Failings of a categorical systemFor decades, standardized classification systems have attempted to define psychiatric disorders in our mental health care system, with the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association (APA), 2013) and International Statistical Classification of Diseases and Related Health Problems 10th revision (ICD-10; World Health Organization, 2010) being internationally best-known. One of the major advantages of the DSM must be that it has seriously diminished the international linguistic confusion regarding psychiatric disorders. Since (...) its introduction, it contributed extensively towards one common international language for defining and conceptualizing psychiatric disorders. Strikingly, within the field of psychological testing a similar step forward seems to have not yet been taken. At present, there exists no international standard for the use of psychological tests that takes the definition of a specific symptom as listed in DSM-5 as its starting point, and reliably and validly measures this symptom. Rather, the majority of tests are measuring constructs consisting of a multitude of symptoms. For example, the Beck’s Depression Inventory (Beck et al., 1996) measures core symptoms of depression summing up to a depression score. Accordingly, we believe it is time for a change. The diagnostics of psychiatric disorders, where disorders are defined as nosological units with a single cause, a single organic substrate, and a single time course, has been problematic for centuries. The field of psychiatry has always been ambivalent about its desire to follow a medical model (Blaney, 2015), but afflicted due to its definitions of pathology. The definition of a psychiatric disorder in DSM-5 offers little room for a clear cut pathogenesis and harsh demarcation of syndromes. This is reflected in the DSM-5, where it states: “A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning” (APA, 2013, p.20). An unfortunate and recognized consequence of this definition within the current system is that many symptoms overlap within categories of psychiatric disorders and patients end up diagnosed with many co-morbid disorders.Two fundamental problemsRegardless of new attempts to improve the diagnostics of psychiatric disorders, the DSM-5 represents the status quo. Consequently, the distinction between diagnosis and classification remains substantial and more than a discussion on semantics. We identify two fundamental problems within the current framework. Generally, a psychiatric diagnosis is considered to be descriptive (Hengeveld and Schudel, 2003). The clinician will describe a syndrome (its nature, timespan, and severity) within the framework of a disorder, and often include a differential diagnosis, predisposing protective or vulnerability factors, and provoking or maintaining factors. Within the DSM-5 framework, a similar ‘approach to clinical case formulation’ is taken (APA, 2013, p. 19). Evidently, a descriptive diagnosis has a hypothetical character. It consists of the clinician’s hypothesis and is based on his or hers professional considerations according to the abovementioned factors. Once the clinician has formulated a descriptive diagnosis, it is then complementary ‘translated’ into a DSM-5 classification. Herein lies the problem. For the layman, the existence of this distinction between diagnosis and classification is usually unknown. Preceding treatment, the clinician will give the client a classification of the existing psychiatric problems and the client may attribute more meaning to it than appropriate, thereby fostering the risk of reification. Second, the DSM-5 is a categorical system. Thus, individual disorders are regarded as discrete units – ‘you either have it, or you don’t’. DSM-5 states about this: “(…) scientific evidence places many, if not most, disorders on a spectrum with closely related disorders that have shared symptoms, shared genetic and environmental risk factors (…)”. And “(…) we have come to recognize that the boundaries between disorders are more porous than originally perceived.” (APA, 2013, p. 6). This leads to a fundamental problem. Because the overwhelming majority of psychiatric disorders examined thus far using taxometric methods appear to be dimensional in nature (Haslam, 2003; Widiger and Samuel, 2005), consequently all of their categorizations become artificial and debatable. Even though DSM-5 took a modest step towards a more dimensional approach, its core remains categorical. To illustrate, consider the Borderline Personality Disorder (BPD). This classification consists of nine diagnostic criteria of which a minimum of five need to be present for the diagnosis of BPD. A simple numerical combination algorithm leads to a staggering number of 256 distinct presentations of BPD (Albion et al., 2013). Due to this chameleon-like nature, the disorder’s diagnostic validity becomes questionable. Strikingly, this number is relatively small when compared to other conditions, e.g., there are 636,120 ways to have posttraumatic stress disorder (Galatzer-Levy and Bryant, 2013).DSM-5 does propose an alternative model for personality disorders based on personality functioning and traits (APA, 2013, p. 761), as a possible answer to the problem that most patients fit with multiple co-morbid personality disorders or to the category of personality disorder not otherwise specified. In November 2012, the chair committee of APA decided to move this alternative model to section III of DSM-5 and to sustain the categorical system in section II. A potential solutionDSM-5 and its predecessors have brought about an invaluable improvement regarding the formulation of a common international language for psychiatric disorders. However, the individual disorders fit poorly with its starting point of discrete units and strict boundaries. Van Os (2014) has argued for a better balance between the categorical and personalized aspects of psychiatric disorders. We argue for a two-step approach.Particularly due to the ‘weak boundaries’ between disorders, it might be beneficial to limit ourselves by merely categorizing clients into the main categories of the DSM-5 according to their most prominent symptoms (Van Os, 2014), i.e. their main complaint. In other words, clinicians could first ask themselves whether the symptomatology is concerning a neurodevelopmental disorder, or a bipolar and related disorder, or a depressive disorder, and so on. It will drastically reduce the over 400 classifications in DSM-5 down to 20 categories. Van Os (2014) even argues to combine some of the main categories, reducing this number even further to 15 categories. The advantages of reducing the over 400 classifications are fivefold: 1) a syndrome, being an aggregation of symptoms, creates a false relation between symptoms that are that are already heterogeneous themselves; 2) 15 broad categories are functional: it results into a very heterogeneous group of clients within a category and thus prevents stereotypes and invites further personalizing of complaints; and 3) a dimensional measure of a symptom rather than a syndrome will correspond better with the client regardless of it not providing the complete picture. Focusing on the main complaint will indicate where there is an immediate need for care (Van Os, 2014); 4) it will allow clinicians to recognise subthreshold conditions more easily (Magruder and Calderone, 2000); and 5) it might facilitate the development of clear demarcations between normal and abnormal functioning (Kessler, 2002; Widiger and Samuel, 2005). Please, see also Table 1.This also fits well within scientific advances, as thus far strongest evidence has been found for a distinction between internalizing and externalizing disorders, even superseding these 15 main categories (DSM-5; APA, 2013, p.13, but see Weiss et al., 1998). The second step would concern the personalized aspect, which we argue to define on a level of core symptoms of the specific main category, to be agreed upon later. To assess these core symptoms, the field of psychological testing could develop an internationally applicable instrument to reliably and validly measure each (core) symptom on a dimensional scale. Many of these instruments are readily available and have proven its psychometric properties within scientific research. Elements from these instruments could be easily transformed to work within the new system. Within the field of psychology, this approach could aid development of a common international language to define symptoms, analogous to the field of psychiatry. Importantly, current psychological testing mainly implies the use of self-report measures. This leads to an abundance of auto-amnestic information. To increase the reliability and validity of psychological tests to assess DSM-5 symptoms, it may be important to add two additional information resources. This would entail psychological tests where a next of kin answers questions about the symptom of the client, and psychological tests that include the clinicians’ judgment, such as structured clinician-based interviews. Conversely, we also need to acknowledge the well-known limitations of clinical judgment (e.g., Faust, 1986; Garb, 1998). Advantages of a new frameworkThe changes we suggest have big implications and are not easily implemented in the current framework. Clients may prefer the comfort of a single clear label, similar to what they are used to in other areas of medicine. Health insurance providers and policy makers may argue for single labels as well. Therefore, it would require a lot of explanation from our clinicians to promote a change. Our suggestions for broader categories may not disambiguate the current situation better than the existing approach, but it will promote personalisation of health care. Difficulties in diagnostic reliability will remain in disorders that fall on the boundaries of the taxons, e.g., schizoaffective disorder versus bipolar disorder with psychotic characteristics, which may benefit from further study. There are also some politically tinged questions to keep in mind: How will we finance our health care, and how will we ensure a gradual transition from the current financing system, including clients who already have their labels? What about visitations from insurers and health inspection? How can they control for a good standard of quality in health care when considering the increasing heterogeneity? Nevertheless, we argue that the benefits outweigh the disadvantages. We will see a shift from a categorical to a personalized approach, which will lead to less (self) stigmatizing, less estrangement, and it will challenge reification thinking. DSM-V states that “a reformulation of research goals should also keep DSM-5 central to the development of dimensional approaches to diagnosis that will likely supplement or supersede current categorical approaches to diagnosis in coming years” (APA, 2013, p. 13). Our proposition for psychological testing on symptom level could contribute to this development. Furthermore, this new approach will do more justice to the heterogeneity of symptoms within and outside of classification categories, see also Table 1. Moreover, in this new approach we join forces of expert knowledge from the fields of psychiatry and psychological science. Finally, it offers new and potentially better opportunities to map health care needs. This in turn will lead to a better interface for allocation of appropriate treatment. It will present a clearer picture of when preventative care is preferred over treatment and vice versa. Importantly, health care needs will be more closely attuned to the ‘own story’ of the client.We argue for the national and international psychological associations in Europe and the United States of America to support the idea of a collective approach to develop an internationally standardized psychological testing battery to reliably assess all the core symptoms of the main categories in DSM-5. (shrink)

