Fellowship Training in Neuropsychiatry

DEFINITION OF NEUROPSYCHIATRY
Neuropsychiatry is the area of psychiatry concerned with the biopsychosocial treatment of disorders associated with brain dysfunction. A Neuropsychiatric approach permits a broad conceptualization of a clinical problem which transcends a basic psychiatric or neurologic paradigm. The approach will represent a fundamental departure from traditional psychiatry and neurology. The reciprocal influences of psychology and cerebral dysfunction will be appreciated for its own unique and significant influence on behavior. Localization of signs and symptoms in the brain will take precedence over standard psychiatric diagnoses, so a more comprehensive assessment of mental status can be undertaken.

The neuropsychiatric assessment will be objective, data driven, and the collection of the data and their synthesis into a coherent formulation will serve to distinguish neuropsychiatry as a unique clinical discipline. The following guidelines reflect the opinions of the Educational Committee of the American Neuropsychiatric Association, and are intended to provide a standard for achieving competence in the field of neuropsychiatry.

GOALS AND OBJECTIVES

Goals of the Fellowship:

• To teach the clinical skills of performing a thorough, efficient, and reliable neuropsychiatric history and physical examination.
  • The fellow will participate in attending supervised neuropsychiatric clinics both within the department of psychiatry as well as neurology. Attending physicians from the areas of adult psychiatry, geriatric psychiatry, epileptology, will supervise the fellow in performing a thorough, efficient, and reliable history and physical exam.
    
• To enhance understanding of structural and functional neuroanatomy as they relate to behavior and cognition.
  • The fellow will participate in a weekly neuroanatomic case conference and review with attending physicians where cases will be reviewed focusing upon the behavioral indications leading to the exam request as well as exam findings.
    
• To achieve competence in the evaluation and diagnosis of neuropsychiatric disorders.
  • The fellow will participate in three half-day clinics per week at Loyola University Medical Center and Hines Veterans Affairs Medical Center devoted exclusively to neuropsychiatric patients and disorders. Supervising attending physicians will be readily available for consultation and supervision at all times.
    
• To develop an understanding of the indications for, and interpretation of diagnostic studies relevant to neuropsychiatry.
  • The fellow will participate in a weekly case conference and review with attending physicians from the Departments of Nuclear Medicine, Psychiatry, Neuropsychology, Hines Veterans Affairs Medical Center, Hines, IL where cases will be reviewed focusing upon the behavioral correlates of objective evaluations leading to understanding of the referral questions as related to findings.
  • The fellow will participate in daily studies of clinical electrophysiology involving qEEG and evoked potential studies conducted by certified electrophysiologists to gain an appreciation of the tools in clinical as well as research settings
  • The fellow will participate in a weekly neuropsychiatry conference focusing upon the integration of medical assessment and neuropsychological assessment in selected patients. The role of neuropsychological testing and limitations will be stressed.
  • The fellow will participate in discussions of biological substrates of abnormal behavior focusing on the integration of neurotransmitter based conceptualization of cases.
    
• To train academic leaders in the field of neuropsychiatry and stimulate interest in clinical research in this field.
  • Fellow will be expected to peruse an independent research project and present the results of this project at one national meeting or convention, preferably the annual conference of the American Neuropsychiatric Association or Biological Psychiatry Meeting.
    
• To promote understanding of the functions of an interdisciplinary team in the care and management of patients with neuropsychiatric disorders.
  • The fellowship is designed to promote maximal interaction between psychiatry, neurology, electrophysiology, biological psychiatry, and neuropsychology in the assessment of neuropsychiatric patients.
    
• To educate psychiatry and neurology residents, medical students and other professional in the field of clinical brain sciences about the clinical squeal of neuropsychiatric disorders.
  • Each fellow will be responsible for medical student education on neuropsychiatric topics, and will give each third-year medical student rotation an introductory lecture in neuropsychiatry covering various topics including by not limited to dementia, delirium, migraine, traumatic brain injury, movement disorders, and epilepsy.
  • Each fellow will be responsible for instructing psychiatry residents and other professional in the field of clinical brain sciences during scheduled didactic time in topics relating to neuropsychiatry including but not limited to dementia, delirium, migraine, traumatic brain injury, movement disorders, and epilepsy.
  • Each fellow will be responsible for supervising resident continuity clinics of one-half day per week to stress the importance of neuropsychiatric assessment in patient presenting to a general psychiatry outpatient clinic.

