Incels: An Introduction for Mental Health Clinicians.

Involuntary celibates ("incels") refers to a group consisting mostly of heterosexual men that exists predominantly in online spaces. These men are united by a belief that they are victimized by a postfeminist society, leading to an inability to engage in sexual intimacy with women. Recent acts of mass violence have been linked to self-identified incels, leading to an increased need for awareness of incel worldviews, argot, and demographics among psychiatrists. Limited research exists to describe this heterogenous group, with existing data suggesting higher rates of depression, anxiety, and suicidal ideation within the demographic. This column reviews the incel worldview, existing literature, how to identify an individual with incel beliefs based on vocabulary and internet usage, and treatment modalities.

Searching for the Whole Truth: Considering Culture and Gender in Forensic Psychiatric Practice.

Contemporary forensic psychiatrists practice in a system that has gender and cultural biases. Though we are only one small piece of the criminal justice system, learning about cultural and gender concerns is critical so that we properly engage and fulfill our mission of striving toward objectivity. Paternalism or chivalry are not the answer when faced with gender questions, as presuming color-blindness is not the answer when faced with cultural questions. Rather, we need to examine our own biases and educate ourselves. Many opportunities for teaching and public health exist in our field, each of which can help address these challenges on a larger scale as well.

Postpartum Psychosis.

PURPOSE OF REVIEW: Postpartum psychosis is a psychiatric emergency that can affect the health and life of mothers, infants, and families. Postpartum psychosis (PPP) is distinct from non-postpartum psychosis in many ways, and it is crucial to study and understand PPP to identify, treat, and possibly prevent this condition. We therefore sought to review the latest research findings about PPP with the intention of updating readers about the latest evidence base. RECENT FINDINGS: Multiple physiologic pathways have been implicated in the development of PPP, and further understanding these pathways may allow for early detection and treatment. Risk assessment and treatment should include consideration of the woman patient but also the mother-infant dyad and the larger family. It is our hope that this review of research updates in postpartum psychosis may inform clinical practice and promote specialized, evidence-based diagnosis, risk assessment, and treatment.

Ending the Cycle of Abuse in Battered Women Defenses.

Intimate partner violence (IPV) is a public health concern, and multiple types of IPV have been described. Women, like men, have various motives for committing intimate partner homicide. This issue of The Journal includes an article reviewing the use of a Battered Woman Syndrome (BWS) defense in American courts. The time was right for a BWS defense a generation ago when there was a lack of understanding of the reasonableness of a woman's action, but not at present. We review the inherent problems of having a gendered law, looking to infanticide acts, as examples. We discuss the validity of BWS considering the DSM and the ICD-10. We explore the role of a forensic psychiatrist in these evaluations, particularly given the lack of a diagnostic, scientific basis for BWS, and consider the similarities with sexually violent predator hearings. In conclusion, we outline considerations for forensic psychiatrists when conducting these examinations. This includes awareness of potential gender bias, recognizing clinical and scientific challenges in the legal diagnosis of BWS, and consideration of the role of posttraumatic stress disorder.

Involuntary Celibates and Forensic Psychiatry.

Incels (a term for those who identify as involuntarily celibate) are most commonly heterosexual men who believe that they are sexually rejected by women because of their genetics and the advent of feminism. The incel movement has grown over the past two decades, with help from the internet. The incel worldview is centered around entitlement, the inferiority of women, and fatalism, which they discuss using specific jargon and idioms. Incels may be referred for various types of forensic psychiatric evaluations as a result of their unusual beliefs, as well as engagement in acts of violence related to their worldview. Understanding the extant literature about the incel population, worldview, and mental health concerns will help forensic psychiatrists to identify members of this subgroup, which will assist in completing forensic evaluations.

Characteristics of Older Defendants Referred for Forensic Evaluations.

This study aimed to provide a descriptive analysis of the geriatric forensic population referred to a Regional Forensic Psychiatric Service by the court for evaluation (as inpatient, outpatient, or while incarcerated) in New Zealand, over a 7-year period. Data were collected retrospectively from forensic hospital records, including court-ordered reports for those aged 60 and older. Two-fifths (42%) of the 97 referred study subjects were diagnosed with some form of cognitive impairment such as dementia. The majority had a prior history of offending. Two-fifths (39%) were facing sexual charges, and one-third (33%) violent charges. Over one-quarter (28%) of the elderly sample was found unfit (incompetent) to stand trial. A better understanding of this group is needed to ensure forensic assessments and health and social services meet their various psychiatric needs.

