Positive topline results for the phase 3 EMERGENT-2 trial evaluating the efficacy, safety, and tolerability the investigational agent xanomeline-trospium (KarXT) for adults with schizophrenia was announced by Karuna Therapeutics.

The trial met its primary endpoint: KarXT demonstrated a statistically significant and clinically meaningful 9.6-point reduction in the Positive and Negative Syndrome Scale (PANSS) total score compared to placebo (-21.2 KarXT versus -11.6 placebo, p<0.0001) at week 5 (Cohen’s d effect size of 0.61). Starting at week 2, KarXT also demonstrated an early and sustained statistically significant reduction of symptoms, as assessed by PANSS total score. KarXT maintained this reduction through all timepoints in the trial.

“Despite the number of available treatment options, there continues to be a tremendous unmet need in the treatment of schizophrenia, placing an immense burden on both patients and their caregivers,” said Rishi Kakar, MD, chief scientific officer, Segal Trials and lead investigator of the phase 3 EMERGENT-2 trial. “These data build on the growing body of clinical evidence supporting the potential of KarXT as a new and differentiated approach for schizophrenia, demonstrating notable improvements across both positive and negative symptoms, while not being associated with common problematic side-effects of current therapies, such as weight gain, sedation, and movement disorders. This unique profile of KarXT has the potential to provide a new meaningful treatment option for our patients and their families beyond the current standard of care.”

KarXT also met key secondary endpoints, demonstrating a statistically significant reduction in both positive symptoms (eg, hallucinations or delusions) and negative symptoms (eg, difficulty enjoying life or withdrawal from others) of schizophrenia as measured by the PANSS positive (-6.8 KarXT versus -3.9 placebo, p<0.0001), PANSS negative (-3.4 KarXT versus -1.6 placebo, p=0.0055), and PANSS negative Marder factor subscales (-4.2 KarXT vs. -2.0 placebo, p=0.0022).

KarXT was generally well tolerated. Overall discontinuation rates were similar between KarXT and placebo groups (25% versus 21%). The overall treatment-emergent adverse events rate for KarXT and placebo was 75% and 58%, respectively. The most common treatment-emergent adverse events (>5%) in the KarXT arm were all mild to moderate in severity and included constipation, dyspepsia, nausea, vomiting, headache, increases in blood pressure, dizziness, gastroesophageal reflux disease (acid reflux), abdominal discomfort, and diarrhea.

“We are thrilled that these topline results from the Phase 3 EMERGENT-2 trial confirm what was seen in our Phase 2 EMERGENT-1 trial and underscore the potential for KarXT, with its novel and unique mechanism of action, to redefine what successful treatment looks like for the 21 million people living with schizophrenia worldwide, and potentially usher in the first new class of medicine for these patients in more than 50 years,” said Steve Paul, MD, chief executive officer, president and chairman of Karuna Therapeutics. “These results represent our second positive registrational trial. We look forward to continuing to gather long-term safety data to support our submission of a New Drug Application with the US Food and Drug Administration [FDA] for KarXT as a treatment for schizophrenia, which we expect to occur in mid-2023.”

To see more on KarXT, watch the video “

Promising Publication: The Novel Schizophrenia Treatment Gaining Traction

,” in which Stephen Brannan, MD, chief medical officer of Karuna Therapeutics, shared more information on the phase II clinical data.

1. Karuna Therapeutics announces positive results from phase 3 EMERGENT-2 Trial of KarXT in schizophrenia. Business Wire. August 8, 2022. 

https://www.businesswire.com/news/home/20220808005222/en/Karuna-Therapeutics-Announces-Positive-Results-from-Phase-3-EMERGENT-2-Trial-of-KarXT-in-Schizophrenia

Articles

This novel schizophrenia treatment showed positive results in a phase 3 trial evaluating efficacy, safety, and tolerability. 

“A New and Differentiated Approach for Schizophrenia”: Positive Results for Phase 3 Trial 

Three organizations dedicated to helping address the youth mental health crisis in the United States will be awarded $5.3 million in grants.

The inaugural recipients include The Jed Foundation, the National Alliance of Healthcare Purchaser Coalitions’ Path Forward initiative, and the Think:Kids & Meadows Mental Health Policy Institute (MMHPI) partnership.

The Jed Foundation, which focuses on emotional health support and suicide prevention for adolescents and young adults, plans to use the grant funds to create more partnerships with high schools, colleges, and universities in support of student mental health.

 “We are extremely grateful to receive The Goodness Web’s inaugural grant that fortifies and expands our ability to increase our programming to support youth mental health and suicide prevention nationwide,” said JED CEO John MacPhee in a press release. “Our goal is to partner with more than half of the country’s colleges and universities and more than 1000 high schools to implement a mental health culture of caring that improves well-being and reduces risks for suicide for their more than 13.2 million students.”

The Path Forward, a National Alliance of Healthcare Purchaser Coalitions initiative, focuses on using large employers to drive insurance companies to cover integrated mental health treatment costs in primary care settings. The initiative will use the funds to help create and build national infrastructure supporting greater access to mental health care.

