Editorial

iMedPub Journals Journal of Neuropsychiatry 2018

www.imedpub.com Vol. 2 No.1:1
ISSN 2471-8548
DOI: 10.21767/2471-8548.10004

Neuropsychiatry in Clinical Practice: The Challenge of Diagnosing Behavioral

Variant Frontotemporal Dementia
Flora Gossink1,2*, Everard Vijverberg2,3, Yolande Pijnenburg1,2 and Annemiek Dols1,2
1Department of Old Age Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
2Alzheimer Centre and Department of Neurology, VU University Medical Center, Amsterdam Neuroscience, The Netherlands
3Department of Neurology, HagaZiekenhuis, The Hague, The Netherlands
*Corresponding author: Flora Gossink, Department of Old Age Psychiatry, VU University Medical Center, Amsterdam, The Netherlands, Tel:
+3115618942050; E-mail: F.Gossink@ggzingeest.nl
Received date: January 01, 2018; Accepted date: January 10, 2018; Published date: January 20, 2018
Copyright: © 2018 Flora G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation: Flora G, Everard V, Yolande P, Annemiek D. Neuropsychiatry in Clinical Practice: The Challenge of Diagnosing
Behavioral Variant Frontotemporal Dementia. J Neuropsychiatry 2018, Vol. 2 No. 1:1.

Editorial
The behavioral variant of Frontotemporal dementia (bvFTD)
is an insidious neurodegenerative disease associated with
progressive degeneration of the frontal lobes, anterior
temporal lobes, or both [1]. Alterations in social cognition
represent the core symptoms of bvFTD resulting in emotional
disengagement and socially inappropriate responses or
activities [2,3]. As is apparent in revised consortium criteria,
additional neuropsychiatric symptoms including apathy and
stereotypical and impulsive behavior are prominent in the
clinical presentation [4]. Consequently, both
neurodegenerative diseases and primary psychiatric disorders
are crucial in the challenging differential diagnosis.
The differentiation between bvFTD and Alzheimer’s disease Figure 1 Overlap and differentiation between bvFTD and
(AD) has become easier by the use of biomarkers that are able psychiatric disorders in clinical practice.
to identify underlying AD pathology, such as the amyloid- β (A
β) and tau [1,5]. However, to distinguish bvFTD from The value of different symptom rating scales and clinical
psychiatric disorders can still be difficult, particularly since tools has been proven useful in clinical practice in case of
biomarkers for bvFTD are less robust [6]. Previous studies suspected bvFTD when a psychiatric disorder is also probable
indicated that as a result of symptomatic overlap between (Figure 2) [11,14,15].
bvFTD and psychiatric disorders, bvFTD patients are clinically
often mistaken for psychiatric patients and vice versa [7-10].
The current clinical criteria for bvFTD require that “if
behavioral disturbance is better accounted for by a psychiatric
diagnosis, a diagnosis of bvFTD has to be excluded” [4].

Despite clinical overlap, bvFTD patients do not often fulfill

formal criteria for a psychiatric diagnosis, suggesting that it is
valuable to apply formal criteria for psychiatric disorders [11].
Careful clinical phenotyping of overlapping symptoms can help
to distinguish bvFTD from psychiatric disorders in clinical
practice (Figure 1) [12,13].

© Copyright iMedPub | This article is available from: http://neuropsychiatry.imedpub.com/

1

Figure 2 Clinical hallmarks and supportive measuring
instruments in the differential diagnosis bvFTD and
psychiatric disorders.
According to current criteria, the diagnostic certainty of
bvFTD increases when Frontotemporal abnormalities are
found on neuroimaging. In a large cohort of patients with late-
onset behavioral changes, MRI had a sensitivity of 70% and a
specificity of 93% for a bvFTD diagnosis [4]. The additional
[18F]FDG-PET, when the MRI was inconclusive, had a
sensitivity of 90% at the cost of a lower specificity (68%) [16].
[18F]FDG-PET is mainly useful when Frontotemporal hypo-
metabolism is absent to exclude bvFTD diagnosis. The
interpretation of neuroimaging results should especially be
taken with caution in cases with a psychiatric differential
diagnosis where [18F]FDG-PET is the only abnormal
investigation and in cases with a genetic background where
both MRI and [18F]FDG-PET can show a specific abnormalities
[16-18]. Genetic screening especially for C9orf72 repeat
expansion is emphasized [19,20]. particularly in cases with a
remarkable (prolonged) disease course.
In clinical practice, bvFTD has a broad differential diagnosis
including both neurodegenerative diseases and primary
psychiatric disorders. The current criteria for bvFTD have
clearly improved diagnostics but differentiating bvFTD from
psychiatric disorders remains difficult. The challenge for the
2 This article is available from: http://neuropsychiatry.imedpub.com/
Journal of Neuropsychiatry 2018
ISSN 2471-8548 Vol. 2 No.1:1
next decade is finding specific biomarkers for bvFTD on the
one hand, and optimizing the neuropsychiatric diagnosis of
bvFTD on the other hand. To this end, patient care for
suspected bvFTD patients would be largely improved in a
setting where neurologists and psychiatrists work hand in
hand, ideally applying a consensus set of clinical rating scales
next to their clinical expertise.
References
1. Piguet O, Hornberger M, Mioshi E, Hodges JR (2010)
Behavioural-variant frontotemporal dementia: diagnosis, clinical
staging, and management. Lancet Neurol 10: 162-172.
2. Ibanez A, Manes F (2012) Contextual social cognition and the
behavioral variant of Frontotemporal dementia. Neurology 78:
1354-1362.
3. Special Lecture (2017) Social Cognition in Frontotemporal
Dementia Proceedings: Special Lecture Neuropsychology
Association of Japan 40th Annual Meeting. J Neuropsychol 33:
9-24.
4. Rascovsky K, Hodges JR, Knopman D, Mendez MF, Kramer JH, et
al. (2011) Sensitivity of revised diagnostic criteria for the
behavioural variant of Frontotemporal dementia. Brain 134:
2456-2477.
5. Mckhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR Jr,
et al. (2011) The diagnosis of dementia due to Alzheimer's
disease: recommendations from the National Institute on Aging-
Alzheimer's Association workgroups on diagnostic guidelines for
Alzheimer's disease. Alzheimers Dement 7: 263-269.
6. Vijverberg EGB, Dols A, Krudop WA, Del Campo Milan M,
Kerssens CJ, et al. (2017) Cerebrospinal fluid biomarker
examination as a tool to discriminate behavioral variant
Frontotemporal dementia from primary psychiatric disorders.
Alzheimers Dement (Amst) 7: 99-106.
7. Krudop WA, Dols A, Kerssens CJ, Eikelenboom P, Prins ND, et al.
(2017) The Pitfall of Behavioral Variant Frontotemporal
Dementia Mimics Despite Multidisciplinary Application of the
FTDC Criteria. J Alzheimers Dis 60: 959-975.
8. Woolley JD, Khan BK, Murthy NK, Miller BL, Rankin KP (2011)
The diagnostic challenge of psychiatric symptoms in
neurodegenerative disease: Rates of and risk factors for prior
psychiatric diagnosis in patients with early neurodegenerative
disease. J Clin Psychiatry 72: 126-133.
9. Vijverberg EG, Dols A, Krudop WA, Peters A, Kerssens CJ, et al.
(2016) Diagnostic accuracy of the Frontotemporal dementia
consensus criteria in the late-onset frontal lobe syndrome.
Dement Geriatr Cogn Disord 41: 210-219.
10. Krudop W, Kerssens CJ, Dols A, Prins ND, Moller C, et al. (2014)
Building a new paradigm for the early recognition of behavioral
variant Frontotemporal dementia: Late Onset Frontal Lobe
Syndrome study. Am J Geriatr Psychiatry 22: 735-740.
11. Gossink FT, Dols A, Krudop WA, Sikkes SA, Kerssens CJ, et al.
(2016) Formal Psychiatric Disorders are not Overrepresented in
Behavioral Variant Frontotemporal Dementia. J Alzheimers Dis
51: 1249-1256.
12. Gossink FT, Vijverberg EGB, Krudop W, Scheltens P, Stek ML, et
al. (2017) Psychosis in behavioral variant Frontotemporal
dementia. Neuropsychiatr Dis Treat 13: 1099-1106.

13. Dols A, Van-Liempt S, Gossink F, Krudop WA, Sikkes S, et al.
(2016) Identifying Specific Clinical Symptoms of Behavioral
Variant Frontotemporal Dementia Versus Differential Psychiatric
Disorders in Patients Presenting With a Late-Onset Frontal Lobe
Syndrome. J Clin Psychiatry 77: 1391-1395.
14. Vijverberg EGB, Gossink F, Krudop W, Sikkes S, Kerssens C, et al.
(2017) The Diagnostic Challenge of the Late-Onset Frontal Lobe
Syndrome. J Clin Psychiatry.
15. Gossink FT, Schouws SKW (2017) Social cognition differentiates
behavioral variant frontotemporal dementia from other
neurodegenerative diseases and psychiatric disorders. Am J
Geriatr Psychiatry.
16. Vijverberg EGB, Wattjes MP, Dols A, Krudop WA, Moller C, et al.
(2016) Diagnostic Accuracy of MRI and Additional [ 18 F]FDG-
PET for Behavioral Variant Frontotemporal Dementia in Patients
with Late Onset Behavioral Changes. J Alzheimers Dis 53:
1287-1297.
© Copyright iMedPub
View publication stats
Journal of Neuropsychiatry 2018
ISSN 2471-8548 Vol. 2 No.1:1
17. Steketee RME, Meijboom R, Bron EE, Osse RJ, De-Koning L, et al.
(2016) Structural and functional brain abnormalities place
phenocopy Frontotemporal dementia (FTD) in the FTD
spectrum. NeuroImage Clin 11: 595-605.
18. Crossley NA, Scott J, Ellison-Wright I, Mechelli A (2015)
Neuroimaging distinction between neurological and psychiatric
disorders. Br J Psychiatry 207: 429-434.
19. Kertesz A, Cyn-Ang L, Jesso S, Mac-Kinley J, Baker M, et al.
(2013) Psychosis and Hallucinations in FTD with C9ORF72
mutation: A detailed clinical cohort. Cogn Behav Neurol 26:
146-154.
20. Khan BK, Yokoyama JS, Takada LT, Sha SJ, Rutherford NJ, et al.
(2012) Atypical, slowly progressive behavioural variant
frontotemporal dementia associated with C9ORF72
hexanucleotide expansion. J Neurol Neurosurg Psychiatry 83:
358-364.
3
 International Journal of
Environmental Research
and Public Health
Article
Mobile-Health Technologies for a Child Neuropsychiatry Service:
Development and Usability of the Assioma Digital Platform
Elisa Fucà 1,† , Floriana Costanzo 1, *,† , Dimitri Bonutto 2 , Annarita Moretti 3 , Andrea Fini 3 , Alberto Ferraiuolo 3 ,
Stefano Vicari 1,4 and Alberto Eugenio Tozzi 2






Citation: Fucà, E.; Costanzo, F.;
Bonutto, D.; Moretti, A.; Fini, A.;
Ferraiuolo, A.; Vicari, S.; Tozzi, A.E.
Mobile-Health Technologies for a
Child Neuropsychiatry Service:
Development and Usability of the
Assioma Digital Platform. Int. J.
Environ. Res. Public Health 2021, 18,
2758. https://doi.org/10.3390/
ijerph18052758
Academic Editors: Michael L. Jones,
Frank Deruyter and John Morris
Received: 28 January 2021
Accepted: 4 March 2021
Published: 9 March 2021
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
published maps and institutional affil-
iations.
Copyright: © 2021 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Int. J. Environ. Res. Public Health 2021, 18, 2758. https://doi.org/10.3390/ijerph18052758
1 Child and Adolescent Neuropsychiatry Unit, Department of Neuroscience, Bambino Gesù Children’s
Hospital, IRCCS, 00165 Rome, Italy; elisa.fuca@opbg.net (E.F.); stefano.vicari@opbg.net (S.V.)
2 Multifactorial and Complex Disease Research Area, Bambino Gesù Children’s Hospital IRCCS, Piazza S.
Onofrio 4, 00165 Rome, Italy; dimitri.bonutto1@gmail.com (D.B.); albertoeugenio.tozzi@opbg.net (A.E.T.)
3 Topnetwork S.p.A, 00142 Rome, Italy; annarita.moretti@top-network.it (A.M.); finello76@gmail.com (A.F.);
alberto.ferraiuolo@top-network.it (A.F.)
4 Department of Life Science and Public Health, Catholic University of the Sacred Heart, 00168 Rome, Italy
* Correspondence: floriana.costanzo@opbg.net
† These authors contributed equally to this work.
Abstract: We developed an m-Health platform to support clinical pathways in a child and adolescent
neuropsychiatry unit. The Assioma platform was created for tablets, smartphones and PCs, to
support data collection and clinical workflow, to promote constant communication between patients,
caregivers and clinicians, and to promote active family involvement in day hospital (DH) procedures.
Through the Assioma application for tablets, caregivers filled out an anamnestic questionnaire and
explored contents on the DH procedures and neurodevelopmental conditions. The application
for smartphones included an agenda function for the DH pathways. Through the application for
desktops, clinicians could export anamnestic information in text and Excel formats, send real-time
notifications, and push relative contents to families’ account. We tested the usability and satisfaction
of the Assioma platform in a group of children, caregivers (N = 24) and clinicians (N = 6). Both
families and clinicians gave high scores to almost all usability items. The overall satisfaction reached
the highest levels at 50% satisfied for families and at 33% for clinicians. Our results indicate that
the Assioma platform has the potential to optimize clinical pathways, increasing compliance and
clinical efficiency, and to reduce in-person contacts supporting social distancing for clinical pathways,
a crucial need during the COVID-19 pandemic.
Keywords: mHealth; child neuropsychiatry; day hospital
1. Introduction
The expression “Mobile health” (m-Health) refers to health services supported by
mobile communication devices, such as patient monitoring, alert systems, data collection,
record maintenance, and prevention systems [1]. They are designed to target specific health
topics, such as the prevention of infectious diseases [2], and symptom management for
different medical conditions [3,4]. M-Health technologies can also support the organization
of healthcare services: they have the potential to be used to optimize clinical pathways by
supporting the collection of clinical histories, facilitating long-term clinical data storage
and sharing across institutions [5]. Overall, m-Health technologies have the potential to
improve workflow, the quality and efficiency of communication, and accessibility as well
as inter-team relationships within healthcare services [6].
An increasing amount of research has been focused on the application of telemedicine
and m-Health systems for mental health [7], including interventions for children [8]. M-
Health technologies for mental health for pediatric population have been developed with
different purposes: health promotion [9], prevention [10,11], symptoms monitoring [12,13],
https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 2758 2 of 17

treatment [14,15], the monitoring of, and supporting adherence to, pharmacological and
behavioral treatments [16,17].
In Italy, child and adolescent neuropsychiatry services manage diagnosis, rehabili-
tation, and intervention needs of children with neurodevelopmental and/or psychiatric
disorders. These services are faced with many challenges such as the increasing number of
patients, the lack of an informative and monitoring system and the high heterogeneity in
the services provided across different geographic areas [18]. Thus, the need for resource
optimization among child and adolescent neuropsychiatric services has strongly emerged.
M-Health technologies may contribute to addressing these issues: they have the
potential to help improving organization and efficiency in mental healthcare services. For
example, mobile communication devices allow for the collection of extremely rich data and
can help by automatically organizing and storing the data. Another potential contribution
of m-Health technologies is linked to the possibility of offering health contents to get
families more actively involved in clinical pathways. The available literature investigating
the benefits derived from hospitals adopting digital technologies reports some positive
results for lowering costs, increasing efficiency, improved patient outcomes attributed to
electronic medical records which help facilitate clinician decision making, and improving
data integrity [19]. The use of m-Health in hospitals can also lead to positive effects on
communication between different professionals. For instance, Melby and Hellesø [20]
reported that the introduction of an e-message tool at a Norwegian hospital promoted a
proactive communication among clinicians and staff. Saddik and Al-Mansour [21] have
also reported some positive effects provided by the implementation of a computerized
prescriber order entry system in a hospital in Saudi Arabia, in terms of sustained workflow
and enhanced nurse–physician communication. However, results are mixed and definitive
conclusions on certain aspects as measurements of hospital bed use, equity of access,
resource utilization, patient satisfaction and impact on quality of life provider satisfaction
and perceived ease of use cannot be clearly established [22]. Regarding the application
of digital services in the context of children’s hospital, literature did provide evidence
for the positive effects of digital interventions—as serious games and virtual reality—in
educating and preparing children for care experiences in different hospital contexts such
as surgery and radiology [23–26]. Although a previous study indicated that families of
patients with genetic/neuropsychiatric conditions exhibit a positive attitude toward m-
health technologies [27], to the best of our knowledge, there are no studies investigating
the application of m-Health systems to improve hospital experience for children with these
conditions by supporting their clinical pathways.
In addition to educational needs regarding health procedures, there is also evidence
showing that children and their families need better communication with healthcare
personnel in different areas [28].
Evidence shows that in Italy family members are often involved in the care of young
patients with neuropsychiatric conditions [29,30]. For many families, the assessment
process is a critical component of care but may simultaneously be a source of stress [31]. It
has been suggested that the involvement of the families in the assessment process can be
a central element to improving the overall patient experience [32,33]. The improvement
of communication between patients and clinicians provided by the use of m-Health in
hospital settings could represent a crucial step towards the increase of active involvement
of the families during hospital procedures.
M-Health can also provide a fundamental contribution to public health systems
during this unique historical moment in which we find ourselves. Italy was the first
European country to face the coronavirus disease (COVID-19) pandemic in all of its vivid
forms. Health systems policies issued significant restrictions on social contacts with the
aim of decreasing the exposure to COVID-19 for both patients and providers. Thus, the
pandemic has strongly stimulated clinicians to consider alternative service delivery options
compatible with social distancing. Within such a framework, new technologies have been
considered as a valuable tool to guarantee access to medical services, the World Health
Int. J. Environ. Res. Public Health 2021, 18, 2758 3 of 17

Organization (WHO) actually highlighted telemedicine as an essential service in response

to the COVID-19 emergency [34]. Digital technologies could indeed provide valuable
contributions in large-scale healthcare interventions and relieve pressure on hospitals [35].
Moreover, supporting clinical pathways with m-health can be helpful in reducing in-person
contacts and maintaining social distancing.
We developed an integrated m-Health platform to support clinical pathways and
to promote remote contacts between patients and clinicians in the Child and Adolescent
Neuropsychiatry Unit of the Bambino Gesù Children’s Hospital, a tertiary care children’s
hospital located in Italy. Our unit provides a comprehensive evaluation for diagnostic
purposes, including neurodevelopmental, neuropsychological and psychopathological
assessment; the assessment process in the day hospital (DH) regimen lasts two or three
days according to the estimated clinical needs. Outpatient cooperation and a good ability
to focus during the battery of tests is crucial to providing a reliable assessment of patient’s
neuropsychiatric and neuropsychological abilities. Thus, it is important to minimize
all sources of potential stress in healthcare service delivery, such as long waiting times
and the perception of being uninvolved in the ongoing clinical process. These potential
stressful factors can contribute to reduced co-operation of patients and their families during
the process and could indirectly affect the performance of a child with neuropsychiatric
conditions during the assessment.
In this project, the digital platform Assioma (acronym for the Italian name “ASSIs-
tenza per bambini Ospedalizzati basata su Mobile Application”—Mobile Application-based
Assistance for Hospitalized Children) was designed to: improve remote family/doctor
communication; enhance family involvement during the DH processes; support automa-
tized data collection, and to support the organization and storage of data. The development
of the Assioma platform was performed in compliance with European General Data Pro-
tection Regulation (GDPR) [36] and all participants were provided all of the information
regarding data management during the informed consent process. This study reports on
the usability and user satisfaction of Assioma in a group of families with children attending
our unit. First, we illustrate the phase of development of the platform by describing three
crucial steps: (i) analysis of the functional requirements; (ii) design of the platform’s archi-
tecture; (iii) definition of the functionalities and contents. Then, we report on the results of
a pilot test in a small group of participants recruited from within our Unit.

2. Materials and Methods

In total, the development of the Assioma platform took 18 months and included two
stages: (1) the development of a digital platform according to an analysis of the functional
requirements and needed contents, and the design of the platform’s architecture (2) a pilot
study to test Assioma in the DH in the child and adolescent neuropsychiatry unit.

