Gambler 101

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I'm looking for some advice. I just spent a month on C/L Psych, and I realized my favorite cases usually involved Neurology (brain tumors, seizures, loss of consciousness, Parkinson's, MS, etc). I also have an interest in DBS research and programming DBS devices. I'm concerned I won't be able to accomplish this with a psychiatry residency. Are the combined programs still in existence? How proficient would I be in these areas if I completed the neuropsych fellowship? Should I just do a neurology residency? I don't really care for stroke, migraine, or other neurology basics...


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SmallBird

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May 3, 2010
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I'm looking for some advice. I just spent a month on C/L Psych, and I realized my favorite cases usually involved Neurology (brain tumors, seizures, loss of consciousness, Parkinson's, MS, etc). I also have an interest in DBS research and programming DBS devices. I'm concerned I won't be able to accomplish this with a psychiatry residency. Are the combined programs still in existence? How proficient would I be in these areas if I completed the neuropsych fellowship? Should I just do a neurology residency? I don't really care for stroke, migraine, or other neurology basics...


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If your interested in programming DBS devices for Parkinson's you would need to do neurology. It's also not clear what interested you about those cases. If you found most aspects brain tumors, seizures, MS and Parkinson's interesting that is a big enough chunk of neurology that you could probably survive doing stroke during residency.
 
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Gambler 101

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I should specify. I'm interested in programming DBS devices for depression, OCD, and schizophrenia (now in human trials)


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Blitz2006

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Nov 20, 2006
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I'm looking for some advice. I just spent a month on C/L Psych, and I realized my favorite cases usually involved Neurology (brain tumors, seizures, loss of consciousness, Parkinson's, MS, etc). I also have an interest in DBS research and programming DBS devices. I'm concerned I won't be able to accomplish this with a psychiatry residency. Are the combined programs still in existence? How proficient would I be in these areas if I completed the neuropsych fellowship? Should I just do a neurology residency? I don't really care for stroke, migraine, or other neurology basics...


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I am exactly like you.

I went into Psychiatry...to do Neuropsychiatry. I also LOVE psychopharma/pharm, which I felt lacked in Neurology (IMHO). This is why I chose Psych over Neuro.

Neuropsych fellowship is relatively new, 2003 I believe. Rapidly expanding and hot.

https://www.ucns.org/apps/directory/index.cfm?event=public.program.searchResults&subspecialty_ids=1&inst_state=&submit=Start+Search

I think there are around 30 fellowships now, all NON-ACGME accredited. I even went to the ANPA Annual Conference this year in San Diego to pursue this avenue.

However, a couple realizations:

1) Neuropsychiatry is an extremely research based sub-specialty. I am more clinical. Many of the fellowships are research based, which does not suit me.

2) From my understanding, it is not really necessary to do a fellowship in Neuropsych in order to practice Neuropsychiatry. I'm sure it helps, but its not really a requirement, unless you want to be a Neuropsychiatrist at MGH/Hopkins. Even then, I'm not sure

3) I really have a strong interest in Brain Stimulation, like yourself, DBS, ECT, rTMS, VNS, etc. But you dont need to do a fellowship to be involved in brain stimulation.


Splik is a guru on neuropsych, so I'm sure more info will be provided/clarified.
 
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Blitz2006

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Haha, yeah I just realized when I checked it over! Thanks, I edited it. I always thought she was a Psychiatrist! So I guess Neurology might be the way to go for DBS.
 

splik

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I'm looking for some advice. I just spent a month on C/L Psych, and I realized my favorite cases usually involved Neurology (brain tumors, seizures, loss of consciousness, Parkinson's, MS, etc). I also have an interest in DBS research and programming DBS devices. I'm concerned I won't be able to accomplish this with a psychiatry residency. Are the combined programs still in existence? How proficient would I be in these areas if I completed the neuropsych fellowship? Should I just do a neurology residency? I don't really care for stroke, migraine, or other neurology basics...
There are dual neurology/psychiatry programs some of which exist on a fluctuating basis but check out MUSC, Brown, NYU, Tulane, and UMass. It was unclear to me whether you are interested in treating neurological diseases (in which case you would need to train as a neurologist, not a psychiatrist) or if you were interested in the psychiatric aspects of neurology (in which case you could train as either a neurologist or psychiatrist).

