Mental health care providers increasingly confront challenges posed by the introduction of new neurotechnology into the clinic, but little is known about the impact of such capabilities on practice patterns and relationships with patients. To address this important gap, we sought providers’ perspectives on the potential clinical translation of functional neuroimaging for prediction and diagnosis of mental illness. We conducted 32 semi-structured telephone interviews with mental health care providers representing psychiatry, psychology, family medicine, and allied mental health. Our results suggest (...) that mental health providers have begun to re-conceptualize mental illness with a neuroscience gaze. They report an epistemic commitment to the value of a brain scan to provide a meaningful explanation of mental illness for their clients. If functional neuroimaging continues along its projected trajectory to translation, providers will ultimately have to negotiate its role in mental health. Their perspectives, therefore, enrich bioethical discourse surrounding neurotechnology and inform the translational pathway. (shrink)

The insanity defense presents many difficult questions for the legal system. It attracts attention beyond its practical significance (it is seldom used successfully) because it goes to the heart of the concept of legal responsibility. “Not guilty by reason of insanity” generally requires that as a result of mental illness the defendant was unable to distinguish right from wrong at the time of the crime. The many difficult and complex questions presented by the insanity defense have led some in (...) the legal community to hope that neuroscience might help resolve some of these problems, but that hope is not likely to be realized. (shrink)

This chapter offers a novel defence of Szasz’s claim that mental illness is a myth by bringing to bear a standard type of thought experiment used in philosophical discussions of the meaning of natural kind concepts. This makes it possible to accept Szasz’s conclusion that mental illness involves problems of living, some of which may be moral in nature, while bypassing the debate about the meaning of the concept of illness. The chapter then considers the nature of schizophrenia and the (...) personality disorders (PDs) within this framework. It argues that neither is likely to constitute a scientifically valid category, but that nonetheless their symptoms can be scientifically explained. It concludes with a discussion of the way in which Cluster B or ‘bad’ PDs involve failures of virtue or character, and argues that this does not preclude them from being appropriately treated within contemporary, multidisciplinary, mental health services. (shrink)

The fast-developing field of neuroscience has given philosophy, as well as other disciplines and the public broadly, many new tools and perspectives for investigating one of our most pressing challenges: addressing the health and well-being of our mental lives. In some cases, neuroscientific innovation has led to clearer understanding of the mechanisms of mental illness and precise new modes of treatment. In other cases, features of neuroscience itself, such as the enticing nature of the data it produces compared to previous (...) behavioral methods, together with its costliness and “coldness” have complicated understanding of mental illness and decision making about mental illness. Taking neuroscientific information into account can leave practitioners in psychiatry and law with difficult questions, stemming not only from the complexity of these fields, but also from our rapidly evolving understanding of and facility with neuroscience. In this chapter, we will review several examples of the insights and dilemmas that have unfolded as mental illness has been examined through the lens of neuroscience, covering diagnoses such as obsessive-compulsive disorder (OCD), schizophrenia, addiction, and severe mood disorders. (shrink)

WHO suggests mental ill health in terms of depression to be the highest ranking disease problem in the developed world in 2020–2030 and claims a public health approach to be the most appropriate response. But some argue that the alarming reports on mental ill health have their ground in the methods of inquiry themselves and refer to medicalization as an important issue. The aim of this article is to explore and illuminate the issue of what is meant by mental health (...) and mental ill health and what it means that mental ill health is a major public health problem. Basically, two understandings and aspects of public health exist: a ‘reductionist’ and a ‘holistic’ with connections to different theories of health. These diverging understandings may lead to quite different public health responses, and they may have different consequences with regard to medicalization. It is concluded that we need more clearly elaborated ways to think about public health so that the increased attention to mental ill health as a public health problem does not in itself lead to medicalization in terms of just medical treatment. Otherwise, we risk losing the importance of public health as an overarching social and political instrument. (shrink)

We often hear that certain mental disorders are disorders of the brain, but it is not clear what this claim amounts to. Does it mean that they are like classic brain diseases such as brain cancer? I argue that this is not the case for most mental disorders. Neither does the claim that all mental disorders are brain disorders follow from a materialist world-view. The only plausible way of understanding mental disorders as brain disorders is a fairly modest one, where (...) we label brain differences we find in mental illness as pathological based on their link to mental dysfunction. How many mental disorders will turn out to be brain disorders on this understanding is an empirical question. (shrink)

Disability scholars have argued that the disadvantage of disability is caused primarily by social factors and calls out for social change as a matter of justice. But what about psychiatric disability? While noting several factors that make psychiatric disability a special casethe mentally ill individuals unreliability of judgment and instability of functioningSara Goering argues that much is gained by viewing mental illness through the lens of social oppression and workingtoward recognition of individuals with mental illness as equal members of (...) the human community. (shrink)

This article argues in favor of modifying the medical model of severe psychiatric disturbances that underlies calling them "mental illness." The key reason for this proposal is that numerous specialists other than physicians as well as non-specialists contribute to the process of assisting a person recover from what the author suggests might better be called "extraordinary functional disability." There is little uniformity in existing definitions under state laws, but all involve three types of intervention: civil commitment; civil determination of legal (...) competency; and standing to be subject to criminal law. Physicians typically make relevant determinations in each of these areas; but non-physicians are the principal care-givers once a determination has been made. (shrink)

Practical and evidence-based, this unique book is the first comprehensive text focused on person-centered approaches to people with serious mental illness such as schizophrenia and bipolar disorder. It reflects a range of views and findings regarding assessment, treatment, rehabilitation, self-help, policy-making, education and research. It is highly recommended for all healthcare professionals, students, researchers and educators involved in general practice, psychiatry, nursing, social work, clinical psychology and therapy. Healthcare service providers, and policy makers and shapers, will find the book's wide-ranging, (...) multi-professional approach enlightening. 'Serious Mental Illness reflects a continued distancing from the outmoded and unsubstantiated belief that people with severe mental illnesses could not recover, and that they would respond positively only to goals and treatment plans chosen, designed and implemented by providers in order to prevent their further deterioration. Anyone with an interest in the concept of person-centered approaches will discover new ideas in this book. Indeed, anyone with an interest in person-centered approaches has to read this book. Not only is it the first such book on person-centered approaches, but it will serve as the gold standard in this topic area for years to come.' William A Anthony, in the Foreword. (shrink)

