There has been a spurt in both fundamental and translational research that examines the underlying mechanisms of the human microbiome in psychiatric disorders. The personalized and dynamic features of the human microbiome suggest the potential of its manipulation for precision psychiatry in ways to improve mental health and avoid disease. However, findings in the field of microbiome also raise philosophical and ethical questions. From a philosophical point of view, they may yet be another attempt at providing a biological (...) cause for phenomena that ultimately cannot be so easily localized. From an ethical point of view, it is relevant that the human gut microbiome comprises data on the individual’s lifestyle, disease history, previous medications, and mental health. Massive datasets of microbiome sequences are collected to facilitate comparative studies to identify specific links between the microbiome and mental health. Although this emerging research domain may show promise for psychiatric patients, it is surrounded by ethical challenges regarding patient privacy, health risks, effects on personal identity, and concerns about responsibility. This narrative overview displays the roles and advances of microbiome research in psychiatry and discusses the philosophical and ethical implications of microbiome big data and microbiome-based interventions for psychiatric patients. We also investigate whether these issues are really “new,” or “old wine in new bottles.”. (shrink)

Since the turn of the twenty-first century, biomedical psychiatry around the globe has embraced the so-called precision medicine paradigm, a model for medical research that uses innovative techniques for data collection and analysis to reevaluate traditional theories of disease. The goal of precision medicine is to improve diagnostics by restratifying the patient population on the basis of a deeper understanding of disease processes. This paper argues that precision is ill-fitting for psychiatry for two reasons. First, (...) in psychiatry, unlike in fields like oncology, precision medicine has been understood as an attempt to improve medicine by casting out, rather than merely revising, traditional taxonomic tools. Second, in psychiatry the term “biomarker” is often used in reference to signs or symptoms that allow patients to be classified and then matched with treatments; however, in oncology “biomarker” usually refers to a disease mechanism that is useful not only for diagnostics, but also for discovering causal pathways that drug therapies can target. Given these differences between how the precision medicine paradigm operates in psychiatry and in other medical fields like oncology, while precision psychiatry may offer successful rhetoric, it is not a promising paradigm. (shrink)

The catch 22 situation in psychiatry is that for precise diagnostic categories/criteria, we need precise investigative tests, and for precise investigative tests, we need precise diagnostic criteria/categories; and precision in both diagnostics and investigative tests is nonexistent at present. The effort to establish clarity often results in a fresh maze of evidence. In finding the way forward, it is tempting to abandon the scientific method, but that is not possible, since we deal with real human psychopathology, not just (...) concepts to speculate over. Search for clear-cut definitions/diagnostic criteria in psychiatry must be relentless. There is a greater need to be ruthless and blunt in this, rather than being accommodative of diverse opinions. Investigative tests - psychological, serum, CSF, or neuroimaging - are only corroborative at present; they need to become definitive. Medicalisation appears most prominent in psychiatry; so, diagnostic proliferation and fuzziness appear inevitable. And yet, the established diagnostic entities need to forward greater and conclusive precision. Also, the need for clarity and precision must outweigh pandering to and mollifying diverse interests, moreso in the upcoming revision of diagnostic manuals. This is specially because the DSM-5, being an Association manual, may need to accommodate powerful member lobbies; and ICD-11 may similarly need to cater to diverse country lobbies. Finding precise biological correlates of psychiatric phenomena, whether through neuroimaging, molecular neurobiology and/or neurogenomics, is the right way forward. It is in the 1.5-kg structure in the cranium that all secrets of psychiatric conditions lie. Social forces, behavioural modification, psychosocial restructuring, study of intrapsychic processes, and philosophical insights are not to be discounted, but they are supplementary to the primary goal - studying and deciphering those brain processes that result in psychiatric malfunction. Experimental breakthroughs, both in psychiatric aetiology and therapeutics, will come mainly from biology and its adjunct, psychopharmacology; while supplementary and complementary breakthroughs will come from the psychosocial, cognitive and behavioural approaches; the support base will come from phenomenology, epidemiology, nosology and diagnostics; while insights and leads can hopefully come from many fields, especially the psychosocial, the behavioural, the cognitive and the philosophical. Major energies must now be marshalled towards finding biomarkers and deciphering the precise phenotype-genotype-endophenotype axis of psychiatric disorders. Energies also need to be focussed on unravelling those critical processes in the brain that tip the scale towards psychiatric disorders. At how those critical processes are set into motion by forces de novo, in utero, in the genes and their expression, by the environment's psychopathological social forces - stress, peer pressure, poverty, deprivation, alienation, malnutrition, discrimination of various types (caste, gender, race, etc.), mass conflicts (war, terror attacks, etc.), disasters (natural and man-made), religious/ideological fascism - or social institutions like marriage, family, work place, political governance, etc. Ultimately, we must decipher how the brain goes into malfunction when such varied forces impinge on it, which precise cortical areas and neuronal cellular and molecular processes are involved in such malfunction and its manifestation, as also which of these are involved when malfunction ceases and health is restored, and the psychosocial processes and institutions which aid such health restoration, as also those which promote well-being and help in primary prevention. Emphasis on the brain and its intimate neurological and molecular mechanisms will not impinge on, or nullify, importance of the 'mind,' wherein subtle and gross brain functions in the form of behaviour, thought and emotions in all their ramifications will continue to be the focus of psychological, cognitive, sociological, psychopharmacological, behavioural and philosophical research. Progress in brain research must move in tandem with progress in 'mind' research. (shrink)

Precision medicine impacts virtually all medical specializations, including psychiatry. Though precision psychiatry, in general, is a flourishing area of research and debate, psychotherapy as one pillar of psychiatry has received little attention. Theoretical discussions about precision psychotherapy are rare; research on precision in psychotherapy is just evolving. In this paper we provide a conceptualization of precision psychotherapy providing a common idea of what should be understood as precision in the context of (...) psychotherapy and what kind of psychotherapy research can be considered to contribute to the aims of precision psychotherapy. (shrink)

The biopsychosocial model, which was deeply influential on psychiatry following its introduction by George L. Engel in 1977, has recently made a comeback. Derek Bolton and Grant Gillett have argued that Engel’s original formulation offered a promising general framework for thinking about health and disease, but that this promise requires new empirical and philosophical tools in order to be realized. In particular, Bolton and Gillett offer an original analysis of the ontological relations between Engel’s biological, social, and psychological levels (...) of analysis. I argue that Bolton and Gillett’s updated model, while providing an intriguing new metaphysical framework for medicine, cannot resolve some of the most vexing problems facing psychiatry, which have to do with how to prioritize different sorts of research. These problems are fundamentally ethical, rather than ontological. Without the right prudential motivation, in other words, the unification of psychiatry under a single conceptual framework seems doubtful, no matter how compelling the model. An updated biopsychosocial model should include explicit normative commitments about the aims of medicine that can give guidance about the sorts of causal connections to be prioritized as research and clinical targets. (shrink)