If you are interested in the interface of neurology and psychiatry, then it is astounding that you are not interested in stroke or migraine! I am sure admitted strokes every 4th night would be quite tedious, stroke teaches us so much about brain-behavior correlates, the cerebral basis or mental disease, and creates some fascinating behavioral neurological symptoms. Strokes can result in depression, mania (usually right sided), and pseudobulbar affect. Strokes can lead to some of the most fascinating delusional syndromes including delusions of misidentification (chiefly the Capgras syndrome believed to result from disruption of the circuits between the fusiform facial gyrus and the amygala diminishing emotional response to faces and leading to the belief that an "imposter" has replaced loved ones), delusions of jealousy, erotomanic delusions, and delusions of infestation. Posterior circulation strokes can lead to peduncular hallucinations (vivid visual hallucinations that can be quite fantastical). I have seen patients develop obsessive compulsive disorder following strokes affecting the orbitofrontal cortex. Then there are the plethora of behavioral neurological syndromes that result from strokes including agnosias (including propasagnosia [inability to recognize faces], anosagnosia [inability to recognize deficits leading patients to behave as if they were normal], simultanagonsia[inability to see both parts and the whole]), apraxias, aphasias, aprosodia, amnesias. Posterior strokes can lead to Balint syndrome which is characterized by optic ataxia, optic ataxia, oculomotor apraxia and simultanagnosia. Whereas dominant parietal lobe lesions may lead to Gerstmann's syndrome which is characterized by dysgraphia, dyscalculia, finger agnosia, and left-right disorientation.

Then there are other rarities associated with strokes including foreign accent syndrome and the extremely rare le fou rire prodromique (uncontrollable fits of laughter that precede a catastrophic brainstem stroke/vascular event).

As for migraines, again they are simply fascinating neuropsychiatric occurrences! Migraine is in the differential diagnosis for psychosis, particularly of sudden onset. Persecutory delusions have been associated with the CACNL1A4 mutation which is a channelopathy cause of familial hemiplegic migraine. Distortions of time and space and sensory phenomena are quite classic of migraine. I have had patients describe distortions of the time-space continuum, or feel themselves completely disconnected from the universe during migraines. Oliver Sacks wrote about his amusia during migraines (i.e. the loss of sense of pitch and tone and inability to recognize familiar music). Olfacatory, visual, auditory hallucinations, illusions, synesthesia can all occur in migraine. There are even cases of foreign accent syndrome occuring with migraine; in one case an english woman woke up sounding chinese! Migraines are eminently treatable and so it is very satisfying to make such a diagnosis in someone with more worrisome symptoms like delusions, hallucinations, blindness, hemiplegia etc.

a neuropsychiatry fellowship would give you absolutely no training in managing neurological diseases with the exception of the dementias.

As for DBS, it is not widely used in psychiatry because it is largely ineffective and insurance companies balk at paying for it in young people who will need the stimulator replaced several times. As you may be aware the last DBS depression trial (the BROADEN trial) was terminated by St Jude's Medical because it fared poorly on futility analysis. Currently OCD is the only psychiatric indication for DBS clinically, and that is not based on evidence, but a humanitarian device exception from the FDA because some cases of OCD are so catastrophic that patients (or their families) are desperate for surgery and DBS is by far the least worst surgical option. You could probably learn this during psychiatry residency if you worked with people who were doing this work or where they were clinically using DBS for OCD (I worked with a psychiatrist who did DBS programming when I was a resident). You could also do the interventional psychiatry fellowship at MUSC. I think Mt Sinai does a fair bit of research in this area too. I believe mayo has a brain stimulation fellowship they might be open to taking a psychiatrist. Personally, I think the main reason it's interesting doing this work is because of the fascinating treatment-refractory patients you evaluate and thinking through the management. your job as the psychiatrist is still primarily evaluation - there is nothing particularly fancy about fiddling with a DBS programming device though it is kinda cool at first the novelty wears off as with everything, and while it can sometimes be helpful the results are not typically dramatic (unlike in some movement disorders or epilepsy cases).

