The PDF of our July issue is now available to peruse. The articles will roll out over the next few weeks, but if you want a sneak peek, look no further. From cover to cover, this issue is fully of clinical pearls and the latest in psychiatry. Specifically, you can learn more about

-The 988 Suicide Prevention Hotline going live this month

-Anti-NMDA Receptor Encephalitis Pathophysiology

-8 Key Issues in Major Depressive Disorders

We hope you enjoy. If you think we’ve missed covering something, feel free to reach out. 

Articles

Don’t Miss Our July Issue

What Does America Mean to You?

Slideshows

In honor of Independence Day, Psychiatric Times™ contributors weigh in.

Laughter Therapy: Good Medicine to Make Your Heart Glad

Psychiatry Comic: Reverse Psychology

Richard Berlin, MD, shares Stanley Kunitz's poem, "

has been writing a poem about his experience of being a doctor every month for the past 24 years in

in a column called “Poetry of the Times.” He is instructor in psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts. His latest book is

Videos

"She locked his name in her deepest cabinet and would not let him out, though I could hear him thumping..."


The Portrait

 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

Today is my anniversary, that is, my retirement from my official full-time work 10 years ago. Actually, I wrote an article for 

Mental Bootcamp: Today is the First Day of Your Retirement

,” on June 25th, 2012, a week before that transition. I followed that up about 2 years later in the February 10, 2014 article, “

.” It was a retirement partially planned and anticipated over the prior couple of years.

To Mask or Not to Mask on Broadway: With a Break in the 1/6 Hearings, That is Still a Question

Since then, I have come to conclude that the word retirement does not fit. If I am writing a weekday column and doing a weekly video for 

™, among other psychiatrically-related things, I am not in retirement. Let’s think of other words that might apply: refirement, refinement, realignment. Others come to mind?

The one promise that I made, and have kept pretty well, is to avoid situations which I could predict would be stressful. That stemmed from the burnout that I was in 10 years ago and which quickly dissipated after “retiring.”

I have also found that once a psychiatrist, always a psychiatrist. Given that psychiatry is curious and concerned about how people think and act, that happens in everyday life and it deepens my appreciation of people and society.

In retrospect, it certainly helps to prepare for retirement beforehand, especially if it is forced upon you by illness or something else. Not surprisingly, that includes finances. It is hard to accomplish financial security in the last minute or years.

Finding other things that you enjoy is also helpful. For me, it was traveling with my wife and being with her much more. We even ended up sharing a computer and proved one of my colleagues wrong, who had predicted that this practice would end our marriage! Is ours a rare exception, or can such sharing not only bring marriages closer together, but have diagnostic and therapeutic potential?

Think about your health. Though relatively healthy when I retired, I had sleep apnea for a decade already, and since that gradually takes its toll on the heart even with treatment, I had a sense something more was in store later. Fortunately, last December it was an unanticipated finding of a sudden death risk heart arrhythmia necessitating a pacemaker, which I fondly named Pacey.

Since I do other volunteer work as a psychiatrist, especially on many Boards of Directors, I call myself a Pro Bono Private Community Psychiatrist. It is a great job.

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

Lessons Learned by a Psychiatrist From His So-Called Retirement

, we worked with experts from multiple areas in psychiatry to bring you thoughtful articles about a wide variety of psychiatric issues, from youth mental health in competitive sports to the implications of civil commitment for substance use disorders. Here are some highlights from the issue.

Civil Commitment for Substance Use Disorders: Coercion or Compassion?

The United States of America has entered the third year under siege from not just 1, but 2 epidemics: COVID-19 and addiction. Each scourge has multiplied the victims and magnified the death toll of the other; together, they have caused immeasurable suffering and loss.

 On November 17, 2021, the Centers for Disease Control and Prevention (CDC) made the grim announcement that annual overdoses passed the 100,000 mark. The 100,306 tragic deaths represent a nearly 30% increase from the prior year. Fatalities from synthetic and semisynthetic opioids, especially fentanyl, along with methamphetamine and cocaine were all higher in the past 12 months than in the period before.

 The vast majority of those who overdosed would meet criteria for a substance use disorder (SUD). 

An Update on the Presentation, Nosology, and Causes of Postpartum Psychosis

 (PP) is an umbrella term for the impairing and isolating psychotic-mood symptoms experienced by a small proportion of women (1 to 2 women every 1000 deliveries) shortly after childbirth. Despite being recognized for centuries, the condition has historically been understudied. However, over the past 10 to 15 years, stimulated by a growing interest in women’s health and increasing crosstalk among biomedical practitioners in diverse fields, we are finally starting to characterize PP more comprehensively and beginning to understand its associated risk factors and biological basis. 

