Joseph M. Pierre, MD

The goal of this activity is to better understand, assess, and address malingered auditory hallucinations.

After engaging with the content of this CME activity, you should be better prepared to:

• Identify important features of voice-hearing to assist in assessing for malingered auditory verbal hallucinations.

• Recognize the impact of different motivations for malingered psychosis in forensic versus clinical settings and how these might influence clinical presentations.

• Identify neuropsychological tests that can support clinical suspicions of malingering.

• Implement clinical interventions to manage and disincentivize malingered psychosis.

This continuing medical education (CME) activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Dr Pierre is acting chief of mental health community care systems at the VA Greater Los Angeles Healthcare System and a health sciences clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the David Geffen School of Medicine at UCLA.

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

“I have no lid upon my head, but if I did
You could look inside and see what’s on my mind.” 

“Mr Arnold,” a 50-year-old Army veteran with a history of chronic depression and alcohol use disorder (in remission) was admitted to the hospital after complaining of “voices telling me to bayonet my wife… or someone else.” His outpatient psychiatrist, who had been treating with mirtazapine 45 mg/day and quetiapine 300 mg/day over the previous year, documented new onset command hallucinations and admitted the patient involuntarily based on homicidal ideation.

On subsequent exam with the inpatient team, Mr Arnold did not appear acutely depressed. His chief complaint was that he was hearing the voices of 3 military personnel—“a lieutenant, sergeant, and corporal”— who were all telling him to “kill people.” He then stated that he had “struck a deal with the corporal” such that he would not have to kill anyone if he killed himself. Mr Arnold, therefore, planned to do so by refusing all food other than milk and yogurt.

If the infamous social experiment by the late psychologist David Rosenhan, PhD, published in 1973 with the title “

 taught us anything, it was that psychiatrists working in clinical settings may not always be the best at detecting malingered voice-hearing. Although a recent book has claimed that Rosenhan 

what actually happened when he and 7 others were hospitalized based on false reports of hearing a voice saying words like “empty,” “hollow,” and “thud,”

 the take-home message of his experiment remains the same. When help-seeking individuals present with fabricated claims about hearing voices, psychiatrists will often respond in kind, offering antipsychotic therapy based on a provisional diagnosis of psychosis.

Without the ability to look inside the minds of patients who endorse hearing voices, and in the absence of any established biological marker or reliable neuroimaging blueprint for auditory verbal hallucinations, clinicians often resort to a benefit-of-the-doubt approach that assumes a help-seeking patient is ill. However, colluding with false claims of psychosis and disability and unnecessary exposure to antipsychotic side effects is not beneficial to patients.

In order to distinguish between real and feigned psychotic symptoms, a generation of psychiatrists has followed the guidelines of forensic psychiatrist 

, who first published specific criteria more than 20 years ago to alert clinicians of suspicion of malingered auditory verbal hallucinations.

 However, more recent survey data has revealed that genuine auditory verbal hallucinations are more heterogeneous across the psychosis spectrum than originally thought

, such that Resnick has since de-emphasized typical and atypical features of voice-hearing in favor of “topics of inquiry” when assessing for malingered auditory verbal hallucinations (

 Beyond the details of answers to such inquiries, suspicion of malingering should begin with purported symptoms that are endorsed in a cartoonish fashion with vagueness, evasiveness, inconsistency, and contradiction when further details are probed. The more a clinician asks, the less is learned, and often the encounter ends with hostile defensiveness by the patient. Clinicians must therefore take care to inquire about details as they would any other reported symptom, with open-ended questions that avoids premature confrontation about suspected misrepresentation during initial diagnostic interviews.

Since malingering is defined by feigned symptoms in the service of secondary gain, suspicions of malingering should be plausibly connected to identifiable rewards. When such incentives are not apparent, a broader differential diagnosis that includes factitious disorder should also be considered.

Malingered voice-hearing in clinical settings

Mr Arnold ate well on the unit and was continued on mirtazapine and quetiapine, which was reduced to 50 mg/day for insomnia. On further questioning, he reported hearing voices dating back to military service 20 years prior, and possibly as far back as childhood; chart review revealed no such complaints in previous notes. In addition to hearing voices, he endorsed significant difficulties with memory, including improbable claims that he was unaware of current world events, like the United States was at war with Iraq (which was true at the time). Due to atypical and inconsistently reported symptoms that spanned both psychotic and cognitive domains, malingering was suspected, and psychological testing was ordered for diagnostic clarification.

Most of the published literature on characteristics of malingered psychosis has been derived from studies of those instructed to feign symptoms within forensic samples in which the prevalence of malingering can be as high as 65%.

 Due to several key potential differences, however, the reports of voluntary simulators in such settings may not be a good representation of malingered psychosis encountered by psychiatrists in routine clinical practice (

 Just so, the prevalence of malingering in clinical settings is largely unknown and likely varies widely across different patient populations and health care systems.