(patients with simultagnosia would see the T but not the H)
 
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Gambler 101

7+ Year Member
Dec 31, 2011
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Medical Student
There are dual neurology/psychiatry programs some of which exist on a fluctuating basis but check out MUSC, Brown, NYU, Tulane, and UMass. It was unclear to me whether you are interested in treating neurological diseases (in which case you would need to train as a neurologist, not a psychiatrist) or if you were interested in the psychiatric aspects of neurology (in which case you could train as either a neurologist or psychiatrist).

If you are interested in the interface of neurology and psychiatry, then it is astounding that you are not interested in stroke or migraine! I am sure admitted strokes every 4th night would be quite tedious, stroke teaches us so much about brain-behavior correlates, the cerebral basis or mental disease, and creates some fascinating behavioral neurological symptoms. Strokes can result in depression, mania (usually right sided), and pseudobulbar affect. Strokes can lead to some of the most fascinating delusional syndromes including delusions of misidentification (chiefly the Capgras syndrome believed to result from disruption of the circuits between the fusiform facial gyrus and the amygala diminishing emotional response to faces and leading to the belief that an "imposter" has replaced loved ones), delusions of jealousy, erotomanic delusions, and delusions of infestation. Posterior circulation strokes can lead to peduncular hallucinations (vivid visual hallucinations that can be quite fantastical). I have seen patients develop obsessive compulsive disorder following strokes affecting the orbitofrontal cortex. Then there are the plethora of behavioral neurological syndromes that result from strokes including agnosias (including propasagnosia [inability to recognize faces], anosagnosia [inability to recognize deficits leading patients to behave as if they were normal], simultanagonsia[inability to see both parts and the whole]), apraxias, aphasias, aprosodia, amnesias. Posterior strokes can lead to Balint syndrome which is characterized by optic ataxia, optic ataxia, oculomotor apraxia and simultanagnosia. Whereas dominant parietal lobe lesions may lead to Gerstmann's syndrome which is characterized by dysgraphia, dyscalculia, finger agnosia, and left-right disorientation.

Then there are other rarities associated with strokes including foreign accent syndrome and the extremely rare le fou rire prodromique (uncontrollable fits of laughter that precede a catastrophic brainstem stroke/vascular event).

As for migraines, again they are simply fascinating neuropsychiatric occurrences! Migraine is in the differential diagnosis for psychosis, particularly of sudden onset. Persecutory delusions have been associated with the CACNL1A4 mutation which is a channelopathy cause of familial hemiplegic migraine. Distortions of time and space and sensory phenomena are quite classic of migraine. I have had patients describe distortions of the time-space continuum, or feel themselves completely disconnected from the universe during migraines. Oliver Sacks wrote about his amusia during migraines (i.e. the loss of sense of pitch and tone and inability to recognize familiar music). Olfacatory, visual, auditory hallucinations, illusions, synesthesia can all occur in migraine. There are even cases of foreign accent syndrome occuring with migraine; in one case an english woman woke up sounding chinese! Migraines are eminently treatable and so it is very satisfying to make such a diagnosis in someone with more worrisome symptoms like delusions, hallucinations, blindness, hemiplegia etc.

a neuropsychiatry fellowship would give you absolutely no training in managing neurological diseases with the exception of the dementias.

As for DBS, it is not widely used in psychiatry because it is largely ineffective and insurance companies balk at paying for it in young people who will need the stimulator replaced several times. As you may be aware the last DBS depression trial (the BROADEN trial) was terminated by St Jude's Medical because it fared poorly on futility analysis. Currently OCD is the only psychiatric indication for DBS clinically, and that is not based on evidence, but a humanitarian device exception from the FDA because some cases of OCD are so catastrophic that patients (or their families) are desperate for surgery and DBS is by far the least worst surgical option. You could probably learn this during psychiatry residency if you worked with people who were doing this work or where they were clinically using DBS for OCD (I worked with a psychiatrist who did DBS programming when I was a resident). You could also do the interventional psychiatry fellowship at MUSC. I think Mt Sinai does a fair bit of research in this area too. I believe mayo has a brain stimulation fellowship they might be open to taking a psychiatrist. Personally, I think the main reason it's interesting doing this work is because of the fascinating treatment-refractory patients you evaluate and thinking through the management. your job as the psychiatrist is still primarily evaluation - there is nothing particularly fancy about fiddling with a DBS programming device though it is kinda cool at first the novelty wears off as with everything, and while it can sometimes be helpful the results are not typically dramatic (unlike in some movement disorders or epilepsy cases).