On Thin Ice: Competitive Sports & Youth Mental Health

Your patient is 15 years old. Legally, they cannot smoke, they cannot drink, they cannot drive or make decisions for themselves. But they are pressured to take a cocktail of drugs, vitamins, and supplements, limit their diets, wear skin-tight costumes, and compete under a global microscope. There, the whole world watches them shine…or delights in their failures. What do you advise your patient and their family caregivers? 

Navigating to a Broader Population of First-Episode Patients

One of the core and troubling lessons that I learned during my psychiatric residency in the late 1980s continues to haunt me. For patients with serious mental illnesses (SMI), the greater the duration of time before a patient is diagnosed and enters treatment, the longer a symptomatic episode lasts, the more episodes the patient has, the less adherent the patient is with treatment, the more psychosocial stressors the patient is challenged by, the greater the presence of comorbid substance abuse, and the more disconnected the patient becomes from mainstream society, the worse the patient’s long-term prognosis will be. Intuitively, this is simply common sense. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

The experts weighed in on a wide variety of psychiatric issues for the June 2022 issue of Psychiatric Times.

From the Pages of Psychiatric Times: June 2022

As a clinical and forensic psychologist, I am often court-appointed or privately retained to conduct psychological/custody evaluations in high-conflict divorce cases. My evaluations in these cases usually take at least 6 months or more to complete. Why? Because longitudinal evaluations are the best way to detect, uncover, and describe complicated family dynamics. Family dynamics can be largely or entirely missed in a one-shot, cross-sectional evaluation. Inaccurate or wrong findings, conclusions, and recommendations can be the unfortunate consequence. A child’s well-being and best interest can be lost if the evaluation is completed too fast with too few information/data points over time.

I have had many cases where important family dynamics did not reveal themselves initially in individual interviews and psychological testing. The goal of any psychological/custody evaluation is to determine the impact of parental and family influences on a child and to make recommendations based on those findings.

 Anything short of that is a missed opportunity and will be unhelpful in a legal proceeding.

Uncovering family dynamics is especially fraught in high-conflict divorces that are, by definition, contentious, adversarial, and prone to obfuscation and falsehoods.

 The surest way to see family dynamics clearly is to experience them in real-time as part of the evaluation process. In essence, the evaluator becomes a watchful spectator of the interactions and maneuvers of the various family members over an extended period of time.

Cross-sectional evaluations usually take 3 or 4 sessions per adult and 2 or 3 sessions per child. They include interviews, psychological testing, review of collateral information, and review of mental health records. Such evaluations can be accomplished in short order, like 2 months. But, all too often, these evaluations are not sufficient to uncover vital family dynamics. They often lack depth and breadth because they are based on limited information collected over a short period of time.

My longitudinal evaluations take at least 6 months and always include the filling in of a timeline of events and behaviors as they are occurring in real time.

 Information for the timeline is collected through many interviews, phone contacts, emails, and text messages. Both parents and children can provide valuable data for the timeline. At the end, a comprehensive picture of the family and its dynamics can be described extensively in vivid color and with texture.

Longitudinal evaluations are especially helpful in suspected cases of parental alienation.

 Since alienating or offending parents never admit to their damaging behavior, it behooves the mental health expert to follow the family over many months to see the sequence of events and behaviors as they unfold in real time. A timeline can be established that reveals the ebb and flow of harmful family maneuvers and behaviors.

Longitudinal evaluations also make sense when false allegations of abuse are a part of the case. In my experience, multiple false allegations during a divorce proceeding are a huge red flag for parental alienation.

 If the evaluation process extends for many months, these false allegations can mount up, clearly showing their role in the alienating process. And “not indicated” or “not substantiated” reports by child protective agencies can mount up as well during the evaluation period.

In court, longitudinal evaluations are robust and compelling. They provide many more data points to be considered in the overall assessment and depiction of the family. It is far easier to describe parental alienation in detail if a longitudinal approach has been taken in the evaluation process. Also, it lends itself to gripping courtroom testimony.

The American Psychological Association has published a report regarding the important features of a child custody evaluation.

 Ethical considerations are always paramount. What is missing in their model is an emphasis on a longitudinal evaluation rather than a cross-sectional one. Perhaps this feature should be added to the American Psychological Association’s model of custody evaluations.

By definition, longitudinal evaluations are much more time-consuming than one-shot assessments. But time should not be the guiding factor in mental health evaluations in high-conflict custody cases. Getting it right is far more important for the child. Taking as much time as needed should be the mantra of a highly helpful evaluation.

