Rising M4 interested in neuropsychiatry: Programs to consider

[aspiringdoc09]

Hi All! I'm a rising senior considering my schedule and possible programs to apply to for next year. I have interests in both neurology and psychiatry. I know most people say I will either practice one or the other specialty but I feel strongly about both. Besides the combined programs (Mass, MUSC, NYU, and possibly UTSW??), what other programs have a strong focus in neuropsych, biological psych, or have both strong psychiatry and neurology programs, if I do back to back residencies? Thanks.

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[FlowRate]

MGH/McL, BWH, BIDMC are all strong, as are Partners Neuro and BIDMC Neuro. There's a neuropsych attending at MGH who did back to back psych/neuro residencies.

 

[splik]

If you are interested in behavioral neurology/neuropsychiatry and you have an interest in general neurology beyond the higher functions, I would strongly suggest you do a combined residency program or back to back residencies. If you did back to back residencies (much less time efficient) then you would do neurology first and then psychiatry (it would be much harder, and longer to do psych followed by neurology as psychiatry doesn't do a full intern year so you've have to repeat an intern year later which is just painful). The reason I suggest this is because there really aren't any jobs in neuropsychiatry. They just don't exist. If someone is a researcher then they can certainly go that route but you will be hired on your ability to get grants and be spending 20% of your time or so in some esoteric clinic. As a clinician, it is quite hard to find a neuropsychiatry job particular in psychiatry unless you can convince someone to create something for you. Outside of boston it's not really a thing.

Neurologists might have a somewhat easier time finding a behavioral neurology position, but if you are full time clinical you would almost certainly have to do general neurology clinic or wards too.

i believe brown also has a combined program btw

 

[aspiringdoc09]

MGH/McL, BWH, BIDMC are all strong, as are Partners Neuro and BIDMC Neuro. There's a neuropsych attending at MGH who did back to back psych/neuro residencies.

Thanks for the reply. I plan to look more into these programs.

If you are interested in behavioral neurology/neuropsychiatry and you have an interest in general neurology beyond the higher functions, I would strongly suggest you do a combined residency program or back to back residencies. If you did back to back residencies (much less time efficient) then you would do neurology first and then psychiatry (it would be much harder, and longer to do psych followed by neurology as psychiatry doesn't do a full intern year so you've have to repeat an intern year later which is just painful). The reason I suggest this is because there really aren't any jobs in neuropsychiatry. They just don't exist. If someone is a researcher then they can certainly go that route but you will be hired on your ability to get grants and be spending 20% of your time or so in some esoteric clinic. As a clinician, it is quite hard to find a neuropsychiatry job particular in psychiatry unless you can convince someone to create something for you. Outside of boston it's not really a thing.

Neurologists might have a somewhat easier time finding a behavioral neurology position, but if you are full time clinical you would almost certainly have to do general neurology clinic or wards too.

i believe brown also has a combined program btw

Thanks Splik as always for your reply. My mentor, and based on my on research, said Brown no longer have a combined program after this year. That's where he went. I checked FRIEDA and the ACGME website and Brown's program has been removed. UTSW program comes up but they don't have an official website, so I will have to email to see. My plan was to apply neurology as back up and take that route first as you mentioned because they require 8 months internal med for intern year.

@splik: Audition rotations were suggested to me, so what are your thoughts on that? I am currently trying to update my CV and write a PS to complete a VSAS application. So after applying to the 3 or maybe 4 combined programs in the country, I should focus on 20 or 30 good neurology programs using the "1/3rds rule" that SDN always refer to on here? Thanks

 

[splik]

I would ask in the neurology forum about how many programs you should apply to etc. BTW UCSF has a very strong behavioral neurology program so theoretically you should get excellent training in the dementias. They are one of the few places to focus on early onset dementias and have clinical and research programs for FTD, 4 repeat tauopathies, prion disease, and autoimmune dementias/encephalitis. They have a highly rated rotation in the Memory and Aging Center for MS4s so you might enjoy rotating there. I wouldn't consider it an "audition rotation" whatever that means, but presumably if you were trying to impress you would do neurology wards. It is also arguably (one) the best programs in the country, and the only thing that tempers its competitiveness is how exorbitant it is to live there. UCSF has a strong psychiatry program too, and the neurology and psychiatry departments will be housed together in a new neurosciences building in the coming years. It has never been a particularly biologically oriented psychiatry program but unfortunately it looks like things are increasingly moving in that direction.

