1. Draft Horacio Page 118/10/2010CORE CURRICULUM IN NEUROPSYCHIATRYInternational Neuropsychiatric Association BackgroundNeuropsychiatry is an old discipline with its origins in the mid-nineteenth century, or perhaps even earlier to the 17th century, much before the birth of modern psychiatry. For many decades however, neurology and psychiatry developed as separate disciplines, leading to a dearth of dialogue between the disciplines. Neuropsychiatry has remerged in the last two decades as a sub-discipline which bridges the two established disciplines of neurology and psychiatry. In its broader role, neuropsychiatry applies the principles of neuroscience to the understanding and treatment of emotional, behavioural and cognitive disorders. In its narrower and more practical approach, neuropsychiatry is that branch of psychiatry which is concerned with the diagnosis and management of the psychiatric and behavioural consequences of demonstrable brain disturbance, and psychiatric or behavioural symptoms suggestive of demonstrable brain disturbance. As such, the practice of neuropsychiatry requires skills and knowledge that in part traverse the traditional Psychiatry / Neurology boundary.The discipline of Neuropsychiatry (NP) must be considered in relation to Behavioural Neurology (BN). In many respects, NP and BN are two slightly different approaches to the same set of disorders and conditions, with the former being biased toward traditional Psychiatry and the latter having its route through Neurology. The core competencies are similar, with perhaps differences in emphasis. Since this curriculum is being developed under the aegis of the INA, the term Neuropsychiatry will be used. An effort will be made to identify specific areas that are particularly important to BN so that the curriculum can be readily adapted to BN.Currently there are few training programs worldwide that are exclusive to neuropsychiatry and lead to a specific neuropsychiatry specialist accreditation. In most countries, trainees who gain experience in neuropsychiatry do so within general adult psychiatry, old age psychiatry, child psychiatry or forensic psychiatry. This is true even for countries in which a number of neuropsychiatry specialist positions exist. Some countries have a dual training in Neurology and Psychiatry, with a certification in both disciplines. While this approach meets some of the requirements of training in NP, it is the position of the INA that training in Neuropsychiatry specifically, following basic training in psychiatry and neurology is necessary to meet the requirements of specialist NP training.Goals of a training program:The purpose of a training program in NP is to produce specialists who will be competent in the diagnosis and management of common neuropsychiatric disorders, able to utilize specialized neuropsychiatric investigations in the evaluation of these disorders, able to

2. Draft HoracioPage 218/10/2010 provide secondary and tertiary level consultations to general physicians, psychiatrists and neurologists, and be involved in teaching and research in relation to these disorders. While the range of disorders included in NP is difficult to delineate, an attempt is made in the core competencies section of this document to define this territory, with the acknowledgement that this is an evolving process depending upon the knowledge base of the day.The following are the goals of the training program:1. To develop a sound knowledge base of the neuroscientific principles underlyingneuropsychiatric practice, in relation to neuroanatomy, neurophysiology,neurochemistry and neuropharmacology.2. To gain first hand experience of common neuropsychiatric disorders and becomecompetent in their diagnosis and management.3. To develop an expertise in the use and interpretation of specializedneuropsychiatric investigations, in particular neurophysiology, neuroimaging andneuropsychology.4. To be competent in the recognition and management of common psychiatric andneurologic disorders.5. To develop specialized skills in the physical treatments in neuropsychiatry, butwithout ignoring the principles of psychotherapeutic and rehabilitativeapproaches.6. To develop skills in the critical evaluation of research evidence in thepathophysiology, phenomenology and treatment of neuropsychiatric disorders.7. To conduct research to improve the empirical basis of neuropsychiatricknowledge and practice.8. To act as advocates for sufferers of neuropsychiatric illnesses, and to contribute tothe development of the profession.Structure of a NP training program:There is no one model that will suit all training programs in NP. An attempt is made to outline the basic tenets of such a program. i. A NP training program shall endeavour to create specialists in NP who functionas secondary and tertiary level specialists. They shall provide consultations togeneral psychiatrists, neurologists and general physicians on a range ofneuropsychiatric disorders. ii. A NP training program will generally comprise a 2-year fellowship programwhich will focus on the core competencies detailed below. In some situations,only a one-year fellowship in NP maybe practicable. Full competency should notbe assumed after one year of training. However, if the trainee works for a furthertwo years in a largely or exclusively neuropsychiatric service (but not specificallyas a trainee), it would be considered likely that the training requirements wouldhave been met in this period. iii. The NP Fellow will have previously received training in Psychiatry and/orNeurology. In general, this would have been a 3-year training program in a centrethat offers training in both specialties. It is expected that the psychiatry trainee 3. Draft HoracioPage 318/10/2010 would have received at least 6 months training in neurology, but the neurology trainee would have at least 1 year of training in psychiatry. If this is not the case, the Fellowship period would be used to remedy this with a clinical rotation in the appropriate discipline.iv. The NP training will be in a neuropsychiatric centre with two or more neuropsychiatrists, one or more clinical neuropsychologists, a neurologist (part- time or fulltime), and a working relationship with psychiatric, clinical neurology and neurosurgical services. The centre would be part of a general teaching hospital and have easy access to a neurophysiology service and up-to-date neuroimaging, which would include structural MRI and functional imaging. It would also have a research program.v. The training program will include a research project, which would preferably be based on empirical research.vi. The training