The Joze Jancar memorial lecture on Neurodevelopmental psychiatry given at the 2012 Annual residential conference of the Faculty of Intellectual Disability of the Royal College of Psychiatrists

1. Joze Jancar Memorial Lecture:
Neurodevelopmental psychiatry
Digby Tantam
Professor Emeritus, University of Sheffield
Honorary Senior Visiting Research Fellow,
University of Cambridge
Director, Septimus Ltd
Honorary Consultant Psychiatrist and
Psychotherapist, Sheffield Health and Social Care
NHS Foundation Trust

2. Joze Jancar
• Cross country ski
champion in Slovenia
• Protegee of Iris
Murdoch
• Burden Research
Gold Medal and Prize
• Vice-President and
Honorary Fellow,
RCPsych
• Freeman of the City of
London

3. • 2011, Dr Sylvia Carpenter
• 2010, The Health of Children with Intellectual Disabilities and their Families’,
Professor Sheila Hollins (Immediate Past President, Royal College of
Psychiatrists)
• 2009, ‘Health inequalities: a focus on the remote and rural areas of the UK’,
Professor Richard Collacott
• 2008, Professor Gregory O’Brien, Northgate Hospital, Northumberland
• 2007 Professor Tony Holland, Rights of people with intellectual disability
• 2006, ‘Medical self-regulation in the 21st Century – hallmark of the profession or
archaic artefact’, Dr John Hillery
• 2005, ‘Past, present and future: from stethoscope to crystal ball’, Dr J Calvert.
• 2004,‘People with learning disability: who really cares?’, Dr R A Collacott,
Western Isles Hospital, Stornoway.
• 2003, ‘History of Faculty of Learning Disability as seen through the eyes of Dr
Alan Heaton-Ward’, Dr Alan Heaton-Ward
• 2002, ‘The limits of psychiatry’, Dr Mike Shooter, President, The Royal College of
Psychiatrists, London.
• 2001 Professor Michael Gunn, Nottingham Law School, Nottingham (no available abstract).
• 2000, Dr Leila Cooke, Phoenix NHS Trust Bristol Central (no available abstract).

4. Me?
• General psychiatrist, rehabilitation, intensive care
unit, community mental health team founder,
service for transgender people, service for people
who repeatedly self-wound, group analyst,
consultant psychotherapist, director of general
psychiatry training, psychiatrist to University of
Warwick…
• FBPsS
• providing assessment service for people,
especially adults, suspected of having ASD since
1981

5. An
unashamed
plug

6. • From the Description of Mike Shooter’s Joze
Jancar Memorial Lecture:
• “At the same time, the lecture suggests ways in
which Psychiatry has shifted the borders between
itself, politics and social morality - in its lack of
clarity between social problems, psychiatric need
and service possibilities, and in systems of
classification (ICD and DSM) that hover
uncertainly over the inevitable consequences of
deprivation (conduct disorder), the normal
reactions to catastrophe (grief and PTSD) and a
hotch-potch of mysticism, philosophy and
historical empire-building (personality disorder)”.

7. Psychiatry is a medical speciality
• We are not primarily, and we are not trained to
be:
• Social workers, or sociologists
• Ethicists
• Politicians
• Leaders and managers (well, not so many of us)
• Historians
• Service planners
• Counsellors or psychotherapists
• Psychologists

8. Clinical pathology in mental retardation
Eastham, R. and Jancar, J.
• Nonspecific Laboratory Findings in Mentally 5
• Disorders of Lipid Metabolism 100
• Disorders of Carbohydrate Metabolism 133
• Disorders of Endocrine Metabolism 165
• Disorders of Metabolism of Connective Tissue 184
• Chromosomal Anomalies 195
• Other Conditions known to cause Mental handicap 208
• 210 Infections 216 Disturbance of Immunity 263 Disorders
of Liver Metabolism 268 Disorders of Pancreatic function
281 Disorders of Folic Acid and Related Anaemias 299
Erythrocyte Abnormalities 305 Leucocyte Abnormalities 309
• Conditions known to be associated with Mental disorder
335

9. Intellectual disabilities
• Are of interest as forms of existence, of
interest in itself, and not just as a sign of
underlying derangement
• Inborn errors of metabolism giving way to
SNPs
• Recent reports of SNPs on random trawls with
microarrays suggest frequencies of people with ID
and SNPs to be between 0.8 and 8% (the latter
with ADHD)
• Very many possible SNPs, if ASD is anything
to go by—so no small number of pathologies

10. • Some of us become these things, of course
• Some of us even have further training to
become these things
• So what are we primarily?
• In the past, this has been a problem because
what is there to psychiatry that is over and
above being wise and decent?
• Not pathology

11. Where the wetware meets the
software
• Where the neuroscientists and the
neurogeneticists are—
• And where the medicine of intellectual
disability needs to be

12. Why medicine and not psychology?
• A reliance on observation and deduction,
and not testing
• The importance of emotion in altering
cognitive states
• Mess?

