Behavioral Neurology & Neuropsychiatry Fellowship
NHH - DHMC
Definition of the Subspecialty
Neuropsychiatry and Behavioral Neurology are the disciplines within Psychiatry and Neurology concerned with the identification, assessment, and management of behavioral disorders associated with brain dysfunction. The evolution of this interdisciplinary area reflects the inseparability of Neurology and Psychiatry and the obligatory relationship between brain and behavior. The disorders included within these disciplines include but are not limited to focal neurobehavioral disorders (aphasia, amnesia, agnosia, apraxia), delirium, dementia and neuropsychiatric disorders (depression, mania, psychoses, anxiety, personality changes, obsessive-compulsive behaviors) associated with neurologic diseases. Many psychiatric disorders are increasingly recognized to have an important neurobiologic dimension and the study of the neurological causes of these disorders is within the domain of Neuropsychiatry. Many neurologic disorders are accompanied by significant and often dramatic changes in mood, emotions, personality, cognition, and behavior. Changes in these domains often present the greatest challenges to the individual and those who care for him/her. Special expertise in Neuropsychiatry requires training specific to this clinical area. The body of knowledge subsumed in Neuropsychiatry is distinct from activities within other disciplinary areas. Eligibility for certification by the American Board of Psychiatry and Neurology in either Neurology or Psychiatry will make one eligible for advanced training in Neuropsychiatry.
As of the fall of 2004, the United Council of Neurological Subspecialties granted subspecialty status to the field of Behavioral Neurology & Neuropsychiatry. Preparations are underway for a certification exam and a curriculum has been approved for fellowship training. The first round of applications for accreditation of Behavioral Neurology & Neuropsychiatry fellowships were accepted for July 1, 2005. The Dartmouth Medical School Affiliated Neuropsychiatry Fellowship program submitted a completed application and was fully accredited by UCNS in December 2005.
Duration and Scope of Education
The Neuropsychiatry Fellowship is a 12 month experience. Candidates must have completed training in an ACGME-accredited Psychiatry or Neurology residency or four years of an ACGME-approved dual training program.
Training that occurred in the course of a Psychiatry or Neurology residency or in the first four years of a dual training program will not be counted toward meeting the training period.
Training will optimally occur on a full-time basis. However, part-time participation in this Fellowship for a more extended period of time may be an acceptable alternative to full-time involvement.
Prior to entry into this program, each trainee will be notified in writing of the required length of training. The required length of the program cannot be changed during the trainee's program without the mutual agreement of the trainee and training program unless there is a break in his/her training, or the individual requires remedial training.
Education Goals and Objectives
The Fellowship is intended to provide an intensive focused clinical experience in the evaluation and management of patients with neuropsychiatric disorders. On completion of the program the trainee will be prepared to serve as an expert consultant and to provide principal care for patients with neuropsychiatric and neurobehavioral disorders. The Fellowship emphasizes scholarship, life-long learning, critical analysis of the literature and of clinical problems, and clinical decision-making skills.
Clinical training includes assessment of patients with a variety of types of brain disorders, including: a) patients with many types of neurologic disorders (stroke, trauma, degenerative disorders, epilepsy, demyelinating diseases, brain tumors, developmental disorders), b) patients manifesting a wide variety of behavioral disturbances (e.g., aphasia, amnesia, agnosias, apraxias, frontal lobe syndromes, dementias, delirium, impulse control disorders), and c) patients with a variety of idiopathic behavioral disorders (e.g., depression, mania, psychosis, anxiety, personality changes, OCD, substance abuse).
Fellows will be exposed to and become knowledgeable in the assessment techniques relevant to Neuropsychiatry and Behavioral Neurology including Neuropsychology, Neuroimaging, Clinical Electrophysiology, and evaluations relevant to Neurorehabilitation.
Fellows will be exposed to and become knowledgeable in a wide array of interventions including psychopharmacology, applied behavioral analysis, and psychosocial interventions, and the adjustments necessary for use in Neuropsychiatric populations.
Fellows will become knowledgeable in the specific neuroanatomic brain regions and circuits that subserve normal and abnormal emotions and behaviors.
Fellows will expand their knowledge of the basic sciences relevant to Neuropsychiatry and Behavioral Neurology including other neurochemistry, neurophysiology, neuropsychopharmacology, neuroendocrinology and cognitive neuroscience.
Clinical training will provide the opportunity for trainees to understand a life-span approach to Neuropsychiatry including knowledge about childhood and developmental behavioral disorders as well as geriatric and late-life syndromes.