program will have an evaluation component, based on a formal assessment and/or a series of informal assessments by the supervisors.vii. The program will prepare the trainee for a life-long period of education and professional enhancement.viii.The program will instil by example the highest ethical standards of conduct in clinical practice and scholarly work. 4. Draft HoracioPage 418/10/2010 A survey of required competencies in NeuropsychiatryThe curriculum below identifies some core competencies in the skill base, and specific modules of specialist knowledge base. These shall be acquired over two years. The competencies are described as modules, but they are not necessarily independent of each other. The importance of the Core Skills module is highlighted. The aims and objectives of this module will normally be covered within the specific clinical modules undertaken but should represent an additional and specific focus of study within the individual clinical modules. The level of expertise in each of the specific modules will vary, depending upon the facilities available, but a basic level of competence in each module is expected in a 2-year training program.1. Core Skills Module1.1. Knowledge base in clinical neuroscience1.2. Clinical skills in neuropsychiatry1.2.1.Neuropsychiatric diagnosis including history and examination, neurophysiological investigations, neuroimaging, neuropsychology, and other investigations1.2.2.Treatment, including pharmacology and other physical treatments (ECT, TMS, Surgical interventions), without neglecting psychotherapeutic and rehabilitative interventions1.3. Critical thinking in neuropsychiatry research and scholarship2. Specific modules 2.1. Cognitive disorders:2.1.1.Dementias and Pre-dementia syndromes2.1.2.Non-dementing cognitive disorders2.2. Seizure disorders2.3. Movement disorders2.4. Traumatic brain injury2.5. Secondary psychiatric disorders, i.e. psychosis, depression, mania and anxiety disorders secondary to organic brain disease2.6. Substance-induced psychiatric disorders alcohol, drugs of abuse, etc.2.7. Attentional disorders (adult ADHD and related syndromes)2.8. General Hospital Liaison Neuropsychiatry2.9. Developmental Neuropsychiatry2.10.Sleep disorders2.11.Neuropsychiatric rehabilitation2.12.Forensic neuropsychiatry 5. Draft HoracioPage 518/10/20101. CORE SKILLS MODULESpecific Competencies1.1 Knowledge base in Neuroscience: Knowledge of brain structure at the macroscopic and microscopic levels, inparticular the knowledge of neuronal networks, the limbic system, theneuroanatomical substrates of memory and the frontal executive system A knowledge of CNS structure-function correlations Knowledge of neurochemistry, especially neurotransmitter and receptorfunction. The biochemical basis of neuropsychopharmacology The basic principles of neurophysiology The basic principles of genetics and immunology as they apply to the CNS A basic grasp of issues related to the mind-brain debate, the biology ofconsciousness and other neurophilosophical issues.1.2 Clinical skills in Neuropsychiatry 1) Undertake clinical assessment of patients with apparent or possible neuropsychiatric problems.(i) Take a neuropsychiatric history; this includes all of the information routinely gathered as part of a psychiatric and medical history, but with special emphasis on gathering information about possible illnesses or injury to the central nervoussystem, sudden or gradual changes in intellectualfunctioning, level of consciousness, personality andjudgement, as well as changes in motor and sensory functions, whichmight indicate neurological disease.(ii)Perform a neuropsychiatric assessment. This will again involve and encompass all of the routine skills required to carry out a psychiatric examination, but in addition will include: demonstration of the ability to elicit informationrelevant to possible neuropsychiatric disorders andneurological conditions, for example: the ability tolist the history of stepwise cognitive decline orpsychomotor seizure activity.(iii) Perform a cognitive examination (simple and extended). A core skill in neuropsychiatry is the ability to carry out simple tests at the bedside to determine a patients level of orientation, attention, 6. Draft Horacio Page 618/10/2010 concentration, memory etc. and to do so in the context of a psychiatric examination. A neuropsychiatrist, and in particular one from a neurological background, would be competent in assessing deficits in language, praxis, gnosis, visuospatial function and other cognitive syndromes This would not require the ability to administer formal neuropsychological tests, but may involve carrying out paper and pencil tests and the use of simple material such as word lists or pictures. A neuropsychiatrist should have competency in interpreting results of such an examination in order to determine whether the patient is suffering from a dementing illness, a confusional state or a specific cognitive deficit as well as competency in diagnosing the range of adult psychiatric conditions. Part of the skill would involve placing the results of the examination in the context of the patients educational and social background and pre-morbid level of functioning.(iv) Perform a neurological examination. The trainee should be able to carry out a full anddetailed neurological examination, if necessary,with particular emphasis on the central nervoussystem and higher cortical functioning. The trainee should be able to demonstrate the abilityto interpret any abnormal signs elicited and placethem in the context of the patients presentation anda differential diagnosis. This may include elicitingsigns, which require further specialist investigation,either within the realm of neuropsychiatry orneurology or electrophysiology.(v)Construct a neuropsychiatic differential diagnosis. The trainee neuropsychiatrist should be able todemonstrate familiarity with multi-axial forms ofclassification. S/he should be able to arrange multiple diagnosesinto a rational hierarchy and be able to summarisethe key elements of the history and examination,which support that differential diagnosis. S/he should be able to evaluate the extent to whichpatterns of psychiatric symptomatology andpresentation may be due to underlying organic braindisease. 7. Draft HoracioPage 718/10/2010 Be familiar with the range of organic disorders thatmay account for particular presentations. S/he should be able to communicate this in a clearand concise way to other health professionals aswell as patients and their carers. 