Unlike malingering in forensic settings, in which it is usually related to an avoidance of punishment for criminal behavior, malingering in clinical settings is usually motivated by an attempt to obtain care or social services (eg, hospital admission, medication, disability income) and often co-occurs with real mental illness, including substance use disorders. Malingered psychotic claims in clinical settings are often based on real experience with historical psychotic symptoms, and they may not be as cartoonish as the claims of some forensic simulators.

Clinicians should also bear in mind that feigned symptoms in clinical settings often represent iatrogenic malingering that is incentivized by structural barriers to receiving comprehensive care.

 Since hospital admission criteria have become more stringent with decreasing inpatient beds through the years, claims of suicidality or psychosis are often necessary to justify hospitalization. Consequently, a common complaint from a patient seeking admission is that they are “hearing voices telling me to kill myself.” Beyond auditory verbal hallucinations reflecting a psychotic disorder, such simple claims might variably represent an idiom of distress, a mislabeled experience (eg, a depressive rumination rather than a hallucination), a non-psychotic hallucination

, or iatrogenic malingering. Detailed clinical interviewing is required to tease apart these crucial distinctions.

With increasing recognition of the heterogeneity of voice-hearing experiences across the psychotic spectrum, relying on “correct” answers to questions about features of endorsed auditory verbal hallucinations to guide assessments of malingering has significant limitations.

 However, survey results indicate that typical features of auditory verbal hallucinations include voices that are clear, repetitive, at least partially controllable, and sound like real speech where the speaker is identifiable.

 In contrast, atypical and improbable experiences feigned by those wanting to appear psychotic might include seeing and hearing animals talking, describing an angel and devil on either shoulder alternately encouraging and discouraging bad behavior, claiming no control over voices, or endorsing command hallucinations that are always obeyed.

 Still, the detection of malingered auditory verbal hallucinations is often less about right and wrong answers about such details and more about whether those details can be consistently described at all.

) can be a useful supplement to clinical interviewing to help validate suspicions of malingered psychosis. The Structured Interview for Reported Symptoms (SIRS) 

, the Structured Inventory of Malingered Symptomatology (SIMS)

, and the Miller Forensic Assessment of Symptoms Test (M-FAST)

 represent gold standard assessments for the detection of malingered psychosis, based largely on questions that query endorsement of atypical, absurd, or outlandish psychotic symptoms. Similar tests have been validated to assess malingered cognitive symptoms including the Test of Memory Malingering (TOMM)

 and the Victoria Symptom Validity Test (VSVT).

 Having access to staff trained to administer such tests can be a great aid to reliable diagnostic assessment. However, tests of malingering have established norms that are based on voluntary simulators, may be less useful in clinical settings in the absence of outlandish claims, and should not be relied upon as a substitute for careful and thorough clinical interviewing.

Attempts to complete neuropsychological testing were initially met with resistance, including threats to kill members of the treatment team. (“The deal with the corporal is off . . . I’m going to take everyone out!”) However, after Mr Arnold was told that he would be discharged in response to these threats, he retracted them, became apologetic, and agreed to complete testing. He scored well above the cut-off scores for malingering on the SIMS, M-FAST, TOMM, and VSVT based on gross over-endorsement of unusual symptoms.

Without directly confronting Mr Arnold about his test results, a subsequent interview was held to ascertain potential motives for secondary gain. In doing so, the team learned that he made several unsuccessful attempts to obtain service-connected disability and had been recently told that his case was closed. The team responded empathically and guided him to resources about applying for Social Security Disability Insurance for legitimate medical complaints. He soon stopped endorsing psychotic symptoms and homicidal ideation and self-discharged the next day.

Clinicians should be mindful that confrontations about suspected or detected malingering may result in patients upping the ante with threats of violence or self-injury. It is therefore recommended that clinicians allow patients to save face when providing diagnostic feedback instead of accusing them of lying. Clinicians should also strive to “find the pony” by assessing patients in a thorough but non-confrontational manner with a goal of empathic and compassionate understanding of legitimate sources of personal distress.

Uncovering the secondary gain motives of malingering allow clinicians to identify the biopsychosocial origins of distress and offer interventions in kind, including psychotherapy, housing, disability income support, and treatment of substance use disorders. This holistic approach can be useful in both diagnosing and treating malingering through disincentivization. Non-antipsychotic pharmacotherapy targeting symptoms of insomnia, anxiety, and substance withdrawal can also help resolve co-occurring claims of hearing voices.

Countertransference and treatment success

After discharge, Mr Arnold made no further mention of hearing voices to his outpatient psychiatrist, who had been given a “warm hand-off” by the inpatient team. However, after transferring care to a new psychiatrist the next year, Mr Arnold renewed complaints about hearing voices along with novel endorsement of posttraumatic stress disorder (PTSD) symptoms that he attributed to having a heavy object fall on him during military service. He was prescribed chlorpromazine, sertraline, and prazosin based on a diagnosis of atypical psychosis and PTSD.