Twenty years ago, the biopsychosocial model was proposed by George Engel to be the new paradigm for medicine and psychiatry. The model assumed a hierarchical structure of the biological, psychological and social system and simple interactions between the participating systems. This article holds the thesis that the original biopsychosocial model cannot depict psychiatry's reality and problems. The clinical validity of the biopsychosocial model has to be questioned. It is argued that psychiatric interventions can only stimulate but not determine their target (...) systems, because intervention and outcome are only loosely coupled. Thus, psychiatric interventions have in principle limited ranges which differ according to the type of intervention and according to the system to be stimulated. Psychosocial interventions face far more obstacles to be overcome than psychopharmacogical therapy. (shrink)

Setting the terms of praise‐ and blameworthiness has long dominated philosophers’ discussions of responsibility. Analytic philosophy has most often looked to reason and the abstract relations between individual rational judgements and actions to advance the discourse on moral responsibility. Those whose capacity for reasoned judgement is impaired are deeply problematic. Is it proper to morally appraise ‘the mentally ill’? The philosopher T.M. Scanlon discusses moral responsibility as a precondition of moral appraisal and contends that it is not appropriate to (...) appraise a person as (morally) praise‐ or blameworthy if that person cannot be held responsible for the action(s) for which he is being praised or blamed. What are the conditions, then, under which one can properly be said to be responsible for one's actions? Can one hold ‘the mentally ill’ responsible for their actions? If not, can it in any way be reasonable to expect them to ‘take responsibility’ for their actions and/or characters? The expectation that ‘the mentally ill’ will attempt to control, i.e. take responsibility for their behaviour despite the fact of their mental illness is a pervasive feature of psychiatric approaches to the care and treatment of ‘the mentally ill’. It would seem that such treatment approaches are coherent only to the degree ‘the mentally ill’ can be considered responsible moral agents. This paper explores these issues with regard to that form of mental illness categorized as the personality disorders. It describes the morally and clinically relevant features of personality disorder, explains how they do not fit traditional analytic paradigms of ‘mental illness’ and elaborates the argument that persons with this category of mental illness are fully moral persons who are rightly subject to praise and blame. (shrink)

Some illnesses, e.g. OCD and schizophrenia, corrupt the activity mediated by one's basic psychological framework but do not corrupt that framework itself. But some illnesses, e.g. psychopathy, corrupt that framework itself. Thus, whereas OCD and schizophrenia are structure-internal mental illnesses, psychopathy is a structural mental illness. Structure-internal mental illnesses can be alleviated, but structural mental illnesses cannot.

This paper surveys some philosophical issues with the language surrounding mental illness, but is especially focused on pejoratives relating to mental illness. I argue that though 'crazy' and similar mental illness-based epithets (MI-epithets) are not best understood as slurs, they do function to isolate, exclude, and marginalize members of the targeted group in ways similar to the harmfulness of slurs more generally. While they do not generally express the hate/contempt characteristic of weaponized uses of slurs, MI-epithets perpetuate epistemic injustice by (...) portraying sufferers of mental illness as deserving minimal credibility. After outlining the ways in which these epithets can cause harm, I examine available legal and social remedies, and suggest that the best path going forward is to pursue a reclamation project rather than aiming to censure the use of MI-epithets. (shrink)

Psychiatry’s inchoate wish for a paradigm shift and the biopsychosocial model of mental illness’ critically examines the much discussed goal of a paradigm shift in psychiatric taxonomy. The chapter first highlights some illustrative calls for such a change and then sets these against the Kuhnian account of science from which the idea is taken, highlighting the connection to incommensurability. Relative to a distinction drawn from Winch, between putative sciences where the self-understanding of subjects plays no role and those where it (...) is fundamental, psychiatry falls into the latter kind. This suggests that the wish for a paradigm shift in psychiatry is either incoherent or a wish for a radical but unpredictable overhaul of a significant aspect of our self-understanding as subjects and agents. The biopsychosocial model of mental illness is thus a helpful reminder of the cost of a paradigm shift in psychiatry. (shrink)

A compelling and incisive book that questions the overuse of mental health terms to describe universal human emotions Public awareness of mental illness has been transformed in recent years, but our understanding of how to define it has yet to catch up. Too often, psychiatric disorders are confused with the inherent stresses and challenges of human experience. A narrative has taken hold that a mental health crisis has been building among young people. In this profoundly sensitive and constructive book, psychologist (...) Lucy Foulkes argues that the crisis is one of ignorance as much as illness. Have we raised a 'snowflake' generation? Or are today's young people subjected to greater stress, exacerbated by social media, than ever before? Foulkes shows that both perspectives are useful but limited. The real question in need of answering is: how should we distinguish between 'normal' suffering and actual illness? Drawing on her extensive knowledge of the scientific and clinical literature, Foulkes explains what is known about mental health problems-how they arise, why they so often appear during adolescence, the various tools we have to cope with them-but also what remains unclear: distinguishing between normality and disorder is essential if we are to provide the appropriate help, but no clear line between the two exists in nature. Providing necessary clarity and nuance, Losing Our Minds argues that the widespread misunderstanding of this aspect of mental illness might be contributing to its apparent prevalence. (shrink)

This book is psychiatry's reply to the diverse group of antipsychiatrists, including Laing, Foucault, Goffman, Szasz and Bassaglia, that has made fashionable the view that mental illness is merely socially deviant behaviour and that psychiatrists are agents of the capitalist society seeking to repress such behaviour. It establishes, by the use of evidence from historical and transcultural studies, that mental illness has been recognised in all cultures since the beginning of history and goes on to explore the philosophical and medical (...) basis for psychiatry's diagnosis and treatment of mental illness. Finally, it tackles two issues where psychiatry has recently been seen as at odds with the values prevailing in society: involuntary hospitalization and the insanity defence. The Reality of Mental Illness does not pretend to offer simple answers to the complex problems it discusses, but will leave the reader with a much greater understanding of psychiatry's aims, practices and problems. (shrink)