2) Undertake and plan investigation of a patient with apparent or possibleneuropsychiatric problems.i) Trainees should be familiar with the relevant haematological,metabolic, bacteriological, virological, immunological andtoxicological investigations of relevance to neuropsychiatry. This willinclude: Demonstrating knowledge and judgement that the relevant parameter is of central importance to the neuropsychiatric presentation Knowing which investigations need to be pursued with further tests, and knowing which may be incidental or within normal limits. Interpretation of examination of cerebro-spinal fluid, nerve, muscle and brain biopsy will also be required, although detailed knowledge is not necessary.ii) Unlike many other specialities within psychiatry, neuropsychiatry requires familiarity with EEG and other neurophysiological investigations and their interpretation. The trainee should be able to discuss the advantages and limitations of the routine EEG, sleep EEG and longer term EEG telemetry in patients with possible neuropsychiatric problems. While the trainee is not expected to be competent in reading EEGs independently, s/he should have working knowledge of the profiles of normal and abnormal EEGs. In addition s/he should understand the use and application of sensory evoked potentials and nerve conduction studies and EMG as they occur in neurological disorders with neuropsychiatric complications, and also as a tool to exclude neurological causes of abnormal function, which may in fact have a psychological basis. The trainee should be familiar with the settings in which these investigations are carried out, should be able to query the interpretation with a consultant or 8. Draft HoracioPage 818/10/2010experienced technician in the area and to conveythis information to members of the multi-disciplineteam, carers and patients alike.iii) Neuropsychiatry requires sound understanding of the indications for,and interpretations of, the various forms of brain imaging, bothstructural and functional, including MRI, CT, SPECT and PET etc. The trainee should have sufficient familiarity with these techniques to be able to describe them to a patient and their family/carer and to be able to interpret the results. The trainee should know when such investigations are likely to alter management or treatment decisions and should have some understanding of their theoretical importance. The trainee should have sufficient first hand knowledge of CT and MRI brain scans to be able to detect salient abnormalities and critically assess an expert report.3) Prescribe and oversee treatment to patients with neuropsychiatric disorderssuch as those with psychiatric and behavioural symptoms and co-existingneurological disorder. Be familiar with social, psychological and biologicalinterventions for neuropsychiatric disorders.i) The trainee should have sufficient skill to explain the mode of action,benefits and side effects of these treatments to fellow healthprofessionals, patients and their families. Be familiar with the principles of treatment of majorneurological disorders and be familiar withneuropsychiatric complications of such treatment. The neuropsychiatrist should also be aware of theneurological manifestations and complications ofpsychiatric treatment and advise patients andprofessionals on evaluating the importance of theseand in minimising their occurrence and severity. ii) Be familiar with potential drug interactions between psychiatric andneurological medications and other treatments. This will include the awareness of the risks associated withprescribing psychotropic drugs to patients with neurological andneurosurgical diseases. iii) Be familiar with non-pharmacological treatments in neurological and neuropsychiatricdisorders. The trainee will have competence in the assessmentfor and the administration of electro-convulsivetherapy (ECT) in its current form. 9. Draft Horacio Page 918/10/2010 The trainee should have some understanding of the newer physical treatments such as transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), deep brain stimulation (DBS), and other physical treatments. S/he should also acquire knowledge of the principles of neuro-rehabilitation and familiarity with the concepts of disability and handicap 4) To diagnose and treat patients with medically unexplained symptoms which present as neurological and neuropsychiatric problems, this includes working with colleagues in other disciplines to determine which further tests and investigations are necessary or not as the case may be. (i) Neuropsychiatry should involve competence in understanding thepossible social, cultural and family influences on unexplainedneurological symptoms. (ii)The trainee should be able to develop a grasp of the principles behindcognitive behavioural treatments for such patients and be able to planand oversee such treatments carried out by another professional suchas a trained nurse or clinical psychologist. (iii) S/ he should be aware of the relationship between neuropsychiatryand allied psychiatric subspecialties such as old age, child and learningdisability psychiatry and which service patients might mostappropriately be served by.1.3Critical thinking in neuropsychiatry research and scholarshipA specialist training in NP will equip the trainee to think critically in the field. The trainee should be able to critically assess the empirical evidence in support of any clinical practice, including the ability to criticize published material. This skill can be developed by means of journal clubs, attendance at research meetings, research presentations, short-term courses, etc. It is expected that in the second year of training, the trainee will undertake a research project. This should ideally involve all the steps in an empirical project (background review, design of study, applying for ethics clearance, data gathering, analysis and report preparation). However, it may take up the form of a critical review of a current topic, or a case series. The trainee will produce a report of a publishable standard, as judged by the supervisors, and will be encouraged to publish in a peer- reviewed journal. The research report will be a mandatory component of the second year of training. 