Objectives of the Fellowship

The Fellow will:

• Develop clinical expertise regarding the psychiatric care of persons with disorders of brain function to include diagnostic skills, neurological and mental status examinations, cognitive testing, electrophysiological testing, neuroimaging, differential diagnosis, crisis intervention, application of time-limited psychotherapy, and referral for rehabilitative therapies.
  • The fellow will participate in attending supervised neuropsychiatric clinics both within the department of psychiatry as well as neurology. Attending physicians from the areas of adult psychiatry, geriatric psychiatry, epileptology, and movement disorders will supervise the fellow in performing a thorough, efficient, and reliable history and physical exam.
  • The fellow will participate in an established weekly multidisciplinary Brain Case Conference in the Nuclear Medicine Department at Hines VA Medical Center, Hines, IL and review with attending physicians, cases focusing upon the behavioral indications leading to the exam request as well as study findings.
  • The fellow will coordinate efforts with social work and the physical medicine for referral to rehabilitation centers for appropriate neuropsychiatric patients.
  • The fellow will demonstrate a basic knowledge of cognitive-behavioral and interpersonal psychotherapies and have basic competence with their application to appropriate neuropsychiatric patients.
    
• Gain broad knowledge in the field of neuropsychiatry through extensive exposure to the core literature in neuropsychiatry, biological psychiatry, neuropsychology, and behavioral neurology. Neuroanatomy, pharmacology, clinical electrophysiology, neurochemistry and imaging of behavioral disorders will be emphasized.
  • The fellow will be given the bibliography of the core literature in neuropsychiatry, neuropsychology, and behavioral neurology as compiled by the American Neuropsychiatric Association. By the completion of the fellowship, the fellow will be expected to have a working knowledge of neuropsychiatric literature including electroconvulsive therapy and transcranial electromagnetic therapy.
  • The fellow will be given the opportunity to discuss relevant neuropsychiatric reading with participating fellowship specialty faculty including geriatric psychiatry, polysomnography, electrophysiology, neuroimaging, and neurology.
    
• Gain an advanced understanding of psychopharmacology, including neuropsychopharmacology, with special emphasis on anticonvulsants, psychostimulants, and the interactions of psychotropic medications with other medications on the central nervous system.
  • The fellow will gain an advanced understanding of psychopharmacology, including neuropsychopharmacology, with special emphasis on anticonvulsants, psychostimulants, and the interactions of psychotropic medications with other medications on the central nervous system by participation in didactics in psychiatry and/or neurology as well as by increasing one’s experience in the appropriate use of such medications in neuropsychiatric patients.
    
• Participate in the curriculum which may include rounds, conferences, supervision, didactics, and seminars.
  • Each fellow will be responsible for medical student education on neuropsychiatric topics, and will give each third-year medical student rotation an introductory lecture in neuropsychiatry covering various topics including by not limited to dementia, delirium, migraine, traumatic brain injury, movement disorders, and epilepsy.
  • Each fellow will be responsible for instructing psychiatry residents during scheduled didactic time in topics relating to neuropsychiatry including but not limited to dementia, delirium, migraine, traumatic brain injury, movement disorders, and epilepsy.
  • Each fellow will be responsible for supervising resident continuity clinics of one-half day per week to stress the importance of neuropsychiatric assessment in patient presenting to a general psychiatry outpatient clinic.
  • The fellow will participate in an established weekly multidisciplinary Brain Case Conference in the Nuclear Medicine Department at Hines VA Medical Center, Hines, IL and review with attending physicians, cases focusing upon the behavioral indications leading to the exam request as well as study findings. f. The fellow will participate in a weekly neuropsychiatry conference focusing upon the integration of medical assessment and neuropsychological assessment in selected patients. The role of neuropsychological testing and limitations will be stressed.
    
