differential and formulation
for patients with mental disorder in this setting Suggested
learning methods Suggested assessment methods Supervised clinical
practice Clinical supervision Appropriate readingCase
presentationClinical logbook4iii Make assessments of capacity in
critically ill patients Suggested learning methods Suggested
assessment methods Supervised clinical practice Clinical
supervision Observation/modellingCase presentation4iv Advise on
management of disturbed behaviour in critically ill patients
Suggested learning methods Suggested assessment methods Supervised
clinical practice Direct observation Observation/modellingClinical
supervision Working as a team member 26. Draft Horacio Page
2618/10/2010 MODULE 2.10 - SLEEP DISORDERSCore competencies in
assessment & management of patients with sleep disorders 1.
Specific CompetenciesHave knowledge of aetiology, prevalence,
diagnosis, categorisation and treatment ofsleep disorders:i.
Primary insomniaii. Secondary insomniaiii. Hypersomniasiv.
Parasomniasv. Neuropsychiatric consequences of sleep apnoea
syndrome 2. Diagnostic techniques i. Take an appropriate history
relevant to sleep problems.ii.Perform appropriate examination of
mental, neurological and physical status.iii. Be able to relate
history and clinical findings to relevant medical,
neurological,psychological and social issues associated with
aetiology and treatment.iv. Have knowledge of use, reliability and
validity of generally accepted techniquesand investigations for
diagnostic assessment and the interpretation of results.v. Have a
basic understanding of the EEG, polysomnogram, oximetry and
actigraphyvi. Understand the major theories of sleep
mechanisms.vii. Have competence to form differential diagnosis and
to diagnose medical,neurological and psychiatric sleep disorders
and those sleep problems associated withmedical, psychiatric and
neurological conditionsviii. Understand the biological,
psychological, social, economic factors that influenceevaluation
and management of sleep disorders 3. Management i. Formulate
appropriate management plans.ii. Be familiar with therapies used
(behaviour therapy, psychotherapy, drug treatmentand physical
treatments such as CPAP).iii. Have competence of being aware when
to refer to a sleep disorders clinic.iv. Have basic knowledge
relating to ethical and legal aspects of sleep medicineSuggested
learning methods1. Observation/modelling2. Supervised clinical
practice3. Reading relevant texts4. Peer group discussion5.
Multidisciplinary case conferences, journal clubs6. Specific
teaching from relevant health professionals (e.g. EEG, respiratory,
neurology) 27. Draft Horacio Page 2718/10/20107. Primary
responsibility for diagnosis and treatment of reasonable number and
adequate variety of patients with acute and chronic sleep disorders
(eg at least 5 hypersomnia, 5 parasomnia, 10 insomnia, of range of
ages)8. Attendance at respiratory sleep disorder clinic for the
diagnosis of sleep apnoea9. Attendance at multidisciplinary
national conferencesSuggested assessment methods1. Validated
self-assessment2. Clinical supervision and feedback3. Case
presentation4. Clinical Log book 28. Draft HoracioPage 2818/10/2010
MODULE 2.11 - REHABILITATION NEUROPSYCHIATRY.Clinical
settingsRehabilitation Units providing neurophysical
rehabilitation; District and/orRegional Rehabilitation
Units.Neuropsychiatric/Cognitive Behavioural Rehabilitation Units
for people withbrain injury.Neuropsychiatry / Liaison psychiatry
services to Clinical Neurosciences Centres,General District
Hospitals, and nursing homes and other residential
units.Neuropsychiatry / liaison psychiatry outpatient
clinics.Knowledgeof the pathophysiology of common causes of
acquired brain injury.of brain - behaviour relationships, in
particular following acquired focal lesions tothe brain and diffuse
brain injury.of the neuropsychiatric sequelae of acquired brain
injury, including aetiology andmanagement of symptoms.of the
principles of cognitive behaviour therapy and behaviour therapy
forbehavioural problems and other symptoms following brain injuryof
the ICIDH model of impairment, disability and handicap
(impairment,activities and participation).of outcome measures
suitable for patients with acquired brain injury.of Rehabilitation
Service provision, organisation and funding, including
voluntarysector provision.Skillsto undertake an assessment to
understand the role of brain injury inneuropsychiatric symptom
formation.to assess the role of psychological processes and mental
illness in symptomformation after acquired brain injury.to use
pharmacotherapy to manage neuropsychiatric symptoms after
acquiredbrain injury. 29. Draft HoracioPage 29 18/10/2010 to work
with the multidisciplinary team (MDT), including psychologists and
othertherapists, to produce an overall treatment strategy for
symptoms. to interpret neuropsychometric test results sufficiently
to produce aneuropsychiatric formulation to set up, in
collaboration with the MDT, a programme of therapy based on
goalplanning. to work alongside psychologists, behavioural nurse
therapists and others toimplement cognitive behavioural treatments
and behavioural treatments. to set up effective aftercare following
inpatient rehabilitation, based on goodcommunication across health
services, social services, statutory services andvoluntary sector.