How might critical realism provide a better metatheoretical framework to understand the complex causality behind experiences of mental illness? How do we understand the agency of people suffering from mental illness? Prior work on critical realism and disability has argued that critical realism helps move past one or another form of reductionist explanations for illness, whether that is biological, environmental or psychological. But using a critical realist framework to study mental illness also raises issues about the agency of people whose (...) rational capacities are thought to be diminished. In this article, I present the life history of one of 26 young adults I interviewed as part of a project on resilience. Because interviews reveal the complex causal forces in any person's life, they remind us that scientific explanations should not be reductionistic. Human agency can be diminished by biological illness, power structures in psychiatry, and cultural categories of mental illness diagnoses. But a critical realist framework allows me to explore how people who experience mental illness still exercise their capacity to reflect on the moral ends to which to direct their actions. (shrink)

pSara Ahmed’s emWillful Subjects/em develops an account of willfulness as a site of simultaneous oppression and resistance: a diagnosis attributed to particular (not-quite-)subjects and to modes of behavior that are thereby diminished, pathologized, and controlled, and a “diagnosis” that may be positively affirmed as a way of living and doing otherwise. This essay puts Ahmed’s work on willfulness in conversation with María Lugones’ decolonial feminism, particularly her theory of active subjectivity. With Lugones, we offer, one can better understand the resistant (...) potential of willfulness, not simply as the willful subject possessing an oppositional “will of her own” (which risks reinscribing a unitary notion of the self), but rather, as exercising a different kind of subjectivity altogether—one that relies on multiplicity and arises through relationships across non-dominant difference. Extending the connections that Ahmed herself draws between willfulness and “madness,” we further explore the willful elements in experiences relating to mental illness and cognitive disability, categories of experience that we understand to be important (and undertheorized) aspects of what Aníbal Quijano has termed “the coloniality of power.”/p. (shrink)

My three main points are: Mental disease is a metaphor, but mental illness is not. Feeling ill and having a physical illness are logically related. If there were no such thing as feeling ill, there would be no such thing as suffering from a physical illness. Yet there is no logical connection between feeling ill and being mentally ill. Mental illness is manifested in various forms of behaviour, for example, suspiciousness, elation, depression, etc.; if a form of behaviour is (...) to count as mental illness, it has to be an insane form; yet it is possible to be mentally ill without being insane and it is possible to be insane without being mentally ill. (shrink)

In ?Some Myths about ?Mental Illness'? (Inquiry, Vol. 18 [1975], No. 3), Michael Moore attempts to clarify and refute what he takes to be the radical (existential) position concerning the nature and diagnosis of mental illness. Moore's dissatisfaction with certain formulations and conceptualizations of the radical position is endorsed; as also the need to introduce greater rigor and precision into the discussion of mental illness. But Moore's clarifications are really misunderstandings and, in consequence, his refutations do not succeed. Moore's five?fold (...) interpretative classification of the radical thesis is retained. (shrink)

The distinction between mental illness and bodily illness would seem to presuppose some sort of distinction between mind and body. But dualist theories that the mind is a substance separable from the body, or that mental events could occur without any bodily events, raise ancient conceptual problems, which I do not propose to review here. What I want to do is to examine the psychiatric implications of materialist theories, which hold that the mind is the brain, or a function of (...) the brain. If all character has a basis in chemistry, can we still attribute some mental distress to character and some to chemistry, as if the two categories were different? (shrink)

In the wake of the Stoneman Douglas School shooting, Republican and Democratic leaders—like the American electorate they represent—remain sharply divided in their responses to gun violence. They are united in their condemnation of these mass shootings, but they disagree about whether stricter or looser gun control laws are the answer. Those on the right side of the political aisle suggest that the issue is one of mental illness rather than gun control. Conversely, those who are more liberal or progressive in (...) their political learnings are quick to condemn attempts to reframe the issue of mass shootings as a mental health problem. Both sides are wrong. Mass shootings are indeed partially a mental health problem, albeit one poorly addressed by our current laws and policies. But the solution to mass shootings also needs to consider strategies that may reduce gun violence in general. (shrink)

This interdisciplinary article explores the intersection between the virtue ethics tradition and psychological therapies exploring the meaning of happiness for people living with a disabling mental illness. The logic of virtue ethics faces the challenge of mental illness, which is how to conceive of eudaimonia in the context of an illfness that targets happiness and potentially disrupts a person’s capacity to function rationally and exercise virtue. Drawing on two illustrative case studies of schizophrenia and major depression disorder, this article identifies (...) substantive points of contact between virtue ethics and the therapeutic strategies of recovery theory and Acceptance and Commitment Therapy. In so doing, it aims to provide ways of thinking about happiness that can help therapists and people with a mental illness conceive of flourishing, not despite mental illness, but by incorporating the experience into the storied meaning of life. And since mental illness reflects the vulnerabilities that are central to human life, its examination also expands the horizons of the virtue ethics tradition. (shrink)

Mild and moderate mental illnesses can hinder labor force participation, lead to work interruptions, and hamper earning potential. Targeted interventions have proven effective at addressing these problems. But their potential depends on labor protections that enable people to take advantage of these interventions while keeping jobs and income.

I’m grateful to the commentators for their thoughtful and thought-provoking replies. Psychiatric service-users often feel disempowered relative to a profession (psychiatry) and so sometimes enlist the aid of another profession (philosophy) to redress the balance. All well and good, but it is vital in this context not to set one’s critical faculties on one side. Although Dr Kious1 thinks that is just what I have done, what I was trying to do was to call a halt to the uncritical use (...) of a piece of philosophy, the concept of testimonial injustice. It is a fine tool in many contexts, it is the newest tool in the …. (shrink)

