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The gun debate in America is often framed as a stand-off between two immutable positions with little potential to move ahead with meaningful legislative reform. Attempts to resolve this impasse have been thwarted by thinking about gun ownership attitudes as based on rational choice economics instead of considering the broader socio-cultural meanings of guns. In this essay, an additional psychological perspective is offered that highlights how concerns about victimization and mass shootings within a shared culture of fear can drive cognitive bias and motivated reasoning on both sides of the gun debate. Despite common fears, differences in attitudes and feelings about guns themselves manifest in variable degrees of support for or opposition to gun control legislation that are often exaggerated within caricatured depictions of polarization. A psychological perspective suggests that consensus on gun legislation reform can be achieved through understanding differences and diversity on both sides of the debate, working within a common middle ground, and more research to resolve ambiguities about how best to minimize fear while maximizing personal and public safety.

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.

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

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.

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.

Prescription stimulant medications have been sought for cognitive “neuroenhancement”, the practice of enhancing ostensibly normal cognitive function such as attention span, focus, and memory. This trend, particularly studied in college students, has driven a debate about many ethical aspects related to cognitive enhancement; however, the central role of physicians and the medical ethics of this practice have been minimally investigated. In this paper, a clinical case serves as the focal point to review the current state of prescription stimulant use for enhancement, beginning with the medical and legal problems related to the surreptitious, yet common, behaviors of diversion and malingering. In contrast, there may be a growing trend for individuals to seek prescription stimulants “openly” (without malingering or diversion) as a direct request from their physician, which leads to complex ethical questions. A model of clinical-ethical decision making (the “four-box model” from Jonsen et al.) is applied to analyze the factors that a physician must consider when deciding whether to engage in the open prescribing of a stimulant neuroenhancer to otherwise healthy, autonomous adults. Four domains are explored in depth: medical indications, quality of life/beneficence, patient preferences, and contextual factors. Relevant experiences from the medical disciplines involved in athletic enhancement and cosmetic enhancement are discussed. Although an overall ethical framework for neuroenhancement continues to evolve, from a perspective of medical ethics there are presently significant reasons to be wary of cognitive neuroenhancement with stimulant medications.

SummaryThe language of psychiatry can be ambiguous and idiosyncratic, reflecting the elastic borders of mental illness and psychiatric disorder. This problem is not unique to psychiatry, but as the medical specialty moves closer towards a 'spectrum view’ of mental illness, psychiatric terminology increasingly risks misappropriation and conflation with lay concepts of normal suffering. Deciding what words mean and how psychiatric disorders are defined requires ongoing consideration of the pragmatic consequences, both intended and unintended. Refining the lexicon of psychiatry with an eye towards precision and the minimisation of stigma requires that terms be revised and updated from time to time, but often suitable word replacements remain elusive.

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.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.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.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.

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. We investigated behavioral weight management interventions for veterans with mental illness across four medical centers within the Veterans Affairs (VA) Healthcare System. We conducted a 12-month, multi-site extension of our previous randomized, controlled study, comparing treatment and control groups. Veterans (and some non-veteran women) diagnosed with mental illness, overweight (defined as having a BMI over 25), and required ongoing antipsychotic therapy. 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. 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. Participants in both groups lost weight. LB participants had a greater decrease in average waist circumference [F(1,1244) = 11.9, p

Background: Second-generation antipsychotic medications have proven effective for individuals with serious mental illness (SMI) but may cause weight gain and other metabolic sequelae. Investigators designed and assessed a 12-month behavioral intervention for overweight/obese patients with SMI called “Lifestyle Balance” (LB), based on the Diabetes Prevention Program (DPP), which was tested at 4 VA sites.

Background: The delivery of mental health care is shifting to one that is patient-centered and recovery-oriented, with the goal of increasing quality of life. These pilot studies test an adjunctive, holistic, behavioral approach to treating serious mental illness (SMI) and medication-associated weight gain; investigators hypothesized 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.