Treatment recommendations can be more accurate and specific when a longitudinal approach is taken in the evaluation. Treatment should always follow from diagnosis, and a comprehensive evaluation can set the stage for ongoing interventions that will be both effective and efficient.

In my experience, attorneys and judges make better decisions about custody arrangements when they are provided longitudinal information. Judges seem moved by timelines, documentation, and real-time examples.

There is 1 additional advantage to a longitudinal approach. Sometimes, the evaluation process itself can lead to significant awareness, changes, and resolution. The evaluation itself can be an intervention. In mild cases of parental alienation, for example, the evaluation process can convince the alienating parent to cease his or her damaging behavior, thereby resolving the crisis at hand.

One final note: In some cases of divorce, when parental alienation is not suspected and false allegations of abuse are not present, a one-time, cross-sectional evaluation does make sense. Simpler cases can indeed call for simpler evaluations.

In summary, parental alienation cases need longitudinal evaluations in order to detect and describe the damaging alienating behavior. These cases can be complicated and confusing at the beginning, but the evaluation process can tease out the prominent problematic dynamics in the family. A one-time, cross-sectional assessment can miss powerful and conclusive information in a case.

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.

Assessing for alienation in child custody and access evaluations.

2. Bernet W. Children of high-conflict divorce face many challenges. 

https://www.psychiatrictimes.com/view/children-high-conflict-divorce-face-many-challenges

3. Blotcky AD. Timelines are a critical tool in cases of false allegations of abuse and parental alienation. 

https://www.psychiatrictimes.com/view/timelines-are-a-critical-tool-in-cases-of-false-allegations-of-abuse-and-parental-alienation

Parental alienation: the blossoming of a field of study.

Current Directions in Psychological Science

5. Blotcky AD. Child abuse allegations: sorting out lies versus truths. 

https://www.psychiatrictimes.com/view/child-abuse-allegations-lies-versus-truths

Guidelines for child custody evaluations in family law proceedings

Here’s why longitudinal evaluations in high-conflict divorce cases are critical. 

The Benefits of Longitudinal Evaluations in Parental Alienation Cases

 is a practicing adult psychiatrist with special interests in health disparities and public health. She completed her residency training at George Washington University Hospital and received her Master of Public Health from Yale School of Public Health.

 varies depending on the focus and purpose of different agencies. Essentially, mental health disparities refer to gaps in the health status, health outcome, quality of treatment, or access to care among various populations.

The National Institute of Mental Health (NIMH) defines significant disparity in the overall rate of mental illness incidence or prevalence, morbidity, mortality, or survival rates in a health disparity population as compared with the health status of the general population. NIMH defines health disparity populations to include: American Indians/Alaska Natives, Asian Americans, Blacks/African Americans, Hispanics/Latinos, Native Hawaiians and other Pacific Islanders, sexual and gender minorities, socioeconomically disadvantaged populations, and underserved rural populations.

 Alternatively, the National Conference of State Legislatures refer to behavioral health disparities in terms of differences in outcomes and access to services related to mental health and substance use, which are experienced by groups based on their social, ethnic, and economic status.

Factors That Influence Mental Health Disparities

The field of medicine and public health are increasingly recognizing how external factors can impact individuals’ health, and not solely attributing mental health disorders to the fault of the individual. Social determinants of health, or those “conditions in which people are born, grow, live, work, and age, which are shaped by the distribution of money, power, and resources” are underlying drivers that exacerbate gaps in health status and care access.Underlying social and economic inequalities such as economic instability, neighborhood environment, food security, educational-level, and structural racism/discrimination systemically impact health. These factors serve as important framework to consider when planning health interventions.

 surrounding mental health care, lack of access to high-quality mental health care services, and various factors can contribute to poor mental health outcomes.

 For example, rates of suicide and death rates from suicide remain significantly higher among American Indian/Alaska Native populations from late adolescence through adulthood.

 Moreover, suicidal thoughts and behaviors increased markedly among Black and Asian youths.

 In terms of substance use disorder, although there is a dramatic rise in opioid-related deaths, especially among Blacks and Hispanics, fewer Latinos and African Americans receive needed treatment for mental health and substance abuse care.

 While racial/ethnic minorities are more likely to have more severe and persistent courses of disorders, minorities in the United States are more likely than whites to delay or fail to seek mental health treatment and to have less access to mental health services. They are also less likely to receive needed care and more likely to receive poor-quality care when treated.

, for instance, are the least likely to access mental health care compared to other racial-ethnic groups.

