What’s wrong with ‘mental’ disorders? : a commentary on ‘What is a mental/psychiatric disorder? : from DSM-IV to DSM-V’ by Stein et al

The editorial by Stein et al. (2010) is timely and relevant given the development of DSM-V and the likely impact that such a development will have on mental health services in the USA. The revision of the DSM will also affect international psychiatric research and global practice thanks to the interplay between the development of DSM and ICD (Fulford & Sartorius, 2009). The editorial by Stein and colleagues is very rich and there are many themes suitable for further examination and discussion. For this response, however, we have chosen to focus on two themes: the use of the term ‘mental’ and the idea of psychiatric disorders being ‘in’ an individual

Moral responsibility and mental illness : a case study

Various authors have argued that progress in the neurocognitive and neuropsychiatric sciences might threaten the commonsense understanding of how the mind generates behavior, and, as a consequence, it might also threaten the commonsense ways of attributing moral responsibility, if not the very notion of moral responsibility. In the case of actions that result in undesirable outcomes (e.g., someone being harmed), the commonsense conception—which is reflected in sophisticated ways in the legal conception—tells us that there are circumstances in which the agent is entirely and fully responsible for the bad outcome (and deserves to be punished accordingly) and circumstances in which the agent is not at all responsible for the bad outcome (and thereby the agent does not deserve to be punished)

Hardy's paradox and violation of a state-independent Bell inequality in time

Tests such as Bell's inequality and Hardy's paradox show that joint probabilities and correlations between distant particles in quantum mechanics are inconsistent with local realistic theories. Here we experimentally demonstrate these concepts in the time domain, using a photonic entangling gate to perform nondestructive measurements on a single photon at different times. We show that Hardy's paradox is much stronger in time and demonstrate the violation of a temporal Bell inequality independent of the quantum state, including for fully mixed states.Comment: Published Version, 4 pages, 3 figures. New, more boring titl

Street slang and schizophrenia

We report the case of a 26 year old streetwise young postman who presented with a six month history of reduced occupational and social function, low mood, and lack of motivation. He complained of feeling less sociable and less interested in his friends and of being clumsy and finding it harder to think. He was otherwise fit and healthy, with no physical abnormalities, neurological signs, or objective cognitive impairments. There was no history of a recent stressor that might have precipitated his symptoms. He was referred to a specialist service for patients in the prodromal phase of psychotic illness for further assessment after he had seen his general practitioner and the local community mental health team. The differential diagnosis at this stage was depression, the prodrome of schizophrenia, or no formal clinical disorder. His premorbid occupational and social function had been good. There was no history of abnormal . social, language, and motor development and he left school with two A levels. After three years of service at the post office he had been promoted to a supervisory role. He had a good relationship with his family and had six or so good friends. There has been a number of previous heterosexual relationships, although none in the past year. Aside from smoking cannabis on two occasions when he was 19, there was no history of illicit substance use. Detailed and repeated assessment of his mental state found a normal affect, no delusions, hallucinations, or catatonia, and no cognitive dysfunction. His speech, however, was peppered with what seemed (to his middle class and older psychiatrist) to be an unusual use of words, although he said they were street slang (table).Go It was thus unclear whether he was displaying subtle signs of formal thought disorder (manifest as disorganised speech, including the use of unusual words or phrases, and neologisms) or using a "street" argot. This was a crucial diagnostic distinction as thought disorder is a feature of psychotic illnesses and can indicate a diagnosis of schizophrenia. We sought to verify his explanations using an online dictionary of slang (urbandictionary.com). To our surprise, many of the words he used were listed and the definitions accorded with those he gave (see table). We further investigated whether his speech showed evidence of thought disorder by examining recordings of his speech as he described a series of ambiguous pictures from the thematic apperception test, a procedure that elicits thought disordered speech. His speech was transcribed and rated with the thought and language index, a standardised scale for assessing thought disorder. Slang used in a linguistically appropriate way is not scored as abnormal on this scale. His score was 5.25, primarily reflecting a mild loosening of associations. For example, he described a picture of a boat on a lake thus: "There’s a boat and a tree. There seems to be a reflection. There are no beds, and I wonder why there are no beds. There’s a breeze going through the branches of the tree." His score was outside the normal range (mean for normal controls 0.88, SD 1.15) and indicates subtle thought disorder, equivalent to that evident in remitted patients with schizophrenia (mean in remitted patients 3.89, SD 2.56) but lower than that in patients with formal thought disorder (mean 27.4, SD 8.3). Over the following year his social and occupational functioning deteriorated further, and he developed frank formal thought disorder as well as grandiose and persecutory delusions to the extent that he met DSM-IV criteria for schizophrenia. His speech was assessed as before, and the thought and language index score had increased to 11.75. This mainly reflected abnormalities on items comprising "positive" thought disorder, particularly the use of neologisms such as "chronocolising" and non-sequiturs. To our knowledge this is the first case report to describe difficulties in distinguishing "street" argots from formal thought disorder. It is perhaps not surprising that slang can complicate the assessment of disorganised speech as psychotic illnesses usually develop in young adults, whereas the assessing clinician is often from an older generation (and different sociocultural background) less familiar with contemporary urban slang. Online resources offer a means of distinguishing street argot from neologisms or a peculiar use of words, and linguistic rating scales may be a useful adjunct to clinical assessment when thought disorder is subtle. Differentiating thought disorder from slang can be especially difficult in the context of "prodromal" signs of psychosis, when speech abnormalities, if present, are usually subtle. Nevertheless, accurate speech assessment is important as subtle thought disorder can, as in this case, predate the subsequent onset of schizophrenia, and early detection and treatment of psychosis might be associated with a better long term clinical outcome