10. Draft HoracioPage 10 18/10/2010 2. SPECIFIC MODULES MODULE 2.1 Cognitive DisordersA. Specific CompetenciesI.Dementias and pre-dementia syndromes:Be familiar with the diagnosis and investigation of dementias resulting from: - Alzheimers disease (AD) - Vascular Cognitive Impairment (VCI) - Dementia with Lewy Bodies (DLB) - Fronto-temporal dementia (FTD) , including semantic dementia, progressive aphasia, etc. - Dementias related to Parkinsonism+ syndromes (progressive supranuclear palsy, corticobasal degeneration, multiple system atrophy) - Prion diseases, esp. Creutzfeldt-Jakob disease and variant CJD - Huntingtons disease - Dementia resulting from head injury, alcohol use, medical conditions including HIV, brain tumours, encephalitis, etc.II. Other cognitive disorders:a. Be familiar with the diagnosis and investigation of specific memorydisorders (amnesic syndromes), in particular:- Alcoholic Korsakoffs syndrome- Other causes of thiamine deficiency- Brain infection such as herpes encephalitis or other encephalopathies- Brain dysfunction resulting from cerebral hypoxia e.g. carbon monoxide poisoning- Vascular disorders, such as thalamic infarction or subarachnoid haemorrhage b. Be familiar with the diagnosis and investigation of frontal/executive syndromes of disinhibitory and non-spontaneous types c. Be familiar with the diagnosis and investigation of other, more posterior cognitive disorders:- including language disorders (anomias, and disorders of comprehension orexpression), reading disorders (surface and deep dyslexia), mentalcalculation (whether or not part of Gerstmanns syndrome), disorders ofvisuo-spatial awareness, perception, construction, and the agnosias. III. Be familiar with the diagnosis and investigation of psychologically-basedcognitive impairments: - Hysterical conditions, including psychogenic amnesias 11. Draft HoracioPage 1118/10/2010-Pseudodementias, as in depression-Cognitive impairment as part of somatisation, factitious, or malingering syndromes IV. Be familiar with the status and controversies regarding Mild Cognitive ImpairmentB. Diagnostic techniques: - Clinical assessment including neurological and clinical cognitive examination. - Be familiar with the role, importance, and principles of neuropsychological testing. - Be familiar with the interpretation of Occupational Therapy and Speech and Language Therapy assessments and reports. - Be familiar with the relevant investigations in a clinical blood screen. - Be aware of when an EEG can be helpful or even crucial. - Be familiar with the purpose and interpretation of CT and MRI brain scans. - Be aware of the putative role of other forms of neuroimaging including SPECT, PET, DTI, and fMRI.C. Be familiar with the main principles involved in the management and treatment ofcognitive disorders and of dementias:- The work of a multidisciplinary team- The contribution of cognitive behaviour therapy and psychological counselling in specific conditions- The use of cognitive enhancing drugs including cholinesterase inhibitors and memantine- The use of other medications in neuropsychiatry, including anti-convulsants and anti-depressants- The management of behavioural disturbances in dementia- The use of outreach and community support servicesD. How taught:- Observation and modelling- Working as a team member- Supervise clinical practice- Review of suitable texts and papers in scientific publications, including reviewarticlesE. How assessed: - Clinical supervision - Direct observation - Clinical log book - Clinical audit - Case presentations, etc. 12. Draft HoracioPage 1218/10/2010 MODULE 2.2 - SEIZURE DISORDERSSpecific competencies:1. Undertake a clinical assessment of patients with suspected epilepsy i.Take a seizure history ii. Take a neuropsychiatric history focusing on eliciting impact of seizuredisorder on the patient iii.Take a history from an informant iv. Perform a neurological examination on patients with suspected epilepsy v.Construct a formulation with differential diagnoses for the seizure type andsyndrome, along with discussion of aetiology 2. Assess patients suspected of having non epileptic seizures (NEAD) i.Be familiar with the main features differentiating epilepsy and NEAD ii. Be familiar with the co-existence of epilepsy and NEAD iii.Be familiar with the management of NEAD 3. Undertake investigation of patients with suspected epilepsy i.Be familiar with EEG recording and interpretation (including the limitations)in people with epilepsy ii. Be familiar with the indications for and interpretation of structural andfunctional neuroimaging in people with epilepsy 4. Prescribe treatment to patients with coexisting neurological disorder i.Be familiar with social and psychological interventions for the treatment ofepilepsy including relaxation techniques and other behavioural methods ofcontrolling/ inhibiting seizures ii. Be familiar with the principles of the medical treatment of the differentseizure and syndrome types 13. Draft Horacio Page 1318/10/2010iii.Be familiar with potential drug interactions between psychiatric medicationsand anticonvulsants iv. Be aware of the risks associated with prescribing psychotropic agents topatients with epilepsy v.Be familiar with the surgical treatment of epilepsy including vagal nervestimulation 5. Assess and manage special patient groups with epilepsy i.Be familiar with the difficulties in assessing and managing seizure disordersin children and adolescents with epilepsy, including issues around puberty ii. Be familiar with the difficulties in assessing and managing seizure disordersin women with epilepsy, including catamenial epilepsy, contraception,pregnancy, teratogenicity, polycystic ovarian syndrome, menopause iii.Be familiar with the difficulties in assessing and managing seizure disordersin older age patients, including cognition and issues regarding concomitantphysical illnesses and medication iv. Be familiar with the difficulties in assessing and managing seizure disordersin patients with learning disability including aetiology, difficulty eliciting ahistory, cognitive and treatment issues6. Assess and manage psychiatric co-morbidity in people with epilepsy: pre-ictal, ictal, post-ictal, interictal and iatrogenic i.Be familiar with the diagnosis and management of depression in people withepilepsy including the risk of suicide ii. Be familiar with the diagnosis and management of anxiety/panic attacks inpeople with epilepsy, including the difficulties in differentiating betweenpanic attacks and ictal panic iii.Be familiar with the diagnosis and management of psychosis (post-ictalpsychosis, chronic interictal psychosis and forced normalisation) in peoplewith epilepsy iv. Be familiar with the diagnosis and management of cognitive dysfunction inpeople with epilepsy, resulting from seizures and anticonvulsant medication,including the role of neuropsychological assessments 14. Draft Horacio Page 14 18/10/2010 v.Be familiar with the diagnosis and management of sexual dysfunction inpeople with epilepsy vi. Be familiar with the diagnosis and management of disorders of impulsecontrol (anger/irritability, drug/alcohol problems) in people with epilepsy vii.Be