Core Curriculum for Training in Behavioral Neurology & Neuropsychiatry

Behavioral neurology and neuropsychiatry are disciplines among the clinical neurosciences that focus on the clinical and pathological aspects of neural processes associated with cognition, emotion, and behavior. The seminal work of late 19th- and early 20th-century neuroscientists such as Griesenger, Broca, Wernicke, Harlow, Charcot, Freud, Alzheimer, and Pick laid the foundation for the development of neuropsychiatry and behavioral neurology as subspecialties within the traditional medical specialties of psychiatry and neurology, respectively.^1–4 Although neurology and psychiatry evolved into distinct medical specialties during the 20th century, behavioral neurology and neuropsychiatry developed in parallel and remained complementary specialties given their common roots in cognitive and behavioral neuroscience.^5–7 Recent advances in structural and functional brain imaging, clinical electrophysiology, and experimental psychology fostered unprecedented growth in the clinical neurosciences, and enlightened our understanding of both normal and disturbed cognition, emotion, and behavior. These technologies and the findings from them complement the clinical interview and examination and extend the core knowledge base and clinical skills that define modern neuropsychiatry and behavioral neurology.

Behavioral neurology and neuropsychiatry share the core philosophical position that brain and behavior are inseparable.^3,4,8,9 Reciprocal interactions between psychological factors and neuropsychiatric illness are appreciated, yet both are fundamentally understood in terms of brain function and dysfunction.^3,4,8–11 Clinically, behavioral neurologists and neuropsychiatrists elicit and construct comprehensive patient histories that emphasize neurodevelopmental and environmental influences on cognitive, emotional, behavioral, and elementary neurological function. Assessment of these functions requires of practitioners both an extensive knowledge of brain-behavior relationships and also the skills to apply that knowledge to clinical practice. The assessment is also guided and made more systematic by the use and interpretation of standardized, validated, and reliable metrics of cognitive, emotional, behavioral, and elementary neurological functions developed specifically for use in behavioral neurology and neuropsychiatry. The use and interpretation of neuroimaging, electrophysiologic, and other laboratory measures that inform diagnosis and/or treatment planning is emphasized as an essential element of neurobehavioral and neuropsychiatric assessment. Interpreting clinical signs, symptoms, and syndromes as reflecting neural processes supercedes conventional (i.e., DSM-based) psychiatric diagnoses, and the historical dichotomization of clinical conditions into strict “psychiatric” or “neurological” types is rejected in favor of a more integrative approach. A principal goal of this integrative approach is to transcend the mind-brain duality reflected in the separation of psychiatry and neurology. Consequently, the clinical and scientific purview of behavioral neurology and neuropsychiatry is broad and includes, at a minimum, the following:

Given the breadth of the clinical problems encountered by behavioral neurologists and neuropsychiatrists, expertise in pharmacological, behavioral, psychosocial, and environmental interventions is required to address comprehensively the needs of patients with these conditions and their families. This comprehensive approach to clinical assessment and treatment both blends and adds to the historically distinct neurological and psychiatric examinations. This approach to assessment and treatment distinguishes the clinical paradigm employed in behavioral neurology and neuropsychiatry as unique among other medical subspecialties in the clinical neurosciences.

Recognizing the fundamental congruence between behavioral neurology and neuropsychiatry, the Joint Committee on Subspecialty Certification of the American Neuropsychiatric Association (ANPA) and the Society for Behavioral and Cognitive Neurology (SBCN) assert that the body of knowledge pertaining to the phenomenology, pathophysiology, diagnosis, and treatment of cognitive, emotional, and behavioral disturbances among persons with neurological conditions is common to both behavioral neurology and neuropsychiatry. These historically separate but parallel subdisciplines can therefore be merged into a single subspecialty area of medicine that herein will be referred to as Behavioral Neurology & Neuropsychiatry.

Behavioral Neurology & Neuropsychiatry is defined as a medical subspecialty committed to better understanding links between neuroscience and behavior, and to the care of individuals with neurologically based behavioral disturbances.¹² Expertise and clinical competence in Behavioral Neurology & Neuropsychiatry requires a combination of knowledge and skills that are beyond the scope of those required for the practice of general neurology or general psychiatry, either alone or in combination. While the knowledge base and clinical skills of behavioral neurologists and neuropsychiatrists are built upon on the foundation established by primary training in one or both of these specialties, expertise and clinical competence in Behavioral Neurology & Neuropsychiatry requires experience specific to the evaluation, differential diagnosis, prognosis, pharmacological treatment, psychosocial management, and neurorehabilitation of persons with complex neuropsychiatric and neurobehavioral conditions.^{3,4,7–9,13–18} The body of knowledge and clinical skills circumscribed by Behavioral Neurology & Neuropsychiatry is additive to those of general psychiatry and general neurology and are distinct from other subdisciplines of these medical specialties. Accordingly, training and experience in Behavioral Neurology & Neuropsychiatry are needed to achieve competence to practice in this area of medicine.