After a few more years in treatment, Mr Arnold’s psychiatrist revised his diagnosis to reflect malingering and discontinued antipsychotic medication in favor of antidepressant monotherapy. However, Mr Arnold eventually decided that he no longer wanted to take any psychiatric medication and dropped out of psychiatric care. Over the next 5 years—12 years after his original hospitalization—he did well without psychiatric treatment and did not endorse psychiatric symptoms during primary care visits.

Successfully managing malingering requires clinicians to maintain awareness of countertransference issues. Physicians are 

in medical school to consider malingering within a differential diagnosis or how to withhold requests for diagnoses and interventions that are requested but are harmful or not indicated.

 Psychiatrists may, therefore, find it difficult to diagnose malingering and are often more concerned about missing real mental illness (eg, false negatives) than the problem of inappropriate diagnosis (eg, false positives).

 Longitudinal assessment can often help resolve diagnostic ambivalence.

When a diagnosis of malingering is ultimately made, psychiatrists and other mental health workers must manage their reactions to the fact that the patient lied to them. This is best accomplished by understanding the ubiquity of lying as a normal and adaptive human behavior—the average person lies once or twice a day

—that is further incentivized by the limited resources for help available to people in distress due to difficult life circumstances. Like any clinical diagnosis, a diagnosis of malingering should ideally guide appropriate interventions, not steer patients away from mental health care altogether. Over time, however, resolution of malingering’s “symptoms” and the motivations that underlie them should be considered a treatment success.

Auditory verbal hallucinations are a common claim when people malinger psychiatric symptoms since they suggest the presence of a severe mental illness and are largely unverifiable beyond clinical judgment. Careful clinical interviewing, identification of secondary gains, and supplemental psychological testing provide the best approach to assessment. Once a diagnosis of malingering is made, clinical management that recognizes iatrogenic causes and disincentivizes misrepresentation by addressing legitimate sources of distress can be therapeutic and can help to confirm the diagnosis.

3. Resnick PJ. Malingered psychosis. In: Rogers R, Bender SD, eds. 

Clinical Assessment of Malingering and Deception, 2nd Edition

4. Resnick PJ. The detection of malingered psychosis. 

5. McCarthy-Jones S, Trauer T, Mackinnon A, Sims E, Thomas N, Copolov DL. A new phenomenological survey of auditory hallucinations: evidence for subtypes and implications for theory and practice. 

6. Resnick PJ, Knoll JL. Malingered psychosis. In: Rogers R, Bender SD, eds. 

Clinical Assessment of Malingering and Deception, 4th Edition

7. McDermott BE, Dualan I, Scott CL. Malingering in the correctional system: does incentive affect prevalence? 

8. Pierre JM. Assessing malingered auditory verbal hallucinations in forensic and clinical settings. 

9. Pierre JM, Wirshing DA, Wirshing WC. “Iatrogenic malingering” in VA substance abuse treatment. 

10. Pierre JM. Hallucinations in nonpsychotic disorders: toward a differential diagnosis of “hearing voices.” 

11. Woods A, Jones N, Alderson-Day B, et al. Experiences of hearing voices: analysis of a novel phenomenological survey. 

12. Waters F, Blom JD, Jardi R, Hugdahl K, Sommer IEC. Auditory hallucinations, not necessarily a hallmark of psychotic disorder. 

13. McCarthy-Jones S, Resnick PJ. Listening to voices: the use of phenomenology to differentiate malingered from genuine auditory verbal hallucinations. 

14. Rogers R, Kropp PR, Bagby RM, Dickens SE. Faking specific disorders: a study of the structured interview of reported symptoms (SIRS). 

15. Smith GP, Burger GK. Detection of malingering: validation of the Structured Inventory of Malingered Symptomatology (SIMS). 

16. Guy LS, Kwartner PP, Miller HA. Investigating the M-FAST: Psychometric properties and utility to detect diagnostic specific malingering. 

17. Tombaugh TN. The Test of Memory Malingering (TOMM): Normative data from cognitively intact and cognitively impaired individuals. 

18. Slick DJ, Hopp G, Strauss E, Spellacy FJ. Victoria Symptom Validity Test: efficiency for detecting feigned memory impairment and relationship to neuropsychological tests and MMPI-2 validity scales. J Clin Exp Neuropsychol. 1996;18(6):911-922.

19. Pierre JM. Nonantipsychotic therapy for monosymptomatic auditory hallucinations. 

20. Pierre JM. “What do you mean, I don’t have schizophrenia?” 

. February 1, 2009. Accessed August 8, 2020. 

https://www.psychiatrictimes.com/view/what-do-you-mean-i-dont-have-schizophrenia

21. Muzinic L, Kozaric-Kovacic D, Marinic I. Psychiatric aspects of normal and pathological lying. 

Articles

Malingering in clinical settings is usually motivated by an attempt to obtain care or social services (eg, hospital admission, medication, disability income) and often co-occurs with real mental illness, hence the dilemma.