Bizarre delusions are not specific to schizophrenia and can be found in other psychotic disorders. However, to date, there are no studies investigating socio-demographic and clinical characteristics associated with BizD across the psychosis spectrum. In this study 819 subjects with a diagnosis of SZ, schizoaffective disorder and bipolar I disorder were included. Patients with history of BizD and with no BizD were compared with respect to socidemographic and clinical variables, and predictors of BizD were explored. Patients with (...) BizD were less educated, less likely to be married, had higher Positive and Negative Syndrome Scale negative scores and lower Young Mania Rating Scale scores. Younger age, SZ and SZA diagnoses, higher PANSS positive scores, presence of reference delusions, tactile and olfactory hallucinations were predictors. Our results indicate that BizD are associated with higher illness severity, lower functionality and specific set of symptoms. (shrink)

This manuscript describes the responses and correlates of outpatients with schizophrenia spectrum disorders to a tool designed to measure comprehension before obtaining informed consent for research participation. We used the Evaluation to Sign Consent form to document comprehension in 100 outpatients as part of their consent to participate in an ongoing study of an exercise intervention. The findings suggest that using this form is a feasible and acceptable approach to documenting comprehension of research procedures prior to obtaining informed consent. Age (...) 49 years and older and the receipt of intramuscular antipsychotic medication predicted the need for additional assistance to complete the Evaluation to Sign Consent form successfully (χ2 = 8.29, P = 0.016). Nurse researchers should consider documenting comprehension with this tool owing to its availability, time efficiency and utility. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Carmen MirandaJessica LesCarmen Miranda, she called herself today. She suffered from decades of schizoaffective disorder and now more recently, end–stage renal disease from uncontrolled diabetes. I first met Carmen two weeks prior when she had been brought to the hospital on a 72 hour psychiatric hold for self–harm. She failed to go to dialysis for a week, an act that would kill her if allowed to continue. (...) Now she was here again, for the same reason.Everyone of competent mind has the right to refuse medical treatment. Unfortunately, Carmen’s mind was not currently grounded in reality. So against her will, our family medicine team admitted her to the hospital and arranged for dialysis early the next morning. None of us liked doing this. Fortunately, when the time came for the dialysis tech to insert the dialysis catheter into her shunt, Carmen agreed peacefully. After her dialysis, we had no right to keep her in the hospital because her life was no longer in danger, at least until the next week. We discharged her to home. However the question remained, what about next time?To navigate this ethical gray zone, we called an ethics committee meeting. An ethicist, nurses, hospital social workers, the inpatient family medicine resident team, and most importantly, two people who knew her very well—her caseworker and long–term psychiatrist—discussed her case for an [End Page 103] hour. Our medicine team learned that in her last period of clarity two months prior, Carmen made contradictory statements regarding her wishes. Carmen told her caseworker she was tired of dialysis and being sick and stated it was time to let herself go. During the same lucid week she told her psychiatrist that she was grateful she had been forced to complete dialysis against her wishes after a run of non–adherence while suffering psychosis a couple of months prior. Now months later she was in a downward spiral, exacerbated by the deterioration of her mentally ill husband. If she missed a dialysis treatment here and there, it was okay, but when she went on a run missing several treatments, it was slow suicide.The ethics meeting concluded that Carmen needed to complete an advanced directive and select a power of attorney other than her gravely incompetent husband as soon as she was deemed competent. If she did not become lucid again, her psychiatric team should apply for conservatorship, a legally appointed person who serves as guardian for a gravely disabled mentally ill person. However, conservatorship would take months. In the interim, the ethics committee ruled that our medicine team would continue to provide lifesaving treatment for her, against her wishes if necessary.The ethics meeting adjourned but our medicine team remained in a gray area. To what length should we go to treat her? If she continued to refuse dialysis would we hold her in the hospital until she became sufficiently docile by inevitable uremia that we could peacefully dialyze her? Possibly. Would we go so far as to put her under anesthesia to complete her dialysis? Personally, I hoped not.Just three days after the ethics committee meeting, her caseworker found Carmen yelling nonsensical phrases through the front door of her home while her husband held the door shut with his beer belly and good shoulder. After gaining entry later in the day, Carmen’s caseworker found their mutual medication collection strewn in the bathtub and no food in the house. He placed Carmen on a psychiatric hold and transported her to the hospital. The emergency department paged me when Carmen arrived. I braced myself for the possibilities that lay ahead. When I reached Carmen, she was sitting in a room reserved for psychiatric patients and under watch by a friendly police officer accustomed to these situations.“Hi, Carmen,” I said, one step into her room. She sat on the edge of the gurney, wrapped in three blankets.“Cold,” she said.The police officer spoke from behind my shoulder, “She has been requesting cup after cup of ice water, she won’t take anything else.”“Let’s get you more comfortable.” I returned with a warm blanket and draped it over her... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Psychiatric Comorbidity:More Than a Kuhnian AnomalyPeter Zachar (bio)Keywordscomorbidity, classification, epidemiology, differential diagnosis, personality disorderDr. Aragona's article in this issue of Philosophy, Psychiatry, & Psychology makes some important points regarding the relationship between comorbidity rates and the classification system currently used in psychiatry. Particularly persuasive is his claim that observed patterns of comorbidity are, in important respects, consequences of the structure of the classification system. I am not convinced, however, (...) that comorbidity is best conceptualized as an artifact of the taxonic structure of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). Instead, I suggest that the use of dichotomies such as true versus artifactual should be used with caution when psychiatric classification is being discussed.In contrast with the artifact hypothesis, I argue that the phenomena covered by the term "comorbidity" are real, expectable features of the psychiatric domain. They are not the phlogiston and luminiferous ether of psychiatry. I am skeptical of the notion that high comorbidity rates as a whole can be understood as Kuhnian anomalies, or that there is a crisis, or that after a period of revolutionary science a new paradigm would eliminate these 'anomalies.' In short, high rates of comorbidity in psychiatry will not simply disappear once scientists develop a better nosological paradigm. High levels of comorbidity can, however, be both lowered and provided a better, evidence-based conceptual framework.Many Conditions, One OrganIn general medicine, comorbidity conventionally refers to the simultaneous occurrence of two independent disease processes or distinct clinical entities, such as heart disease and liver cancer (Feinstein, 1970; Jablensky 2004). The presence of one disease is supposed to affect the other in such a way that the co-occurrence of the two has implications for prognosis and treatment.Comorbidity in psychiatry is a broader concept, referring to a variety of conditions that overlap in multiple ways. The different kinds of overlap are amenable to detailed empirical analysis (e. g., Klein and Riso 1993; Neale and Kendler 1995). Depressive reactions to primary disorders, attention deficit symptoms associated with mania, panic attacks in the context of severe borderline personality disorder, substance abuse disorders among psychopaths, histrionic dynamics combined [End Page 13] with narcissistic personality traits, and emergent conditions such as schizoaffective disorder are all distinct types of comorbidity. The kinds of overlapping conditions just listed are sometimes termed psychiatric comorbidity. Also important is comorbidity between psychiatric disorders and general medical conditions as is studied in behavioral medicine and health psychology. The crisis, if there is one, is a crisis of comorbidities.The heart disease and liver cancer type of comorbidity as independent organ systems being affected is ruled out a priori in psychiatric comorbidity proper. In psychiatry, "psychopathological disease processes" can all be expected to affect a single organ, namely the brain or, more likely, affect the different systems that are tightly integrated in the brain. The tight integration can make putative comorbid psychiatric disorders difficult to disentangle.It is a widely held consensus that causes, not organ systems, are what matter in comorbidity. In this tradition, Dr. Aragona claims that in general medicine shared symptoms between two diseases (such as fever and fatigue) are not a problem because the diseases are differentiated with respect to etiology; in psychiatry, however, where syndromes are differentiated by a description of symptoms only, symptomatic overlap is a problem.Is descriptive psychopathology, therefore, a root cause of the "crisis of comorbidity" and should it be abandoned in favor of etiological classification? Unfortunately, forcing psychiatric nosology to conform to an etiological paradigm is unlikely to resolve the problem of psychiatric comorbidity. As noted, the problem is one of distinguishing between the different etiological disease processes that are affecting tightly integrated systems in the brain. The brain as a whole is a multilevel, dynamic, and open system, which has an ecology (Zachar 2000). As argued by Kendler (2005) and Schaffner (2002, 2008), it has not thus far, and may never be fully possible to segregate causes and their associated psychiatric disorders into parsimonious etiological packages. In the ecology of neuroscience, causes and effects tend to merge in a continuous series of common pathways.It would be foolish... (shrink)