2.1. Stage 1. Development

Assioma was developed in accordance with the WHO recommendations on m-Health
applications, with particular attention paid to the acknowledged role of m-Health as a
complement and an enhancer of health system functions by mechanisms such as accelerat-
ing the exchange of information. We also referred to the conceptual foundation provided,
regarding accountability, supply, demand, quality, and affordability [37]. The aim of the
platform was to meet specific clinical needs for the clinical practice in our mental health ser-
vice for children and adolescents. The outline of a typical DH clinical pathway is provided
in Figure 1.
As reported in Figure 1, the first interaction between the clinician, the patient and
his/her family occurs after checking in to collect their clinical history. This is a crucial
passage for the entire evaluation, because caregivers’ interviews are the only way to collect
information about the patients that DH staff is not able to observe directly during the
assessment. For this reason, it is essential to find the right trade-off between collecting
comprehensive and detailed data while completing the task in the shortest amount of
Int. J. Environ. Res. Public Health 2021, 18, 2758 4 of 17
Int. J. Environ. Res. Public Health 2021, 18, x 4 of 19

time. Moreover,
health an efficient
service for childrenorganization of these
and adolescents. Thedata, usually
outline of a collected
typical DHin clinical
plain language
pathway
during an interview, is highly
is provided in Figure 1. desirable for both clinical and research purposes.

Figure1.1.The
Figure The patient
patient journey
journey of
of aatypical
typicalDH
DHaccess forfor
access patients in our
patients Child
in our andand
Child Adolescent Neu-
Adolescent
ropsychiatry Unit.
Neuropsychiatry Unit.

AAs reported
second in Figure
aspect to take1,intotheaccount
first interaction between
for improving the clinician,
clinical practice the is topatient
increase and
his/herand
patient family occursknowledge
caregiver after checking andinaddressing
to collect their clinical history.
expectations about theThisDH is aprocedure
crucial pas-
sage
they forexperience.
will the entire evaluation,
Families canbecause caregivers’
be confused about the interviews
organization are the only way
of clinical to collect
procedures
information about the patients that DH staff is not able to observe
before encountering the clinicians who provide instructions (nurses or neuropsychiatrists), directly during the
assessment. For this reason, it is essential to find the right trade-off
and this may sometimes cause delays or ineffective collaboration. Providing simple, clear between collecting
comprehensive
and child-friendlyand detailed data
explanations can while completing
be useful to support thefamilies
task in at thetheshortest amount of
very beginning
oftime. Moreover,
the hospital an efficient
experience, but organization of these them
could also support data, usually
along all collected in plain
their clinical language
pathways
during anfurther
providing interview,
and is highly desirableinformation
always-available for both clinical and research
in addition to the purposes.
clinician’s verbal
A second
instructions. aspect to
Moreover, take into
keeping accountremotely
caregivers for improving clinical practice
and constantly updated is about
to increase
the
patient
timing andongoing
of the caregiver knowledge
procedure mayand addressing
encourage expectations
their active aboutduring
involvement the DH theprocedure
clinical
they will
process. experience.
Finally, a third Families
aspect that cancanbe improve
confusedclinical
about practice
the organization
is to enhance of clinical proce-
caregivers’
awareness
dures before of their child’s clinical
encountering condition.
the clinicians who After a child
provide has received
instructions a diagnosis
(nurses or neuropsy-from
the clinicians,and
chiatrists), providing
this may caregivers
sometimes with supportive
cause delays and constant, clear
or ineffective information
collaboration. about
Providing
their child’s
simple, condition,
clear symptomsexplanations
and child-friendly and treatment, cancan
be be crucial
useful to guiding
to support themat
families towards
the very
anbeginning
improvedofawareness,
the hospital which may be but
experience, essential
couldtoalso better patient
support management.
them along all their clinical
To sum up, the aims of our m-Health platform were to:
pathways providing further and always-available information in addition to the clini-
cian’s
(A) verbaldata
Support instructions.
collectionMoreover, keeping and
and organization caregivers
to provide remotely andinformation;
effective constantly updated
about
(B) the timing
Promote of the
constant andongoing
remoteprocedure
communication may encourage their active
between patients, involvement
caregivers and clini- dur-
ing cians;
the clinical process. Finally, a third aspect that can improve clinical practice is to en-
hance
(C) caregivers’
Promote awareness
families’ of their child’s
active involvement clinical
in the DH condition.
processing,After during a child has received
and after the DH a
diagnosis
visits. from the clinicians, providing caregivers with supportive and constant, clear
information about their child’s condition, symptoms and treatment, can be crucial to guid-
2.1.1. Analysis
ing them of theanFunctional
towards improvedRequirements
awareness, which may be essential to better patient man-
agement.
The analysis of the requirements was carried out in accordance with the American
Telemedicine
To sumAssociation
up, the aims guidelines, which recommend
of our m-Health platform were a contextual
to: analysis of the clinical,
technical and administrative
(A). Support data collectionfield and of the medicaland
organization framework
to provide under investigation
effective information; [38]. The
non-functional requirements (an expression used to refer to
(B). Promote constant and remote communication between patients, caregivers and the ways in which the systemclini-
must cians;
provide the different functionalities) have been studied. A list of requirements is
provided in Table
(C). Promote 1.
families’ active involvement in the DH processing, during and after the DH
visits.
Int. J. Environ. Res. Public Health 2021, 18, 2758 5 of 17

Table 1. Functional and nonfunctional requirements of the platform.

Functional Requirements Non-Functional

Requirements
Performance and scalability
Guide to the facility
Acceptance and registration The software should be an
adaptable tool that can be
1. A feature that enables univocal association of a code to every patient into the system;
improved in its functions and
2. Authentication of user whenever he/she logs into the system;
capacity according to users’
3. Enforce automatic logoff.
requests and needs.
Role and times Interoperability
1. Two types of users’ accounts: clinicians and families;
2. A feature that enables clinicians to create the agenda of the planned activities of the DH; The software should be able to
3. A feature that enables families to visualize the agenda of fu-ture appointments and the schedules of the DH communicate with other
activities. software.

Procedures Portability
1. A function that enables families to have information to navi-gate through the building and on hospital facilities;
The software should be able to
2. A page with informative contents (video cartoons) on the steps for specific instrumental examinations be used in different hospital
(electroencephalography). contexts and by different
users.
Communication and assistance Privacy and security

Medical History The software should

1. Different users’ dashboard pages (clinicians, families); guarantee adequate privacy
2. A page with a list of anamnestic questions focused on neuro-psychiatric and psychological development; and security protections for
3. A feature that enables users to explore different sections of the anamnestic questionnaire; sensitive data exchanged
4. A feature that enables users (families) to fill the anamnestic questionnaire; remotely (compliance with
5. A feature that enables users (clinicians) to visualize and validate anamnestic data provided by families. GDPR).

Patients communications and notifications Accessibility

1. A push notification service that enables prompt information exchange from clinicians to families about the DH
The software should include
steps and procedures; different devices for a wide
2. Pages with educational contents about: (i) neuropsychiatric conditions and treatment; (ii) the DH organization range of users, allowing
and clinicians’ roles (e.g., psychologists, nurses); 3. A feature that enables clini-cians to associate educational sufficient response time also
contents to specific users’ account; for the slowest users.
4. A feature that enables families to visualize and explore the associated educational contents (patient education).
Usability

The software should be

user-friendly, allowing an
Diagnostic interaction perceived as
Survey management effective by the users. It
1. A feature that enables remote anamnestic data acquisition by clinicians; should also re-quire minimal
2. A function that enables the automatized conversion of data collected through the anamnestic questionnaire into training time for using the
a text for-mat. system.

Reporting Supportability
1. A function that enables accessibility and extraction for statistical analysis through the automatized conversion The software should be: (i)
of data collected into a database. easy to install and configure:
2. A function that enables clinicians to complete, edit, add, and delete different fields in the resume file for the (ii) cost-effective to maintain.
DH discharge.
Manageability
The software should support
system admin in
troubleshooting problems.

2.1.2. Design of the Assioma’s Architecture

The architectural description of Assioma provides an overview of the functional char-
acteristics of the model and the relationships between its different properties (Figure 2).
The policy adopted to adhere to GDPR, implements data security and limits the
possibility of external attacks by using: (a) firewalls (b) HTTPS communication protocol;
(c) data encryption; (d) token validation and authentication. The Assioma infrastructure
had two firewalls: one between the application server and the devices and one between
the application server and the MySQL database server. The Assioma system required the
use of the HTTPS protocol to ensure data integrity and security in data exchange. Data
sent via HTTPS were protected by the transport layer security protocol, which provided
three fundamental protection levels: cryptography (used to secure the confidentiality of a
 Int. J. Environ. Res. Public Health 2021, 18, 2758 6 of 17

message between sender and receiver), data integrity (data cannot be modified or corrupted
during
Int. J. Environ. Res. Public Health 2021, 18, x transfer) and authentication (protection against man-in-the-middle attacks).7 of An
19
authorization mechanism has also been developed involving the use of a token (based on
the Json Web Token standard) for logging into the system.

PlatformArchitecture.
Figure2.2.Platform
Figure Architecture.The
Thearchitecture
architectureofof
thethe Assioma
Assioma system
system involves
involves thethe use
use of:of:
anan in-
frastructure for Cloud Computing; an infrastructure for sending push notifications—a
infrastructure for Cloud Computing; an infrastructure for sending push notifications—a cross- cross-platform
cloud messaging
platform solution;solution;
cloud messaging a technology for wireless
a technology forlocal area local
wireless networks
area (WLAN)
networksusing(WLAN)devices
usingbased
devices
on IEEE based
802.11 onstandards;
IEEE 802.11a standards;
public accessa public access
network for network
connectingfor the
connecting
various the various
devices; de-
a Database
vices; a Database
Server; Server; an
an Application Application
Server; differentServer;
typesdifferent
of clientstypes of clients
to access to access
to the to the
different different
functionalities
functionalities (Smartphone, Tablet, Personal Computer). The application server
(Smartphone, Tablet, Personal Computer). The application server is deployed in the cloud and is deployed initthe
is a
cloud and it is a system upon which the applications run handling connections
system upon which the applications run handling connections to the database on one side and toto the database onthe
one side and to the clients (smartphone, tablet, PC) on the other.
clients (smartphone, tablet, PC) on the other.

The policy adopted

Interoperability andtoadherence
adhere to GDPR, implements
to the standards useddata
bysecurity and limits
the Assioma the pos-
platform guar-
sibility
anteed its extension and maintenance with limited efforts. The Assioma platform was(c)
of external attacks by using: (a) firewalls (b) HTTPS communication protocol; an
data encryption;
example (d) tokensystem
of an integrated validation and authentication.
through an implementation Thecharacterized
Assioma infrastructure had
by: (a) database
two firewalls:
compliant withonethebetween the application
SQL standard; server and
(b) web services basedtheondevices and one between
REST protocol; the
(c) automatic
application server and
push information the MySQL
services; database
(d) multiple server.
devices forThe Assioma
content system required the use
delivery.
of the HTTPS protocol to ensure data integrity and security in data exchange. Data sent
2.1.3.
via HTTPS Definition of Functionalities
were protected and Contents
by the transport layer security protocol, which provided three
fundamental protection levels: cryptography
Finally, the application suite was composed (usedof to secure
three the confidentiality
elements, namely Assioma of a mes-
Desk-
sage
top, between
Assioma sender
Parents,andandreceiver),
Assiomadata Diary. integrity
Examples (data cannot
of the be modified
Assioma contentsorare corrupted
provided
during
in Figure transfer)
3. Arialandfontauthentication (protection
style, size 12, was used foragainst
the textman-in-the-middle
included in Assiomaattacks).
Parents An
and
authorization
Assioma Diary, mechanism has also been
based on literature developed
indicating involving
that some the use
font styles of a token
have positive(based
effecton
on
the Json Web
reading Token
abilities for standard)
individuals forwith
logging into thepopulation
dyslexia—a system. that has been included in our
Interoperability
sample [39]: and adherence to the standards used by the Assioma platform guar-
anteed
1) its extension
Assioma Desktopand maintenance
was developed withforlimited efforts. The
PC, dedicated Assioma platform
to clinicians. was an
It contained the
example of an integrated system through an implementation characterized
information sheet and videos associated with families’ accounts, patient registra- by: (a) data-
base compliant with entry
tion and data the SQL standard;physiological
of patients’ (b) web services based onfunctions,
parameters REST protocol; (c) auto-
possible drugs
matic push information services; (d) multiple devices for content
prescription, medication intake monitoring, DH appointment management and notifi-delivery.
cations. Through such functionality, clinicians could consult information provided by
2.1.3. Definition of Functionalities and Contents
Finally, the application suite was composed of three elements, namely Assioma
Desktop, Assioma Parents, and Assioma Diary. Examples of the Assioma contents are
provided in Figure 3. Arial font style, size 12, was used for the text included in Assioma
 Int. J. Environ. Res. Public Health 2021, 18, 2758 7 of 17

caregivers filling in the clinical history questionnaire, and then validating it during the
interview. Once anamnestic information included in the questionnaire was validated
by the clinician, it was automatically exported in text and Excel standard formats. Ed-
itable text format was designed accordingly to the format used for hospital discharge,
thus only a selected amount of information was included in the editable text form.
All the information collected by the anamnestic questionnaire were thus coded and
automatically organized in a database format.
2) Assioma Parents was developed for tablet for families during clinical activities. It con-
tained summary information on neurodevelopmental and neuropsychiatric patholo-
gies (epidemiology, etiology, age of onset) to be associated with a participant account
n. Res. Public Health 2021, 18, x
at check-in in case of a second visit (according to previous diagnosis)
9 of 19
or, in the case
of a first visit, at the moment of hospital discharge (according to the diagnosis at the
moment of discharge).

Figure
Figure 3. 3. Examples
Examples of Assioma
of Assioma contents.
contents. (A) schematization
(A) schematization of the anamnestic
of the anamnestic questionnaire’s
questionnaire’s sections and example of a
sections and example of a screen. (B) examples of data export in text and in Excel of data collected
screen. (B) examples of data export in text and in Excel of data collected through the anamnestic questionnaire. (C) screen
through the anamnestic questionnaire. (C) screen of the Video Cartoon 1.
of the Video Cartoon 1.
2.2. Stage 2. Pilot Test Child-friendly video cartoons were created. Cartoon1 explained the DH procedures,
2.2.1. Families andwhile
Clinicians’ Enrollment
Cartoon2 explained the electroencephalography procedure under deep sedation.
The enrollment of Caregivers filled
clinicians was out a detailed
performed in Mayanamnestic
2018 during questionnaire
a meeting wherewiththe
items in 10 different
areas: demographics, pregnancy and delivery, developmental
investigators informed the neuropsychiatry staff about the aims and the design of the phases, previous assessment,
habits and issues (e.g., dietary and sleep habits), family history,
study, and collected adhesion from psychologists and physicians willing to be involved past and current treatments,
in the study. school and activities, peer relationships and life events (e.g., potentially traumatic events
such as mourning). The questionnaire is available in Supplementary
We enrolled outpatients aged 6–10 years who were referred to our Child and Ado- Materials.
lescent Neuropsychiatry In order to provide
Unit for logistic information
a psychological aboutassessment
and psychiatric the ongoing DH procedures
related to and more
general material, Assioma Parents also contained a
neurodevelopmental and neuropsychiatric conditions. The ownership of a smartphone hospital map, and information on the
agenda of the ongoing DH visits.
device with Android operating system represented the third inclusion criterion, given that
3) Assioma
Assioma was not available Diary
for iOS. was developed
Exclusion for smartphones,
criteria were: to allow
less than 6 years of agefamilies
or olderto use the applica-
than 10 years; presencetion outsideneurosensory
of severe of the hospital. It contained
impairment; two ofsuspicion
clinical the sameof functionalities
abuse; as Assioma
Parentssmartphone
absence of an Android-based (video cartoons
deviceand informative
within sheets),The
the household. andstudy
a push notification service to
partic-
ipation was voluntary.
Patients matching the inclusion criteria for age and diagnostic suspicion were se-
lected among the patients referred to the Unit at the beginning of the planned DH visits.
A general outline of the study was provided and informed consent was obtained from all
Int. J. Environ. Res. Public Health 2021, 18, 2758 8 of 17

receive direct communication from clinicians about the ongoing DH procedures (e.g.,
“appointment at 10.30 in room three after the break”), plus the agenda of future
appointments.

2.2. Stage 2. Pilot Test

2.2.1. Families and Clinicians’ Enrollment
The enrollment of clinicians was performed in May 2018 during a meeting where
the investigators informed the neuropsychiatry staff about the aims and the design of the
study, and collected adhesion from psychologists and physicians willing to be involved in
the study.
We enrolled outpatients aged 6–10 years who were referred to our Child and Ado-
lescent Neuropsychiatry Unit for a psychological and psychiatric assessment related to
neurodevelopmental and neuropsychiatric conditions. The ownership of a smartphone
device with Android operating system represented the third inclusion criterion, given
that Assioma was not available for iOS. Exclusion criteria were: less than 6 years of age
or older than 10 years; presence of severe neurosensory impairment; clinical suspicion of
abuse; absence of an Android-based smartphone device within the household. The study
participation was voluntary.
Patients matching the inclusion criteria for age and diagnostic suspicion were selected
among the patients referred to the Unit at the beginning of the planned DH visits. A general
outline of the study was provided and informed consent was obtained from all participants.
The investigators trained the caregivers in using the mobile app during the first day of the
DH programs; caregivers were specifically instructed to supervise the children during the
use of Assioma for both tablet and smartphone.
The project was conducted in accordance with the Declaration of Helsinki and was
approved by the hospital Ethical Committee (1804_OPBG_2019).

2.2.2. Procedure
After patient registration on the Assioma platform by the clinician, a tablet with the
Assioma Parents application was provided to the families at the beginning of the DH
program, with specific instructions to return it at the end of each day at the DH. Figure 4
summarizes the tasks required of participant and clinicians involved in the study.

2.2.3. Questionnaires and Data Analysis

The clinical evaluation consisted in a neuropsychiatric interview followed by neu-
ropsychological and psychopathological assessment, including the administration of psy-
chological tests and parent-report questionnaires.
Once they completed the clinical procedure, families and clinicians involved in the
pilot study completed two questionnaires, which included rating their likelihood to use
the mobile app and their satisfaction levels from low (disagree) to high (strongly agree).
The usability questionnaire for families was composed of 11 items, whereas the version
for clinicians was made up of nine items. The satisfaction questionnaire included 8 items
for both families and clinicians. At the end of each questionnaire, an additional section for
improvement suggestions was added.
 After patient registration on the Assioma platform by the clinician, a tablet with the
Assioma
Int. J. Environ. Res. Public Health 2021, 18, 2758
Parents application was provided to the families at the beginning of the DH pro-
9 of 17
gram, with specific instructions to return it at the end of each day at the DH. Figure 4
summarizes the tasks required of participant and clinicians involved in the study.

Figure4.4.Overview
Figure Overviewof ofthe
theusers
usersofofthe
thethree
threeAssioma
Assiomaapplications
applicationsand
andtheir
theirtasks.
tasks.Assioma
Assiomadesktop
desk-
was only for clinicians, whereas Assioma Parents was for children and their caregivers,
top was only for clinicians, whereas Assioma Parents was for children and their caregivers, withwith
video
cartoons designed for children under caregiver supervision. Assioma Diary was an
video cartoons designed for children under caregiver supervision. Assioma Diary was an agendaagenda app for
app for caregivers. Bidirectional exchange of information was allowed only between
caregivers. Bidirectional exchange of information was allowed only between Assioma Desktop and Assioma
DesktopParents,
Assioma and Assioma
when Parents, when using
using Assioma DiaryAssioma Diary
caregivers caregivers
could could
only access only access
contents contents
associated with
associated with their account by the clinicians and check
their account by the clinicians and check push-notifications. push-notifications.

3.2.2.3.
Results
Questionnaires and Data Analysis
We
Theenrolled 28 childrenconsisted
clinical evaluation and theirin caregivers (globally indicated
a neuropsychiatric interviewas “families”),
followed and
by neuro-
24 completed the testing. Two families refused to participate because they
psychological and psychopathological assessment, including the administration of psy- perceived the
tasks required by the testing as too complex
chological tests and parent-report questionnaires. and onerous; two families decided to interrupt
the testing
Once because of behavioral
they completed problems
the clinical of the children
procedure, inand
families handling the tablet
clinicians provided
involved in the
by thestudy
pilot investigators.
completed two questionnaires, which included rating their likelihood to use
A total app
the mobile of 24andfamilies and six clinicians
their satisfaction (three
levels from psychologists
low (disagree) toand
highthree physicians)
(strongly agree).
completed the pilot test and filled out the questionnaires. Children were
The usability questionnaire for families was composed of 11 items, whereas the version aged between 6–
10 years old (mean 7.33, standard deviation 2.3). Eleven children (45.83%) were
for clinicians was made up of nine items. The satisfaction questionnaire included 8 items diagnosed
with Specific
for both learning
families and disorder,
clinicians.six At(25%) with
the end ofattention deficit/hyperactivity
each questionnaire, disorder,
an additional four
section for
with intellectual disability (16.66%)
improvement suggestions was added. and three (12.5%) with autism spectrum disorder.