At-risk mental state for psychosis : identification and current treatment approaches

© The Royal College of Psychiatrists 2016. The concept of an ‘at-risk mental state’ for psychosis arose from previous work attempting to identify a putative psychosis prodrome. In this article we summarise the current criteria used to identify ‘at-risk’ individuals, such as the ultra-highrisk (UHR) criteria, and the further identification of important clinical risk factors or biomarkers to improve prediction of who might develop a psychotic disorder. We also discuss important ethical issues in classifying and treating at-risk individuals, current treatment trials in this area and what treatment current services can offer

Entanglement-free certification of entangling gates

Not all quantum protocols require entanglement to outperform their classical alternatives. The nonclassical correlations that lead to this quantum advantage are conjectured to be captured by quantum discord. Here we demonstrate that discord can be explicitly used as a resource: certifying untrusted entangling gates without generating entanglement at any stage. We implement our protocol in the single-photon regime, and show its success in the presence of high levels of noise and imperfect gate operations. Our technique offers a practical method for benchmarking entangling gates in physical architectures in which only highly-mixed states are available.Comment: 5 pages, 2 figure

Occupational transitions: How do work-related factors influence the work-to-retirement transition process?

Background: The work-to-retirement transition process results in changes to life structure and identity making retirement from work a major occupational transition. This paper will explore the influence of work-related factors on the work-to-retirement transition. Findings will be discussed in terms of opportunities for occupational therapy in this occupational transition. Method: Semi-structured individual interviews were conducted with participants aged 50 years and over who had voluntarily retired within the past five years. Recruitment occurred via a range of mechanisms including through local services and organisations and the research teams' networks. Thematic analysis was conducted for each of the work-to-retirement transition stages (preparation, transition, and retired). Discussion/Outcomes: To date, eleven interviews (5 females, 6 males) have been conducted with people from a variety of pre-retirement occupations. Preliminary findings include themes around: time to move on, wrapping up work (preparation); work influencing retirement timing, work infiltrating retirement, feeling retired, (transition); freedom from work, identity reconceptualisation, filling retirement with work-like activities (retired). Conclusion: Work-related factors influence all stages of the work-to-retirement transition process. Occupational therapy's role encompasses vocational rehabilitation and ageing. Occupational therapy can also play an important role in facilitating the work-to-retirement transition process with the ultimate goal to enable active (and) healthy ageing

Threats to epistemic agency in young people with unusual experiences and beliefs

A good therapeutic relationship in mental health services is a predictor of positive clinical outcomes for people who seek help for distressing experiences, such as voice hearing and paranoia. One factor that may affect the quality of the therapeutic relationship and raises further ethical issues is the impact of the clinical encounter on users’ sense of self, and in particular on their sense of agency. In the paper, we discuss some of the reasons why the sense of epistemic agency may be especially fragile in young people with unusual experiences and beliefs. We argue that it is important to identify and avoid behaviours that can undermine young people’s contributions as epistemic agents in the clinical encounter