The traditional legal verdict of not guilty by reason of insanity as well as the more recent verdict of guilty but mentally ill rest on often unquestioned epistemological assumptions about human behavior and its causes, unjustified reliance on forensic psychiatrists, and questionable, if not deplorable ethical standards. This paper offers a critique of legal perspectives on insanity, historical and current, based on the altermative epistemological and ethical assumptions of Thomas S. Szasz. In addition, we examine Szasz''s unique (...) rhetorical analysis of mental illness and its implications for forensic psychiatry. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.2 (2003) 125-132 [Access article in PDF] Incomprehensibility and Understanding:On the Interpretation of Severe Mental Illness Louis A. Sass Keywords hermeneutics, psychopathology, paradox, Wittgenstein, solipsism, delusion, principle of charity, phenomenological psychopathology. I would like to begin by thanking Rupert Read for the care he has put into reading my work, and into thinking through its implications in the context of the "new-Wittgensteinian" interpretation of the (...) thought of Ludwig Wittgenstein. This interpretation derives from an influential reading of this philosopher's early book, the Tractatus Logico-Philosophicus (1961), that is not explicitly discussed in Read's article, yet that lies behind much of his argument. Read does allude to this reading of the Tractatus when he refers to the concept of "logically alien thought" (see Conant [1992]), and by citing, in his endnotes, the Diamond, Conant, and Cerbone articles that appear in Crary and Read's edited collection, The New Wittgenstein (2000). In an earlier paper that also addresses my work, "On approaching schizophrenia through Wittgenstein," Read (2001) explicitly discusses the relevance of the new-Wittgensteinian interpretation of the Tractatus.According to this new-Wittgensteinian interpretation of the Tractatus, Wittgenstein took absolutely seriously his own realization (explicitly stated at the end of the Tractatus) that his book was internally self-contradictory, and he therefore realized that all or nearly all the sentences of the Tractatus must be totally devoid of any meaning or semantic reference. According to this austere view, the vast bulk of the Tractatus only pretends to be making meaningful statements about the nature of logic and semantics; its real purpose is to give the reader the illusion of meaning, and this it does in order to lead the reader to the eventual realization that there can in fact be no meaningful statements or thoughts at the level of self-referential abstraction at which the Tractatus pretends to be operating. Further, when Wittgenstein (1961) writes (in the famous last line of the book), "Whereof one cannot speak, thereof one must be silent" (p. 189), this statement should, supposedly, not be taken as any kind of mystical pointing toward some ineffable realm or truth, but, rather, as an austere recognition that there just are no ineffable truths—that, so to speak, there just is no mystical there there. [End Page 125]Rupert Read sees an analogy between, on the one hand, the (supposedly mistaken) readers of Wittgenstein's Tractatus who think that Wittgenstein is exploiting self-contradiction to allude to some higher, ineffable truth (i.e., something that can be pointed at even if it cannot be said), and, on the other hand, my own elucidation of Schreber's contradictions (see especially Chapter 2 of Paradoxes of Delusion [1994]) to argue that Schreber can be said to be having particular kinds of experiences, which I refer to as solipsistic or quasi-solipsistic in nature. Just as Wittgenstein's self-contradictions can (supposedly) point nowhere other than to their own failure to mean, so Schreber's self-contradictory and other nonstandard statements cannot (according to Read) be used to illuminate in any meaningful way the form of experience that supposedly lies behind them—as I, for example, have tried to do by offering a phenomenological account of Schreber and schizophrenia. Patients like Schreber and Renée cannot really be understood, just as we cannot really understand logically alien thought—which, in fact, is not really thought at all; in both cases, there is only the illusion of meaning, only the mirage of an alternative mode of thinking or of living. This, at least, is Read's new-Wittgensteinian claim.Few readers of Philosophy, Psychiatry, & Psychology will, I suspect, be familiar with these discussions centering on Wittgenstein's Tractatus, which were introduced largely by the philosophers Cora Diamond and James Conant (see Crary and Read [2000]). (I myself have found their writings fascinating and inspiring in many ways, despite my ultimate disagreement on fundamental issues.) 1 Most readers of Philosophy, Psychiatry, & Psychology will have no way of assessing the validity of this austere reading of the Tractatus... (shrink)

Abstractabstract:Most of Charles Darwin's ideas have withstood the test of time, but some of them turned out to be dead ends. This article focuses on one such dead end: Darwin's ideas about the connection between piloerection and mental illness. Piloerection is a medical umbrella term to refer to a number of phenomena in which our hair tends to stand on end. Darwin was one of the first scientists to study it systematically. In The Expression of the Emotions in Man and (...) Animals (1872), he discusses piloerection in the context of his analysis of the expressions involved in fear and anger, relying heavily on the evidence provided by one of his correspondents, the British psychiatrist James Crichton Browne. This essay reveals how Darwin's initial doubts about the similarity between piloerection in animals and psychiatric patients were eased when studying photographic portraits of female psychiatric patients sent to him by Crichton Browne. It considers arguments against Darwin's reading of these portraits and the apparent contrast between this reading and his own skepticism, in later years, about the value of documentary photography. The article concludes with some notes regarding the reception of Darwin's ideas about psychopathology. (shrink)

Abstract:If climate change is as bad as many now predict, we may be faced with the problem of how to cope with a natural world that is changing more rapidly than our ability to form emotional attachments can keep pace with. How can we love a natural world that seems so strange and unfamiliar to us? For help in answering this question, I turn to structurally similar problems that we face in our emotional attachments to other people. Using the cases (...) of dementia and mental illness, I investigate how people adapt their love in cases where their beloved changes in ways that render her, at least at times, unfamiliar, strange, and unpredictable. I argue that in both human and nonhuman cases, love can be compatible with dramatic and rapid changes in one's beloved, but to achieve this one must remain open-minded about the nature of the beloved and morally attentive to the ongoing question of which states will promote its well-being. (shrink)

According to the “discrimination argument,” it would be discriminatory and hence impermissible to categorically exclude people with mental illness (PMI) from access to assisted suicide (AS) if AS is accessible to people with somatic illnesses. In objection to this, it could be argued that excluding PMI is not discriminatory, but rather based on their inability to meet certain eligibility criteria for AS. Which criteria are deemed necessary depends on the approach taken to justifying AS. In this article, we describe two (...) distinct ethical approaches to justifying AS and the eligibility criteria they entail and examine whether PMI can fulfill these criteria. A widespread “joint” approach based on beneficence and autonomy assumes that AS is justified when it alleviates the severe and irremediable suffering of a person who autonomously requests AS. An alternative, exclusively autonomy‐based approach assumes that providing AS is justified when a person's request is autonomous, regardless of whether AS is in her best interests. The latter approach underlies an important judgment of the German Federal Constitutional Court from 2020. We argue that PMI can in principle fulfill both beneficence‐ and autonomy‐based eligibility criteria for AS, and that a blanket exclusion of all PMI from AS is thus discriminatory on either approach. However, depending on which approach is taken, there are differences regarding the subgroups of PMI that would be eligible for AS. Whether the exclusion of specific PMI is discriminatory therefore depends on how we understand and justify AS. (shrink)

BackgroundDespite five decades of increasingly elegant studies aimed at advancing the pathophysiology and treatment of mental illness, the results have not met expectations. Diagnoses are still based on observation, the clinical history, and an outmoded diagnostic system that stresses the historic goal of disease specificity. Psychotropic drugs are still based on molecular targets developed decades ago, with no increase in efficacy. Numerous biomarkers have been proposed, but none have the requisite degree of sensitivity and specificity, and therefore have no usefulness (...) in the clinic. The obvious lack of progress in psychiatry needs exploration.MethodsThe historical goals of psychiatry are reviewed, including parity with medicine, a focus on diagnostic reliability rather than validity, and an emphasis on reductionism at the expense of socioeconomic issues. Data are used from Thomas Picketty and others to argue that our failure to advance clinical care may rest in part on the rise in social and economic inequality that began in the 1970s, and in part on our inability to move beyond the medical model of specificity of disease and treatment.ResultsIt is demonstrated herein that the historical goal of specificity of disease and treatment has not only impeded the advance of diagnosis and treatment of mental illness, but, in combination with a rapid increase in socioeconomic inequality, has led to poorer outcomes and rising mortality rates in a number of disorders, including schizophrenia, anxiety, and depression.ConclusionsIt is proposed that Psychiatry should recognize the fact of socioeconomic inequality and its effects on mental disorders. The medical model, with its emphasis on diagnostic and treatment specificity, may not be appropriate for investigation of the brain, given its complexity. The rise of scientific inequality, with billions allocated to connectomics and genetics, may shift attention away from the need for improvements in clinical care. Unfortunately, the future prospects of those suffering from mental illness appear dim. (shrink)

