As emphasized in this volume, lone-actor terrorists comprise a broad group of individuals influenced by an array of variables. Research in this area has indicated some more common factors and patterns running through this group. An interesting and potentially informative perspective is a comparison of the lone-actor group to other groups posing a higher risk to society and national security. A comparison review with three other high-risk groups—those committing treason, those engaging in mass violence without an identified ideology, and school shooters, each show common and distinguishing features that add to the base of knowledge in understanding lone-actor terrorism.

The internet and social media may function as critical enabling forces in the development of lone-actor terrorists. This chapter reviews several aspects of information and communications technology that contribute to its relevance in lone-actor terrorism today: information access; logistics and planning; social needs and reinforcement; propaganda, misinformation, and escalation; and leakage. Three hypothetical case vignettes drawn from factors in recent real-life cases help to illustrate the potential roles of social media and the internet in the processes of radicalization, knowledge- and skill-building, attack planning and logistics, spreading extremist beliefs and inciting violence, and providing outlets for leakage of violent or terrorist intent, potentially enabling intervention before an attack takes place. The chapter also discusses several recent trends relevant to the intersection of lone-actor terrorism with the internet and social media, such as the rise of right-wing extremism in the west and the rapid development of artificial intelligence tools.

OBJECTIVE:This study evaluated student satisfaction with an educational exercise using feature films to learn about performing a psychiatric mental status examination. METHODS:Following the completion of an educational exercise designed by the first author, students in a behavioral medicine course completed surveys regarding their satisfaction with the exercise as a tool for learning how to perform a mental status examination. The educational exercise involved an initial didactic lecture followed by group exercises and individual presentations, utilizing feature films as tools for understanding the mental status examination. Each student selected a movie depicting a character with a psychiatric or substance-use disorder and performed a hypothetical mental status examination for the character, which they presented to their classmates. RESULTS:One hundred nine (109) students (97.3%) in the course completed evaluations of the educational exercise, and the majority found the exercise valuable; 93.6% of respondents felt that their ability to conceptualize a case had improved because of the exercise. In general evaluations of the course, this particular educational exercise was frequently mentioned in response to a free-form question about "the best part of the course." CONCLUSION:Movies depicting psychiatric illness and substance use disorders can be a fun and highly effective tool for helping students to learn and develop competency in the performance of mental status examinations.

In 2005, responding to several studies, the FDA issued a black box warning on atypical (second generation) antipsychotic medications, noting that the drugs may increase the risk of cerebrovascular adverse events in elderly patients with dementia-related behavior disturbances. The black box warning has raised concern for clinicians, among whom atypical antipsychotics have gained favor for having a more tolerable side-effect profile than many other pharmacological treatment options. Complicating this concern are studies suggesting that other medications may have similar risks and a dearth of unbiased head-to-head studies comparing different treatment options. To effectively manage risk when treating elderly patients with dementia-related psychosis, physicians, patients, and caregivers must consider both acute risks (such as danger of bodily harm to the patient and others) and long-term risks (such as placement in a restrictive nursing home). If an atypical antipsychotic is chosen, additional risk management may be warranted. This paper presents a brief overview of relevant concerns and suggests some techniques to help minimize and manage risk, such as increased monitoring, informed consent, and thorough documentation. A sample clinical risk management form and a sample letter to the primary care physician are provided to help guide clinicians in improving their risk management practices when working with elderly patients suffering from dementia-related psychosis and related behavioral difficulties.

Supervision of outpatient psychiatry residents plays the dual role of protecting the public by monitoring care and improving the educational experience of residents. The responsibility of supervisors may leave them vulnerable to liability under several legal theories. They may be vicariously liable for residents' negligence or may be directly liable for their own negligence in supervision or administration. Plaintiffs may bring claims alleging both vicarious and direct liability. There are particular risks with respect to residents' misconduct and liability to third parties, such as victims of a dangerous patient. Many of these legal issues are unsettled and may not apply to all situations. The authors discuss various risk-management techniques supervisors can use to mitigate risk.

Objective: This study examined what a person seeking e-therapy services might find on the Internet, and how e-therapy Web sites characterize their services and providers.Method. Using the search engines Google and Yahoo!, we obtained a list of 55 e-therapy Web sites, which we reviewed from May 2005 to September 2005. We used the search terms online counseling, online therapy, and e-therapy. We reviewed the Web sites' content for data in 7 categories: description of services, terminology for providers, providers' qualifications, terminology for service users, characteristics of clients, information for individuals in crisis, and information about confidentiality and security.Results: There was a wide range in the Web sites we accessed. Web sites often contained confusing information about the nature of the service offered and did not always specify qualifications of providers. Some providers did not appear qualified to provide the services the Web sites advertised. Other sites offered Internet-based services of legitimate mental health professionals. Most sites referred to users as clients rather than patients, and some sites specified criteria that would render prospective clients ineligible to receive services (e.g., suicidality). Some Web sites excluded individuals with specific diagnoses. Web sites were not generally proactive about providing resources for visitors in crisis. Less than half of the Web sites disclosed limits to client data security and confidentiality.Conclusion: Experiences with e-therapy might influence a patient's attitude toward traditional psychotherapy. With the wide variety in e-therapy services that are searchable on the Web, clinicians may want to be more aware of what their patients might encounter online.

E-therapy, the provision of mental health treatment through the Internet, poses many risks as well as benefits. This article addresses some relevant risks and benefits of e-therapy and discusses the practicality of using computers in the informed consent process. Although e-therapy has numerous proponents, no clinical trials have assessed its long-term effectiveness. To limit liability and to protect patients, e-therapy providers should disclose material risks as well as possible benefits and engage patients in an active dialogue. A thorough informed consent procedure enables patients to make an educated decision about whether e-therapy is right for them. In the future, e-therapy and informed consent online may become more common; in the mean time, clinicians must be prepared for e-therapy's uncertain legal status and allow patients to decide for themselves whether or not to seek counseling on the Internet.

Guest columnist PATRICIA RECUPERO, JD, MD, is Clinical Professor of Psychiatry, Brown Medical School, and President/CEO of Butler Hospital, Providence, RI 02906. Guest columnist SAMARA E. RAINEY is a Paralegal/Research Assistant at Butler Hospital.