The BNPA conference this year was a special one, celebrating 30 years since a small band of Neuropsychiatrists, Neurologists and Psychologists banded together to have an academic meeting. To mark the occasion, there was a special day looking at Neuropsychiatry – past, present and future.
Jonathan Bird, the founding member of the BNPA, started us off by detailing the split between Neurology and Psychiatry which he proposed started because of the opposing philosophies of clinicians like Charcot and Maudsley. This resulted in the Neurologists having a steady stream of well to do patients asking for private consultations. The separation was consolidated with Freudian views, which finally enabled the Psychiatrists to obtain some private work! In typical style Jonathan was frank and contentious in his views and referred to the aristocratic Neurologist of the time – a theme that was continued throughout the day, although no Neurologist sported a bow tie as resplendent as Jonathan’s! Laura Goldstein followed him to give a moving account of Maria Wyke, a Neuropsychologist and founding member of the BNPA who died recently. She was one of the first on the executive committee for the BNPA.
Andrew Lees was invited back to talk, having last been invited in 1988. He talked about the link between anxiety and Parkinson’s disease (PD) and the phenomena described by Gowers where a sudden shock could seemingly unmask PD and the possibility of chronic stress triggering PD. As usual there were lots of interesting snippets of information, but perhaps his most interesting, from an introspective point of view, is the assertion made by William Burroughs, that “Doctors are limited in their outlook…they have read all there is to read on a subject and that is that”.
Due to a software hitch on Jon Stone’s computer (luckily not the hardware which would be bad news for a functional Neurologist!) Michael Trimble came next, taking us from Hippocrates, through the development of EEG by Berger, to Meduna and the development of electro-convulsive therapy as a treatment for schizophrenia.
Jon Stone did eventually get his software working and treated us to a masterful account of the history of functional disorders. As he stated, they were very popular disorders in the time of Charcot and before the 1930s and then apparently disappeared from view after that until the 1990s. This was not because they had all got better but because they were all going to Neurology clinics and not to the psychiatrists! He treated us to a range of films showing us the similarities in gait between the patients in the early part of the 20th Century and now.
Anyone who has heard Ray Dolan speak will know what a tour de force he is. He managed to explain neuro-economics to us and show that his computational analysis explained the change in gambling strategies over different age groups when correlated with decline in dopamine levels, which we all suffer after the age of 20. He did this by showing us a range of mathematical equations, quelling our fears by telling us that “It is all very simple really”. Despite the maths he also managed to explain why happiness does not depend on winning money – a lucky thing really if you work for the NHS.
Brian Simpson told us about neurosurgery in psychiatry and the frontal lobe operations which were done widely with no good evaluation of the side effects in the 1930s. He also postulated on the possibility of using deep brain stimulation for Alzheimer’s disease, which is apparently in trial as we speak.
Modern psychopharmacology was started with Jean Delay as recounted by David Healy. He described the discovery of the benefits of chlorpromazine and went on to explain the pitfalls of psychopharmacology in relation to side effects and the rise of rating scales and the possible demise of the role of the doctor! David Linden finished off the section by detailing the various methods by which patients can communicate or control devices with their mind.
The last part of the day was explaining the training regimes for Neurology, Neuropsychiatry and Neuropsychology. It appears that everyone takes 12 years to train apart from the Neurologists who take 14 years at the moment. However Tom Hughes, chair of the Neurology Specialist Advisory Committee for Neurology, was very descriptive with 5 glasses, a tea cup and 5 bottles of water in explaining that shape of training would mean that we would all have less water…..and trainees, in the new neurology system.
The next day started with a giant in the field, Trevor Robbins. He took us through the neurobiology of addiction relating to impulsivity and compulsivity in rats and humans. A learning point for me was that addicts may well have a predisposition to impulsivity. Importantly changes in the brain occur in addicts to suggest that they have more habitual responses than goal directed behaviours therefore compounding the problem as they are cognitively less able to come off the drug.
Valerie Voon continued the theme, talking about impulsivity in Parkinson’s disease. She postulated that the lack of dopamine made patients more susceptible to the reward effects of the dopamine or dopamine agonists that they are given, therefore leading to impulsivity. Importantly, dopamine agonists can turn off autoreceptors, leading to reduced reuptake of dopamine from the synaptic cleft, therefore further potentiating the reinforcing effect of the drugs.