The Behavioral Neurology & Neuropsychiatry Fellowship is a component of the Dartmouth Hitchcock Affiliated Hospital Residency Program in Psychiatry. The latter is fully accredited by the ACGME. Fellowship training takes place in the component institutions of the Dartmouth-Hitchcock Affiliated programs.
New Hampshire Hospital (NHH)--located in Concord, NH, this 110 bed facility serves as the sole state psychiatric hospital for New Hampshire. The NHH houses a 12 bed Neuropsychiatry unit charged with the evaluation and management of patients with a mixture of neurologic and psychiatric disorders. Under the supervision of the Unit Neuropsychiatrists (T. McAllister, M.D., R. Ferrell, M.D.) and in consultation with an attending Neurologist (M. Lombardo, M.D.,), the fellow directs the evaluation and management of this unit. A multidisciplinary team collaborates with the fellow in this endeavor including faculty Neuropsychologists (L. Flashman, Ph.D., S. McGurk, Ph.D.), neuropsychology post-doctoral fellows, a behavioral psychologist (J. Crampton, Ph.D.), an internist (R. Luckoor, M.D.), a social worker (G. Ashley, M.S.S.), nursing staff, occupational therapist and recreational therapist. This experience provides exposure to very ill hospitalized patients with complex neuropsychiatric disorders. The multidisciplinary faculty and team ensure exposure to the broad array of biopsychosocial perspectives and interventions needed in this patient population, as well as providing the supervision necessary for good patient care and learning.
The fellow, in collaboration with the program faculty (T. McAllister, M.D., R. Ferrell, M.D., L. Flashman, Ph.D.), provide neuropsychiatric consultation to the rest of the faculty and staff at NHH. This experience provides exposure to the neuropsychiatric consultative process. On average, 3.5 days per week are spent at NHH.
Dartmouth-Hitchcock Medical Center (DHMC)--is the teaching hospital of Dartmouth Medical School and a tertiary referral center for New Hampshire, Vermont and parts of Maine and Massachusetts. Within the Department of Psychiatry at DHMC is an outpatient Neuropsychiatry Clinic which evaluates and treats patients with a full array of neuropsychiatric disorders. Consultative-liaison services are provided to the Neurology and Neurosurgery services of DHMC, particularly the surgical epilepsy program. Under the supervision of program faculty (T. McAllister, M.D., R. Green, M.D., R. Ferrell, M.D.) the neuropsychiatry fellow performs evaluations in the Neuropsychiatry Clinic, consults to the Neurology and Neurosurgery services at DHMC, and provides supervision and teaching to the psychiatry residents and medical students in the Neuropsychiatry Clinic. On average, 1.5 days per week are spent at DHMC.
The fellow has library resources including journals addressing psychiatry, neurology, behavioral neurology, and neuropsychiatry, as well as computerized literature search capabilities at both primary teaching facilities; the Dorothy Breene Library at NHH, and the Dana Biomedical Library at DHMC.
Faculty and Staff
Thomas W. McAllister, M.D., Professor of Psychiatry, is the Director of the Section of Neuropsychiatry. He previously held faculty positions at the University of Kentucky and the University of Pennsylvania, where he was Director of the Brain Injury and Behavior program. His clinical and research interests focus on behavioral syndromes produced by different types of brain injury, particularly traumatic brain injury. Differences in the experience and expression of common behavioral syndromes (such as depression) as a function of injury type and location are studied to shed light on the mechanisms that underlie these syndromes in idiopathic psychiatric disorders. He is the PI on several federally funded grants looking at the neurobehavioral consequences of traumatic brain injury.
Ronald L. Green, M.D., Professor of Psychiatry, is the Residency Training Director in Psychiatry. His major teaching contribution, in addition to individual resident supervision, is his co-directorship of the Neuroscience for Psychiatry Residents series. His principal research interests have been in the genetics of bipolar disorder, the neurological and psychiatric aspects of emotional behaviors such as crying, and alteration of regional cortical surface area in dyslexia and schizophrenia. He has developed an award-winning brain cutting for psychiatrists class that is used in the fellowship
Richard Ferrell, M.D., Associate Professor of Psychiatry, is a neuropsychiatrist and geropsychiatrist, who directs the inpatient Neuropsychiatry Unit at New Hampshire Hospital. His research and clinical interests are in the behavioral effects of medical and neurological disorders and the sequelae of TBI in the elderly.