(patients with simultagnosia would see the T but not the H)
I don't think I gave neurology a fair shake. Maybe I should do an extra rotation in Neurology before I enter the application cycle. Thank you so much!


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clausewitz2

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Oct 13, 2008
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There are dual neurology/psychiatry programs some of which exist on a fluctuating basis but check out MUSC, Brown, NYU, Tulane, and UMass. It was unclear to me whether you are interested in treating neurological diseases (in which case you would need to train as a neurologist, not a psychiatrist) or if you were interested in the psychiatric aspects of neurology (in which case you could train as either a neurologist or psychiatrist).

If you are interested in the interface of neurology and psychiatry, then it is astounding that you are not interested in stroke or migraine! I am sure admitted strokes every 4th night would be quite tedious, stroke teaches us so much about brain-behavior correlates, the cerebral basis or mental disease, and creates some fascinating behavioral neurological symptoms. Strokes can result in depression, mania (usually right sided), and pseudobulbar affect. Strokes can lead to some of the most fascinating delusional syndromes including delusions of misidentification (chiefly the Capgras syndrome believed to result from disruption of the circuits between the fusiform facial gyrus and the amygala diminishing emotional response to faces and leading to the belief that an "imposter" has replaced loved ones), delusions of jealousy, erotomanic delusions, and delusions of infestation. Posterior circulation strokes can lead to peduncular hallucinations (vivid visual hallucinations that can be quite fantastical). I have seen patients develop obsessive compulsive disorder following strokes affecting the orbitofrontal cortex. Then there are the plethora of behavioral neurological syndromes that result from strokes including agnosias (including propasagnosia [inability to recognize faces], anosagnosia [inability to recognize deficits leading patients to behave as if they were normal], simultanagonsia[inability to see both parts and the whole]), apraxias, aphasias, aprosodia, amnesias. Posterior strokes can lead to Balint syndrome which is characterized by optic ataxia, optic ataxia, oculomotor apraxia and simultanagnosia. Whereas dominant parietal lobe lesions may lead to Gerstmann's syndrome which is characterized by dysgraphia, dyscalculia, finger agnosia, and left-right disorientation.

Then there are other rarities associated with strokes including foreign accent syndrome and the extremely rare le fou rire prodromique (uncontrollable fits of laughter that precede a catastrophic brainstem stroke/vascular event).

As for migraines, again they are simply fascinating neuropsychiatric occurrences! Migraine is in the differential diagnosis for psychosis, particularly of sudden onset. Persecutory delusions have been associated with the CACNL1A4 mutation which is a channelopathy cause of familial hemiplegic migraine. Distortions of time and space and sensory phenomena are quite classic of migraine. I have had patients describe distortions of the time-space continuum, or feel themselves completely disconnected from the universe during migraines. Oliver Sacks wrote about his amusia during migraines (i.e. the loss of sense of pitch and tone and inability to recognize familiar music). Olfacatory, visual, auditory hallucinations, illusions, synesthesia can all occur in migraine. There are even cases of foreign accent syndrome occuring with migraine; in one case an english woman woke up sounding chinese! Migraines are eminently treatable and so it is very satisfying to make such a diagnosis in someone with more worrisome symptoms like delusions, hallucinations, blindness, hemiplegia etc.

a neuropsychiatry fellowship would give you absolutely no training in managing neurological diseases with the exception of the dementias.