Assessing Malingered Voice-Hearing

How do we, as clinicians, assess the benefits and harms of any medication, including but not limited to psychiatric medications? More specifically, how do we decide whether long-term antipsychotic treatment does more good than harm-or vice versa, as some critics of psychiatry have claimed? Certainly, a careful examination of the literature on relapse and remission rates in schizophrenia spectrum disorders is an important part of the answer.

However, we reject the notion that this is the only criterion for judging the risks and benefits of long-term antipsychotic use. Equally, we do not believe that armchair analyses of the literature by non-clinicians will answer the risk to benefit question in a humane and judicious manner. On the contrary, we believe that working with psychotic patients, and appreciating their often profound suffering, is an essential part of the equation. Critics of psychiatry who have never spent time with patients and families coping with the ravages of schizophrenia simply do not grasp the human tragedy of this illness. These critics also miss the deep-seated satisfaction that comes from seeing severely impaired patients achieve remission, and even recovery-in which antipsychotic medication usually plays an important role.

As clinicians with many years of experience in treating patients with 

, our views on antipsychotic medication are shaped not only by our understanding of the scientific literature, but also by our personal care of many hundreds of patients over several decades. Recent studies that pointed to the benefits of long-term antipsychotic use in schizophrenia, including reduction of relapse rates and the risk of suicide, were examined previously.

 Here we examine the concept of quality of life (QOL) and what we know about its relationship to antipsychotic use. We focus primarily on placebo-controlled studies, despite the paucity of such investigations in the published literature.

 noted in their 2003 review, the concept of QOL is relatively new in the psychiatric literature and “embraces a whole spectrum of uses and meanings.” In general, however, QOL refers to “. . . how patients feel and how satisfied they are with treatment, besides the traditional focus on disease outcomes.” In 1998, the World Health Organization described QOL in these terms: “It is a broad-ranging concept affected in a complex way by . . . physical health, psychological state, level of independence, social relationships and their relationship to salient features of their environment.”

 Berlim and Fleck list nearly a dozen instruments or scales designed to measure QOL, including the Quality of Life Scale (QLS), the Wisconsin Quality of Life Index (W-QLI), and the Medical Outcomes Study Short Form-36 Items (SF-36). The main items on the original (21-item) version of the QLS are shown in the 

 provide a comprehensive review of QOL in schizophrenia, based mainly on open-label and/or naturalistic studies. Only 2 studies compared QOL of patients who received an antipsychotic (either olanzapine or long-acting risperidone) with QOL of patients in the placebo group. Hamilton and colleagues

 evaluated patients (N = 76) over a 6-month period; Nasrallah and colleagues

 evaluated patients (N = 369) over 3 months. In both studies, patients who received the antipsychotic showed significantly greater improvement in QOL than those treated with placebo. Indeed, Nasrallah and colleagues found that long-acting risperidone (25 mg q 2 weeks) improved QOL to levels “not significantly different from normal,” based on the SF-36.

 acknowledge the “wide range of adverse [antipsychotic drug] effects that may negatively affect the quality of life” in patients with schizophrenia, and they observe that atypical antipsychotics may not improve QOL more than typical agents. Nevertheless, the authors conclude that “. . . the longer the length of the illness, the worse the quality of life . . . the combination of psychopharmacological and psychotherapeutic treatment improve quality of life.” They also observed that “. . . patients integrated in community support programs demonstrate a better quality of life than those who are institutionalized.” (Unfortunately, adequate outpatient and community supports are sadly lacking in many if not most parts of the US.)

One notable study not included in the review by Bobes and colleagues is that of Beasley and colleagues.

 This 52-week, double-blind, relapse prevention trial tested whether stable patients with schizophrenia who were taken off active drug treatment would experience greater improvements in long-term quality of life than those who were continued on antipsychotic treatment. The study found that, on average, Heinrichs-Carpenter Quality-of-Life Scale total scores improved by 4.3 ± 10.6 points during treatment with olanzapine (10 to 20 mg/d; n = 212), but decreased by 7.1 ± 14.6 points during treatment with placebo (n = 92; P < .001). The researchers also found that “. . . stable patients with schizophrenia who were taken off active drug treatment experienced no greater improvements in long-term quality of life than those who were continued on antipsychotic treatment, even in the absence of psychotic symptoms.”

 studied subjective well-being in patients with schizophrenia, using the Subjective Well-being Under Neuroleptic Treatment scale (SWN). (Subjective well-being overlaps substantially with QOL.) They reviewed open and controlled trials between 1994 and 2010, covering 44 studies. Most studies were short-term (< 1 year), and none used a placebo control; rather, most compared one antipsychotic with another, with regard to improvement on the SWN. However, 6 studies had a duration of 1 year or longer (up to 3 years). The key conclusion of this review was that “subjective well-being of patients with schizophrenia improved during treatment in almost all studies.”