 Furthermore, providers’ own implicit biases may also influence diagnosis and treatment quality among certain groups.

Mental health parity laws try to ensure that mental health conditions and 

 will be provided the same level of insurance coverage. The Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008 required insurance coverage for mental health/substance use disorder conditions to be no more restrictive than insurance coverage for other medical conditions. In 2020, Congress required insurers and health plans to show that they are complying with such provisions.

 Benefit plans that must be covered equally include services like inpatient and outpatient care both in-network and out-of-network, intensive outpatient services, partial hospitalizations, copays, prescription drugs, and criteria used to approve or deny care.

 However, it can be difficult to measure and determine how effectively these policies are being implemented on the grounds to ensure equal access to care.

Focused, targeted efforts are needed at personal, community, and national levels to address 

 and promote equity. The first question to consider is, which population would I like to focus my efforts on (eg, a particular minority group, women, children/youth, or rural populations)? The second question to clarify is, what is my desired outcome (such as a target to reduce suicide rates, enhance health-seeking behavior, or increase access to addiction services)? The third question to evaluate is, what is the evidence for effectiveness, feasibility, and sustainability of such interventions? How can I continue to evaluate its impact?

Following are some ideas for creating personal and systematic changes to promote health equity.

-Assess patients’ cultural beliefs, attitudes, and stigma related to mental health in clinical interactions.

-Provide culturally appropriate interventions such as suicide hotlines targeted for specific populations (such as for the 

, veterans, youth, or Asian Americans), or assistance in finding local resources for safe gun storage.

-Advocate for changes in your health care organization—eg, ask for support staff to help with prior authorizations, promote availability of addiction services, advocate for appropriate interpreters and staff members, and create workgroups to examine data on health disparities, outcomes, and access.

-Understand your own potential biases. You can take free 5-minute Implicit Association Test that may reveal certain implicit biases at 

Addressing mental health disparities through research:

 Although it is important to examine the incidence or prevalence of disease burden among various populations (such as how many individuals are impacted by serious mental illness or suicide attempts), research efforts must also move beyond incidence or prevalence data. Further research should acknowledge the underlying structural and cultural factors that contribute to mental health disparities and seek for ways to address them.

NIMH encourages researchers to examine underlying causes of mental health disparities as well as to explore ways to test novel approaches to reduce disparities.

 seem to have effective impact on improving mental health. For example, providing universal school meal programs in several states were associated with improvement in psychosocial outcomes, including reductions in hyperactivity, anxiety, depression symptoms as well as academic outcomes and school attendance.

 Encouraging savings accounts demonstrated improved socioeconomic outcomes and mental health outcomes for those from low- and moderate-income backgrounds.

 There is also evidence that these saving accounts can also reduce mothers’ depression symptoms around 3 years after intervention.

 Expansion of green (eg, parks, fields, and gardens) and blue (eg, oceans and lakes) spaces in neighborhood seems to be associated with mental health well-being and decreased feelings of depression and worthlessness amongst residents compared to control sites.

 Continual research that focuses on addressing social determinants of health is needed to examine the effectiveness of public health interventions on mental health.

 Partnerships are needed between mental health providers, physicians, educators, community leaders, and government agencies to create targeted, effective interventions. Such efforts may focus on destigmatizing mental health, improving insurance coverage access, providing culturally and linguistically appropriate mental health services, or addressing other barriers to care. Promoting connectedness among members of a community, building alliances with local communities, and improving culturally appropriate access to care can help reduce some factors that contribute to disparity. For example, the Centers for Disease Control and Prevention (CDC) works with local partners/states to reduce suicide disparities: They teach community members how to identify and refer individuals at risk of suicide, work on reducing access to lethal means by promoting 

, and provide social-emotional learning programs to promote coping and problem-solving skills in youth activities in schools.

 Such efforts require coordination and alliance building at community and national levels. Collaborative networks, such as National Network to Eliminate Disparities in Behavioral Health (NNED), is one way to share information amongst health care works and community-based organizations.

 Get involved with local or national mental health policy advocacy organizations,

 contact your local representative or Congress person, and stay informed.

Although the general media and research narrative focus on disparities, much attention should also be paid to emphasize each groups’ strengths and resiliencies and current efforts to promote equity. Carefully considered, targeted, and collaborative efforts are needed at individual and systemic levels to address underlying causes of mental health disparities. Only when we commit to creating individual changes will we be able to create changes at a larger scale together.