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.

Belief in free will has been a mainstay in philosophy throughout history, grounded in large part in our intuitive sense that we consciously control our actions and could have done otherwise. However, psychology and psychiatry have long sought to uncover mechanistic explanations for human behavior that challenge the notion of free will. In recent years, neuroscientific discoveries have produced a model of volitional behavior that is at odds with the notion of contra-causal free will and our sense of conscious agency. Volitional behavior instead appears to have antecedents in unconscious brain activity that is localizable to specific neuroanatomical structures. Updating notions of free will in favor of a continuous model of volitional self-control provides a useful paradigm to conceptualize and study some forms of psychopathology such as addiction and impulse control disorders. Similarly, thinking of specific symptoms of schizophrenia as disorders of agency may help to elucidate mechanisms of psychosis. Beyond clinical understanding and etiological research, a neuroscientific model of volitional behavior has the potential to modernize forensic notions of responsibility and criminal punishment in order to inform public policy. Ultimately, moving away from the language of free will towards the language of volitional control may result in an enhanced understanding of the very nature of ourselves.

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.

Over the past 60 years, the Diagnostic and Statistical Manual of Mental Disorders (DSM) has evolved from early efforts to collect statistical information to a modern compendium of mental disorders that can be reliably diagnosed, but have not been validated. Throughout this history, DSM architects have struggled with the seemingly fundamental, but complex question of how to define a mental disorder. Current proposals indicate that a spectrum model of mental illness will be embraced in DSM-5, prompting renewed concern and debate about pathologizing normal existence. While a spectrum view of mental illness may reflect biologic reality and help pave the path towards validated models of psychiatric disorder, diagnostic expansion does have important practical implications and could give rise to problems in clinical work and society at large, including the further sanctioning of a shift from psychiatric treatment to neuroenhancement. Debates about what should or should not be considered a mental illness in DSM-5 are likely to remain unresolved and, in the future, must be framed according to contextual utility. Diagnosis and thresholds of pathology are ultimately value-based so that careful analysis and perhaps even different definitions of disorder may be required to guide decision-making in research, clinical work, and public policy.

While auditory hallucinations (AH) are prototypic psychotic symptoms whose clinical presence is often equated with a psychotic disorder, they are commonly found among those without mental illness as well as those with nonpsychotic disorders not typically associated with hallucinations in DSM-IV. This incongruity presents a significant challenge for clinical work and efforts to revise the next iteration of the DSM. Auditory hallucinations found among "normal" people suggest that either AH are not as pathologic as they are typically taken to be, or that less-than-hallucinatory experiences are routinely mischaracterized as AH. Such hallucinations in the context of conversion disorder, trauma, sensory deprivation, and certain cultural settings strengthen an association between AH and psychopathology but suggest limited diagnostic specificity and relevance. It may be useful to think of AH like coughs-common experiences that are often, but not always, symptoms of pathology associated with a larger illness. Although these issues have been known for many years, they are rarely discussed in American psychiatry and need to be addressed in future research and clinical work.

Considerable effort is focused on a revised definition of schizophrenia for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) anticipated in 2012. Among the core debates are how to define a disorder without an established pathophysiology, whether diagnosis is improved by implementing continuous symptomatic dimensions, and to what extent neurocognitive deficits should be integrated into schizophrenia for DSM-V. Although lacking in validity, the diagnosis "schizophrenia" remains a useful term for clinical communication, with current antipsychotic therapies encouraging diagnostic "lumping" rather than "splitting." Much evidence supports a move to a dimensional model for psychosis, but doing so raises the potential for overdiagnosis. Validity problems exist not only with schizophrenia, but also with its defining symptoms such as delusions and hallucinations. Integrating dimensional symptom clusters into DSM-V schizophrenia, exemplified by models based on neurocognitive defic...