 “Employers overwhelmingly identify the need to improve access to effective, affordable, and timely behavioral health care as a top priority,” said National Alliance of Healthcare Purchaser Coalitions about The Path Forward. “Five evidence-based reforms can dramatically improve early detection and access to more effective behavioral health care. The Path Forward’s goal is implementation of these reforms.” These reforms include measurement-based care, mental health parity compliance, tele-behavioral health, collaborative care, and network access.

The grant funds will also support the partnership between Think:Kids, an organization dedicated to helping clinicians, parents, and educators work more effectively with children who have behavioral challenges

; and MMHPI, an organization dedicated to driving equitable systemic changes in Texas to provide all individuals with access to effective behavioral health care.

 The organizations will use the grant funds to develop the evidence-based Collaborative Problem Solving (CPS) approach to working effectively with children who have behavioral challenges.

 “We are thrilled and honored to be among the inaugural grantees of The Goodness Web,” said Think:Kids said in a tweet. “We look forward to partnering with [MMHPI] supporting #MentalHealth for youth.”

The grants are being awarded by The Goodness Web (TGW) in collaboration with more than 70 donors. They will award $1.7 million in 2022, with additional funds to be distributed over the next 4 years totaling $5.3 million.

“Today, mental health support is highly fragmented and largely ineffective,” said Jan Swartz, co-founder of TGW, in a press release. “TGW looks to encourage next-level collaboration among mental health donors and nonprofits so that we can have a larger, faster impact in helping our youth. We believe better support for youth mental health is one of the greatest needs of our age.”

1. The Goodness Web Foundation names inaugural grant recipients, awarding $5.3 million to accelerate initiatives addressing the youth mental health crisis. The Goodness Web. News release. July 26, 2022. Accessed August 3, 2022. 

https://www.thegoodnessweb.org/july-26-2022-inaugural-grant-recipients

2. The Jed Foundation (JED) awarded 1.5M inaugural grant from The Goodness Web. The Jed Foundation. Press release. July 26, 2022. Accessed August 5, 2022. 

https://jedfoundation.org/news-views/the-jed-foundation-jed-awarded-15m-inaugural-grant-from-the-goodness-web/

3. The Path Forward for mental health and substance use: health equity for all Americans. National Alliance of Healthcare Purchaser Coalitions. March 26, 2021. Accessed August 5, 2022. 

https://higherlogicdownload.s3.amazonaws.com/NAHPC/3d988744-80e1-414b-8881-aa2c98621788/UploadedImages/One-Page_Path_Forward_Summary_03_26_21_LW_1318.pdf

4. Kids with challenging behavior are tragically misunderstood. it’s time for a more compassionate and effective approach. Think:Kids. Accessed August 5, 2022. 

5. Our mission. Meadows Mental Health Policy Institute. Accessed August 5, 2022. 

6. @ThinkKids. “We are thrilled and honored to be among the inaugural grantees of The Goodness Web. We look forward to partnering with the @MeadowsInst in supporting #MentalHealth for youth. Learn about The Goodness Web and the grantees: 

Inaugural recipients will use funds to support infrastructure, student mental health, and programs for children with behavioral challenges.

$5.3 Million in Grants Awarded to Address Youth Mental Health Crisis

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

It took only 48 hours for the pop psychology “diagnosis” of the Uvalde, Texas, shooter to hit the internet. One headline screamed, “A teenage psychopath is still a psychopath….”

 One prominent politician declared the shooter to be a “psychopath”

 and another upped the ante, describing him as a “heartless psychopath.”

Several anonymous online comments ran along the lines of, “Who else but a psychopath could murder a room full of innocent schoolchildren?” That is a perfectly understandable question among the general public, but it amounts to little more than a circular argument and plays fast and loose with the concept of “psychopath.”

What does psychopath really mean? In professional literature, “psychopaths” were defined by the pioneering forensic psychologist, Robert D. Hare, PhD, as “intraspecies predators who use charm, manipulation, intimidation, and violence to control others and to satisfy their own selfish needs. Lacking in conscience and in feelings for others, they cold-bloodedly take what they want and do as they please, violating social norms and expectations without the slightest sense of guilt or regret.”

Hare’s description amounts to a kind of archetype, describing what some have called—perhaps inaccurately—a “

 But as Hare himself later demonstrated, psychopathy is not an all or none characteristic. Rather, psychopathy is a trait that exists along a continuum of severity and a spectrum of psychopathology. More on this shortly.

A useful psychodynamic definition of psychopathy was provided by forensic psychologist J. Reid Meloy, PhD, in his classic book 

: “Psychopathy is a deviant developmental disturbance characterized by an inordinate amount of instinctual aggression and the absence of an object relational capacity to bond.”

Psychopathy is not defined in the DSM-5, although the category of antisocial personality disorder (APD) has substantial overlap with psychopathy. The diagnosis of APD requires evidence of conduct disorder prior to age 15 years, and the individual must be at least 18 years of age at the time of diagnosis. The gold standard for the diagnosis of psychopathy is the Psychopathy Checklist-Revised (PCL-R), originally developed by Hare.

