Pathological narcissism (PN) and narcissistic personality disorder (NPD) are common yet highly stigmatized conditions for which no empirically validated treatment currently exists, despite growing evidence of the central role of psychoeducation. The goal of this study was to evaluate the feasibility and acceptability of our recently published group psychoeducation program for patients with PN, with or without a diagnosis of NPD. Twenty-five adult patients, who met ≥3 NPD criteria or presented with mean grandiosity and vulnerability scores ≥3 on the Pathological Narcissism Inventory-Brief Form and who were participating in our psychoeducation program, were recruited from a psychiatric outpatient center. Feasibility outcomes included attendance, completion, drop-out rates, as well as safety measures (between-session changes in state narcissism and hospitalization rates). Acceptability was assessed using a mixed-methods satisfaction questionnaire and by comparing pre- and post-group levels of trait narcissism using the Pathological Narcissism Inventory-Brief Form. Overall, attendance and completion rates were high (83% mean attendance with only 1 dropout). There were no between-session narcissistic activations and only 1 hospitalization unrelated to the group program; however, participants did report substantial emotional activation and a need for concomitant individual support. They also reported high levels of satisfaction and perceived usefulness. Exploratory pre-post changes suggested a decrease in self-reported grandiosity but not vulnerability, even though no causal conclusions could be drawn due to the uncontrolled design of the study. A major limitation of the study was the high rate of comorbidity with borderline personality disorder (92%), which limits the generalizability to all narcissistic patients. Overall, these findings support the feasibility and acceptability of a brief group psychoeducation program for PN.
The first column in this 2-part series covered the history of clinical psychopharmacology from the author's perspective from 1975 to 2000. This column covers the last 26 years of clinical psychopharmacology as experienced by the author from 2000 to 2026. It focuses on the following major areas: (1) system-level neurobiology of neuropsychiatric drugs with an early focus on antidepressants; (2) circuit-based drug discovery; (3) pharmacokinetic, pharmacodynamic, and metabolic determination of psychotropic drug response as encompassed by Preskorn's Organizing Equation; (4) therapeutic drug monitoring (TDM) and pharmacology safety based on the use of TDM's ability to measure the functional as opposed to just the genetic capability of a patient to metabolize a medication; (5) enzyme-mediated drug-drug interactions; (6) multiple medication use in everyday clinical practice; (7) the results and implications of the results of the NIMH-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study; and (8) early phase clinical investigation of novel central nervous system mechanisms. The column illustrates the author's goal to bring science to the practice of psychiatry, beginning in the mid-1970s, when psychoanalysis dominated psychiatric thinking, up through 2026, within our current limits of understanding. It also illustrates how, at least for one psychiatrist, knowledge in our field has evolved and his reason for having this goal.
First responders, correctional officers, and military personnel face heightened risks for mental health disorders such as posttraumatic stress disorder, depression, substance use disorders, and suicidal behavior, yet they are often reluctant to seek care due to stigma, job-related consequences, and structural barriers. These populations are also prone to occupational injuries and chronic health conditions linked to physically demanding, high-stress roles involving repeated exposure to trauma and dangerous environments. This article provides an overview of the unique occupational stressors and barriers to care across different service sectors in the United States, including law enforcement, firefighting, emergency medical services, corrections, and the military. This review also offers guidance for community mental health providers in delivering context-sensitive, collaborative psychiatric care. With increasing societal stressors, including civil unrest and public scrutiny, supporting the psychological well-being of these frontline professionals is both a clinical and social imperative.