Failure to follow prescribed treatment has devastating consequences for those who are seriously and persistently mentally ill. Nurses, therefore, try to get clients to take psychotropic medication on a long-term basis. The goal is either compliance or adherence. Although current nursing literature has abandoned the term compliance because of its implications of coercion, in psychiatric nursing practice with patients suffering from serious long-term mental illness compliance and adherence are in fact different goals. The ideal goal is adherence, which requires (...) the patient to be an active participant in the team. This goal is consistent with nurses’ ethical values, but for such patients this is frequently unrealistic. If the person is severely psychotic, treatment may be involuntary and the goal compliance. Psychiatric nurses participate in involuntary treatment and thus should acknowledge the ethical implications of compliance as a goal and not obscure the issue by calling compliance adherence. (shrink)

People with mental illness are treated, in research, as a ‘class’ or category who are vulnerable, without always being clear why they should be treated as such, not why an individual, rather than the class, is vulnerable. The two main reasons given are lack of competence and power imbalance. Competence issues include incapacity and legislation, assessment and the impact of the illness in decisions. Power issues cover the role of mental health legislation, coercion, protectiveness and paternalism, stigma and discrimination and (...) the ‘well’ and ‘ill’ self. These are examined within a framework of risk assessment, both to the patient and to others. Over-concern to protect the vulnerable can lead to gate-keepers preventing their inclusion in studies at various stages of the research. This denies such groups a voice in the research process. It is suggested that ethical scrutiny of research is not only to prevent harm to the vulnerable, but also to provide a framework to empower such people to take part in research. To do otherwise is to further stigmatize and marginalize them. One way forward is to look at the risk presented by different types of research, from clinical intervention trials to non-therapeutic, qualitative studies and to modify capacity and access requirements in the light of the risks presented. (shrink)

The potential for artificial intelligences and robotics in achieving the capacity of consciousness, sentience and rationality offers the prospect that these agents have minds. If so, then there may be a potential for these minds to become dysfunctional, or for artificial intelligences and robots to suffer from mental illness. The existence of artificially intelligent psychopathology can be interpreted through the philosophical perspectives of mental illness. This offers new insights into what it means to have either robot or human mental disorders, (...) but may also offer a platform on which to examine the mechanisms of biological or artificially intelligent psychiatric disease. The possibility of mental illnesses occurring in artificially intelligent individuals necessitates the consideration that at some level, they may have achieved a mental capability of consciousness, sentience and rationality such that they can subsequently become dysfunctional. The deeper philosophical understanding of these conditions in mankind and artificial intelligences might therefore offer reciprocal insights into mental health and mechanisms that may lead to the prevention of mental dysfunction. (shrink)

On June 16, 2003, the Supreme Court ruled that forced administration of antipsychotic drugs to a defendant facing serious criminal charges is appropriate in order to render that defendant competent to stand trial, but only in limited circumstances. The treatment must be medically appropriate, substantially unlikely to have side effects that may undermine the fairness of the trial, and necessary to significantly further important government interests, after taking account of less-intrusive alternatives.Charles Sell, a former dentist, had a long history of (...) mental illness. He had been hospitalized twice, in 1982 and 1984, after expressing paranoid ideas to law enforcement officials. In May 1997, Sell was charged with fifty-six counts of mail fraud, six counts of Medicaid fraud, and one count of money laundering. He was released on bail after a magistrate determined that he was currently competent to stand trial. (shrink)

On June 16, 2003, the Supreme Court ruled that forced administration of antipsychotic drugs to a defendant facing serious criminal charges is appropriate in order to render that defendant competent to stand trial, but only in limited circumstances. The treatment must be medically appropriate, substantially unlikely to have side effects that may undermine the fairness of the trial, and necessary to significantly further important government interests, after taking account of less-intrusive alternatives.Charles Sell, a former dentist, had a long history of (...) mental illness. He had been hospitalized twice, in 1982 and 1984, after expressing paranoid ideas to law enforcement officials. In May 1997, Sell was charged with fifty-six counts of mail fraud, six counts of Medicaid fraud, and one count of money laundering. He was released on bail after a magistrate determined that he was currently competent to stand trial. (shrink)