1. Overview. National Institute on Minority Health and Health Disparities. Updated May 5, 2021. Accessed June 29, 2022. 

https://www.nimhd.nih.gov/about/overview/

2. Behavioral health disparities. National Conference of State Legislatures. December 20, 2017. Accessed June 29, 2022. 

https://www.ncsl.org/research/health/behavioral-health-disparities636355423.aspx#:~:text=Behavioral%20health%20disparities%20refer%20to,%2C%20ethnic%2C%20and%20economic%20status

3. Ndugga N, Artiga S. Disparities in health and health care: 5 key questions and answers. KFF. May 11, 2021. Accessed June 29, 2022. 

https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/

4. Mental health disparities: diverse populations. American Psychiatric Association. Accessed June 29, 2022. 

https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts#:~:text=Racial%2Fethnic%2C%20gender%2C%20and,of%20awareness%20about%20mental%20health

5. Barksdale C, Pérez-Stable E, Gordon J. 

Innovative directions to advance mental health disparities research. 

New evidence regarding racial and ethnic disparities in mental health: policy implications.

7. Behavioral health equity data. Substance Abuse and Mental Health Services Administration. Accessed June 29, 2022. 

https://www.samhsa.gov/behavioral-health-equity/obhe-data#:~:text=Some%20measures%20include%20data%20presented,their%20male%20counterparts%20(3.9%25)

8. Yang K, Rodgers C, Lee E, Lê Cook B. 

Disparities in mental health care utilization and perceived need among asian Americans: 2012–2016

Implicit bias in healthcare professionals: a systematic review.

10. The Mental Health Parity and Addiction Equity Act (MHPAEA). Centers for Medicare & Medicaid Services. Accessed June 29, 2022. 

https://www.cms.gov/CCIIO/Programs-and-Initiatives/Other-Insurance-Protections/mhpaea_factsheet

11. What is mental health parity? National Alliance on Mental Illness. Accessed June 29, 2022. 

https://www.nami.org/Your-Journey/Individuals-with-Mental-Illness/Understanding-Health-Insurance/What-is-Mental-Health-Parity

12. NIMH’s approach to mental health disparities research. National Institute of Mental Health. Accessed June 29, 2022. 

https://www.nimh.nih.gov/about/organization/od/odwd/nimhs-approach-to-mental-health-disparities-research#addressing-mental-health-disparities-through-research

13. Alegría M, Zhen-Duan J, O’Malley I, DiMarzio K. 

A new agenda for optimizing investments in community mental health and reducing disparities. 

14. Disparities in suicide. Center for Disease Control and Prevention. Accessed June 29, 2022. 

https://www.cdc.gov/suicide/facts/disparities-in-suicide.html

15. Mental health policy and advocacy organizations. National Center on Domestic Violence, Trauma & Mental Health. Accessed June 29, 2022. 

http://www.nationalcenterdvtraumamh.org/resources/mental-health-policy-and-advocacy-organizations/

Targeted and collaborative efforts are needed at individual and systemic levels to address underlying causes of mental health disparities.

How Would You Tackle Mental Health Disparities?

Niall (“Jock”) McLaren is an Australian psychiatrist. He is Honorary Research Fellow in the Department of Philosophy at University of Queensland. He recently retired after nearly half a century of practice, including 25 years in the far north of Australia. He has extensive experience in remote and military psychiatry and posttraumatic states. He has published extensively on the application of the philosophy of science to psychiatry, most recently with a formal integrative theory for psychiatry, the biocognitive model. He was previously interviewed as part of this series in 

 Since your participation in this series in 2019, you have written and published your new book 

Natural Dualism and Mental Disorder: The Biocognitive Model for Psychiatry

 I am excited to have you back in the series to discuss the details of your model. Our earlier exchange gives the readers a fair idea of your discontents with contemporary psychiatry. Let’s begin with the notion of “natural dualism.” What do you mean by that, and how does it differ from the more commonplace notion of “dualism” that many mental health professionals are familiar with?

 Thank you, and that is an important question to start with. Talking philosophy to a psychiatric audience is never easy, as too many psychiatrists seem to think that they are biological scientists, so it does not apply to their activities—but it does. 

 is simply the process of confronting and trying to answer complex questions, and what is more complex than the nature of mind and its disorders? Dualism is one attempt at answering the question of the nature of mind, but it gets a bad press these days, mainly due to misunderstanding. Dualism means 2-fold—that mind and body are not obviously the same. Richard Watson said, “The crux of dualism is an apparently unbridgeable gap between 2 incommensurable orders of being that must be reconciled if we (wish to justify)  our assumption that there is a comprehensible universe…”

 That is neat, because it also tells us there are 2 forms of causation.