3.1. Usability Questionnaire

3. Results
Among families, the majority (more than 66%) of caregivers expressed the highest
We enrolled 28 children and their caregivers (globally indicated as “families”), and
level of approval for the provided explanation of the applications, instructions of use,
24 completed the testing. Two families refused to participate because they perceived the
ease of the log-in, moving among the various functionalities and the completion of the
tasks required by the testing as too complex and onerous; two families decided to inter-
anamnestic questionnaire. The majority of families also expressed scores in the highest
rupt the testing because of behavioral problems of the children in handling the tablet pro-
range for the items related to the intuitiveness of Assioma for tablets (namely, Assioma
vided by the investigators.
Parents) and for the font size and style used. However, mixed results were detected for the
A total of 24 families and six clinicians (three psychologists and three physicians)
items related to the graphical interface (58% of responses gave in the highest score), to the
completed
usability the pilot for
of Assioma testsmartphone
and filled out the questionnaires.
(namely, MyDiary; 62.5%Children
of the were agedwere
responses between 6–
in the
10 years old (mean 7.33, standard deviation 2.3). Eleven children (45.83%) were diagnosed
highest range) and also its navigability (54% of the responses were in the highest range).
withAmong
Specificclinicians,
learning disorder, six (25%)
the majority (more with
than attention deficit/hyperactivity
66%) of physicians disorder,
and psychologists
four with intellectual disability (16.66%) and three (12.5%) with autism spectrum
expressed the highest level of approval for all the items, with the only exception being disorder.
the
navigability of Assioma Desktop (50% of responses were in the highest range).
3.1. Usability Questionnaire
Table 2 summarizes the results of the usability questionnaires filled out by caregivers
and clinicians. Results are expressed in percentages.
Int. J. Environ. Res. Public Health 2021, 18, 2758 10 of 17

Table 2. Percentages of usability for each statement.

Usability-Caregivers Questionnaire Strongly Agree Moderately Agree Disagree Missing

The explanations provided for the use of Assioma
87.5% (21) 12.5% (3) - -
were clear.
I would have preferred more detailed explanation for
4% (1) 21% (5) 75% (18) -
using Assioma.
It was easy to perform log-in. 79% (19) 17% (4) - 4% (1)
58% 42%
The graphical interface of the platform was pleasant. - -
(14) (10)
The contents of the platform were clear and easy to 79% 21%
- -
understand. (19) (5)
It was easy to move from one section to another of 67% 33%
- -
Assioma for tablet. (16) (8)
71% 29%
It was easy to complete the anamnestic questionnaire. - -
(17) (7)
It was easy to move from one section to another
62.5% (15) 29% (7) - 8.5% (2)
within Assioma for smartphone.
Assioma for tablet was intuitive and easy to navigate. 75% (18) 25% (6) - -
Assioma for smartphone was intuitive and easy to
54% (13) 29.5% (7) 4% (1) 12.5% (3)
navigate.
I am satisfied of the font size and style used in
83.5% (20) 12.5% (3) - 4% (1)
Assioma application.
Usability-Clinicians Questionnaire Strongly Agree Moderately Agree Disagree Missing
The explanations provided for the use of Assioma
100% (6) - - -
were clear.
I would have preferred more detailed explanation for
83% (5) 17% (1) - -
using Assioma.
Patients’ registration was easy. 67% (4) 33% (2) - -
The graphical interface of the platform was pleasant. 83% (5) 17% (1) - -
I was satisfied with the font size of Assioma. 100% (6) - - -
The contents were clear and easy to understand. 100% (6) - - -
It was easy to move from one session to another of
50% (3) 50% (3) - -
Assioma for PC.
The validation and integration of the medical history
67% (4) 33% (2) - -
questionnaire was easy.
Assioma for PC was intuitive and easy to navigate. 67% (4) 33% (2) - -

3.2. Satisfaction Questionnaire

Among families, the majority (more than 66%) of caregivers expressed the highest
level of approval solely for the perceived improved experience of the DH. Results for the
remaining items were mixed. 50% expressed highest scores to evaluate the overall satisfac-
tion of their experience with Assioma. Around half of the families expressed a medium
level of satisfaction about the usefulness of the push notifications, video cartoons, and
Assioma for smartphone (namely, MyDiary), as well as for the improved communication
with clinicians. Finally, 58% gave sufficient scores for the item concerning the usefulness of
the information sheets on neuropsychiatric diseases. Of note, the items about the usefulness
of MyDiary and information sheets registered quite a high percentage of missing answers
(25% and 13%, respectively).
Int. J. Environ. Res. Public Health 2021, 18, 2758 11 of 17

Among clinicians, the majority (more than 66%) expressed the highest level of sat-
isfaction for the items concerning the usefulness of automatized anamnestic data export
in both text and excel formats, as well as for the inclusion of informative contents on
neuropsychiatric diseases. Half of the clinicians (50%) expressed the highest level of satis-
faction regarding the improved efficiency of DH pathways and improved communication
between families and clinicians. Sufficient satisfaction levels for the items concerning
the digitalization of the anamnestic questionnaire and overall satisfaction of the Assioma
platform were expressed by the majority of clinicians (83% and 67% respectively).
Table 3 summarizes the results of the satisfaction questionnaires filled by caregivers
and clinicians. Results are expressed in percentages.

Table 3. Percentages of satisfaction for each statement.

Satisfaction-Caregivers Questionnaire Strongly Agree Moderately Agree Disagree Missing

Assioma made the Day Hospital experience more
67% (16) 33% (8) - -
comfortable.
The Day Hospital notifications were helpful for
34% (8) 54% (13) 4% (1) 8% (2)
hospital experience.
The vision of the video cartoon on the Day Hospital
42% (10) 50% (12) 4% (1) 4% (1)
procedure was useful.
The vision of the video cartoon on the EEG
29% (7) 50% (12) 12% (3) 9% (2)
procedure was useful.
The vision of the information sheets was useful. 25% (6) 58% (14) 4% (1) 13% (3)
Assioma for smartphone was useful. 21% (5) 46% (11) 8% (2) 25% (6)
Assioma improved the communication with
42% (10) 54% (13) - 4% (1)
clinicians.
I am globally satisfied of Assioma platform. 50% (12) 46% (11) - 4% (1)
Satisfaction-Clinicians Questionnaire Strongly Agree Moderately Agree Disagree Missing
The digitalization of the anamnestic questionnaire
17% (1) 83% (5) - -
was useful for the clinical practice.
The export of the anamnestic questionnaire in text
83% (5) 17% (1) - -
format was useful for the clinical practice.
The export of the anamnestic questionnaire in excel
100% (6) - - -
format was useful for the clinical practice.
The inclusion of informative contents on
neuropsychiatric diseases was useful for the clinical 83% (5) 17% (1) - -
practice.
The use of Assioma made the Day Hospital
50% (3) 50% (3) - -
procedure more efficient.
Notifications on the Day Hospital activities were
33% (2) 33% (2) 17% (1) 17% (1)
useful for the clinical practice.
Assioma improved the communication between
50% (3) 50% (3) - -
patients/parents and clinicians.
I am globally satisfied of Assioma platform. 33% (2) 67% (4) - -

4. Discussion
To the best of our knowledge, this is the first study to report on the usability and
satisfaction of an m-health platform designed to support clinical pathways in a child
and adolescent neuropsychiatry unit. Given the literature gap on the application of m-
Health platform specifically developed to support clinical pathways in hospital services
for children with neurodevelopmental disorders, we designed Assioma to target specific
Int. J. Environ. Res. Public Health 2021, 18, 2758 12 of 17

aspects of the DH procedures, namely data collection and organization, family-clinicians

communication and families’ involvement in the clinical pathway.
Overall, the data obtained from this pilot study confirmed an excellent level of usability
of the platform, with very high scores obtained from both patients and clinicians, and
provided some important suggestions to improve the development of the platform for
future application purposes. The excellent usability of a digital platform is an indispensable
prerequisite for the effectiveness of m-Health as even applications with high utility may
become unlikely to be accepted if they are not user-friendly [40,41].
Usability. Most caregivers attributed high scores in evaluating the usability of the
different functions of Assioma. The item receiving most heterogeneous answers concerned
the intuitiveness of MyDiary (the Assioma app for smartphones). This result could be
interpreted by considering the heterogeneity in digital literacy among the involved partici-
pants since the use of MyDiary required the ability to download the app from Playstore,
installing it and using it during the DH.
Clinicians attributed very high scores to nearly all of the items, with the only exception
being the navigability of Assioma for desktop. This data can be interpreted by recognizing
the greater number of functions of the platform the clinicians handled during the pilot
study. Moreover, as an integration of the routine clinical procedure, the testing of Assioma
during the pilot study was carried out parallel to the use of other software employed in
our clinical practice.
Notably, both groups attributed high scores to the font size used for the platform.
This represents an important point considering that our child and adolescent neuropsy-
chiatry unit also includes patients with specific deficits in reading skills; for such patients,
the introduction of new devices into clinical practice should consider the application of
compensatory measures—such as highly legible characters—to meet their specific needs.
Differences between the two groups emerged for some functionalities, such as patients’
registration and anamnestic data validation, as well as for the perception of platform
navigability and intuitiveness, where clinicians specifically gave scores in low ranges. This
divergence can be attributed to possible difficulties experienced by clinicians using the
Assioma Desktop. One possible explanation could be the higher number of the platform’s
functionalities in the clinician version than those in the patient families’ version. Moreover,
the validation of the data from the anamnestic questionnaire consisted in the review of
the amount of information collected and then made to flow into the clinical interview that
made validation possible. It was therefore a procedure closely connected to clinical practice
and, to some extent, additional to routine care. For a future optimization of the application,
the clinicians suggested they could benefit from a longer period of training on the use of
the platform before starting to use it in the clinical setting. The use of m-Health implicates a
reshaping of the conventional clinical pathways [42], and today’s clinicians and healthcare
providers are called to drive innovation in clinical practice, especially considering the
current pandemic emergency. This process involves the necessity of reflecting on peculiar
medicolegal and ethical issues, such as privacy, informed consent, and the doctor-patient
relationship [43]. Therefore, an effective training of the healthcare providers should be
considered as a crucial step to promote innovation and to bypass resistance to change.
Regarding satisfaction, in the results obtained from the satisfaction questionnaire, a
higher discrepancy emerged for answers provided by caregivers and clinicians for the
same items. Overall satisfaction reached the highest levels for 50% of caregivers, but only
for 33% of clinicians. As stated previously, former findings had indicated a possible reluc-
tance of clinicians towards the use of m-Health tools within clinical settings and a limited
knowledge of information technology [44–47]. Lapointe and Rivard [48] found that the re-
sistance occurring in the adoption of new m-Health technologies in hospital settings could
be fruitfully modulated by the developers. In the present work, we mainly focused on
improving, by way of Assioma, the aspects related to the exchange of information between
patient families and clinicians. Importantly for the purposes of our study, nearly the 50% of
both caregivers and clinicians indicated satisfaction levels in the middle range for the item
Int. J. Environ. Res. Public Health 2021, 18, 2758 13 of 17

concerning the improvement of patient-clinician communication. This is in line with litera-

ture reporting mixed findings on the improvement of communication between patients
and clinicians induced by the introduction of technologies into clinical practice [19]. The
heterogeneity of findings could be explained, at least in part, by the variety of the aspects
related to patient-clinician communication that can be influenced by the use of m-Health,
such as the exchange of information, the adequate response to emotion, the management
of uncertainty, the decision-making process, and the enhancement of self-management [49].
However, it must be highlighted that, despite the fact that it represents only one aspect
of the multidimensional process of patient-clinician communication, the improvement
of information exchange by remote is a crucial goal for clinical pathways in the specific
context of a pandemic, where m-Health could be a key ally in promoting social distancing.
The absence of answers in the lowest range of satisfaction levels observed in our study
could be interpreted as an encouraging suggestion of the noninferiority of the m-Health
mediated exchange of information during the DH procedure in child neuropsychiatry
services. Finally, we can speculate that the use of the detailed anamnestic questionnaire
developed for tablets made it possible for caregivers to focus on some questions which
often require more time to respond to, for instance, questions related to life events that
may have an impact on the child’s behavior. On the other hand, we could hypothesize
that the automatized data collection allowed clinicians to double-check information accu-
racy, therefore improving the quality of information exchange [50]. Future works should
specifically target and investigate the effects of m-Health platforms on the other aspects of
communications and should directly compare the efficacy of different remote systems for
communication during the DH procedure when face to face communication is discouraged.
Considering group-specific questions, it must be noted that the highest satisfaction
ratings for the video cartoons only reached 42% (Video 1) and 29% (Video 2) for families.
These findings were in line with our expectations, considering that Video 2 concerned a
specific medical procedure, EEG under sedation, thus not all families were interested in
receiving information on it.
The export in text and Excel formats of the anamnestic questionnaire and the in-
formation sheets obtained elevated percentages of high scores (more than 80%), in line
with our expectations. Data collection, organization and storage—especially anamnestic
information—have a central role in the evaluation process in mental healthcare: neuropsy-
chiatric conditions represent very complex phenomena, as individuals included in the
same diagnostic category may display a unique combination of factors—both genetic and
phenotypic. For this reason, in the past few years great attention has been paid to the
possibility of investigating neuropsychiatric condition using big data and machine learning
approaches to deal with such high complexity and to help in improving classification of
diseases and/or treatment selection, to predict treatment outcomes or test new hypothe-
ses [51,52]. The growing interest in the interaction between technology and mental health
led to the possibility of retrieving and analyzing data on multiple health indicators by mak-
ing patient information available anywhere, anytime [53]. Moreover, it contributed to the
creation of a “digital phenotype”, namely the “moment-by-moment quantification of the
individual-level human phenotype in situ using data from personal digital devices”, which
crucially contributes to the establishment of an ecological and comprehensive approach to
mental health measurement [54,55].
A further consideration concerns the potential usefulness of the Assioma platform in
reducing the in-person contacts between clinicians and patient families. The acquisition
of anamnestic information through an m-health system clearly represents an important
step towards the optimization of in-person contacts throughout the clinical pathway. Such
optimization could allow the clinicians to focus the in-person visit on the direct observation
of the patient and physical examination. Therefore, m-health platforms such as Assioma
could be valuable tools in situations in which face-to-face visits are not deferrable. This
should be then considered an additional way to sustain social distancing in child psychiatry,
in partnership with the use of telemedicine.
Int. J. Environ. Res. Public Health 2021, 18, 2758 14 of 17

To sum up, the optimization of data collection and storage provided by the use of
mobile-communication devices could contribute to improving data collection for both
clinical and research purposes. The Assioma platform moved in this direction: results from
the pilot test indicated that Assioma could effectively support data collection, organization
and storage. Moreover, it supported the communication between families and clinicians
along the DH pathway, promoting greater involvement by the families in the DH processing
procedure and provided a more comfortable experience wothin the DH pathways. Our
results confirm and extend previous findings, which have reported a positive attitude
toward m-health technologies from families of patients with genetic/neuropsychiatric
conditions. We have provided further support for the crucial role of m-Health in child
mental healthcare in the relatively unexplored context of the DH clinical pathway
However, some issues must be underlined. The refusal of two families to be involved
in the study due to the perceived complexity of the tasks should make us reflect on the
possibility of dividing future pilot testing into two parts: one devoted to Assioma Parents
and one devoted to MyDiary. Another consideration concerns the interruption of the study
related to behavioral issues of two of the children involved at the beginning of the study;
in both cases, the children had a diagnostic suspicion (subsequently confirmed at the end
of the DH evaluation) of attention deficit/hyperactivity disorder, associated with marked
behavioral dyscontrol. This could lead to a change in the exclusion criteria for further
studies. A further limitation of the study was the lack of development for iOS, which
restricted the number of families recruitable for the pilot testing.
Clinicians suggested investigating the usability of Assioma for the outpatient proce-
dures of our Unit, where the functionality of the Assioma anamnestic questionnaires would
be highly useful. A further step towards the digitalization of clinical pathways could be
the administration of the digital version of some of the open-source questionnaires used in
the assessment process, and their automated scoring, thus allowing the clinician to further
optimize the time of the evaluation process. Moreover, it would be desirable to design
additional video cartoons to introduce other medical procedures, such as blood sampling,
which is a common procedure for some patients. Finally, considering the gap in satisfaction
levels between caregivers and clinicians, the involvement of families (for instance, through
focus groups) could be helpful in designing additional platform functionalities, for the
families’ side. Conversely, for the clinicians’ side, planning for a longer training time
could help them to reach an optimum level of familiarity for the best integration between
platform use and clinical activities.
Despite the encouraging results, we must underline that this study was conducted in a
single center on a small sample size. The nature of the study was chosen to provide detailed
qualitative information useful for planning future larger studies. Not only would large
multicenter studies be helpful to better and more precisely assess the impact of mHealth
tools in the neuropsychiatry setting, but the heterogeneity of the population under study
would also help in evaluating their applicability based on cultural differences and age
groups. These studies will be necessary to definitely confirm our results.
The use of digital tools is also relevant to regulation for data management. All digital
applications developed in the EU should comply with GDPR [36]. Our study was con-
ducted in compliance with current regulations and all information about data management
was included in the informed consent for participating. It is worth noticing that beyond
GDPR compliance, the evaluation of digital tools for clinical uses is currently conducted
with different approaches at the international level. Regulations for authorization of digital
tools for the clinic, for example, vary from the US to the EU. Moreover, in Europe, some
countries like Germany, recently issued specific regulations for digital tools for clinical use.
Future studies should be conducted taking into account the evolution of regulations for
digital health.
Int. J. Environ. Res. Public Health 2021, 18, 2758 15 of 17

5. Conclusions
The data obtained from this pilot study constitute a promising background for fur-
ther improvement and validation studies of the Assioma platform as a medical device
potentially usable in different contexts of clinical pathways, such as the DH and outpatient
regime, with the aim of improving patient-doctor communication, to support clinical path-
ways in the hospital and to potentially sustain social distancing in this a unique historical
moment of the COVID-19 pandemic. The Assioma platform therefore could pave the way
towards new digitalization procedures for clinical procedures, with important expected
benefits for optimizing clinical times, increasing compliance, improving clinical efficiency
and supporting safety procedures through social distancing during pandemic emergencies.