Hepatitis B and C are public health problems. Psychiatric patients may be at risk of hepatitis B and C exposure due to lifestyle and inadequate health care. We aimed to determine prevalence of hepatitis B and C virus exposure and associated risk factors in acutely hospitalized psychiatric veterans. A total of 234 individuals consecutively admitted to the psychiatric wards at the West Los Angeles Veterans Affairs Hospital were asked to participate. A total of 129 patients consented and were screened for viral hepatitis risk factors, hepatitis B surface antigen, hepatitis B surface and core antibodies, and hepatitis C antibodies. About 31 and 38% of the patients had been exposed to hepatitis B and C viruses, respectively. Several risk factors were associated with exposure. Inpatient psychiatric veterans seem to have increased rates of hepatitis B and C exposure. This highlights the need for prevention of risk behavior in this vulnerable population.

People with schizophrenia commonly lack insight, that is, they are unaware of their illness and the consequences thereof. One of the most important consequences of lack of insight is a failure to recognise the need for treatment, leading to treatment nonadherence. With several scales that now enable objective measurement of insight, it is possible to examine correlates of insight change, including course of illness and treatment adherence. Specific interventions, both pharmacological and psychotherapeutic, have been developed to enhance illness insight and treatment adherence. The extent to which second-generation antipsychotic medications, including a recently released long-acting formulation, improve insight and/or enhance treatment adherence remains to be determined.

The metabolic syndrome has become a focus of clinical attention due to its high prevalence in the United States (23%) and impact on cardiovascular risk, yet limited data exist on the prevalence of this syndrome among U.S. veterans with schizophrenia.A convenience sample of patients diagnosed with schizophrenia or schizoaffective disorder was obtained from inpatient units and outpatient clinics at Veterans Affairs medical centers in San Diego and Los Angeles.In this predominantly male (92.5%) sample of 80 veterans, with mean age of 49.0 years, the age-adjusted prevalence of the metabolic syndrome was 51.2%, more than twice the age-adjusted prevalence in the general U.S. population. The female cohort was small (n = 6), but had a greater mean body mass index and higher prevalence of metabolic syndrome than the male subjects.The metabolic syndrome is highly prevalent in this sample of patients with schizophrenia and represents an enormous source of cardiovascular disease risk. Clinicians who treat patients with schizophrenia should monitor for the parameters that define the metabolic syndrome as part of the ongoing management of patients treated with antipsychotics.

The treatment of schizophrenia changed drastically with the discovery of antipsychotic medications in the 1950s, the release of clozapine in the US in 1989 and the subsequent development of the atypical or novel antipsychotics. These newer medications differ from their conventional counterparts, primarily based on their reduced risk of extrapyramidal symptoms (EPS). EPS can be categorised as acute (dystonia, akathisia and parkinsonism) and tardive (tardive dyskinesia and tardive dystonia) syndromes. They are thought to have a significant impact on subjective tolerability and adherence with antipsychotic therapy in addition to impacting function. Unlike conventional antipsychotic medications, atypical antipsychotics have a significantly diminished risk of inducing acute EPS at recommended dose ranges. These drugs may also have a reduced risk of causing tardive dyskinesia and in some cases may have the ability to suppress pre-existing tardive dyskinesia. This paper reviews the available evidence regarding the incidence of acute EPS and tardive syndromes with atypical antipsychotic therapy. Estimates of incidence are subject to several confounds, including differing methods for detection and diagnosis of EPS, pretreatment effects and issues surrounding the administration of antipsychotic medications. The treatment of acute EPS and tardive dyskinesia now includes atypical antipsychotic therapy itself, although other adjunctive strategies such as antioxidants have also shown promise in preliminary trials. The use of atypical antipsychotics as first line therapy for the treatment of schizophrenia is based largely on their reduced risk of EPS compared with conventional antipsychotics. Nevertheless, EPS with these drugs can occur, particularly when prescribed at high doses. The EPS advantages offered by the atypical antipsychotics must be balanced against other important adverse effects, such as weight gain and diabetes mellitus, now known to be associated with these drugs.