Frontotemporal dementia (FTD) and Lewy body dementia (LBD) are distinct neurodegenerative disorders that rarely co-occur. However, their overlapping features can obscure diagnosis and complicate management. We present the case of a 65-year-old man with a history of alcohol use disorder, diabetes, and blindness who developed acute behavioral changes, catatonia, and fluctuating mental status. He exhibited signs consistent with a behavioral variant FTD, including disinhibition, executive dysfunction, and hypersexuality, as well as features associated with LBD, including visual hallucinations, autonomic instability, and waxing-and-waning impairment in cognition. His hospital course was marked by episodic disorientation, variable language use, and persecutory delusions. Neuroimaging, cerebrospinal fluid analysis, and serial neuropsychological testing yielded mixed and inconclusive results, contributing to the diagnostic ambiguity. Treatment included lorazepam, which improved catatonic symptoms but was discontinued due to risk of delirium, and aripiprazole, which was tapered due to suspected neuroleptic sensitivity. The patient was ultimately discharged to memory care with a diagnosis of an unspecified dementia. This case underscores the challenges of diagnosing and managing patients with overlapping features of multiple neurodegenerative disorders. Recognizing points of overlap between syndromes like FTD and LBD is key to tailoring interventions and avoiding harm. Serial cognitive assessments, functional neuroimaging, and biomarker analysis may improve diagnostic accuracy, although these tools have limitations. A deeper understanding of the pathophysiology of overlapping dementia syndromes is crucial for improving diagnostic clarity and guiding treatment strategies.
OBJECTIVE:This study aimed to systematically investigate the efficacy of a psychological stratified intervention in alleviating anxiety and depression symptoms and optimizing pregnancy outcomes among pregnant women. METHODS:A prospective, single-center, randomized controlled trial was conducted. Between March and July 2024, 80 pregnant women who underwent prenatal care registration at Suzhou Hospital Affiliated to Nanjing Medical University and tested positive for anxiety or depression [scoring ≥ 5 on the Generalized Anxiety Disorder 7-item scale (GAD-7) or ≥ 9 on the Edinburgh Postpartum Depression Scale (EPDS)] were recruited. Participants were randomly allocated into an intervention group (n=40), who received a customized psychological stratified intervention, and a control group (n=40), who received conventional nursing care. The primary outcomes included changes in anxiety/depression scores, whereas secondary outcomes encompassed pregnancy-related metrics, such as the incidence of postpartum hemorrhages. RESULTS:The intervention group demonstrated significantly lower EPDS scores than the control group during the third-trimester and postpartum follow-up phases (both P<0.05). Notably, the incidence of postpartum hemorrhage in the intervention group was lower than that in the control group, and the difference was statistically significant (P=0.034). CONCLUSIONS:The psychological stratified intervention, as an evidence-based, tiered psychological support approach, effectively mitigates late-pregnancy and postpartum depressive symptoms, enhances maternal mental health, and reduces the risk of postpartum hemorrhage. These findings underscore its potential as a valuable addition to antenatal care protocols and support its widespread implementation in clinical settings.
The rapid adoption of social media and now artificial intelligence (AI)-based chatbots has outpaced formal clinical guidelines on their use. Cases of alleged harm from both social media and AI use have accumulated in 2026. The recent Meta social media verdict hinged on a clinical question answered outside the clinical context. A similar pattern is repeating with AI, where litigation is moving faster than psychiatric consensus and even the pace of technological change. Assessing the risks and benefits of AI is thus critical but remains challenging, as harms may vary across rapidly evolving models, and benefits can change as well. Thus, clinicians need to be well informed about AI, and we present a framework for clinician competency in AI, including fundamentals of how AI is trained, how to ask about patient uses, and how to evaluate for risky engagement. We also propose using a familiar approach, the biopsychosocial formulation, to document and conceptualize AI use within a patient’s life for a more nuanced assessment. With this discussion, we inaugurate the Digital Psychiatry column in the Journal of Psychiatric Practice and welcome submissions on the intersection of technology and mental health.
Syphilis, a condition known as "the great imitator," is a sexually transmitted infection caused by the bacterium Treponema pallidum that can present with a myriad of symptoms, including psychiatric and neurological changes. Severe complications of syphilis are rare nowadays due to the widespread availability of antibiotics. Nonetheless, the incidence has been increasing over the past few years. We describe the case of a middle-aged man who presented with neuropsychiatric symptoms that were initially thought to be secondary to substance use and who was eventually diagnosed with neurosyphilis. A brief review of the most common features of this condition, as well as treatment options, is presented. As this patient was part of a minority group and had a history of substance misuse that delayed the diagnosis of neurosyphilis, we will also comment on stigmas, disparities, and biases in clinical settings, and some mitigation strategies that can be implemented to prevent adverse health outcomes in marginalized populations.
