Forensic Psychiatry versus the Varieties of Delusion-Like Belief.

The available categorical constructs within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, do not allow forensic psychiatrists to distinguish easily between the varieties of delusion-like belief. This dilemma is especially challenging when seemingly delusional beliefs are shared online. Although the term "extreme overvalued belief" has been proposed to aid with such distinctions, its definition has conceptual problems, including diagnostic overlap with shared delusions, "extremism" that refers to behavior rather than belief, and the potential to be applied with prosecutorial bias to thwart defense strategies attempting to establish connections between criminal behavior and less than optimal mental health. Beliefs and behavior that are not obviously symptomatic of mental illness are best explained by integrating psychiatric expertise with that of other disciplines such as psychology, sociology, and political science. Dimensional quantification of belief conviction and preoccupation as well as established concepts like conspiracy theories and sacred values can help forensic evaluators characterize ideological motives for deviant behavior more accurately to better inform legal decisions about criminal responsibility and therapeutic justice.

Assessing Malingered Auditory Verbal Hallucinations in Forensic and Clinical Settings.

The gold standard for the detection of malingered psychosis involves expert clinical assessment augmented by standardized psychometric testing. The evaluation of malingered auditory verbal hallucinations is complicated, however, by increasing evidence that voice-hearing is a broadly heterogeneous experience that does not always reflect psychopathology, with atypical features nearly as common as typical characteristics. The detection of malingered auditory verbal hallucinations in clinical settings may be particularly vulnerable to false positives and false negatives due to low suspicion on the part of clinicians, low utilization and poor specificity of psychometric testing, and "iatrogenic malingering" that is less likely to include cartoonish claims and more likely to involve voice-hearing as a sole presenting symptom (i.e., monosymptomatic auditory verbal hallucinations). In both clinical and forensic settings, the detection of malingered auditory verbal hallucinations requires detailed exploration of phenomenologic features along with mediating factors that influence the risk of associated violence or suicide.

Integrating Non-Psychiatric Models of Delusion-Like Beliefs into Forensic Psychiatric Assessment.

In both clinical and forensic psychiatry, it can often be difficult to distinguish delusions from normal beliefs. The categorical approach of the Diagnostic and Statistical Manual of Mental Disorders (DSM) leaves few options to describe intermediate delusion-like beliefs (DLBs). Neurocognitive models offer an alternative view of DLBs as existing on a continuum that can be quantified based on dimensions of severity as well as underlying cognitive biases. The Internet provides broadened access to putative evidence for diverse beliefs, with filter bubbles and echo chambers that can amplify confirmation bias and strengthen conviction. It is therefore much easier now for fringe beliefs to be shared and much less clear when they should be considered delusional. To place DLBs into a forensically relevant framework, psychiatric expert witnesses should adopt a broad biopsychosocial understanding of belief formation and maintenance that integrates clinical expertise with knowledge about dimensional aspects of delusions, cognitive biases, and the processing of online misinformation. The unavoidable conclusion that normal thinking is replete with cognitive biases and misbeliefs challenges the legal concept of mens rea that forms the foundation of a retributivist American justice system.

Tattoos as a window to the psyche: How talking about skin art can inform psychiatric practice.

Tattooing the skin as a means of personal expression is a ritualized practice that has been around for centuries across many different cultures. Accordingly, the symbolic meaning of tattoos has evolved over time and is highly individualized, from both the internal perspective of the wearer and the external perspective of an observer. Within modern Western societies through the 1970s, tattoos represented a cultural taboo, typically associated with those outside of the mainstream such as soldiers, incarcerated criminals, gang members, and others belonging to marginalized and counter-cultural groups. This paper aims to review the more recent epidemiology of tattoos in Western culture in order to establish that tattooing has become a mainstream phenomenon. We then review psychological and psychiatric aspects of tattoos, with a goal of revising outmoded stigmas about tattooing and helping clinicians working with tattooed patients to facilitate an exploration of the personal meaning of skin art and self-identity. We suggest that as a kind of augmentation of the physical exam, looking at and talking to patients about their tattoos can provide a valuable window into the psyche, informing clinical practice.

Therapeutic Lifestyle Changes: Impact on Weight, Quality of Life, and Psychiatric Symptoms in Veterans With Mental Illness.