familiar with quality of life issues in people with epilepsy, such as stigma,locus of control, employment/relationship difficulties.7. Be aware of the issues involved in the medico-legal aspects of epilepsy i.Be aware of the driving license implications of having epilepsy ii. Be familiar with the concept of automatisms when used as a defence in court.8. Liaison with Epilepsy Surgery Program:In centres affiliated with Epilepsy Surgery programs, the trainee should becomefamiliar with the psychiatric issues involved in the assessment of candidates forepilepsy surgery, and be able to provide pre-operative consultations and post-operative follow-up to such patients. B. How taught / clinical settingsC. How assessed 15. Draft HoracioPage 1518/10/2010 Module 2.3 Movement DisordersSpecific Competenciesi. Clinical assessment 1) Take a history of movement disorder 2) Assess psychiatric history 3) Assess neurological history 4) Perform psychiatric examination 5) Perform neurological examination 6) Construct differential diagnosis of movement disorderii. Investigation 1) Review previous neurological examinations 2) Review previous neurological treatment 3) Review previous psychiatric treatment 4) Order further relevant investigationsiii. Treatment 1) Review previous psychiatric treatment 2) Review previous neurological treatment 3) Recommend alterations to current treatment 4) Prescribe new appropriate treatment 5) Review effects of treatmentSuggested learning methods 1) Attend movement disorders clinic 2) Discuss neurological treatment of movement disorders with neurologistSuggested assessment method clinic logbook 1) Parkinsons disease 2) Tourettes syndrome tics 3) Tremor 4) Dystonia 5) Catatonia 6) Neuroleptic induced movement disorders tardive dyskinesia, tardive dystonia, akathisia, NMS, drug-induced parkinsonism, etc. 7) Hysterical conversion/somatisation disorders 16. Draft HoracioPage 16 18/10/2010 Module 2.4 Traumatic Brain injuryClinical settings: i. Emergency services, with patient presenting with psychiatric disturbancefollowing head injury ii. Medical or surgical ward, involving patients with neuropsychiatric disturbancefollowing head injury iii. Outpatient clinics iv. Neurorehabilitation settings v. Medicolegal settingsSpecific competencies: i. To take a competent trauma history, including the assessment of PTA, administration of GCS, etc.ii. To assess psychiatric morbidity related to head injuryiii. To assess the relative contributions of brain injury, post-traumatic epilepsy, physical disability, personality, psychosocial and medicolegal factors contributing to neuropsychiatric presentationsiv. To be able to assess cognitive disturbances following head injury, including the interpretation of neuropsychological assessmentsv. To be able to manage neuropsychiatric disturbances in head injured patients using drug treatment, cognitive and behavioural interventions. Suggested learning methods: i. Participate in emergency, medical and surgical consultations with supervisorii. Assess patients in outpatient clinics and follow-up these patientsiii. Attend rehabilitation rounds and participate in consultations. 17. Draft HoracioPage 1718/10/2010 Module 2.5 Secondary psychiatric syndromes and deliriumClinical settings:i. Psychiatric wards ii. Neuropsychiatric outpatient clinics iii. Medical and surgical wardsSpecific competencies:i. Familiarity with common presentations of delirium and secondary psychiatricsyndromes, including secondary delusional disorder, secondary hallucinosis,secondary depression or mania, secondary anxiety disorder, secondary OCD, andorganic personality disorders. ii. Knowledge of the common causes of these syndromes iii. Competency in the investigation of the aetiology of secondary syndromes, and theinterpretation of the results of the investigations. iv. Experience in the treatment of such syndromes, including the use of psychotropicand neurotherapeutic drugs. v. Knowledge of the pathophysiological mechanisms underlying the development ofsecondary syndromes.Suggested learning methods:i. Review of published material ii.Neuropsychiatric clinic attendance iii. Consultations on psychiatric, medical and surgical wards iv.Case discussions 18. Draft Horacio Page 18 18/10/2010 Module 2.6Substance-induced neuropsychiatric psychiatric syndromesClinical settings:i. Drug-dependence clinic ii.Psychiatric wards iii. Neuropsychiatric outpatient clinics iv.Medical and surgical wardsSpecific competencies:i. Familiarity with common presentations of alcohol and substance relatedneuropsychiatric syndromes ii. Competency in the investigation of these syndromes, including biological andpsychosocial investigations iii. Experience in the treatment of such syndromes, including the use of psychotropicdrugs and psychosocial and rehabilitative interventions iv. Knowledge of the pathophysiological mechanisms underlying the development ofthese syndromes.Suggested learning methods:i. Review of published material ii.Clinic attendance iii. Consultations on psychiatric, medical and surgical wards iv.Case discussions 19. Draft HoracioPage 1918/10/2010 Module 2.7 Attentional and dysexecutive syndromes (including Adult ADHD)Clinical settings: i. Specialised Adult ADHD Clinicii. Psychiatric wardsiii. Neuropsychiatric outpatient clinicsSpecific competencies: i. Familiarity with common presentations of ADHD in adultsii. Competency in the investigation of attentional and frontal dysexecutive syndromes, including biological and psychosocial investigationsiii. Experience in the treatment of such syndromes, including the use of psychotropic drugs and psychosocial and rehabilitative interventionsiv. Knowledge of the pathophysiological mechanisms underlying the development of these syndromes.Suggested learning methods:i. Review of published material ii.Clinic attendance iii. Consultations on psychiatric, medical and surgical wards iv.Case discussions 20. Draft HoracioPage 2018/10/2010 MODULE 2.8 - GENERAL HOSPITAL LIAISON NEUROPSYCHIATRYKey competencies.1. Undertake assessment of patients with unexplained neurological symptoms i)Take an appropriate neuropsychiatric historyii) Interpret previously performed investigationsiii)Perform examination of mental and physical statusiv) Assess the patients function in the context of their disabilityv)Understand the concepts of conversion, somatisation and dissociation in aneurological context.vi) Formulate appropriate management plansvii)Communicate information to the neurological teamLearning and assessment methods;1i Take an appropriate neuropsychiatric history (see other sections)1ii Interpret previously performed investigations Suggested learning methods