Neuropsychiatry

[Sidus1011]

I'm a current M2 at a DO school who is interested interested in Psych and Neuro. I have a great deal of experience in both and recognize the differences between the two, but have enjoyed both the subject matter and what I've seen in shadowing. I recognize I will likely figure out which one I'll be going into next year - but I was wondering if there was any way to scratch my interests in both fields? I understand that Movement and Epilepsy both see a good deal of psychiatric comorbidities - so if I go into Neuro there is that component there. However, I was wondering what exactly Neuropsychiatry consists of? Is it primarily managing psychiatric manifestations of neurological disorders?

---

Members don't see this ad.

 

[Ivos]

The neuropsychiatric triad is mainly ADHD, autism and cognitive impairment. If somatic symptoms of psychiatric diseases is your thing then maybe look into C&L psychiatry. Also, don’t worry about what you like most. Once you practice, you will find out. Both fields are good options when you like them both!

 

[mistafab]

Your main driver in med school needs to be psych vs neuro. If you find yourself leaning towards one more I would recommend just going the single specialty route and figure out how to scratch the itch later. I would not recommend the combined residency unless you are really die-hard after your psych and neuro rotations.

 

[splik]

There are few dual neurology/psychiatry residencies so if you really want to practice both you can. Some people also do psych training after neuro (doesn't make sense the otherway around as will be too long!) Otherwise you can do psych and then do a neuropsychiatry fellowship. Incidentally, movement disorders fellowships are often open to psychiatrists. If you do neuro, you can also do a cognitive and behavioral neurology fellowship.

I am a neuropsychiatrist. I specialize in brain-behavior relationships in the context of function and dysfunction in the brain. We can perform physical examinations, neurobehavioral examinations, make medical diagnoses, order and interpret brain scans, laboratory tests, and neurophysiological tests, prescribe (and de-prescribe) medications, and perform psychotherapy. Common neuropsychiatric disorders including the dementias (Alzheimer's, bvFTD, DLB, vascular dementia etc), TBI, persistent post-concussive symptoms, functional neurological disorders, chronic pain, amnestic disorders, and psychiatric manifestations of neurological disease (e.g. epilepsy, movement disorders, autoimmune encephalitis, stroke, neurogenetic disorder, MS).

I'll give you and idea of the sorts of cases I might see or get consulted on for an expert opinion:

An patient with parkinsonism, paranoia, and hallucinations
An older woman patient with a history of breast cancer and no prior psychiatric history presenting with catatonic symptoms and episodic memory loss
A young women with episodes of unexplained amnesia where she does not recognize her children or her own home
A young woman with a history of extensive childhood sexual trauma with recurrent orthostasis and fainting spells
An autistic patient with persistent headaches, dizziness, photophobia, phonophobia, sleeplessness, panic attacks following a head injury w/o LOC from an MVA
A patient who presented with sudden onset unexplained stroke-like symptoms who now speaks in a slow British Accent
A patient with MELAS with unexplained episodic hemiparesis
A patient with stiff person syndrome with severe anxiety, exaggerated startle response, and abnormal gait
A patient with severe intellectual disability and autism with self-injurious behaviors
A patient who was diagnosed with normal pressure hydrocephalus s/p VP shunt placement now experiencing cognitive decline, paranoia, and apathy
An older patient with parkinson's disease who sees the devil and tries to kill their husband
A patient with refractory epilepsy who has multiple "rage attacks" with amnesia without ictal correlate for which the police are frequency called
An older patient with Alzheimer's who believes that their husband and father is the same person

You do get some zebras and it can be very intellectually stimulating. But it can be hard work regardless of whether you are on the more psychological side (vicarious traumatization and dealing with personality disorders) or neurodegenerative side (dealing with angry relatives who won't accept why you can't or won't 'fix' their demented loved one). Doing this work properly requires time and medicine rewards volume. Which is another way of saying that most healthcare systems do not value this work. There are very few advertised jobs for neuropsychiatrists. And for historical reasons, about half of the behavioral neurologists and neuropsychiatrists in the US are in Boston.