 

[HarryMTieboutMD]

There is no practical reason to do more than one residency (in anything)- you are wasting time and sacrificing money/meaningful research time, etc, and as Splik said the job market is virtually nonexistent. Even behavioral neurology jobs hardly exists outside of academia, and most of the clinical skills should be learned in a decent neurology residency (eg, dementia evaluations). One of my mentors in medical school (Ken Heilman) is one of the godfathers of behavioral neurology who was one of Norm Geschwind's original disciples (along with Marcel Mesulaum, Antonio Damasio, etc), but even then his clinical fellows would do 1 day of clinic and spend the rest of the time on research. Bruce Miller is in charge at UCSF and though not a Geschwind protege (I don't think) is one of the all time greats.

Bottom line- if you want to learn how to treat disorders of the sensorymotor neuronal system- strokes, seizures, MS, neuromuscular disease do a neurology residency. If you want to treat CNS disorders of the NON sensorymotor neuronal system- affective/psychotic/anxiety/addictive/personality disorders do psychiatry because that is what you will spend your time doing in either residency. If you want to treat dementias you can do either (since actual treatments aren't that complicated) but its typically neurologists who do the initial evals (though again, this can be learned in a psychiatry residency), and as a psychiatrists you will likely be managing the above comorbidities.

That said, if you really can't decide between the two and see yourself switching, I would recommend doing neurology first (as Splik mentioned) because you will have a full intern year. Also, since ACGME mandates psychiatry rotations for neurology residents, you will get to see the specialties juxtaposed on the resident level (whereas in psychiatry this is typically done during the intern year when the other neuro residents are PGY2s and often treated as glorified medical students- I had to fight back against this!)

If you are interested in neuromodulation specifically for psychiatric disorders, you can do a psychiatry residency, and most major academic programs have a lot of opportunities for exposure to ECT, TMS, etc.

 

[splik]

Bruce Miller is in charge at UCSF and though not a Geschwind protege (I don't think) is one of the all time greats.

Bruce Miller is a disciple of Frank Benson, who was one of Norm Geschwind's protege's

 

[Asklepian]

UTSW has a combined program (the newest in the country)! We are strong in all three facets of combined training (Medicine, Neurology, and Psychiatry). I will be working on getting the website up in the next few months, so bear with me. Feel free to shoot me a message with any questions, and I will do my best to answer them in the interim.

 

[splik]

Thanks Splik as always for your reply. My mentor, and based on my on research, said Brown no longer have a combined program after this year. That's where he went. I checked FRIEDA and the ACGME website and Brown's program has been removed.

thats a shame if the case, but i assure you the program shows up on the ACGME website (btw combined programs aren't ACGME accredited). Neuro/psych programs are a dying combo as the fields continue to diverge. And it takes a rare person to be interested in both. I would recommend contact them anyway and expressing an interest. If you are an exceptional candidate they may wish to make arrangements for you anyway.

 

[aspiringdoc09]

Ok. Thanks everyone for your replies. I went back and looked at the ACGME website. It does have Brown listed. I went to their website and found this https://www.brown.edu/academics/medical/about/departments/neurology/neuropsychiatry-residency. I'm confused because this also comes up without that message https://www.brown.edu/academics/med...d-residency-neurology-and-psychiatry-overview. Either way, I'll have to email them to be sure.

@Asklepian, I'll probably be sending questions your way about UTSW's program.

 

[slappy]

Per Curt LaFrance, NP program no longer exists at Brown.

 

[Merovinge]

Hi All! I'm a rising senior considering my schedule and possible programs to apply to for next year. I have interests in both neurology and psychiatry. I know most people say I will either practice one or the other specialty but I feel strongly about both. Besides the combined programs (Mass, MUSC, NYU, and possibly UTSW??), what other programs have a strong focus in neuropsych, biological psych, or have both strong psychiatry and neurology programs, if I do back to back residencies? Thanks.

If you are looking to be a psychiatrist first and want great exposure to neuropsychiatry I strongly recommend Northwestern. They have folks both in behavioral neurology and neuropsychiatry who are great. This is obviously a very different path than a combined program and the field has been shrinking, although I think there is a tremendous amount to learn from neuropsychiatry and I hope the field stays afloat.

 

[aspiringdoc09]

If you are looking to be a psychiatrist first and want great exposure to neuropsychiatry I strongly recommend Northwestern. They have folks both in behavioral neurology and neuropsychiatry who are great. This is obviously a very different path than a combined program and the field has been shrinking, although I think there is a tremendous amount to learn from neuropsychiatry and I hope the field stays afloat.