Laura A. Flashman, Ph.D., Associate Professor of Psychiatry, directs the Neuropsychology Laboratory at NHH. She has extensive experience in using neuroimaging techniques to study brain-behavior relationships in neuropsychiatric disorders. She was previously with the MHCRC at the University of Iowa studying major psychoses. Her current research focuses on the neuroanatomical substrate of awareness of illness, functional MRI approaches to schizophrenia and traumatic brain injury, and cognitive functioning in patients with mild mental retardation.
Heather Wishart, Ph.D., Assistant Professor of Psychiatry, directs the Clinical Neuropsychology Laboratory at DHMC. Her current research interests include the work described above studying cognitive processes in patients with neuropsychiatric disorders using functional MRI. She is also actively involved in the use of functional MRI to localize specific cognitive and motor functions in the brains of patients with Multiple Sclerosis, and has recently been awarded several grants to pursue these interests. She is also actively involved in the use of functional MRI to localize specific cognitive and motor functions in the brains of patients with refractory epilepsy, cancer, Alzheimer's disease, and ADD. She has recently been awarded the Joshua Burnett, M.D. Clincal Research Fellowship to assist her studies of individuals with multiple sclerosis.
The goal of the training program is to provide the trainee with experience and advanced training in the field of Neuropsychiatry. This objective will be accomplished by a combination of supervised clinical experiences as described above, and formal didactic conferences and seminars. The curriculum assures the opportunity for trainees to achieve the knowledge, interpersonal skills, professional attitudes, and practical experience required of a physician caring for patients with neuropsychiatric and neurobehavioral disorders.
The training program includes the following clinical components:
- Consultation Experience--Attaining consultative skills is an essential objective of the training program. A broad range of consultative experiences are available. They include consultation to inpatients at NHH, outpatient consultation experience through the Neuropsychiatry Clinic at DHMC, and consultation to the Surgical Epilepsy and Multiple Sclerosis Programs at DHMC.
- Principal Care--In addition to the consultation experience, Fellows provide continuing principal care to patients on both the inpatient Neuropsychiatry Unit at NHH and the outpatient Neuropsychiatry Clinic at DHMC.
- Other Experience--Optional experiences that can supplement the training experience include clinical, consultation, or research experiences directed toward neuropsychology, geriatric psychiatry, pediatric psychiatry, pediatric neurology, neurosurgery, neuroscience, neuroimaging, neuropharmacology, neurorehabilitation, dementia, clinical neurology (epilepsy, stroke, multiple sclerosis, movement disorders) or clinical psychiatry (depression, mania, psychoses, anxiety, personality disorders, OCD, substance abuse disorders, eating disorders).
Educational Program Content
The program curriculum insures that graduates have basic expertise in all the following content and skill areas. In some cases, the Fellow will have some of these skills at the time of program entry and the instructional module pertaining to these existing skills can be waived for that individual upon satisfactory demonstration of the skills and knowledge to the program director. Graduates are not expected to have well developed expertise in all areas of Neuropsychiatry and trainees with a background in Psychiatry will have different skill areas from those with a background in Neurology. Along with basic expertise in the broad areas of the specialty, education should provide the graduate with knowledge regarding appropriate referral of patients for more expert evaluations or intervention.
Neuropsychiatric Interview and Mental Status Examination
The training program provides the opportunity for the Fellow to become expert in conducting a neuropsychiatric interview of patients with neuropsychiatric disorders. Training opportunities include instruction in executing and interpreting the mental status examination. This includes the assessment of comportment, attention, language, memory, visuospatial skills, executive functions, calculation, and abstraction. The program includes instruction in the anatomic correlates of disturbances of these functions and the etiologic differential diagnosis of the disorders. The program provides the Fellow with the skills to be able to recognize and characterize dementia, delirium, aphasia, and amnesia on the basis of the mental status examination. The training opportunity also provides instruction regarding the pertinent observations to be made in a patient who is unable to cooperate with a formal examination
The training program provides the opportunity for the Fellow to become knowledgeable in clinical neuropsychiatric assessment including the identification and elucidation of depression, mania, psychosis, anxiety, personality disorders, substance abuse, conversion disorder, and OCD occurring in the context of neurologic disease.
The training program provides experience in the use of standardized mental status questionnaires and standardized psychodiagnostic rating scales and interview schedules including the SCID, SANS, SAPS, and SUMD.
The training program familiarizes the Fellow with the basic aspects of the forensic evaluation including determination of testamentary capacity, specific competencies, criminal responsibility, and degree of disability in patients with brain dysfunction. Fellows are encouraged to evaluate and follow several cases in which expert testimony will be required.