 The PCL-R consists of 20 items and is completed on the basis of a semistructured 90- to 120-minute interview. Scoring yields evidence of high, medium, and low levels of psychopathy. The 20 traits are shown in the 

 Items on Psychopathy Checklist-Revised (PCL-R)

So far as I am aware, no school shooters in recent US history have been evaluated in a semistructured interview using the PCL-R. Many school shooters take their own lives before they can be seen by a mental health professional (ie, in a homicide-suicide). Hence, retrospectively labeling school shooters as 

 is not supported by the gold standard of objective clinical evidence. Of course, absence of evidence is not evidence of absence. It is certainly possible that a subset of school shooters would indeed score highly on the PCL-R or other 

Alternative Ways of Assessing Psychopathy

One trait often associated with psychopathy but not formally assessed by the PCL-R is cruelty to animals. In this regard, Arluke and Madfis studied 23 school shooters from 1988 to 2012 and found reports of prior animal cruelty in the histories of 10 of 23 of these shooters (43%)—a rate almost as high as that in the backgrounds of serial killers. They note, for example, that Columbine killers Eric Harris and Dylan Klebold boasted about mutilating animals for fun.

But it is far from clear how specific or predictively useful this finding is, given that, in one study, 28% of 260 undergraduates admitted to having abused animals when they were children. As Arluke commented, “If we flag every incident of animal abuse, our mental health and justice systems would be overwhelmed with tens of thousands of cases to review.”

Moreover, in a study of 10 “rampage school shooters,” investigator Peter Langman, PhD, found that the shooters fell into 3 main types or categories: traumatized, psychotic, and psychopathic. Langman described the psychopathic type as characterized by “a lack of empathy; a sense of superiority and contempt for others; skill in impression management; pleasure in deceiving others; and sadistic delight in inflicting pain on humans and/or animals.” Of the 10 shooters studied, 3 were traumatized, 5 were psychotic, and only 2 were psychopathic. This study, of course, involved a very small N and extended only from 1997 to 2007; generalizing from the data is therefore risky. Nevertheless, Langman commented, “Though it might seem logical to think that mass murderers are psychopaths, most of the school shooters in this study were not psychopathic.”

Toward a General Understanding of Young School Shooters

Because the Uvalde gunman was killed by US border patrol agents, we will never have a clinically based psychological profile of this individual—the kind of thorough psychiatric evaluation that could clarify the shooter’s personality structure or psychodynamics. Absent a professionally conducted psychological autopsy, any claims regarding the shooter’s psychopathology amount to speculation and an unwarranted rush to judgment.

That said, we can state some general, tentative conclusions about school shooters. It is important to note that I am focusing narrowly on school shooters—most of whom are under 18 years of age—and not on 

 in general, which represent a heterogeneous group sometimes motivated by racial, religious, or political animus, often inflamed by extremist propaganda.

Two investigators who have studied school shooters extensively—James Densley, PhD, and Jillian Peterson, PhD—paint this picture of the typical school shooter: “Inspired by past school shooters, some perpetrators are seeking fame and notoriety. However, most school shooters are motivated by a generalized anger. Their path to violence involves self-hate and despair turned outward at the world, and our research finds they often communicate their intent to do harm in advance as a final, desperate cry for help. The key to stopping these tragedies is for society to be alert to these warning signs and act on them immediately.”

Note that generalized anger, self-hatred, and despair are not key features of psychopathy, based on the PCL-R item list. At least in that respect, the evidence for psychopathy as a key characteristic of most school shooters appears weak. But there is a caveat here: In recent years, investigators have identified a group of youth with traits that look like precursors to psychopathy—youths who display anger, hostility, and emotional volatility after experiencing serious traumas. That condition is sometimes called “secondary psychopathy,” and this pattern may overlap to some degree with the Densley-Peterson profile previously described. Psychologist Abigail Marsh, PhD, describes this “secondary psychopathy” group: “The idea is that they were not born at particularly high risk for psychopathy…but that truly terrible life experiences caused their development to go awry. You tend not to see the fearless temperament in those kids but rather a lot of emotional dysregulation and anxiety.”

Indeed, it appears that many school shooters have experienced childhood traumas such as physical or emotional abuse. Many grew up in unstable families with violent, absent, or alcoholic parents or siblings. Many have been bullied or harassed at school, and most have experienced significant losses.

Recently, a more neurologically based understanding of psychopathy has been developed by Nathaniel E. Anderson, PhD, and Kent A. Kiehl, PhD. They argue: “Psychopathy is a neuropsychiatric disorder marked by deficient emotional responses, lack of empathy, and poor behavioral controls, commonly resulting in persistent antisocial deviance and criminal behavior. Accumulating research suggests that psychopathy follows a developmental trajectory with strong genetic influences, and which precipitates deleterious effects on widespread functional networks, particularly within paralimbic regions of the brain.”