Only a handful of placebo-controlled studies of QOL have been published since the 2007 article by Bobes and colleagues. Leucht and colleagues

 reviewed randomized trials that compared maintenance treatment with antipsychotic drugs compared with placebo, for persons with schizophrenia or schizophrenia-like psychoses. In addition to finding superiority of antipsychotic drugs compared with placebo in preventing relapse at 7 to 12 months, the researchers found some evidence that QOL was better in drug-treated participants (based on 3 randomized, controlled trials: n = 527; standardized mean difference, -0.62; confidence interval, -1.15 to -0.09).

 undertook an 8-week randomized, double-blind, placebo-controlled trial of olanzapine (long-acting injection) versus placebo in 404 acutely ill inpatients with schizophrenia. Participants were randomized to olanzapine long-acting injectable (LAI) 210 mg/2 weeks (n = 106); olanzapine-LAI 300 mg/2 weeks (n = 100); olanzapine-LAI 405 mg/4 weeks (n = 100); or placebo (n = 98). All active treatment groups were superior to placebo on the QLS total score (P < .01).

Finally, in an 8-week, randomized, placebo-controlled study of patients with acute schizophrenia, Isitt and colleagues

 compared a new sustained-release formulation of risperidone (RBP-7000) with placebo. Patients (N = 337) were assessed on health status, subjective well-being, treatment satisfaction, and preference of medicine. Health-related QOL (HRQoL) was measured using several scales. Findings indicated a significantly greater improvement in HRQoL and overall well-being in patients randomized to RBP-7000. Patients who received RBP-7000 also reported greater medication satisfaction on the Preference of Medicine Questionnaire (POM).

There are certainly large gaps in our knowledge of how antipsychotic medication affects “quality of life,” compared with placebo or no medication treatment. In particular, most studies are not randomized or placebo-controlled, and of those that are, most are short-term (< 1 year). Our conclusions, therefore, must be considered provisional. Nonetheless, our review finds no support for the notion that antipsychotic medication worsens QOL for patients with schizophrenia. Considerable controlled evidence shows that antipsychotic treatment improves QOL by various measures-at least within the first year of treatment, and perhaps for as long as 3 years.

 reviewed studies of patients with psychotic disorders that compared outcomes in those who received, or did not receive, antipsychotic medication during a follow-up period of at least 2 years. The researchers did not specifically study QOL; rather, they examined recidivism, negative symptoms, positive symptoms, and social functioning. Although the authors found the evidence base methodologically inadequate to determine the benefit-to-harm ratio of long-term antipsychotic use, they did not find evidence pointing to long-term harm from antipsychotics. Specifically, they concluded, “Our study did not support the hypothesis that long-term treatment with antipsychotic medication causes harm.”

Similarly, with regard to QOL, we find no placebo-controlled evidence that use of antipsychotics for up to a year causes any decline in QOL; indeed, the studies we reviewed show that antipsychotic treatment typically enhances QOL for patients with schizophrenia. That said, it is clear that we need more long-term (> 1 year), placebo-controlled studies of QOL and its relationship to antipsychotic treatment.

The decision to continue antipsychotic medication for the long term requires more than a survey of the research literature. It is a decision based, among other considerations, on the particular patient’s history; risk factors; response to initial treatment; adverse effect burden; and perhaps most important, the degree of suffering and incapacity the patient has endured as a consequence of having schizophrenia. Thus, careful assessment of the patient’s QOL should also be a part of the decision-making process, which should involve active and respectful collaboration with the patient (and, sometimes, the patient’s family). An ongoing process of informed consent and periodic monitoring of the patient’s response to treatment is essential.

The decision regarding long-term treatment is not a binary either/or choice; rather, the goal is to find the best medication and dose, with the fewest adverse effects. For some carefully selected patients with schizophrenia-and in most cases of “brief psychotic disorder”

-a slow tapering and discontinuation of antipsychotic medication may be warranted, with close monitoring of the patient’s response.

In our view, when non-clinician critics argue that most patients with schizophrenia would be “better off” without long-term antipsychotic medication-or that antipsychotics have done more harm than good-they misrepresent the best available evidence. Moreover, patients who impulsively discontinue their medication on the basis of such misinformation are jeopardizing their health, safety, and QOL.

 Our review suggests that amidst the shrill rhetoric of anti-psychiatry, the voices of patients who have done well on antipsychotic medication often go unheard.

Note: We use the term “schizophrenia” in the syndromal sense; ie, we recognize that the DSM-5 construct of schizophrenia most likely represents a “final common pathway” with several different etiologies; that there is probably a spectrum of schizophrenia-like conditions; and that the genetics and pathophysiology of schizophrenia probably overlap with other types of psychotic illness. The treatment of these conditions must be individualized, including decisions concerning the use of long-acting antipsychotic medication.

This article was originally posted on 8/10/2016 and has since been updated.

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

. Dr Pierre is Associate Director of Residency Education, UCLA Semel Institute for Neuroscience and West Los Angeles VA Medical Center; Acting Chief, Inpatient Psychiatry, West Los Angeles VA Medical Center; and Health Sciences Clinical Professor, Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA. The authors report no conflicts of interest concerning the subject matter of this article.