Supplementary Materials: The following are available online at https://www.mdpi.com/1660-460

1/18/5/2758/s1, Anamnestic Questionnaire S1.
Author Contributions: Conceptualization, E.F., F.C. and A.E.T.; methodology, E.F. and D.B.; software,
A.M., A.F. (Andrea Fini) and A.F. (Alberto Ferraiuolo); formal analysis, E.F. and F.C.; investigation E.F.
and D.B.; data curation, E.F. and D.B.; writing—original draft preparation, E.F., F.C. and D.B.; writing—
review and editing, E.F., F.C., A.E.T. and S.V.; supervision, S.V. and A.E.T.; project administration,
A.E.T.; funding acquisition, A.E.T. All authors have read and agreed to the published version of
the manuscript.
Funding: This research was funded by an innovation fund for SMEs (Lazioinnova N. Prot. n
A0112-2016-13312; 12 December 2016).
Institutional Review Board Statement: The study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by the Institutional Ethics Committee of Bambino Gesù
Chilren’s Hospital (1804_OPBG_2019, approved 8 May 2019).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to the consent provided by participants
on the use of confidential data.
Acknowledgments: We are very grateful to Kiersten Pilar Miller, who helped us improving our work
by providing the English editing.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Silva, B.M.; Rodrigues, J.J.; Díez, I.D.L.T.; López-Coronado, M.; Saleem, K. Mobile-health: A review of current state in 2015. J.
Biomed. Inform. 2015, 56, 265–272. [CrossRef] [PubMed]
2. Vargas, B.R.; Ferrández, J.S.-R.; Fuentes, J.G.; Velayos, R.; Verdugo, R.M.; Piñol, F.S.; González, A.O.; Sagrado, M.; Ángel, R.
Usability and Acceptability of a Comprehensive HIV and Other Sexually Transmitted Infections Prevention App. J. Med. Syst.
2019, 43, 175. [CrossRef] [PubMed]
3. Barrett, M.A.; Humblet, O.; Marcus, J.E.; Henderson, K.; Smith, T.; Eid, N.; Sublett, J.W.; Renda, A.; Nesbitt, L.; Van Sickle, D.; et al.
Effect of a mobile health, sensor-driven asthma management platform on asthma control. Ann. Allergy Asthma Immunol. 2017,
119, 415–421.e1. [CrossRef] [PubMed]
4. Zhu, J.; Ebert, L.; Xue, Z.; Shen, Q.; Chan, S.W.-C. Development of a mobile application of Breast Cancer e-Support program for
women with breast cancer undergoing chemotherapy. Technol. Health Care 2017, 25, 377–382. [CrossRef] [PubMed]
5. Liu, C.-H.; Chung, Y.-F.; Chen, T.-S.; Wang, S.-D. Mobile Agent Application and Integration in Electronic Anamnesis System. J.
Med. Syst. 2010, 36, 1009–1020. [CrossRef]
6. Martin, G.; Khajuria, A.; Arora, S.; King, D.; Ashrafian, H.; Darzi, A. The impact of mobile technology on teamwork and
communication in hospitals: A systematic review. J. Am. Med. Inform. Assoc. 2019, 26, 339–355. [CrossRef]
7. Torous, J.; Friedman, R.; Keshavan, M. Smartphone Ownership and Interest in Mobile Applications to Monitor Symptoms of
Mental Health Conditions. JMIR mHealth uHealth 2014, 2, e2. [CrossRef] [PubMed]
8. Grist, R.; Porter, J.; Stallard, P. Mental Health Mobile Apps for Preadolescents and Adolescents: A Systematic Review. J. Med.
Internet Res. 2017, 19, e176. [CrossRef]
9. Turvey, C.; Fortney, J. The Use of Telemedicine and Mobile Technology to Promote Population Health and Population Management
for Psychiatric Disorders. Curr. Psychiatry Rep. 2017, 19. [CrossRef]
Int. J. Environ. Res. Public Health 2021, 18, 2758 16 of 17

10. Larsen, M.E.; Nicholas, J.; Christensen, H. A Systematic Assessment of Smartphone Tools for Suicide Prevention. PLoS ONE 2016,
11, e0152285. [CrossRef]
11. Whittaker, R.; Stasiak, K.; McDowell, H.; Doherty, I.; Shepherd, M.; Chua, S.; Dorey, E.; Parag, V.; Ameratunga, S.; Rodgers,
A.; et al. MEMO: An mHealth intervention to prevent the onset of depression in adolescents: A double-blind, randomised,
placebo-controlled trial. J. Child Psychol. Psychiatry 2017, 58, 1014–1022. [CrossRef]
12. Kauer, S.D.; Reid, S.C.; Crooke, A.H.D.; Khor, A.; Hearps, S.J.C.; Jorm, A.F.; Sanci, L.; Patton, G. Self-monitoring Using Mobile
Phones in the Early Stages of Adolescent Depression: Randomized Controlled Trial. J. Med. Internet Res. 2012, 14, e67. [CrossRef]
13. Dubad, M.; Winsper, C.; Meyer, C.; Livanou, M.; Marwaha, S. A systematic review of the psychometric properties, usability and
clinical impacts of mobile mood-monitoring applications in young people. Psychol. Med. 2018, 48, 208–228. [CrossRef] [PubMed]
14. Pennant, M.E.; Loucas, C.E.; Whittington, C.; Creswell, C.; Fonagy, P.; Fuggle, P.; Kelvin, R.; Naqvi, S.; Stockton, S.; Kendall, T.
Computerised therapies for anxiety and depression in children and young people: A systematic review and meta-analysis. Behav.
Res. Ther. 2015, 67, 1–18. [CrossRef]
15. Vigerland, S.; Lenhard, F.; Bonnert, M.; Lalouni, M.; Hedman, E.; Ahlen, J.; Olén, O.; Serlachius, E.; Ljótsson, B. Internet-delivered
cognitive behavior therapy for children and adolescents: A systematic review and meta-analysis. Clin. Psychol. Rev. 2016, 50,
1–10. [CrossRef]
16. Wilansky, P.; Eklund, J.M.; Milner, T.; Kreindler, D.; Cheung, A.; Kovacs, T.; Shooshtari, S.; Astell, A.; Ohinmaa, A.; Henderson,
J.; et al. Cognitive Behavior Therapy for Anxious and Depressed Youth: Improving Homework Adherence Through Mobile
Technology. JMIR Res. Protoc. 2016, 5, e209. [CrossRef] [PubMed]
17. Weisman, O.; Schonherz, Y.; Harel, T.; Efron, M.; Elazar, M.; Gothelf, D. Testing the Efficacy of a Smartphone Application in
Improving Medication Adherence, Among Children with ADHD. Isr. J. Psychiatry Relat. Sci. 2018, 55, 59–63. [CrossRef]
18. Costantino, A. Rete dei Servizi per i Disturbi Neuropsichici dell’età Evolutiva: Risorse e Criticità; Rapporti ISTISAN 17/16; 2017.
Available online: https://www.iss.it/documents/20126/45616/17_16_web.pdf/180e0642-b28c-cc3d-db59-a3204227b896?t=15
81099285972#page=16 (accessed on 17 May 2018).
19. Eden, R.; Burton-Jones, A.; Scott, I.; Staib, A.; Sullivan, C. Effects of eHealth on hospital practice: Synthesis of the current literature.
Aust. Health Rev. 2018, 42, 568–578. [CrossRef] [PubMed]
20. Melby, L.; Hellesø, R. Introducing electronic messaging in Norwegian healthcare: Unintended consequences for interprofessional
collaboration. Int. J. Med. Inform. 2014, 83, 343–353. [CrossRef]
21. Saddik, B.; Al-Mansour, S. Does CPOE support nurse-physician communication in the medication order process? A nursing
perspective. Stud. Health Technol. Inform. 2014, 204, 149–155.
22. Keasberry, J.; Scott, I.A.; Sullivan, C.; Staib, A.; Ashby, R. Going digital: A narrative overview of the clinical and organisational
impacts of eHealth technologies in hospital practice. Aust. Health Rev. 2017, 41, 646–664. [CrossRef] [PubMed]
23. Liszio, S.; Masuch, M. Virtual Reality MRI: Playful Reduction of Children’s Anxiety in MRI Exams. In Proceedings of the 2017
Conference on Interaction Design and Children IDC0 17, Stanford, CA, USA, 27–30 June 2017. [CrossRef]
24. Buffel, C.; Van Aalst, J.; Bangels, A.-M.; Toelen, J.; Allegaert, K.; Verschueren, S.; Stichele, G.V.; Antoniades, A.; Bestek, M.
A Web-Based Serious Game for Health to Reduce Perioperative Anxiety and Pain in Children (CliniPup): Pilot Randomized
Controlled Trial. JMIR Serious Games 2019, 7, e12431. [CrossRef] [PubMed]
25. Kim, J.; Chiesa, N.; Raazi, M.; Wright, K.D. A systematic review of technology-based preoperative preparation interventions for
child and parent anxiety. Can. J. Anesth. 2019, 66, 966–986. [CrossRef] [PubMed]
26. Bray, L.; Sharpe, A.; Gichuru, P.; Fortune, P.-M.; Blake, L.; Appleton, V. The Acceptability and Impact of the Xploro Digital
Therapeutic Platform to Inform and Prepare Children for Planned Procedures in a Hospital: Before and After Evaluation Study. J.
Med. Internet Res. 2020, 22, e17367. [CrossRef] [PubMed]
27. Tozzi, A.E.; Carloni, E.; Gesualdo, F.; Russo, L.; Raponi, M. Attitude of Families of Patients with Genetic Diseases to Use m-Health
Technologies. Telemed. e-Health 2015, 21, 86–89. [CrossRef] [PubMed]
28. Karisalmi, N.; Kaipio, J.; Lahdenne, P. Improving Patient Experience in a Children’s Hospital: New Digital Services for Chil-dren
and Their Families. Stud. Health Technol. Inform. 2018, 247, 935–939.
29. Luciano, M.; Sampogna, G.; Del Vecchio, V.; Giacco, D.; Mulè, A.; De Rosa, C.; Fiorillo, A.; Maj, M. The family in Italy: Cultural
changes and implications for treatment. Int. Rev. Psychiatry 2012, 24, 149–156. [CrossRef]
30. Del Vecchio, V.; Luciano, M.; Sampogna, G.; De Rosa, C.; Giacco, D.; Tarricone, I.; Catapano, F.; Fiorillo, A. The role of relatives in
pathways to care of patients with a first episode of psychosis. Int. J. Soc. Psychiatry 2015, 61, 631–637. [CrossRef]
31. Carmichael, B.; Pembre, M.; Turner, G.; Barnicoat, A. Diagnosis of fragile-X syndrome: The experiences of parents. J. Intellect.
Disabil. Res. 1999, 43 Pt 1, 47–53. [CrossRef]
32. Bultas, M.W.; McMillin, S.E.; Zand, D.H. Reducing Barriers to Care in the Office-Based Health Care Setting for Children With
Autism. J. Pediatr. Health Care 2016, 30, 5–14. [CrossRef]
33. Kelleher, B.; Halligan, T.; Garwood, T.; Howell, S.; Martin-O’Dell, B.; Swint, A.; Shelton, L.-A.; Shin, J. Brief Report: Assessment
Experiences of Children with Neurogenetic Syndromes: Caregivers’ Perceptions and Suggestions for Improvement. J. Autism Dev.
Disord. 2020, 50, 1443–1450. [CrossRef] [PubMed]
34. World Health Organization. Implementing Telemedicine Services during COVID-19: Guiding Principles and Considerations for a Stepwise
Approach; WHO Regional Office for the Western Pacific: Manila, Philippines, 2020.
Int. J. Environ. Res. Public Health 2021, 18, 2758 17 of 17

35. Visconti, R.M.; Morea, D. Healthcare Digitalization and Pay-For-Performance Incentives in Smart Hospital Project Financing. Int.
J. Environ. Res. Public Health 2020, 17, 2318. [CrossRef]
36. European Parliament and Council. Regulation (EU) 2016/679 of 27 April 2016 on the Protection of Natural Persons with Regard to the
Processing of Personal Data and on the Free Movement of Such Data, and Repealing Directive 95/46/EC (General Data Protection Regulation);
EC: Brussels, Belgium, 2016. Available online: http://eurlex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32016R0679
(accessed on 17 May 2018).
37. World Health Organization. Recommendations on Digital Interventions for Health System Strengthening; Web Supplement 2: Summary
of Findings and GRADE Tables; World Health Organization: Geneva, Switzerland, 2019.
38. Turvey, C.; Coleman, M.; Dennison, O.; Drude, K.; Goldenson, M.; Hirsch, P.; Jueneman, R.; Kramer, G.M.; Luxton, D.D.;
Maheu, M.M.; et al. ATA Practice Guidelines for Video-Based Online Mental Health Services. Telemed. e-Health 2013, 19, 722–730.
[CrossRef] [PubMed]
39. Bernard, M.L.; Chaparro, B.S.; Mills, M.M.; Halcomb, C.G. Examining children’s reading performance and preference for different
computer-displayed text. Behav. Inf. Technol. 2002, 21, 87–96. [CrossRef]
40. Zaidi, S.T.; Marriott, J.L. Barriers and Facilitators to Adoption of a Web-based Antibiotic Decision Support System. South Med.
Rev. 2012, 5, 42–50. [PubMed]
41. Sun, H.-M.; Li, S.-P.; Zhu, Y.-Q.; Hsiao, B. The effect of user’s perceived presence and promotion focus on usability for interacting
in virtual environments. Appl. Ergon. 2015, 50, 126–132. [CrossRef] [PubMed]
42. Montemurro, N.; Perrini, P. Will COVID-19 change neurosurgical clinical practice? Br. J. Neurosurg. 2020, 1, 1–2. [CrossRef]
43. Ateriya, N.; Saraf, A.; Meshram, V.P.; Setia, P. Telemedicine and virtual consultation: The Indian perspective. Natl. Med. J. India
2018, 31, 215–218. [CrossRef]
44. Ash, J.S.; Bates, D.W. Factors and Forces Affecting EHR System Adoption: Report of a 2004 ACMI Discussion. J. Am. Med. Inform.
Assoc. 2004, 12, 8–12. [CrossRef]
45. Poon, P.; Hui, E.; Dai, D.; Kwok, T.; Woo, J. Cognitive intervention for community-dwelling older persons with memory problems:
Telemedicine versus face-to-face treatment. Int. J. Geriatr. Psychiatry 2005, 20, 285–286. [CrossRef]
46. Byambasuren, O.; Beller, E.; Glasziou, P. Current Knowledge and Adoption of Mobile Health Apps among Australian General
Practitioners: Survey Study. JMIR mHealth uHealth 2019, 7, e13199. [CrossRef]
47. Minou, J.; Mantas, J.; Malamateniou, F.; Kaitelidou, D. Health Professionals’ Perception about Big Data Technology in Greece.
Acta Inform. Med. 2020, 28, 48–51. [CrossRef] [PubMed]
48. Lapointe, L. Getting physicians to accept new information technology: Insights from case studies. Can. Med. Assoc. J. 2006, 174,
1573–1578. [CrossRef] [PubMed]
49. Rathert, C.; Mittler, J.N.; Banerjee, S.; McDaniel, J. Patient-centered communication in the era of electronic health records: What
does the evidence say? Patient Educ. Couns. 2017, 100, 50–64. [CrossRef] [PubMed]
50. Arar, N.H.; Wen, L.; McGrath, J.; Steinbach, R.; Pugh, J.A. Communicating about medications during primary care outpatient
visits: The role of electronic medical records Inform. Prim. Care 2005, 13, 13–21. [CrossRef] [PubMed]
51. Huys, Q.J.M.; Maia, T.V.; Frank, M.J. Computational psychiatry as a bridge from neuroscience to clinical applications. Nat.
Neurosci. 2016, 19, 404–413. [CrossRef]
52. Visconti, R.M.; Morea, D. Big Data for the Sustainability of Healthcare Project Financing. Sustainability 2019, 11, 3748. [CrossRef]
53. Weiner, J.P. Doctor-patient communication in the e-health era. Isr. J. Health Policy Res. 2012, 1, 33. [CrossRef]
54. Torous, J.B.; Chan, S.R.; Yellowlees, P.M.; Boland, R. To Use or Not? Evaluating ASPECTS of Smartphone Apps and Mobile
Technology for Clinical Care in Psychiatry. J. Clin. Psychiatry 2016, 77, e734–e738. [CrossRef]
55. Sequeira, L.; Battaglia, M.; Perrotta, S.; Merikangas, K.; Strauss, J. Digital Phenotyping with Mobile and Wearable Devices:
Advanced Symptom Measurement in Child and Adolescent Depression. J. Am. Acad. Child Adolesc. Psychiatry 2019, 58, 841–845.
[CrossRef]
N e u ro p s y c h i a t r y
Definitions, Concepts, and Patient Types

Vassilis E. Koliatsos, MDa,b,c,d,*, Robert Wisner-Carlson, MD

a
,
Crystal Watkins, MD, PhDa,d

KEYWORDS
 Neurology  Psychiatry  Medicine  Neuroanatomy  Neuroscience
 Neuroplasticity  Evolutionary biology  Neuropathology

KEY POINTS
 Neuropsychiatry is a field of medicine in which neurology and/or neuroscience is neces-
sary or helpful in the understanding and management of mental illness.
 The “mother”’ of modern neurology and psychiatry, neuropsychiatry experiences a re-
naissance because of an explosion of new technologies and methods to study the human
brain and the increasing prevalence of certain disorders, especially neurodegenerative
and vascular brain disease.
 Patients especially benefitting from neuropsychiatric expertise are those in whom neuro-
pathology is key driver of psychopathology but also those in whom neuropathology is a
modifier, a coincidence, or merely a “language” to express illness or conflict.
 Complex psychopharmacological problems may also benefit from neuropsychiatric
expertise.

WHAT IS NEUROPSYCHIATRY
Main Ideas: The Purview of Neuropsychiatry
Neuropsychiatry is a field of medicine in which neurology, and by extension neurosci-
ence, is necessary or at least helpful in the understanding and management of mental
and behavioral illness. It is best viewed as an integrative specialty combining psychi-
atry, neurology, and neuropsychology. Modern neurology and psychiatry started from
a common neuropsychiatric matrix in the late 1800s that continued to prevail in Euro-
pean training and practice until recently. Ever since Hippocrates, there has been a

a
Neuropsychiatry Program, Sheppard Pratt Health System, The Sheppard and Enoch Pratt
Hospital, 6501 North Charles Street, Baltimore, MD 21204, USA; b Department of Pathology
(Neuropathology), Johns Hopkins University School of Medicine, Baltimore, MD, USA;
c
Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA;
d
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of
Medicine, Baltimore, MD, USA
* Corresponding author. Neuropsychiatry Program, The Sheppard and Enoch Pratt Hospital,
6501 North Charles Street, Baltimore, MD 21204.
E-mail addresses: vkoliatsos@sheppardpratt.org; koliat@jhmi.edu

Psychiatr Clin N Am 43 (2020) 213–227

https://doi.org/10.1016/j.psc.2020.02.007 psych.theclinics.com
0193-953X/20/ª 2020 The Author(s). Published by Elsevier Inc. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
214 Koliatsos et al

broad acceptance of the role of brain in mental life and mental illness, although the
fundamental nature of the relationship between brain and mind has been debated
and the debate continues. At the dawn of modern scientific medicine in the late eigh-
teenth to early nineteenth century, physicians identified as neurologists or psychia-
trists for reasons that had more to do with nature and location of practice than
approach to the mind-brain problem: psychiatrists were mostly in charge of psychotic
and other patients with unusual behaviors in asylums, whereas neurologists were
practicing in office settings and managing neuroses, along with general practitioners.1
Many eminent academic psychiatrists were neuropathologists, and neurologists like
Freud (and Charcot before him) had no reservation (or difficulty) to cross over to the
clinical care of neuroses or altogether to psychology (Box 1). The challenges faced
by psychiatrists who were managing severely ill inpatients were likely a great motiva-
tion for the exploration of brain pathology. To the point, many key early discoveries in
neurosyphilis, a very common diagnosis of asylum patients, was made by psychia-
trists. This is not the place to fully explain the astonishingly creative record of this
neuropsychiatric matrix, but suffice it to say that many pioneers in neurology and psy-
chiatry by the late 1900s emerged from this environment and closely interacted with
each other: the psychiatrist and neuroanatomist Von Gudden at the University of
Munich was the mentor of figures such as Bleuler, Forel, Ganser, Kraepelin, and Nissl.
Kraepelin turned Munich into a school that nurtured clinician scientists such as

Box 1
Pioneer neuropsychiatrists

Franz Nissl (1860–1919)

Psychiatrist and neuropathologist. Professor of psychiatry at Heidelberg, invited there by
Kraepelin and succeeding him as Chair. Interacted with most major figures in neuroanatomy/
neuropathology of his era. Close friend of Alzheimer. Also said to be a fine physician. In his
attempt to understand psychosis he was transecting the cranial nerves of rodents and
studying the responses of central neurons using a new staining technique based on basic
dyes that revolutionized neuroanatomy. He also described the role of specific type of
microglia in general paresis.
Auguste Forel (1848–1931)
Psychiatrist and neuroanatomist. Professor of psychiatry at Zurich and director of the
Burghölzli asylum. Mental health reformer. He described the so-called Forel fields ventral to
thalamus that contain the ansa lenticularis, lenticular fasciculus, and cerebellothalamic tract;
these tracts are presently targeted with deep brain stimulation to treat tics in Tourette
syndrome. A Renaissance man, he also wrote on sexology and he was an accomplished
myrmecologist.
Alois Alzheimer (1864–1915)
Psychiatrist and neuropathologist. Professor of psychiatry at Munich. Protégé of and
assistant to Kraepelin. While a psychiatrist at the state asylum in Frankfurt, he associated
himself closely with Nissl and together they wrote a lengthy treatise on the anatomy and
pathology of cerebral cortex. He was the first to describe neurofibrillary tangles and neuritic
plaques in the brain of a middle-aged patient with memory loss, hallucinations, and
confusion that was then named Alzheimer disease by Kraepelin.
Sigmund Freud (1856–1939)
Neurologist and neuropathologist. Professor of neuropathology at the University of Vienna. He
practiced on an office basis. His extensive early work on neuroanatomy on the crayfish and
lamprey is considered by some to have contributed to the neuron doctrine. The founder of
psychoanalysis, arguably out of the awareness of the limitations of neuropathology for many
patients. His structural model and his Project for a Scientific Psychology has strong, although
somewhat primitive, neuroanatomical notions and metaphors.
 Neuropsychiatry as specialty 215

Alzheimer, von Economo, Brodmann, Lewy, and Kleist. The latter worked closely with
Creutzfeldt and Kurt Schneider. Jaspers, the father of psychiatric phenomenology,
had also worked under Nissl.2
In the United States, Adolf Meyer and his late views on the determinism of biography
and then the domination of psychoanalytic paradigm in American psychiatry beyond
the clinical indications envisioned by Freud were responsible for a progressive rift be-
tween medicine or neurology (practiced by “physicians”) and psychiatry (practiced by
“therapists”). The ascent of psychopharmacology in the 1950s and 1960s and then the
explosion of basic neurosciences in the 1980s and 1990s, which demonstrated that
there are few problems or models in brain science that apply to neurology but not
to psychiatry, led to the rapprochement between the 2 fields. A prime demonstration
of commonality in disease models and hypotheses between neurology and psychiatry
is the discovery of compounds that modulate dopamine neurotransmission and the
use of such compounds in psychotic patients first and then, inspired by the side ef-
fects of that use, for the treatment of Parkinson disease.
An important reason for renewed interest in neuropsychiatry is that “core” neuro-
psychiatric disorders are on the rise in view of current demographic trends, especially
the aging of the population, but also widespread habits and styles of life that endanger
the adult brain, especially the white matter and associative cortex (Fig. 1). The need for

Fig. 1. Major neuropsychiatric diseases are very common, and primarily affect associative or
paralimbic cortical areas and associative or commissural white matter tracts. Associative
cortices, representing the vast majority of human neocortex, are indicated here with light
blue (frontal), green (parietal), and gray (temporal). A brain artery and its arteriolar branch-
ing is also indicated on top. Alzheimer disease (AD) causes atrophy in parietal and temporal
associative cortex (outlined); AD affects close to 6 million Americans, a number that is ex-
pected to double by 2030. TBI predominantly affects orbitofrontal and anterior temporal
areas (outlined) or dorsal associative white matter tracts and the corpus callosum (outlined).
TBI has risen in importance, among else because of increased frequency or falls in the aged
population but also the spread in popularity of collision and contact sports; there are 5 to 6
million Americans living with TBI-related disability and there are close to 3 million new
cases of TBI requiring medical attention annually. Atherosclerotic vascular disease of the
brain has also increased with the aging of the population; although not all cases have
intracranial etiology, each year 0.8 million Americans suffer a stroke. Stroke is a cause
of dementia, but the more common problem of small-vessel atherosclerosis and asso-
ciated leukoencephalopathy (circle) may be associated with depression and late-onset
paraphrenias.
216 Koliatsos et al

reintegration of neurology and psychiatry was formally recognized by the United

Council for Neurologic Subspecialties, as the new subspecialty of Behavioral
Neurology and Neuropsychiatry in 2004 and the first Board examination was conduct-
ed in the fall of 2006.