Although the term mental illness is problematic, it is unavoidable for those most deeply harmed by it. In contrast to some current theological responses to mental illness, fully intersectional responses recognize not only gender, race, and class but also religion as a factor in some mental illness experience. A panentheistic theological response begins with a relational ontology, understands bodily diversities as part of finitude, and affirms the already-beloved identity of persons living with mental illness. This starting point of original blessing (...) rather than original sin dismantles stigma rather than obscuring it through associating mental illness with the Fall. A theology of Spirit as that which opens to and empowers possibilities within repeated losses and turmoil responds to mental illness without minimizing suffering. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Changing Functions, Moral Responsibility, and Mental IllnessCraig Edwards (bio)Keywordsmental illness, responsibility, character, dysfunction, personhoodI thank both Wakefield and Tomasini for their illuminating comments. Both commentaries are thought provoking and warrant a full response. However, as always, space is limited and I must make the all-too-predictable apology for not addressing both commentaries in full. Wakefield's contribution more directly engages with, and challenges, my claims, and so I focus on addressing (...) his concerns.ClarificationsWakefield correctly notes that I am interested in how mental illness (and illness generally) operates to remove moral responsibility for one's actions. Despite this, it seems at several points that he and I are talking about two different, albeit related, concepts of mental illness. 'Mental illness' is used to both explain and excuse certain behaviors, but these two functions, explanatory and exculpable, do not always operate simultaneously. As we discover biological explanations for apparently immoral behaviors, the question arises as to whether the explanation should remove the immorality and liability for punishment. The 'sick role' can be divided into two aspects. One is the role of deserving and warranting medical treatment. The other is the negation of moral responsibility. Wakefield's own example, pedophilia, involves the first sense of the sick role but not the second. Wakefield's use of this example is unusual, because it deftly highlights the limitation of his HD account. Pedophilia is a mental disorder in the sense of warranting treatment, and is a mental illness under Wakefield's model, but it is not something that negates moral responsibility. There is a sense of the term 'mental illness'—an important and, as I argue, an objective sense—that is relevant to establishing one's moral responsibility for such behaviors.In addressing my account of mental illness as though it contained two distinct answers, 'mental illness as dysfunction of rational agency, or 'mental illness as moral judgment,' it is unclear whether Wakefield takes them to be conjunctive or alternative. Hence it is worth reiterating in point form the structure of my account:1. Illness involves dysfunction;2. The 'proper function' of a bodily or psychological mechanism is determined by the purpose that we impose upon that mechanism (within the constraints of our biological needs);3. Dysfunction of rational agency is necessary, but not sufficient, for 'mental illness' in the normative sense relevant to negating moral responsibility; and [End Page 105]4. The distinction between 'mental illness' (in the above sense) and the many dysfunctions of rational agency for which we are morally responsible, turns upon (objective) normative facts rather than features internal to the dysfunctions themselves.Functions and ValueWakefield misses the point when he criticizes my comment that, although bodily mechanisms are fairly uniformly valued, there is substantial historical and cross-cultural variation in the way people value personhood. He notes—accurately, but irrelevantly—that people almost always place great value on their capacity for rational agency, probably more so than many aspects of their physical health. My comment, taken in context, has nothing to do with how much people value personhood, but has everything to do with what kinds of purposes people want their mental and physical processes to achieve. A heart has the same function for a Londoner today as it did for a Japanese peasant a thousand years ago, and although it is possible for us to want it to achieve other purposes, any culture that seriously imputes a different set of vital functions on the heart is likely to be rather disappointed. By contrast, our species has experienced vast changes in the demands we make of our rational and intellectual capacities—dysfunctions like dyslexia and alcoholism were irrelevant before the availability of written communication and alcohol.Wakefield's HD account is unable to deal with the relevance of such change. The link between evolutionary function and illness is tenuous in any event. Evolutionary explanations of specific mechanisms are often untestable, simply positing some evolutionary purpose that happens to fit our understanding of what the mechanism does. If we were to discover that alcoholism evolved as a means of increasing birthrates, or (perhaps more plausibly) that anxiety disorders occur among those for whom... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 11.1 (2004) 87-94 [Access article in PDF] Talk and the Nature of Delusions:Defending Sociocultural Perspectives on Mental Illness Eugenie Georgaca Keywords discourse, social constructionism, delusions, psychosis, mental illness, context It is very pleasing to see writers from philosophy, psychiatry and psychology, the three disciplines represented by this journal, debating the issue of delusions. The majority of the papers in this volume set out to determine (...) the underlying mechanisms responsible for delusions. As such, they offer themselves as discussions of the etiological factors of the formation and maintenance of delusions. My paper analyzes the interactional presentation and negotiation of statements that would be considered as delusional. This led some commentators (Ghaemi 2004; Sass 2004) to argue that the analysis of talk about delusions is useful, but cannot be extended to claims about the nature of delusions. In the following section, I discuss the ways in which analyzing interactions can be useful in clinical research and practice. Subsequently, I identify and critically discuss the assumptions about the nature of delusions that underlie these criticisms and the majority of the papers in this volume. The Usefulness of the Study of Interaction My paper can be seen as part of a growing body of studies that attempt to elucidate the role of interactional and discursive processes in the identification and management of disorders (Barrett 1988; Coulter 1975; Hak 1989; Pollner 1975; Smith 1978; Soyland 1994). Microsociological and ethnographic studies look at the properties of client-professional interaction with the aim of clarifying the tacit skills and knowledges used in such encounters. Palmer (2000), for example, argues that the recognition of disorder is a social and interactional issue both in the sense that the judgment of disorder is based on social criteria and in the sense that diagnosis is an interpersonal process with its own inherent social order. The aim, therefore, of analyzing professional-client interactions would be to articulate the properties of this implicit social order. Other researchers argue that diagnosis is not a process of identification or recognition of disorder, but rather a process of active construction of disorder and of transforming the person to a mental patient. Barrett's (1988) analysis of the transformation of a [End Page 87] person to a "person suffering from schizophrenia" and subsequently a "schizophrenic" through interviewing and report writing is an excellent example of this kind of work.The application of this approach to the field of delusions would attempt to address the issue of how delusions are diagnosed and managed through the interactions between the delusional patient and the clinician. In this paper and in previous work (Georgaca 1996, 2000) I showed that statements that have been diagnosed as delusional are presented and argued through using appropriate conversational strategies, drawing on socially meaningful systems of knowledge and applying appropriate rules of evidence. Moreover, I argued that there was no way in which these disagreements over competing versions of reality could be definitely settled conversationally, and that instances of breakdown in communication were due not to the delusional version being proven wrong, but to lack of explanatory frameworks within which the competing versions could be negotiated. At least in the exchanges analyzed, the criteria of implausibility, conviction, and incorrigibility were shown not to apply.Clinicians do not customarily investigate the truth of patient claims against empirical data (Maher 1992), which means that they have to judge claims on the basis of the patient's presentation in the diagnostic interview. Because there are no technical guidelines for the assessment of truth and falsity, plausibility and implausibility, rationality and irrationality, clinicians have to rely on personal judgment. The question then is on what grounds the clinician's personal judgment is granted the status of determining the truth of someone else's claim and in what capacity clinicians are called to make such decisions. I will not pursue this argument any further here. The point I want to make is that the analysis of professional-client interactions foregrounds the active role of professionals in clinical decisions and questions the criteria upon which decisions are... (shrink)