Despite substantial research on overall decision-making capacity levels in schizophrenia, the factors that cause individuals to make errors when making decisions regarding research participation or treatment are relatively unknown. We examined the responses of 84 individuals, middle-aged or older, with schizophrenia or schizoaffective disorder. We used a structured decision-making capacity measure, the MacArthur Competence Assessment Tool for Clinical Research, to determine the frequency and apparent cause of participants’ errors. We found that most errors were due to difficulty recalling (...) the disclosed information, particularly the study’s procedures, potential risks, and purpose. Errors attributable to concrete thinking, psychotic symptoms, or perceived coercion were rarer. These results suggest that informed consent procedures for this population might be improved by providing information in a way that facilitates learning and memory, such as iterative disclosure of the information, corrective feedback, and emphasis of key points of the study—for instance, its purpose, procedures, and potential risks. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Lack of Autonomy: A View From the InsideSteve Weiner (bio)Keywordsagency, autonomy, deficit, determinismThe most vivid and truly overwhelming response I have to all arguments stressing agency/autonomy, that is, what lay people call free will, is this: that I’ve never had the sensation of acting autonomously since the onset of my mental illness on August 28, 1965. I have never been comfortable with saying that “I made a choice,” or (...) with other people either lecturing me or attempting to reassure me, often at the same time, by saying that I acted with autonomy/primary agency, as it were. That is my overwhelming subjective experience. I usually refrain from attempting to make a general case for determinism about myself or the universe in general, although, again, I feel far more determined than free. (I would note that Mary Midgley [2006] points out that the word determined and the concept, by extension, of determinism have two different meanings in say, social theory and geometry.)One strong criticism of this article I would put forward is that the Davidson and Shahan seemed to mention only depression among many diagnoses to make their case, although their French mentors/ co-thinkers apparently focused on schizophrenia, however unusually defined by them. In obsessive-compulsive disorder, we all have the very strong impression of the obsessive thoughts having been forced into our mind by something or someone else. My impression is that we all engage in our warding-off rituals, especially in the later, most frequent, most ritualistic repetitions, “against our will.”My most frequent diagnoses over the decades have been paranoid schizophrenia and schizoaffective disorder, and I more or less agree most of the time with those labels. I find Louis Sass’ “discovery” that our delusions are better thought of as semi-delusions with our simultaneously believing and not believing them, and our usual failure to take action on them, pretty well describes my own long-term experience. I know he is insistent on ascribing some degree of agency/whole personality involvement to us as compared with the standard National Alliance on Mental Illness/biological model, but I feel that he is getting closer to most of the “truth” when he talks about a subtle interweaving of affliction/deficit and agency.The authors’ reliance on French thinkers almost inevitably sends me back to a once-prominent French intellectual, one of my favorite writers Albert Memmi, the Tunisian-Jewish born socialist and Zionist. In a book that mentions The Story of O, (Memmi 1984) a story of extreme sexual submission or masochism, he makes the striking remark that the mentally ill are “oppressed from within.” I have spoken of this often because it seems to touch perfectly on my experience and that of fellow mentally ill people I have met. From the perspective of the outsider, it seems that the whole [End Page 237] and integrated person is involved in every behavior. What looks like agency to others, especially when it comes to undesirable behaviors, when experienced from within, is actually a situation of affliction from a seemingly autonomous place. We experience this as coming, yes, from within us, but not ultimately of us.I cannot be sure, but a belief in some degree of metaphysical choice from the beginning of one’s life seems to me the only way the authors of this article can firmly, enthusiastically come down on the side of agency as opposed to deficit/malfunction in trying to explain human problems. In contrast, I suppose I could be called a physicalist. I have noticed that physical substances (alcohol, caffeine, psychiatric drugs) have such a vivid and consistent effect on my mind that it makes sense to me to conclude that yes, mind is probably ultimately reducible to brain/body/experience of the senses. That is my private opinion based on experience as mediated through knowledge/intellect.One final point: Despite the (almost certainly) radical left politics of the authors, as an officially disabled person almost completely dependent on the welfare state, I fear that in competitive individualist America, the authors’ hoped-for far greater emphasis on autonomy will feed into popular “blame the victim” ideology. I believe... (shrink)

Individuals with autistic spectrum disorder (ASD) display diverse deficits in social, cognitive and behavioral functioning. To date, there has been mixed findings on the profile of executive function deficits for high-functioning adults (IQ >70) with ASD. A conceptual distinction is commonly made between “cold” and “hot” executive functions. Cold executive functions refer to mechanistic higher-order cognitive operations (e.g., working memory), whereas hot executive functions entail cognitive abilities supported by emotional awareness and social perception (e.g., social cognition). This study aimed (...) to determine the independence of deficits in hot and cold executive functions for high-functioning adults with ASD. Forty-two adults with ASD (64% male, aged 18-66 years) and 40 age and gender matched controls were administered The Awareness of Social Inference Test (TASIT; emotion recognition and social inference), Letter Number Sequencing (working memory) and Hayling Sentence Completion Test (response initiation and suppression). Between-group analyses identified that the ASD group performed significantly worse than matched controls on all measures of cold and hot executive functions (d =.54-1.5). Hierarchical multiple regression analyses revealed that the ASD sample performed more poorly on emotion recognition and social inference tasks than matched controls after controlling for cold executive functions and employment status. The findings also indicated that the ability to recognise emotions and make social inferences was supported by working memory and response initiation and suppression processes. Overall, this study supports the distinction between hot and cold executive function impairments for adults with ASD. Moreover, it advances understanding of higher-order impairments underlying social interaction difficulties for this population which, in turn, may assist with diagnosis and inform intervention programs. (shrink)