The training program provides instruction in the performance of a competent neurologic examination including assessment of cranial nerves, motor system, sensory system, muscle stretch reflexes, pathological reflexes, and primitive release signs. Instruction will include the evaluation of gait posture, "soft" neurological signs, and hyperkinetic disorders. The program develops in its trainees the ability to identify pyramidal system abnormalities, basal ganglia disturbances, cerebellar ataxia, peripheral neuropathy, abnormal eye movements, tardive dyskinesia, and catatonia. The training program teaches the relationships between abnormal findings on the neurologic examination and the related neuroanatomy and neurologic disorders (neurodegenerative disorders, stroke, multiple sclerosis, hydrocephalus, brain tumors, CNS infections, head traumas). These goals are accomplished by working with a Neurologist (M. Lombardo, M.D., ) to perform neurological exams on the inpatients on the Neuropsychiatry Unit and selected consults at NHH.
An adequate neurological assessment includes a neurodevelopmental history, assessment of acquired brain injury, history pertinent to neurological conditions (seizures, transient ischemic attacks, progressive degeneration), and family history. The program provides instruction in skills to obtain this information.
Neuropsychiatric and Behavioral Neurology Syndromes
The training program provides the trainee with the opportunity to study the clinical features and neurologic correlates of affective, psychotic, anxiety, personality, somatoform, dissociative, sexual, sleep, impulse control, and factitious disorders.
Clinical experience and didactic material help to develop the trainee's ability to detect, describe, and manage recognized neurobehavioral syndromes including aphasia, amnesia, apraxia, agnosia, alexia, agraphia, dysprosody, executive dysfunction, unilateral neglect, visuospatial disturbances, acalculias, anosognosia, dementia, and delirium. Emphasis is paid to the relationship of these syndromes to neuroanatomy and to relevant etiologies of neurologic dysfunction (neurodegenerative disorders, stroke, multiple sclerosis, hydrocephalus, brain tumors, CNS infections, traumatic brain injury, and toxic-metabolic encephalopathies).
Clinical experience and didactic material provide instruction regarding the onset, course, expected duration, and management of the major Neuropsychiatric and Behavioral Neurology syndromes including dementia, delirium, human immunodeficiency virus syndrome, epilepsy, stroke, movement disorders, traumatic brain injury, multiple sclerosis, developmental disability, autism, and sleep disorders.
At both NHH and DHMC the trainee is provided with the opportunity to become familiar with tools commonly used in the standardized neuropsychological assessment (WAIS-R, WMS-R, Wisconsin Card Sorting Test, Trail Making Tests, Stroop Test, Rey-Osterreith Figure, and others). Trainees review neuropsychological test findings on their patients in detail with faculty neuropsychologists and post-doctoral neuropsychology fellows. Early in the fellowship, trainees participate in the administration of neuropsychological tests to gain a fuller appreciation of their strengths and limitations and the effects. The Fellow will gain experience in how to incorporate the results of neuropsychological testing into a patient's evaluation and treatment planning. This takes place under the supervision of Drs. Saykin, Flashman, McGurk, and Wishart in the Neuropsychology laboratories at both NHH and DHMC.
Neurobiological Basis of Behavior
Through the emphasis on understanding the neuroanatomical and neurophysiological substrate of patient specific behaviors and through scheduled brain cuttings, autopsy conferences and seminars/didactics etc., the trainee is given instruction concerning the neurobiological basis of normal and abnormal behavior including human neuroanatomy, neurochemistry, and brain embryology and development. Anatomical instruction includes the organization of the cerebral cortex, white matter tracts, basal ganglia, thalamus, hypothalamus, and brainstem. The anatomy of the vascular system and the ventricular system are also studied.
Supplementary Disciplinary Areas
Childhood and Childhood-Onset Behavioral Disorders
Trainees are expected to become familiar with the course of normal human development and developmental milestones, through working with the faculty around the evaluation and care of both inpatients and outpatients, as well as self-directed learning as indicated. Craig Donnelly, M.D., Director of Child and Adolescent Psychiatry at Dartmouth Medical School is available to consult on selected age-appropriate Neuropsychiatric patients.
Geriatric Neuropsychiatry/Behavioral Neurology
Through clinical and didactic experience the program provides the opportunity for trainees to become familiar with the late-onset behavioral disorders associated with brain dysfunction, the impact of normal aging on cognitive function, and the assessment of elderly patients. Instruction is provided on the identification and management of common geriatric neuropsychiatric/behavioral neurological disorders including the dementias, delirium, depression, late-onset psychoses, behavioral disturbances associated with Parkinson's Disease, and behavioral alterations associated with cerebrovascular disease.