The authors wish to thank Dr. Dieter Naber and Dr. A. George Awad for their helpful correspondence.

 Pies R. How antipsychotic medication may save lives. 

http://www.psychiatrictimes.com/blogs/couch-crisis/how-antipsychotic-medication-may-save-lives

 Pies R. Long-term antipsychotic treatment: effective and often necessary, with caveats. 

http://www.psychiatrictimes.com/blogs/long-term-antipsychotic-treatment-effective-and-often-necessary-caveats

 Berlim MT, Fleck MPA. Quality of life: presentation of the concept. 

 The World Health Organization. Quality of life assessment: development and general psychometric properties. 

 Heinrichs DW, Hanlon TE, Carpenter WT Jr. The Quality of Life Scale: an instrument for rating the schizophrenic deficit syndrome. 

 Bobes J, Garcia-Portilla MP, Bascaran MT, et al. Quality of life in schizophrenic patients. 

 Hamilton SH, Revicki DA, Genduso LA, Beasley CM. Olanzapine versus placebo and haloperidol: quality of life and efficacy results of the North American double-blind trial. 

 Nasrallah HA, Duchesne I, Mehnert A, et al. Health-related quality of life in patients with schizophrenia during treatment with long-acting, injectable risperidone. 

 Beasley CM Jr, Sutton VK, Taylor CC, et al. Is quality of life among minimally symptomatic patients with schizophrenia better following withdrawal or continuation of antipsychotic treatment? 

 Vothknecht S, Schoevers RA, de Haan L. Subjective well-being in schizophrenia as measured with the Subjective Well-Being Under Neuroleptic Treatment scale: a review. 

 Leucht S, Tardy M, Komossa K, et al. Maintenance treatment with antipsychotic drugs for schizophrenia. 

 Witte MM, Case MG, Schuh KJ, et al. Effects of olanzapine long-acting injection on levels of functioning among acutely ill patients with schizophrenia. 

 Isitt JJ, Nadipelli VR, Kouassi A, et al. Health-related quality of life in acute schizophrenia patients treated with RBP-7000 once monthly risperidone: an 8-week, randomized, double-blind, placebo-controlled, multicenter phase 3 study. 

 Sohler N, Adams BG, Barnes DM, et al. Weighing the evidence for harm from long-term treatment with antipsychotic medications: a systematic review. 

. December 14, 2015; Epub ahead of print.

 Memon MA, Bienenfeld D. Brief psychotic disorder. Medscape. November 17, 2015. (Updated). 

http://emedicine.medscape.com/article/294416-overview

 Frances A. Setting the record straight on antipsychotics. 

 http://www.psychiatrictimes.com/couch-crisis/setting-record-straight-antipsychotics

Awad AG, Voruganti LN. The impact of newer atypical antipsychotics on patient-reported outcomes in schizophrenia. 

Cortesi PA, Mencacci C, Luigi F, et al. Compliance, persistence, costs and quality of life in young patients treated with antipsychotic drugs: results from the COMETA study. 

Pies R. Trivializing the suffering of psychosis. 

http://www.psychiatrictimes.com/schizophrenia/trivializing-suffering-psychosis

Staring AB, Mulder CL, Duivenvoorden HJ, et al. Fewer symptoms vs more side-effects in schizophrenia? Opposing pathways between antipsychotic medication compliance and quality of life. 

Strakowski SM, Johnson JL, Delbello MP, et al. HGDH Research Group: quality of life during treatment with haloperidol or olanzapine in the year following a first psychotic episode. 

The authors examine the literature on "quality of life" and how antipsychotics improve that for patients with schizophrenia.

Quality of Life and the Case for Antipsychotics

Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5

by Allen Frances, MD;
New York: The Guilford Press; 2013

[A note from the publisher: The revised edition features ICD-10-CM codes where feasible throughout the chapters, plus a Crosswalk to ICD-10-CM codes in the Appendix.]

Although I am fond of saying that DSM-5 is still a “good enough guide for clinical work,” 

 is a sort of guide to that guide. Perhaps the book is in the same vein as the APA 

-which Dr Frances co-authored in 1995 in his role as DSM-IV chairperson. This time, however, Dr Frances writes as a DSM-5 critic rather than an insider. This easy-to-read manual represents his concise views on how to achieve “more accurate” 

, as well as when to avoid DSM-5 altogether.

The book is made up of 18 chapters covering major categories of psychiatric disorders, with a screening question (eg, “Do you ever get so depressed that you can’t function?”). This is followed by a clinical description of a patient, as an adjunct to DSM-5 diagnostic criteria (which are not included). Brief sections on differential diagnoses and diagnostic tips follow.

Although written in a casual style, much of the information represents the kind of valuable clinical wisdom that one accumulates after years of diagnostic experience. These clinical pearls focus on the fuzzy boundaries and gray areas between threshold diagnoses and non-diagnostic problems of living, as well as Dr Frances’ concerns about diagnostic inflation in psychiatry. For example, he cautions that 

ADHD is sometimes overdiagnosed in children

 who are born at the end of the calendar year because they are less mature than their grade-matched peers.