INTRODUCTION: Veterans with mental illness tend to have shorter life spans and suboptimal physical health because of a variety of factors. These factors include poor nutrition, being overweight, and smoking cigarettes. Nonphysical contributors that may affect quality of life are the stigma associated with mental illness, social difficulties, and spiritual crises. Current mental health treatment focuses primarily on the delivery of medication and evidence-based psychotherapies, which may not affect all the above areas of a Veteran's life as they focus primarily on improving psychological symptoms. Clinicians may find greater success using integrative, comprehensive, multifaceted programs to treat these problems spanning the biological, psychological, social, and spiritual domains. These pilot studies test an adjunctive, holistic, behavioral approach to treat mental illness. This pilot work explores the hypotheses that engagement in a greater number of therapeutic lifestyle changes (TLCs) leads to improvement in quality of life, reduction of psychiatric symptoms, and weight loss. MATERIALS AND METHODS: Institutional Review Boards for human subjects at the Veterans Affairs (VA) Greater Los Angeles and Long Beach Healthcare Systems approved pilot study activities at their sites. Pilot Study 1 was a prospective survey study of Veterans with mental illness, who gained weight on an atypical antipsychotic medication regimen, participating in a weight management study. At each session of the 1-year study, researchers asked a convenience sample of 55 Veterans in the treatment arm whether they engaged in each of the eight TLCs: exercise, nutrition/diet, stress management and relaxation, time in nature, relationships, service to others, religious or spiritual involvement, and recreation. Pilot Study 2 applied the TLC behavioral intervention and examined 19 Veterans with mental illness, who attended four classes about TLCs, received individual counseling over 9 weeks, and maintained journals to track TLC practice. Besides weekly journals, researchers also collected prospective data on quality of life, psychiatric symptoms, vitals, and anthropometric measurements. In both studies, investigators tested for main effects of the total number of TLCs practiced and study week using mixed-effects linear models with independent intercepts by participant. RESULTS: In Study 1, engagement in more TLC behaviors was significantly associated with higher ratings of quality of life, as well as greater weight loss for each additional type of TLC practiced. In Study 2, TLC practice increased significantly over 9 weeks, and was significantly associated with improvements in quality of life and diastolic blood pressure. CONCLUSION: Counseling Veterans to practice TLCs provides a holistic adjunct to current treatments for mental illness. TLCs may confer multiple benefits upon Veterans with mental illness, enhancing quality of life and well-being along with weight management efforts. As these were pilot studies, the samples sizes were relatively small and a control group was lacking. Our findings may have broader implications supporting a holistic approach in both primary and mental health care settings. Future research will expand this work to address its weaknesses and examine the cost differential between this holistic approach and traditional mental health treatment.

A Randomized, Controlled Multisite Study of Behavioral Interventions for Veterans with Mental Illness and Antipsychotic Medication-Associated Obesity.

BACKGROUND: Weight gain and other metabolic sequelae of antipsychotic medications can lead to medication non-adherence, reduced quality of life, increased costs, and premature mortality. Of the approaches to address this, behavioral interventions are less invasive, cost less, and can result in sustained long-term benefits. OBJECTIVE: We investigated behavioral weight management interventions for veterans with mental illness across four medical centers within the Veterans Affairs (VA) Healthcare System. DESIGN: We conducted a 12-month, multi-site extension of our previous randomized, controlled study, comparing treatment and control groups. PARTICIPANTS: Veterans (and some non-veteran women) diagnosed with mental illness, overweight (defined as having a BMI over 25), and required ongoing antipsychotic therapy. INTERVENTIONS: One group received "Lifestyle Balance" (LB; modified from the Diabetes Prevention Program) consisting of classes and individual nutritional counseling with a dietitian. A second group received less intensive "Usual Care" (UC) consisting of weight monitoring and provision of self-help. MAIN MEASURES: Participants completed anthropometric and nutrition assessments weekly for 8 weeks, then monthly. Psychiatric, behavioral, and physical assessments were conducted at baseline and months 2, 6, and 12. Metabolic and lipid laboratory tests were performed quarterly. KEY RESULTS: Participants in both groups lost weight. LB participants had a greater decrease in average waist circumference [F(1,1244) = 11.9, p < 0.001] and percent body fat [F(1,1121) = 4.3, p = 0.038]. Controlling for gender yielded statistically significant changes between groups in BMI [F(1,1246) = 13.9, p < 0.001]. Waist circumference and percent body fat decreased for LB women [F(1,1243) = 22.5, p < 0.001 and F(1,1221) = 4.8, p = 0.029, respectively]. The majority of LB participants kept food and activity journals (92%), and average daily calorie intake decreased from 2055 to 1650 during the study (p < 0.001). CONCLUSIONS: Behavioral interventions specifically designed for individuals with mental illness can be effective for weight loss and improve dietary behaviors. "Lifestyle Balance" integrates well with VA healthcare's patient-centered "Whole Health" approach. ClinicalTrials.gov identifier NCT01052714.