Despite the wide availability of peer-led grief support groups, there has been limited study of their methodology or outcomes. This pilot study examined a nonclinical sample of 99 adults who self-referred to a peer-led group. This group involved a time-limited, manualized, closed group intervention (Restorative Retelling) that was co-facilitated by peer volunteers. The study documented a low dropout rate from this free service with preimprovement/postimprovement in scores of grief distress as measured by the Prolonged Grief Disorder (PG-13) scale. The peer volunteers were preselected and trained to serve as co-facilitators. They formed a working alliance of facilitator rotation, continuing education, and future commitment. Presentation of a group member's progress during the group intervention clarifies the supportive focus and experiential dimensions of the intervention.
A significant proportion of patients with obsessive-compulsive disorder (OCD) are admitted to inpatient hospital facilities. This most often occurs within general psychiatric units, given the scarcity of options specialized to OCD. This study surveyed 69 adults with self-reported OCD who had experienced 1 or more inpatient hospitalizations, with the goal of exploring perceptions of OCD-related care in general inpatient settings. Overall, participants reported negative views of their providers' attention to OCD-specific needs. Nearly half indicated that none of their providers appeared proficient in or confident working with OCD. Participants were also dissatisfied with the OCD treatment they received. At the same time, more positive perceptions of providers' ability to treat OCD were associated with a greater likelihood of perceived OCD symptom reduction during hospitalization. These findings are among the first to empirically highlight potential limitations in the standard of care for OCD in general psychiatric units. We discuss avenues for future research, including the need to develop and evaluate provider approaches that balance reducing accommodation of compulsions with supportive responding, which may lay the groundwork for evidence-based practices to better prepare providers to work with patients who have OCD in inpatient settings.
OBJECTIVES:Perceived stress is a significant concern among health care professionals, with potential consequences for mental health and clinical performance. This study examined associations between dispositional mindfulness and perceived stress among Indian physicians working in psychiatric and nonpsychiatric specializations within hierarchical systems with limited institutional support. METHODS:In this cross-sectional pilot study, 62 clinicians (39 nonpsychiatric and 23 psychiatric physicians) completed the Perceived Stress Scale and the Five Facet Mindfulness Questionnaire-Short Form. Independent samples t tests compared perceived stress and mindfulness scores between the groups. Correlations and linear regression analyses were conducted to examine relationships between mindfulness and perceived stress. RESULTS:No statistically significant differences were found between psychiatric and nonpsychiatric physicians in perceived stress, t(59)=0.98, P=0.329, d=0.27, or total mindfulness, t(59)=-1.31, P=0.186, d=0.35. Across the sample, higher dispositional mindfulness was strongly associated with lower perceived stress, r(60)=-0.65, P<0.001, r²=0.43, particularly for the Describe and Acting with Awareness facets. Linear regression indicated that mindfulness was significantly related to perceived stress, β=-0.65, t=-6.66, P<0.001, accounting for 42.5% of the variance. CONCLUSIONS:These findings cautiously suggest that dispositional mindfulness may serve as a potential psychological resource for stress regulation and burnout prevention among clinicians. Further research is warranted to validate these associations in larger and more diverse samples and to explore practical applications within wellness initiatives.
This column presents a first draft of the Psychotherapy Selection Algorithm (PSA 1.0), developed by a workgroup of the American Psychoanalytic Association. The goal of PSA 1.0 is to address bias in psychotherapy selection and to reexamine treatment selection so that it is based on evidence that includes the effectiveness and efficacy of psychodynamic therapy and psychoanalysis.
OBJECTIVE:Childhood anxiety disorders are prevalent and impair children's socioemotional functioning. Abnormalities in sensory processing may play a role in the presentation of anxiety disorders. One important domain of sensory processing is sensory sensitivity, referring to heightened or diminished responses to sensory stimuli. While anxiety and sensory sensitivity frequently co-occur, research thus far has primarily focused on associations among autistic children, with limited investigation in anxious children. This study examined the associations between sensory sensitivity and anxiety symptom severity, externalizing problems, emotion dysregulation, and quality of peer and family relationships in children with elevated anxiety symptoms without neurodevelopmental disorders. METHOD:Ninety-four children aged 8 to 17 years (mean age=12.41, SD=2.55 y) with elevated anxiety symptoms but without neurodevelopmental disorders completed self-report assessments of sensory sensitivity, anxiety symptom severity, externalizing behaviors, emotion dysregulation, and quality of peer and family relationships. Participants' parents completed a parent-report assessment of children's externalizing behaviors. RESULTS:Sensory sensitivity and anxiety symptom severity were not statistically significantly associated. Controlling for anxiety symptom severity and relevant sociodemographic covariates, sensory sensitivity explained a statistically significant amount of variance in youth-reported (but not parent-reported) externalizing symptoms, emotion dysregulation, and quality of family but not peer relationships. CONCLUSION:Anxious youth with sensory sensitivity may experience externalizing symptoms, emotion dysregulation, and difficulties with family relationships. Study limitations included a racially/ethnically homogeneous sample and a cross-sectional design. Further research is necessary to better understand the causal impact of sensory sensitivity on behavioral difficulties and quality of life, identify potential protective factors, and test intervention strategies for this population.