That's good to know because I'm looking at programs to consider after I apply to the combined programs. I'll look more into this one too. Thanks.

 

[Electricity]

Really interesting thread, thanks for the posts everyone.

Can anyone explain why the job market for behavioral neurologists and neuropsychiatrists is so poor?

One would imagine that with such a large number of people with dementia, there would be a large need for doctors trained in their care (diagnosis, prevention, management, family counseling, etc), certainly enough to employ graduates of a relatively a niche fellowship. Even if in private practice, as opposed to academia.

Is it that the special training does not lead to increased reimbursements because the available treatments have not been shown to be very helpful?

 

[splik]

Really interesting thread, thanks for the posts everyone.

Can anyone explain why the job market for behavioral neurologists and neuropsychiatrists is so poor?

Lots of reasons. Neuropsychiatry for various reasons never really took off as a specialty and if anything, has been shrinking. Many people don't even know what a neuropsychiatrist is or what we do. The term is often misused or used in multiple different ways. For example psychiatrists involved in "brain stimulation" might market themselves as neuropsychiatrists when they are nothing of the sort; some academic departments use the term "neuropsychiatry" to flex their biological psychiatry muscles, and others still conflaate biological psychiatry with neuropsychiatry (though to be a great neuropsychiatrist you must understand the psychological basis of neurology as well as the neurological basis of psychiatry). We tend not to be all that interested in treating patients with Alzheimer's disease or vascular dementia, cuz it's kinda boring and can be done in primary care. Geriatricians, geriatric psychiatrists, general psychiatrists, general neurologists, geriatric neurologists, movement disorder specialists may also be involved in managing these patients. It is a very academic subspecialty which means people tend to be researchers who earn their crust through grants and do the occasional clinic. It is possible to have more of a clinical role if you create a position, but I would hazard that most of the neuropsychiatrists like this are in the Boston area. And if you aren't a researcher then you won't be afforded anywhere near the level of respect you would otherwise get, which might be grating. The other thing is no one wants to pay for the ridiculously long evaluations, and the consulting providers may not be very interested in your thoughtful analyses. Doing 3+hr evals and writing long waffling reports in the double digits is not uncommon.

Also neurologists tell me they are quite confident managing psychiatric manifestations of neurological disease, and believe they can prescribe psychotropic drugs for these conditions as well as me (which may or may not be true). What they want is for someone to deal with the "psychological" stuff, which may be better managed by (neuro)psychologists, or to treat the psyrimarly psychiatric disorders that were wrongly referred to neurology. Technically, the latter could be managed by general psychiatrists (though I don't think general psychiatrists do a good job of it).

Some neuropsychiatrists do work in private practice, but since the work is multidisciplinary, being able to work with neuropsychologists, neurologists, neuroradiologists, speech therapy and so on is much more difficult to do in private practice than a solo psychotherapy practice for example.

One can potentially charge a lot of money if you are dealing with medicare patients for doing comprehensive evaluations. There is demand for excellent forensic neuropsychiatrists to do IMEs in both civil and increasingly criminal cases.

 

[slappy]

Lots of reasons. Neuropsychiatry for various reasons never really took off as a specialty and if anything, has been shrinking. Many people don't even know what a neuropsychiatrist is or what we do. The term is often misused or used in multiple different ways. For example psychiatrists involved in "brain stimulation" might market themselves as neuropsychiatrists when they are nothing of the sort; some academic departments use the term "neuropsychiatry" to flex their biological psychiatry muscles, and others still conflaate biological psychiatry with neuropsychiatry (though to be a great neuropsychiatrist you must understand the psychological basis of neurology as well as the neurological basis of psychiatry). We tend not to be all that interested in treating patients with Alzheimer's disease or vascular dementia, cuz it's kinda boring and can be done in primary care. Geriatricians, geriatric psychiatrists, general psychiatrists, general neurologists, geriatric neurologists, movement disorder specialists may also be involved in managing these patients. It is a very academic subspecialty which means people tend to be researchers who earn their crust through grants and do the occasional clinic. It is possible to have more of a clinical role if you create a position, but I would hazard that most of the neuropsychiatrists like this are in the Boston area. And if you aren't a researcher then you won't be afforded anywhere near the level of respect you would otherwise get, which might be grating. The other thing is no one wants to pay for the ridiculously long evaluations, and the consulting providers may not be very interested in your thoughtful analyses. Doing 3+hr evals and writing long waffling reports in the double digits is not uncommon.

