Behavioral Neurology and Neuropsychiatry Is a Subspecialty

I t is with great pleasure that I announce that Behavioral Neurology and Neuropsychiatry has been approved as a subspecialty area by the United Council for Neurologic Subspecialties (UCNS). One of the key goals for the American Neuropsychiatric Association (ANPA) has been to develop and implement a plan for certification in neuropsychiatry (see editorial by Coffey et al. in 2004 issue of the Journal. 1 When I assumed the presidency of ANPA in February 2003, my main focus was toward fulfilling this objective.

What is the importance of this designation? At our annual meeting in 2004, I spoke about “Neuropsychiatry as a Subspecialty.” Some have proposed that neuropsychiatry be viewed as a “superspecialty,” which would subsume psychiatry and neurology. 2 I posited, however, that neuropsychiatry is a clinical subspecialty that focuses on a specific patient population, a view shared by numerous textbooks in this area. 3 – 8 Neuropsychiatry has been so popular that it is losing its meaning. If you perform a Google search with the terms neuropsychiatry or neuropsychiatric, you will find approximately 100,000 hits. Examine those programs labeled as neuropsychiatry. While some clearly are within our definition of a clinical subspecialty, others are used as a marketing term to differentiate from nonbiological approaches and to avoid the stigma of psychiatry. While this is laudable in intent, it detracts from who neuropsychiatrists are and what we do: the care of emotional, cognitive, and behavioral problems in individuals with recognized neurological disorders. When neuropsychiatry becomes synonymous with psychiatry and all psychiatrists are neuropsychiatrists, how can anyone tell who is qualified to take care of our patients? Patients with neuropsychiatric disorders such as traumatic brain injury, cerebrovascular disease, epilepsy, dementia, basal ganglia disorders, and multiple sclerosis require professionals with specific expertise and training for appropriate evaluation and treatment. Without a process for certification in neuropsychiatry, qualifications often are defined by other organizations and professions (such as lawyers).

With this in mind, ANPA recognized the need to develop certification in neuropsychiatry. Our options were to apply through the American Board of Psychiatry and Neurology (ABPN), develop internal certification, or seek another venue for external certification. Certification should lead to recognition of special training, funding for fellowships, and reimbursement for treatment. We expect that this would lead to increased interest, involvement, research, and clinical advances. Over the past several years, ANPA built the foundation for certification. The ANPA Education Committee developed a training directory, a core curriculum, standards for fellowship training, a neuropsychiatry bibliography, a web-based neuropsychiatry self-assessment and expanded continuing medical education at our annual meetings.

In the spring of 2003, the ANPA surveyed the Fellows of ANPA as well as the membership, to ascertain their views on certification, including whether these efforts should be done in conjunction with behavioral neurology. It should come as no surprise that there is a significant overlap between behavioral neurology and neuropsychiatry. In fact, many ANPA members are behavioral neurologists. Those two fields share a common body of knowledge pertaining to the phenomenology, pathophysiology, diagnosis, and treatment of cognitive, emotional, and behavioral disturbances in relation to brain dysfunction, clinical diagnosis, and treatment. Both Fellows and members believed that certification was important and that it should be done with behavioral neurology—although most believed that this would not be possible. In conversations during the summer of 2003 with David Bachman, M.D., who at that time was president of the Society for Behavioral and Cognitive Neurology (SBCN), we learned that behavioral neurology also wanted to apply for certification and believed that it should be done as a combined effort with neuropsychiatry.

A new organization, the United Council for Neurologic Subspecialties (UCNS), incorporated in 2003, is a nonprofit professional medical organization sponsored by five parent organizations: American Academy of Neurology (AAN), American Neurological Association, Association of University Professors of Neurology, Child Neurology Society, and Professors of Child Neurology. The mission of UCNS is to enhance quality of training, provide certification for completion of training, and to improve quality of care. Neurologic subspecialty areas (NSAs) are described as unique and defined fields in neurology, with a defined body of knowledge and comprehensive training requirements. UCNS is designed to recognize added competence and to assist subspecialties that have matured to the point where accreditation of training programs and certification of graduates are appropriate, yet these subspecialties are unable to seek or have not grown enough for SPN certification. While certification through the ABPN is the gold standard, it was clear that neuropsychiatry had insufficient numbers to accomplish this through psychiatry only (where the requirement was 25 training programs). In addition, the ABPN process is long, and it has only recently approved Psychiatry for the Medically Ill, after many years.

The SBCN presented the proposal for a joint application from Behavioral Neurology and Neuropsychiatry to the AAN Governing Board and Committee on Subspecialties in late fall 2003, which approved this proposal. ANPA then prepared the application to UCNS for the new subspecialty, “Behavioral Neurology and Neuropsychiatry,” defined as “a medical specialty committed to better understanding links between neuroscience and behavior, and to the care of individuals with neurologically based behavioral disturbances.” While the application was the combined effort of many individuals, specific recognition must go to David Arciniegas, M.D. (on behalf of ANPA), and Daniel Kaufer, M.D. (representing SBCN, although also a member of ANPA). The curriculum was published recently in this Journal . 9 This application was submitted to UCNS in March 2004.

On June 30, 2004, the ANPA was informed that the application of Behavioral Neurology and Neuropsychiatry as a neurological subspecialty area was approved. In our collaboration with UCNS, ANPA and SBCN have finalized the subspecialty curriculum and the accreditation procedures for fellowship programs. The first group of fellowship programs (eight as of January 2006) have been approved for accreditation. An examination has been developed to certify individuals in this subspecialty. The committee writing the examination consists of five neuropsychiatrists from ANPA and five behavioral neurologists from SBCN. As chair of the examination committee, I believe this is a fair and reasonable examination that reflects the knowledge necessary for the practice of behavioral neurology and neuropsychiatry. The first examination will be administered in September 2006. Since many neuropsychiatrists and behavioral neurologists currently in practice have not had fellowship training, UCNS has developed criteria for grandfathering for the next 5 years to determine eligibility to take the examination. After that time, completion of an accredited fellowship program will be required.

Please visit the UCNS website (www.UCNS.org) for further information on this organization, the process for applying for accreditation of fellowship training programs, and the necessary qualifications and procedures for taking the examination (which will be given yearly, if you missed this year’s deadline).

Our challenge is to demonstrate the importance of this certification in the care of patients, recognition for reimbursement of specialized procedures, and approval of the higher level of care that we provide. We need your participation to make this effort successful. ANPA is one of the two representative organizations for this field (SBCN is the other). We urge you to visit our redesigned website (www.anpaonline.org), become a member, and attend our excellent annual meetings.

This is a historic moment in neuropsychiatry. Neurology and psychiatry—or parts of them, at least—have become reunited.