In 2002 I began a graduate program in an Experimental Psychology Department. My primary advisor, Dr. V.S. Ramachandran (Professor in the Department of Experimental Psychology) was, in fact, a trained Neurologist. What was a Neurologist doing in an Experimental Psychology Department? In addition to his medical training as a Neurologist, he also had a Ph.D. in Neuroscience and believed that the brain and more specifically, brain dysfunction underlies behavioral symptoms that define Psychological Disorders. Having just completed a bachelor’s degree in “Neuroscience and Behavioral Biology”, I was drawn to this perspective and began working in Dr. Ramachandran’s lab. Through my graduate program, I took courses in Clinical Neuropsychology, patient-based Cognitive Neuroscience, and Brain Imaging in Psychiatry. It seemed that the field did not know what to call itself, but what was clear was that the fields of Psychology (Behavior) and Psychiatry (Mental Illness) were embracing Neuroscience.
After obtaining my Ph.D. in Experimental Psychology, I continued my training as a postdoctoral fellow developing TMS protocols for Autism in the Division of Behavioral Neurology at Beth Israel Deaconess Medical Center under Dr. Alvaro Pascual-Leone (Neurologist). Here again, we were combining the study and treatment of brain and behavior in an effort to develop brain device-based treatments for psychiatric disorders. Despite the decidedly psychiatric therapeutic indications for TMS (currently Depression and OCD), much of the early basic science and clinical research were conducted by Neurologists like Dr. Pascual-Leone. Thus began my confusion as to what to call my area of study. Was it: Experimental Psychology? Clinical Neuroscience? Behavioral Neurology? Functional Neuropsychiatry? Is there a difference? In order to understand this blurring of lines between these disciplines, I’d like, for a moment, to give a historical perspective.
The study of brain, mind, and behavior were overlapping for most of the 19th and early 20th centuries with researchers and clinicians such as Charcot, Korsakoff, Babinski, Janet, Freud, Bleuler, Kraepelin, and Alzheimer all known as “Neuropsychiatrists” often holding dual affiliations in Neurology and Psychiatry academic and clinical departments. Around the 1930s the fields began to separate from each other. At this time, Neurology laid claim to disorders of the nervous system with established biological etiologies and demonstrable anatomic pathology based on tests available at that time (CSF, post-mortem pathology, and EEG). These disorders included stroke, epilepsy, and dementia. In contrast, Psychiatry focused on disorders of the mind where there was no visible pathology. It was said that “Neurologists knew about the brain, but not the mind and Psychiatrists knew about the mind, but not the brain.” This divide was further strengthened by the Psychoanalytic approach to Psychiatry, which was pervasive in the late 1940s-1970s. Psychoanalytic Psychiatrists and Psychologists saw mental illness as rooted in the unconscious mind and through psychoanalysic therapy, repressed emotions and experiences in the unconscious mind could become conscious and the patient could be healed. The field of Psychiatry itself was quite divided at this time with some Psychiatrists embracing the psychoanalytic approach and others criticizing the lack of evidence to support its claims and taking a decidedly more biological approach to treatment.
Though Biological Psychiatrists were in the minority in the mid 20th century, by the 1970s and 1980s neurophysiological and neurochemical bases for Psychiatric Disorders, were increasingly being recognized and Psychiatrists had other tools besides psychoanalysis in their tool kit to treat mental illness. By the end of the 1980’s neuroimaging technology including CT, MRI, SPECT and PET were available and the first “biomarkers” of psychiatric disorders were identified. There was also a shift in the scientific, clinical, and lay communities to accept mental illnesses as having a biological and neurological origin. Literature accumulated supporting alterations in genes as well as structural and functional neuroanatomy and neurophysiology across a number of psychiatric disorders including depression, schizophrenia, and OCD. The pathophysiology underlying these disorders was found to not only be diagnostically useful but also to mark a response to treatment and relapse. Psychotropic medications were coming on the market with first-generation antipsychotic and antidepressant medications then later SSRIs and atypical neuroleptics with fewer side effects than their predecessors.
Building upon these Neuroscientific developments and pharmaceutical innovations, the 1990s heralded the “Decade of the Brain” and “evidence-based medicine.”. The Decade of the Brain was launched to “enhance public awareness of the benefits to be derived from brain research” while the evidence-based medicine movement emphasized the use of evidence from well-designed and well-conducted research to support medical decisions. That was an important period for Clinical Psychology with the validation of cognitive behavioral therapy (CBT). Thus, as the 21st century began and I entered graduate school and early career, I had the benefit of not only structural but advanced functional imaging technology as well as Neuromodulation, with the first therapeutic TMS trials beginning in the late 1990s and early 2000s.
Today, a growing number of academic and medical centers have embraced multidisciplinary approaches to the study and treatment of the brain in health and disease. Many centers employ Psychiatrists, Psychologists, and Neurologists working together as a team to treat patients with Neuropsychiatric and Neurodevelopmental Disorders, including depression, anxiety, and ADHD just to name a few. The walls separating these fields are beginning to break down. Patients have options of being treated with psychotropic medication, psychotherapy and other behavioral approaches, TMS and other neuromodulatory techniques and in the best of circumstances a combination of all three! The FDA ensures that approved treatments are both safe and effective and is increasingly requiring an understanding of the biological mechanism of action for novel treatments. There is also growing recognition that Psychiatric symptoms often co-occur with classic Neurological Disorders, including Alzheimer’s Disease and Parkinson’s Disease. “Decade” movements such as the “Decade of Behavior” and the “Decade of the Mind” have emerged, but have not been as well supported or influential as the Decade of the Brian was. Despite over 40 Million Americans (or 1 in 6) taking Psychiatric Medications, over the past decade pharmaceutical companies have increasingly reduced or in some cases completely eliminated their Neurology and Psychiatry R&D departments. Individuals are increasingly looking for nonpharmacological, evidence-based options.
Enter the “BRAIN Initiative (Brain Research through Advancing Innovative Neurotechnologies)”. This public-private collaborative effort was proposed and initiated in 2013 and will run through 2025. The BRAIN Initiative aims to develop new experimental tools that will revolutionize our understanding of the brain and brain diseases. As the Decade of the Brain brought us functional MRI and Magnetic Resonance Spectroscopy and other advanced imaging techniques, the BRAIN initiative promises to bring the advancement of technology across all levels from optogenetics and other nanotechnologies that allow us to study and modulate cells and molecules in the brain to high-powered 7 Tesla fMRI scanners that can image even the smallest brain regions to novel neurostimulatory devices that use not only magnetic and electrical fields, but also focused ultrasound and pulsed infrared energy to modulate the brain. These technologies will open up new doors to explore how the brain records, processes, uses, stores, and retrieves vast quantities of information, and shed light on the complex links between brain function and behavior in individuals with and without Neurological or Psychiatric Disorders.
I continue to be humbled and grateful to be working in the field of Clinical Neuroscience/Functional Psychiatry/Behavioral Neurology where we have the tools and knowledge to understand and treat pathophysiology of Psychiatric Disorders in ways we never could before. Every day I work side by side with Neurologists, Psychiatrists, Clinical Psychologists, and Neuropsychologists to bring all of our backgrounds and expertise to bear on the most complex and still enigmatic mystery of our time, the workings of the human mind and brain!