Some neuropsychiatrists do work in private practice, but since the work is multidisciplinary, being able to work with neuropsychologists, neurologists, neuroradiologists, speech therapy and so on is much more difficult to do in private practice than a solo psychotherapy practice for example.

One can potentially charge a lot of money if you are dealing with medicare patients for doing comprehensive evaluations. There is demand for excellent forensic neuropsychiatrists to do IMEs in both civil and increasingly criminal cases.

How are you defining a neuropsychiatrist (and neuropsychiatry) here? What 3+ hr evals are you referring to, and what is a forensic neuropsychiatrist?

 

[splik]

A neuropsychiatrist is a psychiatrist who specializes in the evaluation, diagnosis, and management of disorders at the brain-behavior interface, including:

• unexplained or functional neurological symptoms
• emotional, behavioral, perceptual, and cognitive symptoms that can occur in neurological diseases, including brain injury, stroke, dementia, epilepsy, multiple sclerosis, and other autoimmune diseases
• delirium and dementia
• neurobehavioral symptoms related to specific brain lesions

The latter two typically come under the field of "cognitive/behavioral neurology" which is subsumed under neuropsychiatry, though came out of neurology.

Neuropsychiatrists conduct a detailed psychiatric evaluation like their general psychiatry counterparts, but with particular emphasis on developmental insults, occupational and toxic exposures, family history, and medical/neurological history. The neuropsychiatric evaluation may include a full neurological examination, but tends to focus on the neurobehavioral mental status examination which focuses on the evaluation of higher cortical functions. Neuropsychiatrists routinely use neuropsychological testing, neuroimaging (MRI, FDG-PET, amyloid PET etc), neurophysiological testing (EEG, sleep studies), and laboratory studies (e.g. CSF studies such as antineuronal antibodies, QT-Quik, tau/phospho-tau/abeta42 etc) as part of their workup.

A forensic neuropsychiatrist is a neuropsychiatrist who uses their expertise to answer psycholegal questions. Forensic neuropsychiatrists conduct independent medical examinations in civil and criminal cases. These cases involve TBI, functional neurological symptoms, dementia (including bvFTD), and amnesia. Malingering of neuropsychiatric symptoms is extremely common in civil cases, and the forensic expert will perform symptom validity testing (or work with a neuropsychologist) to evaluate this possibility. The American Neuropsychiatric Association has a special interest group in this area, and the American Academy of Psychiatry and the Law has a forensic neuropsychiatry committee. Increasingly, neuroimaging features in the courtroom and forensics neuropsychiatrists may be called on to testify as to the relevance of this often used and abused modality. Of note, the neurologist Helen Mayberg, who is best known for her neuroimaging and DBS research in depression, actually makes her fortune as a plaintiff expert in death penalty cases regarding functional neuroimaging that has been presented in mitigation by the defense.

 

[clausewitz2]

). We tend not to be all that interested in treating patients with Alzheimer's disease or vascular dementia, cuz it's kinda boring and can be done in primary care. .

This is actually good to know, as I am in principle interested in neuropsychiatry, but also the thought of a clinic primarily made up of these dementias filled me with a very profound, existential dread of literally fatal boredom.

 

[aspiringdoc09]

I am interested in the dementia and neurodegenerative diseases and how psychiatry plays a role. Dementia is cool in my book. I like the geriatric side of things too, which I plan to focus on in my career (I just love old people ). I didn't even realize forensic neuropsychiatrists existed, so thanks for the enlightenment.

 

[slappy]

A neuropsychiatrist is a psychiatrist who specializes in the evaluation, diagnosis, and management of disorders at the brain-behavior interface, including:

• unexplained or functional neurological symptoms
• emotional, behavioral, perceptual, and cognitive symptoms that can occur in neurological diseases, including brain injury, stroke, dementia, epilepsy, multiple sclerosis, and other autoimmune diseases
• delirium and dementia
• neurobehavioral symptoms related to specific brain lesions

The latter two typically come under the field of "cognitive/behavioral neurology" which is subsumed under neuropsychiatry, though came out of neurology.