 

[Sidus1011]

There are few dual neurology/psychiatry residencies so if you really want to practice both you can. Some people also do psych training after neuro (doesn't make sense the otherway around as will be too long!) Otherwise you can do psych and then do a neuropsychiatry fellowship. Incidentally, movement disorders fellowships are often open to psychiatrists. If you do neuro, you can also do a cognitive and behavioral neurology fellowship.

I am a neuropsychiatrist. I specialize in brain-behavior relationships in the context of function and dysfunction in the brain. We can perform physical examinations, neurobehavioral examinations, make medical diagnoses, order and interpret brain scans, laboratory tests, and neurophysiological tests, prescribe (and de-prescribe) medications, and perform psychotherapy. Common neuropsychiatric disorders including the dementias (Alzheimer's, bvFTD, DLB, vascular dementia etc), TBI, persistent post-concussive symptoms, functional neurological disorders, chronic pain, amnestic disorders, and psychiatric manifestations of neurological disease (e.g. epilepsy, movement disorders, autoimmune encephalitis, stroke, neurogenetic disorder, MS).

I'll give you and idea of the sorts of cases I might see or get consulted on for an expert opinion:

An patient with parkinsonism, paranoia, and hallucinations
An older woman patient with a history of breast cancer and no prior psychiatric history presenting with catatonic symptoms and episodic memory loss
A young women with episodes of unexplained amnesia where she does not recognize her children or her own home
A young woman with a history of extensive childhood sexual trauma with recurrent orthostasis and fainting spells
An autistic patient with persistent headaches, dizziness, photophobia, phonophobia, sleeplessness, panic attacks following a head injury w/o LOC from an MVA
A patient who presented with sudden onset unexplained stroke-like symptoms who now speaks in a slow British Accent
A patient with MELAS with unexplained episodic hemiparesis
A patient with stiff person syndrome with severe anxiety, exaggerated startle response, and abnormal gait
A patient with severe intellectual disability and autism with self-injurious behaviors
A patient who was diagnosed with normal pressure hydrocephalus s/p VP shunt placement now experiencing cognitive decline, paranoia, and apathy
An older patient with parkinson's disease who sees the devil and tries to kill their husband
A patient with refractory epilepsy who has multiple "rage attacks" with amnesia without ictal correlate for which the police are frequency called
An older patient with Alzheimer's who believes that their husband and father is the same person

You do get some zebras and it can be very intellectually stimulating. But it can be hard work regardless of whether you are on the more psychological side (vicarious traumatization and dealing with personality disorders) or neurodegenerative side (dealing with angry relatives who won't accept why you can't or won't 'fix' their demented loved one). Doing this work properly requires time and medicine rewards volume. Which is another way of saying that most healthcare systems do not value this work. There are very few advertised jobs for neuropsychiatrists. And for historical reasons, about half of the behavioral neurologists and neuropsychiatrists in the US are in Boston.

This sounds right up my alley honestly - while not every psychiatric or neurological issue have interplay with each other, I find when they do absolutely fascinating. In order to see cases like this I'm guessing you have to work for a large academic center, is it difficult to find a job outside of the boston area?

 

[Asklepian]

I do both for a living and absolutely love it. Did the dual residency and don't regret for a second. My life is pretty awesome.

 

[Cath Up]

There are few dual neurology/psychiatry residencies so if you really want to practice both you can. Some people also do psych training after neuro (doesn't make sense the otherway around as will be too long!) Otherwise you can do psych and then do a neuropsychiatry fellowship. Incidentally, movement disorders fellowships are often open to psychiatrists. If you do neuro, you can also do a cognitive and behavioral neurology fellowship.

I am a neuropsychiatrist. I specialize in brain-behavior relationships in the context of function and dysfunction in the brain. We can perform physical examinations, neurobehavioral examinations, make medical diagnoses, order and interpret brain scans, laboratory tests, and neurophysiological tests, prescribe (and de-prescribe) medications, and perform psychotherapy. Common neuropsychiatric disorders including the dementias (Alzheimer's, bvFTD, DLB, vascular dementia etc), TBI, persistent post-concussive symptoms, functional neurological disorders, chronic pain, amnestic disorders, and psychiatric manifestations of neurological disease (e.g. epilepsy, movement disorders, autoimmune encephalitis, stroke, neurogenetic disorder, MS).