Specifically, Anderson and Kiehl cite data linking psychopathy with abnormalities in the ventral-medial areas of the prefrontal cortex, including the orbitofrontal cortex, as well as in limbic structures such as the amygdala and hippocampus, and surrounding paralimbic regions. Not surprisingly, studies examining these brain regions have not been performed in school shooters, who comprise a minuscule proportion of gun violence perpetrators in the United States.

At this stage, there is no clear evidence that most school shooters fit the developmental trajectory or neurological profile posited by Anderson and Kiehl, although some might. We simply do not have the kind of comprehensive neuropsychiatric assessments available to determine this.

Why were some prominent public figures so quick to label the Uvalde shooter a “heartless psychopath”? The answer seems obvious: They were reacting as shocked human beings to a heinous crime, using a term that expressed their revulsion. Well, yes. But I think there is more to it than that. I believe that the use of this chilling label—

—serves at least 2 defensive functions for the general public: (1) It essentially removes any societal responsibility (eg, in the area of firearms regulation) for the horrific act of the shooter (“There’s really nothing you can do to stop a determined, cold-blooded killer”); and (2) it allows the general public to distance itself from the psychology of the shooter, who is written off as a kind of sick, twisted monster—the feared and despised “Other” who is, of course, “nothing at all like us.” With these 2 defense mechanisms in place, people can shrug and accept school shootings as simply unavoidable facts of life—the result of “evil in the world”—and then do little or nothing to prevent them.

What Can Be Done to Reduce School Shootings?

To be sure, we will never have the means to prevent all school shootings, but we can take steps to reduce their likelihood and lethality. Most perpetrators of K-12 shootings are male and under the age of 18 years who commit their crimes using unsecured handguns, not “assault rifles.” Indeed, according to Robin M. Kowalski, PhD, handguns were used in more than 91% of K-12 shootings, and almost half of shooters stole the gun from a family member.

 In addition to taking legislative steps to prevent these guns from falling into the hands of seriously disturbed adolescents, we can follow the advice of Densley and Peterson and be alert to the warning signs of impending gun violence and take immediate preventive action.

A foundational study of active shooters by the FBI found that the majority of perpetrators demonstrated at least 4 to 5 concerning behaviors that were observable to others, such as problematic interpersonal interactions or communicating their 

 (leakage) through verbal or physical behavior.

 Through collaboration between the public and responsible authorities, some planned shootings can be averted. Indeed, data from one study of thwarted mass homicide plots found that the friends, family members, and acquaintances of threateners all played an important role in discovering and thwarting homicidal plots.

Finally, when a school shooting occurs, we can recognize and resist the tendency to demonize the “Other.” Rather than immediately writing off school shooters as heartless psychopaths, we can view them as damaged and despairing young individuals who urgently need our proactive help and intervention.

 is professor emeritus of psychiatry and a lecturer on bioethics and humanities at SUNY Upstate Medical University in Syracuse, New York; a clinical professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts; and editor in chief emeritus of 

(2007-2010). He is the author of several books. A collection of his works can be found on Amazon.

1. Larson L. A teenage psychopath is still a psychopath and the public needs to know. KXL. May 27, 2022. Accessed July 8, 2022. 

https://www.kxl.com/a-teenage-psychopath-is-still-a-psychopath-and-the-public-needs-to-know/

2. Derysh I. Ted Cruz thinks he has a better solution to Uvalde school shooting than gun control: door control. 

https://www.salon.com/2022/05/26/ted-cruz-thinks-he-has-a-better-solution-to-uvalde-school-than-control-door-control/

3. Ogles J. Florida politicians respond to deadly school shooting in Texas. Florida Politics. May 25, 2022. Accessed July 8, 2022. 

https://floridapolitics.com/archives/527785-florida-politicians-respond-to-deadly-school-shooting-in-texas/

4. Hare RD. Psychopaths: new trends in research. 

http://minet.org/www.trancenet.net/hearts/research/psychopath.shtml

The Psychopathic Mind: Origins, Dynamics, and Treatment

7. The Hare Psychopathy Checklist – Revised (PCL-R): Hare, 1991. ClinTools. Accessed July 8, 2022. 

https://www.clintools.com/victims/resources/assessment/personality/psychopathy_checklist.html

8. Arluke A. How reliably does animal torture predict a future school shooter? 

. February 21, 2018. Accessed July 8, 2022. 

https://www.washingtonpost.com/news/posteverything/wp/2018/02/21/how-reliably-does-animal-torture-predict-a-future-mass-shooter/

10. Gollom M. Speculation about motive in mass shootings could encourage copycats, some psychiatrists suggest. 

. April 23, 2020. Accessed July 8, 2022. 

https://www.cbc.ca/news/canada/nova-scotia-shootings-psychiatrists-motive-1.5540911

11. Norrholm SD, Blotcky AD. Most mass shooters are terrorists, not mentally ill. 

https://www.psychiatrictimes.com/view/most-mass-shooters-are-terrorists-not-mentally-ill