• Develop an understanding of research methodology and apply it to a research question in neuropsychiatry. This could be accomplished through a critical review of the literature, or through publishing or participating in research projects.
  • Each fellow will be expected to pursue an independent research project and present the results of this project at one national meeting or convention, preferably the annual conference of the American Neuropsychiatric Association or Biological Psychiatry.

LENGTH OF FELLOWSHIP
The fellowship will be full time for one year duration.

CANDIDATES
Fellows may enter neuropsychiatry fellowship training at the 5th post-graduate year of training. All candidates for the neuropsychiatry fellowship must have completed an adult psychiatry residency, adult neurology residency, and be board eligible in their respective discipline.

FACULTY
The program director for the fellowship will be Angelos Halaris, M.D., who is an ABPN certified psychiatrist who has expertise in neuropsychiatry, in particular polysomnography. In addition fellows will receive regular supervision from M. Rao, M.D., attending geriatric psychiatrist, G. Kartje, M.D., attending neurologist, and L.M. Konopka AM, Ph.D, ECNS Pharmacologist /Clinical Neurophysiologist, Director of Neurophysiology

FACILITIES
The clinical facilities in which the fellowship is based will center around Hines Veterans Affairs Medical Center, Hines, IL, and Loyola University Medical Center, Maywood, IL. Both facilities are capable of providing inpatient and outpatient care for neuropsychiatric patients including ECT. In addition, both facilities provide a full range of neurology services including general neurology, extensive cerebrovascular disease, movement disorders, neuro-oncology, electrophysiology, neuroimaging, and neuropathology. Patient disorders seen at these institutions are diverse and include but are not limited to:

• delirium
• various dementias including Alzheimer’s, Lewy Body, and frontotemporal types
• HIV-associated neuropsychiatric patients
• traumatic brain injury
• cerebrovascular disease
• epilepsy
• anoxic injuries
• movement disorder patients (Parkinson’s, Multiple Sclerosis, Multiple System Atrophy)
• migraine and chronic headache syndromes
• neuro-oncology
• schizophrenia.

In addition, Loyola University Medical Center is a tertiary care medical center, which supports a large medical sciences library.

EDUCATIONAL PROGRAM
Clinical
The core educational content should include:

• Functional neuroanatomy and Neuroimaging
  • The fellow will participate in a weekly neuroanatomic case conference and review with attending physicians from the Departments of Radiology and Nuclear Medicine, Hines Veterans Affairs Medical Center, Hines, IL where cases will be reviewed focusing upon the behavioral indications leading to the exam request as well as exam findings.
    
• Behavioral and cognitive assessment
  • The fellow will participate in attending supervised clinics both within the department of psychiatry as well as neurology. Attending physicians from the areas of adult psychiatry, geriatric psychiatry, epileptology, and movement disorders will supervise the fellow in performing a thorough, efficient, and reliable history and physical exam for the purpose of complete behavioral and cognitive assessment.
    
• Evaluation and biopsychosocial treatment of neuropsychiatric syndromes
  • The fellow will participate in attending supervised clinics both within the department of psychiatry as well as neurology. Attending physicians from the areas of adult psychiatry, geriatric psychiatry, epileptology, and movement disorders will supervise the fellow in performing a thorough, efficient, and reliable history and physical exam for the purpose of complete behavioral and cognitive assessment.
  • The fellow will demonstrate a basic knowledge of cognitive-behavioral and interpersonal psychotherapies and have basic competence with their application to appropriate neuropsychiatric patients.
  • The fellow will gain an advanced understanding of psychopharmacology, including neuropsychopharmacology, with special emphasis on anticonvulsants, psychostimulants, and the interactions of psychotropic medications with other medications on the central nervous system by participation in didactics in the departments of psychiatry and/or neurology as well as by increasing one’s experience in the appropriate use of such medications in neuropsychiatric patients.
    