Until recently, training programs in behavioral neurology and neuropsychiatry throughout the U.S. produced practitioners in one or the other of these previously separate subspecialties. Although the goals and objectives for training used by these programs overlapped substantially, the core curriculum used in those programs varied considerably. In the service of standardizing fellowship training in these areas, the ANPA promulgated Standards for Fellowship Training in 2001.¹⁹ Recognizing the need to specify further the educational content that programs are expected to provide to fellows undertaking subspecialty training in this area, the SBCN and the ANPA partnered to develop a core curriculum for training in the unified medical subspecialty of Behavioral Neurology & Neuropsychiatry. The Joint Committee for Subspecialty Certification of the ANPA and the SBCN drew upon work in this area undertaken previously by the Behavioral Neurology Section of the American Academy of Neurology and the Curriculum Task Force of ANPA to identify potential curricular content for training in Behavioral Neurology & Neuropsychiatry. This group also undertook a review of the Accreditation Council on Graduate Medical Education (ACGME) program requirements for training in psychiatry²⁰ and neurology;²¹ review and comparison of potential curricular content for Behavioral Neurology & Neuropsychiatry with that of other established neurological and psychiatric subspecialties, including addiction psychiatry, clinical neurophysiology, forensic psychiatry, geriatric psychiatry, and neurodevelopmental disabilities as specified by the American Board of Psychiatry and Neurology (ABPN),²² as well as review of and comparison with the program requirements for residency education in psychosomatic medicine;²³ integration of the proposed core curriculum with the standards for fellowship training in neuropsychiatry as specified by the ANPA;¹⁹ and review of content in current textbooks as a guide to essential elements of the core curriculum for training Behavioral Neurology & Neuropsychiatry^{3,4,7–9,13–18,24–32} fellows.

It is not the objective of this document to specify the manner in which the educational goals and objectives for subspecialty training are met in an individual training program or the methods by which competence in Behavioral Neurology & Neuropsychiatry is achieved or evaluated. This document serves instead to outline broadly the core curricular content for training programs in Behavioral Neurology & Neuropsychiatry. Although training programs may differ in their methods, it is expected that fellows will master the core curricular content described herein regardless of differences in their clinical experiences. Accordingly, the methods by which knowledge and performance skills are taught during the course of training are considered separately from the core curricular content. For more information regarding possible methods of educational programming, readers should consult the United Council for Neurological Subspecialties (UCNS) website (http://www.ucns.org/accreditation/application/) and the document there entitled “Training Program Requirements.”

Finally, the core curriculum for training in Behavioral Neurology & Neuropsychiatry described in this article should be regarded as an initial formulation of the core knowledge and skill set expected of practitioners in this subspecialty. As new knowledge and skills are incorporated into this area of clinical practice and education, the core curriculum for training in this area will undoubtedly require revision. Additionally, the process of continued review and implementation of this core curriculum by the UCNS may entail changes in its formatting and content. Readers are encouraged to consult the UCNS website to view the final form of this core curriculum when preparing for the certification examination and/or designing training programs in Behavioral Neurology & Neuropsychiatry.

Goals and Objectives for Training in Behavioral Neurology & Neuropsychiatry

Curriculum for Training in Behavioral Neurology & Neuropsychiatry

The core curriculum for Behavioral Neurology & Neuropsychiatry is composed of four primary content areas: 1) structural and functional neuroanatomy, 2) neurobehavioral and neuropsychiatric assessment, 3) treatment, and 4) neurobehavioral and neuropsychiatric syndromes.

These content areas collectively reflect the breadth and diversity of the field. Clinical training in Behavioral Neurology & Neuropsychiatry must emphasize the principles of clinical assessment and treatment. Accordingly, training programs should emphasize mastery of the first three core curricular content areas described herein regardless of the specific clinical focus (e.g., dementias, stroke, TBI) of those programs. Fellows in Behavioral Neurology & Neuropsychiatry are expected to both complement and supplement their “bedside-learning” with guided self-directed learning activities (i.e., reading relevant textbooks and peer-reviewed articles) and didactic experiences (i.e., seminars, case conferences, grand rounds, local or national conferences) related to the fourth core curricular content area (neurobehavioral and neuropsychiatric syndromes).