Neuropsychiatrists conduct a detailed psychiatric evaluation like their general psychiatry counterparts, but with particular emphasis on developmental insults, occupational and toxic exposures, family history, and medical/neurological history. The neuropsychiatric evaluation may include a full neurological examination, but tends to focus on the neurobehavioral mental status examination which focuses on the evaluation of higher cortical functions. Neuropsychiatrists routinely use neuropsychological testing, neuroimaging (MRI, FDG-PET, amyloid PET etc), neurophysiological testing (EEG, sleep studies), and laboratory studies (e.g. CSF studies such as antineuronal antibodies, QT-Quik, tau/phospho-tau/abeta42 etc) as part of their workup.

A forensic neuropsychiatrist is a neuropsychiatrist who uses their expertise to answer psycholegal questions. Forensic neuropsychiatrists conduct independent medical examinations in civil and criminal cases. These cases involve TBI, functional neurological symptoms, dementia (including bvFTD), and amnesia. Malingering of neuropsychiatric symptoms is extremely common in civil cases, and the forensic expert will perform symptom validity testing (or work with a neuropsychologist) to evaluate this possibility. The American Neuropsychiatric Association has a special interest group in this area, and the American Academy of Psychiatry and the Law has a forensic neuropsychiatry committee. Increasingly, neuroimaging features in the courtroom and forensics neuropsychiatrists may be called on to testify as to the relevance of this often used and abused modality. Of note, the neurologist Helen Mayberg, who is best known for her neuroimaging and DBS research in depression, actually makes her fortune as a plaintiff expert in death penalty cases regarding functional neuroimaging that has been presented in mitigation by the defense.

Good stuff.

 

[Blitz2006]

A neuropsychiatrist is a psychiatrist who specializes in the evaluation, diagnosis, and management of disorders at the brain-behavior interface, including:

• unexplained or functional neurological symptoms
• emotional, behavioral, perceptual, and cognitive symptoms that can occur in neurological diseases, including brain injury, stroke, dementia, epilepsy, multiple sclerosis, and other autoimmune diseases
• delirium and dementia
• neurobehavioral symptoms related to specific brain lesions

The latter two typically come under the field of "cognitive/behavioral neurology" which is subsumed under neuropsychiatry, though came out of neurology.

Neuropsychiatrists conduct a detailed psychiatric evaluation like their general psychiatry counterparts, but with particular emphasis on developmental insults, occupational and toxic exposures, family history, and medical/neurological history. The neuropsychiatric evaluation may include a full neurological examination, but tends to focus on the neurobehavioral mental status examination which focuses on the evaluation of higher cortical functions. Neuropsychiatrists routinely use neuropsychological testing, neuroimaging (MRI, FDG-PET, amyloid PET etc), neurophysiological testing (EEG, sleep studies), and laboratory studies (e.g. CSF studies such as antineuronal antibodies, QT-Quik, tau/phospho-tau/abeta42 etc) as part of their workup.

A forensic neuropsychiatrist is a neuropsychiatrist who uses their expertise to answer psycholegal questions. Forensic neuropsychiatrists conduct independent medical examinations in civil and criminal cases. These cases involve TBI, functional neurological symptoms, dementia (including bvFTD), and amnesia. Malingering of neuropsychiatric symptoms is extremely common in civil cases, and the forensic expert will perform symptom validity testing (or work with a neuropsychologist) to evaluate this possibility. The American Neuropsychiatric Association has a special interest group in this area, and the American Academy of Psychiatry and the Law has a forensic neuropsychiatry committee. Increasingly, neuroimaging features in the courtroom and forensics neuropsychiatrists may be called on to testify as to the relevance of this often used and abused modality. Of note, the neurologist Helen Mayberg, who is best known for her neuroimaging and DBS research in depression, actually makes her fortune as a plaintiff expert in death penalty cases regarding functional neuroimaging that has been presented in mitigation by the defense.

How can you become a fellow of ANPA? Is there an exam or certification a Psychiatrist can do? Do you have to do a Neuropsych fellowship to be eligible?

 

[splik]

its an honorary thing not a qualification, you have be approved by the fellowship committee, which is based on having spent a certain amount of years in practice and your contributions to ANPA. I am sure you will find the criteria on the ANPA website.

 

[splik]

This is actually good to know, as I am in principle interested in neuropsychiatry, but also the thought of a clinic primarily made up of these dementias filled me with a very profound, existential dread of literally fatal boredom.