Researchers are studying how artificial intelligence (AI) can be used to better detect, prognosticate and subgroup diseases. The idea that AI might advance medicine’s understanding of biological categories of psychiatric disorders, as well as provide better treatments, is appealing given the historical challenges with prediction, diagnosis and treatment in psychiatry. Given the power of AI to analyse vast amounts of information, some clinicians may feel obligated to align their clinical judgements with the outputs of the AI system. However, a (...) potential epistemic privileging of AI in clinical judgements may lead to unintended consequences that could negatively affect patient treatment, well-being and rights. The implications are also relevant to precision medicine, digital twin technologies and predictive analytics generally. We propose that a commitment to epistemic humility can help promote judicious clinical decision-making at the interface of big data and AI in psychiatry. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Arguing about PsychiatryNatural Selection, Austinian Conservatism, and Finding Our Way to the BestJoseph Gough (bio)Professors Murphy and Lieberman have offered two generous and interesting commentaries on my article, each very insightful and helpful in its own way, and each offering an interesting alternative characterization of the subject matter of psychiatry. I found each extremely thought-provoking, hence this rather bloated response. I strongly disagree with each. In brief, I (...) disagree with the 'preliminaries' of each commentary, struggle to see the tension between Hull's view of science and my view of psychiatry, reject Lieberman's appeal to the history of mind-like and mental-illness-like concepts, and finally, believe my position neither suffers from the instability of psychiatry, nor blocks the route to best practice, nor counsels despair.Metaphysical Precision and Conceptual Evolution: Response to MurphyMurphy begins by offering some helpful context for the debate, and for our disagreement within that debate. Partly it is helpful because it raises a cluster of questions, which I agree with him, are related to the topic at hand. Partly it is helpful because it lays out Murphy's background metaphysics, with which I broadly agree, but where I think it is important to be more pedantic than Murphy himself is. Murphy and I agree that there are animate objects, importantly different from inanimate objects; we also agree that there is no object in nature that is a mind. However, in that [End Page 45] opening paragraph, there are a few things that look to me a little like conflations—and while I am happy to grant this as pedantry, I am not happy to deny its importance.First, not everything animate is intelligent and unpredictable—a presumably accidental implication of Murphy's use of 'these' throughout the paragraph. Second, intelligence and unpredictability do not in my view cluster in the way that Murphy suggests in the passage—a highly intelligent system may be exceptionally predictable at least so long as its goals and knowledge are fixed, and a highly unpredictable system may, of course, be entirely unintelligent. Of course, when some systems behave other than we expect, we count this as a failing of the system; but this is a feature of artifacts as well as animate systems, and perhaps also of objects that are neither artifacts nor animate (think of a farmer whose crops fail to go—might they not think there is something wrong with the soil?). The class of 'predictions' Murphy identifies is what I would describe as a class of normative expectations, that, of course, must be somewhat in line with the way things actually are, but are not 'predictions' in the paradigmatic sense of guesses about what will happen.This pedantry matters because this implied (or perhaps less charitably, enforced) alignment between non-coextensive categories in this picture of Murphy's is leveraged, I think, to gesture towards an objection. First, Murphy claims that this class of systems has required a special vocabulary, 'mental' vocabulary. Second, it is, I think, suggested in Murphy's set-up (and perhaps in Murphy's work; Murphy & Stich, 1999) that at some level this vocabulary anchors what we are talking about when we are talking about 'mental illness.'But here, of course, I disagree—or at least, I might disagree if I were clear what is being claimed. Which class of systems is that gives rise to this 'special vocabulary? Several have been mentioned. It should also come as no surprise that I think it is deeply unclear what counts as 'mental' vocabulary. Is it the vocabulary of animacy? Of normative expectation and function-ascription? Perhaps of intentionality? Or of consciousness? Maybe it is defined 'ostensively' with respect to terms like belief and desire?After these preliminaries, Murphy offers an objection to my position, and a brief defense of his own. I would like to begin with his defense of his own position:the best way to think about the claim that mental illnesses are brain diseases … is to see them as committing us to a form of explanation that treats psychiatry as continuous with other sciences of mind, in... (shrink)

The paper by Szasz is about mental illness and its meaning, and like Procrustes, who altered hapless travellers to fit his bed, Szasz changes the meanings of words and concepts to suit his themes.1 Refuting the existence of “mental illness”, he suggests that the term functions in an apotropaic sense. He submits that in this sense it is used to avert danger, protect society, and hence justify preventive detention of “dangerous” people.But his arguments misrepresent the precise meaning of the term (...) “apotropaic”, which is an adjective, defined in Webster’s, Chambers and the New Shorter Oxford dictionaries as averting or turning aside evil. It is possible that amulets and incantations ward off evil, in the same way as garlic repels vampires, but evil and danger are different concepts. Yet Szasz talks of using phrases like ‘“dangerousness to self and others’ as apotropaics to ward off dangers we fear”, and the word “evil” does not appear in his paper.I will argue that “dangerousness to self and others” and “psychiatric treatment” have a prosaic rather than an apotropaic function.The word “danger” is familiar rather than arcane, and includes many risks. A predatory paedophile is usually both dangerous and evil, but many dangerous people are not evil. For example, a child who plays with a box of matches is dangerous, as is a demented person who drives a car, or a schizophrenic who, acting on delusional beliefs, arms herself with a knife and roams the streets believing she is an avenging angel.Suppose …. (shrink)

La crise structurelle de la psychiatrie questionne aujourd’hui le modèle médical dans son ensemble. Premier poste de dépense de l’assurance maladie, les techniques de soins psychiatriques, soins de la subjectivité malade, sont-elles destinées à être numérisées? L’influence étasunienne, vecteur d’un retour de la neuropsychiatrie, tend à le laisser croire. À partir des constats observés au fil de l’histoire de la psychiatrie française, nous interrogerons cette tendance, ses fantasmes et réalités, pour préciser les conditions d’une appropriation des technologies qui améliore le (...) service médico-psychiatrique individuel et collectif. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.1 (2002) 87-90 [Access article in PDF] Phenomenological and Biological Psychiatry:Complementary or Mutual? James Morley Keywords: phenomenology, psychiatry, psychoanalysis, ontology. We feel that even if all possible scientific questions be answered the problems of life have still not been touched at all. (Witgenstein, Tractatus, 6.52) IF ONE WAS TO PERFORM a thought experiment by imagining a scientifically explained universe, how would this (...) explained universe resolve my issues of value and meaning? Would it help me to live a better life? In one sentence, Witgenstein expressed exactly the issues dividing, and defining, the phenomenological and biophysical approaches to psychiatry. (Natural) scientific questions are concerned with relations of physical causality while phenomenology is aimed at the problems of life, i.e., the elucidation of lived personal meanings.Clarifying the relation between phenomenology and the general psychiatric literature is clearly a significant undertaking. At this juncture in the history of psychiatry where the biophysical model is so dominant, the authors' efforts are especially welcome, as I wholeheartedly appreciate, and thank the authors for this endeavor. I only wish to explicate a few issues latent within the article and perhaps add a few supportive points. Explicitly or implicitly, the need for phenomenology in psychiatry is long enduring and will always persist (Ellenberger 1981, 1993). The integration of phenomenology with general psychiatric practice would certainly serve the needs of patients and society generally. But, in the present state of affairs where the biological model is so preeminent, a full accounting of the dramatic divergences between the two approaches is necessary if there is to be authentic dialogue between them.Essentially, I want to stress that phenomenology and natural science medicine are genuinely distinct paradigms for construing reality and organizing knowledge. As distinct scientific paradigms, each one is holistically self-contained. Like soap bubbles, if pushed together too forcefully one or the other may burst. In this case, it is more likely that the smaller, less prevalent paradigm would burst by becoming absorbed into the more dominant paradigm. I believe that this is precisely the risk when phenomenology is introduced to conventional psychiatry as "complementary." Whereas one could hardly object to any application of empathy and understanding toward the experiences of patients, it would be tragic if the [End Page 87] full philosophical power of phenomenology were to be overlooked in favor of its mere utility as a preliminary stage of diagnosis and assessment, a framework for bedside manners, or worst of all, an appendage to neuroscience or pharmacology. This would not be phenomenology but the very symptomatology that the authors have has so clearly distinguished from true phenomenology.This equation of phenomenology with symptomatology is exactly the misunderstanding that the authors so effectively address. However, I would hesitate to join the authors' optimism in regard to phenomenology's potential complementary role to conventional psychiatric practice. Furthermore, in the process of paradigm mix, certain constituents of each paradigm may be taken out of context and the strength of each paradigm thus diluted. For example, the very power of the experimental method is its reduction of phenomena to measurable variables that can be altered in order to discern causality. Unmeasurable variables detract form the rigor of this entire approach. Then on the other hand, phenomenological empathy is only possible within a standpoint that is severed from the causal thinking of experimental science. This is the holistic perceptual shift that cannot be accomplished when one only appends phenomenological insights to an otherwise materialist approach to psychiatry. Thus, it is not at all clear how one can be both phenomenological and nonphenomenologically natural scientific. Instead of positioning phenomenology as a potential complimentary component of natural-science psychiatry, both world views need to be examined, on their own terms, in a framework of mutuality.Empathy or the understanding of other peoples subjective experience is indeed an essential component of the application of phenomenology to clinical assessment and especially therapeutic treatment. But, to limit phenomenology to this theme alone may not honor the profoundly radical character of this paradigm. As the authors point out, phenomenology asks the practitioner to... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.4 (2002) 381-382 [Access article in PDF] The Borderlands of Psychiatry and Theology Stephen Sykes Keywords: psychiatry, theology, spirituality. THE DISCUSSION OF THE TERMS we use to speak of experiences on the boundaries between spirituality and mental disorder is very important. Jackson and Fulford (1997) have gone a long way to avoid flattening the concepts into a single conceptual scheme, too far (...) for some of their critics like Littlewood (1997) and Storr (1997), but not far enough for Bratton and Marzanski (2002), who eventually accuse them of "anthropocentric psychologism." They want to preserve theological categories intact, mainly because this is how the subjects themselves see their experiences, but also because there is, they hold, additional explanatory value in such a language schema. As evidence they point to unremarkable attitudes and practices, which are nonetheless demonstrably part of the Christian way of life.The borderlands between theology and psychiatry are not alone in witnessing this dispute. A similar conflict has arisen in the discussion of public policy. In politics, people of religious conviction or representatives of faith communities have sometimes been told either to hold their tongues (because "not many people believe these things nowadays" or because "it's wrong to impose your beliefs on other people") or to formulate their proposals in nonreligious language. It is far from obvious that this is not a sophisticated form of discrimination, nonetheless objectionable for its being practiced by nonreligious people. The creation of genuine equality of access to the space for public discussion of political proposals is not at all easy.I have personal experience of the analogous difficulty in psychiatric practice. In a discussion of the overinvolvement of carers for a person with mental health problems self-sacrificing behavior was used with a negative connotation. But, as in the case of Carol, how were these actions to be construed—were they normal for a Christian or psychopathological? My personal response is that it is correct to say that a boundary exists between ordinary Christian spiritual experience (the kind that religious believers would immediately recognize as part of their religious lives) and disturbed or distorted perceptions that are the result of mental illness and can be mitigated by appropriate treatment. But the fact that a boundary exists in principle does not necessarily imply that it is always easy to draw the distinction in practice. Typically the cases that cause the most difficulty lie on the borderlands. Although on the face of it, it looks attractive to demonstrate the security of the criteria by making discriminations in precisely this area (and the point of the cases in Jackson and Fulford is precisely that they raise these complexities), in [End Page 381] fact it may be that such instances require both languages. In this case, Bratton and Marzanski are correct to argue for the retention of a theological frame of reference. The strength of their argument lies precisely in the support that fellow members of the respective faith communities are able to give to the people who, despite their manifest illnesses, persist in religiously justifiable courses of action.The paper raises one very important matter that bedevils a lot of the current literature, namely how spirituality is to be understood. In my view, there is a lot of purely arbitrary definition of this term, whose meaning has developed rapidly under specific social conditions (Sykes 2000a). In medicine, it functions best when it is taken to be a reminder that a patient may have had contact with a specific religious tradition that has contributed or still contributes to her worldview. In modern Western society, account has to be taken both of residual religiosities or fallback positions, and of new religions, as well as of traditional religious groupings. In the case of mental illness, it may be very important for a medical practitioner to be aware of the impact of these religious promptings on the formulation of the narrative identity of an individual—no easy task (Sykes 2000b).The generality of spirituality ought not to deflect the professional from attending to the particular tradition or traditions which have... (shrink)