to undertake a risk assessment for all commonly occurring risks
followingacquired brain injury, and ensure that there are
procedures in place to offer areasonable risk management strategy.
to understand the symptoms and signs of the post concussion
syndrome andprovide advice to patients following a brain injury to
minimise the risk ofproblems on returning to work, and/or return to
living in the community withfamily and / or carers. to appreciate
the psycho-dynamic processes that follow brain injury and
otherforms of disability, and provide appropriate psychotherapeutic
support. to manage the common sequelae of brain injury, including
disturbances of mood,psychotic disorders, personality change
(especially associated with antisocialbehaviour), reduced
initiation and motivation.Learning and assessment methods.
attending neuropsychiatric clinics, liaison assessments in
rehabilitation units,general hospitals etc. attachment to
rehabilitation unit attending management rounds/ward rounds.
attending postgraduate teaching programmes / conferences on
neuropsychiatry /brain injury specific attachments to
rehabilitation neuropsychologists and therapists. assessment
methods:- self-assessment, clinical supervision and case
presentationand clinical log book. 30. Draft HoracioPage
3018/10/2010Module 2.12 FORENSIC NEUROPSYCHIATRYKey competencies:
i. Knowledge of organic basis of violence, antisocial and criminal
behaviourii. Competence in the clinical assessment of individuals
with violent or criminal behaviour, from both biological and
psychosocial perspectivesiii. Ability to intervene in the
management of such behaviour from a neuropsychiatric perspective,
including drug management and psychosocial interventionsiv.
Awareness of the ethical and medicolegal aspects of such
disordersv. Ability to write an expert report for the court or
other forensic settings. Learning and assessment methods:i.
Attending neuropsychiatric clinics in a forensic settingii.
Assessing patients referred for forensic reportsiii. Preparation of
reports under supervisioniv. Attending court proceedings when
medicolegal evidence presented 31. Draft HoracioPage
3118/10/2010RECOMMENDED READINGNeuropsychiatry textbooksi.Yudofsky
SC, Hales RE: Textbook of Neuropsychiatry and Clinical
Neurosciences, 4th Edition. American Psychiatric Publishing
Washington DC, 2002 ii. Lishman WA. Organic Psychiatry. 3rd
Edition. Oxford: Blackwell Scientific.1998. iii.Cummings JL, Mega
MS: Neuropsychiatry and Behavioral Neuroscience. Oxford University
Press, Oxford, 2003 iv. Schiffer RB, Rao SM, Fogel BS:
Neuropsychiatry: A Comprehensive Textbook, 2nd Edition. Lippincott
Williams & Wilkins, Baltimore, 2003v.Coffey CE, Brumback RA:
Textbook of Pediatric Neuropsychiatry. American Psychiatric
Publishing, Washington DC, 1998 vi. Coffey CE, Cummings JL:
Textbook of Geriatric Neuropsychiatry. American Psychiatric
Publishing, Washington DC, 2000 vii.Arciniegas D, Beresford TP:
Neuropsychiatry: An Introductory Approach. Cambridge University
Press, Cambridge, 2001, pp. 3-12Behavioural Neurology:1. Mesulam
M-Marsel: Principles of Behavioral and Cognitive Neurology, 2nd
Edition. OxfordUniversity Press, Oxford, 2002.2. Pincus JH and
Tucker GJ. Behavioral Neurology, 4th Edition. Oxford University
Press,Oxford, 20033. Feinberg TE, Farah MJ: Behavioral Neurology
and Neuropsychology. McGraw-Hill, NewYork, 1997.4. Kirshner HS:
Behavioral Neurology: Practical Science of Mind and Brain.