I dont know how you can be interested in neuropsychiatry if you aren't interested in Alzheimer's or cerebrovascular disease! Stroke is literally the basis for behavioral neurology. Alzheimer's disease is not just a memory disorder, and you commonly see illusions, delusions, obsessional behavior, eating behaviors, sexual disorders (typically in those who were sexpests before the disease!), pathological laughing and crying, and the Kluver-Bucy syndrome. Although we tend to think of AD as a disease primarily affecting the temporo-parietal region, AD is a disease of the whole brain, and can begin in the frontal lobes (leading to frontal variant Alzheimer's) or the occipito-parietal region (which is called posterior cortical atrophy and leads to the development of Balint's syndrome, and possibly Gerstmann's syndrome). You can really fascinating cognitive neurological symptoms in Alzheimer's disease. As a genetic disease it is truly fascinating as well. I have seen patients misdiagnosed with depression, hysteria, bipolar disorder, and limbic encephalitis, who have be found at necropsy to have Alzheimer's disease. The genetics of the disease is fascinating (and devastating), and rarely you will see the autosomal dominant forms related to mutations of APP, PS1, and PS2. You can see seizures and myoclonus in AD. The genetic forms often present psychiatrically, and are often rapidly progressive. AD is commonly comorbid with VaD, LBD and even FTD.

Cerebrovascular disease in addition to the cognitive symptoms commonly results in psychiatric symptoms including bipolar dementia (which can occur in Alzheimer's too), and delusional disorders including Ekbom's syndrome (delusional parasitosis), Othello syndrome (delusional jealousy), De Clerambault syndrome (erotomania) and delusional misidentification syndromes including the Capgras syndrome. You can also see obsessionality including the aforementioned which lie on a continuum with delusions. Cerebrovascular disease itself may have various etiologies including CADASIL cerebral amyloid angiopathy, and Biswanger's disease. More rarely, it is the result of vasculitis.

Only dull if you fail to see what is in front of you!

 

[Blitz2006]

its an honorary thing not a qualification, you have be approved by the fellowship committee, which is based on having spent a certain amount of years in practice and your contributions to ANPA. I am sure you will find the criteria on the ANPA website.

Yep, found it:

http://www.anpaonline.org/Fellow

 

[clausewitz2]

I dont know how you can be interested in neuropsychiatry if you aren't interested in Alzheimer's or cerebrovascular disease! Stroke is literally the basis for behavioral neurology. Alzheimer's disease is not just a memory disorder, and you commonly see illusions, delusions, obsessional behavior, eating behaviors, sexual disorders (typically in those who were sexpests before the disease!), pathological laughing and crying, and the Kluver-Bucy syndrome. Although we tend to think of AD as a disease primarily affecting the temporo-parietal region, AD is a disease of the whole brain, and can begin in the frontal lobes (leading to frontal variant Alzheimer's) or the occipito-parietal region (which is called posterior cortical atrophy and leads to the development of Balint's syndrome, and possibly Gerstmann's syndrome). You can really fascinating cognitive neurological symptoms in Alzheimer's disease. As a genetic disease it is truly fascinating as well. I have seen patients misdiagnosed with depression, hysteria, bipolar disorder, and limbic encephalitis, who have be found at necropsy to have Alzheimer's disease. The genetics of the disease is fascinating (and devastating), and rarely you will see the autosomal dominant forms related to mutations of APP, PS1, and PS2. You can see seizures and myoclonus in AD. The genetic forms often present psychiatrically, and are often rapidly progressive. AD is commonly comorbid with VaD, LBD and even FTD.

Cerebrovascular disease in addition to the cognitive symptoms commonly results in psychiatric symptoms including bipolar dementia (which can occur in Alzheimer's too), and delusional disorders including Ekbom's syndrome (delusional parasitosis), Othello syndrome (delusional jealousy), De Clerambault syndrome (erotomania) and delusional misidentification syndromes including the Capgras syndrome. You can also see obsessionality including the aforementioned which lie on a continuum with delusions. Cerebrovascular disease itself may have various etiologies including CADASIL cerebral amyloid angiopathy, and Biswanger's disease. More rarely, it is the result of vasculitis.

Only dull if you fail to see what is in front of you!

Yeah, see, this divorce between the fascinating aspects of the etiology of these conditions and some of the potential manifestations and then the actual business of treating it in clinic, this is what gives me pause. As you yourself said, the actual treatment of AD and vascular dementia is "kinda boring, and can be done in primary care." Careful and exhaustive evaluation is one thing, handing someone aricept or aspirin/statin/script for PT as the daily bread and butter is another thing. As someone who has turned his back fairly definitively on a serious research career and is also uninterested in having predominantly non-therapeutic relationships with patients as you are pursuing, the relative paucity of implications for management once the correct diagnosis is ascertained is something that I can forsee posing an obstacle to my enjoying the work very much.