People suffering from Obsessive-Compulsive Disorder (OCD) do things they do not want to do, and/or they think things they do not want to think. In about 10 percent of OCD patients, none of the available treatment options is effective. A small group of these patients is currently being treated with deep brain stimulation (DBS). Deep brain stimulation involves the implantation of electrodes in the brain. These electrodes give a continuous electrical pulse to the brain area in which they are (...) implanted. It turns out that patients may experience profound changes as a result of DBS treatment. It is not just the symptoms that change; patients rather seem to experience a different way of being in the world. These global effects are insufficiently captured by traditional psychiatric scales, which mainly consist of behavioural measures of the severity of the symptoms. In this article we aim to capture the changes in the patients’ phenomenology and make sense of the broad range of changes they report. For that we introduce an enactive, affordance-based model that fleshes out the dynamic interactions between person and world in four aspects. The first aspect is the patients’ experience of the world. We propose to specify the patients’ world in terms of a field of affordances, with the three dimensions of broadness of scope (‘width’ of the field), temporal horizon (‘depth’), and relevance of the perceived affordances (‘height’). The second aspect is the person-side of the interaction, that is, the patients’ self-experience, notably their moods and feelings. Thirdly, we point to the different characteristics of the way in which patients relate to the world. And lastly, the existential stance refers to the stance that patients take towards the changes they experience: the second-order evaluative relation to their interactions and themselves. With our model we intend to specify the notion of being in the world in order to do justice to the phenomenological effects of DBS treatment. (shrink)

Deep Brain Stimulation (DBS) is a relatively new, experimental treatment for patients suffering from treatment-refractory Obsessive Compulsive Disorder (OCD). The effects of treatment are typically assessed with psychopathological scales that measure the amount of symptoms. However, clinical experience indicates that the effects of DBS are not limited to symptoms only: patients for instance report changes in perception, feeling stronger and more confident, and doing things unreflectively. Our aim is to get a better overview of the whole variety of changes (...) that OCD patients experience during DBS treatment. For that purpose we conducted in-depth, semi-structured interviews with 18 OCD patients. In this paper, we present the results from this qualitative study.We list the changes grouped in four domains: with regard to (a) person, (b) (social) world, (c)characteristics of person-world interactions, and (d) existential stance. We subsequently provide an interpretation of these results. In particular, we suggest that many of these changes can be seen as different expressions of the same process; namely that the experience of anxiety and tension gives way to an increased basic trust and increased reliance on one’s abilities. We then discuss the clinical implications of our findings, especially with regard to properly informing patients of what they can expect from treatment, the usefulness of including CBT in treatment, and the limitations of current measures of treatment success. We end by making several concrete suggestions for further research. (shrink)

The National Institute of Mental Health (Bethesda, MD) reports that approximately 5.2 million Americans experience post-traumatic stress disorder (PTSD) each year. PTSD can be severely debilitating and diminish quality of life for patients and those who care for them. Studies have indicated that propranolol, a beta-blocker, reduces consolidation of emotional memory. When administered immediately after a psychic trauma, it is efficacious as a prophylactic for PTSD. Use of such memory-altering drugs raises important ethical concerns, including some futuristic dystopias put (...) forth by the President's Council on Bioethics. We think that adequate informed consent should facilitate ethical research using propranolol and, if it proves efficacious, routine treatment. Clinical evidence from studies should certainly continue to evaluate realistic concerns about possible ill effects of diminishing memory. If memory-attenuating drugs prove effective, we believe that the most immediate social concern is the over-medicalization of bad memories, and its subsequent exploitation by the pharmaceutical industry. (shrink)

The main concepts of the free energy (FE) neuroscience developed by Karl Friston and colleagues parallel those of Freud's Project for a Scientific Psychology. In Hobson et al. ( 2014 ) these include an innate virtual reality generator that produces the fictive prior beliefs that Freud described as the primary process. This enables Friston's account to encompass a unified treatment—a complexity theory—of the role of virtual reality in both dreaming and mental disorder. In both accounts the brain operates to (...) minimize FE aroused by sensory impingements—including interoceptive impingements that report compliance with biological imperatives—and constructs a representation/model of the causes of impingement that enables this minimization. In Friston's account (variational) FE equals complexity minus accuracy, and is minimized by increasing accuracy and decreasing complexity. Roughly the brain (or model) increases accuracy together with complexity in waking. This is mediated by consciousness-creating active inference—by which it explains sensory impingements in terms of perceptual experiences of their causes. In sleep it reduces complexity by processes that include both synaptic pruning and consciousness/virtual reality/dreaming in REM. The consciousness-creating active inference that effects complexity-reduction in REM dreaming must operate on FE-arousing data distinct from sensory impingement. The most relevant source is remembered arousals of emotion, both recent and remote, as processed in SWS and REM on “active systems” accounts of memory consolidation/reconsolidation. Freud describes these remembered arousals as condensed in the dreamwork for use in the conscious contents of dreams, and similar condensation can be seen in symptoms. Complexity partly reflects emotional conflict and trauma. This indicates that dreams and symptoms are both produced to reduce complexity in the form of potentially adverse (traumatic or conflicting) arousals of amygdala-related emotions. Mental disorder is thus caused by computational complexity together with mechanisms like synaptic pruning that have evolved for complexity-reduction; and important features of disorder can be understood in these terms. Details of the consilience among Freudian, systems consolidation, and complexity-reduction accounts appear clearly in the analysis of a single fragment of a dream, indicating also how complexity reduction proceeds by a process resembling Bayesian model selection. (shrink)

This paper explores how the diagnosis of mental disorder may affect the diagnosed subject’s self-concept by supplying an account that emphasizes the influence of autobiographical and social narratives on self-understanding. It focuses primarily on the diagnoses made according to the criteria provided by the Diagnostic Statistical Manual of Mental Disorders (DSM), and suggests that the DSM diagnosis may function as a source of narrative that affects the subject’s self-concept. Engaging in this analysis by appealing to autobiographies and memoirs written (...) by people diagnosed with mental disorder, the paper concludes that a DSM diagnosis is a double-edged sword for self- concept. On the one hand, it sets the subject’s experience in an established classificatory system which can facilitate self-understanding by providing insight into subject’s condition and guiding her personal growth, as well as treatment and recovery. In this sense, the DSM diagnosis may have positive repercussions on self-development. On the other hand, however, given the DSM’s symptom-based approach and its adoption of the Biomedical Disease model, a diagnosis may force the subject to make sense of her condition divorced from other elements in her life that may be affecting her mental- health. It may lead her frame her experience only as an irreversible imbalance. This form of self-understanding may set limits on the subject’s hopes of recovery and may create impediments to her flourishing. (shrink)

Christopher Boorse’s biostatistical theory of medical disorder claims that biological part-dysfunction (i.e., failure of an internal mechanism to perform its biological function), a factual criterion, is both necessary and sufficient for disorder. Jerome Wakefield’s harmful dysfunction analysis of medical disorder agrees that part-dysfunction is necessary but rejects the sufficiency claim, maintaining that disorder also requires that the part-dysfunction causes harm to the individual, a value criterion. In this paper, I present two considerations against the sufficiency claim. (...) First, I analyze Boorse’s central argument for the sufficiency claim, the “pathologist argument,” which takes pathologists’ intuitions about pathology as determinative of medical disorder and conclude that it begs the question and fails to support the sufficiency claim. Second, I present four counterexamples from the medical literature in which salient part-dysfunctions are considered nondisorders, including healthy disease carriers, HIV-positive status, benign mutations, and situs inversus totalis, thus falsifying the sufficiency claim and supporting the harm criterion. (shrink)

Wakefield’s harmful dysfunction analysis asserts that the concept of medical disorder includes a naturalistic component of dysfunction and a value component, both of which are required for disorder attributions. Muckler and Taylor, defending a purely naturalist, value-free understanding of disorder, argue that harm is not necessary for disorder. They provide three examples of dysfunctions that, they claim, are considered disorders but are entirely harmless: mild mononucleosis, cowpox that prevents smallpox, and minor perceptual deficits. They also reject (...) the proposal that dysfunctions need only be typically harmful to qualify as disorders. We argue that the proposed counterexamples are, in fact, considered harmful; thus, they fail to disconfirm the harm requirement: incapacity for exertion is inherently harmful, whether or not exertion occurs, cowpox is directly harmful irrespective of indirect benefits, and colorblindness and anosmia are considered harmful by those who consider them disorders. We also defend the typicality qualifier as viably addressing some apparently harmless disorders and argue that a dysfunction’s harmfulness is best understood in dispositional terms. (shrink)