Butterworth-Heinemann, Boston, 20025. Leon-Carrion J, Giannini MJ:
Behavioral neurology in the elderly. CRC Press, Boca Raton,20016.
Strub RL, Black FW: Neurobehavioral Disorders: A Clinical Approach.
FA Davis Company,Philadelphia, 1988Cummings JL, Trimble MR: Concise
guide to neuropsychiatry andbehavioral neurology. Washington DC,
American Psychiatric Publishing, 20027. Trimble MR, Cummings JL:
Contemporary Behavioral Neurology. Butterworth-Heinemann,Boston,
1997 32. Draft HoracioPage 32 18/10/20108. Cummings JL, Trimble MR:
Concise Guide to Neuropsychiatry and Behavioral Neurology,2nd
Edition. American Psychiatric Publishing, Washington DC,
2002.Neuropsychology i.Lezak MD. Neuropsychological Assessment. New
York: Oxford University Press. 1983. ii. Walsh K. Neuropsychology:
a Clinical Approach. 3rd Edition. Edinburgh: Churchill Livingstone.
1994. Neuroimaging Neuroscience i.Kendel ER et al. Principles of
Neural Sciences. New York: Elsevier. 2000. ii. Bloom F et al.
Fundamentals of Neuroscience. Academic Press. 1998.General
neuropsychiatric education1. Sachdev P. Neuropsychiatry a
discipline for the future (Editorial). J PsychosomRes
2002;53(2):625-627.2. Sachdev P. Whither Neuropsychiatry? J
Neuropsychiatry Clin Neuroscience 2005;3. Price BH, Adams RD, Coyle
JT. Neurology and psychiatry: closing the great divide.Neurology
2000, 54:8-14.4. ANPA Standards for Fellowship Training in
Neuropsychiatry. I. Definition ofNeuropsychiatry, 2001.
http://www.neuropsychiatry.com/ANPA5. Accreditation Council on
Graduate Medical Education: Program Requirements for Trainingin
Psychiatry, 2001. http://www.acgme.org/RRC/Psy_Req2.asp6.
Accreditation Council on Graduate Medical Education: Program
Requirements for Trainingin Neurology, 2002.
http://www.acgme.org/RRC/Psy_Req2.asp7. American Board of
Psychiatry and Neurology, Inc.: Information for Applicants
forCertification in the Subspecialties of Addiction Psychiatry,
Clinical Neurophysiology,Forensic Psychiatry, Geriatric Psychiatry,
and Neurodevelopmental Disabilities, 2003.
http://www.abpn.com/Downloads/2003subspec_ifa.pdf8. Academy of
Psychosomatic Medicine: Standards for Fellowship Training in
Consultation-Liaison Psychiatry, 1998.
http://www.apm.org/fellow.html JOURNALS 33. Draft HoracioPage
3318/10/2010 Journal of Neurology, Neurosurgery and Psychiatry
Journal of Neuropsychiatry and Clinical Neuroscience.
Neuropsychiatric Disorders and Treatment Trends in Neuroscience
Neuropsychiatry, Neuropsychology and Behavioural Neurology. Nature
Reviews Neuroscience Nature Neuroscience Lancet Neurology
Biological Psychiatry Neurology Archives of Neurology Archives of
General Psychiatry Journal of Clinical Psychiatry Acta Psychiatrica
Scandinavica Acta Neurologica Scandinavica Acta Neuropsychiatrica
British Journal of Psychiatry American Journal of Psychiatry
Australian and New Zealand Journal of Psychiatry Nature Science
British Medical Journal New England Journal of Medicine