In 1848 Dorothea Dix, the famous 19th century advocate for the indigent mentally ill, appealed to the United States Congress to support the setaside of a very large tract of land that was to be used for the “Relief and Support of the Indigent Curable and Incurable Insane.” She stated:It will be said by a few, perhaps that each State should establish and sustain its own institutions; that it is not obligatory upon the general government to legislate for maintenance (...) of State charities…. But may it not be demonstrated as the soundest policy of the federal government to assist in the accomplishment of great moral obligations, by diminishing and arresting wide-spread miseries which mar the face of society; and weaken the strength of communities? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 11.4 (2001) 391-400 [Access article in PDF] Bioethics Inside the Beltway A Shooting on Capitol Hill: "The Ruby Satellite System," Mental Illness, and Failure of the American Legal System Peter J. Cohen On 24 July 1998, Russell Eugene Weston, Jr., stormed the United States Capitol, forced his way through a security checkpoint, bypassed a metal detector, and entered the office complex of Representative Tom (...) DeLay (R-TX), the House Majority Whip (Weil 1998). During this period of terror, he shot and killed two officers of the Capitol Police and seriously wounded another as they attempted to end his foray. 1 Weston was severely wounded by several Capital police officers and taken into custody. After being treated for his injuries, he was incarcerated in the District of Columbia. 2On 5 May 1999, Weston was transferred to the Federal Correctional Institute in Butner, North Carolina (United States v. Weston, 69 F. Supp. 2d 99 (D.D.C. 1999), 103), where he remains to this day. He has neither been brought to trial nor received appropriate psychiatric therapy, but continues to be warehoused "in solitary confinement under constant observation... in a psychotic state (United States v. Weston, 255 F.3d 873; LEXIS 16851 (U.S. App. 2001b), 3-4 [LEXIS]). I will briefly detail the legal events responsible for this mad situation and suggest alternative actions that should have been taken at the very onset of the case. Early Chronology Although overtly the crime appeared to be senseless and without any conceivable motivation, Weston believed that his acts were justified and necessary. The story he told to the court-appointed forensic psychiatrist, Sally C. Johnson, M.D., 3 was that while working for NASA in the early 1980s, he had developed a "Ruby Satellite System," a powerful machine that could reverse time. With access to this system, nothing was permanent--the user could simply reverse time and exit from the current scene. However, the "System" was now controlled by cannibals who were developing and spreading "Black Heva," the deadliest disease known to [End Page 391] humankind, similar to HIV or the plague. It resulted from human corpses rotting and turning black. Time was running out, and Weston believed he had to return to override the "Ruby Satellite System" in the Capitol so that he could stem the spread of "Black Heva" and prevent world calamity. He believed that if he were tried, convicted, and even executed, he could simply time reverse himself, place himself in a safe within the Capitol, and subsequently resume his life at whatever point he chose (United States v. Weston, 206 F.3d 9 (D.C. Cir. 2000), 19-20).On 22 April 1999, the district court accepted Dr. Johnson's diagnosis that Weston suffered from paranoid schizophrenia, the symptoms of which were so severe that he would be incapable of understanding the proceedings against him and of assisting in his own defense. On this basis, the court had no difficulty in finding him incompetent to stand trial (U.S. v. Weston 1999, 102).At Weston's initial hearing, Dr. Johnson had testified that medication would be efficacious in treating Weston's delusions: [T]he standard of care in someone suffering from this type of symptom picture would be to treat them with medication.... [T]here is a good likelihood that he'll have a positive response, positive in the sense that his symptoms will diminish in response to treatment.... The potential benefits to treating the defendant far outweigh the risks.... (U.S. v. Weston 1999, 108) The defense presented no expert testimony refuting Dr. Johnson's presentation. The district court then ordered that Weston begin receiving medication in order to render him nondangerous and competent for trial (U.S. v. Weston 1999, 108-9). The Problem Weston refused to be medicated! 4 He has continued to claim that the administration of antipsychotic drugs against his will would violate his Fifth Amendment due process liberty interest in avoiding unwanted bodily intrusion and implicated... (shrink)

This thesis is concerned with philosophical perspectives on the stigma of mental illness, with each chapter exploring different philosophical issues. Chapter one delineates the central concept around which the rest of the work revolves: the stigma of mental illness. It provides an outline of the stigma mechanism, how it applies to mental illness, why it is such a large public health concern and what has been done so far to combat it. Chapter two is concerned with the application of recent (...) literature in the philosophy of implicit bias to the topic of mental illness. It suggests that we have hitherto been preoccupied with explicit formulations of the stigma mechanism, but argues that there are distinctive issues involved in combatting forms of discrimination in which the participants are not cognisant of their attitudes or actions, and that anti-stigma initiatives for mental illness should take note. Chapter three applies the philosophical literature concerning the ethics of our epistemic practices to the stigma of mental illness. It contains an analysis of how epistemic injustice- primarily in the forms of testimonial injustice and stereotype threat- affects those with mental illnesses. The fourth chapter brings in issues in the philosophy of science to explore the possibility of intervening on the stigma process to halt the stigma of mental illness. The first candidate is discounted, and the second is tentatively endorsed. The fifth chapter is concerned with how language facilitates the stigma of mental illness. It suggests that using generics to talk about mental illness is deeply problematic. In the former, it conveys insidious forms of social stereotyping. In the latter, it propagates misinformation by presenting the category as a quintessential one. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Eclecticism and Adolf Meyer’s Functional Understanding of Mental IllnessD. B. Double (bio)KeywordsAdolf Meyer, eclecticism, functionalism, biopsychosocial modelGhaemi’s Commentary and Meyer’s ‘Eclecticism’I am not against humanism. How could anyone be against the humanistic wisdom rooted in the worthy writings of Socrates, Hippocrates, Shakespeare, Cervantes, Osler, and the others listed by Nassir Ghaemi? Psychiatry should recognize the dignity and value of all people. The problem is that it may not always (...) do so, coming from a reductionist paradigm as it so often does.Ghaemi appreciates that Meyer’s compromising attitude meant that he was “unable to inoculate psychiatry from biological dogmatism.” My emphasis is on the challenge of Meyer’s psychobiology to biomedicine. In the same way, Engel’s biopsychosocial model acknowledged the need to neutralize the power of an impersonal and mechanical medicine. Doctors tend to overemphasize physical abnormalities at the expense of dealing with difficult personal issues.At the risk of oversimplification, I am juxtaposing biopsychosocial and biomedical models in psychiatry. Or in other terms, for our modern understanding, I am asserting a neo-Meyerian approach in contrast to neo-Kraepelinianism. Merely restating the Meyerian perspective will not do, because of Meyer’s ‘give and take,’ and his consequent failure to follow through the implication of his position. At least the ethical ramifications of his conceptual framework need to be acknowledged.Neo-Meyerianism also needs to be realized in the context of the reaction to anti-psychiatry. After anti-psychiatry’s attack, our modern understanding of mental illness has tended to be been subsumed into the binary opposition of ‘pro-psychiatry’ and ‘anti-psychiatry.’ But neo-Meyerianism is as much pro-psychiatric as biomedical psychiatry. It is in this sense that biopsychological approaches have been undermined by the biomedical reaction to anti-psychiatry. [End Page 355]I also agree with Ghaemi that there is a way in which the failures of the biopsychosocial model allowed the development of anti-psychiatry. For example, even though Laing quoted favorably from psychologically minded psychiatrists such as Manfred Bleuler, as far as I know he never made any reference to Meyer. There was never a systematic Meyerian theory to which Laing could refer. In fact, Laing wished to move beyond an interpretative understanding to abandon the metaphor of pathology (Double 2006). Perhaps if the biopsychosocial model had been more clearly defined, Laing would not have felt he needed to take this step. Or, at least in doing so, he would have been clearer about where he stood on this issue. When labeling Laing’s views as ‘anti-psychiatry,’ biomedical psychiatry would have had to state more precisely how Laing’s position was anti- rather than pro-psychiatric.My main disagreement with Ghaemi is his view of Meyer as eclectic. Meyer’s willingness to allow ‘anything goes’ in psychiatry meant that he did not oppose or challenge too much the views of those with whom he disagreed. Nonetheless, he did not combine together different sources to create an unintegrated philosophical and conceptual understanding. His theoretical position is internally consistent.Modern American psychiatry studied by participant observation is “of two minds,” in that there is a divided consciousness created between the practices of drug therapy and psychotherapy (Luhrmann 2000). In this sense, it is eclectic because there is no consistent theory that combines the two practice modes. True, psychiatry often claims that the foundation for this mixture is the biopsychosocial model. It asserts that everyday psychiatry is not as purely biomedical as is often maintained because it takes into account psychosocial factors that may precipitate mental disorders. It, therefore, says that it bring together the biological and psychosocial. This compromise avoids the adoption of any one model and was proposed to neutralize the dogmatism engendered by the anti-psychiatry debate (Clare 1980). I agree with Ghaemi that such eclecticism has outlived its usefulness.Where I think Ghaemi is mistaken is that he sees Meyer and Engel as the originators of this eclecticism. I regard the Meyerian approach as more genuinely pragmatic than Ghaemi suggests. Meyer’s dynamic psychology sought an integration of mind and brain as a way of dealing with the philosophical dilemma of the mind–body... (shrink)