Structural and Functional Neuroanatomy

The Behavioral Neurology & Neuropsychiatry fellow will develop expertise in:

The fellow in Behavioral Neurology & Neuropsychiatry will develop expertise in the structural and functional bases of cognition, emotion, and behavior, including:

Neuropsychiatric Assessment

The Behavioral Neurology & Neuropsychiatry fellow will be provided with education and experience in the areas of clinical assessment listed below. Note that neuropsychological assessment is an exception to this requirement, and instead is most appropriately regarded as area in which acquisition of advanced knowledge, and not necessarily performance skills, is an appropriate goal of fellowship training.

Neurological Examination

Mental Status Examination

Neuropsychological Assessment

Neuroimaging

Electrophysiologic Testing

Laboratory Studies

Integration and Presentation of Findings

Treatments

The Behavioral Neurology & Neuropsychiatry fellow will demonstrate knowledge about and clinical competency in the prescription and/or monitoring of somatic therapies, psychosocial interventions, crisis intervention, and basic neurorehabilitation, as specified below:

Somatic Therapies

Psychosocial Interventions

Neurobehavioral and Neuropsychiatric Syndromes

Fellows in Behavioral Neurology & Neuropsychiatry are expected to develop in-depth knowledge regarding the neuropsychiatric and neurobehavioral consequences of many neurological and psychiatric conditions. All fellows are expected to bring to subspecialty training the level of knowledge and clinical competence required by the ACGME-RRC in Neurology or Psychiatry for completion of and board-eligibility in the area of their pre-fellowship training (i.e., neurology, psychiatry, and/or both). However, since training in Behavioral Neurology & Neuropsychiatry may follow primary training in neurology, psychiatry, and/or pediatric neurology, it is not expected that the fellows will develop the same fund of knowledge or clinical competency in the management of the primary neurological or psychiatric disorders listed herein as that obtained by primary specialty training. Instead, it is expected that the fellow will develop sufficient knowledge regarding these conditions such that he or she can competently evaluate and manage their neurobehavioral and neuropsychiatric manifestations.

Given the limited duration of training in Behavioral Neurology & Neuropsychiatry, some fellows may have little direct experience evaluating and caring for patients with some of these problems during the period of fellowship training. The elements of the Core Curriculum described in sections I-III (above) are designed to ensure that fellows develop the knowledge base and clinical skills required to understand, evaluate, and treat patients with neurobehavioral and neuropsychiatric problems through mastery the principles of Behavioral Neurology & Neuropsychiatry. In the service of preparing fellows to evaluate and treat neurobehavioral and neuropsychiatric problems arising in any of the conditions in which such problems develop, fellows are expected to both complement and supplement “bedside-learning” through guided self-directed learning activities and/or didactic experiences. Guided self-directed learning activities may include reading relevant textbooks, peer-reviewed articles, or other materials recommended by training program faculty. Didactic experiences may include seminars or other course work provided by the training program itself or by other programs either within or affiliated with the institution in which the fellowship training occurs. Additionally, fellows should be encouraged to attend local or national conferences relevant to this aspect of training in Behavioral Neurology & Neuropsychiatry.

Through these means, it is expected that the fellow will develop an advanced level of knowledge regarding the neurobehavioral and neuropsychiatric aspects, epidemiology, neurogenetics, putative neurological substrates, and typical neuropathological features of the conditions listed below, where such are known.

Supplementary Curricular Content

Training programs may elect to facilitate the fellow’s development of special expertise and/or clinical competence in additional areas in Behavioral Neurology & Neuropsychiatry. Emphasis on these supplementary areas should not detract from the emphasis needed to master all of the elements of the Core Curriculum. Possible supplementary curricular content may include:

ACKNOWLEDGMENTS

The authors thank Jeffrey L. Cummings, M.D., whose early endeavors to develop subspecialty certification in neuropsychiatry laid the foundations for the present work.

The authors also thank C. Alan Anderson, M.D. (Denver Veterans Affairs Medical Center and University of Colorado School of Medicine, Denver, CO); David P. Moore, MD (Louisville, KY); Paula T. Trzepacz, M.D. (Eli Lilly and Company, Indianapolis, IN); and the members of the ANPA Education Committee for their development of the ANPA Standards for Fellowship Training in Neuropsychiatry and the ANPA Core Curriculum for Fellowship Training in Neuropsychiatry, which contributed substantively to the development of the present work.