So perhaps something I will read about, and nod sagely when mentioned, and regale impressionable medical students concerning.

 

[aspiringdoc09]

Bump!

So I'm running into a dilemma. As you all know, there are only a handful of combined programs, so I will need to apply backup psych or neuro. I genuinely like both and was going to apply backup neuro in case I didn't get into a combined program, so I could do back to back residencies. Here is my dilemma: the more I do medicine rotations, the more I find myself hating it. I am completely detached when we are rounding. They round for so long it's hard for me to remain engaged. I realize neurologies intern year is made up mostly of medicine, so I don't know what I'm going to do. I HATE medicine. Now, I'm trying to decide if I should just apply backup psych. I really love neuro, neurological diseases, and the neuro exam; however, I can live with out the medicine portion. I need advice.

 

[HarryMTieboutMD]

Bump!

So I'm running into a dilemma. As you all know, there are only a handful of combined programs, so I will need to apply backup psych or neuro. I genuinely like both and was going to apply backup neuro in case I didn't get into a combined program, so I could do back to back residencies. Here is my dilemma: the more I do medicine rotations, the more I find myself hating it. I am completely detached when we are rounding. They round for so long it's hard for me to remain engaged. I realize neurologies intern year is made up mostly of medicine, so I don't know what I'm going to do. I HATE medicine. Now, I'm trying to decide if I should just apply backup psych. I really love neuro, neurological diseases, and the neuro exam; however, I can live with out the medicine portion. I need advice.

Medicine as a medical student at a US allopathic school generally sucks for a lot of reasons because you aren't actually important to the team (and you can slow down the pace of things if you are on it later in the year); it's really a lot of glorified shadowing, brown nosing, and shelf studying- I HATED it, and I saw the same agony in the med students when I was an intern (different hospitals). HOWEVER, it is MUCH better as an intern because this is when you learn how to be a doctor. Yes the social work and dispo issues still suck and the paperwork is equally horrible, but actually being in the center of the decision making (though frustrating for the first month or so for most 'terns, the categorical IMs included) is really a good experience. Also, as a PGY2 neuro resident you will be responsible for handling most of the medical issues (and there will be a ton) that come up in your patients- you do not want to feel inept in this respect

It is a really bad idea to choose a specialty or even residency based on intern year. It's very common for students to do the latter and is extremely myopic. yes it is true psychiatry doesn't have a full intern year but you are better off deciding which specialty you would rather do. And bear in mind you would have to a full intern year for combined programs. Which specialty would you rather do for the rest of your life? do you see yourself wearing bow ties and cardigans or not? Do you want to lay hands on pts and do procedures or avoid that? Would you rather see pts with headaches, epilepsy and stroke or depression, anxiety and psychosis?

I have yet to meet a medical student who chose a specialty based on the intern year. Most people who choose psych who want an easy lifestyle/don't like internal medicine choose it for the specialty and the residency as a whole, not because they don't want to do 6 more months of medicine. Also, this is hardly a concern for most people (OP is an exception) choosing between psych and neuro because they tend to be better quality students (at least from US MD schools) and this issue is inconsequential (though not having the full intern year may be a deterrent for some people- it almost was for me). Now, within psych people will pick programs based on the intensity of the medicine months, and certainly SOME people going into ophtho/derm/rads will gravitate towards transitional years because they are jokes compared to real medicine intern years.

 

[HarryMTieboutMD]

I dont know how you can be interested in neuropsychiatry if you aren't interested in Alzheimer's or cerebrovascular disease! Stroke is literally the basis for behavioral neurology. Alzheimer's disease is not just a memory disorder, and you commonly see illusions, delusions, obsessional behavior, eating behaviors, sexual disorders (typically in those who were sexpests before the disease!), pathological laughing and crying, and the Kluver-Bucy syndrome. Although we tend to think of AD as a disease primarily affecting the temporo-parietal region, AD is a disease of the whole brain, and can begin in the frontal lobes (leading to frontal variant Alzheimer's) or the occipito-parietal region (which is called posterior cortical atrophy and leads to the development of Balint's syndrome, and possibly Gerstmann's syndrome). You can really fascinating cognitive neurological symptoms in Alzheimer's disease. As a genetic disease it is truly fascinating as well. I have seen patients misdiagnosed with depression, hysteria, bipolar disorder, and limbic encephalitis, who have be found at necropsy to have Alzheimer's disease.