12. Densley J, Peterson J. What we know about mass school shootings in the US – and the gunmen who carry them out. 

. May 25, 2022. Updated June 6, 2022. Accessed July 8, 2022. 

https://theconversation.com/what-we-know-about-mass-school-shootings-in-the-us-and-the-gunmen-who-carry-them-out-183812

13. DeAngelis T. A broader view of psychopathy. American Psychological Association. March 1, 2022. Accessed July 8, 2022. 

https://www.apa.org/monitor/2022/03/ce-corner-psychopathy

14. Chatterjee R. School shooters: understanding their path to violence is key to prevention. NPR Illinois. February 10, 2019. Accessed July 8, 2022. 

https://www.nprillinois.org/generationlisten/2019-02-10/school-shooters-understanding-their-path-to-violence-is-key-to-prevention

Psychopathy: developmental perspectives and their implications for treatment.

16. Kowalski RM. School shootings: what we know about them, and what we can do to prevent them. Brookings Institution. January 26, 2022. Accessed July 8, 2022. 

https://www.brookings.edu/blog/brown-center-chalkboard/2022/01/26/school-shootings-what-we-know-about-them-and-what-we-can-do-to-prevent-them/

17. Silver J, Simons A, Craun S. A study of pre-attack behaviors of active shooters in the United States between 2000 and 2013. Federal Bureau of Investigation. June 2018. Accessed July 8, 2022. 

https://www.fbi.gov/file-repository/pre-attack-behaviors-of-active-shooters-in-us-2000-2013.pdf/view

An examination of thwarted mass homicide plots and threateners.

 In: Gold LH, Simon RI, eds. Gun Violence and Mental Illness. American Psychiatric Association Publishing; 2016:81-104.

Pies RW. Mass shooters and the psychopathology spectrum. 

https://www.psychiatrictimes.com/view/mass-shooters-and-psychopathology-spectrum

Pies RW. Is the plague of mass school shootings in the US here to stay? 

https://www.psychiatrictimes.com/view/is-the-plague-of-mass-school-shootings-in-the-us-here-to-stay-

Moffic HS. Remember John Hinckley Jr: a triumph for psychiatry, but a failure for gun safety. 

https://www.psychiatrictimes.com/view/remember-john-hinckley-jr-a-triumph-for-psychiatry-but-a-failure-for-gun-safety

What is a psychopath? Here's why school shooters may not fit the definition. 

School Shooters and Psychopathy: A Rush to Judgment?

Lilly was able to live as well as she did, for as long as she did, because the sun does not shine in Soho. In New York City’s Soho district, cast-iron constructions, built more than a century ago, cast long, dark shadows, much like the inky black shadows sketched for 

comic books. Narrow alleyways separate back-to-back buildings, leaving next to no room for shafts of sunlight to seep in. Film noir-style shadows are plentiful in that part of town, as they are in 

’s fictional Gotham City, which owes its inspiration to Manhattan’s cast shadows.

Soho began as a manufacturing zone, where floor-through factories did not demand sunny views of cityscapes. Yet today’s Soho is a fashionable area with no trace of its past. It housed my psychiatry practice for the last decade. When manufacturing left New York City, those large Soho spaces turned into artists’ lofts, which then gave way to art galleries. Gradually, pricey designer boutiques replaced galleries, and fashionably dressed shoppers and shop girls displaced artists.

Lilly was unlike other Soho shop girls who wore unaffordable dress samples that turned them into breathing billboards. She was an apprentice jewelry designer at an established shop on Prince Street, a few blocks from my office. Even though she was only an intern and still a student, she had already amassed an impressive portfolio. She was wearing one of her creations when she arrived at my office for her first appointment—a little late, because passers-by had stopped her on the street to ask where she sold her unique broaches. Such was life in Soho.

Lilly was referred by Fashion Institute of Technology (FIT) Student Health Services to resume attention-deficit/hyperactivity (ADHD) treatment that had begun in grade school. FIT Student Health Services addressed acute symptoms only and referred students with long-standing conditions to private psychiatrists like me. Records documenting treatment that started when Lilly was young had arrived in advance, making it easy enough to refill her prescription for amphetamine salts. It was equally easy to add a selective serotonin reuptake inhibitor (SSRI)—and supportive therapy—when her social anxiety surged in this city of strangers, and when she felt overwhelmed by the stereotypically assertive New Yorkers who surrounded her.

Previously, Lilly was treated at a federally funded clinic. This rural area grappled with physician shortages. Her stimulants did not relieve the dyslexia that caused her more distress than inattention—but there were no local resources for cognitive remediation to help with reading and spelling. Luckily, Lilly preferred an arts-related career that sidestepped academic studies.

As her social anxiety subsided, she shared details about her early life in small-town Phoenicia, which was a few hours from Manhattan, geographically speaking, but lightyears away on a cultural level. Lilly was forthcoming about her struggles in school and the fact that most of her family members lacked so much as a high school diploma, much less advanced degrees. Still, despite her dyslexia—or maybe because of it—Lilly created clever necklaces from discarded tin cans that she scavenged near the Esopus, where shabby trailer camps contrasted with picturesque waterfalls that attracted tourists.