Caveats
Neuropsychiatry is defined as much by its competencies as it is by its limits. The
sharing of the underlying organ (brain), the organic causality in many diseases with
mental or behavioral symptoms, the presence of psychiatric symptoms in almost all
types of brain disease, and the commonality of basic neuroscience questions and
models between neurology and psychiatry does not make them identical medical spe-
cialties. Neuropsychiatry is not advocating an across-the-board primacy of neural
causes and mechanisms of mental illness, thus claiming all psychiatry as its domain.
In fact, a neurologic understanding is not necessary (or desirable) in many conditions
encountered in clinical psychiatric settings, and the use of neurologic language in
these cases is often gratuitous if not absurd (one of us recalls a colleague explaining
that, in the course of doing psychotherapy, he told the patient that he was “tickling”
the patient’s amygdala).
The assignment of cause is especially problematic. The fact that brain lesion a may
cause disease c is not the same as saying that whatever illness looks like c is caused
by lesion a. Part of the reason is that, in psychiatry, we are mostly dealing with syn-
dromes, not diseases in the classic clinicopathological sense. For example, the fact
that an aneurysm of the anterior cerebral artery or a traumatic brain contusion causes
apathy does not mean that any presentation of apathy is caused by a “lesion” in
medial prefrontal-orbitofrontal regions. Functional impairment of that region may be
involved, for example, in psychomotor retardation related to severe depression, but
in this case it may represent an important or obligatory site or “hub” for the expression
of low emotion and motivation/energy. These general areas also appear to be involved
in states of sadness from depression to normal conditions such as grief and romantic
disappointment.3,4 Therefore, although it is possible that a high functional MRI (fMRI)
signal in the anterior cingulate in the brain of a melancholic patient causes psychomo-
tor retardation, it is equally possible that psychomotor retardation, caused by what-
ever top-down mechanism, results in a large-scale network configuration that
overengages or misengages that critical region.
Another important point is that, just as a change in the brain can bring about change
in mental state or behavior, changes in behavior or feeling dictated by social or other
external circumstances may also lead to enduring changes in the brain. This 2-way
communication is illustrated in 2 classic neuropsychiatric paradigms, one from clinical
psychiatry and the other from basic science: the former is the earlier finding that, in
patients with obsessive-compulsive disorder (OCD) undergoing successful
cognitive-behavioral therapy, blood flow to the caudate decreases and that decrease
may correlate with symptom improvement.5 The second, reductionist, paradigm is
work on the sea snail, Aplysia: Aplysia displays a reflexive withdrawal of her gill and
siphon when disturbed that she can learn to overdo (sensitization) or underdo (habit-
uation) based on the pairing or not or the usual mechanical stimulus with a painful
stimulus to the tail. Direct observations of the responsible part of Aplysia’s primitive
nervous system, that is, the abdominal ganglion, under the microscope, shows an in-
crease in number of synapses between the sensory and motor neuron in the course of
sensitization and a corresponding decrease with habituation, thereby directly proving
that “psychosocial” events and learning can change the structure of the nervous
system.6,7
 Neuropsychiatry as specialty 217

NEUROPSYCHIATRIC PATIENT TYPES

Outline
Here we distinguish 5 patient types or clinical approaches based on our experience in
practicing and teaching neuropsychiatry at Sheppard Pratt in the period 1997 to
today. In the type I patient, neuropathology explains all or most of abnormal behavior.
This category includes patients with neurodegenerative diseases, stroke, develop-
mental disabilities, and many cases of acquired brain injury. This category may incor-
porate idiopathic psychiatric illnesses in which neurologic causes are likely, for
example, certain types of schizophrenia. In the type II patient, neurology is only a lan-
guage or “meme”; this category includes patients with what today is called “functional
neurologic disorders,” including conversion disorder that is perhaps the purest form.
In the type III patient, neurology interacts with traits and with co-occurring idiopathic
psychiatric illness. Interactions take place both longitudinally, for example, in the case
of a premorbidly labile patient who becomes bipolarlike after traumatic brain injury
(TBI) and cross-sectionally, as in the case of the patient with parkinsonism whose
motoric symptoms worsen with depression and improve with mania. The type IV pa-
tient is the psychophysiological (psychosomatic) patient. Here we view psychoso-
matic illness as a neuropsychiatric problem involving the peripheral sensory (pain)
or autonomic nervous system and its various interactions with other complex factors
to cause enduring illness. Finally, we claim as “neuropsychiatric” the patient who is on
psychotropic medications: this patient should be understood in terms of neurologic
effects (or side effects) of central nervous system (CNS)-acting medications. The
neuropsychiatric approach has advantages in the management of complex patients
in psychiatry and often in neurology as well. Epilepsy is a classic example: a single
epileptic patient can be viewed as type I (simple partial seizures arising in the temporal
lobe can present with psychic phenomena), as type II (epileptic seizures commonly
coincide with nonepileptic seizures), as type III (in alternative psychosis, treatment
of epilepsy may bring about psychotic episodes), and as type V (the antiepileptic
drug levetiracetam may cause mental status changes with aggression). To paraphrase
Charcot, clinical medicine is the study of complexities and a patient is under no obli-
gation to have a simple disease just to please the physician.8

The Type I Patient: the Behavioral Neurology Model

Here, neuropathology is both a necessary and sufficient cause of neuropsychiatric
disease and the knowledge of it is key to understand and manage psychopathology.
Patients who fall in this category have acute or chronic, specific neuropathologies. In
addition, animal models and extensive clinical experience since the dawn of modern
neurology and psychiatry allow for one-direction “translation” between brain and
mind. Type I patients include patients with some developmental disabilities, many
cases of TBI, stroke/vascular disease, hypoxic/ischemic encephalopathy, demyelin-
ating disorders, and most cases of neurodegenerative diseases. Regardless of cause
(eg, developmental, traumatic, ischemic), there is a finite set of patterns of symptom
formation often predicted from neuropathological patterns, for example, the fronto-
temporal patient often has disinhibition and environmentally dependency, the patient
with Lewy Body dementia that afflicts associative visual cortex has visual hallucina-
tions, patients with Alzheimer disease have rapid forgetfulness associated with
parieto-temporal degeneration, and patients with traumatic contusions have execu-
tive dysfunction and organic personality changes because of frontal lesions (Fig. 2).
An extension of type I patients is cases in which neuropathology is necessary, but
insufficient to understand and manage psychopathology. Certain types of idiopathic
218 Koliatsos et al

Fig. 2. Brain images from representative type I patients. (A) This transverse CT image shows
some parietal and predominantly temporal atrophy in an 85-year old patient with memory
loss, semantic deficits, and exaggeration of explosive personality traits. The differential in-
cludes frontotemporal lobar degeneration (perhaps of the semantic type) and Alzheimer
disease. (B, C) Two cases of patients with Alzheimer disease. (B) Single-photon emission
computed tomography scan showing a typical pattern of blood flow deficits in a 68-year-
old patient with memory loss and severe failures in social judgment; note the sharp
 Neuropsychiatry as specialty 219

psychotic illness, for example patients with “Crow II” schizophrenia, fall in this cate-
gory and present with chronic and variable neuropathologies, such as enlarged ven-
tricles and left-lateralizing developmental findings. Lack of direct animal models to
test cause-and-effect assumptions do not allow for a 1:1 correspondence between
brain and mind. Anything from genes to adverse in utero/perinatal environment and,
usually, their interactions, can cause a schizophrenic phenotype,9 yet neuropathology
remains elusive. The hope is that, with the advent of new complex models of genetics
and human brain development, some uncertainties related to these conditions may be
clarified.
The Type II Patient: Neurology as a “Meme”
Here neurologic symptoms are ways to express discomfort or intolerable conflict,
sometimes in culturally stereotyped ways. Neuropathology is probably not necessary
and certainly not sufficient for symptom formation. These patients have what is pres-
ently termed, rather problematically, “functional neurologic disorders.” These are
common conditions that include conversion disorder in the form of psychogenic non-
epileptic seizures or psychogenic speech, movement and sensory disorders,10 or
such symptoms as part of complex somatoform disorders like Briquet. These prob-
lems used to fall under the inclusive term “hysteria” that played a historical role in
neuropsychiatry because it excluded neuropathology from a whole host of disorders
appearing as neurologic. Psychological mechanisms continue to be viewed as likely
causes, and a history of sexual abuse is commonly present in female patients.11
Dissociative phenomena, another hallmark of Freud’s hysteria, are also common in
such conditions.12
There is no evidence that patients classified under this category have consistent un-
derlying neuropathologies, although they often have comorbid psychiatric illness such
as depression. Symptoms represent phenocopies of neurologic problems that can be
understood either as simple units of communication like songs or “advertising” jingles
(the “memes” of Dawkins13) or as more complex narratives along psychodynamic
symbolic lines.14–16 It is important that the laws of neuroanatomy and neurophysiology
are violated. Direct animal models do not exist, except perhaps models that heuristi-
cally support the importance of various types of learning, including state-dependent
learning. There is often coexistence with type I conditions as, for example, in patients
with epilepsy who are typically at higher risk than nonepileptic patients to develop psy-
chogenic nonepileptic seizures and who may have both epileptic and nonepileptic fits.

=
demarcation of normal blood flow fields in the frontal lobes (left and top right) and basal
ganglia and low blood flow in parietal and temporal lobes, along the central sulcus and Syl-
vian fissure (arrows). (C) PET scan showing classic parieto-temporal metabolic deficits (blue)
in an 82-year-old patient with chronic delirium in the aftermath of back-to-back surgeries.
(D) This 54-year-old patient presented with pseudobulbar affect, dysprosodia, and vertical
gaze palsy; the PET scan shown here reveals metabolic deficits in premotor frontal fields (ar-
rows); brain pathology was diagnostic of progressive supranuclear palsy. (E) This T1
sequence from the brain of a 20-year-old college junior who suffered a fall in the course
of skateboarding shows a large orbitofrontal contusion (arrows); the patient presented
with behavioral disinhibition, social inappropriateness, and tangentiality; most other cogni-
tive functions were intact; he was expelled due to crude and aggressive behaviors and has
since remained unemployed. (F) This is a T2 sequence from the brain of a 40-year-old with
multiple sclerosis, showing the classic Dawson fingers of periventricular demyelination; the
patient, with a history of premorbid cyclothymia, presented with treatment-resistant mood
lability that was indistinguishable from manic depressive illness.
220 Koliatsos et al

Focusing on specific complaints, managing comorbid anxiety or depression, and us-

ing specific psychotherapeutic approaches are usually helpful.

The Type III Patient: the Interactive Model

Here neuropathology is necessary, but not a sufficient cause of symptoms and not
sufficient to understand/manage psychopathology. The essential feature of this group
of patients is the parallel existence of well-established neurologic and idiopathic psy-
chiatric illness (syndromal or subsyndromal), which is a common occurrence in med-
icine. The former include both conditions with acute onset, for example, TBI,
encephalopathy, or stroke, and chronic conditions, for example, neurodegenerative,
demyelinating, or cerebrovascular disease. The latter can present as traits/personality
disorders or full-blown psychiatric syndromes. Some late paraphrenias seen in geri-
atric patients fall into this category. Animal models exist only as heuristic supporters
of the concept of diathesis (vulnerability) interacting with stress or injury.
Problems can interact cross-sectionally, for example, the patient with parkinsonism
whose motoric symptoms worsen with depression and improve with mania or longitu-
dinally, or the epileptic patient who develops psychotic symptoms when seizures are
treated (alternative psychosis). Psychiatric/psychological and neurologic problems
can also interact longitudinally, for example, the premorbidly mood-labile individual
(trait) whom TBI or multiple sclerosis transforms into a bipolarlike patient (state).
The developmental neuropsychiatric patient may also fall into this category, if we
prospectively assume that many of these patients have underlying neuropathologies.
It is possible that, with better understanding, some of these patients will eventually fall
into the type I category. Another way to look into this is that components of the “core”
developmental phenotype may be eventually explained based on neuropathology, but
the neuropathology (or the core phenotype) may also represent risk factors for com-
mon psychiatric syndromes. For example, patients with autism-spectrum disorder
(ASD) who have executive communication and social cognition deficits and also ste-
reotypies as core symptoms, are also at higher risk for developing anxiety, attention-
deficit/hyperactivity, and sleep problems as children and depression in adulthood. The
latter is especially common in patients who perform better cognitively and, while
struggling to transition into adulthood, they recognize their differences from peers
with respect to independence, intimacy, and other demands of the adult life. Patients
with 22q11 deletion and Prader-Willi Syndrome are both at a substantially greater risk
of developing psychosis (especially those with maternal uniparental disomy). Differen-
tial diagnostic issues are often paramount is such patients, for example, distinguishing
OCD from the rigid routines, special interests, and stereotypies that are part of the
core ASD phenotype or bipolar disorder from impulse control and emotion regulation
problems that are also characteristic in many developmental patients.

The Type IV Patient: the Neuropsychiatry of Pain and the Autonomic Nervous
System
Neuropsychiatry is primarily concerned with dysfunction of neocortical associative or
high-level limbic circuits. Still, many problems that affect psychological well-being
originate within the peripheral nervous system (PNS) and the autonomic nervous sys-
tem (ANS). Both PNS and ANS are directly linked with higher limbic centers with great
potential for consolidation and learning and, as such, they take part in complex circuits
that can become sensitized and remain turned on even after the original trigger is gone
or sometimes without trigger at all. These concepts are at the core of a number of
somatoform pain and visceral conditions that were traditionally the perusal of psycho-
somatic medicine and that, with the domination of the descriptive paradigm in
 Neuropsychiatry as specialty 221

psychiatric nosology, have nearly lost their connection with the nervous system in the
minds of many clinicians. Most practicing neuropsychiatrists do not deal with such
problems on a daily basis, for reasons unrelated to scientific or clinical imperatives.
Psychosomatic (psychophysiological) conditions of the viscera in particular do not
even have an independent entry in the recent classification systems and are sub-
sumed under somatic symptom disorder in the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition. The inclusion in this article is meant for the sake of
completeness and because we genuinely believe that the neuropsychiatric perspec-
tive greatly helps the clinician to comprehend and formulate such problems. We
were often asked to assess and treat such patients, especially patients in chronic
pain, and did so with an integrated neuropsychiatric approach including eclectic phar-
macotherapy with antidepressants and mood stabilizers, buprenorphine (especially
for opioid addicts), and cognitive or dynamic psychotherapy.
Pain is different from nociception: there is no universal painful stimulus. In the
ascending spinothalamic tract, nociception is perceived as mere injury at the spinal level
of integration, as pain at the thalamic level, and as psychological suffering at the limbic
level of processing: dorsal anterior cingulate (area 24) and insula. The latter are espe-
cially important in chronic pain. Lesions of the insula cause pain asymbolia, that is,
experience of pain without suffering. Classic clinical examples of the previous hierar-
chies are the wounded soldiers with injuries severe enough to require amputation
who do not experience pain until they are gone from the front line,17 and individuals
who derive pleasure from usually painful stimuli in the course of masochistic rituals.18
On the other hand, patients with major depression have lower thresholds to pain
perception.19 The psychiatrist and neuropsychiatrist have an important role to play in
a comprehensive treatment approach to these problems, especially in view of the iatro-
genic addiction to opiates that is endemic in the treatment of chronic pain.
The role of the ANS is well established in numerous general medical diseases such
as hypertension and asthma, in neurologic conditions featured by dysautonomia
(orthostatic hypotension, constipation, erectile dysfunction), and in the elaboration
and expression of emotions based on the historical James-Lange theory of emotions
as interpretation of bodily reactions, the classic case of Beaumont’s observations on
Alexis St. Martin, and numerous other examples. The hypothalamus, a major part of
the limbic circuit with inputs from paralimbic insular and cingulate inputs and also
the amygdala, issues long projections to both the central parasympathetic division
(dorsal motor vagal nucleus, nucleus ambiguous) and the central sympathetic division
in the intermediolateral cell column of the spinal cord. Thus, emotional processes
affect multiple target organs. The types of emotionally driven visceral dysfunction
are multiple and even include life-threatening conditions, such as takotsubo
cardiomyopathy.20

The Type V Patient: the Neuropsychiatry of Psychotropic Drug Use

Psychopharmacology is a prime neuropsychiatric example: “psychotropic” affects are
de facto mediated via neurologic mechanisms. There are 3 ways to appreciate this
argument. The most straightforward is that psychotropics have potent neurologic ef-
fects: a classic example is parkinsonism caused by neuroleptic medications, an effect
that was in fact pivotal in developing L-dopa as treatment for Parkinson disease.
Another fact is that psychotropic medications also have nonpsychotropic effects,
for example, tricyclic or mixed antidepressants work in neuropathic pain, and many
mood stabilizers are effective antiepileptic drugs (or vice versa). In addition, the effects
of psychotropic medications are not mediated via direct neurotransmitter release or
uptake. For example, although the effects of antidepressants on synaptic
222 Koliatsos et al

monoamines occur within hours and regulatory effects on receptors are complete
within a few days,21 clinically meaningful antidepressant effects usually require a 2-
week to 4-week delay. The incongruence between simple pharmacologic explana-
tions and the timing of clinical response has prompted the elaboration of alternative
hypotheses for antidepressant drug actions, including effects on neuronal survival/
neurogenesis and synaptic anatomy.22,23
The previous thoughts have clinical implications, especially for complex patients
with comorbidities and polypharmacy. The neuropsychiatrist may be better able to
differentiate between a side effect of a CNS-acting medication and a symptom of
neuropsychiatric disease. Here are some examples requiring expert differential diag-
nosis: apathy as a symptom of depression versus a side effect of antidepressant;
mental status changes from topiramate versus other causes in a patient with brain
injury and comorbid migraine headaches; or suicidality and homicidality from certain
activating anticonvulsants such as levetiracetam versus psychosis or depression in a
patient with epilepsy and comorbid psychiatric illness. Another important implication
of a neurologic approach to psychopharmacology is the prescription of single CNS-
acting drugs such as to avoid polypharmacy, for example, serotonin-norepinephrine
reuptake inhibitors for comorbid major depression and neuropathy, or gabapentin
for comorbid anxiety and neuropathy.