Externalist theories hold that a comprehensive understanding of mental disorder cannot be achieved unless we attend to factors that lie outside of the head: neural explanations alone will not fully capture the complex dependencies that exist between an individual’s psychiatric condition and her social, cultural, and material environment. Here, we firstly offer a taxonomy of ways in which the externalist viewpoint can be understood, and unpack its commitments concerning the nature and physical realization of mental disorder. Secondly, we (...) apply a strongly externalist approach to the case of Autistic Spectrum Disorder, and argue that this condition can be illuminated by appeal to the hypothesis of extended cognition. We conclude by briefly considering the significance this strongly externalist approach may have for psychiatric practice and pedagogy. (shrink)

The diagnostic category of borderline personality disorder (BPD) has come under increasing criticism in recent years. In this paper, we analyze the role and impact of epistemic injustice, specifically testimonial injustice, in relation to the diagnosis of BPD. We first offer a critical sociological and historical account, detailing and expanding a range of arguments that BPD is problematic nosologically. We then turn to explore the epistemic injustices that can result from a BPD diagnosis, showing how they can lead to (...) experiences of testimonial injustice which impede patient engagement in meaning-making activities, thereby undermining standard therapeutic goals. We conclude by showing how our arguments bolster ongoing efforts to replace the diagnostic category of BPD with alternatives such as complex post-traumatic stress disorder. (shrink)

This study investigated the understanding of underinformative sentences like “Some elephants have trunks” by children with autism spectrum disorder (ASD). The scalar term ‘some’ can be interpreted pragmatically, ‘Not all elephants have trunks’, or logically, ‘Some and possibly all elephants have trunks’. Literature indicates that adults with ASD show no real difficulty in interpreting scalar implicatures, i.e., they often interpret them pragmatically, as controls do. This contrasts with the traditional claim of difficulties of people with ASD in other pragmatic (...) domains, and is more in line with the idea that pragmatic problems are not universal. The aim of this study was to: a) gain insight in the ability of children with ASD to derive scalar implicatures, and b) do this by assessing not only sensitivity to underinformativeness, but also different degrees of tolerance to violations of informativeness. We employed a classic statement-evaluation task, presenting optimal, logical false, and underinformative utterances. In Experiment 1, children had to express their judgment on a binary option ‘I agree’ vs ‘I disagree’. In Experiment 2, a ternary middle answer option ‘I agree a bit’ was also available. Sixty-six Flemish-speaking 10-year-old children were tested: 22 children with ASD, an IQ-matched group, and an age-matched group. In the binary judgment task, the ASD-group gave more pragmatic answers than the other groups, which was significant in the mixed effects logistic regression analysis, although not in the non-parametric analysis. In the ternary judgment task, the children with ASD showed a dichotomized attitude towards the speaker’s meaning, by tending to either fully agree or fully disagree with underinformative statements, in contrast with TD children, who preferred the middle option. Remarkably, the IQ-matched group exhibited the same pattern of results as the ASD group. Thanks to a fine-grained measure such as the ternary judgment task, this study highlighted a neglected aspect of the pragmatic profile of ASD, whose struggle with social communication seems to affect also the domain of informativeness. We discuss the implications of the dichotomized reaction towards violations of informativeness of these two groups in terms of the potential role of ASD and of cognitive and verbal abilities. (shrink)

In this paper, my goal is to use an epistemic injustice framework to extend an existing normative analysis of over-medicalization to psychiatry and thus draw attention to overlooked injustices. Kaczmarek has developed a promising bioethical and pragmatic approach to over-medicalization, which consists of four guiding questions covering issues related to the harms and benefits of medicalization. In a nutshell, if we answer “yes” to all proposed questions, then it is a case of over-medicalization. Building on an epistemic injustice framework, I (...) will argue that Kaczmarek’s proposal lacks guidance concerning the procedures through which we are to answer the four questions, and I will import the conceptual resources of epistemic injustice to guide our thinking on these issues. This will lead me to defend more inclusive decision-making procedures regarding medicalization in the DSM. Kaczmarek’s account complemented with an epistemic injustice framework can help us achieve better forms of medicalization. I will then use a contested case of medicalization, the creation of Premenstrual Dysphoric Disorder in the DSM-5 to illustrate how the epistemic injustice framework can help to shed light on these issues and to show its relevance to distinguish good and bad forms of medicalization. (shrink)

We present results from a single case study based on semi-structured interviews with a student (a boy in school year 3) diagnosed with autism spectrum disorder and his school staff after participating in a short and small-scale intervention carried out in a socio-economically disadvantaged Swedish elementary school in 2019. The student participated in a seven week long intervention with a total of 12 philosophical dialogues (ranging from 45 to 60 minutes). Two facilitators, both with years of facilitation experience and (...) teacher degree and at least BA in philosophy, facilitated the majority of the dialogues and mainly followed a ”routine” procedure. The student was interviewed in direct connection to the end of the intervention about his experiences from the dialogues and his perceptions about whether and how the dialogues had influenced him. The student’s two teachers, who had participated in the dialogues as participants, were interviewed as a pair, also in direct connection to the end of the intervention, while the school principal was interviewed two years after the study. These staff interviews concerned the staff’s experiences of the influence of the dialogues on the students within the intervention as well as transfer effects to other contexts in school. The data from the study include detailed elaborations from a student perspective of different effects on the student’s communicative and cognitive development, which are in several respects supported also by staff reports. The results show that the student was able, interested, and willing to participate in philosophical dialogues, and our data point to several positive outcomes for the student in the communicative and cognitive domains. (shrink)

According to Jerome Wakefield’s harmful dysfunction analysis of medical disorder, the inability of some internal part or mechanism to perform its natural function is necessary, but not sufficient, for disorder. HDA also requires that the part dysfunction be harmful to the individual. I consider several problems for HDA’s harm criterion in this article. Other accounts on which harm is necessary for disorder will suffer from all or almost all of these problems. Comparative accounts of harm imply that (...) one is harmed when one is made worse off, that is, worse off than one otherwise would have been. Non-comparative accounts imply that one is harmed when one is put into some kind of condition or state that is, in some way, bad in itself. I argue that whether harm is construed comparatively or non-comparatively, HDA’s harm criterion is problematic. I tentatively conclude that an analysis of medical disorder should not make use of the concept of harm. (shrink)

In this paper, I address the question whether mental disorders should be understood to be brain disorders and what conditions need to be met for a disorder to be rightly described as a brain disorder. I defend the view that mental disorders are autonomous and that a condition can be a mental disorder without at the same time being a brain disorder. I then show the consequences of this view. The most important of these is that (...) brain differences underlying mental disorders derive their status as disordered from the fact that they realize mental dysfunction and are therefore non-autonomous or dependent on the level of the mental. I defend this view of brain disorders against the objection that only conditions whose pathological character can be identified independently of the mental level of description count as brain disorders. The understanding of brain disorders I propose requires a certain amount of conceptual revision and is at odds with approaches which take the notion of brain disorder to be fundamental or look to neuroscience to provide us with a purely physiological understanding of mental illness. It also entails a pluralistic understanding of psychiatric illness, according to which a condition can be both a mental disorder and a brain disorder. (shrink)