This article has reviewed the emerging side-effect profiles of second-generation antipsychotic medications. Although these medications have favorable extrapyramidal side-effect profiles, clinicians must be aware of their propensity to cause weight gain, glucose and lipid abnormalities, and cardiac and sexual side effects. If clinicians are proactive about warning patients about these side effects and appropriately monitoring them, further morbidity and mortality may be prevented in this patient population. Initial choices of medication should be made based on the relative side-effect profiles in light of a particular patient's medical status. In the future, new treatments may be developed, with even fewer side effects.

Background : The novel antipsychotic medications offer a more favorable extrapyramidal side effect profile than conventional agents. It is uncertain that the novel antipsychotics have a benefit in terms of sexual side effects. Methods : We prospectively administered a survey of sexual functioning to 25 male patients with DSM-IV schizophrenia, taking conventional and novel antipsychotics. Contrasts were made between three treatment groups: clozapine (CLOZ), risperidone (RIS), and a combined haloperidol/fluphenazine (HAL/FLU) group. Results : A decrease in overall sexual functioning was reported in all medication groups (40–71%). The majority of subjects taking RIS or HAL/FLU reported a decline in one or more aspects of sexual functioning. Examining specific aspects of sexual functioning revealed that, a decline in sexual interest was significantly less common on CLOZ compared to RIS (0 vs. 64%; χ 2 =6.1, df=1, p =0.01) or HAL/FLU (0 vs. 67%; χ 2 =5.2, df=1, p =0.02), while a decline in the erectile frequency was significantly more common on RIS compared to CLOZ (40 vs. 93%; χ 2 =6.2, df=1, p =0.01) or HAL/FLU (50 vs. 93%; χ 2 =4.8, df=1, p =0.03) (0%). For enjoyment of orgasm and ejaculatory volume, significantly fewer CLOZ compared to RIS subjects reported a decline (20 vs. 86%; χ 2 =7.4, df=1, p =0.01). Conclusions : Sexual side effects are common clinically pertinent adverse effects associated with both novel and conventional antipsychotic medications. They deserve increased attention in clinical work and future research with emerging antipsychotic drugs.

The novel antipsychotic drugs offer significant advantages over conventional antipsychotic drugs because of their favorable extrapyramidal side-effect profiles. These medications do have some side effects that are clinically significant to our patients with psychotic disorders, however. We summarize

Center, Greater Los Angeles, CA; Hollie A. L. Gelberg, PhD, RD, clini Medical Center, Greater Los Angeles, CA; Jennifer A. Rosen, PharmD PGY-2 pharmacy residency program director in psychiatry, Departmen Long Beach, CA; Valery Chamberlin, MD, co-investigator, Sepulveda UCLA, and associate residency director, UCLA-SFV Psychiatry, Departm Chandresh Shah, MD, co-investigator, Los Angeles Ambulatory Care Veterans Affairs Medical Center, Greater Los Angeles, CA; Charles N Mental Health, Department of Veterans Affairs Medical Center, Long Angeles VA, associate director of residency education, UCLA Semel In co-chief, Schizophrenia Treatment Unit, West Los Angeles VA Medica chiatry & Biobehavioral Sciences, David Geffen School of Medicine at Los Angeles, CA; Zachary D. Erickson, program manager, Medical Re Los Angeles, CA; Shirley J. Mena, MSN, RN, research assistant, Med Greater Los Angeles, CA; Michael King, Jr, research assistant, Medic Greater Los Angeles, CA; Irina Arnold, MS, MD (MD obtained in Russia Affairs Medical Center, Greater Los Angeles, CA; Matthew R. Baker, Affairs Medical Center, Greater Los Angeles, CA; Hilary B. Meyer, resea Medical Center, Greater Los Angeles, CA; and Donna Ames, MD, pri tation and Recovery Center, and professor in residence, David Geffen Medical Center, Greater Los Angeles, CA.