• Basic electrophysiology
  • The fellow will participate in daily EEG interpretation sessions with board certified electrophysiologists to gain an appreciation of the usefulness and role of EEG and QEEG in evaluating neuropsychiatric disorders. In addition, the fellow has the option of expanding his time in the EEG/QEEG laboratory to achieve eligibility for certification in EEQ/QEEG from ABEN by the completion of the fellowship.
    
• Neuropsychological testing
  • The fellow will participate in a weekly neuropsychiatry conference focusing upon the integration of medical assessment and neuropsychological assessment in selected patients. The role of neuropsychological testing and limitations will be stressed.
    
• Neuropathology
  • The fellow will have the opportunity to attend neuropathological gross dissections and microscopy in the Department of Pathology, Division of Neuropathology, Loyola University Medical Center.
    
• Neurologic examination
  • Fellows will receive regular supervision from G. Kartje, M.D., attending neurologist in the performance of neurological exams and the treatment of neurological disorders.

Additional expertise in at least two supplementary areas is encouraged:

• Polysomnography
  • The program director for the fellowship will be Angelos Halaris, M.D., who is an ABPN certified psychiatrist who has expertise in polysomnography, and is additionally board certified in polysomnography. Interested candidates may pursue further studies in polysomnography as related to neuropsychiatry.
    
• Geriatric psychiatry
  • Fellows will have regular supervision and contact with Murali Rao, M.D., ABPN certified geriatric psychiatrist. Attention to cognitive and mood changes in the elderly including delirium, dementia, and depression will be addressed on a regular basis.
    
• Child psychiatry
  • Interested fellows will have the opportunity to persue a more in-depth neuropsychiatric concentration in disorders of child and adolescence through regular contact with ABPN certified child and adolescent psychiatrists including R. Robertson, M.D., Osama El-Shaffie, M.D, and Anna Ivanenko, MD, PhD.
    
• Neurorehabilitation
  • Interested fellows will have the opportunity to pursue a more in-depth neuropsychiatric concentration in neurorehabilitation by interaction with the attending physiatrists in the Department of Orthopaedics and Rehabilitation Medicine at Loyola University Medical Center, Maywood, IL.

Teaching
The fellow will actively participate in the education of other trainees. Teaching activities may include presenting literature reviews, giving lectures on selected topics, and providing clinical supervision of residents and students.

• Each fellow will be responsible for medical student education on neuropsychiatric topics, and will give each third-year medical student rotation an introductory lecture in neuropsychiatry covering various topics including by not limited to dementia, delirium, migraine, traumatic brain injury, movement disorders, and epilepsy.
• Each fellow will be responsible for instructing psychiatry residents during scheduled didactic time in topics relating to neuropsychiatry including but not limited to dementia, delirium, migraine, traumatic brain injury, movement disorders, and epilepsy.
• Each fellow will be responsible for supervising resident continuity clinics of one-half day per week to stress the importance of neuropsychiatric assessment inpatient presenting to a general psychiatry outpatient clinic.

Supervision
Each fellow will choose two different supervisors for a required minimum of 2 hours per week clinical supervision.

Research
Each fellow will be expected to demonstrate familiarity with basic research methodologies and designs as well as pursue an independent research project and present the results of this project at one national meeting or convention, preferably the annual conference of the American Neuropsychiatric Association.

Evaluation
Formal and informal evaluation will take place with respect to the performance of fellows, the extent and quality of supervision and the structure and substance of the program.

• Evaluation of fellows
  • A standard psychiatric training evaluation form will be completed by all
    program supervisors and reviewed with the fellow. This form will be used to document progress in specific areas. Ongoing evaluation will occur less formally and more personally in the context of individual supervision. The fellow is judged from the observation of interviewing skills, clinical expertise, and relationship with patients and peers. In addition, the fellow’s level of knowledge is assessed in the course of case discussions, written reports, and other academic activities. The comments of attending physicians and other non-psychiatric or neurologic staff will also be used to evaluate the fellow’s activities. A fellow must be directly observed doing a complete initial evaluation of a neuropsychiatric patient at least quarterly.
    
• Evaluation of faculty
  • In a reciprocal manner, the fellow will be expected to evaluate supervisors formally and informally.