Detecting and Managing Adverse Effects of Antipsychotic Medications: Current State of Play.

Antipsychotics are some of the most frequently prescribed medications not only for psychotic disorders and symptoms but also for a wide range of on-label and off-label indications. Because second-generation antipsychotics have largely replaced first-generation antipsychotics as first-line options due to their substantially decreased risk of extrapyramidal side effects, attention has shifted to other clinically concerning adverse events associated with antipsychotic therapy. The focus of this article is to update the nonextrapyramidal side effects associated with second-generation antipsychotics. Issues surrounding diagnosis and monitoring as well as clinical management are addressed.

Behavioral interventions for antipsychotic medication-associated obesity: a randomized, controlled clinical trial.

OBJECTIVE: To demonstrate the effectiveness of a Diabetes Prevention Program-inspired 12-month behavioral intervention for patients with severe mental illness (SMI) and medication-associated obesity. METHOD: This randomized, controlled, parallel, superiority study screened 225 volunteers from November 2005 to August 2008 at the VA Greater Los Angeles Healthcare System. 122 outpatients with DSM-IV-diagnosed SMI taking antipsychotic medications who had ≥ 7% weight gain or body mass index (BMI) > 25 were randomized by computer-generated number to Lifestyle Balance treatment intervention (n = 60) or usual care control (n = 62) groups. Clinical raters were masked to randomization. Treatment intervention included weekly classes and individual counseling for 8 weeks, food and exercise diaries, rewards, caregiver consultations, and monthly booster classes and counseling for 1 year. Controls received self-help materials and visited at equivalent intervals without formal classes or counseling. Outcomes were changes in anthropometric measurements, psychiatric symptoms, health knowledge, and glucose, hemoglobin A1c, and lipid levels. RESULTS: Our intention-to-treat analysis found significant differences in predicted trajectory of mean weight change between the groups over 12 months (P < .01), with treatment participants expected to lose an average 4.6 kg, while control participants would gain an average 0.6 kg. BMI and body fat percentage followed the same pattern. Both groups demonstrated statistically significant improvements in health knowledge quiz scores over time (P = .006), without significant difference between groups. CONCLUSIONS: Treatment was more effective than usual care control in treating medication-associated obesity, independent of SMI diagnosis, antipsychotic medication, and knowledge gained, suggesting that behavioral interventions are effective in SMI patients. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00344500.

Cannabis-induced psychosis associated with high potency "wax dabs".

With mounting evidence that the risk of cannabis-induced psychosis may be related to both dose and potency of tetrahydrocannbinol (THC), increasing reports of psychosis associated with cannabinoids containing greater amounts of THC are anticipated. We report two cases of emergent psychosis after using a concentrated THC extract known as cannabis "wax," "oil," or "dabs" raising serious concerns about its psychotic liability. Although "dabbing" with cannabis wax is becoming increasingly popular in the US for both recreational and "medicinal" intentions, our cases raise serious concerns about its psychotic liability and highlight the importance of understanding this risk by physicians recommending cannabinoids for purported medicinal purposes.

Culturally sanctioned suicide: Euthanasia, seppuku, and terrorist martyrdom.

Suicide is one of the greatest concerns in psychiatric practice, with considerable efforts devoted to prevention. The psychiatric view of suicide tends to equate it with depression or other forms of mental illness. However, some forms of suicide occur independently of mental illness and within a framework of cultural sanctioning such that they aren't regarded as suicide at all. Despite persistent taboos against suicide, euthanasia and physician-assisted suicide in the context of terminal illness is increasingly accepted as a way to preserve autonomy and dignity in the West. Seppuku, the ancient samurai ritual of suicide by self-stabbing, was long considered an honorable act of self-resolve such that despite the removal of cultural sanctioning, the rate of suicide in Japan remains high with suicide masquerading as seppuku still carried out both there and abroad. Suicide as an act of murder and terrorism is a practice currently popular with Islamic militants who regard it as martyrdom in the context of war. The absence of mental illness and the presence of cultural sanctioning do not mean that suicide should not be prevented. Culturally sanctioned suicide must be understood in terms of the specific motivations that underlie the choice of death over life. Efforts to prevent culturally sanctioned suicide must focus on alternatives to achieve similar ends and must ultimately be implemented within cultures to remove the sanctioning of self-destructive acts.

The six most essential questions in psychiatric diagnosis: a pluralogue. Part 4: general conclusion.