This chapter evaluates the multiple roles of technology in psychiatry, drawing on philosophical resources and mindful of psychiatry's need to benefit from technology without reducing itself to nothing but a technology. It approaches the topic of technology and psychiatry from three perspectives. First, it addresses technology as a way of thinking-technical or instrumental reason-and how technical reason informs psychiatric theory and practice. For this analysis it invokes a philosophical tradition that stretches from Aristotle to Toulmin and Gadamer. (...) Second, it takes up technology as achievement, the most obvious example of which is psychotropic medications. For this dimension of technology in psychiatry it recruits philosopher Albert Borgmann, who has analyzed the tendency of technological products, analyzed as device paradigms, to transmute into commodities. Finally, the chapter takes up technology as instrument of investigation. Philosopher Don Ihde is the guide in this investigation into how the psychiatrically real can become what is revealed through the technological instrument. The final section addresses the overarching question of how to set the right balance between the technological and the non-technological in psychiatry-how psychiatry can make use of technology without losing its humanistic core. It notes that the binary of the technological and non-technology in psychiatry can be mapped onto other binaries: biology and psychology, mind and brain, medication and psychotherapy, diagnosis and patient, theory and instance, general and individual, technical and practical reason. These binaries are not precisely isomorphic with each other, but all contribute to evaluating the role of technology in psychiatry, both in the present and in the desired future. (shrink)

Computational psychiatry offers promising opportunities for understanding and treating mental health disorders, yet achieving ecological validity—the accurate reflection of real-world experiences—remains a critical challenge. This perspective examines how digital health technologies can enhance ecological validity in computational psychiatry while addressing barriers in data collection, participant representation, validation, engagement, and methodological integration. We review key approaches, including digital phenotyping and adaptive design optimization, that enable more naturalistic data collection. However, achieving representative sampling and mitigating algorithmic biases remain unresolved challenges, (...) particularly in AI-driven assessments. We discuss how expert-by-experience collaboration, systematic validation efforts, and structured open science practices can improve model generalizability and clinical applicability. Additionally, we explore the role of federated learning and edge computing in balancing privacy with robust, scalable model development. The paper concludes by integrating these challenges and solutions within a broader methodological framework, emphasizing the need for interdisciplinary approaches that bridge computational precision with real-world psychiatric care. (shrink)

In their recent paper, Natalie Banner and Tim Thornton evaluate seven volumes of the Oxford University Press series “International Perspectives in Philosophy and Psychiatry,” an international book series begun in 2003 focusing on the emerging interdisciplinary field at the interface of philosophy and psychiatry. According to Natalie Banner and Tim Thornton, the series represents a clear indication that the interdisciplinary field of philosophy of psychiatry has been flourishing lately. Philosophers and psychiatrists face a “new philosophy of (...) class='Hi'>psychiatry”. However, the optimism which the “new” philosophy of psychiatry celebrates is precisely the exiling of philosophy from the foundations of psychiatry. The 150 year old belief that psychopathology cannot do without philosophical reflection has virtually disappeared from common psychiatric education and daily clinical practice. Though the discipline of psychiatry is particularly suited to contributions from philosophy, the impact of philosophy on psychiatry nowadays remains limited. With some exceptions, philosophical papers are embedded in a philosophical context inscrutable to ordinary psychiatrists. Much current philosophical work is perceived by psychiatrists as negativistic. I would encourage the field of psychiatry to incorporate once again basic philosophical attitudes which render possible true dialogue with philosophy and enrich both disciplines. The views developed here should not discredit the value and importance of Natalie Banner and Tim Thornton’s paper and the excellent series “International Perspectives in Philosophy and Psychiatry.” As Jaspers said “Everybody inclined to disregard philosophy will be overwhelmed by philosophy in an unperceived way”. (shrink)

ArgumentResearch into the biological markers of pathology has long been a feature of British psychiatry. Such somatic indicators and associated features of mental disorder often intertwine with discourse on psychological and behavioral correlates and causes of mental ill-health. Disorders of sociality – particularly psychopathy and antisocial personality disorder – are important instances where the search for markers of pathology has a long history; research in this area has played an important role in shaping how mental health professionals understand the (...) conditions. Here, I characterize the multiplicity of psychiatric praxis that has sought to define the mark of antisociality as a form of “ontological anarchy.” I regard this as an essential feature of the search for biological and other markers of an unstable referent, positing that uncertainties endure – in part – precisely because of attempts to build consensus regarding the ontology of antisociality through biomedical means. Such an account is suggestive of the co-production of biomarkers, mental disorder, and psychiatric institutions. (shrink)