Clinical and Legal Considerations Regarding Breastfeeding on Psychiatric Units.

Women in the postpartum period are at especially high risk of developing psychiatric disorders, and in severe cases, they may require inpatient psychiatric hospitalization. Because of the lack of specialized units for peripartum mothers in the United States, this treatment is usually relegated to general inpatient psychiatric units. Despite the clear benefit of breastfeeding for both mother and child, lactation can be a barrier to placement on a general inpatient psychiatric unit and often is not supported during the hospital stay. Limiting access to inpatient psychiatric care for postpartum mothers with mental illness could be considered sex discrimination under the Affordable Care Act (ACA) because of failure to accommodate lactation. With improvements in education and accommodations around breastfeeding, general inpatient psychiatric units could provide appropriate care for this population.

Occupational Hazards versus Professional Duty in Reviewing Potentially Traumatizing Evidence.

Electronic evidence, including real-time recordings of crimes by police cameras and smart phones, is becoming increasingly relevant to the practice of forensic psychiatry. A developing literature in fields parallel to our own has described vicarious trauma experienced by mental health and legal professionals exposed to traumatic material in the line of duty. The impact of potentially traumatizing media on the forensic psychiatric evaluation and on the individual forensic psychiatrist is unknown. Calling upon the research and practices of adjacent fields, as well as the personal experience of the authors, this article outlines the benefits and hazards of examining graphic media, addresses potential strategies to mitigate its traumatogenic potential (including among trainees), and suggests how future scholarship may improve understanding of these hazards and inform strategies to prevent them.

Characteristics of Pacific Island People Admitted to a New Zealand Inpatient Forensic Service.

This study describes the characteristics of Pacific Island patients admitted to the Auckland Regional Forensic Psychiatry Service, at Mason Clinic, the largest of five forensic hospitals in New Zealand. Sixty-nine Pacific Island patients admitted over a 9-year period (2009--2017) are described in terms of their sociodemographic and clinical characteristics, access to community mental health care prior to arrest, and their legal history. The majority were men, born in New Zealand, who were single, with poor educational achievement, unemployed, with minimal religious and cultural affiliations, and still living with family prior to the index offense. Almost all had a major psychotic illness, with a mean duration of untreated psychosis of 2.5 years. Most used alcohol and cannabis, and almost half used methamphetamine. The majority of index offenses were violent in nature. These findings identified a disadvantaged and vulnerable group with multiple diagnoses and limited access to mental health services. Culture is fundamental to the causes, course, and care of mental illness. The design and delivery of services that are responsive to the mental health needs of this culturally diverse group may lead to better health outcomes and reduced inequities.

Forensic Evaluation of Sexsomnia.

Sexsomnia is a non-rapid eye movement parasomnic behavior characterized by sexual activity during sleep. Recognized in the most recent editions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Sleep Disorders, sexsomnia is likely to arise with increasing frequency in court as a potential explanation for sexual offending. The forensic psychiatrist has a unique role in the evaluation and management of sexsomnia. The psychosexual evaluation may elucidate the presence or absence of paraphilias and paraphilic disorders and identify any overlap between the alleged sexsomnic behavior and paraphilic interest. In addition, forensic psychiatrists may assess for malingered sexsomnia, provide an opinion regarding criminal responsibility, or evaluate the risk for committing future sexual offenses. Forensic psychiatrists should therefore understand basic information regarding the disorder, as well as how to conduct a psychosexual evaluation effectively in cases of alleged sexsomnia. This article describes the various considerations involved in the forensic evaluation of sexsomnia.

The Realities of Pregnancy and Mothering While Incarcerated.

Women of reproductive age may experience pregnancy and mothering in a correctional environment designed for men. Rates of incarceration for women in the United States are high by international standards, and they continue to rise. Mothers were often single mothers prior to incarceration, and they are often separated from their children for the first time upon entering prison. Pregnancy, delivery, lactation, and parenting each require special consideration. Outcomes of pregnancy in prison are better overall than for similarly disadvantaged women in the community. Breastfeeding, despite being recommended by medical groups, is problematic for most who are awaiting forced separation from their infant, due to a lack of mother-baby units in most U.S. states. Mother-baby units have crucial goals, including improved family relations and decreased recidivism. They should not discriminate against mothers with treated perinatal mental illness. Many barriers for visitation of incarcerated mothers exist, including that, because there are fewer women's prisons, there are greater distances between mothers and children. This article reviews data about pregnancy and motherhood in corrections, and it discusses the international state of mother-baby units, with implications for U.S. corrections.