I'll give you and idea of the sorts of cases I might see or get consulted on for an expert opinion:

An patient with parkinsonism, paranoia, and hallucinations
An older woman patient with a history of breast cancer and no prior psychiatric history presenting with catatonic symptoms and episodic memory loss
A young women with episodes of unexplained amnesia where she does not recognize her children or her own home
A young woman with a history of extensive childhood sexual trauma with recurrent orthostasis and fainting spells
An autistic patient with persistent headaches, dizziness, photophobia, phonophobia, sleeplessness, panic attacks following a head injury w/o LOC from an MVA
A patient who presented with sudden onset unexplained stroke-like symptoms who now speaks in a slow British Accent
A patient with MELAS with unexplained episodic hemiparesis
A patient with stiff person syndrome with severe anxiety, exaggerated startle response, and abnormal gait
A patient with severe intellectual disability and autism with self-injurious behaviors
A patient who was diagnosed with normal pressure hydrocephalus s/p VP shunt placement now experiencing cognitive decline, paranoia, and apathy
An older patient with parkinson's disease who sees the devil and tries to kill their husband
A patient with refractory epilepsy who has multiple "rage attacks" with amnesia without ictal correlate for which the police are frequency called
An older patient with Alzheimer's who believes that their husband and father is the same person

You do get some zebras and it can be very intellectually stimulating. But it can be hard work regardless of whether you are on the more psychological side (vicarious traumatization and dealing with personality disorders) or neurodegenerative side (dealing with angry relatives who won't accept why you can't or won't 'fix' their demented loved one). Doing this work properly requires time and medicine rewards volume. Which is another way of saying that most healthcare systems do not value this work. There are very few advertised jobs for neuropsychiatrists. And for historical reasons, about half of the behavioral neurologists and neuropsychiatrists in the US are in Boston.

I didn’t know we have access to such a fellowship- thank you!

This seems far more intellectually stimulating from a diagnostic sense primarily- have you found that to be the case compared to general psychiatry? The management side of things seems like you’re either going up against more rapid degenerative processes, or states that may be poorly treatable for other reasons- maybe more frustrating than general psychiatry? Though I cannot imagine the satisfaction and usefulness of correcting false diagnoses and changing management for things that were misidentified.

 

[TexasPhysician]

This sounds right up my alley honestly - while not every psychiatric or neurological issue have interplay with each other, I find when they do absolutely fascinating. In order to see cases like this I'm guessing you have to work for a large academic center, is it difficult to find a job outside of the boston area?

I’m going to disagree a bit with your above statement. This disagreement is merely for educational value as I find it always helpful to look at different perspectives to make the best decision.

Neuro crosses into psych more often than not. It is often quite difficult to process and move forward with a neuro diagnosis. Your life is not the same after MS, seizures, stroke, Parkinson’s, dementia, etc. It is, in every case I’ve seen, always worse after symptoms begin. That said, there is plenty of demand for neurologists. We can’t logically have neuro start doing hour long CBT for psych issues from a national health perspective. I don’t think most would want too anyway.

While psych and neuro often should co-exist on patients, I rarely see a reason to be trained in both. There is plenty of demand for psychiatrists and neurologists. Cases either have a neuro component in which neuro wants to follow the case or they don’t. Neuro doesn’t want to keep patients with psychogenic seizures and manage it from a psych perspective. I’ve never met a neurologist that wants to do CBT (not saying they don’t exist). Most neurologists that enter the psych realm seem to be over-diagnosing ADHD and then punting to me to manage the side effects. I’m not saying there aren’t a ton of great neurologists out there, but the few pushing into psych are generally the ones causing problems.

