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Papers by Stephen Xenakis

Last week, the FDA announced that it plans to approve cranial electrotherapy stimulation, the sim... more Last week, the FDA announced that it plans to approve cranial electrotherapy stimulation, the simple handheld medical device currently cleared to treat depression, anxiety, and insomnia. The FDA "has determined that there is sufficient information to establish special controls, and that these special controls, together with general controls, will provide a reasonable assurance of safety and effectiveness for CES devices." In short, cranial electrotherapy will soon become the only medical device in the United States that is FDA-approved to treat insomnia and anxiety, and the only home-use device approved to treat depression. As such, it becomes part of the psychiatric armamentarium. To some, this is jaw-dropping news. But this device has been used in psychiatry practice for years and can be an essential adjunctive treatment to standard modalities of care for soldiers and veterans. Cranial electrotherapy devices are essentially handheld pulse generators that deliver very low electric outputs. The device generates 1/1000 the output of electroconvulsive therapy (ECT) and connects with sponge electrodes to the side of the head. Patients use the device for 20 minutes twice a day for the first 6 weeks, then less frequently as needed. The device is easy to use and comfortable; it allows patients to go about their morning routine comfortably. The electrical current is gentle (no greater than 4 mA). This is why these devices are often referred to as electroceuticals-not quite as handy as popping a pill, but a lot more convenient than transcranial magnetic stimulation or ECT treatments in doctors' offices. And cranial electrotherapy causes no serious adverse effects-only a headache or dizziness in fewer than 1 of 250 patients.

Journal of the American Academy of Psychiatry and the Law, Sep 1, 2020

Interrogation and Torture

The United States is only just beginning to grapple with the fallout from the program known as Re... more The United States is only just beginning to grapple with the fallout from the program known as Rendition, Detention and Interrogation (RDI), an illegal interrogation practice designed to further the United States counter-terrorism efforts against al-Qaeda and the Taliban. One of the most consequential legacies of the program stems from the way it was justified: lawyers for the Bush administration sought to legitimize the program through distorted legal doctrines, some of which remained in currency even after the RDI program was finally abandoned. The attempt to justify illegal conduct with false legal arguments, along with the failure of the subsequent administration to hold the principal architects of the program responsible, has eroded the rule of law in the United States and done permanent damage to norms of armed conflict as well as to domestic and international law. This chapter discusses the consequences of the RDI program, with particular attention paid to the impact of legal...

Clinical Case Maintaining Medical Neutrality in Conflict Zones Commentary by Stephen N. Xenakis, ... more Clinical Case Maintaining Medical Neutrality in Conflict Zones Commentary by Stephen N. Xenakis, MD, and by Yishai Ofran, MD Asher is a fourth-year medical student doing an international elective in northern Uganda. The clinic he's stationed in serves primarily the local community, and he's seen everything from routine ear infections to advanced AIDS, encephalitis, parasitic infections, and disseminated tuberculosis. As one of the few Westerners the villagers have ever seen, Asher has created quite a stir. Although he's starting to feel more at home in the village, he knows that his actions are watched closely by the townspeople, and he's scrupulous about his interactions with them, always respectful and deferential to local customs and values. The organization he's working with can only staff the clinic for eight months out of the year, so when an American medical team is there, news travels fast to neighboring communities, and occasionally people come from quite a distance to seek care. One evening, Asher heard a commotion outside the clinic. Several men and women had gathered, and there was shouting. Asher asked a nurse what was causing the upset, and she explained that men thought to be affiliated with a group of rebel fighters from the north were approaching town, and some had been wounded. Asher moved to send for the local physicians and ready the procedure suites, but the nurse stopped him. "We've worked for years to establish trust among the local people here-trust that's enabled us to dramatically improve the health in these communities. It would be a grave insult if we offered care to their violent enemies, and that would surely result in a huge setback for all our hard work. We should shut down the clinic before the rebels arrive because they're not welcome here." Commentary 1 by Stephen N. Xenakis, MD Candidates for the Supreme Court react to hypothetical questions as if they are radioactive and creatively dodge them at confirmation hearings. But physicians use them for teaching. This case study could fall under the teaching module entitled, "How Physicians Serving in a Hostile Environment Can Make Ethical and Practical Decisions." Asher, the medical student in northern Uganda who is in charge of the clinic for the evening, must make an urgent decision about treating potentially hostile, even dangerous, patients and does not have time to consult with others.