Defining the borders of mental illness is challenging due to the lack of established validity for psychiatric disorders, a diagnostic system based largely on reported symptoms, and the highly subjective nature of distress and functional impairment. Consequently, debates about the potential perils of overdiagnosis (e.g., false positives) and underdiagnosis (e.g., false negatives) with new diagnostic revisions are ongoing as we prepare for the release of DSM-5. Such debates are rooted in the many different and often conflicting applications of psychiatric diagnosis, with clinical work generally favoring lowered diagnostic thresholds on the one hand and the work of rationing of healthcare resources necessitating higher thresholds on the other. Deciding what should or should not be considered a mental disorder in DSM can only be resolved by a pragmatic analysis of contextual utility. A philosophically satisfying, scientifically grounded, and economically viable model of future psychiatry should more formally acknowledge a continuum of mental illness and mental health, apply research evidence-based guidelines regarding optimal interventions along this continuum rather than assuming pharmacotherapy is a panacea, and concede that specialty care provided by psychiatrists must be integrated within the larger scope of mental health care.

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.

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.

Background: Although historically neglected in clinical research, negative symptoms of schizophrenia are now considered distinct targets of pharmacotherapy. While second-generation antipsychotic treatments were heralded as having a greater therapeutic impact on negative symptoms than their conventional antipsychotic counterparts, the size of this effect is modest. Adjunctive medications such as antidepressants offer limited efficacy, while stimulants have a poor risk–benefit profile. More recently, promising results have been demonstrated with pro-glutamatergic agents such as glycine or D-cycloserine, although a larger trial found no advantage with either agent compared with placebo. Modafinil, a novel wakefulness-promoting agent, is an intriguing candidate for adjunctive pharmacotherapy to treat negative symptoms in schizophrenia. We explored this therapeutic potential through a placebo-controlled trial of patients with prominent negative symptoms. Methods: We randomly assigned patients with schizophrenia or schizoaffective disorder to treatment with either modafinil or placebo for 8 weeks. Double-blind assessments of clinical symptoms and neurocognition were administered at baseline and every 2 weeks thereafter. Results: Twenty subjects were enrolled (N = 10 modafinil, N = 10 placebo). There were no significant differences between modafinil and placebo for changes in negative symptom ratings, the primary study endpoint. However, modafinil treatment was associated with a greater rate and degree of global improvement at study endpoint compared with placebo. No significant worsening of psychopathology was observed and modafinil was well-tolerated. Interpretation: Although no effect on negative symptoms was found, adjunctive therapy with modafinil may result in global improvements in patients with schizophrenia who have prominent negative symptoms. These findings support additional research into a potential role for modafinil in the treatment of negative symptoms in schizophrenia.

Negative symptoms are core features of schizophrenia that are functionally debilitating, associated with poor outcomes, and resistant to existing pharmacotherapies. We performed a randomized, double-blind, placebo-controlled study of modafinil, a medication approved for the treatment of excessive daytime sleepiness, to explore its efficacy as an adjunctive therapy for negative symptoms in schizophrenia.Twenty subjects with DSM-IV schizophrenia or schizoaffective disorder were randomly assigned to double-blind treatment with modafinil or placebo for 8 weeks. The study ran from March 2002 through March 2006. Outcome measures included the Scale for the Assessment of Negative Symptoms (SANS), Brief Psychiatric Rating Scale (BPRS), Clinical Global Impressions (CGI) scale, Quality of Life Interview, neurocognitive assessments (California Verbal Learning Test, Degraded Performance-Continuous Performance Test, Trail-Making Test B), and somatic measures (sleep, weight, side effects).Modafinil treatment was associated with a greater rate (CGI-Improvement [CGI-I] scoreor = 3, 7/10 vs. 1/10) and degree (mean CGI-I score, 3.2 vs. 4.1) of global improvement at study endpoint compared with placebo. However, modafinil did not significantly improve global negative symptoms as measured by the total SANS or SANS individual global items. Modafinil did not significantly worsen psycho-pathology (according to the BPRS), compared with placebo, and was well tolerated.Although no effect on negative symptoms was found, adjunctive therapy with modafinil may result in global improvements in patients with schizophrenia who have prominent negative symptoms.