Attention-deficit/hyperactivity disorder (ADHD) is currently defined as a cognitive/behavioral developmental disorder where all clinical criteria are behavioral. Inattentiveness, overactivity, and impulsiveness are presently regarded as the main clinical symptoms. The dynamic developmental behavioral theory is based on the hypothesis that altered dopaminergic function plays a pivotal role by failing to modulate nondopaminergic (primarily glutamate and GABA) signal transmission appropriately. A hypofunctioning mesolimbic dopamine branch produces altered reinforcement of behavior and deficient extinction of previously reinforced behavior. This gives rise (...) to delay aversion, development of hyperactivity in novel situations, impulsiveness, deficient sustained attention, increased behavioral variability, and failure to “inhibit” responses (“disinhibition”). A hypofunctioning mesocortical dopamine branch will cause attention response deficiencies (deficient orienting responses, impaired saccadic eye movements, and poorer attention responses toward a target) and poor behavioral planning (poor executive functions). A hypofunctioning nigrostriatal dopamine branch will cause impaired modulation of motor functions and deficient nondeclarative habit learning and memory. These impairments will give rise to apparent developmental delay, clumsiness, neurological “soft signs,” and a “failure to inhibit” responses when quick reactions are required. Hypofunctioning dopamine branches represent the main individual predispositions in the present theory. The theory predicts that behavior and symptoms in ADHD result from the interplay between individual predispositions and the surroundings. The exact ADHD symptoms at a particular time in life will vary and be influenced by factors having positive or negative effects on symptom development. Altered or deficient learning and motor functions will produce special needs for optimal parenting and societal styles. Medication will to some degree normalize the underlying dopamine dysfunction and reduce the special needs of these children. The theory describes how individual predispositions interact with these conditions to produce behavioral, emotional, and cognitive effects that can turn into relatively stable behavioral patterns. Key Words: catecholamine; clumsiness; dopamine; hyperkinesis; hyperkinetic disorder; impulsivity; monoamine; neuromodulator; overactivity; pollutants; reinforcement; reward; verbally governed behavior; soft signs; variability. (shrink)

Based on previous studies implicating increased functional connectivity within the self-referential brain network in major depressive disorder (MDD), and considering the functional roles of three distinct modules of such brain net (responsible for three-dimensional components of Selfhood) together with the documented abnormalities of self-related processing in MDD, we tested the hypothesis that patients with depression would exhibit increased connectivity within each module of the self-referential brain network and that the strength of these connections would correlate positively with depression severity. (...) Applying the electroencephalogram (EEG) operational synchrony analysis to extract three modules of the self-referential brain network in 12 medication-free depressive outpatients and 10 control subjects we have found an increase in the strength of EEG synchrony within all three modules in depressive patients (though non-significant for the right module). Furthermore, multiple regression analysis that used 3 factors (values of synchrony strength for all three modules) as input indicated that combined increase in the strength of synchrony in all three modules was positively associated with severity of depression. Taken together the findings of this study suggest that depression is primarily associated with hypersynchrony in all three modules of the brain self-referential network (the anterior module been responsible for “witnessing observation and first–person perspective”, the left posterior module been responsible for “reflective agency and narration” and the right posterior module been responsible for “bodily representational-emotional agency”), thus contributing to excessive self-focus, rumination, and body tension. (shrink)

In this opinion piece we propose the investigation of psychedelic-assisted psychotherapy for the treatment of body dysmorphic disorder (BDD). BDD is a psychiatric disorder characterised by appearance-based preoccupations and accompanying compulsions. While safe and effective treatments for BDD exist, non-response and relapse rates remain high. Therefore, there is a need to investigate promising new treatment options for this highly debilitating condition. Preliminary evidence suggests safety, feasibility, and potential efficacy of psychedelic treatments in disorders that share similar psychopathological mechanisms (...) with BDD. Drawing on this evidence, as well as on relevant qualitative reports and theoretical proposals, we argue that it would be worthwhile to conduct a phase 2a study aimed at assessing the safety and feasibility of psychedelic-assisted psychotherapy in BDD. We also offer some suggestions for how future research ought to proceed. (shrink)

Obsessive-compulsive disorder (OCD) is a deeply enigmatic psychiatric condition associated with immense suffering worldwide. Efficacious therapies for OCD, like exposure and response prevention (ERP) are sometimes poorly tolerated by patients. As many as 25 percent of patients refuse to initiate ERP mainly because they are too anxious to follow exposure procedures. Accordingly, we proposed a simple and tolerable (immersive yet indirect) low-cost technique for treating OCD that we call “multisensory stimulation therapy.” This method involves contaminating a rubber hand during (...) the so-called “rubber hand illusion” (RHI) in which tactile sensations may be perceived as arising from a fake hand. Notably, Jalal and Ramachandran (2015), showed that such fake hand contamination during the RHI provokes powerful disgust reactions in healthy volunteers. In the current study, we explored the therapeutic potential of this novel approach. OCD patients (n = 29) watched as their hidden real hand was being stroked together with a visible fake hand; either synchronously (inducing the RHI) (i.e., the experimental condition; n = 16) or asynchronously (i.e., the control condition; n = 13). After 5 minutes of tactile stimulation, the rubber hand was contaminated with fake feces, simulating conventional exposure therapy. Intriguingly, results suggested sensory assimilation of contamination sensations into the body image via the RHI: patients undergoing synchronous stimulation did not report greater contamination sensations when the fake hand was initially contaminated relative to asynchronous stroking. But contrary to expectations, they did so after the rubber hand had been contaminated for 5 minutes; as assessed via disgust facial expressions (a secondary outcome) and in vivo exposure (upon discontinuing the illusion). Further to our surprise, synchronous and asynchronous stroking induced an equally vivid and fast emerging illusion, which helps explain why both conditions initially (5 minutes after initiating tactile stimulation) provoked contamination reactions of equal magnitude. This study is the first to suggest heightened malleability of body image in OCD. Importantly, it may pave the way for a tolerable technique for the treatment of OCD—highly suitable for poorly resourced and emergency settings, including low-income and developing countries with minimal access to high-tech solutions like virtual reality. (shrink)

The study of Attention Deficit Hyperactivity Disorder addresses variables related to three core symptoms: inattention, hyperactivity, and impulsivity. However, it has been suggested that in recent years emotional difficulties and subsequent social challenges have not received sufficient attention. This study had two objectives: 1) to compare the performance of participants (age range: 8-14 years) on facial emotion recognition tasks using the Affect Recognition subtest of the Children Neuropsychological Battery II; and 2) to assess the perceptions of family members in (...) relation to variables associated with emotional problems, difficulty in regulating emotions, and anger management using the Spanish Assessment System for Children and Adolescents. Assessments were conducted before and after applying an emotion regulation intervention designed for this study. Following the intervention, there was a significant decrease in scores associated with emotional regulation, and an improvement in the identification of affect on facial recognition tasks. The results suggest that despite Attention Deficit Hyperactivity Disorder children and adolescents having social and emotional deficits secondary to the core symptom triad, emotional regulation in this group can be improved by the application of socio-emotional intervention programs. (shrink)

Autism spectrum disorder (ASD) is a psychopathological condition characterized by persistent deficits in social interaction and communication, and restricted, repetitive patterns of behavior and interests. To build an ecological-enactive account of autism, I propose we should endorse the affordance-based approach of the skilled intentionality framework (SIF). In SIF, embodied cognition is understood as skilled engagement with affordances in the sociomaterial environment of the ecological niche by which an individual tends toward the optimal grip. The human econiche offers a whole (...) landscape of affordances, and situated individuals respond to a field of relevant affordances. An important part of SIF is an ecological-enactive interpretation of the free energy principle and predictive processing. Predictive processing accounts indicate that in ASD too much precision is assigned to prediction errors. Autistic persons depend heavily on current sensory information and less on prior beliefs and cannot attune to stable regularities. To reduce uncertainty, they over-rely on routines, strict habits, and a familiar environment—a predictable ecological niche they construct. I argue that skilled intentionality gives us the framework from which to analyze the autistic field of affordances. Autistic patterns of affordance-related bodily states of action readiness are only sensitive to very specific solicitations in the environment and achieve optimal grip in well-known situations. Autism is to be understood as a disorder of bodily normativity. Taking this approach helps us figure out what neurotypical people can do to attune their environment in order to scaffold the needs of autistic individuals by redesigning the landscape of affordances. (shrink)

Cannabis use in some individuals can meaningfully introduce de novo risk for the initiation of opioid use and development of opioid use disorder. These risks may be particularly high during adolescence when cannabis use may disrupt critical periods of neurodevelopment. Current research studying the combination of genetic and environmental factors involved in substance use disorders is poorly understood. More research is needed, particularly to identify which adolescents are most at risk and to develop effective interventions addressing contributing factors such (...) as trauma and psychiatric comorbidity. (shrink)