Ethics Challenges in Forensic Psychiatry and Psychology Practice, 2018

Psychiatrists and other mental health practitioners are thrust into a unique role when confronted... more Psychiatrists and other mental health practitioners are thrust into a unique role when confronted with warfare in the twenty-first century. Their involvement draws them into the epicenter of the war on terrorism. The realities of modern warfare push them beyond the principle of “first, do no harm,” which has historically grounded the healing professions, and into unprecedented dilemmas that challenge roles and responsibilities.

Military Health Care, 2013

When an individual has more than one professional role, the potential or possibility for strain a... more When an individual has more than one professional role, the potential or possibility for strain among role obligations exists. In the case of military medicine, a physician is placed at a nexus of the profession of arms and the profession of medicine. Each of these professions has an ultimate end, or telos, with corresponding responsibilities and obligations. In the case scenario, Amanda asserts that the ends or goals of medicine and those of the military are incompatible. To oppose that view, one must look to the theoretical constructs and practical realities of both the professions.

Psychiatric Times, 1998

In 2004, the news that Americans had committed abuse and mistreatment in Abu Ghraib and Guantanam... more In 2004, the news that Americans had committed abuse and mistreatment in Abu Ghraib and Guantanamo was shocking. Even more alarming were the revelations that physicians, psychiatrists, and other mental health professionals had assisted with interrogations that ...

Proceedings of the Annual Meeting (American Society of International Law), 2014

The Psychiatric clinics of North America, Dec 1, 2016

Understanding the occurrence and nature of violence in the military entails appreciating military... more Understanding the occurrence and nature of violence in the military entails appreciating military culture, the sociology and demographics of its personnel, military training, combat experiences, and injuries and illnesses that veterans suffer. The military is grounded in the principles and practice of conducting violent operations, and the psychology of violence fundamentally anchors its professionalism. The occurrence of unwanted violence and tragic incidence of suicides, homicides, and abuse expose the challenges to containing the behavior outside of the combat and training theaters.

Military Medicine, 1983

... Abstract. 70 military personnel were assigned to medic and chemical and conventionalwarfare c... more ... Abstract. 70 military personnel were assigned to medic and chemical and conventionalwarfare casualty roles and divided into 4 groups. Each group was assigned a military task to complete within the 1-hr time of the medical simulation. ...

The journal of the American Academy of Psychiatry and the Law, 2014

Torture Journal

Fallon documents the source of misguided interrogations and torture after 9/11.

The journal of the American Academy of Psychiatry and the Law, 2017

There is no agreement on how to manage hunger strikers. The health professionals called to interv... more There is no agreement on how to manage hunger strikers. The health professionals called to intervene in a hunger strike are faced with a dilemma: commit themselves to good order and discipline or comply with best practices for providing healthcare. Handling cases of hunger strikers confronts practitioners with the ethics dilemma of managing apparent intentional behavior that carries serious morbidity or mortality, but recognizing that hunger striking is a military and political tactic, and not a medical condition. The study by Reeves, published in the enhances our understanding of the motives and psychology of hunger strikers. Their analysis indicates that improving communication with custody administration and mitigating unnecessarily aversive housing environments can likely reduce the incidence of hunger strikes.

Journal of Comparative and Physiological Psychology, 1981

Adult female rats given bilateral parasagittal knife cuts in the medial hypothalamus (VMH group) ... more Adult female rats given bilateral parasagittal knife cuts in the medial hypothalamus (VMH group) were hyperphagic and became obese on a chow diet, compared with sham-operated controls. The VMH rats also overconsumed, relative to controls, sucrose and glucose solutions during 30 min/day tests. Pretreating the VMH and control rats with atropine methyl nitrate (1.0, 5.0, or 10.0 mg/kg) reduced their intake of the sugar solutions in three out of five experiments, and in all experiments it suppressed their 24-hr chow intake. However, the VMH rats continued to drink more of the sugar solutions than did the controls after all atropine treatments, and in three out of four experiments their hyperphagia on the chow diet was not blocked by the atropine. The results do not support the hypothesis that vagally stimulated insulin release or other cholinergically mediated cephalic responses of digestion are essential for the expression of hypothalamic hyperphagia and finickiness.