The Diagnostic and Statistical Manual of Mental Disorders contains the official diagnostic criteria for recognized mental illnesses. Some have asserted that DSM revisions have caused the boundaries of specific disorders to expand to include more behaviors, but no previous research has examined if such expansion is isolated or endemic. The current research consisted of an exploration of revisions to diagnostic criteria for 81 disorders. Each change between editions of the DSM was conceptually analyzed as making the disorder more exclusive or (...) more inclusive in terms of the number of people who could theoretically meet the criteria. Results indicated that 63% of disorders moved toward inclusivity, that each edition of the DSM moved toward inclusivity, and that most types of revisions increase inclusivity. (shrink)

The term “effective,” on its own, is honorific but vague. Interventions against serious mental illness may be “effective” at goals as diverse as reducing “apparent sadness” or providing housing. Underexamined use of “effective” and other success terms often obfuscates differences and incompatibilities in interventions, degrees of effectiveness, key omissions in effectiveness standards, and values involved in determining what counts as “effective.” Yet vague use of such success terms is common in the research, clinical, and policy realms, with consequences that negatively (...) affect the care offered to individuals experiencing serious mental illness. A pragmatist-oriented solution to these problems suggests that when people use success terms, they need to explain and defend the goals and supporting values embedded in the terms, asking and answering the questions, “Effective at what? For whom? How effective? And why that goal?” Practical and epistemic standards for effectiveness will likely remain plural for good reasons, but each standard should be well explained and well justified. (shrink)

An evaluation of mental capacity is critical to a clinician's judgment about whether or not persons can make medical treatment decisions on their own behalf, and uncertainty about their ability to meaningfully participate in that process is one of the more common reasons an ethics consult is requested. The care of decisionally incapable patients—particularly those who lack advance care documents and no living relative who can speak for them—presents a quandary to healthcare personnel attempting to plan care in their best (...) interest, especially when options are multiple but none are ideal. These situations can be further complicated if involving a patient with a dual diagnosis of mental retardation and mental illness living in a community group home. (shrink)

Going beyond the scope of psychiatric diagnoses, this study introduces the concept of human vulnerability as a means of linking the phenomenological approach—focusing on the patient’s experience—with psychotherapeutic treatment. To this end, it applies Karl Jaspers’ concept of “limit situation” to the existential vulnerability in the manifestation of mental illness and the ontological vulnerability in schizophrenia. From a psychological or empathic standpoint, vulnerability, as experienced in different cases of mental illness, refers to the condition of being confronted with disturbing meaningful (...) social encounters with others. In these social encounters, existential meanings acquire disturbing qualities for a person’s integrity, giving rise to various psychopathological phenomena. This study incorporates the practice of psychotherapy and empirical research to suggest that the experience of vulnerability is crucial not only in understanding the manifestation of mental illness but also a key element of phenomenological psychotherapeutic treatment, and it uses schizophrenia as an example. (shrink)

While research has consistently found that general distress and psychopathology are not predictive of sexual recidivism, examination of specific syndromes and their relationship to offending has revealed a potentially more complicated relationship. One proposed mechanism for the mixed findings with respect to major mental illness and sexual offending may be the confound of neurological injury. As identified in Mann et al. work on psychologically meaningful risk factors, mental illness represents an area in need of more study given the indirect influence (...) it may exert on risk. To this end, the current paper summarizes the study of the relationship between neurological injury, psychosis and problematic sexual behavior among two Canadian samples of forensic and civil psychiatric patients. In the first study we observed higher than expected rates of sexually-themed psychotic symptoms and problematic sexual behavior among a combined group of forensic and civil psychiatric patients. Indeed 70 percent of those individuals who engaged in PSB endorsed sexually-themed psychotic symptoms. While comorbidity is common amongst this group, brain injury appeared to represent a specific liability. Compared to those who did not engage in PSB, those who did were almost 4x more likely to have a documented history of brain injury. In the second study we sought to replicate this finding in a larger forensic sample of 1,240. However, the recorded rates of brain injury were significantly less, such that no relationship to PSB was observed. Based on the mixed findings to date, including our own data, questions remain about the nature of a potential shared vulnerability for psychosis and PSB previously postulated. Among psychiatrically complex individuals who engage in PSB, understanding etiology and links to risk are helpful, but perhaps more importantly is attention to the mechanisms through which symptoms confer risk and how best to treat and manage them. (shrink)