When I discover that agitation is a sign of dementia, I have 0 interest in working up/treating the dementia or MS or whatever instead of pulling in neuro. If I believe the seizure meds are contributing to a psych decline, I’ll consult with neuro about options, not takeover. Would most of us want to do both if we could? Absolutely not.

I am sure that there are some really cool cases in major referral academic centers where doing both or being a C&L psych would assist with reaching the right rare diagnosis. Even if you don’t go for “both”, there are plenty of cool cases in psych and neuro respectively.

There are probably rural areas that would love a specialist of any kind. 99.8% of jobs will not want nor know what to do with someone wanting to do both. I’d bet the majority of graduates end up mainly doing one or the other field. In most cases, it is whatever pays the most.

It is wonderful in theory like the triple board programs (peds, psych, and child psych). In the real world, most graduates won’t stay in academia and end up doing exclusively child psych. The peds value mostly disappears.

I also recognize that not everything is about money. A good friend is an academic pediatric hand surgeon. Every decision he made after becoming a hand surgeon has been progressively less lucrative - peds fellowship - academia. He loves it.

The value all of us physicians bring to the world is immense. Splik appears quite pleased with the decision as I would hope most of us are with our chosen paths. If you read my post after both psych and neuro rotations and still incredibly love both, I’d recommend doing both.

 

[Asklepian]

There are probably rural areas that would love a specialist of any kind. 99.8% of jobs will not want nor know what to do with someone wanting to do both. I’d bet the majority of graduates end up mainly doing one or the other field. In most cases, it is whatever pays the most.

Actually, I'll have to disagree here. I'm dual-boarded and get to practice both specialties at the same place at a high level and it's extremely rewarding.

I recommend checking out Practice and Career Outcomes of Double-Boarded Psychiatrists.
They state, "Psychiatrist-neurologists appear to have a distinct career path from other double-boarded physicians, perhaps due to the close overlap of the two fields. This group, along with those who were trained in double-board programs, were more likely to have practiced and to still be practicing their medical specialty."

I have several friends in a similar situation. It's not very difficult to practice both as both specialties are in shortage and, in fact, having the training of both allows you an extremely high amount of flexibility. If you're savvy, you can leverage this huge boon to your advantage and create the practice and lifestyle setting that favors your personal style.

 

[smalltownpsych]

There are few dual neurology/psychiatry residencies so if you really want to practice both you can. Some people also do psych training after neuro (doesn't make sense the otherway around as will be too long!) Otherwise you can do psych and then do a neuropsychiatry fellowship. Incidentally, movement disorders fellowships are often open to psychiatrists. If you do neuro, you can also do a cognitive and behavioral neurology fellowship.

I am a neuropsychiatrist. I specialize in brain-behavior relationships in the context of function and dysfunction in the brain. We can perform physical examinations, neurobehavioral examinations, make medical diagnoses, order and interpret brain scans, laboratory tests, and neurophysiological tests, prescribe (and de-prescribe) medications, and perform psychotherapy. Common neuropsychiatric disorders including the dementias (Alzheimer's, bvFTD, DLB, vascular dementia etc), TBI, persistent post-concussive symptoms, functional neurological disorders, chronic pain, amnestic disorders, and psychiatric manifestations of neurological disease (e.g. epilepsy, movement disorders, autoimmune encephalitis, stroke, neurogenetic disorder, MS).

I'll give you and idea of the sorts of cases I might see or get consulted on for an expert opinion:

An patient with parkinsonism, paranoia, and hallucinations
An older woman patient with a history of breast cancer and no prior psychiatric history presenting with catatonic symptoms and episodic memory loss
A young women with episodes of unexplained amnesia where she does not recognize her children or her own home
A young woman with a history of extensive childhood sexual trauma with recurrent orthostasis and fainting spells
An autistic patient with persistent headaches, dizziness, photophobia, phonophobia, sleeplessness, panic attacks following a head injury w/o LOC from an MVA
A patient who presented with sudden onset unexplained stroke-like symptoms who now speaks in a slow British Accent
A patient with MELAS with unexplained episodic hemiparesis
A patient with stiff person syndrome with severe anxiety, exaggerated startle response, and abnormal gait
A patient with severe intellectual disability and autism with self-injurious behaviors
A patient who was diagnosed with normal pressure hydrocephalus s/p VP shunt placement now experiencing cognitive decline, paranoia, and apathy
An older patient with parkinson's disease who sees the devil and tries to kill their husband
A patient with refractory epilepsy who has multiple "rage attacks" with amnesia without ictal correlate for which the police are frequency called
An older patient with Alzheimer's who believes that their husband and father is the same person