As I prepare to step down from my position as Psychopharmacology Columnist for the Journal of Psychiatric Practice after over 30 years in that role, it seemed appropriate to look back and discuss some major developments in psychopharmacology that have occurred over the course of the 50+ years of my career. To keep this narrative manageable in a column format, it is divided into 2 columns. Neither this column nor the next will cover everything-that would require a textbook. Instead, I will cover selected topics from a personal perspective. This column will principally focus on the first 25 years of my career and covers 5 main topics: therapeutic drug monitoring, which led to pharmacogenomics, studies in child and adolescent psychiatry, drug development research, neurobiology, and forensic psychiatry.
BACKGROUND:Birthdays are typically a joyous occasion, but they can paradoxically conjure negative feelings, including reflections on failures and underachievement. In this study, we investigated a relationship between admission dates and patients' birthdays. METHODS:Electronic health records from the Dunn Center hospitals were obtained from April 2021 to June 2024. Patients who were 12 to 80 years of age, except for those in competency restoration units, were included in the analysis. Any admissions occurring 2 weeks before and after the patient's birthday were defined as birthday-associated admissions. A case-crossover analysis was employed to examine the plausible temporal relationship between the birthday period and the acute psychiatric hospitalization. A conditional logistic regression model was used to test the odds of birthday-associated admission versus non-birthday-associated admission. Relevant covariates consisted of age, sex, primary diagnosis, and social determinants of health. RESULTS:A total of 17,847 admissions were included. The case-crossover analysis found that patients were approximately twice as likely (OR=2.08, 95% CI=1.89-2.30, P<0.0001) to be admitted 14 days before or after their birthday relative to a 28-day control window randomly selected within each calendar year. Potentially confounding variables, such as age, admission diagnosis, and social determinants of health, showed no difference in the likelihood of admission. CONCLUSIONS:This analysis supports the hypothesis that, for persons with psychiatric disorders, birthdays may represent periods of increased risk/stress that can manifest in increased inpatient psychiatric admissions. With these results, we can supplement education efforts to inform patients, families, and providers to recognize birthdays as a possible risk factor for worsening psychiatric symptoms.
A boxed warning, or "black box" warning, represents the US Food and Drug Administration's most serious cautionary statement for prescription drugs. These warnings communicate clinically significant risks that may alter prescribing decisions, patient consent, and medicolegal responsibility. This narrative review explores the regulatory history, creation, and modification of boxed warnings, emphasizing their role in psychopharmacology. Using the case of varenicline (Chantix) as a focal example, we trace how emerging postmarketing data led to the implementation and subsequent removal of its boxed warning. We then summarize major boxed warnings across psychotropic classes, highlighting practical implications for prescribing, documentation, and informed consent. Finally, we discuss strategies for integrating boxed warning awareness into clinical decision-making and patient communication. Boxed warnings serve not merely as restrictions but as instruments of safety, vigilance, and shared decision-making that enhance the quality of psychiatric care.