13. Montague PR, Dolan RJ, Friston KJ, Dayan P. Computational psychiatry.
Trends in Cognitive Sciences. 2012;16(1):72-80

14. • Working memory
• Narrative and theory of mind
• The interbrain

15. WORKING MEMORY

16. Working memory
• Perceptual and verbal
• Processed (links with perceptual cortex) but still short-
term memory
• Required for pre-processing memories for hippocampal
and then cortical storage
• Not correlated with intelligence
• Affected by anxiety
• Affected by practice

17. Working memory
• Verbal working memory involved in parsing phrases (Fernell, E.,
Norrelgen, F., Bozkurt, I. et al, 2002;Adams, A. M. and Gathercole, S.
E., 2000), language learning {Cohen, 2000 #14361}, mental
arithmetic, following instructions, returning to a task after an
interruption, ‘multitasking’ (actually switching attention from one task
to another, but maintaining a ‘tab’ on each task to mark progress so
that switching goes back to the point of the time and money
budgetting, organization and planning
• Dysexecutive problems, secondary to reduced working memory, are
common causes of failure of independent living
• Improved by practice
• Splinted by note pads, personal organizers, phones

18. • These results suggest that when presented with a complex scene consisting of items from
a variety of categories, the underlying representations of those categories will compete for
representation. When those representations do not overlap, there is little to no competition
and an increase in behavioral performance is obtained. However, when those
representations do overlap, they interact in a mutually suppressive manner, which leads to
difficulty remembering the items
• http://tech.groups.yahoo.com/group/boston-neurotalks/message/6820

19. NARRATIVE

20. Narrative
• IQ 60
• Recent severe hypoxic episode
• Parents rowed, sometimes about him
• He said, ““I do get worried about something
happening to mum… I’ve got fits haven’t I, I
can’t protect my mum, what if she’s old”.

21. Animals that gain
information from
conspecifics gaze
direction

22. Narrative impairment
• Narrative
•

23. The orbitofrontal cortex as cache? fNIRS evidence
Brink, T. T., Urton, K., Held, D., Kirilina, E., Hofmann, M. J., Klann-Delius, G., et al. (2011). The role of
orbitofrontal cortex in processing empathy stories in 4- to 8-year-old children. Front Psychol, 2, 80.
Negative
affective
empathy
Positive
affective
empathy
Logical
cognitive
empathy
Non-
logical
cognitive
empathy

24. Two kinds of empathy: fNIRS evidence
Brink, T. T., Urton, K., Held, D., Kirilina, E., Hofmann, M. J., Klann-Delius, G., et al. (2011). The role of
orbitofrontal cortex in processing empathy stories in 4- to 8-year-old children. Front Psychol, 2, 80.
Similar picture for auditory stimuli

25. THE INTERBRAIN

27. Atttention direction

28. Brain regions showing positive change in coupling with the right pSTS (red to yellow) and FG
(blue to turquoise) while viewing gaze shifts versus opening/closing the eyes.
Nummenmaa L et al. Cereb. Cortex 2010;20:1780-1787
© The Authors 2009. Published by Oxford University Press.

29. Perlman, S. B., Hudac, C. M., Pegors, T., Minshew, N. J., & Pelphrey, K. A. (2011). Experimental
manipulation of face-evoked activity in the fusiform gyrus of individuals with autism. Soc
Neurosci, 6(1), 22-30.

31. Schurmann M, Hesse MD, Stephan KE, Saarela M, Zilles K, Hari R, et al.
Yearning to yawn: the neural basis of contagious yawning. Neuroimage. [doi:
DOI: 10.1016/j.neuroimage.2004.10.022]. 2005;24(4):1260-4.

32. Reflective
NVC
Reflexive NVC

33. • Neurons are linked by electrical impulses and
chemicals into a network
• Our brains can be linked to other brains the
way that one computer can be linked to
another via the internet
• These links are the nonverbal communications
that pass between us, principally consisting of
imitation and of gaze following
• Imitation and gaze following are automatically
initiated by local brain networks apparently
specialized for this

34. Morishima Y, Schunk D, Bruhin A, Ruff CC, Fehr E. Linking Brain
Structure and Activation in Temporoparietal Junction to Explain the
Neurobiology of Human Altruism. Neuron. 2012;75(1):73-9.

35. CONCLUSIONS

36. • Psychiatry needs to overcome its identity crisis
• And shrug off its alienist function
• Needs, in fact, to have an organ or physical
function in which it specializes
• The interface between wetware and software/
brain and consciousness provides this
• Intellectual disability stands to gain particularly
• Let’s dust off our observational skills
• Add a pinch of wisdom about emotions
• Start to identify ‘modules’ of higher order
functioning