You do get some zebras and it can be very intellectually stimulating. But it can be hard work regardless of whether you are on the more psychological side (vicarious traumatization and dealing with personality disorders) or neurodegenerative side (dealing with angry relatives who won't accept why you can't or won't 'fix' their demented loved one). Doing this work properly requires time and medicine rewards volume. Which is another way of saying that most healthcare systems do not value this work. There are very few advertised jobs for neuropsychiatrists. And for historical reasons, about half of the behavioral neurologists and neuropsychiatrists in the US are in Boston.

With that kind of work, you should be a neuropsychologist too! Seriously though, I’m sure that you realize that understanding the functional aspects of what the tests measure is essential and as a clear expert, you probably don’t just take the findings or conclusions of psych testing at face value anymore than I would. Chasing zebras and solving those kinds of puzzles is what made me consider pursuing neuropsychology. So much fun!

 

[Merovinge]

Actually, I'll have to disagree here. I'm dual-boarded and get to practice both specialties at the same place at a high level and it's extremely rewarding.

I recommend checking out Practice and Career Outcomes of Double-Boarded Psychiatrists.
They state, "Psychiatrist-neurologists appear to have a distinct career path from other double-boarded physicians, perhaps due to the close overlap of the two fields. This group, along with those who were trained in double-board programs, were more likely to have practiced and to still be practicing their medical specialty."

I have several friends in a similar situation. It's not very difficult to practice both as both specialties are in shortage and, in fact, having the training of both allows you an extremely high amount of flexibility. If you're savvy, you can leverage this huge boon to your advantage and create the practice and lifestyle setting that favors your personal style.

I have a psychiatrist/neurologist who practices in my area. I find it a little hard to wrap my head around them doing both specialties on a daily basis but I do think they are a pretty good dos\c with a good reputation. They do seem to do a bit more mental health than neurology but clearly practice both specialties. I don't think it's the right career pathway for 99+% of us interest in brain based areas of medicine but I am glad that it exists for the occasional person to find the right place to call home.

 

[comp1]

Ugh, I hated neuro sooo much. I'm not sure a neuropsychiatry fellowship exactly would do what you want. As others said, neuropsych is mostly dementia and maybe some ADHD. It's also mostly done very well (better?) by psychologists in the community since dementia has very limited non-behavioral treatment options. I think you might have to do the dual training which sounds extraordinarily painful and definitely will NOT result in a higher salary. Hopefully you instead find that you can be satisfied in one of these fields. In my opinion, they are dramatically different and you'll probably be drawn more to one than the other during your clinical rotations. Neuro isn't a core everywhere (although it should be, even as painful as it is), so you'll have to make sure to schedule that relatively early.

 

[clozareal]

I do a bunch of neuropsychiatry in my practice but I'm not double boarded. I pursued a lot of clinical electives working with neuropsychiatric conditions in different settings, particularly geriatrics, ADHD, autism, tourette's, movement disorders, dementia, traumatic brain injury, funcitonal neurological disorders, epilepsy, neuro-oncology, stroke, autoimmune encephalitis. I enjoy working with patient population.

I do have a some big academic centers near me that refer many patients to me that they don't have the capacity for as their neuropsych "clinics" often have a long waitlist.

I do a lot of CAP neuropsych which I really enjoy. I market myself as "interested in neuropsychiatric conditions, such as autism, FND, epilepsy, ADHD, TBI, etc." Once you build your referral network with neurologists, PM&R, developmental-behavioral pediatricians, oncologists, then you can definitely develop a niche without a fellowship.