Showtime's The Affair: the Rashomon effect, eyewitness testimony, and lack of reliability in homicide.

OBJECTIVE: The Rashomon effect explores point of view in storytelling, and the subjectivity of even honest narratives is based on point of view. In 1950, Rashomon was the first film to explore this. Currently, The Affair explores the differences in story based on point of view. Both clinical and forensic psychiatrists must consider point of view when hearing narratives from patients or defendants. CONCLUSION: The Affair provides an excellent contemporary example through which to explore the Rashomon effect in conceptualization of eyewitness testimony and reliability of reporting.

Prescribing for Women in Corrections.

Prescribing for women in jails and prisons requires special consideration and should be informed by extant evidence. Incarcerated women have higher rates of mental illness than both females in the community and incarcerated men. Medication administration concerns that may disproportionately affect female prisoners include drug-drug interactions with contraceptives, intermittent dosing schedules, and concerns about metabolic side effects. Further, pregnancy, lactation, and menopause may all affect medication choices. Incarcerated women frequently have comorbid mental illness, substance use disorders, and personality disorders. Finally, specific disorders, such as posttraumatic stress disorder, are more common in this population and merit special consideration for recognition and treatment.

The myth of school shooters and psychotropic medications.

There has been an assertion in certain parts of the media, especially social media, that the majority of individuals who have engaged in a school shooting were prescribed psychotropic medications prior to the event. To determine if there is any validity to this assertion, the authors of this article reviewed publicly available information regarding individuals involved in "educational shootings" per FBI publications for active shooters from 2000 to 2017. Sources of information included news reports with official citations, official reports regarding events, available court records, and FBI Freedom of Information Act requests. Secondary data-points were also collected, such as location, number of weapons used, number of victims, legal outcome, and whether the shooter committed suicide. From the information obtained, it appears that most school shooters were not previously treated with psychotropic medications - and even when they were, no direct or causal association was found.

Medical Privacy versus Public Safety in Aviation.

Confidentiality, considered a fundamental principle of medical ethics, is potentially at odds with public safety when an airplane pilot is experiencing symptoms of mental illness. Reporting requirements for pilots vary across the world, and pilots can be subject to multiple national regulatory authorities for international flights. Stigma exists about getting treated for depression. If one's livelihood and core sense of identity is placed at risk by seeking treatment, people will naturally avoid assessments and engagement with mental health clinicians, the very treatment that could mitigate risk. Suicide and homicide by aircraft are rare events and are difficult to predict, but the impact can be catastrophic. Variables other than mental illness, such as personality structure, occupational and relationship stressors, and coping mechanisms are also critical in conceptualizing risk in this population. Requirements for those employed in other methods of transportation are contrasted with those for pilots. Finally, legal and ethics concerns regarding reporting requirements for pilots are discussed and suggestions made.

Insanity: A Legal and Cinematic Diagnosis.

The term "insanity" has been retired from medical nomenclature for about 100 years. Formerly interchangeable with the legal term, implying unsoundness of mind, it persists as a legal determination, mainly in criminal matters. However, the most prevalent uses of "insanity" are in colloquial speech and media. We track "insanity" in medical and legal parlance, reasons for its disappearance from psychiatry, and its persistence in popular culture. During the 19th century, specific types of legal insanity fell out of favor, especially "moral insanity," referring to irresistible impulses. The term persisted, for example, in some civil cases and in criminal cases, both denoting lack of capacity. In America, early 20th century focus on disease classification and nomenclature shifted from catchall terms (such as insanity, dementia, mania, and idiocy) to medical labels (psychosis and neurosis). Psychiatrist William Alanson White led the movement to change nomenclature. In 1921, the American Journal of Insanity became the American Journal of Psychiatry. By the time White was the American Psychiatric Association president in 1925, the medical use of "insanity" had been replaced in textbooks by progressive terminology. However, variations on "insane," suggesting loss of reason without diagnostic specificity, have become a staple among film tropes.