ABSTRACT I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments. INTRODUCTION In contrast to the classic model of randomized-control trials, often with a large number of (...) subjects enrolled, precision medicine attempts to optimize therapeutic outcomes by focusing on the individual.[i] A recent publication highlights the strengths and weakness of both traditional evidence-based medicine and precision medicine.[ii] Plus, it outlines a tension in the shift from evidence-based medicine’s inductive reasoning style (the collection of data to postulate general theories) to precision medicine’s abductive reasoning style (the generation of an idea from the limited data available).[iii] The paper’s main example is the application of precision medicine for the treatment of cancer.[iv] I argue that this examination and appreciation for the shift to abductive reasoning should be extended to the intersection of neuroscience and novel brain-computer interfaces too. As the name suggests, brain-computer interfaces are a significant advancement in neurotechnology that directly connects someone’s brain to external or implanted devices.[v] Among the various kinds of brain-computer interfaces, adaptive deep brain stimulation devices require numerous personalized adjustments to their settings during the implantation and computation stages in order to provide adequate relief to patients with treatment-resistant disorders. What makes these devices unique is how adaptive deep brain stimulation integrates a sensory component to initiate the stimulation. While not commonly at the level of sophistication as self-supervising or generative large language models,[vi] they currently allow for a semi-autonomous form of neuromodulation. This paper highlights the implications of applying abductive reasoning to personalized implantable neurotechnologies. Then, it explores whether abductive reasoning is sufficient to justify insurance coverage for devices absent widespread clinical trials, which are better applied to one-size-fits-all treatments.[vii] ANALYSIS I. The State of Precision Medicine in Oncology and the Epistemological Shift While a thorough overview of precision medicine for the treatment of cancer is beyond the scope of this article, its practice can be roughly summarized as identifying clinically significant characteristics a patient possesses (e.g., genetic traits) to land on a specialized treatment option that, theoretically, should benefit the patient the most.[viii] However, in such a practice of stratification patients fall into smaller and smaller populations and the quality of evidence that can be applied to anyone outside these decreases in turn.[ix] As inductive logic helps to articulate, the greater the number of patients that respond to a particular therapy the higher the probability of its efficacy. By straying from this logical framework, precision medicine opens the treatment of cancer to more uncertainty about the validity of these approaches to the resulting disease subcategories.[x] Thus, while contemporary medical practices explicitly describe some treatments as “personalized”, they ought not be viewed as inherently better founded than other therapies.[xi] A relevant contemporary case of precision medicine out of Norway focuses on the care of a patient with cancer between the ventricles of the heart and esophagus, which had failed to respond to the standard regimen of therapies over four years.[xii] In a last-ditch effort, the patient elected to pay out-of-pocket for an experimental immunotherapy (nivolumab) at a private hospital. He experienced marked improvements and a reduction in the size of the tumor. Understandably, the patient tried to pursue further rounds of nivolumab at a public hospital. However, the hospital initially declined to pay for it given the “lack of evidence from randomised clinical trials for this drug relating to this [patient’s] condition.”[xiii] In rebuttal to this claim, the patient countered that he was actually similar to a subpopulation of patients who responded in “open‐label, single arm, phase 2 studies on another immune therapy drug” (pembrolizumab).[xiv] Given this interpretation of the prior studies and the patient’s response, further rounds of nivolumab were approved. Had the patient not had improvements in the tumor’s size following a round of nivolumab, then pembrolizumab’s prior empirical evidence in isolation would have been insufficient, inductively speaking, to justify his continued use of nivolumab.[xv] The case demonstrates a shift in reasoning from the traditional induction to abduction. The phenomenon of ‘cancer improvement’ is considered causally linked to nivolumab and its underlying physiological mechanisms.[xvi] However, “the weakness of abductions is that there may always be some other better, unknown explanation for an effect. The patient may for example belong to a special subgroup that spontaneously improves, or the change may be a placebo effect. This does not mean, however, that abductive inferences cannot be strong or reasonable, in the sense that they can make a conclusion probable.”[xvii] To demonstrate the limitations of relying on the abductive standard in isolation, commentators have pointed out that side effects in precision medicine are hard to rule out as being related to the initial intervention itself unless trends from a group of patients are taken into consideration.[xviii] As artificial intelligence (AI) assists the development of precision medicine for oncology, this uncertainty ought to be taken into consideration. The implementation of AI has been crucial to the development of precision medicine by providing a way to combine large patient datasets or a single patient with a large number of unique variables with machine learning to recommend matches based on statistics and probability of success upon which practitioners can base medical recommendations.[xix] The AI is usually not establishing a causal relationship[xx] – it is predicting. So, as AI bleeds into medical devices, like brain-computer interfaces, the same cautions about using abductive reasoning alone should be carried over. II. Responsive Neurostimulation, AI, and Personalized Medicine Like precision medicine in cancer treatment, computer-brain interface technology similarly focuses on the individual patient through personalized settings. In order to properly expose the intersection of AI, precision medicine, abductive reasoning, and implantable neurotechnologies, the descriptions of adaptive deep brain stimulation systems need to deepen.[xxi] As a broad summary of adaptive deep brain stimulation, to provide a patient with the therapeutic stimulation, a neural signal, typically referred to as a local field potential,[xxii] must first be detected and then interpreted by the device. The main adaptive deep brain stimulation device with premarket approval, the NeuroPace Responsive Neurostimulation system, is used to treat epilepsy by detecting and storing “programmer-defined phenomena.”[xxiii] Providers can optimize the detection settings of the device to align with the patient’s unique electrographic seizures as well as personalize the reacting stimulation’s parameters.[xxiv] The provider adjusts the technology based on trial and error. One day machine learning algorithms will be able to regularly aid this process in myriad ways, such as by identifying the specific stimulation settings a patient may respond to ahead of time based on their electrophysiological signatures.[xxv] Either way, with AI or programmers, adaptive neurostimulation technologies are individualized and therefore operate in line with precision medicine rather than standard treatments based on large clinical trials. Contemporary neurostimulation devices are not usually sophisticated enough to be prominent in AI discussions where the topics of neural networks, deep learning, generative models, and self-attention dominate the conversation. However, implantable high-density electrocorticography arrays (a much more sensitive version than adaptive deep brain stimulation systems use) have been used in combination with neural networks to help patients with neurologic deficits from a prior stroke “speak” through a virtual avatar.[xxvi] In some experimental situations, algorithms are optimizing stimulation parameters with increasing levels of independence.[xxvii] An example of neurostimulation that is analogous to the use of nivolumab in Norway surrounds a patient in the United States who was experiencing both treatment-resistant OCD and temporal lobe epilepsy.[xxviii]Given the refractory nature of her epilepsy, implantation of an adaptive deep brain stimulation system was indicated. As a form of experimental therapy, her treatment-resistant OCD was also indicated for the off-label use of an adaptive deep brain stimulation set-up. Another deep brain stimulation lead, other than the one implanted for epilepsy, was placed in the patient’s right nucleus accumbens and ventral pallidum region given the correlation these nuclei had with OCD symptoms in prior research. Following this, the patient underwent “1) ambulatory, patient-initiated magnet-swipe storage of data during moments of obsessive thoughts; (2) lab-based, naturalistic provocation of OCD-related distress (naturalistic provocation task); and (3) lab-based, VR [virtual reality] provocation of OCD-related distress (VR provocation task).”[xxix] Such signals were used to identify when to deliver the therapeutic stimulation in order to counter the OCD symptoms. Thankfully, following the procedure and calibration the patient exhibited marked improvements in their OCD symptoms and recently shared her results publicly.