As for DBS, it is not widely used in psychiatry because it is largely ineffective and insurance companies balk at paying for it in young people who will need the stimulator replaced several times. As you may be aware the last DBS depression trial (the BROADEN trial) was terminated by St Jude's Medical because it fared poorly on futility analysis. Currently OCD is the only psychiatric indication for DBS clinically, and that is not based on evidence, but a humanitarian device exception from the FDA because some cases of OCD are so catastrophic that patients (or their families) are desperate for surgery and DBS is by far the least worst surgical option. You could probably learn this during psychiatry residency if you worked with people who were doing this work or where they were clinically using DBS for OCD (I worked with a psychiatrist who did DBS programming when I was a resident). You could also do the interventional psychiatry fellowship at MUSC. I think Mt Sinai does a fair bit of research in this area too. I believe mayo has a brain stimulation fellowship they might be open to taking a psychiatrist. Personally, I think the main reason it's interesting doing this work is because of the fascinating treatment-refractory patients you evaluate and thinking through the management. your job as the psychiatrist is still primarily evaluation - there is nothing particularly fancy about fiddling with a DBS programming device though it is kinda cool at first the novelty wears off as with everything, and while it can sometimes be helpful the results are not typically dramatic (unlike in some movement disorders or epilepsy cases).

(patients with simultagnosia would see the T but not the H)

Excellent post, minor quibble: if the English patient you described genuinely had a consistently Chinese accent, this is something very different from the classic foreign accent syndrome, which is characterized by a micro-prosodic instability due to a disruption in the normal network for speech feedback integration. As such, the patient definitely sounds like a non-native speaker, but is not consistent from utterance to utterance and certainly does not really have any specific accent (though of course individuals around them will assert this on the basis of no linguistic evidence).

Source: this was half of my doctoral dissertation
 
H

HarryMTieboutMD

I struggled with neuro vs psych because I absolutely love behavioral neurology and did research with one of the godfathers of the field Ken Heilman (who is still going strong). But in choosing a specialty I had to look at the practical, day to day aspects of the two fields.

Of course neurology would be great if your time were spent localizing rare stroke syndromes, but it isn't. In 2016 stroke neurology is largely focused on reducing door to needle time and following an algorithm that keeps changing. Post stroke depression is pretty common- there is a nice review of it in JAMA Psych from a few months ago, and you will see some Gerstmanns, Balints, Dejerines, etc, but mostly the clinical focus is going to be on acute management and dispo. Also (and it took me doing another MS4 rotation in neurology to remember this), A LOT of day to day neurology does NOT involve the CNS, which was a dealbreaker for me. Sure, the classic syndromes are still interesting, but I start mentally checking out distally from the NMJ...

However, if you do psychiatry, zebras will be even more rare and you have to get excited about basic schizophrenia, depression, mania, etc, all of which can nonetheless vary greatly in presentation. However, if you train in a high volume hospital, you will see plenty of interesting things

Agree that if you are interested in clinical DBS, neurology or NSGY are your go to specialties. And aside from Wayne Goodman at Sinai, Holly Lisanby at NIMH (formerly Duke), and Mark George at MUSC, DBS research in psych seems to be less captivating and en vogue than it was a few years ago. Nevertheless in med school we had one of the biggest OCD DBS programs in the country (largely because Goodman was the former chair of our dept and Michael Okun and Kelly Foote are two of the leading DBS superstars in the country for DBS in movement disorders), and the results for treatment refractory cases were really quite dramatic.
 
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northernpsy

Psychiatrist. No, I'm not analyzing you
Jan 20, 2016
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Of course neurology would be great if your time were spent localizing rare stroke syndromes, but it isn't. In 2016 stroke neurology is largely focused on reducing door to needle time and following an algorithm that keeps changing. Post stroke depression is pretty common- there is a nice review of it in JAMA Psych from a few months ago, and you will see some Gerstmanns, Balints, Dejerines, etc, but mostly the clinical focus is going to be on acute management and dispo.
I agree. If Neurology really was as full of fascinating zebras as Oliver Sacks made it seem, I would love to be a neurologist. Unfortunately, that wasn't quite my experience. :)
If nothing else, I feel psych is one specialty that is less predictable and less "routine" than most others just because people's personalities are unique. No matter how many patients with depression or psychosis I 've seen, I still don't feel like I've seen it all just because each individual has been so different.

It might also be worth mentioning that the Academy of Psychosomatic Medicine has a special interest group for those who are interested in Neuropsychiatry:
http://www.apm.org/sigs/index.shtml