Killian Welsh discussed alcohol dependence and the effects of withdrawal. He showed evidence that patients were more likely to develop seizures if they had withdrawn from alcohol on more than 5 occasions. On the positive side, he stated that improvement in cognition and brain volumes do occur after abstinence and can occur even up to 7 years after giving up.
Sanjay Manohar used saccadic eye movements to explain apathy, discovering that eye movements are not confined to the main sequence and can move faster than expected and with more accuracy if suitably motivated. Apparently noradrenaline is related to the effort of an action and this was used as the explanation why dopamine agonists and cholinesterase inhibitors can be used to help patients with apathy.
Irene Tracey from Oxford was the JNNP plenary lecturer talking about Magnetic Resonance imaging in pain. She was my favourite speaker of the conference and showed clearly how a peripheral source of pain, for example osteoarthritis of a joint, can be magnified by central processes and lack of inhibition of the pain signals by the dorsal horns and midbrain. Crucially she stated that chronic pain is not all in the patient’s mind but is enhanced pain. She intimated that there are drugs on the way to effectively block peripheral pain which will therefore open up the path for those central processes, divorced from a peripheral stimulus, to die away.
Three junior presentations showed us what great researchers we have in the making with subjects as diverse as: phenotypes of different types of organic psychosis; deep brain stimulation in obsessive compulsive disorder and cognitive loss in limbic encephalitis. Sarosh Irani from Oxford expanded on testing of limbic encephalitis and explained that there are a number of assays that are not clinically relevant when testing for voltage gated potassium channel antibody. Some assays detect patient immunoglobulin binding to the snake venom used as a vector rather than the channel! He therefore urged us to request LGI1 and CASPR2 antibodies only. Lastly Niels Detert, also from Oxford, discussed the widespread advantage of mindfulness training in depression, fibromyalgia, chronic pain and many other conditions. Most importantly it stands alone as a treatment which can provide cognitive benefits, although the patient may need to attend a 3 month retreat!
It is a tradition of the BNPA to have a dinner somewhere special. Previous years have been in the magic circle and the museum of comedy. This year was in the headquarters of the Order of St John in Clerkenwell, an ancient building full of history. There we were given tours and regaled by a choir while we ate and drank.
Our last day started with David Sharp discussing brain imaging and traumatic brain injury (TBI). He discussed, among other things, the finding of Tau protein deposition in sulci after injuries and the model he developed showing that, in head injury, the majority of the damaging forces acting on the brain are in the sulci. This contrasted with our third talk by Alan Carson who asserted that pathologists cannot always reliably determine chronic traumatic encephalopathy and that American football players, who have many head injuries, are on the whole healthier and have a lower risk of Alzheimer’s disease than the general population. He coped admirably as first the projector stopped working and then the technicians took away his computer thereby removing his prompts for his speech. Peter Hutchinson continued the theme of TBI, albeit in patients with more severe injuries, by discussing trials looking at the early decompression of bleeds (not helpful) with late decompression, after extensive medical therapy to reduce rising intracerebral pressure, which did seem beneficial.
Nick Ward talked about stroke and the importance of starting rehabilitation as soon as possible after the onset in order to capitalise on the best chance of plasticity and recovery. Perhaps we will soon see physiotherapists called urgently to the ward to treat our stroke patients.
Martin Rossor gave the BNPA medal lecture detailing his long involvement in dementia. He described his attendance at the first BNPA meeting in 1987 when he apparently stood up and suggested it should be called the “Association of Behavioural Neurology”. This did not seem to go down well for some reason! He presented his involvement in the discovery of presenilin and the surprises that he has encountered over the years: the tau mutation which presented with hippocampal atrophy and the man with posterior cortical atrophy who couldn’t see static objects but could play badminton due to the preservation of visual networks for moving objects. A fascinating talk.
After lunch we were treated to a talk by Lord David Owen who trained as a doctor with rotations in Neurology and Psychiatry. He discussed the Hubris syndrome, the tendency for people with power to be corrupted. He warned us to be on the lookout for leaders who treated those who worked for them with contempt and described the previous prime ministers who he felt had Hubris Syndrome including Margaret Thatcher. His insights into the working of the Government in his role as foreign secretary were even more revealing and compelling.
The BNPA conference is always varied and stimulating and this year was no exception. The introduction of guided poster presentations really helped showcase the many posters received.
The next BNPA event is the teaching weekend on the 8-10th December 2017 aimed at registrars who wish to understand neurology and psychiatry at the points they overlap and the next conference will be held on the 1st and 2nd of March – see bnpa.org.uk for details.