Phoenicia was a simple place, known for camping and tubing and long stretches of tall, fragrant pine trees. There, Lilly’s mother tended garden at a vacation home owned by a Cobble Hill couple. Her father functioned as a live-in caretaker, allowing the family to live rent-free. Their basement apartment was drafty and cold in the winter, when the owners were away and the heat was off, but it was still better than the trailers that lined the riverbanks, according to Lilly.

Her family lived underground—no taxes, no voting—until Lilly applied for a state scholarship. But every weekend, her father packed his pick-up truck with a fresh supply of repotted hostas, selling them to second-home owners. Lilly joked about weekenders’ willingness to pay outsized prices for minimal efforts needed to propagate common plants that grew in their shade garden.

Eventually, Lilly’s father added her tin broaches and bracelets to his hosta display. This caught the eye of an elderly tourist, who suggested that she create a portfolio and apply for a scholarship to FIT so she could hone her skills and prepare for a “real world” career. Lilly had never heard the word “portfolio” before, but she was impressed when she heard that both husband and wife were college professors. So, she followed their advice. She won a scholarship, thanks to this chance encounter. Her creations also impressed a jeweler in Soho, who offered her an internship at his shop, with a chance to make jewelry from “real” metals, not just tin cans.

At each appointment, Lilly shared more details of her day-to-day life. She made her way to work early each morning, exiting the tenement apartment she shared with an elderly aunt on Mulberry Street, located a short, shaded block from my office. She scheduled the earliest appointment available and then darted between the shadows, crossing narrow cobblestone streets that paved those deep caverns created by cast-iron towers. To commute to FIT, she jumped on the N train at Prince Street, half a block away. To travel to her job at the jewelry store—which offered course credit toward her jewelry-making certificate—she sped down Prince Street in the opposite direction. Sometimes, she said, she headed for a hidden alley near Houston Street, where she studied at a library that was sheltered from public view, but which gave her full view of discreetly staged fashion shoots at the far end of the alley.

Lilly did not resent her limited itinerary, for she found the New York City crowds too overwhelming, and she appreciated the predictability of a set schedule. And Lilly’s life was indeed predictable until something changed in late winter.

For Presidents’ Day weekend, a classmate invited her on a ski trip at an upstate resort—and that was when things started to shift. Embarrassed to admit that she could not afford a lift ticket, much less skis, Lilly sat on the sidelines for hours, near the snow-covered and sun-drenched trails. Upon return, she complained that her hands hurt, and that her fingers turned blue.

Lilly was describing Raynaud syndrome, which could worsen with vasoconstricting stimulants. Still, it seemed odd that such a side effect started so suddenly, after so many years on the same medication. Besides, she lived further north, where winters were far worse, yet she never previously had such symptoms in the cold. Then the clues started to fall into place. She also began experiencing fatigue once she sat outside on the slopes, which was equally strange, considering that stimulants are energizing and are sometimes used (illicitly) to combat fatigue.

I was unwilling to write these symptoms off to side effects, but I was also unwilling to continue a stimulant that could conceivably worsen Raynaud’s, especially since the medication offered minimal benefit for Lilly’s major dyslexia symptoms. So, we tapered her off the ADHD medication, but the pain in her fingers persisted—even though she was on SSRIs, which can relieve Raynaud’s. It was time to see the primary care physician (PCP) to find other explanations for concomitant fatigue, Raynaud’s, and joint pain in a 20-year-old female. I ordered basic labs and added an ANA test. Her PCP referred her to a rheumatologist when the ANA read a telling 1:360.

Lilly was still waiting for a specialist appointment when college graduation came around. By then, she had a solid job offer from the jewelry boutique that hired her as an intern. Her family was ecstatic. To celebrate this unanticipated success, they scheduled a surprise family vacation, with plans to drive their battered old pick-up truck south and stay with relatives in Key West.

Sadly, the trip was not the intended celebration, but it did explain her symptoms. While walking outside in the intense Florida sun, Lilly developed a raised, red rash on her nose, which sounded like the butterfly rash of lupus. Her joints hurt so much that she sidestepped the subspecialist and accepted the soonest appointment available, with a nurse practitioner (NP).

Without reviewing her history—or noting that symptoms worsened with strong sunlight (or from reflected sunlight on snowy ski slopes)—the NP prescribed tramadol for pain and sent her on her way. Her family objected and drove her back to Soho to see me. I was sorry to see Lilly in such distress, but I was happy to hear that she deferred starting a potentially habituating medication before exploring safer approaches or identifying the source of her symptoms.

Luckily, Lilly’s rural health center had ties with the regional medical school. They landed her an immediate immunology appointment at the State University in Albany, near her family’s home. The good news was that she would be near her family, and she could continue to design for her new job remotely (but without accessing expensive metals that were available onsite only). Her father was thrilled to restart selling her creations from his truck, and she was relieved to return to an existence that was far simpler and slower than Soho. She could rest up with relatives while awaiting more targeted treatment—and simultaneously brace for possibly bad diagnostic news.