Only dull if you fail to see what is in front of you!

This statement doesn't follow; none of these syndromes are mutually exclusive with DAT. Are you implying that the post mortem neuropathological findings explained the phenomenology that led the ostensibly erroneous diagnoses? Also, BPAD epidemiologically is associated with higher risk for dementia. Presumably if one is diagnosed with limbic encephalitis there is antibody testing used in the diagnosis, so again, I don't follow you.

 

[aspiringdoc09]

It is a really bad idea to choose a specialty or even residency based on intern year. It's very common for students to do the latter and is extremely myopic. yes it is true psychiatry doesn't have a full intern year but you are better off deciding which specialty you would rather do. And bear in mind you would have to a full intern year for combined programs. Which specialty would you rather do for the rest of your life? do you see yourself wearing bow ties and cardigans or not? Do you want to lay hands on pts and do procedures or avoid that? Would you rather see pts with headaches, epilepsy and stroke or depression, anxiety and psychosis?

Thanks for your response. I spoke with the chair of my department about this today, and he stated something similarly. He said I won't even remember my intern year and to choose a backup in something I can see myself doing everyday. For me it can be either, thus my interest in the combined. I guess when I only have a medical student experience, then that's all I have to go on. It's good to get more experienced people's opinions. I appreciate it.

Medicine as a medical student at a US allopathic school generally sucks for a lot of reasons because you aren't actually important to the team (and you can slow down the pace of things if you are on it later in the year); it's really a lot of glorified shadowing, brown nosing, and shelf studying- I HATED it, and I saw the same agony in the med students when I was an intern (different hospitals). HOWEVER, it is MUCH better as an intern because this is when you learn how to be a doctor. Yes the social work and dispo issues still suck and the paperwork is equally horrible, but actually being in the center of the decision making (though frustrating for the first month or so for most 'terns, the categorical IMs included) is really a good experience. Also, as a PGY2 neuro resident you will be responsible for handling most of the medical issues (and there will be a ton) that come up in your patients- you do not want to feel inept in this respect

I have yet to meet a medical student who chose a specialty based on the intern year. Most people who choose psych who want an easy lifestyle/don't like internal medicine choose it for the specialty and the residency as a whole, not because they don't want to do 6 more months of medicine. Also, this is hardly a concern for most people (OP is an exception) choosing between psych and neuro because they tend to be better quality students (at least from US MD schools) and this issue is inconsequential (though not having the full intern year may be a deterrent for some people- it almost was for me). Now, within psych people will pick programs based on the intensity of the medicine months, and certainly SOME people going into ophtho/derm/rads will gravitate towards transitional years because they are jokes compared to real medicine intern years.

It really does suck and I normally blank out if it's not my patient because I'm so disengaged. I don't find myself as passionate about internal medicine as I am about neurology or psych. I was more passionated about ophtho, rads, and path even. I don't feel the same way about internal and its subspecialties especially the inpatient side. Thanks. You get me.

 

[AcronymAllergy]

antibody testing is neither necessary nor sufficient to make a diagnosis of limbic encephalitis. The diagnosis may be made on the basis of the clinical history and neuroimaging findings for instance. new antibodies are being discovered all the time. conversely serum antibodies are often +ve in pts with psychosis and in many cases probably have nothing whatsoever to do with the psychosis.

If someone first becomes manic in their 60s, receives a bipolar dx, dies 3 yrs later and had neuropathological finds consistent with AD, I find that pretty compelling that the patient did not have a primary bipolar disorder but that AD pathology substantially contributed to the development of manic symptoms. Anyone working with EOD pts is aware that many of the early features of early-onset AD, of which emotional symptoms feature strongly, are often dx with hysteria or mood disorder in the first instance. As these early onset (particularly the autosomal dominant form) types are more likely to have a rapidly progressive course, I would say yes, if a few yrs later the pt in their early 50s or before, has necropsy findings of extensive AD pathology, then the dx of depression and hysteria were incorrect.

It's an N=1, but RE: the early-onset AD patient I saw a few months back, if I'd seen only his behavioral presentation and knew nothing about his history, bipolar would've been one of my first considerations (although he also had notable word-finding problems). His neuropsychological profile was also "atypical" when compared with late-onset AD, which of course is not unusual.