Integrating a Neuroscience Perspective Into Clinical Psychiatry Today

Abstract

As psychiatrists, we are asked to treat patients with extremely complex illnesses. There are many possible ways to think about and formulate cases, including a range of psychological and social perspectives, each with their own strengths and limitations. To varying degrees, these perspectives have rightfully guided the development of our field and continue to shape the standards of our practice.During the past 20 years, revolutionary new tools and approaches in neuroscience have led to unprecedented progress in our ability to understand the biological underpinnings of psychiatric illnesses. 1 This work very much complements rather than competes with our other rich traditions. In fact, distinctions between "psychological" and "biological" are rapidly fading as evidence demonstrates that all effective treatments (whether psychotherapy or pharmacologic agents) alter core brain networks and thus are all biological in nature. 2 Cognitive neuroscience is providing contemporary neural system models for understanding psychodynamic concepts such as our sense of self, defenses and drives, and unconscious thoughts and motivations. 1 In addition, an understanding of epigenetics offers novel insights into how social context and environmental factors translate into biological changes at the level of gene expression. 3 Collectively, these advances offer a new framework for drawing together the seemingly diverse perspectives of a traditional biopsychosocial formulation. 4 They present an opportunity to create a new dialogue with our patients, their families, and other health care professionals about the cause and meaning of psychiatric symptoms. They ground psychiatric disorders and associated maladaptive behaviors in the context of a brain disease and away from issues of character and moral fiber that often drive the shame, blame, and stigma many patients face. While many of these findings have not yet translated into novel therapeutic approaches, they can still guide and inform our treatment choices. For example, understanding the role that fear conditioning and learning plays in posttraumatic stress disorder helps to clarify why trauma-focused psychotherapies are currently our most effective treatments. 5,6 Despite the relevance of neuroscience to the practice of psychiatry, figuring out how to best integrate this perspective into our field remains a challenge. 7 Psychiatry has been a well-established clinical discipline since long before we had the power to study the brain in a nuanced manner, let alone to develop sophisticated biological explanations of psychiatric illness. Accordingly, it is no surprise that such a large practice gap should exist: although mental illness is increasingly understood in terms of genetics, developmental neurobiology, and underlying neural circuitry, these essential perspectives are

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