The dominant philosophical conceptions of obsessive-compulsive behavior present its subject as having a deficiency, usually characterized as volitional, due to which she lacks control and choice in acting. Compulsions (mental or physical) tend to be treated in isolation from the obsessive thoughts that give rise to them. I offer a different picture of compulsive action, one that is, I believe, more faithful to clinical reality. The clue to (most) obsessive-compulsive behavior seems to be the way obsessive thoughts, which are grounded (...) in an irrational cognitive style in matters of risk, danger, and responsibility, motivate compulsions through bizarre means–end reasoning. I show that the patient with obsessive-compulsive disorder (OCD) is not weak and passive with regard to the compulsive act; rather, the act is voluntary and regarded by the patient as an instrument of control. I also defend the idea that OCD-related cognitions are either beliefs or mental states with relevantly similar functional roles. (shrink)

In this paper, I present a challenge for Michael McKenna’s conversational theory of moral responsibility. On his view, to be a responsible agent is to be able to engage in a type of moral conversation. I argue that individuals with autism spectrum disorder present a considerable problem for the conversational theory because empirical evidence on the disorder seems to suggest that there are individuals in the world who meet all of the conditions for responsible agency that the theory (...) lays out but who are nevertheless not responsible agents. Attending to the moral psychology of such individuals will, I think, help shed light on an important gap in the conversational theory. (shrink)

In this article, I compare and evaluate R. D. Laing and A. Esterson’s account of schizophrenia as developed in Sanity, Madness and the Family, social models of disability, and accounts of extended mental disorder. These accounts claim that some putative disorders should not be thought of as reflecting biological or psychological dysfunction within the afflicted individual, but instead as external problems. In this article, I consider the grounds on which such claims might be supported. I argue that problems should (...) not be located within an individual putative patient in cases where there is some acceptable test environment in which there is no problem. A number of cases where such an argument can show that there is no internal disorder are discussed. I argue, however, that Laing and Esterson’s argument—that schizophrenia is not within diagnosed patients—does not work. The problem with their argument is that they fail to show that the diagnosed women in their study function adequately in any environment. (shrink)

Summary Background Self-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, service users’ views on self-binding directives have not been investigated substantially. This study aimed to explore whether reasons for endorsement, ambivalence, or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity, and (...) human rights. Methods This study used qualitative data from an internet-based survey distributed to the mailing list of the UK charity Bipolar UK, which contained multiple closed and open questions on advance decision-making in bipolar disorder. Quantitative analysis of a closed question about self-binding directives had already demonstrated endorsement amongst a very high proportion of participants with bipolar disorder who completed the survey. We conducted thematic analysis of responses from those participants who answered a subsequent open question about reasons for their view. Research was co-produced within a multi-disciplinary team, with clinical, legal, and ethical expertise, and lived experience of bipolar disorder. Ideas and methodologies associated with all these areas of expertise were used in the analysis of these reasons and to gain insight into the thoughts of individuals with bipolar disorder about self-binding directives and associated issues. Findings Between Oct 23 and Dec 5, 2017, 932 individuals with a self-reported clinical diagnosis of bipolar disorder completed the internet survey, with 565 (154 men; 400 women; 11 transgender or other) providing free text answers to the open question. A large majority of respondents endorsed self-binding directives, nearly all describing a determinate shift to types of distorted thinking and decision-making when unwell as their key justification. Responses indicating ambivalence were dominated by logistical concerns about the drafting and implementation of self-binding directives, while those who rejected self-binding directives also cited logistical concerns, validity of their thinking when unwell, and potential contravention of human rights. Interpretation This study is, to our knowledge, the first large study of reasons why mental health service users might endorse or reject the use of self-binding directives. The findings provide empirical support for introducing self-binding directives into mental health advance decision-making practice and policy and may help to address enduring ethical concerns surrounding possible implementation of the directive while a person retains decision-making capacity. The opinions expressed here in responses given by multiple service users with bipolar disorder challenge a prominent view within international disability rights debates that involuntary treatment and recognition of impaired mental capacity constitute inherent human rights violations. Funding The Wellcome Trust . (shrink)

In the aftermath of the Port Arthur shootings, Dunblane or the schoolyard killings in America, communities try to come to terms with private and public trauma and there is a need to understand what kind of person can commit such terrible acts. The problem of how to understand dangerousness often centres on the role of the mental health and criminal justice systems and it is from the intersection of these two institutions that the categorisation of dangerous persons has emerged. This (...) 2001 book traces the history of the category of antisocial personality disorder and shows how it is linked to particular kinds of governing. It examines key legal and institutional developments in Australia, the UK and the US and also parallel developments within psychiatry and psychological medicine. Applying a social theoretical analysis to this material, McCallum challenges our assumptions about the formation and control concepts of dangerousness and personality. (shrink)

In this commentary on Anneli Jefferson’s Are Mental Disorders Brain Disorders? I endorse her capacitarian approach to responsibility but suggest that the effects of at least some mental/brain disorders on the agent’s psychology show that we cannot neatly separate the epistemic condition from the control condition when assessing agential capacity. I then discuss the labeling issue in the context of rival attributionist accounts of responsibility which hold that agents are responsible if their actions are attributable to them. The incorporation of (...) mental disorders into identity through social processes may open agents with mental or brain disorders open to unfair blame. However, we cannot fully understand the effects of the disorders on agential capacity without closely attending to the social environment that shapes the way the disorder is conceived, enacted, perceived, and responded to over time. (shrink)

While the prevalence of opioid use disorder among pregnant women has multiplied in the United States in the last decade, buprenorphine treatment for peripartum women with OUD has been administered to reduce risks of repeated cycles of craving and withdrawal. However, the maternal behavior and bonding in mothers with OUD may be altered as the underlying maternal behavior neurocircuit is opioid sensitive. In the regulation of rodent maternal behaviors such as licking and grooming, a series of opioid-sensitive brain regions (...) are functionally connected, including the ventral pallidum. In humans, these brain regions, interact with the supplementary motor area to regulate maternal behaviors and are functionally dysregulated by opioids. It is unclear how these brain regions respond to the emotions of their child for mothers receiving BT. In this functional magnetic resonance imaging pilot study in 22 mothers within the first postpartum year, including six mothers receiving BT and 16 non-OUD mothers as a comparison group, we devised a child face mirroring task in fMRI settings to assess maternal responses to pictures of facial expressions of own child and an unknown child in an empathic mirroring condition and a non-mirroring observation condition. In each condition, faces of neutral, ambiguous, distressed, and joyful expressions of each child were repeatedly displayed in a random order. The response of SMA during empathic mirroring vs. non-mirroring of own child was reduced among BT/OUD vs. CG. Within MBN, the left VP, critical for parental sensitivity, had a similar deficit. This study outlines potential mechanisms for investigating the risks of deficits in the neural responses to actual maternal sensitivity and parenting behavior in mothers with OUD, and potential targets for interventions that reduce stress and augment maternal behavior and child outcome. (shrink)

Recently there has been a trend of moving towards biological and neurocognitive based classifications of mental disorders that is motivated by a dissatisfaction with the syndrome-based classifications of mental disorders. The Research Domain Criteria (indicated with the acronym RDoC) represents a bold and systematic attempt to foster this advancement. However, RDoC faces theoretical and conceptual issues that need to be addressed. Some of these difficulties emerge when we reflect on the plausible reading of the slogan “mental disorders are brain disorders”, (...) that according to proponents of RDoC constitutes one of its main presuppositions. Some authors think that endorsing this idea commits RDoC to a form of biological reductionism. We offer empirical and theoretical considerations for concluding that the slogan above should not be read as a reductionist thesis. We argue, instead, that the slogan has a pragmatic function whose aim is to direct research in psychopathology. We show how this function might be captured in the framework of a Carnapian explication as a methodological tool for conceptual engineering. Thus, we argue that a charitable interpretation of the aims of the proponents of RDoC should be understood as an attempt at providing an explication of the concept of mental disorder in terms of brain disorder whose main goal is to provide a more precise and fruitful notion that is expected to have a beneficial impact on classification, research, and treatment of psychiatric conditions. (shrink)