 

[Sidus1011]

I do a bunch of neuropsychiatry in my practice but I'm not double boarded. I pursued a lot of clinical electives working with neuropsychiatric conditions in different settings, particularly geriatrics, ADHD, autism, tourette's, movement disorders, dementia, traumatic brain injury, funcitonal neurological disorders, epilepsy, neuro-oncology, stroke, autoimmune encephalitis. I enjoy working with patient population.

I do have a some big academic centers near me that refer many patients to me that they don't have the capacity for as their neuropsych "clinics" often have a long waitlist.

I do a lot of CAP neuropsych which I really enjoy. I market myself as "interested in neuropsychiatric conditions, such as autism, FND, epilepsy, ADHD, TBI, etc." Once you build your referral network with neurologists, PM&R, developmental-behavioral pediatricians, oncologists, then you can definitely develop a niche without a fellowship.

This is really encouraging! I'd rather not pursue double boards due to the length of time and I'll likely be couples matching as well making it harder to get into them anyways. It's nice to know you can formulate your niche in practice without needing to pursue a fellowship for it as well.

 

[Celexa]

This is really encouraging! I'd rather not pursue double boards due to the length of time and I'll likely be couples matching as well making it harder to get into them anyways. It's nice to know you can formulate your niche in practice without needing to pursue a fellowship for it as well.

Double boards psych-neuro is a waste of time imo, and people endorsing double residencies of any type tend to be older and myopic to how much more information is contained in each field now compared to when they trained and what volumes are now. Do you really want to do stroke call? If you want to be more academic/make sure you get in the specialized training, one option in psych is to do psych residency and then CL fellowship at a place where you can do a lot of neuro related electives. All the intellectual fun, way better flexibility and work hours.

 

[Merovinge]

Double boards psych-neuro is a waste of time imo, and people endorsing double residencies of any type tend to be older and myopic to how much more information is contained in each field now compared to when they trained and what volumes are now. Do you really want to do stroke call? If you want to be more academic/make sure you get in the specialized training, one option in psych is to do psych residency and then CL fellowship at a place where you can do a lot of neuro related electives. All the intellectual fun, way better flexibility and work hours.

It's for people that can't stand not knowing everything possible about the brain. You either stay in academics and eat, drink, and breathe brain science or you craft a private practice that incorporates the parts of psych and neuro you most want to treat on a daily basis. Frankly I listen to economics, finance, and a little bit of psych when it comes to my podcasts; if there was a me that listened to neuro science, neuroscience, and neuro science applied to human behavior, I could definitely see doing a combined residency. Plus imagine the self selection of your co-residents in the combined program, nerdaholics annonymous!

 

[comp1]

Somehow...I'm still imagining the combined residents as less nerdy than just the neuro residents.

 

[Asklepian]

A lot of opinions from people who don't live the dual-boarded life, but I'm telling you it's been 100% worth it for me. You're super marketable and I've had multiple sites offer to create new roles just to accommodate me.

In the end, I didn't want to just know part of the brain. I wanted to be a brain expert in all realms and that is what I get to do. I practice both specialties and very frequently my patients need both anyway, so it's easy for me to manage. Other docs love having the resource, and I frequently get questions / consults from other physicians in psych and neuro. I have significant leadership roles. In regard to the training, most people don't want to do the extra work or maybe they just love neuro or just love psych, but if you really love everything from stroke and seizure to psychosis and mania, this can't be beat.

I think you might have to do the dual training which sounds extraordinarily painful and definitely will NOT result in a higher salary.

This is 100% false. At least the latter part. The training is pretty tough

 

[docksan]

I do plenty of neurology in psychiatry. The question is would you want to spend an extra year learning about treating neurological diseases as a psychiatrist or psychiatric illness as a neurologist or would that time be better spent practicing one or the other and doing electives?

 

[Therapist4Chnge]

It's for people that can't stand not knowing everything possible about the brain. You either stay in academics and eat, drink, and breathe brain science or you craft a private practice that incorporates the parts of psych and neuro you most want to treat on a daily basis. Frankly I listen to economics, finance, and a little bit of psych when it comes to my podcasts; if there was a me that listened to neuro science, neuroscience, and neuro science applied to human behavior, I could definitely see doing a combined residency. Plus imagine the self selection of your co-residents in the combined program, nerdaholics annonymous!