Historically, dualism relates to the French polymath, Rene Descartes (1596-1650), who said mind and body are composed of 2 different substances: the physical stuff of bodies and brains, and the mental stuff of the mind, each requiring nothing other than itself to exist. That leads to the problem of how those substances can possibly interact—the classic 

, of which he was perfectly well aware. It also leads people these days to deride his work. For example, philosopher Daniel Dennett of Tufts University in Boston dismisses with contempt any idea of dualism as pure magical thinking. Instead, they try to eliminate 1 side of the question by building a nondualist or monist philosophy of mind, such as “Mind and brain are a unity” or “Mind reduces to the brain.” That does not work, and never will work.

Natural dualism says “Yes, mind and body are profoundly different, with no properties in common, but mind arises from the brain by natural, law-like processes (laws of supervenience),” which we can probably understand. The idea is closely associated with philosopher David Chalmers, but very explicitly, there is no magic involved. My work takes it further and offers a biological mechanism by which a nonphysical mind supervenes upon or emerges from the physical brain. I have suggested what those laws are, but crucially, it uses processes that we have known about for a long time.

 You present a computational model of the mind as an informational space. What do you see as the boundaries of your notion of the “mind” here? When it comes to psychological processes such as memory and perception, which possess an essential neurobiological dimension, where does 

This can be confusing because we are sentient beings; our entire perception of ourselves is based in this point. We are first and foremost information detectors, collectors, processors, storers, and transmitters. In the book, I derive a formal definition of information, but essentially, it is what we know and experience—what we can act on and communicate. That is the result of the brain doing its job as a very high-speed, multichannel information processor of ineffable complexity. The main boundary of the mind is that it is utterly private. My brain generates my mind, and you cannot share it unless I use speech or action to convey a small part of it. The next boundary is that the sense of mind or consciousness the brain generates is completely dependent on the healthy brain. Even slight variations in physiology, such as a fever, can interfere with the natural process of generating the mind. We call that confusion or delirium. Physicians have to be very aware of it.

Descartes said that if you want to know the mind, the only place to start was in the dissecting room, and I totally agree. It is not possible to understand the concept of a mind emerging from the brain without a detailed knowledge of the brain and neurophysiological processes. This means, of course, that if the biocognitive model gets any traction, then the field of a nonmedical psychology will shrink dramatically. But it also means that the concept of a reductionist biological psychiatry is headed for the history books, replaced by a well-grounded mentalist psychiatry.

 within this framework? How does your view of personality differ from how personality is conceptualized in psychodynamic terms, or how it is conceptualized by the 5-factor model proponents?

I spend quite a lot of time deriving a formal definition of personality, which doubles as a description. Because this is a computational model, not hydraulic as the Freudian model was or static as in DSM terms, personality devolves to the particular set of rules which determines each of us as a unique human being. Remember that this set of rules is vast, and we often do not know what they are, but I explain all of this. Personality must be seen as a very dynamic process, not a fixed thing. What we call a normal personality results from a set of rules which are both internally consistent and consistent with the rules of the larger society, producing a cheerful (euthymic) person who meshes with the surroundings. However, if my rules are internally contradictory, producing distress or confusion, or clash with the larger society’s rules, producing conflict (or both), then we have personality disorder. Of course, my rules can change, for better or for worse. That means personalities can change; they are not genetically fixed. This may be abrupt as in posttraumatic cases, or gradual as in education and life experience. But the biocognitive model allots a much greater role to personality in mental disorder than biological psychiatry does. Biological psychiatry wants to see everything as “chemical imbalances.” No, it is not.

 How are “mental disorders” defined in the biocognitive model? How does your notion of mental disorder differ from, say, how the DSM understands mental disorders (a syndrome that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning that leads to significant distress or 

First point to mention: Mental disorder is real. It is as real as hunger or the pain of appendicitis, so the so-called “

” approach—that mental disorder is a myth—is completely wrong. Second: DSM is avowedly atheoretical. It is a nosology, not a model of mental disorder, although it implicitly supports the reductionist approach. It is descriptive, not explanatory, so, except in the case of posttraumatic disorders, it does not assign causes. DSM-5 gives only 3 pages to discussing “psychological factors affecting medical conditions” in the vaguest terms possible.

In a few words, the biocognitive model says that mental disorder is a state of self-sustaining mental distress and dysfunction. Mental disorder is not like ordinary grief, which resolves itself, or a bit of a fear that people can work on, or being angry over your team losing, because we get over that sort of thing. That is our nature. The mere presence of distress or poor performance does not 

 constitute a mental illness—it only becomes mental disorder when it is self-sustaining and the person cannot recover.