Dr Frances also offers black box cautions for diagnoses he believes represent the greatest risk of being overdiagnosed. For example, he favors using the bereavement exclusion for major depression that was removed from DSM-5 and warns against conflating normal childhood behavior with bipolar disorder and ADHD. He also recommends using ICD criteria for substance abuse and dependence rather than the unified definition of addiction in 

. He advises abandoning the use of disorders that he believes should not have been included in DSM-5 (eg, mild neurocognitive disorder, dissociative identity disorder). These black box warnings represent areas of controversy that are clearly stated as Dr Frances’ personal recommendations; it is up to the clinician to decide whether it is practical or useful to boycott entire sections of DSM-5.

Using a decidedly Kraepelinian perspective, Dr Frances emphasizes the clear difference between psychiatric disorders and the suffering of normal life. He realizes that diagnostic boundaries are fuzzy but falls short of acknowledging a mental illness–mental health continuum and recognizes the potential value of diagnosing minor disorders and subthreshold states.

Much of this volume offers sound clinical wisdom that will be particularly insightful to those with limited clinical experience, as well as those of us suffering from “clinician’s bias,” whereby all mental health consumers are assumed to be mentally ill (or are assigned a diagnostic code in any case to justify insurance reimbursement). Reading this book may very well help temper overzealous diagnosis and intervention.

This article was originally posted online on 8/13/2014 and has since been updated.

Dr Pierre is Associate Director of Residency Education at UCLA Semel Institute for Neuroscience; Health Sciences Clinical Professor in the department of psychiatry and biobehavioral sciences at David Geffen School of Medicine at UCLA; and Co-Chief of the Schizophrenia Treatment Unit at West Los Angeles VA Medical Center.

This easy-to-read manual represents the author's concise views on how to achieve “more accurate” diagnoses with DSM-5, as well as when to avoid DSM-5 altogether.

When I was an undergraduate studying molecular biology in the early 1990s when the Human Genome Project had just begun, my required coursework included several lectures on the ethical implications of sequencing, understanding, and ultimately being able to manipulate the “code of life.” As members of the generation that might one day be able to purposefully alter individual gene expression, our class was urged to consider the vital questions arising from such potential-How should the new technology be applied? For whom and in what situations? Should it be done at all?

As DSM-5 is being drafted, on the heels of the promise of a “paradigm shift,”

 I find myself thinking again of such questions, and at the same time wondering why psychiatry as a field, from the top down, does not seem to be widely discussing them. Certainly a debate has been ignited, fueled by the likes of old-guard DSM architects Drs. Robert Spitzer and Allen Frances on the one hand, and current DSM-5 framers forging relentlessly onward to 2013 on the other. But that debate has many facets involving both content and process, and in my mind the most fundamental issues-for example, what constitutes a mental illness and what are the appropriate targets of psychiatric intervention-often seem to be lost in the shuffle.

Towards a Spectral Model of Mental Illness


I have long been fascinated by the “grey areas” of mental illness-those hard to define intermediate zones between normal and pathologic modes of behavior-but have usually found myself siding with those wary of diagnostic expansion. Perhaps that’s an expected stance for a psychiatrist primarily working on an inpatient unit focusing on the treatment of psychosis, where drawing a line in the sand to demarcate pathology is often, though not always, fairly straightforward. On the other hand, I’ve also worked at the other end of the psychotic spectrum, in a “prodromal schizophrenia” research clinic, where debate about the boundaries of mental illness was a daily discussion. As DSM-5 moves towards a more dimensional view of mental illness with the proposal of a “psychosis risk syndrome” and the broadening of other diagnostic categories, the time is ripe for us all to pause and carefully consider the implications of this direction.

The idea of conceptualizing mental illness on a spectrum that spans from normal behavior to clear disorder is not new. Incorporation of a dimensional model was considered for DSM-IV, but eventually abandoned due to “serious limitations,”

 including the belief that categorical boundaries are vital to clinical decision making. In order to define those boundaries more reliably, DSM-IV was the first edition of the manual to fully integrate a requirement of “clinically significant distress or impairment of functioning” into the criteria for each disorder (though the “not otherwise specified (NOS)” disorders lack both symptomatic criteria and any explicit requirement of distress/impairment). In contrast, recognizing that few patients neatly fit DSM-IV disorder criteria and that NOS diagnoses abound, a central agenda for DSM-5 has been to move towards a dimensional view of mental disorder.

There are reasonable arguments on either side of the debate over such dimensionalization. On the one hand, those wary of adopting a spectral view of mental disorder are concerned that psychiatry is already guilty of over-diagnosis, with the number of cataloged mental disorders more than tripling from DSM-I (106 disorders) to DSM-IV (357 disorders) and the most recent epidemiologic studies indicating that about half of Americans will meet criteria for a DSM-IV disorder at some point in their lives.

