GREAT EXPECTATIONS A Warm Welcome to 21st Century Psychiatry

In the last third of the 20th century, psychiatry boldly shook off a 120-year-long philosophical funk and rushed to catch up in the thrilling march of medicine. The biopsychosocial model that once sounded trendy now seems to be an indispensable approach. The pioneers of psychopharmacology who once labored at the margins have now been joined by thousands of bright young doctors who treat patients with depression, psychosis and impulsive aggression and realize that a troubled soul is often expressing the cries of a troubled brain. This issue of Psychiatric Times celebrates the stirring giant that is 21st-century neuropsychiatry--a discipline that derives its immense power and scope from the glad embrace of the twin Enlightenment ideals of humanism and the scientific method.

We are grateful for contributions from some of the leaders of this new psychiatry. To start off, Paul Thompson, Ph.D., of University of California, Los Angeles tackles one of the toughest questions in psychiatry: What causes schizophrenia? Collaborating with Judith Rapoport, M.D., of the National Institutes of Mental Health in an impressive longitudinal study, Dr. Thompson has discovered exciting evidence that children who are destined to have schizophrenia experience a dynamic wave of tissue loss that starts in the parietal lobe and sweeps across the cortex over a five-year period. He has gone further, finding evidence of both genetic and nongenetic factors in this devastating process. These findings, taken together, guide us one step closer to understanding the core pathophysiology of nuclear schizophrenia.

Traumatic brain injury is often called America's silent epidemic, because it occurs with astonishing frequency and gets surprisingly little attention by the community of medical researchers. One reason for this lack of attention is that, unlike so many neurological conditions with unambiguous focality and relatively circumscribed presentations, the battered brain can be damaged in innumerable ways, leading to a dazzling spectrum of symptoms. Daryl Fujii, Ph.D., University of Hawaii, explores one part of the spectrum of posttraumatic behavioral disturbances: psychosis. Dr. Fujii proposes a helpful new framework for the classification of different types of posttraumatic psychosis, based upon the new appreciation that brain injury can produce a thought disorder via several different routes: from a direct assault on frontal dopaminergic systems, to a lowering of the seizure threshold, to an unmasking of a psychotic predisposition.

Larry J. Siever, M.D., Mount Sinai School of Medicine, has taken up an extremely timely question: Why are some people especially aggressive? Of course, the answer to such a deep question is not simple. Understanding a given act of aggression may require an appreciation of evolutionary prescriptions, inborn temperament, developmental influences, precipitating events and the disinhibiting influence of intoxicants. But the bottom line is that the brain mediates aggression, and the study of the brain--from focal lesion studies to psychopharmacology to molecular genetics--is beginning to illuminate the physiology of human interpersonal violence.

Finally, Ole Bernt Fasmer, M.D., and Ketil Joachim Oedegaard, M.D., University of Bergen, alert us to a new issue in neuropsychiatric epidemiology: the possible link between migraine and bipolar mood disorders. Since migraine has a clear genetic component, and since both conditions seems to involve atypical serotonergic function, the discovery of this epidemiological link may unlock the gate to a new pathway of investigation; we may soon come to understand how discreet abnormalities in the developing brain may cause multiple types of symptoms--some that have traditionally been considered within the domain of neurology and others traditionally claimed by psychiatry.

I am honored and pleased to introduce this special section of PT--a tribute to some pulse-pounding advances in the state of the art of neuropsychiatry and a promise of great days to come.