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are a hoped-for intervention to reduce nonadherence to psychotropic medications due to metabolic syndrome and, potentially, to reduce metabolic syndrome-related premature cardiovascular death among those undergoing treatment for bipolar disorder. GLP-1 RAs are currently approved by the US Food and Drug Administration for weight loss in patients with type 2 diabetes, for patients with cardiovascular disease, obesity, and type 2 diabetes, and for reduction of risk of sustained low estimated glomerular filtration rate in patients with chronic kidney disease or end-stage renal disease. Research into the use of GLP-1 RAs in patients with metabolic dysfunction-associated steatohepatitis and other conditions is ongoing. The expanding research into indications for the use of GLP-1 RAs will likely include individuals with bipolar disorder and, among them, patients treated with lithium carbonate. Here, we report a case of GLP-1 RA-induced lithium neurotoxicity, which suggests the need for further investigation and enhanced surveillance for lithium toxicity in patients who are coadministered lithium and GLP-1 RAs.
BACKGROUND:The COVID-19 pandemic has challenged everyone's adaptive resources. However, a limited number of studies have examined its effects on mental health workers, a population at increased risk for vicarious traumatization. METHODS:A mediation model was tested using longitudinal self-report data (N=1597). The association among occupation, severity of trauma-related and stressor-related (TSR) symptoms during the first wave of the COVID-19 pandemic, and self-efficacy was explored. RESULTS:Mental health workers reported greater self-efficacy than other survey participants (health care workers, general population) (unstandardized β=1.53, P<0.001), and greater self-efficacy was associated with lower TSR symptoms (-0.09, P<0.001). Hence, mental health workers reported lower TSR symptoms through both direct (-0.80, P=0.005) and indirect associations (-0.94, P<0.001), with higher self-efficacy compared with other survey participants. CONCLUSIONS:Despite being at greater risk for vicarious traumatization, mental health workers fared well during the first wave of COVID-19. Increasing self-efficacy in high-risk populations in the context of stressful/traumatic events may have some value, an avenue requiring further investigation.
INTRODUCTION:Diagnosing attention deficit/hyperactivity disorder (ADHD) among adults is challenging, given reliance on retrospective symptom reporting and the overlap of core, nonspecific diagnostic symptoms with other psychiatric disorders such as depression and anxiety. This study examined the effect of perceived stress on ADHD symptom reporting. METHODS:Cross-sectional data from 638 diverse adult outpatients referred for ADHD neuropsychological evaluation, who were administered the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Perceived Stress Scale (PSS), and Clinical Assessment of Attention Deficit-Adult (CAT-A), were analyzed. Linear regressions were conducted with BDI-II/BAI (block 1) and PSS (block 2) as predictor variables and ADHD symptom endorsement in childhood and adulthood (CAT-A) as the dependent variable. RESULTS:PSS/BDI-II (r=0.648) and PSS/BAI (r=0.523) were moderately correlated. BDI-II and BAI significantly predicted overall ADHD symptom endorsement and current/adult symptom reporting, whereas only BAI predicted childhood symptoms. After entering the PSS in block 2, all models remained significant (P<0.001; R2=0.03 to 0.08), but BDI-II and BAI became nonsignificant; only perceived stress remained a significant predictor. The results were replicated after excluding those with potentially invalid ADHD symptom reporting, so that the PSS again was the only significant predictor of ADHD symptom endorsement (R2=0.02 to 0.06). CONCLUSIONS:Patients' subjective experience of stress was significantly associated with nonspecific inattention symptom endorsement among adults undergoing ADHD evaluation and shared more variance with attention complaints than active depression and anxiety symptoms. Findings emphasize routinely assessing perceived stress during psychiatric evaluation of ADHD, as high stress levels may masquerade as nonspecific inattention symptoms and contribute to misdiagnosis of ADHD if not considered/assessed, and high stress levels may also exacerbate genuine ADHD symptoms.
Later this year, Dr. Preskorn will be stepping down from his position as Psychopharmacology Columnist for the Journal of Psychiatric Practice after over 30 years in that role. This column is intended to provide readers who have read or will read Dr Preskorn's articles on psychopharmacology in the Journal of Psychiatric Practice and other journals with a perspective on the author. Over his 50+ year career, the author has been and continues to be passionate about bringing science to the practice of psychiatry. The column describes the author's contributions in the following areas: (1) direct impact on psychiatric drug development and approval, (2) publication of peer-reviewed publications that have influenced both researchers and practitioners, (3) influence on psychiatrists and other prescribers to improve the prescribing of psychiatric medications for patients, and (4) regulatory, translational, and mechanistic contributions to the understanding of the science of psychiatry and clinical psychopharmacology.