THE IMPORTANCE OF NEUROSCIENCE AND OTHER ALLIED SCIENCES

Neuroscience
Medicine, although founded on clinical experience and the art of healing, is also sup-
ported by clinical research and the basic sciences. In the case of neuropsychiatry,
neuroscience, genetics/epigenetics, but also evolutionary and social anthropology
are sciences that readily come to mind. With regard to neuroscience, a key concept
is the view of illness as a failure of plasticity and a drastic restriction of options,
whether temporary, permanent, or progressive. Symptoms such as perseverative
behavior or paranoia or catastrophic reactions reflect nervous systems that cannot
adapt, embrace, anticipate, or transcend. Malleability of neural structure (dendritic
spines, synapses, whole circuitries) as a function of experience is one of the key dis-
coveries in the mature period of neuroscience and 2 classic paradigms are visual
deprivation in development24 and the sensitization or habituation of a defensive reflex
in Aplysia (reviewed in the section on Caveats). The neurotrophin brain-derived neuro-
trophic factor is a key molecular signal leading from experience to structure in
mammalian systems,25 and N-methyl-D-aspartate receptor signaling plays a very
important role as well. Experience-related or disease-related plasticity may also
involve changes in groups of neurons in select CNS sites by neurogenesis or cell
death.26 As noted in the section “The Type V Patient: The Neuropsychiatry of Psycho-
tropic Drug Use,” the effects of psychotropic compounds also appear to require plas-
tic changes in cortex and the limbic system.
Another neuroscience discipline, neuroanatomy, is essential for any in-depth under-
standing of issues related to formulating and treating neuropsychiatric patients. Here
are a couple of important neuroanatomical concepts that have had major influence in
the field: First is the evolutionary organization of the primate and human brain in quasi-
hierarchical levels of complexity, the lower of which is in direct communication with the
inner milieu and the higher with the external environment, that relate to along
McLean’s notion of the limbic system.27 This functional hierarchy is accompanied
by a progressive cytoarchitectonic complexity at the microscopic level from subcor-
tical to 2-layer limbic cortex of hippocampus and piriform cortex and then
 Neuropsychiatry as specialty 223

progressively to 6-layer neocortex, a progression that is one of the foundations of

modern behavioral neuroanatomy.28–30 Another concept is the role of large-scale net-
works: the idea that the functional role of any area of the nervous system is determined
not by its location, but by its pattern of connections with other parts. When it comes to
higher CNS functions, this notion was initially founded on tract-tracing experiments in
nonhuman primates and its parallel distributed processing mode of operation was
beautifully articulated by Rumelhart and McClelland31 and then by Mesulam.32 A third,
very influential, concept, is that of the reentrant loops linking cortex, basal ganglia, and
thalamus that serve to modulate a whole host of functions from motor to cognitive and
emotional; this concept showcases the importance of subcortical regions in cortical-
level processing.33 The discovery of the BOLD signal and the widespread use of fMRI
has extended the previous experimental and conceptual work to the human brain
where we now have fairly detailed resting-state functional connectivity maps based
on large numbers of subjects and sophisticated statistical analyses.34 Although
such networks are not always consistent among studies and the terminology can
be confusing to the nonexpert, consensus networks important for neuropsychiatry
are the default network specializing in internally directed cognitive processes, the cen-
tral executive network devoted to externally directed processes, and the salience
network that may facilitate a switch from the former to the latter and serves a number
of complex functions, including social behavior and self-awareness35 (Fig. 3). More
recent, technologically advanced multimodal strategies that combine cytoarchitec-
tonic, connectional, and functional aspects of different cortical areas begin to bridge
structure and function at a high level of detail and confirm the idea that earlier
anatomic specializations are also functionally relevant.36

Evolutionary and Anthropological Notions

Here we include ideas from sciences that deal with complex social and other phenom-
ena that may influence the brain in a top-down fashion. Among else, top-down as-
sumes a direction of cause from the more to the less complicated and applies
anywhere from genetics (to the extent that complex patterns of inheritance may repre-
sent historical adaptations), epigenetics, and evolutionary biology to comparative and
cultural anthropology. Such fields contribute important perspectives dealing with the
history of our species and similarities or differences from nonhuman primates, as well
as the importance of social systems and rituals.
There have been several attempts to understand and explain normal and abnormal
behaviors on the basis of evolutionary theory. One such attempt was by Paul McLean,
who combined comparative neuroanatomy, genetics, ethology, and descriptive psy-
chopathology to come up with a historical view of all normal and abnormal behavior.37
His conceptualization of the limbic system as the decisive developmental step that
allowed the evolution of mammals from reptiles had a strong behavioral agenda: the
superimposition of 2-layer cortex on the primordial basal ganglionic brain enabled
the encoding and expression of attachment behaviors such as separation cry, which
has some resemblance to depression. In the case of cellular and molecular biology of
learning, the goal is to capture complexity in simple, but dynamic systems that can be
interrogated at the bench; in the case of evolutionary theory, the goal is to capture the
root of complexity in its historical making.
If experience changes the brain (see the section on “Caveats”), then social and cul-
tural factors are also very important in normal and abnormal mental life because they
may change brain biology. In addition, as neuropsychiatrists, we are dealing with pa-
tients with impaired executive and social faculties who are often grouped together in
day programs or residential quarters. The struggle to establish dominance hierarchies
224 Koliatsos et al

print & web 4C/FPO

 Neuropsychiatry as specialty 225

and issues related to gender display and competition for potential mates are often
important factors that drive aggression and depressive or catastrophic reactions
and should be taken into consideration in history taking and clinical formulation.
Some of these issues are at the core of what might be called “human nature.”38 Of
course, more complex aspects of our nature of interest to psychoanalysts may
need to be considered as well.39
An elegant synthesis of the previous approaches is the older formulation of the
Research Committee of the Group for the Advancement of Psychiatry on the social
brain as the unifying foundation for psychiatry.40 Key points were as follows: the brain
is a body organ that mediates social interactions while also being shaped by those in-
teractions; the brain derives from ancient adaptations to diverse environments and is
itself an archive of phylogenetic adaptations; individual experiences shape the brain
through epigenesis and the brain encodes individual development; and that, on an
ongoing basis, the brain is further refined through social interactions that cause
both physiologic and anatomic modifications through life. In contrast to the conven-
tional biopsychosocial model, the social brain formulation emphasizes that all psycho-
logical and social factors are biological.

SUMMARY

Neuropsychiatry is an integrative medical specialty combining knowledge and exper-

tise in psychiatry with knowledge or expertise in neurology/neuroscience and neuro-
psychology. Such a combined expertise is extremely helpful in the formulation and
management of complex patients, especially patients in whom neuropathology is a
primary cause or mechanism of psychopathology, for example, patients with TBI
and neurodegenerative disease, or cases in which the neurologic symptom is just a
“way” of expressing psychopathology, as in patients with functional neurologic disor-
ders. Complex psychopharmacological cases may also benefit from expert neuropsy-
chiatric management. A century or more after key discoveries were made in neurology
and psychiatry by clinician-scientists comfortable in both fields, a new explosion of
knowledge in the neurosciences but also important demographic trends, for example
the increasing prevalence of age-associated neurodegenerative and vascular disease,
make a compelling case for a renewed focus on the neuropsychiatric approach.
Without a pretense that the mind-problem problem is about to be resolved, modern
imaging techniques and powerful multidimensional approaches to exploring the hu-
man brain enable clinicians and scientists alike to deepen the understanding of illness
and hopefully improve effectiveness of patient care. Progress along this path will
depend on both a careful synthesis of diverse findings but also the critical evaluation
of ever-accumulating clinical and research data.

=
Fig. 3. Two different ways of depicting large-scale networks underlying complex cognitive
and affective/behavioral operations in the brain. The top is based on a detailed resting-state
functional connectivity map from a large numbers of subjects and sophisticated statistical
analysis. The bottom is a simpler sketch representing the 3 major networks of relevance
to neuropsychiatry, the default mode network illustrated with hatched blue, the central ex-
ecutive indicated with hatched red, and the salience network illustrated with hatched light
brown. (Adapted from Yeo BT, Krienen FM, Sepulcre J, et al. The organization of the human
cerebral cortex estimated by intrinsic functional connectivity. J Neurophysiol
2011;106(3):1125-65; and Lanius RA, Frewen PA, Tursich M, et al. Restoring large-scale brain
networks in PTSD and related disorders: a proposal for neuroscientifically-informed treat-
ment interventions. Eur J Psychotraumatol 2015;6:27313; with permission.)
226 Koliatsos et al

DISCLOSURE

A grant from the Leonard & Elen R. Stulman Foundation, Spyros N. Lemos Memorial
Fund, and the Sidran Family Foundation.

REFERENCES

1. Shorter E. A history of psychiatry : from the era of the asylum to the age of Prozac.
New York: John Wiley & Sons; 1997. p. 436, xii.
2. Trimble MR. The intentional brain : motion, emotion, and the development of mod-
ern neuropsychiatry. Baltimore: Johns Hopkins University Press; 2016. p. 308, xix.
3. Najib A, Lorberbaum JP, Kose S, et al. Regional brain activity in women grieving a
romantic relationship breakup. Am J Psychiatry 2004;161(12):2245–56.
4. Freed PJ, Mann JJ. Sadness and loss: toward a neurobiopsychosocial model.
Am J Psychiatry 2007;164(1):28–34.
5. Baxter LR Jr, Schwartz JM, Bergman KS, et al. Caudate glucose metabolic rate
changes with both drug and behavior therapy for obsessive-compulsive disorder.
Arch Gen Psychiatry 1992;49(9):681–9.
6. Bailey CH, Chen M. Morphological basis of long-term habituation and sensitiza-
tion in Aplysia. Science 1983;220(4592):91–3.
7. Bailey CH, Kandel ER. Synaptic remodeling, synaptic growth and the storage of
long-term memory in Aplysia. Prog Brain Res 2008;169:179–98.
8. Goetz CG. Charcot, hysteria, and simulated disorders. Handb Clin Neurol 2016;
139:11–23.
9. Crow TJ. Schizophrenia as failure of hemispheric dominance for language.
Trends Neurosci 1997;20(8):339–43.
10. Espay AJ, Aybek S, Carson A, et al. Current concepts in diagnosis and treatment
of functional neurological disorders. JAMA Neurol 2018;75(9):1132–41.
11. Nicholson TR, Aybek S, Craig T, et al. Life events and escape in conversion dis-
order. Psychol Med 2016;46(12):2617–26.
12. Brown RJ. Dissociation and functional neurologic disorders. Handb Clin Neurol
2016;139:85–94.
13. Dawkins R. The selfish gene. Oxford (England): Oxford University Press; 1976.
p. 224, xii.
14. Breuer J, Freud S, Sigmund Freud Collection (Library of Congress). Studies on
hysteria. New York: Basic Books; 1957. p. 335, xxxi.
15. Carson A, Ludwig L, Welch K. Psychologic theories in functional neurologic dis-
orders. Handb Clin Neurol 2016;139:105–20.
16. Fenichel O, Rangell L. The psychoanalytic theory of neurosis. 50th anniversary
edition. New York: Norton; 1996. p. 705, xx.
17. Beecher HK. Pain in men wounded in battle. Ann Surg 1946;123(1):96–105.
18. Kamping S, Andoh J, Bomba IC, et al. Contextual modulation of pain in masoch-
ists: involvement of the parietal operculum and insula. Pain 2016;157(2):445–55.
19. Adler G, Gattaz WF. Pain perception threshold in major depression. Biol Psychi-
atry 1993;34(10):687–9.
20. Nayeri A, Rafla-Yuan E, Krishnan S, et al. Psychiatric illness in takotsubo (stress)
cardiomyopathy: a review. Psychosomatics 2018;59(3):220–6.
21. Shader RI, Fogelman SM, Greenblatt DJ. Epiphenomenal, causal, or correla-
tional–more on the mechanism(s) of action of antidepressants. J Clin Psychophar-
macol 1998;18(4):265–7.
 Neuropsychiatry as specialty 227

22. Malberg JE, Eisch AJ, Nestler EJ, et al. Chronic antidepressant treatment in-
creases neurogenesis in adult rat hippocampus. J Neurosci 2000;20(24):
9104–10.
23. Zhou L, Huang KX, Kecojevic A, et al. Evidence that serotonin reuptake modula-
tors increase the density of serotonin innervation in the forebrain. J Neurochem
2006;96(2):396–406.
24. Hubel DH, Wiesel TN. The period of susceptibility to the physiological effects of
unilateral eye closure in kittens. J Physiol 1970;206(2):419–36.
25. Koliatsos VE, Mamounas LA, Lyons WE. Neurotrophins and animal models of
neuropsychiatric disease: From survival and phenotype to neuronal plasticity.
In: Mocchetti I, editor. Neurobiology of the neurotrophins. Johnson City (TN):
FP Graham Publishing Co.; 2001. p. 399–425.
26. Goncalves JT, Schafer ST, Gage FH. Adult neurogenesis in the hippocampus:
from stem cells to behavior. Cell 2016;167(4):897–914.
27. Heimer L. Anatomy of neuropsychiatry : the new anatomy of the basal forebrain
and its implications for neuropsychiatric illness. Amsterdam: Boston Academic
Press/Elsevier; 2008. p. 176, xix, p., 10 p. of plates.
28. Mesulam MM. Principles of behavioral and cognitive neurology. 2nd edition. New
York: Oxford University Press; 2000. p. 540, xviii.
29. Pandya DN, Seltzer B, Petrides M, et al. Cerebral cortex : architecture, connec-
tions, and the dual origin concept. Oxford (England): Oxford University Press;
2014. p. 458, xxii.
30. Sanides F. Architectonic and functional differentiation of the frontal lobe of the
brain. Nervenarzt 1963;34:159–68 [in German].
31. Rumelhart DE, McClelland JL, University of California San Diego. PDP Research
Group. Parallel distributed processing : explorations in the microstructure of
cognition. Cambridge (Mass): MIT Press; 1986.
32. Mesulam MM. Large-scale neurocognitive networks and distributed processing
for attention, language, and memory. Ann Neurol 1990;28(5):597–613.
33. Alexander GE, DeLong MR, Strick PL. Parallel organization of functionally segre-
gated circuits linking basal ganglia and cortex. Annu Rev Neurosci 1986;9:
357–81.
34. Yeo BT, Krienen FM, Sepulcre J, et al. The organization of the human cerebral cor-
tex estimated by intrinsic functional connectivity. J Neurophysiol 2011;106(3):
1125–65.
35. Bressler SL, Menon V. Large-scale brain networks in cognition: emerging
methods and principles. Trends Cogn Sci 2010;14(6):277–90.
36. Glasser MF, Coalson TS, Robinson EC, et al. A multi-modal parcellation of human
cerebral cortex. Nature 2016;536(7615):171–8.
37. MacLean PD. The triune brain in evolution : role in paleocerebral functions. New
York: Plenum Press; 1990. p. 672, xxiv.
38. Wilson EO. On human nature. Cambridge (England): Harvard University Press;
1978. p. 260, xii.
39. Winnicott DW. Human nature. 1st American edirion. New York: Schocken Books;
1988. p. 189, xii.
40. Bakker C, Gardner R Jr, Koliatsos V, et al. The social brain: a unifying foundation
for psychiatry. Acad Psychiatry 2002;26(3):219.
Neuropsychiatry
Neuropsychiatry or Organic Psychiatry is a branch of medicine that deals with psychiatry as it relates to
neurology, in an effort to understand and attribute behavior to the interaction of neurobiology and social
psychology factors.[1] Within neuropsychiatry, the mind is considered "as an emergent property of the
brain",[2] whereas other behavioral and neurological specialties might consider the two as separate entities.
Neuropsychiatry preceded the current disciplines of psychiatry and neurology, which previously had
common training,[3] however, those disciplines have subsequently diverged and are typically practiced
separately.

Currently, neuropsychiatry has become a growing subspecialty of psychiatry as it closely relates the fields
of neuropsychology and behavioral neurology, and attempts to utilize this understanding to better treat
illnesses that fall under both neurological and mental disorder classifications (e.g., autism, ADHD,
Tourette's syndrome).

Contents
The case for the rapprochement of neurology and psychiatry
Mind/brain monism
Causal pluralism
Organic basis
Improved patient care
Better management model
US institutions
International organizations
See also
References
External links
Subspecialty Certification
Journals
International/National Organizations
Specific Neuropsychiatry Programs

The case for the rapprochement of neurology and psychiatry

Given the considerable overlap between these subspecialities, there has been a resurgence of interest and
debate relating to neuropsychiatry in academia over the last decade.[3][4][5][6][7] Most of this work argues
for a rapprochement of neurology and psychiatry, forming a specialty above and beyond a subspecialty of
psychiatry. For example, Professor Joseph B. Martin, former Dean of Harvard Medical School and a
neurologist by training, has summarized the argument for reunion: "the separation of the two categories is
arbitrary, often influenced by beliefs rather than proven scientific observations. And the fact that the brain
and mind are one makes the separation artificial anyway."[4] These points and some of the other major
arguments are detailed below.
Mind/brain monism

Neurologists have focused objectively on organic nervous system pathology, especially of the brain,
whereas psychiatrists have laid claim to illnesses of the mind. This antipodal distinction between brain and
mind as two different entities has characterized many of the differences between the two specialties.
However, it has been argued that this division is fictional; evidence from the last century of research has
shown that our mental life has its roots in the brain.[4] Brain and mind have been argued not to be discrete
entities but just different ways of looking at the same system (Marr, 1982). It has been argued that
embracing this mind/brain monism may be useful for several reasons. First, rejecting dualism implies that all
mentation is biological, which provides a common research framework in which understanding and
treatment of mental disorders can be advanced. Second, it mitigates widespread confusion about the
legitimacy of mental illness by suggesting that all disorders should have a footprint in the brain.

In sum, a reason for the division between psychiatry and neurology was the distinction between mind or
first-person experience and the brain. That this difference is taken to be artificial by proponents of
mind/brain monism supports a merge between these specialties.

Causal pluralism

One of the reasons for the divide is that neurology traditionally looks at the causes of disorders from an
"inside-the-skin" perspective (neuropathology, genetics) whereas psychiatry looks at "outside-the-skin"
causation (personal, interpersonal, cultural).[7] This dichotomy is argued not to be instructive and authors
have argued that it is better conceptualized as two ends of a causal continuum.[7] The benefits of this
position are: firstly, understanding of etiology will be enriched, in particular between brain and
environment. One example is eating disorders, which have been found to have some neuropathology (Uher
and Treasure, 2005) but also show increased incidence in rural Fijian school girls after exposure to
television (Becker, 2004). Another example is schizophrenia, the risk for which may be considerably
reduced in a healthy family environment (Tienari et al., 2004).

It is also argued that this augmented understanding of etiology will lead to better remediation and
rehabilitation strategies through an understanding of the different levels in the causal process where one can
intervene. It may be that non-organic interventions, like cognitive behavioral therapy (CBT), better
attenuate disorders alone or in conjunction with drugs. Linden's (2006) demonstration of how
psychotherapy has neurobiological commonalities with pharmacotherapy is a pertinent example of this and
is encouraging from a patient perspective as the potentiality for pernicious side effects is decreased while
self-efficacy is increased.

In sum, the argument is that an understanding of the mental disorders must not only have a specific
knowledge of brain constituents and genetics (inside-the-skin) but also the context (outside-the-skin) in
which these parts operate (Koch and Laurent, 1999). Only by joining neurology and psychiatry, it is
argued, can this nexus be used to reduce human suffering.

Organic basis

To further sketch psychiatry's history shows a departure from structural neuropathology, relying more upon
ideology (Sabshin, 1990). A good example of this is Tourette syndrome, which Ferenczi (1921), although
never having seen a patient with Tourette syndrome, suggested was the symbolic expression of
masturbation caused by sexual repression. However, starting with the efficacy of neuroleptic drugs in
attenuating symptoms (Shapiro, Shapiro and Wayne, 1973) the syndrome has gained pathophysiological
support (e.g. Singer, 1997) and is hypothesized to have a genetic basis too, based on its high inheritability
(Robertson, 2000). This trend can be seen for many hitherto traditionally psychiatric disorders (see table)
and is argued to support reuniting neurology and psychiatry because both are dealing with disorders of the
same system.

Linking traditional psychiatric symptoms or disorders to brain structures and genetic abnormalities.
(This table is in not exhaustive but provides some neurological bases to psychiatric symptoms.)
Psychiatric Psychodynamic
Neural correlates Source
symptoms explanation
Limbic-cortical dysregulation,
Depression Anger turned inward Mayberg (1997)
monoamine imbalance
Mania Barrett et al. (2003),
Prefrontal cortex and hippocampus,
(Bipolar Narcissistic Vawter, Freed, & Kleinman
anterior cingulate, amygdala
disorder) (2000)
NMDA receptor activation in the human
Schizophrenia Narcissistic/escapism Ross et al. (2006)
prefrontal cortex
Projection, cold
Visual Retinogeniculocalcarine tract, ascending Mocellin, Walterfang,
distant mother
hallucination brainstem modulatory structures Velakoulis, (2006)
causing a weak ego
Projection, cold
Auditory
distant mother Frontotemporal functional connectivity Shergill et al., 2000
hallucination
causing a weak ego
Obsessive- Harsh parenting Saxena et al. (1998),
Frontal-subcortical circuitry, right caudate
compulsive leading to love-hate Gamazo-Garran, Soutullo
activity
disorder conflict and Ortuno (2002)
Atypical serotonin system, right frontal Kaye et al. (2005), Uher
Eating Attempted control of
and temporal lobe dysfunction, changes and Treasure (2005), Olsen
disorder internal anxiety
to mesolimbic dopamine pathways (2011), Slochower (1987)

Improved patient care

Further, it is argued that this nexus will allow a more refined nosology of mental illness to emerge thus
helping to improve remediation and rehabilitation strategies beyond current ones that lump together ranges
of symptoms. However, it cuts both ways: traditionally neurological disorders, like Parkinson's disease, are
being recognized for their high incidence of traditionally psychiatric symptoms, like psychosis and
depression (Lerner and Whitehouse, 2002). These symptoms, which are largely ignored in neurology,[3]
can be addressed by neuropsychiatry and lead to improved patient care. In sum, it is argued that patients
from both traditional psychiatry and neurology departments will see their care improved following a
reuniting of the specialties.