[xxx] In both cases, there is a similar level of abductive justification for the efficacy of the delivered therapy. In the case study in which the patient was treated with adaptive deep brain stimulation, they at least had their neural activity tested in various settings to determine the optimum parameters for treatment to avoid them being based on guesswork. Additionally, the adaptive deep brain stimulation lead was already placed before the calibration trials were conducted, meaning that the patient had already taken on the bulk of the procedural risk before the efficacy could be determined. Such an efficacy test could have been replicated in the first patient’s cancer treatment, had it been biopsied and tested against the remaining immunotherapies in vitro. Yet, in the case of cancer with few options, one previous dose of a drug that appeared to work on the patient may justify further doses. However, as the Norwegian case presents, corroboration with known responses to a similar drug (from a clinical trial) could be helpful to validate the treatment strategy. (It should be noted that both patients were resigned to these last resort options regardless of the efficacy of treatment.) There are some elements of inductive logic seen with adaptive deep brain stimulation research in general. For example, abductively the focus could be that patient X’s stimulation parameters are different from patient Y’s and patient Z’s. In contrast, when grouped as subjects who obtained personalized stimulation, patients X, Y, and Z demonstrate an inductive aspect to this approach’s safety and/or efficacy. The OCD case holds plenty of abductive characteristics in line with precision medicine’s approach to treating cancer and as more individuals try the method, there will be additional data. With the gradual integration of AI into brain-computer interfaces in the name of efficacy, this reliance on abduction will continue, if not grow, over time. Moving forward, if a responsive deep brain stimulation treatment is novel and individualized (like the dose of nivolumab) and there is some other suggestion of efficacy (like clinical similarities to other patients in the literature), then it may justify insurance coverage for the investigative intervention, absent other unrelated reasons to deny it. III. Ethical Implications and Next Steps While AI’s use in oncology and neurology is not yet as prominent as its use in other fields (e.g., radiology), it appears to be on the horizon for both.[xxxi] AI can be found in both the functioning of the neurotechnologies as well as the implementation of precision medicine. The increasing use of AI may serve to further individualize both oncologic and neurological therapies. Given these implications and the handful of publications cited in this article, it is important to have a nuanced evaluation of how these treatments, which heavily rely on abductive justification, ought to be managed. The just use an abductive approach may be difficult as AI infused precision medicine is further pursued. At baseline, such technology relies on a level of advanced technology literacy among the general public and could exclude populations who lack access to basic technological infrastructure or know-how from participation.[xxxii] Even among nations with adequate infrastructure, as more patients seek out implantable neurotechnologies, which require robust healthcare resources, the market will favor patient populations that can afford this complex care.[xxxiii] If patients already have the means to pay for an initial dose/use of a precision medicine product out of pocket, should insurance providers be required to cover subsequent treatments?[xxxiv] That is, if a first dose of a cancer drug or a deep brain stimulator over its initial battery life is successful, patients may feel justified in having the costs of further treatments covered. The Norwegian patient’s experience implies there is a precedent for the idea that some public insurance companies ought to cover successful cancer therapies, however, insurance companies may not all see themselves as obligated to cover neurotechnologies that rely on personalized settings or that are based on precision/abductive research more than on clinical trials. CONCLUSION The fact that the cases outlined above rely on abductive style of reasoning implies that there may not be as strong a justification for coverage by insurance, as they are both experimental and individualized, when compared to the more traditional large clinical trials in which groups have the same or a standardized protocol (settings/doses). If a study is examining the efficacy of a treatment with a large cohort of patients or with different experimental groups/phases, insurance companies may conclude that the resulting symptom improvements are more likely to be coming from the devices themselves. A preference for inductive justification may take priority when ruling in favor of funding someone’s continued use of an implantable neurostimulator. There are further nuances to this discussion surrounding the classifications of these interventions as research versus clinical care that warrant future exploration, since such a distinction is more of a scale[xxxv] than binary and could have significant impacts on the “right-to-try” approach to experimental therapies in the United States.[xxxvi] Namely, given the inherent limitations of conducting large cohort trials for deep brain stimulation interventions on patients with neuropsychiatric disorders, surgically innovative frameworks that blend abductive and inductive methodologies, like with sham stimulation phases, have traditionally been used.[xxxvii] Similarly, for adaptive brain-computer interface systems, if there are no large clinical trials and instead only publications that demonstrate that something similar worked for someone else, then, in addition to the evidence that the first treatment/dose worked for the patient in question, the balance of reasoning would be valid and arguably justify insurance coverage. As precision approaches to neurotechnology become more common, frameworks for evaluating efficacy will be crucial both for insurance coverage and for clinical decision making. ACKNOWLEDGEMENT This article was originally written as an assignment for Dr. Francis Shen’s “Bioethics & AI” course at Harvard’s Center for Bioethics. I would like to thank Dr. Shen for his comments as well as my colleagues in the Lázaro-Muñoz Lab for their feedback. - [i] Jonathan Kimmelman and Ian Tannock, “The Paradox of Precision Medicine,” Nature Reviews. Clinical Oncology 15, no. 6 (June 2018): 341–42, https://doi.org/10.1038/s41571-018-0016-0. [ii] Henrik Vogt and Bjørn Hofmann, “How Precision Medicine Changes Medical Epistemology: A Formative Case from Norway,” Journal of Evaluation in Clinical Practice 28, no. 6 (December 2022): 1205–12, https://doi.org/10.1111/jep.13649. [iii] David Barrett and Ahtisham Younas, “Induction, Deduction and Abduction,” Evidence-Based Nursing 27, no. 1 (January 1, 2024): 6–7, https://doi.org/10.1136/ebnurs-2023-103873. [iv] Vogt and Hofmann, “How Precision Medicine Changes Medical Epistemology,” 1208. [v] Wireko Andrew Awuah et al., “Bridging Minds and Machines: The Recent Advances of Brain-Computer Interfaces in Neurological and Neurosurgical Applications,” World Neurosurgery, May 22, 2024, S1878-8750(24)00867-2, https://doi.org/10.1016/j.wneu.2024.05.104. [vi] Mark Riedl, “A Very Gentle Introduction to Large Language Models without the Hype,” Medium (blog), May 25, 2023, https://mark-riedl.medium.com/a-very-gentle-introduction-to-large-language-models-without-the-hype-5 f67941fa59e. [vii] David E. Burdette and Barbara E. Swartz, “Chapter 4 - Responsive Neurostimulation,” in Neurostimulation for Epilepsy, ed. Vikram R. Rao (Academic Press, 2023), 97–132, https://doi.org/10.1016/B978-0-323-91702-5.00002-5. [viii] Kimmelman and Tannock, 2018. [ix] Kimmelman and Tannock, 2018. [x] Simon Lohse, “Mapping Uncertainty in Precision Medicine: A Systematic Scoping Review,” Journal of Evaluation in Clinical Practice 29, no. 3 (April 2023): 554–64, https://doi.org/10.1111/jep.13789. [xi] Kimmelman and Tannock, “The Paradox of Precision Medicine.” [xii] Vogt and Hofmann, 1206. [xiii] Vogt and Hofmann, 1206. [xiv] Vogt and Hofmann, 1206. [xv] Vogt and Hofmann, 1207. [xvi] Vogt and Hofmann, 1207. [xvii] Vogt and Hofmann, 1207. [xviii] Vogt and Hofmann, 1210. [xix] Mehar Sahu et al., “Chapter Three - Artificial Intelligence and Machine Learning in Precision Medicine: A Paradigm Shift in Big Data Analysis,” in Progress in Molecular Biology and Translational Science, ed. David B. Teplow, vol. 190, 1 vols., Precision Medicine (Academic Press, 2022), 57–100, https://doi.org/10.1016/bs.pmbts.2022.03.002. [xx] Stefan Feuerriegel et al., “Causal Machine Learning for Predicting Treatment Outcomes,” Nature Medicine 30, no. 4 (April 2024): 958–68, https://doi.org/10.1038/s41591-024-02902-1. [xxi] Sunderland Baker et al., “Ethical Considerations in Closed Loop Deep Brain Stimulation,” Deep Brain Stimulation 3 (October 1, 2023): 8–15, https://doi.org/10.1016/j.jdbs.2023.11.001. [xxii] David Haslacher et al., “AI for Brain-Computer Interfaces,” 2024, 7, https://doi.org/10.1016/bs.dnb.2024.02.003. [xxiii] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 103–4; “Premarket Approval (PMA),” https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P100026. [xxiv] Burdette and Swartz, “Chapter 4 - Responsive Neurostimulation,” 104. [xxv] Burdette and Swartz, 126. [xxvi] Sean L. Metzger et al., “A High-Performance Neuroprosthesis for Speech Decoding and Avatar Control,” Nature 620, no. 7976 (August 2023): 1037–46, https://doi.org/10.1038/s41586-023-06443-4. [xxvii] Hao Fang and Yuxiao Yang, “Predictive Neuromodulation of Cingulo-Frontal Neural Dynamics in Major Depressive Disorder Using a Brain-Computer Interface System: A Simulation Study,” Frontiers in Computational Neuroscience 17 (March 6, 2023), https://doi.org/10.3389/fncom.2023.1119685; Mahsa Malekmohammadi et al., “Kinematic Adaptive Deep Brain Stimulation for Resting Tremor in Parkinson’s Disease,” Movement Disorders 31, no. 3 (2016): 426–28, https://doi.org/10.1002/mds.26482. [xxviii] Young-Hoon Nho et al., “Responsive Deep Brain Stimulation Guided by Ventral Striatal Electrophysiology of Obsession Durably Ameliorates Compulsion,” Neuron 0, no. 0 (October 20, 2023), https://doi.org/10.1016/j.neuron.2023.09.034. [xxix] Nho et al. [xxx] Nho et al.; Erik Robinson, “Brain Implant at OHSU Successfully Controls Both Seizures and OCD,” OHSU News, accessed March 3, 2024, https://news.ohsu.edu/2023/10/25/brain-implant-at-ohsu-successfully-controls-both-seizures-and-ocd. [xxxi] Awuah et al., “Bridging Minds and Machines”; Haslacher et al., “AI for Brain-Computer Interfaces.” [xxxii] Awuah et al., “Bridging Minds and Machines.” [xxxiii] Sara Green, Barbara Prainsack, and Maya Sabatello, “The Roots of (in)Equity in Precision Medicine: Gaps in the Discourse,” Personalized Medicine 21, no. 1 (January 2024): 5–9, https://doi.org/10.2217/pme-2023-0097. [xxxiv] Green, Prainsack, and Sabatello, 7. [xxxv] Robyn Bluhm and Kirstin Borgerson, “An Epistemic Argument for Research-Practice Integration in Medicine,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 43, no. 4 (July 9, 2018): 469–84, https://doi.org/10.1093/jmp/jhy009. [xxxvi] Vijay Mahant, “‘Right-to-Try’ Experimental Drugs: An Overview,” Journal of Translational Medicine 18 (June 23, 2020): 253, https://doi.org/10.1186/s12967-020-02427-4. [xxxvii] Michael S. Okun et al., “Deep Brain Stimulation in the Internal Capsule and Nucleus Accumbens Region: Responses Observed during Active and Sham Programming,” Journal of Neurology, Neurosurgery & Psychiatry 78, no. 3 (March 1, 2007): 310–14, https://doi.org/10.1136/jnnp.2006.095315. (shrink)