 With dimensionalization, this diagnostic boundary will almost surely be expanded further, suggesting that if it’s not already the case, it will soon be “normal” to have a mental illness. Such alarming and seemingly oxymoronic conclusions threaten the already shaky reputation of psychiatry in the public eye, where many are already worried that “psychiatrists think everyone is crazy.” Professional skepticism about diagnostic expansion is just as abundant, particularly with specific DSM disorders such as major depression,

 attention deficit hyperactivity disorder (ADHD),

 At their core, each of these arguments contends that psychiatry is overstepping its bounds by applying a label of pathology to some variant of normal human existence and behavior.

On the other side of this debate, defenders of diagnostic expansion argue that available research findings do support identification of and intervention at the “soft” end of spectral conditions such as bipolar disorder, depression, and psychosis. At a phenomenologic level, the dimensionalization position is intuitively defensible given that many of the core symptoms that make up DSM criteria-anxiety, dysphoria, and even psychosis-are indeed part of normal everyday human existence. Admittedly, for me this is one of the things that makes psychiatry so interesting-the very real sense that mental illness is, to paraphrase Susanna Kaysen,


Ever since DSM-III, the hope has been that neurobiological research of categorical diagnoses would result in the discovery of underlying pathophysiologies that would in turn elevate DSM disorders to the status of “disease entities.” Thirty years later, that vision remains unrealized. For DSM-5 and beyond, the new hope is that a spectral view of mental illness that addresses the continuum between mental disorder and mental health will better facilitate etiologic research resulting in the discovery of underlying mechanisms of symptoms as opposed to disorders 

 (e.g. it is more likely that mechanisms for “fear” or “paranoia” will be discovered than for “PTSD” or “schizophrenia”). Perhaps when future revisions are truly informed by research into spectral models of mental illness, a DSM reflecting a true “paradigm shift” will bear little resemblance to DSM-IV or DSM-5 and will instead take the form of something more akin to the Research Domain Criteria (RDoC) currently in development at the National Institutes of Mental Health.

If the promise of that vision is realized, the end-game in psychiatric research will include not only the elucidation of “pathologic” processes, but “normal” neuropsychologic processes as well-just as the early study of simple genetic mutations paved the way for the full sequencing of the DNA code in the Human Genome Project. Therefore, while the hope has been that the discovery of underlying pathophysiologies would result in the validation of psychiatric disorders, it becomes apparent that discovering an underlying biological mechanism to account for a mental process or behavior does not alone make it pathological. Thresholds of “pathology” or “disorder” will always require some value-based judgment about “clinical significance”

 On the other hand, what elucidated genetic or biochemical mechanisms do reveal is the potential to intervene using biologically-based strategies.

While I have spent considerable time pondering what is and is not a mental disorder, and wondering whether it “should” be the role of psychiatrists to intervene at the soft end of disorder spectrum,

 it appears that such debate is becoming increasingly academic rather than clinically pertinent. Clinical intervention is not and will not be dictated by DSM definitions of mental disorder, but by the discovery and availability of interventions. Intervention already occurs across a spectrum of suffering, from traditional medical diseases (e.g. cancer) by medical doctors to “problems of everyday life” by clergy and all points in between. What will change as the doors of dimensionalization open into the psychiatry of tomorrow is the potential, through pharmacologic and other “somatic” interventions, to change the course of both pathologic as well as normal mental processes and behaviors. Such potential to make people “better than well” through “cosmetic psychopharmacology” was widely discussed at the beginning of the selective serotonin reuptake inhibitor (SRRI) era with the publication of 

 but has since been strangely absent in mainstream American psychiatry.


Perhaps clinicians and patients feel comfortable relegating questions about whether this is where psychiatry “should” be headed to the domain of ethics. Indeed, some have now proposed the creation of a specific branch of “neuroethics” where debates about “neuroenhancement” are already ongoing.

But these issues are not merely ethical or philosophical, as if a part of some imagined, futuristic 

. As scientific discovery and DSM embrace a spectral view of brain disorder and inch more closely to unraveling the biological basis of not only “disease states,” but normal mental processes and behaviors as well, these questions will become more timely and pertinent before we know it. As such, it is already time for DSM architects, clinicians, researchers, patients, and families to seriously ponder them.

Although such discussions have begun to emerge concerning the development of the “cognitive enhancers,”

 the questions that arise-Who should get them? Would taking them confer an “unfair advantage” upon those with access to them? Would you still be the same person if you took them? How would their widespread use transform our notions of “normal” vs. “ideal” functioning? Could some individuals be mandated to take them? Should they be regulated? Should psychiatric physicians be involved in the practice of enhancement? Should insurance companies reimburse for such therapies?-apply to 

When I was an undergraduate studying molecular biology in the early 1990s when the Human Genome Project had just begun, my required coursework included several lectures on the ethical implications of sequencing, understanding, and ultimately being able to manipulate the “code of life.”

Author | Joseph M. Pierre, MD

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