This is the most "real world" response I've seen. I'm a neuropsychologist that works primarily w head injury and polytrauma, but I have a strong background in psychosomatic assessment, so I also get a lot of zebra cases thrown my way. Having access to a behavioral neurologist (or psych equivalent the other way) would be so helpful. Even if the OP doesn't formally pursue both, there will always be plenty of work out there to cherry-pick to scratch that itch.

For better or worse, most academics I know did what I did, put in your 5-10yrs and escape to private practice when the administrative BS, university politics, and grant grinding take their toll. The side PP usually starts small, but it'll grow and then most ask themselves why they didn't do it sooner.

Keep that excitement for learning and pursue your interests, just know the real world often doesn't care about the details and scope of your training, they just need someone to lessen their patient load. The more you can carve out your niche, the better your chances are at doing work you mostly enjoy. Best of luck OP.

 

[vespers]

There are few dual neurology/psychiatry residencies so if you really want to practice both you can. Some people also do psych training after neuro (doesn't make sense the otherway around as will be too long!) Otherwise you can do psych and then do a neuropsychiatry fellowship. Incidentally, movement disorders fellowships are often open to psychiatrists. If you do neuro, you can also do a cognitive and behavioral neurology fellowship.

I am a neuropsychiatrist. I specialize in brain-behavior relationships in the context of function and dysfunction in the brain. We can perform physical examinations, neurobehavioral examinations, make medical diagnoses, order and interpret brain scans, laboratory tests, and neurophysiological tests, prescribe (and de-prescribe) medications, and perform psychotherapy. Common neuropsychiatric disorders including the dementias (Alzheimer's, bvFTD, DLB, vascular dementia etc), TBI, persistent post-concussive symptoms, functional neurological disorders, chronic pain, amnestic disorders, and psychiatric manifestations of neurological disease (e.g. epilepsy, movement disorders, autoimmune encephalitis, stroke, neurogenetic disorder, MS).

I'll give you and idea of the sorts of cases I might see or get consulted on for an expert opinion:

An patient with parkinsonism, paranoia, and hallucinations
An older woman patient with a history of breast cancer and no prior psychiatric history presenting with catatonic symptoms and episodic memory loss
A young women with episodes of unexplained amnesia where she does not recognize her children or her own home
A young woman with a history of extensive childhood sexual trauma with recurrent orthostasis and fainting spells
An autistic patient with persistent headaches, dizziness, photophobia, phonophobia, sleeplessness, panic attacks following a head injury w/o LOC from an MVA
A patient who presented with sudden onset unexplained stroke-like symptoms who now speaks in a slow British Accent
A patient with MELAS with unexplained episodic hemiparesis
A patient with stiff person syndrome with severe anxiety, exaggerated startle response, and abnormal gait
A patient with severe intellectual disability and autism with self-injurious behaviors
A patient who was diagnosed with normal pressure hydrocephalus s/p VP shunt placement now experiencing cognitive decline, paranoia, and apathy
An older patient with parkinson's disease who sees the devil and tries to kill their husband
A patient with refractory epilepsy who has multiple "rage attacks" with amnesia without ictal correlate for which the police are frequency called
An older patient with Alzheimer's who believes that their husband and father is the same person

You do get some zebras and it can be very intellectually stimulating. But it can be hard work regardless of whether you are on the more psychological side (vicarious traumatization and dealing with personality disorders) or neurodegenerative side (dealing with angry relatives who won't accept why you can't or won't 'fix' their demented loved one). Doing this work properly requires time and medicine rewards volume. Which is another way of saying that most healthcare systems do not value this work. There are very few advertised jobs for neuropsychiatrists. And for historical reasons, about half of the behavioral neurologists and neuropsychiatrists in the US are in Boston.

Did you do a dual residency, or two separate residencies? Or just a psychiatry residency with some lesser certification afterwards?