Better management model

Schiffer et al. (2004) argue that there are good management and financial reasons for rapprochement.

US institutions
"Behavioral Neurology & Neuropsychiatry" fellowships are accredited by the United Council for
Neurologic Subspecialties (UCNS; www.ucns.org (https://web.archive.org/web/20190502155806/http://w
ww.ucns.org/)), in a manner analogous to the accreditation of psychiatry and neurology residencies in the
United States by the American Board of Psychiatry and Neurology (ABPN).
The American Neuropsychiatric Association (ANPA) was established in 1988 and is the American medical
subspecialty society for neuropsychiatrists. ANPA holds an annual meeting and offers other forums for
education and professional networking amongst subspecialists in behavioral neurology & neuropsychiatry
as well as clinicians, scientists, and educators in related fields. American Psychiatric Publishing, Inc.
publishes the peer-reviewed Journal of Neuropsychiatry and Clinical Neurosciences, which is the official
journal of ANPA.

International organizations
The International Neuropsychiatric Association was established in 1996.[8] INA holds congresses
biennially in countries around the world and partners with regional neuropsychiatric associations around the
world to support regional neuropsychiatric conferences and to facilitate the development of neuropsychiatry
in the countries/regions where those conferences are held. Prof. Robert Haim Belmaker[9] is the current
President of the organization whereas Prof. Ennapadam S Krishnamoorthy[10] serves as President-Elect
with Dr. Gilberto Brofman as Secretary-Treasurer.[11]

The British NeuroPsychiatry Association (BNPA) was founded in 1987[12] and is the leading academic
and professional body for medical practitioners and professionals allied to medicine in the UK working at
the interface of the clinical and cognitive neurosciences and psychiatry.

Recently, a new non-profit professional society named Neuropsychiatric Forum (NPF) was founded. NPF
aims to support effective communication and interdisciplinary collaboration, develop education schemes
and research projects, organize neuropsychiatric conferences and seminars.

See also
American Neuropsychiatric Association
Cognitive neuropsychiatry
Neurology
Neuropsychology
Psychiatry
Psychoneuroimmunology

References
1. Sachdev, Perminder S. (May 2005). "Whither Neuropsychiatry?" (http://psychiatryonline.org/
doi/abs/10.1176/jnp.17.2.140). The Journal of Neuropsychiatry and Clinical Neurosciences.
17 (2): 140–141. doi:10.1176/jnp.17.2.140 (https://doi.org/10.1176%2Fjnp.17.2.140).
ISSN 0895-0172 (https://www.worldcat.org/issn/0895-0172).
2. Sachdev, Perminder S.; Mohan, Adith (2013). "Neuropsychiatry: Where Are We And Where
Do We Go From Here?" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653233/). Mens
Sana Monographs. 11 (1): 4–15. doi:10.4103/0973-1229.109282 (https://doi.org/10.4103%2
F0973-1229.109282). ISSN 0973-1229 (https://www.worldcat.org/issn/0973-1229).
PMC 3653233 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653233). PMID 23678234
(https://pubmed.ncbi.nlm.nih.gov/23678234).
3. Yudofsky, S.C.; Hales, E.H. (2002). "Neuropsychiatry and the Future of Psychiatry and
Neurology". American Journal of Psychiatry. 159 (8): 1261–1264.
doi:10.1176/appi.ajp.159.8.1261 (https://doi.org/10.1176%2Fappi.ajp.159.8.1261).
 4. Martin, J.B. (2002). "The integration of neurology, psychiatry, and neuroscience in the 21st
century". American Journal of Psychiatry. 159 (5): 695–704. doi:10.1176/appi.ajp.159.5.695
(https://doi.org/10.1176%2Fappi.ajp.159.5.695). PMID 11986119 (https://pubmed.ncbi.nlm.ni
h.gov/11986119).
5. Berrios, G.E.; Marková, I.S. (2002). "The concept of neuropsychiatry: a historical overview".
Journal of Psychosomatic Research. 53 (2): 629–638. doi:10.1016/s0022-3999(02)00427-0
(https://doi.org/10.1016%2Fs0022-3999%2802%2900427-0). PMID 12169337 (https://pubm
ed.ncbi.nlm.nih.gov/12169337).
6. Price, B.H.; Adams, R.D.; Coyle, J.T. (2000). "Neurology and psychiatry: Closing the great
divide". Neurology. 54 (1): 8–14. doi:10.1212/wnl.54.1.8 (https://doi.org/10.1212%2Fwnl.54.
1.8). PMID 10636118 (https://pubmed.ncbi.nlm.nih.gov/10636118).
7. Kendler, K.S. (2005). "Toward a Philosophical Structure for Psychiatry". American Journal of
Psychiatry. 162 (3): 433–440. doi:10.1176/appi.ajp.162.3.433 (https://doi.org/10.1176%2Fap
pi.ajp.162.3.433). PMID 15741457 (https://pubmed.ncbi.nlm.nih.gov/15741457).
8. "International Neuropsychiatric Association" (http://www.inawebsite.org/). Official Website.
9. "‫( "אתר הבית של פרופ' חיים בלמקר‬http://haimbelmaker.co.il/en/). haimbelmaker.co.il.
Retrieved 2017-01-25.
10. "Neurokrish - The Neuropsychiatry Center" (http://neurokrish.com/founder-team/our-founde
r/).
11. "International Neuropsychiatric Association" (http://www.inawebsite.org/#!committees-/ieao
y/). Committee Members.
12. "Bulletin Of The Royal College Of Psychiatrists" (http://pb.rcpsych.org/content/pbrcpsych/12/
5/174.2.full.pdf) (PDF).

Arciniegas DB, Kaufer DI; Joint Advisory Committee on Subspecialty Certification of the
American Neuropsychiatric Association; Society for Behavioral and Cognitive Neurology.
Core Curriculum for Training in Behavioral Neurology and Neuropsychiatry. J
Neuropsychiatry Clin Neurosci. 2006 Winter;18(1):6-13.
Barrett, T.B., Hauger, R.L., Kennedy, J.L., Sadovnick, A.D., Remick, R.A. & Keck, P.E,
McElroy, S L, Alexander, L., Shaw, S.H., & Kelsoe, J. (2003) Evidence that a single
nucleotide polymorphism in the promoter of the G protein receptor kinase 3 gene is
associated with bipolar disorder" Molecular Psychiatry 8, 546−557.
Becker, A.E. (2004) Television, Disordered Eating, and Young Women in Fiji: Negotiating
Body Image and Identity During Rapid Social Change. Culture, Medicine and Psychiatry,
28(4): 533–559.
Bell, V., Halligan, P.W., Ellis, H.D. (2006). Explaining delusions: a cognitive perspective.
Trends in Cognitive Sciences,10(5), 219–26.
Ferenczi, S. (1921) Psychoanalytical observations on tic. International Journal of
Psychoanalysis, 2: 1-30.
Gamazo-Garran, P., Soutullo, C.A. & Ortuno, F. (2002) Obsessive compulsive disorder
secondary to brain dysgerminoma in an adolescent boy: a positron emission tomography
case report. Journal of Child and Adolescent Psychopharmacology, 12, 259–263.
Green, M.F. (2001) Schizophrenia Revealed: From Neurons to Social Interactions. New
York: W.W. Norton.
Kaye, W.H., Bailer, U.F., Frank, G.K., Wagner, A., & Henry, S.E. (2005). Brain imaging of
serotonin after recovery from anorexia and bulimia nervosa. Physiology & Behaviour, 86(1-
2), 15-7
Koch, C. & Laurent, G. (1999). Complexity and the nervous system" Science 284(5411), 96–
8.
Lerner, A.J., & Whitehouse, P.J. (2002) Neuropsychiatric aspects of dementias associated
with motor dysfunction. Washington, DC: American Psychiatric (pp 931–937)
 Linden, D. E. J. (2006). How psychotherapy changes the brain – the contribution of
functional neuroimaging" Molecular Psychiatry 11, 528–38.
Marr, D. (1982). Vision: A Computational Approach. San Francisco: Freeman & Co.
Mayberg, H.S. (1997). Limbic-cortical dysregulation: a proposed model of depression.
Journal of Neuropsychiatry and Clinical Neurosciences, 9, 471–481.
Mocellin, R., Walterfang, M., & Velakoulis, D. (2006) Neuropsychiatry of complex visual
hallucinations. Australian and New Zealand Journal of Australian and New Zealand Journal
of Psychiatry, 40, 742-751
Rempel-Clower, N.L., Zola, S.M., Squire, L.R., & Amaral, D.G. (1996). Three cases of
enduring memory impairment after bilateral damage limited to the hippocampal formation"
Journal of Neuroscience 16, 5233–5255
Robertson, M.M. (2000). Tourette syndrome, associated conditions and the complexities of
treatment" Brain 123(3), 425–462.
Ross, C.A., Margolis, R.L., Reading, S.A.J., Pletnikov, M., & Coyle, J.T (2006). Neurobiology
of Schizophrenia" Neuron 52, 139–153.
Sabshin, M. (1990). Turning points in twentieth-century American psychiatry" American
Journal of Psychiatry 147(10),1267-1274.
Sachdev, P.S. (2005). Whither Neuropsychiatry? Journal of Neuropsychiatry and Clinical
Neurosciences,17,140-141.
Saxena, S., Brody, A.L., Schwartz, T.M., & Baxter, L.R. (1998). Neuroimaging and frontal-
subcortical circuitry in obsessive-compulsive disorder. British Journal of Psychiatry,173(35),
26–37.
Schiffer, R.B, Bowen, B., Hinderliter, J., Hurst, D.L., Lajara-Nanson, W.A., & Packard, R.C.
(2004). Neuropsychiatry: A Management Model for Academic Medicine. Journal of
Neuropsychiatry and Clinical Neurosciences, 16, 336–341.
Shapiro, A.K., Shapiro, E., Wayne, H., & Clarkin, J. (1973). Organic factors in Gilles de la
Tourette's syndrome. British Journal of Psychiatry, 122, 659–664.
Shergill, S. S., Brammer, M. J., Williams, S., Murray, R.M., & McGuire, P.K. (2000). Mapping
auditory hallucinations in schizophrenia using functional magnetic resonance imaging"
Archives of General Psychiatry 57, 1033 -1038.
Singer, H.S. (1997). Neurobiology of Tourette syndrome. Neurologic Clinics, 15, 357–379.
Tienari, P., Wynne, L. C., Sorri, A., Lahti, I., Läksy, K., Moring, J., Naarala., M, Nieminen, P., &
Wahlberg K. (2004) Genotype–environment interaction in schizophrenia-spectrum disorder:
long-term follow-up study of Finnish adoptees. British Journal of Psychiatry, 184, 216–222.
Uher, R., & Treasure, J. (2005) Brain lesions and eating disorders. Journal of Neurology,
Neurosurgery & Psychiatry, 76, 852–7.
Vawter, M.P., Freed, W.J., & Kleinman, J.E. (2000). Neuropathology of bipolar disorder"
Biological Psychiatry 48, 486–504.

External links

Subspecialty Certification
Behavioral Neurology & Neuropsychiatry, United Council for Neurologic Subspecialties,
USA (https://web.archive.org/web/20110817124328/http://www.ucns.org/go/subspecialty/be
havioral)

Journals
 The Journal of Neuropsychiatry and Clinical Neurosciences (http://neuro.psychiatryonline.or
g/)
Neuropsychiatric Disease and Treatment (http://www.dovepress.com/NDT.htm)
Clinical Neuropsychiatry: Journal of Treatment Evaluation (http://www.clinicalneuropsychiatr
y.org/)
Cognitive Neuropsychiatry (http://www.tandf.co.uk/journals/pcnp)

International/National Organizations
Neuropsychiatric forum (http://npforum.eu/)
Neuropsychiatric forum - facebook (https://www.facebook.com/npforum/)
American Neuropsychiatric Association (http://www.anpaonline.org/)
The British Neuropsychiatry Association (http://www.bnpa.org.uk/)
Royal College of Psychiatrists, Special Interest Group in Neuropsychiatry (SIGN) (http://ww
w.rcpsych.ac.uk/college/specialinterestgroups/neuropsychiatry.aspx)
International Neuropsychiatric Association (http://www.inaweb.org/)
Neuropsychiatry in New Zealand (http://www.neuropsychiatry.co.nz/)
Society for Behavioral and Cognitive Neurology (https://web.archive.org/web/201905200554
46/http://sbcnonline.org/)

Specific Neuropsychiatry Programs

Royal Melbourne Hospital Neuropsychiatry Unit (http://www.neuropsychiatry.org.au/)
Neuropsychiatry Program, British Columbia, Canada (https://web.archive.org/web/20181006
161243/http://psychiatry.vch.ca/bcnp.htm)
University of Pennsylvania Neuropsychiatry Program (http://www.med.upenn.edu/bbl/)
University of Chicago Neuropsychiatry Program (https://web.archive.org/web/201903190949
02/http://psychiatry.uchicago.edu/page/neuropsychiatry-program)
Neuropsychiatry Program at Sheppard Pratt, USA (http://www.neuropsychiatryatsp.org/)

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Neuropsychology
Neuropsychology is a branch of psychology. It is concerned with how a person's cognition and behavior
are related to the brain and the rest of the nervous system. Professionals in this branch of psychology often
focus on how injuries or illnesses of the brain affect cognitive and behavioral functions.[1]

It is both an experimental and clinical field of psychology, thus aiming to understand how behavior and
cognition are influenced by brain function and concerned with the diagnosis and treatment of behavioral
and cognitive effects of neurological disorders. Whereas classical neurology focuses on the pathology of
the nervous system and classical psychology is largely divorced from it, neuropsychology seeks to discover
how the brain correlates with the mind through the study of neurological patients. It thus shares concepts
and concerns with neuropsychiatry and with behavioral neurology in general. The term neuropsychology
has been applied to lesion studies in humans and animals. It has also been applied in efforts to record
electrical activity from individual cells (or groups of cells) in higher primates (including some studies of
human patients).[2]

In practice, neuropsychologists tend to work in research settings (universities, laboratories or research

institutions), clinical settings (medical hospitals or rehabilitation settings, often involved in assessing or
treating patients with neuropsychological problems), or forensic settings or industry (often as clinical-trial
consultants where CNS function is a concern).

Contents
History
Ancient Egypt
Aristotle
Hippocrates
René Descartes
Thomas Willis
Franz Joseph Gall
Jean-Baptiste Bouillaud
Paul Broca
Karl Spencer Lashley
Approaches
Methods and tools
See also
References
External links

History
Neuropsychology is a relatively new discipline within the field of psychology. The first textbook defining
the field, Fundamentals of Human Neuropsychology, was initially published by Kolb and Whishaw in
1980.[3] However, the history of its development can be traced back to the Third Dynasty in ancient Egypt,
perhaps even earlier.[4] There is much debate as to when societies started considering the functions of
different organs. For many centuries, the brain was thought useless and was often discarded during burial
processes and autopsies. As the field of medicine developed its understanding of human anatomy and
physiology, different theories were developed as to why the body functioned the way it did. Many times,
bodily functions were approached from a religious point of view and abnormalities were blamed on bad
spirits and the gods. The brain has not always been considered the center of the functioning body. It has
taken hundreds of years to develop our understanding of the brain and how it affects our behaviors.

Ancient Egypt

In ancient Egypt, writings on medicine date from the time of the priest Imhotep.[5] They took a more
scientific approach to medicine and disease, describing the brain, trauma, abnormalities, and remedies for
reference for future physicians. Despite this, Egyptians saw the heart, not the brain, as the seat of the
soul.[6]

Aristotle

Senses, perception, memory, dreams, action in Aristotle's biology. Impressions are

stored in the seat of perception, linked by his Laws of Association (similarity, contrast,
and contiguity).[7]

Aristotle reinforced this focus on the heart which originated in Egypt. He believed the heart to be in control
of mental processes, and looked on the brain, due to its inert nature, as a mechanism for cooling the heat
generated by the heart.[8][9] He drew his conclusions based on the empirical study of animals. He found
that while their brains were cold to the touch and that such contact did not trigger any movements, the heart
was warm and active, accelerating and slowing dependent on mood.[8][9] Such beliefs were upheld by
many for years to come, persisting through the Middle Ages and the Renaissance period until they began to
falter in the 17th century due to further research.[9] The influence of Aristotle in the development of
neuropsychology is evident within language used in modern day, since we "follow our hearts" and "learn
by the heart."[9]

Hippocrates

Hippocrates viewed the brain as the seat of the soul. He drew a connection between the brain and
behaviors of the body, writing: "The brain exercises the greatest power in the man."[10] Apart from moving
the focus from the heart as the "seat of the soul" to the brain, Hippocrates did not go into much detail about
its actual functioning. However, by switching the attention of the medical community to the brain, his
theory led to more scientific discovery of the organ responsible for our behaviors. For years to come,
scientists were inspired to explore the functions of the body and to find concrete explanations for both
normal and abnormal behaviors. Scientific discovery led them to believe that there were natural and
organically occurring reasons to explain various functions of the body, and it could all be traced back to the
brain. Hippocrates introduced the concept of the mind – which was widely seen as a separate function apart
from the actual brain organ.

René Descartes

Philosopher René Descartes expanded upon this idea and is most widely known for his work on the mind-
body problem. Often Descartes's ideas were looked upon as overly philosophical and lacking in sufficient
scientific foundation. Descartes focused much of his anatomical experimentation on the brain, paying
special attention to the pineal gland – which he argued was the actual "seat of the soul." Still deeply rooted
in a spiritual outlook towards the scientific world, the body was said to be mortal, and the soul immortal.
The pineal gland was then thought to be the very place at which the mind would interact with the mortal
and machine-like body. At the time, Descartes was convinced the mind had control over the behaviors of
the body (controlling the person) – but also that the body could have influence over the mind, which is
referred to as dualism.[11] This idea that the mind essentially had control over the body, but the body could
resist or even influence other behaviors, was a major turning point in the way many physiologists would
look at the brain. The capabilities of the mind were observed to do much more than simply react, but also to
be rational and function in organized, thoughtful ways – much more complex than he thought the animal
world to be. These ideas, although disregarded by many and cast aside for years led the medical community
to expand their own ideas of the brain and begin to understand in new ways just how intricate the workings
of the brain really were, and the complete effects it had on daily life, as well as which treatments would be
the most beneficial to helping those people living with a dysfunctional mind. The mind-body problem,
spurred by René Descartes, continues to this day with many philosophical arguments both for and against
his ideas. However controversial they were and remain today, the fresh and well-thought-out perspective
Descartes presented has had long-lasting effects on the various disciplines of medicine, psychology, and
much more, especially in putting an emphasis on separating the mind from the body in order to explain
observable behaviors.

Thomas Willis

It was in the mid-17th century that another major contributor to the field of neuropsychology emerged.
Thomas Willis studied at Oxford University and took a physiological approach to the brain and behavior. It
was Willis who coined the words 'hemisphere' and 'lobe' when referring to the brain.[12] He was one of the
earliest to use the words 'neurology' and 'psychology'. Rejecting the idea that humans were the only beings
capable of rational thought, Willis looked at specialized structures of the brain.[9] He theorized that higher
structures accounted for complex functions, whereas lower structures were responsible for functions similar
to those seen in other animals, consisting mostly of reactions and automatic responses.[13] He was
particularly interested in people who suffered from manic disorders and
hysteria.[14][15] His research constituted some of the first times that psychiatry and
neurology came together to study individuals. Through his in-depth study of the
brain and behavior, Willis concluded that automated responses such as breathing,
heartbeats and other various motor activities were carried out within the lower
region of the brain. Although much of his work has been made obsolete, his ideas
presented the brain as more complex than previously imagined, and led the way for
future pioneers to understand and build upon his theories, especially when it came to Thomas Willis
looking at disorders and dysfunctions in the brain.[14]

Franz Joseph Gall

Neuroanatomist and physiologist Franz Joseph Gall made major progress in understanding the brain. He
theorized that personality was directly related to features and structures within the brain. However, Gall's
major contribution within the field of neuroscience is his invention of phrenology. This new discipline
looked at the brain as an organ of the mind, where the shape of the skull could ultimately determine one's
intelligence and personality.[16] This theory was like many circulating at the time, as many scientists were
taking into account physical features of the face and body, head size, anatomical structure, and levels of
intelligence; only Gall looked primarily at the brain. There was much debate over the validity of Gall's
claims however, because he was often found to be wrong in his predictions. He was once sent a cast of
René Descartes' skull, and through his method of phrenology claimed the subject must have had a limited
capacity for reasoning and higher cognition.[17] As controversial and false as many of Gall's claims were,
his contributions to understanding cortical regions of the brain and localized activity continued to advance
understanding of the brain, personality, and behavior. His work is considered crucial to having laid a firm
foundation in the field of neuropsychology, which would flourish over the next few decades.