This story did not have the happy ending that we hoped for, but the ending could have been worse. I shudder to think of what might have happened, or how this syndrome could have progressed, had someone summarily dismissed her symptoms as side effects to psychotropic medication, without additional assessment. Fortunately, psychiatrists are physicians first.

is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.

Psychiatrists are physicians first. This case demonstrates why that’s important.

Because the Sun Doesn’t Shine in Soho

An excellent article has recently been published on the scientific underpinnings of our understanding of parental alienation.

 Parental alienation as a mental condition is indeed founded on scientific research. In addition, there is a wealth of accumulated clinical knowledge of parental alienation in real-life, high-conflict cases. In this article, my goal is to discuss lessons learned from my experiences as an expert in alienation cases.

To provide context, I have been involved in at least 100 parental alienation cases over the years. I have been court-appointed to evaluate both parents in some of these cases. In others, I have been retained by a targeted or rejected parent to serve as an expert advocate on their behalf. Currently, I am retained in cases in 10 states and in Canada and England.

As a clinician, I can tell you that parental alienation is real, toxic, and potentially life changing. Of course, there are varying degrees of parental alienation, ranging from mild to moderate to severe.

 Mild to moderate alienation means the child is partially rejecting the targeted parent. In severe alienation, the parent is being totally rejected.

Estrangement is very different from alienation.

 Estrangement means the child is rejecting the targeted parent due to a legitimate concern about that parent, such as substance abuse or physical altercations or major mental illness. It is important for a mental health expert not to confuse estrangement with parental alienation. They are totally different situations and conditions.

We know that children who are immersed in the middle of a high-conflict separation, divorce, or postdivorce are at much higher risk for psychiatric symptoms, such as anxiety, depression, behavior problems, substance abuse, and more. This is true for children in childhood and later in adulthood.

 This is exactly what I have encountered clinically in my work.

Parental alienation manifests itself in a wide variety of behaviors, maneuvers, and strategies by the offending parent aimed at having the child reject the other parent. Bad-mouthing, interfering with visitation time, interfering with phone calls, cutting off family members, and false allegations of abuse are a few of the common alienating behaviors. A list of 17 frequent alienating strategies has been described in the literature.

False allegations of abuse are weapons that alienating parents use to gain leverage in their court proceedings. Filing criminal charges intensifies the weaponization even more. Such false allegations are hard to disprove, and offending parents use that fact to their advantage. Fortunately, investigations by child protective services often produce a “not indicated” or “unsubstantiated” finding, which helps to show the falseness of the allegations. Here is an important rule of thumb: multiple false allegations of abuse during a divorce proceeding are a huge red flag for parental alienation.

Attorneys involved in parental alienation cases often make the situations worse, not better.

 Winning is their top priority. The alienating parent’s attorney often turns a blind eye or even encourages the destructive behavior to “win” their case. The child’s attorney—the GAL—often has no mental health training and takes what the child says at face value, thus enabling the parental alienation. The rejected parent’s attorney may understand the dynamics but their hands are tied by the roadblocks imposed by the alienating parent’s attorney and the GAL. Passivity and defeatism may set in. Thus, it is often true that the attorneys in parental alienation cases do little to uncover and correct the pathological dynamic.

We know there is a certain treatment template that works in parental alienation cases.

 The alienating parent needs individual therapy that focuses exclusively on ceasing the alienating behavior. At the same time, the alienated child and the rejected parent must have reunification therapy to repair their relationship. If the child’s alienation is severe—meaning total rejection of the parent—the child must be removed from contact with the alienating parent, at least for a while, so that reunification therapy can take hold and be sustained.

Treatment of parental alienation can be successful if all involved in the case—attorneys, mediators, coordinators, experts, and judges—support the template offered above. Parental alienation in a child can be corrected. It is not a hopeless situation. But roadblocks to treatment must be recognized and combated.

Mental health experts are an invaluable asset in parental alienation cases, especially if the expert is knowledgeable and experienced in such dynamics. In my opinion, all high-conflict divorces that involve child custody matters should have a mental health expert in some capacity. Without an expert, these cases can become convoluted, twisted, and confusing very quickly.

As William Bernet, MD, and I have written, winning in a parental alienation case is much different than in all other family-law cases.

 Winning should be defined in terms of exposing and correcting parental alienation in the child. The correction of parental alienation is in the child’s best interest in each and every case. Ignoring it or accepting it as fait accompli is both ethically and professionally unacceptable and harms the child in the short-term and long-term.

Steven Miller, MD, recently passed away. He was an important contributor to our understanding of parental alienation cases.

 He wrote about the counterintuitive nature of parental alienation. The counterintuitive features of parental alienation are at the core of all diagnostic and treatment problems in these cases.