Neuroimaging and Neurodiagnostics
Trainees are taught the appropriate use, interpretation, and integrations of how to order, understand the interpretation, and provide a preliminary interpretation of neuroimaging and neurodiagnostic techniques commonly used in the course of evaluating patients with neurologic disease. These techniques include x-ray computed tomography (CT), magnetic resonance imaging (MRI), and cerebral angiography (conventional or magnetic resonance angiography), single photon emission computed tomography (SPECT), and functional MRI. Trainees become familiar with the expected results of neuroimaging studies in neuropsychiatric illnesses including schizophrenia, Alzheimer's disease, frontal lobe degeneration, Huntington's disease, stroke, and multiple sclerosis.
Working with a neurologist at NHH, the trainee becomes familiar with common electrophysiological techniques used in neuropsychiatric assessment including EEG, brain mapping, and evoked potentials, and with the changes induced by epilepsy, delirium, dementia, and focal neurological disorders.
Neuropsychopharmacology and Patient Management
Both direct clinical supervision and didactic instruction is given regarding the indications, contraindications, drug interactions, and adverse side effects of the major agents used in Neuropsychiatry including anticonvulsants, anti-parkinsonsim agents, antipsychotic agents (including "atypical" agents), antidepressants, anxiolytics, stimulants, analgesics, and drugs used in the treatment of Alzheimer's disease. The trainee becomes skilled in the psychopharmacologic management of the major behavioral disorders including depression, psychosis, anxiety, OCD, agitation, substance abuse, attention deficit disorders, developmental disabilities, and sleep disorders. Other areas include the management of the acutely agitated patient, the non-neuroleptic alternatives for the treatment of agitation and aggression, neuropharmacologic management of the major neurologic disorders including epilepsy, Parkinson's disease, Huntington's disease, traumatic brain injury, stroke, multiple sclerosis, and Alzheimer's disease. The program emphasizes the recognition and management of drug side effects including tremor, tardive dyskinesia and other tardive symptoms, dystonia, neuroleptic malignant syndrome, parkinsonism, and delirium. Applied behavioral analysis and the writing and implementation of appropriate behavioral plans are learned through work at NHH on the Neuropsychiatry unit with J. Crampton, Ph.D.
The clinical experiences are supplemented with the following conference/didactic schedule:
|Neuropsychiatry Consult Rds.||NHH||Weekly 1.5 hrs.|
|Seminars in Cognitive Neuroscience||Dartmouth College||2x/month 1.5 hrs.|
|Neuropsychology Seminar||NHH||1x/month 1.0 hrs.|
|Brain Imaging and Research Conf.||DHMC||Weekly 2.0 hrs.|
|Neuropsychiatric Autopsy Conf.||NHH||2x/year 2.0 hrs.|
|Topics in Clinical NeuroscienceLecture Series||NHH||2x/month 1.0 hrs.|
|Neurology Grand Rds.||DHMC||Weekly 1.0 hrs.|
Throughout the fellowship, the trainee is carefully supervised in all aspects of their clinical practice. The nature of this supervision is somewhat different in each of the core clinical components, and is described below.
Inpatient Neuropsychiatry Unit, NHH - While on the NPU, the trainee is supervised by the unit attending neuropsychiatrist (Dr. Ferrell or Dr. McAllister). Attendings are present at most daily team meetings, walk rounds, and admissions. Admission notes, progress notes, and discharge summaries are reviewed by the attendings, and supplemented by attending notes on a regular basis as per NHH policy. Attendings are available at other times by pager. Additional supervision is provided as needed by other members of the faculty and multi-disciplinary team including Dr. Flashman, Dr. Saykin, Dr. Crampton and others.
Neuropsychiatry Consultations, DHMC, NHH, other facilities - Patients seen in consultation by the trainee are presented to attendings (Drs Ferrell, Green, McAllister, and others), and in most cases are seen jointly with an attending. Clinical assessments and treatment plans are discussed together, and reports are in most instances co-signed by an attending.
Outpatient Neuropsychiatry Clinic, DHMC - Trainees see outpatients in the Neuropsychiatry Clinic at DHMC. In the vast majority of cases, attending faculty (Drs Ferrell, Green, McAllister) see the patient along with the trainee. Trainees then present patients to the clinic faculty and other trainees in a group supervision setting. Assessments and treatment recommendations are jointly arrived at, and evaluation notes/progress notes reviewed and co-signed by faculty. Where appropriate, these notes are supplemented by additional faculty notes. Faculty are available at all times by pager, email, phone, etc for issues that arise outside of the clinic setting.
There will be quarterly evaluations of the trainees by all supervisors and the directors of clinical components or training. These are discussed with the trainees and placed in the training record.