Progress in psychiatry depends on accurate definitions of disorders. As long as there are no known biologic markers available that are highly specific for a particular psychiatric disorder, clinical practice as well as scientific research is forced to appeal to clinical symptoms. Currently, the nosology of obsessive-compulsive disorder is being reconsidered in view of the publication of DSM-V. Since our diagnostic entities are often simplifications of the complicated clinical profile of patients, definitions of psychiatric disorders are imprecise and (...) always indeterminate. This urges researchers and clinicians to constantly think and rethink well-established definitions that in psychiatry are at risk of being fossilised. In this paper, we offer an alternative view to the current definition of obsessive-compulsive disorder from a phenomenological perspective.TranslationThis article is translated from Dutch, originally published in [Handbook Obsessive-compulsive disorders, Damiaan Denys, Femke de Geus (Eds.), (2007). De Tijdstroom uitgeverij BV, Utrecht. ISBN13: 9789058980878.]. (shrink)

This essay is an attempt to reconcile the disturbing contradiction between the striving for order in nature and in man and the principle of entropy implicit in the second law of thermodynamics - between the tendency toward greater organization and the general trend of the material universe toward death and disorder.

This study investigates the procedural learning, retention, and reactivation of temporal sensorimotor sequences in children with and without developmental coordination disorder. Twenty typically-developing children and 12 children with DCD took part in this study. The children were required to tap on a keyboard, synchronizing with auditory or visual stimuli presented as an isochronous temporal sequence, and practice non-isochronous temporal sequences to memorize them. Immediate and delayed retention of the audio-motor and visuo-motor non-isochronous sequences were tested by removing auditory or (...) visual stimuli immediately after practice and after a delay of 2 h. A reactivation test involved reintroducing the auditory and visual stimuli after the delayed recall. Data were computed via circular analyses to obtain asynchrony, the stability of synchronization and errors. Firstly, an overall deficit in synchronization with both auditory and visual isochronous stimuli was observed in DCD children compared to TD children. During practice, further improvements were found for the audio-motor non-isochronous sequence compared to the visuo-motor non-isochronous sequence in both TD children and children with DCD. However, a drastic increase in errors occurred in children with DCD during immediate retention as soon as the auditory stimuli were removed. Reintroducing auditory stimuli decreased errors in the audio-motor sequence for children with DCD. Such changes were not seen for the visuo-motor non-isochronous sequence, which was equally learned, retained and reactivated in DCD and TD children. All these results suggest that TD children benefit from both auditory and visual stimuli to memorize the sequence, whereas children with DCD seem to present a deficit in integrating an audio-motor sequence in their memory. The immediate effect of reactivation suggests a specific dependency on auditory information in DCD. Contrary to the audio-motor sequence, the visuo-motor sequence was both learned and retained in children with DCD. This suggests that visual stimuli could be the best information for memorizing a temporal sequence in DCD. All these results are discussed in terms of a specific audio-motor coupling deficit in DCD. (shrink)

This article discusses a puzzle arising from the phenomenon of insight in obsessive–compulsive disorder. “Insight” refers to an awareness or understanding of obsessive thoughts as false or irrational. I argue that a natural and plausible way of characterizing insight in OCD conflicts with several different possible explanations of the epistemic attitude underlying insight‐directed obsessive thought. After laying out the puzzle for five proposed explanations of obsessive thought and then discussing several possible ways that the puzzle might be avoided, I (...) close the article by arguing that we can avoid the puzzle by adopting a new positive view of insight‐directed obsessive thought. (shrink)

The end-state comfort effect refers to the consistent tendency of healthy adults to end their movements in a comfortable end posture. In children with and without developmental coordination disorder, the results of studies focusing on ESC planning have been inconclusive, which is likely to be due to differences in task constraints. The present pilot study focused on the question whether children with and without DCD were able to change their planning strategy and were more likely to plan for ESC (...) when demanded by complex object manipulations at the end of a task. To this end, we examined ESC planning in 18 children with and without DCD using the previously used sword-task and the newly developed hammer-task. In the sword-task, children had to insert a sword in a wooden block, which could be relatively easily completed with an uncomfortable end-posture. In the hammer-task, children had to strike down a nail in a wooden pounding bench, which required additional force and speed demands, making it relatively difficult to complete the movement with an uncomfortable end-posture. In line with our hypothesis, the results demonstrated that children with and without DCD were more likely to plan for ESC on the hammer-task compared with the sword-task. Thus, while children with and without DCD show inconsistent ESC planning on many previously used tasks, the present pilot study shows that many of them are able to take into account the end-state of their movements if demanded by task constraints. (shrink)

Depersonalization disorder (DPD) is a psychiatric condition in which there is a pervasive change in the quality of subjective experience, in the absence of psychosis. The core complaint is a persistent and disturbing feeling that experience of oneself and the world has become empty, lifeless, and not fully real. A greatly reduced emotional responsivity, or “de-affectualization,” is frequently described. This article examines the phenomenology and neurobiology of DPD with a particular emphasis on the emotional aspects. It is argued that (...) the study of DPD may provide valuable insights into the relationship between emotion, experience, and identity. (shrink)

Psychopathy is often characterized in terms of what I call “the language of disorder.” I question whether such language is necessary for an accurate and precise characterization of psychopathy, and I consider the practical implications of how we characterize psychopathy—whether as a biological, or merely normative, disorder.

In this two-part analysis, I analyze Marc Lewis’s arguments against the brain-disease view of substance addiction and for a developmental-learning approach that demedicalizes addiction. I focus especially on the question of whether addiction is a medical disorder. In Part 1, I argued that, even if one accepts Lewis’s critique of the brain evidence presented for the brain-disease view, his arguments fail to establish that addiction is not a disorder. Relying on my harmful dysfunction analysis of disorder, I (...) defended the view that addiction is a medical disorder and a brain disorder. In Part 2, I consider some broader philosophical issues raised by Lewis’s arguments: I consider a larger puzzle, at the heart of the neo-Kraepelinian program in contemporary psychiatry, that is raised by Lewis’s argument that addiction is not a disorder because the brain displays no damage but only normal learning: must all mental disorders be brain disorders, or can mental disorders occur in normal brains? I argue that mental disorders can occur in normal brains. I critique Lewis’s response to the evolutionary “novel environment” approach to explaining why addiction is a disorder. Lewis agrees with brain-disease proponents that interpreting addiction as brain disorder relieves addicts of moral censure, but I argue that moral defect and brain disease are not exclusive. Finally, I consider Lewis’s “developmental-learning” account of addiction that encourages positive and empowering narrativizing of addiction, but I argue that the developmental-learning view is vacuous due to use of an overly broad notion of “development.”. (shrink)

This paper discusses different frameworks for understanding imagination and metaphor in the context of research on the imaginative skills of children with autism spectrum disorder (ASD). In contrast to a standard linguistic framework, it advances an embodied and enactive account of imagination and metaphor. The paper describes a case study from a systemic therapeutic session with a child with ASD that makes use of metaphors. It concludes by outlining some theoretical insights into the imaginative skills of children with ASD (...) that follow from taking the embodied-enactive perspective and proposes suggestions for interactive interventions to further enhance imaginative skills and metaphor understanding in children with ASD. (shrink)

Phenomenology provides a method for disability theorists to describe embodied subjectivity lacking within the social model of disability. Within the literature on body integrity identity disorder (BIID), dominant narratives of disability are influential, individual bodies are considered in isolation, and experiences of disabled people are omitted. Research on BIID tends to incorporate an individualist ontology. In this article, I argue that Merleau-Ponty's conceptualization of “being in the world,” which recognizes subjectivity as embodied and intersubjective, provides a better starting point (...) for research describing the experiences of those with BIID and amputees. (shrink)