It is unacceptable for a physically or sexually abusive parent to falsely claim that they are the victim of parental alienation. That is a ruse that cannot be condoned or enabled. Parental alienation as an entity is not intended to cover up or hide physical or sexual abuse in a family.

Parental alienation is a diagnosable and treatable mental condition. Detractors who say otherwise are misguided and wrong. The condition is supported by both scientific research and clinical experience. Those of us who work in cases of parental alienation can attest to its toxicity, its confusing presentation, and its ability to be corrected under the right circumstances.

is a clinical and forensic psychologist in private practice in Birmingham, Alabama.He is also clinical associate professor in the department of psychology at the University of Alabama at Birmingham. Dr Blotcky can be reached at alanblotcky@att.net.

1. Harman JJ, Warshak RA, Lorandos D, Florian MJ. 

Developmental psychology and the scientific status of parental alienation.

2. Koszyk PA, Bernet W. Treatment and prevention of parental alienation. 

https://www.psychiatrictimes.com/view/treatment-and-prevention-parental-alienation

The Five-Factor Model for the diagnosis of parental alienation.

The impact of parental alienating behaviours on the mental health of adults alienated in childhood.

Surviving Parental Alienation. A Journey of Hope and Healing

6. Blotcky AD. False allegations of abuse during divorce: the role of alienating beliefs. 

https://www.psychiatrictimes.com/view/false-allegations-of-abuse-during-divorce-the-role-of-alienating-beliefs

7. Blotcky AD, Bernet W. Winning parental alienation cases: a roadmap for family lawyers. 

. January 12, 2022. Accessed July 25, 2022. 

https://familylawyermagazine.com/articles/winning-parental-alienation-cases/

A roadmap for the treatment of parental alienation.

9. Miller SG. Clinical reasoning and decision-making in cases of child alignment: diagnostic and therapeutic issues. In: Baker AJL, Sauber SR, eds. 

Working With Alienated Children and Families: A Clinical Guidebook

. Routledge/Taylor & Francis Group; 2014:8-47.

Parental alienation: a mental condition is indeed founded on scientific research. 

Lessons Learned From Parental Alienation Cases

 is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. To create a better world, he is an advocate for treating mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism. He serves on the Editorial Board of

is Clinical Professor and Chair of Psychiatry and Behavioral Science at the University of North Dakota School of Medicine and Health Sciences.

is a clinical social worker, a visual storyteller, and a creativity consultant.

If anyone thought that trauma was settling down in the Middle East and the US, this weekend belied that assumption. Though these events otherwise seem separate and are of great social psychiatric concern in their own right, all occurring over the weekend may be more than coincidence. They are:

-After a year of relative “quiet,” rockets were launched from Israel to the Gaza Strip and from the Gaza Strip to Israel.

-The fourth Muslin man to be ambushed and killed in Albuquerque over the past 9 months occurred on Friday.

-Saturday night and Sunday was the Jewish commemoration of Tisha b’Av, an annual fast and study day related to several disasters in Jewish history.

-Saturday August 6th was “Hiroshima Day,” the day in 1945 when the first atomic bomb was dropped on Hiroshima.

In canvassing the members of SPIRIT, who have previously written about such traumas for 

™, there was a great diversity of opinion about whether it was the right time to respond, and what could we say of value, yet still be respectful of the mourning associated with these tragedies.

Then there are also the silent international traumas, such as in Lebanon. Two of our members recently visited Lebanon. Plagued with hunger and a lack of social services, they reported a sense of powerlessness, helplessness, resignation, and psychotic-like “zombies” walking the streets there. It seems that we in psychiatry have to avoid feelings of learned helplessness in reacting to these traumas.

Although hundreds of women dressed in white with their mouths taped shut marched in protest in downtown Chicago on Sunday, the invasion of Ukraine continues, with less attention by the media, psychiatry, and public.

Of course, the powers in the situation are beyond formal mental health, including the survival of countries and people. Oil money and politics are a major influence.

Nevertheless, we in psychiatry know how to sit, listen, and help address the harm we humans do to one another. Our trauma stories can be the source of wisdom, resilience, growth, and transformation. Our children and the continued intergenerational transmission of trauma is at stake. Trauma to children, regardless of whoever is responsible, is a psychiatric and global mental health issue.

We hope to make further comments in the near future and are always available to help and contribute our knowledge. In the meanwhile, we bear witness to these psychiatric tragedies of war and other violence.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

All these events that occurred over the weekend bear social psychiatric weight. 

“A New and Differentiated Approach for Schizophrenia”: Positive Results for Phase 3 Trial

$5.3 Million in Grants Awarded to Address Youth Mental Health Crisis

School Shooters and Psychopathy: A Rush to Judgment?

Because the Sun Doesn’t Shine in Soho

Lessons Learned From Parental Alienation Cases

SPIRIT (Social Psychiatry Interested in Recovery from International Trauma) Voices Some Current Concerns

August 8 is National CBD Day 2022

Psychiatry Comic: Stilts

Skilcraft Visible Man Anatomy Kit, 1960

The Dog and Doggone Days of Summer