The model assigns a major role to personality, to current stressors and to cultural factors, but more importantly, it offers a formal mechanism of integrating psychological (including personality) and sociocultural factors into the clinical picture. DSM does not do that; it does not offer a model of mind or any integrative mechanisms. For all those people who have wanted a genuinely integrative “biopsychosocial model,” here it is.

 In your model, how does the process become self-sustaining? Are there analogous ways in which information processing in a computer can be self-sustaining? Another prominent approach in psychiatry that emphasizes the self-sustaining nature of mental disorders is the network theory,

 which conceptualizes mental disorders as symptom networks where symptoms are causally related to each other (instead of being caused by a latent variable or a central disease process), and “If these causal relations are sufficiently strong, symptoms can generate a level of feedback that renders them self-sustaining.”

 It seems like there are different ways in which it is possible for us to theorize how psychiatric syndromes become self-sustaining.

 The process of mental disturbance becomes self-sustaining by a simple feedback loop more or less consistent with what Norbert Wiener described in 1948, the difference here being that part of the loop is cognitive—a matter of what the subject knows and believes. The arrow of causation loops between mental and physical. I have given a number of examples of how seeing or hearing something can generate an unpleasant mental state whose symptoms then cause the person to become more distressed. It is a simple matter; we see it myriad times a day in anticipatory anxiety, but it also applies to normal life.

For example, “Mr Smith” has to give a talk in front of his bosses. He is worried about how he will perform, and his heart starts to beat a bit faster. But he believes a fast pulse means an impending heart attack, so, as soon as he becomes aware of it, he becomes more agitated, which makes it beat faster. Before long, he is so agitated he has to cancel his presentation. That is an easy one—extremely common, for which beta blockers are rapidly effective, and cheap. But the crucial factor is the cognitive element—that the patient must be scared of his own symptoms. I have also emphasised the Challenge Hypothesis and its role in dominance hierarchies, and how the drive to dominance produces its own instability. This is important, not just in psychiatry, but in social and political life.

Network theory, on the other hand, seems to be deficient in that it does not involve this crucial cognitive factor. The concept uses the recursive properties of networks, but inserts symptoms as the nodes, not giving credit to the notion that symptoms do not exist in isolation—that they exist separate from the mind. They are part of a much larger mental state of which the subject’s knowledge state is an integral part. Because network theory is not part of a larger theory of mind, it treats the human as an automaton, not a sentient being. I am not much convinced by these highly abstract theories in cognitive sciences. It always seems to me the theory comes first, then they look for somewhere to apply it.

 Does your definition of mental disorder exclude any conditions presently classified as mental disorders? For example, would “prolonged grief” count as a mental disorder under your framework?

I do not believe in “psychiatry unlimited.” The biocognitive model excludes a lot of what has become “disease” over the past 40 years since DSM-III burst on the scene. Just as 

 is the normal reaction to the perception of a threat, grief is the normal reaction to the perception of a loss—any significant loss. It is the converse of attachment—the downside to our capacity to form relationships—that defines us as humans. For a grief reaction to resolve, the sufferer must be able to build a new and satisfying lifestyle. All that takes time, a supportive environment, opportunities, and so on. Grief only becomes a disorder when it cannot get better or is life-endangering. If it does not get better, it is the psychiatrist’s job to work out why, and to help the sufferer work through the loss to build a different future—not to throw suppressive drugs around. Same goes for childhood disorders such as “attention-deficit/hyperactivity disorder.” The biocognitive model says, “Every child is different, so the learning environment must be tailored to the child, not vice versa.”

At present, psychiatry locates the disorder in the individual. That is what biology and genomics looks for, but that is an ideological stance. It has no argued basis in science. I will give a reference for that: In the interactive model, some disorders are inherent in the individual, some are wholly reactions to social events, but the great majority are a complex mix of biological, psychological, and social factors. Sorting that out brings back the art of psychiatry.

 Psychiatric conditions often entail prominent bodily manifestations, such as psychomotor retardation, appetite changes, sleep changes, blunting of affect… how do you conceptualize these physical manifestations of psychiatric disorders in informational terms?

Everything we do is mediated by informational flows. I move my index finger: Instructions have been sent as information in neurons via pyramidal tracts to AHC to motor end plate; prior to that, the decision to move it was affected by information processing in the cerebrum, but our technology is not quite up to that task yet. I explain all of this in general terms showing how the mind-body problem can be resolved quite easily using available technology. I give an explanation for blunting of affect in depression and put a lot of emphasis on the role of anxiety in mediating many of the changes we see in mental disorder.