The global increase in the incidence of depression has sparked debates about a potential "epidemic". Within this context, there is academic criticism directed at the current state of psychiatric practice and knowledge, particularly concerning the validity of depression diagnostic criteria. Precision Psychiatry, combined with Disease Genomics, emerges as a potential solution to enhance diagnostic accuracy. Our research involves a methodological and epistemological analysis of the biological bases of depression as framed by Disease Genomics, focusing on the strategies used (...) to study depression and their relationship to the development of diagnostic and treatment technologies. We found a scenario where non-significant associations between genetic variants and depression diagnosis in initial genomic studies were interpreted as methodological failures and challenges in statistical power. Consequently, efforts have aimed to increase statistical power through statistical strategies, conceptualizing depression as a genetically-based condition, albeit simplified and decontextualized. This focus on identifying specific genetic bases is also justified by the goal of developing more precise diagnoses and more effective treatments. Finally, we pose the question of whether these strategies truly aim to clarify the boundaries of diagnosis, heavily criticized for pathologizing "normal" human suffering, or rather to deepen this trend towards a more biologically and genetically oriented understanding of depression. (shrink)

Rapid individual cognitive phenotyping holds the potential to revolutionize domains as wide‐ranging as personalized learning, employment practices, and precision psychiatry. Going beyond limitations imposed by traditional lab‐based experiments, new efforts have been underway toward greater ecological validity and participant diversity to capture the full range of individual differences in cognitive abilities and behaviors across the general population. Building on this, we developed Skill Lab, a novel game‐based tool that simultaneously assesses a broad suite of cognitive abilities while providing (...) an engaging narrative. Skill Lab consists of six mini‐games as well as 14 established cognitive ability tasks. Using a popular citizen science platform (N = 10,725), we conducted a comprehensive validation in the wild of a game‐based cognitive assessment suite. Based on the game and validation task data, we constructed reliable models to simultaneously predict eight cognitive abilities based on the users’ in‐game behavior. Follow‐up validation tests revealed that the models can discriminate nuances contained within each separate cognitive ability as well as capture a shared main factor of generalized cognitive ability. Our game‐based measures are five times faster to complete than the equivalent task‐based measures and replicate previous findings on the decline of certain cognitive abilities with age in our large cross‐sectional population sample (N = 6369). Taken together, our results demonstrate the feasibility of rapid in‐the‐wild systematic assessment of cognitive abilities as a promising first step toward population‐scale benchmarking and individualized mental health diagnostics. (shrink)

« L’histoire de la “pensée clinique” – prise en son sens le plus large – peut être dite vectorisée par une dé-singularisation toujours plus nette des situations de soin. Que ce soit en médecine somatique, en psychiatrie ou en psychologie, le colloque soignant/soigné s’est progressivement standardisé, par l’opérationnalisation d’un ensemble de procédures thérapeutiques jugées efficaces. La psychanalyse, dernière-née des sous-disciplines cliniques, occupe à ce titre une position “à la limite”. Soucieuse comme les autres de connaître pour mieux soigne r, elle (...) monte en généralité ( cf. ses étiologies, ses diagnostics et le modèle métapsychologique). Mais elle adopte simultanément – suivant cette même exigence d’efficacité – une démarche inverse qu’on peut à bon droit nommer “descente en singularité”. De fait, Freud met en évidence que certaines représentations uniques verbalisées au cas par cas de ses patients (non reproductibles par d’autres, et non utilisables pour d’autres) constituent le principal levier thérapeutique pour une série de troubles et souffrances psychiques. Son legs scientifique consiste ainsi en une reproblématisation de la question des niveaux logiques opérants dans le champ clinique : est-ce avant tout au niveau du générique (comme en médecine) qu’il faut situer l’effort de vérité pour bien soigner, à l’échelle du typique (comme en psychologie), ou, au contraire, dans l’ordre de l’ unique (proposition originale de la psychanalyse)? Une relecture du fameux cas freudien de Lucy R., tiré des Études sur l’hystérie (1895) – permet de préciser ces enjeux épistémo-cliniques, toujours d’actualité. Est alors discutée la proposition de l’extension de l’usage de l’adjectif “clinique” pour désigner toute pensée du singulier – même hors cadre thérapeutique –, dans l’art, en littérature ou en sciences humaines. ». (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Phenomenology of Superstition or a Phenomenological Superstition?Elena Ibáñez-Guerra (bio)KeywordsBehaviorism, constructionism, intentionality, operant behaviorWhen the editors of Philosophy, Psychiatry, & Psychology asked me to make some brief comments on two articles for the special issue edited by Pérez-Álvarez and Sass, I was delighted to accept, thinking that the task would be a straightforward one, and that I could easily meet the agreed deadline. But nothing could be further (...) from the truth. The articles were of such density and their content of such profundity that it took months of interpretation and study, and of bringing my own knowledge up to date, before I was in a position to understand the concepts, adjust my beliefs, and make some comments. I could certainly have delivered some kind of eulogy about the brilliance of their content; I might have countered with my own article. However, what seemed most coherent to me was to meet their arguments head on and deal with what I consider to be their principal weaknesses, leaving the bouquets for the end.The articles set out, as I understand them and within the clinical context, to relate phenomenology, in its most traditional form, with the most current form of Skinnerian behaviorism, situating themselves in a contextualism that is, at the same time, close to and removed from the most radical type of social constructionism.But let us begin by looking more closely at “Phenomenology and Behaviorism.” It is novel for me, though Professor Pérez-Álvarez had already proposed it several years ago (Pérez-Álvarez 1992), to view operant behavior as intentionality, or at least as involving final causality according to the Aristotelian classification. It is a surprising contention, not least because, as I recall, Skinner lived in a time and a context (historical reason) in which the basic goal of psychology was to convert itself into a natural science, comparable in all respects to physics, which it took as a model, focusing therefore on efficient causality (also according to Aristotle’s terminology), so that behavior was considered as the immediate consequence of a stimulus, and the stimulus–response association became the cornerstone of the discipline. It is true that the operant behavior concept refers to the functional relationship between behavior and reinforcement, but it is no less true that Skinner’s definition of reinforcement is totally empirical—“all that which increases or decreases the probability”—meaning that reinforcement can be considered neither as a motive nor as a reason for behavior, unless it be in the eyes of the observer. [End Page 251]Furthermore, even though Yela (1987) refers to Ortega y Gasset’s formula “I am myself and my circumstances” as a Skinnerian approach, the truth is that Yela himself argues that it is precisely the self that constitutes personality, such that I have a personality because I am me, and not vice versa, as Skinner would appear to argue. In this regard, Ortega’s celebrated formula has generally been interpreted, from the most personalist perspectives, as “the circumstances are myself”—to highlight the denial of the psychological subject by radical behaviorism (Mischel’s [1968] criticism of the concept of personality is relevant here). On top of this, Skinner’s rejection of all that was not directly observable, or at least, that could not be operationalized, calls into question the admissibility of anything called final cause or intentionality of behavior. In his philosophy, all the indications are that contingencies are what determine behavior; and that there would be no room for a structural causality, as Althusser would argue, or of a reciprocal determinism, in Bandura’s terms, or even of an interaction between subject and environment, as modern interactionists would maintain. “I am myself and my circumstances” seems in Skinner to become “the circumstances are me”, and indeed, the reinforcement history – which in the article in question is considered as something akin to the Sartrian idea of “life project” – is for Skinner nothing more than a continuous association of events. In my view, Ortega’s perspectivism would perhaps be closer to the sociology of the American action theorists, Merton, Parsons, etc., than to Skinnerian behaviorism, since “action”—as the action theorists... (shrink)