Suggested assessment methods Observation/modellingValidated self-assessment Supervised clinical practice Clinical Supervision Specific teaching from relevant health Case presentation professionals (e.g. radiologist)1iii Perform examination of physical and mental status (see other sections)1iv Assess patients function in the context of their disability Suggested learning methodsSuggested assessment methods Observation/modelling Validated self-assessment Supervised clinical practiceClinical supervision Specific teaching from relevant healthClinical log-book professionals (e.g. occupational therapist) Case presentation1v Understand the concepts of conversion, somatisation and dissociation Suggested learning methods Suggested assessment methods Supervised clinical practice Clinical supervision Reading relevant texts Clinical log book Peer group discussionCase presentation1vi Formulate appropriate management plans (see other sections)1vii Communicate information to neurology team Suggested learning methods Suggested assessment methods Obervation/modelling Clinical supervision 21. Draft HoracioPage 21 18/10/2010 Supervised clinical practiceDirect observation 2) Undertake assessment of patients with delirium. i)Take a relevant clinical history from patient and informantsii) Gather information from clinical staffiii)Perform examination of physical and mental statusiv) Construct an appropriate differential diagnosis (delirium vs. depression vs.dementia)v)Perform investigation to ascertain aetiologyvi) Initiate and monitor treatment where appropriateLearning and assessment methods 2i Take a relevant clinical history from patients and informants (see other sections) 2ii Gather information form clinical staffSuggested learning methods Suggested assessment methodsObservation/modellingClinical supervisionSupervised clinical practice Direct observationWorking as a team member 2iii Perform examination of physical and mental status (see other sections) 2iv Construct an appropriate differential diagnosis (e.g. delirium vs. depression vs.dementia)Suggested learning methods Suggested assessment methodsSupervised clinical practice Clinical supervisionAppropriate readingCase presentation Clinical log book Validated self-assessment 2v Perform investigation to ascertain aetiologySuggested learning methods Suggested assessment methodsSupervised clinical practice Clinical supervisionAppropriate readingCase presentationSpecific teaching from other healthClinical log bookprofessionalsValidated self-assessment2vi Initiate and monitor treatment where appropriate (see other sections) 22. Draft HoracioPage 22 18/10/2010 MODULE 2.9 : DEVELOPMENTAL NEUROPSYCHIATRYPreamble:Developmental neuropsychiatry is that branch of psychiatry concerned with the diagnosis and management of emotional, behavioural and learning disorders that are associated with demonstrable or suspected organic brain dysfunction, and which manifest during childhood. Because these disorders are primarily disruptive to normal developmental attainments or adjustment, they are known as neurodevelopmental disorders. The practice of developmental neuropsychiatry requires skills and knowledge that encompass not only child psychiatry, in broad terms, but also paediatric neurology and learning disabilities.Currently, there is no formal training programme leading to a specific accreditation in developmental neuropsychiatry. In this respect, the sub-specialty is in the same category as adult neuropsychiatry. Few child psychiatric training programmes explicitly include training in developmental neuropsychiatry. However, it is arguable that within the clinical field of child psychiatry, neurodevelopmental disorders are now the predominant reason for specialist referral.The competencies outlined below describe the minimum range of skills in developmental neuropsychiatry that ought to be acquired by consultant child psychiatrists in training. We recommend that all trainees have at least one year of experience in this specialty, but that those who intend to become specialists in this area may choose to spend additional time gaining particular skills. Skills in developmental neuropsychiatrySpecific competencies: 1. Undertake clinical assessment of patients with apparent neurodevelopmental disorders, a. Take a developmental neuropsychiatric history b. Perform a neurobehavioural assessment c. Arrange for, and interpret a neurocognitive examination d. Perform a neurological examination, and interpret signs e. Construct a neurodevelopmental differential diagnosis 2. Undertake investigation of patients with apparent developmental neuropsychiatric disordersa. Be familiar with relevant haematological and metabolic investigationsb. Be familiar with EEG recording and interpretationc. Be familiar with indications for and interpretation of structural neuroimaging 23. Draft Horacio Page 2318/10/20103. Prescribe treatment to patients on basis of clinical assessmenta. Be familiar with the evidence for the effectiveness of specificpharmacological treatments of common neurodevelopmental disordersb. Be familiar with the constraints on prescribing psychotropic medicationsto children, the indications, approval status and potential side effectsc. Be familiar with the need to undertake appropriate investigations beforeprescription, and the need for monitoring of treatments prescribed, in orderto minimise side-effects and complications.d. Be familiar with indications for non-medical treatments including:behavioural management techniques, educational interventions, skills-training (e.g. motor, social, speech and language). 1a. Taking a developmental neuropsychiatric history: Suggested learning methods Suggested assessment methods Observation/modelling Validated self assessment Working as a team member In-training assessment Supervised clinical practice Clinical supervision Focused training courses Direct observation of clinical work Peer review Clinical logbook Clinical audit Case presentations Review of case notes and other records Chart-stimulated recall 24. Draft Horacio Page 2418/10/2010 3) Work collaboratively with neuroscience colleagues i)Obtain relevant information about patients behaviour from neuroscience staffii) Advise neuroscience ward staff about interpretation and management ofabnormal mental states and behavioursiii)Work collaboratively with neuroscience clinicians to establish correctdiagnoses and treatment plansiv) Develop academic links within the neuroscience communityLearning and assessment methods3i Obtain relevant information about patients behaviour from neuroscience staff Suggested learning methodsSuggested assessment methods Observation/modelling