In the conclusion to this multi-part article I first review the discussions carried out around the six essential questions in psychiatric diagnosis - the position taken by Allen Frances on each question, the commentaries on the respective question along with Frances' responses to the commentaries, and my own view of the multiple discussions. In this review I emphasize that the core question is the first - what is the nature of psychiatric illness - and that in some manner all further questions follow from the first. Following this review I attempt to move the discussion forward, addressing the first question from the perspectives of natural kind analysis and complexity analysis. This reflection leads toward a view of psychiatric disorders - and future nosologies - as far more complex and uncertain than we have imagined.

Mental illness and mental health: is the glass half empty or half full?

During the past century, the scope of mental health intervention in North America has gradually expanded from an initial focus on hospitalized patients with psychoses to outpatients with neurotic disorders, including the so-called worried well. The Diagnostic and Statistical Manual of Mental Disorders (DSM), Fifth Edition, is further embracing the concept of a mental illness spectrum, such that increasing attention to the softer end of the continuum can be expected in the future. This anticipated shift rekindles important questions about how mental illness is defined, how to distinguish between mental disorders and normal reactions, whether psychiatry is guilty of prevalence inflation, and when somatic therapies should be used to treat problems of living. Such debates are aptly illustrated by the example of complicated bereavement, which is best characterized as a form of adjustment disorder. Achieving an overarching definition of mental illness is challenging, owing to the many different contexts in which DSM diagnoses are used. Careful analyses of such contextual utility must inform future decisions about what ends up in DSM, as well as how mental illness is defined by public health policy and society at large. A viable vision for the future of psychiatry should include a spectrum model of mental health (as opposed to exclusively mental illness) that incorporates graded, evidence-based interventions delivered by a range of providers at each point along its continuum.

The six most essential questions in psychiatric diagnosis: a pluralogue part 3: issues of utility and alternative approaches in psychiatric diagnosis.

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part 1 of this article took up the first two questions. Part 2 took up the second two questions. Part 3 now deals with Questions 5 & 6. Question 5 confronts the issue of utility, whether the manual design of DSM-III and IV favors clinicians or researchers, and what that means for DSM-5. Our final question, Question 6, takes up a concluding issue, whether the acknowledged problems with the earlier DSMs warrants a significant overhaul of DSM-5 and future manuals. As in Parts 1 & 2 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

The six most essential questions in psychiatric diagnosis: a pluralogue part 2: Issues of conservatism and pragmatism in psychiatric diagnosis.

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM--whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article took up the first two questions. Part II will take up the second two questions. Question 3 deals with the question as to whether DSM-V should assume a conservative or assertive posture in making changes from DSM-IV. That question in turn breaks down into discussion of diagnoses that depend on, and aim toward, empirical, scientific validation, and diagnoses that are more value-laden and less amenable to scientific validation. Question 4 takes up the role of pragmatic consideration in a psychiatric nosology, whether the purely empirical considerations need to be tempered by considerations of practical consequence. As in Part 1 of this article, the general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.

The six most essential questions in psychiatric diagnosis: a pluralogue part 1: conceptual and definitional issues in psychiatric diagnosis.

In face of the multiple controversies surrounding the DSM process in general and the development of DSM-5 in particular, we have organized a discussion around what we consider six essential questions in further work on the DSM. The six questions involve: 1) the nature of a mental disorder; 2) the definition of mental disorder; 3) the issue of whether, in the current state of psychiatric science, DSM-5 should assume a cautious, conservative posture or an assertive, transformative posture; 4) the role of pragmatic considerations in the construction of DSM-5; 5) the issue of utility of the DSM - whether DSM-III and IV have been designed more for clinicians or researchers, and how this conflict should be dealt with in the new manual; and 6) the possibility and advisability, given all the problems with DSM-III and IV, of designing a different diagnostic system. Part I of this article will take up the first two questions. With the first question, invited commentators express a range of opinion regarding the nature of psychiatric disorders, loosely divided into a realist position that the diagnostic categories represent real diseases that we can accurately name and know with our perceptual abilities, a middle, nominalist position that psychiatric disorders do exist in the real world but that our diagnostic categories are constructs that may or may not accurately represent the disorders out there, and finally a purely constructivist position that the diagnostic categories are simply constructs with no evidence of psychiatric disorders in the real world. The second question again offers a range of opinion as to how we should define a mental or psychiatric disorder, including the possibility that we should not try to formulate a definition. The general introduction, as well as the introductions and conclusions for the specific questions, are written by James Phillips, and the responses to commentaries are written by Allen Frances.