It is common in psychiatry and other sciences to describe an individual or a type of individual in terms of its disposition to manifest specific effects in a particular range of circumstances. According to one understanding, dispositions are statistical regularities of an individual or type of individual in specific circumstances. According to another understanding, dispositions are properties of individuals in virtue of which such regularities hold. This entry considers a number of ways of making each of these senses of (...) disposition more precise while discussing a number of dangers lurking in careless use of the concept of a disposition. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Commentary on “Wilhelm Griesinger”Aaron L. Mishara (bio)Arens situates Wilhelm Griesinger in a historical context with which we are no longer familiar. In doing so, she has performed an important task for contemporary clinicians, philosophers, and historians. We find ourselves working and thinking (both in everyday clinical practice and in the construction of our models of mental disorder) with the same categories that Griesinger struggled to sort out and redefine; (...) we often do so, however, without awareness of their history or lack of permanence. Ackerknecht writes that all the dominant trends in modern psychiatry can be traced back to Griesinger; he states that Griesinger is the “founder of neuropsychiatry,” a “merging of the two disciplines” neurology and psychiatry. Griesinger presents us with a “systematic synthesis of the anatomical, physiological, psychological and clinical points of view” (Ackerknecht 1959, 63). Somewhat contrarily, Karl Jaspers, in his General Psychopathology, groups Griesinger with the great observers and describers of clinical experience rather than among the systematic analyzers (Jaspers 1963, 849–50). Although Griesinger is best known for his identification of mental disorders as a subset of brain diseases, Karl Bonhoeffer, a successor to Griesinger as director of the Charité Clinic in Berlin, cautions that Griesinger “continued to see in psychological causes the most frequent and abundant source of mental disorders” (Bonhoeffer 1911, 53). Kales, Kales, and Vela-Bueno, however, write, “Griesinger was representative of a clinical movement that minimized the value of psychological concepts in the understanding of mental diseases” (Kales, Kales, and Vela-Bueno 1990, 15). Precisely because of his importance, contention surrounds his legacy.If Griesinger is the pioneer of empirical approaches in biological neuropsychiatry (as Ackerknecht and others claim), he is also precursor to philosophical criticisms of their limits. It is not so easy to lump Griesinger to one side of the oppositions with which we think today: Griesinger’s scientific psychiatry (formed on the basis of the newly emergent empirical physiology) was meant to steer between the Scylla of the previously reigning overspeculative romantic medicine and the Charybdis of the antitheoretical and “positivistic” materialism of Magendie. As Arens suggests, even during the same generation of university psychiatry which Griesinger was critical in forming, he was posthumously denounced as belonging to the Hegelian idealists; later, he was proclaimed to be an empiricist. Griesinger’s work contained both idealism and empiricism in a fragile synthesis that soon broke asunder.Hermeneutic theory points out that we inevitably interpret an author, in this case, Griesinger, in terms of the prejudices of our own present context of understanding and our current problems of application to clinical practice (Gadamer 1993). On the one hand, we benefit from the advantage of seeing all that follows Griesinger’s work and are able to “understand the author [End Page 165] better than he understood himself.” We are able to see what he only anticipates but is still not able to explicitly articulate as the unpredicted effects of his work. On the other hand, our interpretations are encumbered by the sedimentations of the views of his successors: his work lies buried under the subsequent interpretations and vicissitudes of a reception with its own agendas, contexts of interpretation, and realms of application. It would be easier if we could simply assign him to one side of our current debates concerning mind/body, individual/culture, and explanation/understanding rather than seeing that our present quandaries in understanding, classifying, and treating mental disorder result precisely from a reading of Griesinger that is not careful enough. It is here that Arens can help us develop our present views further by reviewing their past.Although Griesinger is heralded as the pioneer of an empirical physiological approach which employs a natural scientific concept of mechanism (Ackerknecht, O. Marx, Verwey), Arens situates him in the tradition of Kant and German idealism. It is perhaps this solution of being both philosophical and empirical which seems hard for us, today, to understand. We have come to view these directions as contradictory, to be necessarily in a mutually exclusive relationship. (But that is rather the expression of the present impasse and not the way that Griesinger originally approached these problems.) Arens ambitiously retraces the genealogy of Griesinger’s model... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Aristotle Rules, OK?José M. Villagrán (bio) and Rogelio Luque (bio)KeywordsAristotle, causes, philosophy, psychiatry, psychopathologyPérez-Alvarez, Sass, and García-Montes (2008) propose a theoretical approach to the nature of mental disorders (MD) that attempts to explain the type of reality they constitute. In line with this approach, they argue that (1) MDs should be considered not from within psychology and psychiatry, but rather from the realm of philosophy, so as (...) to avoid what they call the Charcot effect; (2) the resulting theoretical model is in contrast to naturalist models such as that of internal dysfunction, and involves “strong” constructivist assumptions from which they develop an anthropological perspective based on the clinician–patient situation; 3) this model is applicable, in principle, to all MDs (“at least to some extent”); and (4) it is based on the Aristotelian theory of the four causes.We would argue, however, that (1) it is precisely from within psychology and psychiatry that conceptual models accounting for MDs should be proposed; (2) the naturalist–constructivist dichotomy in these models should be deconstructed, and primacy given not to the ontological approach but to the epistemological one; (3) a theoretical model of this scope should account not only for MDs but also for physical disorders; and (4) only in this way would the Aristotelian theory of causes, understood as types of explanation (and therefore as epistemological approaches) be useful.Approaches from within and from WithoutFor Berrios (2006), the theoretical discourse in relation to the conceptualization of MDs in a particular sociocultural context can be formulated in two ways: on the one hand, in a centripetal fashion, using established philosophical systems (be it phenomenology [Jaspers 1977], logical empiricism [Hempel 1994], or analytic philosophy [Fulford, Thornton, and Graham 2006]). This centripetal approach can be used both by professional philosophers and by psychiatrists/psychologists. When developed by professional philosophers, such proposals, despite their possible brilliance, run the risk of being tangential to the psychiatric issues owing to a lack of first-hand experience of them (Murphy 2006). When developed by psychiatrists and psychologists, the majority of the proposals simply mix fragments of different philosophical systems, in either a kind of syncretism or collage that fails to take into account the contradictions between fragments, or a kind of pluralism that reflects, without entering into analysis, a sort of consensus among the different paradigms (Ghaemi 2003; Kendler 2005).A second way of formulating this theoretical discourse (according to Berrios) would employ a centrifugal approach from the very core of the disciplines, through the reflection of professionals (primarily, although not only, psychiatrists/psychologists with philosophical training) who would conceptualize the problems from within and develop a specific metalanguage for analyzing [End Page 265] them (Lanteri-Laura 1991; Reznek 1991; Sass 1992). Not all problems are of the same type. For those that are extrinsic to psychiatry/psychology (definition of the mental, the mind–body relationship, the distinction between causes and reasons, or interdisciplinary reduction), the methods common to the philosophy of science and of the mind can be used. However, issues intrinsic to the disciplines themselves (the nature of mental symptoms and how they are generated, how to explain their heterogeneity, what a MD is, how to diagnose and classify it, or how to implement a psychopathological project) cannot be dealt with using preestablished formulas, and require new and original proposals that take into account the nature of the disciplines and their object of study (Villagrán 2007).The authors of the target article base their preference for the centripetal approach for responding to one of the intrinsic questions of psychiatry (what MDs are) on the consequences of what they call the Charcot effect, a kind of variant of observer bias applied to psychiatric diagnosis. They offer as an example the classic diagnosis ad iuvantibus in its postmodern version, namely, the efficacy of the pharmaceutical industry in contributing to creating nosological entities for which their drugs are indicated. Consequently, clinicians are not only unable to surmount the substantial epistemological obstacles that hamper attempts to theorize, but also find themselves doomed to assuming an ingenuous essentialism that considers MDs as natural kinds (such as apples, trees, or dogs) determined... (shrink)