Clinical supervision Supervised clinical practiceDirect observation3ii Advise staff about the interpretation and management of abnormal mental states and behaviours Suggested learning methodsSuggested assessment methods Observation/modelling Clinical supervision Supervised clinical practiceDirect observation3iii Work collaboratively with neuroscience colleagues to establish correct diagnosis and treatment plans Suggested learning methodsSuggested assessment methods Observation/modelling Clinical supervision Supervised clinical practiceDirect observation3iv Develop academic links with the neuroscience community Suggested learning methodsSuggested assessment methods Observation/modelling Clinical supervision Supervised clinical practiceCase presentation 4) Assess critically ill patients in a neuroscience setting i)Assess the mental states of patients who are in the post-operative period or ina neuro critical care settingii) Produce a differential diagnosis and formulation for patients with mentaldisorder in this settingiii)Make assessments of capacity in critically ill patientsiv) Advise on the management of disturbed behaviour in critically ill patients 25. Draft Horacio Page 2518/10/2010 Learning and assessment methods4i Assess mental states of patients who are in the post operative period or in a neuro critical care setting Suggested learning methods Suggested assessment methods Observation/modellingClinical supervision Working as a team member Direct observation Supervised clinical practice Clinical logbookCase presentation4ii Produce a differential and formulation for patients with mental disorder in this setting Suggested learning methods Suggested assessment methods Supervised clinical practice Clinical supervision Appropriate readingCase presentationClinical logbook4iii Make assessments of capacity in critically ill patients Suggested learning methods Suggested assessment methods Supervised clinical practice Clinical supervision Observation/modellingCase presentation4iv Advise on management of disturbed behaviour in critically ill patients Suggested learning methods Suggested assessment methods Supervised clinical practice Direct observation Observation/modellingClinical supervision Working as a team member 26. Draft Horacio Page 2618/10/2010 MODULE 2.10 - SLEEP DISORDERSCore competencies in assessment & management of patients with sleep disorders 1. Specific CompetenciesHave knowledge of aetiology, prevalence, diagnosis, categorisation and treatment ofsleep disorders:i. Primary insomniaii. Secondary insomniaiii. Hypersomniasiv. Parasomniasv. Neuropsychiatric consequences of sleep apnoea syndrome 2. Diagnostic techniques i. Take an appropriate history relevant to sleep problems.ii.Perform appropriate examination of mental, neurological and physical status.iii. Be able to relate history and clinical findings to relevant medical, neurological,psychological and social issues associated with aetiology and treatment.iv. Have knowledge of use, reliability and validity of generally accepted techniquesand investigations for diagnostic assessment and the interpretation of results.v. Have a basic understanding of the EEG, polysomnogram, oximetry and actigraphyvi. Understand the major theories of sleep mechanisms.vii. Have competence to form differential diagnosis and to diagnose medical,neurological and psychiatric sleep disorders and those sleep problems associated withmedical, psychiatric and neurological conditionsviii. Understand the biological, psychological, social, economic factors that influenceevaluation and management of sleep disorders 3. Management i. Formulate appropriate management plans.ii. Be familiar with therapies used (behaviour therapy, psychotherapy, drug treatmentand physical treatments such as CPAP).iii. Have competence of being aware when to refer to a sleep disorders clinic.iv. Have basic knowledge relating to ethical and legal aspects of sleep medicineSuggested learning methods1. Observation/modelling2. Supervised clinical practice3. Reading relevant texts4. Peer group discussion5. Multidisciplinary case conferences, journal clubs6. Specific teaching from relevant health professionals (e.g. EEG, respiratory, neurology) 27. Draft Horacio Page 2718/10/20107. Primary responsibility for diagnosis and treatment of reasonable number and adequate variety of patients with acute and chronic sleep disorders (eg at least 5 hypersomnia, 5 parasomnia, 10 insomnia, of range of ages)8. Attendance at respiratory sleep disorder clinic for the diagnosis of sleep apnoea9. Attendance at multidisciplinary national conferencesSuggested assessment methods1. Validated self-assessment2. Clinical supervision and feedback3. Case presentation4. Clinical Log book 28. Draft HoracioPage 2818/10/2010 MODULE 2.11 - REHABILITATION NEUROPSYCHIATRY.Clinical settingsRehabilitation Units providing neurophysical rehabilitation; District and/orRegional Rehabilitation Units.Neuropsychiatric/Cognitive Behavioural Rehabilitation Units for people withbrain injury.Neuropsychiatry / Liaison psychiatry services to Clinical Neurosciences Centres,General District Hospitals, and nursing homes and other residential units.Neuropsychiatry / liaison psychiatry outpatient clinics.Knowledgeof the pathophysiology of common causes of acquired brain injury.of brain - behaviour relationships, in particular following acquired focal lesions tothe brain and diffuse brain injury.of the neuropsychiatric sequelae of acquired brain injury, including aetiology andmanagement of symptoms.of the principles of cognitive behaviour therapy and behaviour therapy forbehavioural problems and other symptoms following brain injuryof the ICIDH model of impairment, disability and handicap (impairment,activities and participation).of outcome measures suitable for patients with acquired brain injury.of Rehabilitation Service provision, organisation and funding, including voluntarysector provision.Skillsto undertake an assessment to understand the role of brain injury inneuropsychiatric symptom formation.to assess the role of psychological processes and mental illness in symptomformation after acquired brain injury.to use pharmacotherapy to manage neuropsychiatric symptoms after acquiredbrain injury. 