Jean-Baptiste Bouillaud

Towards the late 19th century, the belief that the size of ones skull could
determine their level of intelligence was discarded as science and medicine
moved forward. A physician by the name of Jean-Baptiste Bouillaud
expanded upon the ideas of Gall and took a closer look at the idea of distinct
cortical regions of the brain each having their own independent function.
Bouillaud was specifically interested in speech and wrote many publications
on the anterior region of the brain being responsible for carrying out the act of
ones speech, a discovery that had stemmed from the research of Gall. He was
also one of the first to use larger samples for research although it took many
years for that method to be accepted. By looking at over a hundred different
case studies, Bouillaud came to discover that it was through different areas of
the brain that speech is completed and understood. By observing people with Jean-Baptiste Bouillaud
brain damage, his theory was made more concrete. Bouillaud, along with
many other pioneers of the time made great advances within the field of
neurology, especially when it came to localization of function. There are many arguable debates as to who
deserves the most credit for such discoveries,[18] and often, people remain unmentioned, but Paul Broca is
perhaps one of the most famous and well known contributors to neuropsychology – often referred to as
"the father" of the discipline.

Paul Broca
Inspired by the advances being made in the area of localized function within the brain, Paul Broca
committed much of his study to the phenomena of how speech is understood and produced. Through his
study, it was discovered and expanded upon that we articulate via the left hemisphere. Broca's observations
and methods are widely considered to be where neuropsychology really takes form as a recognizable and
respected discipline. Armed with the understanding that specific, independent areas of the brain are
responsible for articulation and understanding of speech, the brains abilities were finally being
acknowledged as the complex and highly intricate organ that it is. Broca was essentially the first to fully
break away from the ideas of phrenology and delve deeper into a more scientific and psychological view of
the brain.[19]

Karl Spencer Lashley

Lashley's works and theories that follow are summarized in his book Brain Mechanisms and
Intelligence.[20] Lashley's theory of the Engram was the driving force for much of his research. An engram
was believed to be a part of the brain where a specific memory was stored. He continued to use the
training/ablation method that Franz had taught him. He would train a rat to learn a maze and then use
systematic lesions and removed sections of cortical tissue to see if the rat forgot what it had learned.

Through his research with the rats, he learned that forgetting was dependent on the amount of tissue
removed and not where it was removed from. He called this mass action and he believed that it was a
general rule that governed how brain tissue would respond, independent of the type of learning. But we
know now that mass action was a misinterpretation of his empirical results, because in order to run a maze
the rats required multiple cortical areas. Cutting into small individual parts alone will not impair the rats'
brains much, but taking large sections removes multiple cortical areas at one time, affecting various
functions such as sight, motor coordination and memory, making the animal unable to run a maze properly.

Lashley also proposed that a portion of a functional area could carry out the role of the entire area, even
when the rest of the area has been removed. He called this phenomenon equipotentiality. We know now
that he was seeing evidence of plasticity in the brain: within certain constraints the brain has the ability for
certain areas to take over the functions of other areas if those areas should fail or be removed - although not
to the extent initially argued by Lashley.

Approaches
Experimental neuropsychology is an approach that uses methods from experimental psychology to uncover
the relationship between the nervous system and cognitive function. The majority of work involves
studying healthy humans in a laboratory setting, although a minority of researchers may conduct animal
experiments. Human work in this area often takes advantage of specific features of our nervous system (for
example that visual information presented to a specific visual field is preferentially processed by the cortical
hemisphere on the opposite side) to make links between neuroanatomy and psychological function.[21]

Clinical neuropsychology is the application of neuropsychological knowledge to the assessment (see

neuropsychological test and neuropsychological assessment), management, and rehabilitation of people
who have suffered illness or injury (particularly to the brain) which has caused neurocognitive problems. In
particular they bring a psychological viewpoint to treatment, to understand how such illness and injury may
affect and be affected by psychological factors.[22] They also can offer an opinion as to whether a person is
demonstrating difficulties due to brain pathology or as a consequence of an emotional or another
(potentially) reversible cause or both. For example, a test might show that both patients X and Y are unable
to name items that they have been previously exposed to within the past 20 minutes (indicating possible
dementia). If patient Y can name some of them with further prompting (e.g. given a categorical clue such as
being told that the item they could not name is a fruit), this allows a more specific diagnosis than simply
dementia (Y appears to have the vascular type which is due to brain pathology but is usually at least
somewhat reversible). Clinical neuropsychologists often work in hospital settings in an interdisciplinary
medical team; others work in private practice and may provide expert input into medico-legal
proceedings.[23]

Cognitive neuropsychology is a relatively new development and has emerged as a distillation of the
complementary approaches of both experimental and clinical neuropsychology. It seeks to understand the
mind and brain by studying people who have suffered brain injury or neurological illness. One model of
neuropsychological functioning is known as functional localization.[24] This is based on the principle that if
a specific cognitive problem can be found after an injury to a specific area of the brain, it is possible that
this part of the brain is in some way involved. However, there may be reason to believe that the link
between mental functions and neural regions is not so simple. An alternative model of the link between
mind and brain, such as parallel processing, may have more explanatory power for the workings and
dysfunction of the human brain. Yet another approach investigates how the pattern of errors produced by
brain-damaged individuals can constrain our understanding of mental representations and processes without
reference to the underlying neural structure. A more recent but related approach is cognitive
neuropsychiatry which seeks to understand the normal function of mind and brain by studying psychiatric
or mental illness.[25]

Connectionism is the use of artificial neural networks to model specific cognitive processes using what are
considered to be simplified but plausible models of how neurons operate. Once trained to perform a specific
cognitive task these networks are often damaged or 'lesioned' to simulate brain injury or impairment in an
attempt to understand and compare the results to the effects of brain injury in humans.[26]

Functional neuroimaging uses specific neuroimaging technologies to take readings from the brain, usually
when a person is doing a particular task, in an attempt to understand how the activation of particular brain
areas is related to the task. In particular, the growth of methodologies to employ cognitive testing within
established functional magnetic resonance imaging (fMRI) techniques to study brain-behavior relations is
having a notable influence on neuropsychological research.

In practice these approaches are not mutually exclusive and most neuropsychologists select the best
approach or approaches for the task to be completed.

Methods and tools

Standardized neuropsychological tests
These tasks have been designed so the performance on the task can be linked to specific
neurocognitive processes.[27] These tests are typically standardized, meaning that they
have been administered to a specific group (or groups) of individuals before being used in
individual clinical cases. The data resulting from standardization are known as normative
data. After these data have been collected and analyzed, they are used as the
comparative standard against which individual performances can be compared. Examples
of neuropsychological tests include: the Wechsler Memory Scale (WMS), the Wechsler
Adult Intelligence Scale (WAIS), Boston Naming Test, the Wisconsin Card Sorting Test,
the Benton Visual Retention Test, and the Controlled Oral Word Association.

Brain scans
The use of brain scans to investigate the structure or function of the brain is common,
either as simply a way of better assessing brain injury with high resolution pictures, or by
examining the relative activations of different brain areas. Such technologies may include
fMRI (functional magnetic resonance imaging) and positron emission tomography (PET),
which yields data related to functioning, as well as MRI (magnetic resonance imaging) and
computed axial tomography (CAT or CT), which yields structural data.
Global Brain Project
Brain models based on mouse and monkey have been developed based on theoretical
neuroscience involving working memory and attention, while mapping brain activity based
on time constants validated by measurements of neuronal activity in various layers of the
brain. These methods also map to decision states of behavior in simple tasks that involve
binary outcomes.[28]

Electrophysiology
The use of electrophysiological measures designed to measure the activation of the brain
by measuring the electrical or magnetic field produced by the nervous system. This may
include electroencephalography (EEG) or magneto-encephalography (MEG).

Experimental tasks
The use of designed experimental tasks, often controlled by computer and typically
measuring reaction time and accuracy on a particular tasks thought to be related to a
specific neurocognitive process. An example of this is the Cambridge Neuropsychological
Test Automated Battery (CANTAB) or CNS Vital Signs (CNSVS).[29]

See also
Behavioral neurology List of important publications in
Biological psychology neuropsychology
Clinical neuropsychology List of neurological conditions and
disorders
Cognitive neuropsychiatry
Neurology
Cognitive neuropsychology
Neuropsychoanalysis
Cognitive neuroscience
Neuropsychiatry
Cognitive psychology
Comparative neuropsychology Neuroscience
Psychiatric genetics

References
1. Gluck, Mark A.; Mercado, Eduardo; Myers, Catherine E. (2016). Learning and Memory: From
Brain to Behavior. New York/NY, USA: Worth Publishers. p. 57. ISBN 978-1-319-15405-9.
2. Posner, M. I.; Digirolamo, G. J. (2000). "Cognitive neuroscience: Origins and promise".
Psychological Bulletin. 126 (6): 873–889. doi:10.1037/0033-2909.126.6.873 (https://doi.org/
10.1037%2F0033-2909.126.6.873). PMID 11107880 (https://pubmed.ncbi.nlm.nih.gov/1110
7880).
3. "The Great Canadian Psychology Website - Researchers" (http://www.psych.ualberta.ca/GC
PWS/KolbWhishaw/KolbBio/Kolb_bio1.html). University of Calgary. Retrieved 14 August
2017.
4. Finger, Stanley (2000). Minds Behind the Brain: A History of the Pioneers and their
discoveries (https://archive.org/details/mindsbehindbrain0000fing). New York: Oxford. pp. 22
(https://archive.org/details/mindsbehindbrain0000fing/page/22). ISBN 978-0-19-518182-1.
5. Highfield, Roger. "How Imhotep gave us medicine" (https://www.telegraph.co.uk/news/scien
ce/science-news/3293164/How-Imhotep-gave-us-medicine.html). The Daily Telegraph.
Retrieved 24 March 2018.
6. Carus, Paul (1905). "The Conception of the Soul and the Belief in Resurrection Among the
Egyptians". The Monist. 15 (3): 409–428. doi:10.5840/monist190515326 (https://doi.org/10.5
840%2Fmonist190515326). JSTOR 27899609 (https://www.jstor.org/stable/27899609).
 7. Warren, Howard (1921). "A History of the Association Psychology" (https://books.google.co
m/?id=D4IXAAAAYAAJ&pg=PA19). Nature. 110 (2750): 19–30, 259, 296.
Bibcode:1922Natur.110S..75. (https://ui.adsabs.harvard.edu/abs/1922Natur.110S..75.).
doi:10.1038/110075d0 (https://doi.org/10.1038%2F110075d0). hdl:2027/chi.65413836 (http
s://hdl.handle.net/2027%2Fchi.65413836).
8. "History of Neuropsychology | BRAIN" (https://brainaacn.org/history-of-neuropsychology/).
brainaacn.org. Retrieved 2018-09-25.
9. Benton, A.L.; Sivan, Abigail (2007-04-01). "Clinical Neuropsychology: A Brief History" (http
s://www.researchgate.net/publication/6291178). Disease-a-Month. 53 (3): 142–7.
doi:10.1016/j.disamonth.2007.04.003 (https://doi.org/10.1016%2Fj.disamonth.2007.04.003).
PMID 17544643 (https://pubmed.ncbi.nlm.nih.gov/17544643).
10. Finger 2000, p. 44
11. Finger 2000, p. 92
12. Finger, Stanley (1994), "History of Neuropsychology", Neuropsychology, Elsevier, pp. 1–28,
doi:10.1016/b978-0-08-092668-1.50007-7 (https://doi.org/10.1016%2Fb978-0-08-092668-1.
50007-7), ISBN 9780080926681
13. Finger, Stanley (2005-03-03), "Thomas Willis: The Functional Organization of the Brain",
Minds Behind the Brain, Oxford University Press, pp. 85–100,
doi:10.1093/acprof:oso/9780195181821.003.0007 (https://doi.org/10.1093%2Facprof%3Aos
o%2F9780195181821.003.0007), ISBN 9780195181821
14. Arráez-Aybar, Luis-Alfonso; Navia-Álvarez, Pedro; Fuentes-Redondo, Talia; Bueno-López,
José-L (March 2015). "Thomas Willis, a pioneer in translational research in anatomy (on the
350th anniversary of Cerebri anatome)" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC433
7668). Journal of Anatomy. 226 (3): 289–300. doi:10.1111/joa.12273 (https://doi.org/10.111
1%2Fjoa.12273). ISSN 0021-8782 (https://www.worldcat.org/issn/0021-8782).
PMC 4337668 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4337668). PMID 25688933
(https://pubmed.ncbi.nlm.nih.gov/25688933).
15. Eadie, M. J. (March 2003). "A pathology of the animal spirits -- the clinical neurology of
Thomas Willis (1621-1675). Part II -- disorders of intrinsically abnormal animal spirits".
Journal of Clinical Neuroscience. 10 (2): 146–157. doi:10.1016/S0967-5868(02)00164-9 (htt
ps://doi.org/10.1016%2FS0967-5868%2802%2900164-9). ISSN 0967-5868 (https://www.wo
rldcat.org/issn/0967-5868). PMID 12637040 (https://pubmed.ncbi.nlm.nih.gov/12637040).
16. Benton, Arthur (2000). History of Neuropsychology: Selected Papers. USA: Oxford.
17. Finger 2000, p. 151
18. Viney, Wayne (2003). A History of Psychology: Ideas and Context (3rd ed.). Boston:
Pearson.
19. Cubelli, R.; De Bastiani, P. (2011). "150 Years after Leborgne: Why is Paul Broca so
important in the history of neuropsychology?". Cortex. 47 (2): 146–147.
doi:10.1016/j.cortex.2010.11.004 (https://doi.org/10.1016%2Fj.cortex.2010.11.004).
PMID 21112584 (https://pubmed.ncbi.nlm.nih.gov/21112584).
20. Carmichael, L. (1959). "Karl Spencer Lashley, Experimental Psychologist". Science. 129
(3360): 1410–1412. Bibcode:1959Sci...129.1410C (https://ui.adsabs.harvard.edu/abs/1959S
ci...129.1410C). doi:10.1126/science.129.3360.1410 (https://doi.org/10.1126%2Fscience.12
9.3360.1410). PMID 13658968 (https://pubmed.ncbi.nlm.nih.gov/13658968).
21. "What is Experimental Neuropsychology?" (https://www.allpsychologycareers.com/topics/ex
perimental-neuropsychology.html). www.allpsychologycareers.com. Retrieved 2018-09-25.
22. "Clinical and experimental neuropsychology" (https://www.ukessays.com/essays/psycholog
y/evaluating-the-relationship-between-clinical-and-experimental-neuropsychology-psycholo
gy-essay.php). UKEssays. Retrieved 2018-09-25.
23. Cohen, Dr. Douglas (2008). "Neuropsychology" (http://drdougcohen.com/index.html). Dr
Doug Cohen.
24. Stebbins, Glenn T. (2007), "Neuropsychological Testing", Textbook of Clinical Neurology,
Elsevier, pp. 539–557, doi:10.1016/b978-141603618-0.10027-x (https://doi.org/10.1016%2F
b978-141603618-0.10027-x), ISBN 9781416036180
25. Hall, Jeremy; O'Carroll, Ronan E; Frith, Chris D (2010), "Neuropsychology", Companion to
Psychiatric Studies, Elsevier, pp. 121–140, doi:10.1016/b978-0-7020-3137-3.00007-3 (http
s://doi.org/10.1016%2Fb978-0-7020-3137-3.00007-3), ISBN 9780702031373
26. Garson, James (2018), "Connectionism" (https://plato.stanford.edu/archives/fall2018/entries/
connectionism/), in Zalta, Edward N. (ed.), The Stanford Encyclopedia of Philosophy (Fall
2018 ed.), Metaphysics Research Lab, Stanford University, retrieved 2018-09-25
27. Boyle, G.J., Saklofske, D.H., & Matthews, G. (2012). (Eds.), SAGE Benchmarks in
Psychology: Psychological Assessment, Vol. 3: Clinical Neuropsychological Assessment.
London: SAGE. ISBN 978-0-85702-270-7
28. Xiao-Jing Wang; Wei Wei (New York University Global Brain Project) (7 December 2016).
"Inhibitory Control in the Cortico-Basal Ganglia-Thalamocortical Loop: Complex Regulation
and Interplay with Memory and Decision Processes" (https://www.ncbi.nlm.nih.gov/pmc/articl
es/PMC5193098). Neuron. 92 (5): 1093–1105. doi:10.1016/j.neuron.2016.10.031 (https://do
i.org/10.1016%2Fj.neuron.2016.10.031). PMC 5193098 (https://www.ncbi.nlm.nih.gov/pmc/a
rticles/PMC5193098). PMID 27866799 (https://pubmed.ncbi.nlm.nih.gov/27866799).
29. Bauer, R. M.; et al. (May 2012). "Computerized Neuropsychological Assessment Devices:
Joint Position Paper of the American Academy of Clinical Neuropsychology and the
National Academy of Neuropsychology" (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC349
9090). Archives of Clinical Neuropsychology. 27 (3): 362–373. doi:10.1093/arclin/acs027 (ht
tps://doi.org/10.1093%2Farclin%2Facs027). PMC 3499090 (https://www.ncbi.nlm.nih.gov/p
mc/articles/PMC3499090). PMID 22382386 (https://pubmed.ncbi.nlm.nih.gov/22382386).

External links
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Behavioral neurology
Behavioral neurology is a subspecialty of neurology that studies the impact of neurological damage and
disease upon behavior, memory, and cognition, and the treatment thereof. Two fields associated with
behavioral neurology are neuropsychiatry and neuropsychology. In the United States, 'Behavioral
Neurology & Neuropsychiatry' has been recognized as a single subspecialty by the United Council for
Neurologic Subspecialties (UCNS) since 2004.

Syndromes and diseases commonly studied by behavioral neurology include:

Agraphia
Agnosias
Agraphesthesia
Alexia (acquired dyslexia)
Amnesias
Anosognosia
Aphasias
Apraxias
Aprosodias
Attention deficit/hyperactivity disorder
Autism
Dementia
Dyslexia
Epilepsy
Hemispatial Neglect
Psychosis
Stroke
Traumatic brain injury

Contents
History
See also
References
External links

History
While descriptions of behavioral syndromes go back to the ancient Greeks and Egyptians, it was during the
19th century that behavioral neurology began to arise, first with the primitive localization theories of Franz
Gall, followed in the mid 19th century by the first localizations in aphasias by Paul Broca and then Carl
Wernicke. Localizationist neurology and clinical descriptions reached a peak in the late 19th and early 20th
century, with work extending into the clinical descriptions of dementias by Alois Alzheimer and Arnold
Pick. The work of Karl Lashley in rats for a time in the early to mid 20th century put a damper on
localization theory and lesion models of behavioral function.

In the United States, the work of Norman Geschwind led to a renaissance of behavioral neurology. He is
famous for his work on disconnection syndromes, aphasia, and behavioral syndromes of limbic epilepsy,
also called Geschwind syndrome. Having trained generations of behavioral neurologists (e.g., Antonio
Damasio), Geschwind is considered the father of behavioral neurology.

The advent of in vivo neuroimaging starting in the 1980s led to a further strengthening of interest in the
cognitive neurosciences and provided a tool that allowed for lesion, structural, and functional correlations
with behavioral dysfunction in living people.

See also
Behavioral neuroscience

References
Benson DF (1993). "The history of behavioral neurology". Neurol Clin. 11 (1): 1–8.
PMID 8441365 (https://pubmed.ncbi.nlm.nih.gov/8441365).
Martha J. Farah, Todd E. Feinberg; Behavioral Neurology and Neuropsychology; McGraw-
Hill Professional Publishing; 1st edition (August 1, 1996)
Valenstein, Edward; Heilman, Kenneth M. (2003). Clinical neuropsychology (4th ed.). Oxford
[Oxfordshire]: Oxford University Press. ISBN 0-19-513367-6.

External links
Society for Behavioral and Cognitive Neurology (http://www.the-sbcn.org/)
United Council for Neurologic Subspecialties (https://web.archive.org/web/2019091121472
6/http://www.ucns.org/)

Retrieved from "https://en.wikipedia.org/w/index.php?title=Behavioral_neurology&oldid=992446950"

This page was last edited on 5 December 2020, at 09:09 (UTC).

Text is available under the Creative Commons Attribution-ShareAlike License; additional terms may apply. By using
this site, you agree to the Terms of Use and Privacy Policy. Wikipedia® is a registered trademark of the Wikimedia
Foundation, Inc., a non-profit organization.