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.

In clinical practice, no clear guidelines exist to distinguish between "normal" religious beliefs and "pathological" religious delusions. Historically, psychiatrists such as Freud have suggested that all religious beliefs are delusional, while the current DSM-IV definition of delusion exempts religious doctrine from pathology altogether. From an individual standpoint, a dimensional approach to delusional thinking (emphasizing conviction, preoccupation, and extension rather than content) may be useful in examining what is and is not pathological. When beliefs are shared by others, the idiosyncratic can become normalized. Therefore, recognition of social dynamics and the possibility of entire delusional subcultures is necessary in the assessment of group beliefs. Religious beliefs and delusions alike can arise from neurologic lesions and anomalous experiences, suggesting that at least some religious beliefs can be pathological. Religious beliefs exist outside of the scientific domain; therefore they can be easily labeled delusional from a rational perspective. However, a religious belief's dimensional characteristics, its cultural influences, and its impact on functioning may be more important considerations in clinical practice.

Background: Weight gain, and its associated complications such as the development of diabetes, is becoming increasingly recognized as an important potential side effect of the novel antipsychotic drugs. Methods: Two retrospective cases are described in which patients with schizophrenia developed diabetes while taking the antipsychotic medication risperidone. Results: Both patients had preexisting risk factors for diabetes and developed insulin resistance in the context of weight gain. Both cases necessitated medical intervention and one patient requires ongoing treatment with insulin. Conclusions: Although the exact mechanism of antipsychotic induced diabetes remains obscure, weight gain appears to be a significant risk factor. Careful monitoring of weight and fasting glucoses is recommended for any patient taking novel antipsychotic medications.

Background: This study was undertaken to evaluate whether peripheral (serum) markers of iron status are associated with severity of the choreoathetoid movements seen in tardive dyskinesia (TD). Methods: Serum iron indices (ferritin, iron, and total iron binding capacity) and fluphenazine levels were measured in a group of 30 male DSM-III diagnosed schizophrenic patients chronically treated with fluphenazine decanoate. The severity of choreoathetoid movements was assessed with the Abnormal Involuntary Movement Scale (AIMS), and akathisia was assessed with the Barnes scale. Results: A significant positive correlation was observed between AIMS scores and serum ferritin. This relationship remained significant after controlling for age and plasma fluphenazine levels. No significant correlations were observed between serum iron or total iron binding capacity and choreoathetoid movement ratings. There were no significant associations between serum iron indices and akathisia ratings. Conclusions: The data suggest that choreoathetoid movements are associated with serum ferritin levels in chronically medicated male schizophrenic patients. This relationship does not seem to be caused by an association of these variable with age or plasma fluphenazine levels. In addition, the relationship seems to be specific, since other iron indices and another extrapyramidal side effect (akathisia) do not demonstrate a similar relationship. In view of reports that antipsychotic medications change normal iron metabolism and increase iron uptake into the brain, the current results could be interpreted to suggest that serum ferritin levels may be a risk factor for TD in patients treated with “classic” antipsychotic medications.

The Community Re-Entry Program (CREP) is a psycho-educational program designed to teach schizophrenic patients self-management skills. This program was implemented during brief hospitalizations for psychotic exacerbations. Our goal was to determine the effectiveness of the CREP in decreasing re-hospitalizations, and increasing adherence with outpatient appointments. Ninety-four inpatients with acute psychosis were randomized to either the CREP, or to a standard series of illness education (IE) classes. Post-discharge, CREP participants were more knowledgeable about illness self-management. Attendance to first psychiatric appointment post-discharge improved for both for both groups. Hospital days were reduced for CREP patients over the year post-discharge.

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.

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.