I think anxiety is very important—in fact, I wrote a 

 about it—but that is swimming against the DSM tide, because DSM wants to see discrete categories of mental disorder, whereas I am arguing that it is all dimensional. The biocognitive model is much more complicated than the DSM “tick a box” approach. And quite often that complexity requires judgement and discretion; psychiatrists actually have to work hard to understand what is going on. But anyway, I give precisely defined examples of how somatic changes are enacted. This is not rocket science, but it does require a different mindset. I have to say this: The worst effect of the modern “biological” push in psychiatry is that it made psychiatry boring.

 If mental disorders are purely a matter of informational malfunction, how does your model account for the presence of neurobiological risk factors (such as genetics, HPA axis, inflammation, neurotrophic factors) that influence the probability of experiencing various mental disorders? Similarly, if the mind is purely informational, how do 

 and biological interventions successfully change the informational content?

 Mental disorder is the overt or experienced manifestation of some disturbance in the brain-mind complex. Remember that when something goes wrong in an informational model, there are 2 aspects to consider: (1) the physical, meaning the brain, and (2) the informational or mental. The initial physical state of the brain is determined by the genome; the most extensive studies so far have failed to find any significant genetic contribution to any single mental disorder. At best, there is a generic tendency to mental disorder which, as I argued in the 

 is probably a genetic tendency to overreact to perceived threats. But we know from the Challenge Hypothesis that people who feel threatened will perceive more threats, which has direct effects on activating a wide range of defensive systems in the body. Using the Challenge Hypothesis, I put a lot of emphasis on the role of testosterone as an inherent destabilizing factor, but people do not like it—they see it as threatening. They want to see themselves as coolly rational, but they feel threatened if you want to talk about their response to threats.

the chemicals are under direct mental control. The mental perception is the first event in a long causal chain. That is directly opposite to what reductionist biological psychiatry says and, I say, explains why they cannot find any primary physical causes to mental disorder. There really are not any. But until now, psychiatry has not had a model of mind tailored to its needs, so they tried to write the mind out of the equation.

 You have said that the biocognitive model offers “a genuinely bio-psycho-social model.” Can you elaborate on that? What makes this model bio-psycho-social?

 It is biological in that it says you cannot even begin to work out why the human mind is as it is without taking into account the “wetware” of the entire CNS. And the rest of the body, of course. It is psychological, as it says the mind runs the brain, not the other way around, and it shows just how the mind-body problem is to be approached so that a resolution falls into place. With a formal mentalist theory of mind, firmly grounded in the physical structure and function of the brain, we can integrate social factors into the calculation instead of paying lip service as DSM does. What you believe becomes instrumental in determining how you behave and how you feel, which solves the determinism question: Yes, we most definitely do have free will, but, as 

 and so many others indicated, it is biased.

 We are not half as rational as we think we are.

The problem is what has been called “The Great Twentieth Century Prejudice” of insisting that mentalist constructs are necessarily supernatural. This has led to so many dead-ends, biological reductionism, behaviorism, functionalism, the list goes on. We humans have mental capabilities. The problem for science is to give account to them, not write them out of the equation.

 “Primary physical causes” aside, I want to clarify something here. You emphasize the direction of causality from mind to the brain (eg, “mind runs the brain”). You also mention the importance of biology, which suggests a bidirectional causal relationship. Do you think that the mind-to-brain casual interactions are more important in the case of mental disorders than brain-to-mind interactions?

 Yes. That is the whole thrust of the model: to outline mechanisms by which the individual’s knowledge state triggers the emotional reactions, which are seen as “mental illness.” Anxiety, as I argued in my little monograph, is the model of a pure psychological disorder—there is no brain disease at all. The cognitive model relies on the feedback loops which I mentioned before. Remember the loop goes from mind to body and back to mind again, where the reinforcement occurs. In grief, it is the knowledge that something precious has been lost that triggers the emotional reaction, of misery, despair, hopelessness, etc. 

 starts with the awareness, even less-than-conscious, that life is hopeless and will never get better; the emotions flow from that, not the other way around. The most common cause of a recurrent or chronic depressive condition is an unrecognized anxiety state. But psychiatrists do not take anxiety seriously.

The principle here is important: Psychiatry has to acknowledge that mental states have mental causes. There is in principle no way a mental state can be reduced to a physical state of the brain—that confuses the product with the mechanism. Yes, I know that people like Eric Kandel and Richard Carrier and so many others are sure it can be—all that is lacking is a model. I would like to see one, but they have never produced it.

Does a computational approach to the mind pave the way for practicing a biopsychosocial psychiatry? 