29. Draft HoracioPage 29 18/10/2010 to work with the multidisciplinary team (MDT), including psychologists and othertherapists, to produce an overall treatment strategy for symptoms. to interpret neuropsychometric test results sufficiently to produce aneuropsychiatric formulation to set up, in collaboration with the MDT, a programme of therapy based on goalplanning. to work alongside psychologists, behavioural nurse therapists and others toimplement cognitive behavioural treatments and behavioural treatments. to set up effective aftercare following inpatient rehabilitation, based on goodcommunication across health services, social services, statutory services andvoluntary sector. to undertake a risk assessment for all commonly occurring risks followingacquired brain injury, and ensure that there are procedures in place to offer areasonable risk management strategy. to understand the symptoms and signs of the post concussion syndrome andprovide advice to patients following a brain injury to minimise the risk ofproblems on returning to work, and/or return to living in the community withfamily and / or carers. to appreciate the psycho-dynamic processes that follow brain injury and otherforms of disability, and provide appropriate psychotherapeutic support. to manage the common sequelae of brain injury, including disturbances of mood,psychotic disorders, personality change (especially associated with antisocialbehaviour), reduced initiation and motivation.Learning and assessment methods. attending neuropsychiatric clinics, liaison assessments in rehabilitation units,general hospitals etc. attachment to rehabilitation unit attending management rounds/ward rounds. attending postgraduate teaching programmes / conferences on neuropsychiatry /brain injury specific attachments to rehabilitation neuropsychologists and therapists. assessment methods:- self-assessment, clinical supervision and case presentationand clinical log book. 30. Draft HoracioPage 3018/10/2010Module 2.12 FORENSIC NEUROPSYCHIATRYKey competencies: i. Knowledge of organic basis of violence, antisocial and criminal behaviourii. Competence in the clinical assessment of individuals with violent or criminal behaviour, from both biological and psychosocial perspectivesiii. Ability to intervene in the management of such behaviour from a neuropsychiatric perspective, including drug management and psychosocial interventionsiv. Awareness of the ethical and medicolegal aspects of such disordersv. Ability to write an expert report for the court or other forensic settings. Learning and assessment methods:i. Attending neuropsychiatric clinics in a forensic settingii. Assessing patients referred for forensic reportsiii. Preparation of reports under supervisioniv. Attending court proceedings when medicolegal evidence presented 31. Draft HoracioPage 3118/10/2010RECOMMENDED READINGNeuropsychiatry textbooksi.Yudofsky SC, Hales RE: Textbook of Neuropsychiatry and Clinical Neurosciences, 4th Edition. American Psychiatric Publishing Washington DC, 2002 ii. Lishman WA. Organic Psychiatry. 3rd Edition. Oxford: Blackwell Scientific.1998. iii.Cummings JL, Mega MS: Neuropsychiatry and Behavioral Neuroscience. Oxford University Press, Oxford, 2003 iv. Schiffer RB, Rao SM, Fogel BS: Neuropsychiatry: A Comprehensive Textbook, 2nd Edition. Lippincott Williams & Wilkins, Baltimore, 2003v.Coffey CE, Brumback RA: Textbook of Pediatric Neuropsychiatry. American Psychiatric Publishing, Washington DC, 1998 vi. Coffey CE, Cummings JL: Textbook of Geriatric Neuropsychiatry. American Psychiatric Publishing, Washington DC, 2000 vii.Arciniegas D, Beresford TP: Neuropsychiatry: An Introductory Approach. Cambridge University Press, Cambridge, 2001, pp. 3-12Behavioural Neurology:1. Mesulam M-Marsel: Principles of Behavioral and Cognitive Neurology, 2nd Edition. OxfordUniversity Press, Oxford, 2002.2. Pincus JH and Tucker GJ. Behavioral Neurology, 4th Edition. Oxford University Press,Oxford, 20033. Feinberg TE, Farah MJ: Behavioral Neurology and Neuropsychology. McGraw-Hill, NewYork, 1997.4. Kirshner HS: Behavioral Neurology: Practical Science of Mind and Brain. Butterworth-Heinemann, Boston, 20025. Leon-Carrion J, Giannini MJ: Behavioral neurology in the elderly. CRC Press, Boca Raton,20016. Strub RL, Black FW: Neurobehavioral Disorders: A Clinical Approach. FA Davis Company,Philadelphia, 1988Cummings JL, Trimble MR: Concise guide to neuropsychiatry andbehavioral neurology. Washington DC, American Psychiatric Publishing, 20027. Trimble MR, Cummings JL: Contemporary Behavioral Neurology. Butterworth-Heinemann,Boston, 1997 32. Draft HoracioPage 32 18/10/20108. Cummings JL, Trimble MR: Concise Guide to Neuropsychiatry and Behavioral Neurology,2nd Edition. American Psychiatric Publishing, Washington DC, 2002.Neuropsychology i.Lezak MD. Neuropsychological Assessment. New York: Oxford University Press. 1983. ii. Walsh K. Neuropsychology: a Clinical Approach. 3rd Edition. Edinburgh: Churchill Livingstone. 1994. Neuroimaging Neuroscience i.Kendel ER et al. Principles of Neural Sciences. New York: Elsevier. 2000. ii. Bloom F et al. Fundamentals of Neuroscience. Academic Press. 1998.General neuropsychiatric education1. Sachdev P. Neuropsychiatry a discipline for the future (Editorial). J PsychosomRes 2002;53(2):625-627.2. Sachdev P. Whither Neuropsychiatry? J Neuropsychiatry Clin Neuroscience 2005;3. Price BH, Adams RD, Coyle JT. Neurology and psychiatry: closing the great divide.Neurology 2000, 54:8-14.4. ANPA Standards for Fellowship Training in Neuropsychiatry. I. Definition ofNeuropsychiatry, 2001. http://www.neuropsychiatry.com/ANPA5. Accreditation Council on Graduate Medical Education: Program Requirements for Trainingin Psychiatry, 2001. http://www.acgme.org/RRC/Psy_Req2.asp6. Accreditation Council on Graduate Medical Education: Program Requirements for Trainingin Neurology, 2002. http://www.acgme.org/RRC/Psy_Req2.asp7. American Board of Psychiatry and Neurology, Inc.: Information for Applicants forCertification in the Subspecialties of Addiction Psychiatry, Clinical Neurophysiology,Forensic Psychiatry, Geriatric Psychiatry, and Neurodevelopmental Disabilities, 2003. http://www.abpn.com/Downloads/2003subspec_ifa.pdf8. Academy of Psychosomatic Medicine: Standards for Fellowship Training in Consultation-Liaison Psychiatry, 1998. http://www.apm.org/fellow.html JOURNALS 33. Draft HoracioPage 3318/10/2010 Journal of Neurology, Neurosurgery and Psychiatry Journal of Neuropsychiatry and Clinical Neuroscience. Neuropsychiatric Disorders and Treatment Trends in Neuroscience Neuropsychiatry, Neuropsychology and Behavioural Neurology. Nature Reviews Neuroscience Nature Neuroscience Lancet Neurology Biological Psychiatry Neurology Archives of Neurology Archives of General Psychiatry Journal of Clinical Psychiatry Acta Psychiatrica Scandinavica Acta Neurologica Scandinavica Acta Neuropsychiatrica British Journal of Psychiatry American Journal of Psychiatry Australian and New Zealand Journal of Psychiatry Nature Science British Medical Journal New England Journal of Medicine