Concerns over medical paternalism are especially salient when there exists a conflict of values between patient and clinician. This is particularly relevant for psychiatry, the field of medicine for which the phenomenon of conflicting values is most present and for which the specter of medical paternalism looms large. Few cases are as glaring as that of anorexia nervosa (AN), a disorder that is considered to be egosyntonic (meaning its symptoms are reflectively endorsed by the patient) and maintained by the (...) presence of pathological values. One might think, given this, that an approach to medicine that foregrounds the role of values in clinical encounters would be particularly well suited to address the problem of medical paternalism in treating AN. As it happens, this is precisely the goal of values-based medicine, an approach to medicine that prioritizes the integration of patients’ unique values into the aims of treatment and that has been touted as being particularly applicable to psychiatric conditions such as AN. Although this strategy may initially appear promising, in this paper I will argue that the directive to incorporate patient values (as dictated by values-based medicine) cannot do the work of mitigating medical paternalism in the treatment of egosyntonic disorders such as AN. Rather than chalking this up as a failure due to AN being a particularly challenging case, I will instead conclude that the failure of values-based medicine in this context cuts to the heart of the limitations of rectifying medical paternalism within psychiatry as it currently exists. (shrink)

The general definition of mental disorder stated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders seems to identify a mental disorder with a harmful dysfunction. However, the presence of distress or disability, which may be bracketed as the presence of harm, is taken to be merely usual, and thus not a necessary requirement: a mental disorder can be diagnosed as such even if there is no harm at all. In this paper, we focus on the (...) harm requirement. First, we clarify what it means to say that the harm requirement is not necessary for defining the general concept of mental disorder. In this respect, we briefly examine the two components of harm, distress and disability, and then trace a distinction between mental disorder tokens and mental disorder types. Second, we argue that the decision not to regard the harm requirement as a necessary criterion for mental disorder is tenable for a number of practical and theoretical reasons, some pertaining to conceptual issues surrounding the two components of harm and others pertaining to the problem of false negatives and the status of psychiatry vis-à-vis somatic medicine. However, we believe that the harm requirement can be maintained among the specific diagnostic criteria of certain individual mental disorders. More precisely, we argue that insofar as the harm requirement is needed among the specific diagnostic criteria of certain individual mental disorders, it should be unpacked and clarified. (shrink)

This essay is an attempt to plumb the conventions which exist at a specific historical moment in both the aesthetic and scientific spheres. I will assume the existence of a web of conventions within the world of the aesthetic—conventions which have elsewhere been admirably illustrated—but will depart from the norm by examining the synchronic existence of another series of conventions, those of medicine. I do not mean in any way to accord special status to medical conventions. Indeed, the world is (...) full of overlapping and intertwined systems of conventions, of which the medical and the aesthetic are but two. Medicine offers an especially interesting source of conventions since we do tend to give medical conventions special “scientific” status as opposed to the “subjective” status of the aesthetic conventions. But medical icons are no more “real” than “aesthetic” ones. Like aesthetic icons, medical icons may iconographic in that they represent these realities in a manner determined by the historical position of the observers, their relationship to their own time, and to the history of the conventions which they employ. Medicine uses its categories to structure an image of the diversity of mankind; it is as much at the mercy of the needs of any age to comprehend this infinite diversity as any other system which organizes our perception of the world. The power of medicine, at least in the nineteenth century, lies in the rise of the status of science. He conventions of medicine infiltrate other seemingly closed iconographic systems precisely because of this status. In examining the conventions of medicine employed in other areas, we must not forget this power.One excellent example of the conventions of human diversity captured in the iconography of the nineteenth century is the linkage of two seemingly unrelated female images—the icon of the Hottentot female and the icon of the prostitute. In the course of the nineteenth century, the female Hottentot comes to represent the black female in nuce, and the prostitute to represent the sexualized woman. Both of these categories represent the creation of classes which correspondingly represent very specific qualities. While the number of terms describing the various categories of the prostitute expanded substantially during the nineteenth century, all were used to label the sexualized woman. Likewise, while many groups of African blacks were known to Europeans in the nineteenth century, the Hottentot remained representative of the essence of the black, especially the black female. Both concepts fulfilled an iconographic function in the perception and the representation of the world. How these two concepts were associated provides a case study for the investigation of patterns of conventions, without any limitation on the “value” of one pattern over another. Sander L. Gilman is professor of Humane Studies in the Department of German Literature and Near Eastern Studies and professor of Psychiatry in the Cornell Medical College, Cornell University. He is the author or editor of numerous studies of European cultural history with a focus on the history of stereotypes. In addition, he has coedited Degeneration with J. E. Chamberlin. His study Jewish Self-Hatred is forthcoming. (shrink)

Substance addiction has been historically conceived and widely researched as a brain disease. There have been ample criticisms of brain-centred approaches to addiction, and this paper aims to align with one such criticism by applying insights from phenomenology of psychiatry. More precisely, this work will apply Merleau-Ponty’s insightful distinction between the biological and lived body. In this light, the disease model emerges as an incomplete account of substance addiction because it captures only its biological aspects. When considering addiction as (...) a brain disorder, it will be shown that research fails to account for the contextual, functional, and emotional aspects inherent to subjective health. It is concluded that, while the disease model is fundamental to our understanding of what happens in the brain, its brain-centred approach is cure-oriented. Instead, we suggest a care-orientated approach, which understands and treats the psychological feel as bodily experience situated in an environment, allowing for a more encompassing therapeutic perspective. (shrink)

Research in phenomenology and philosophy of psychiatry has suggested that psychopathological disturbances of experience often involve an alteration of one's ‘sense of possibility’, dependent upon the presence of specific ‘existential feelings’ (Ratcliffe 2012). In this paper I provide an extended account of how the engagement with certain narratives can lead to a transformation of one's sense of possibility by eliciting affective experiences that are not consonant with the person's existential feelings. More precisely, I claim that, even when the experience (...) of some types of emotion is generally precluded by a restricted sense of possibility, such emotions may be aroused by particular self-narratives, and I explore how this dynamic can give rise to enduring and wide-ranging affective changes. (shrink)

Paradigmatically, natural kinds are the kinds of thing or stuff that are classified by the natural sciences. The periodic table provides perhaps the best example of the potential importance of natural kinds for science. In the philosophy of psychiatry, debates over whether mental disorders can be natural kinds emerge because kinds of mental disorder are manifestly different from chemical kinds in various ways. While chemical kinds are precise, psychiatric kinds are fuzzy. While chemical kinds are objective, the identification of (...) psychiatric kinds is value-laden. Psychiatric classification involves classifying people, and unlike chemical elements, those people can respond to being classified in various ways. This chapter goes through these differences, one-by-one, and argues that despite them, mental disorders may be natural kinds. (shrink)

Disturbances in social cognition are a core feature of schizophrenia. While most research in the field has focused on emotion perception, social knowledge, theory of mind, and attribution styles, the domain of social perception has received little specific attention. In this paper, we suggest that this issue can be explained by the lack of a precise and unitary definition of the concept, this leads to the existence of different competing uses of the concept and their conflation with other domains of (...) social cognition. Relying on resources coming from the ecological approach to psychology and the phenomenological tradition in psychiatry, we propose that the concept of Social Perception should be used to refer to low-level pre-reflective processes underlying the awareness of interpersonal interactions with and between others. Clinical data suggests that people with schizophrenia have problems perceiving social situations as opportunities for social engagement, so, in order to fulfil this explanatory need, we propose that the term should be used to capture this important—yet neglected—domain of social cognition. We conclude with the discussion of some future directions for research derived from our proposal. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What Makes a Mental Disorder Mental?Jerome C. Wakefield (bio)Keywordsharmful dysfunction, mental disorder, intentionality, mental dysfunction, mental functioning, phenomenality, somatic disorderWhat makes a medical disorder mental rather than (exclusively) somatic or physical? Psychiatry to some extent depends for its existence as a medical specialty on the distinction between mental and somatic disorders, yet the history of this distinction presents a bewildering array of puzzling judgments, radical shifts, and seemingly (...) arbitrary distinctions. The historical observation that putative mental disorders are often reclassified as physical disorders as soon as their physiologic basis is understood further confuses matters. Moreover, recent debates about such classifications often seem to reflect desires to protect professional turf or obtain optimal reimbursement for treatment more than they do the application of a coherent conceptual distinction. No wonder that Brülde and Radovic (2006) disarmingly admit at the outset of their exploration of this question that there is a case to be made that their topic is relatively unimportant or even meaningless intellectually, a rare way to start an inquiry!Could there nonetheless be a cogent conceptual distinction lurking here? Brülde and Radovic usefully invite us to reframe the question, in effect as follows: Suppose we pay attention to professional and lay judgments as evidence but at the same time try to avoid being ensnared by the distortions resulting from turf issues and other pragmatic motives and constraints. Can we then identify some principled distinction in this domain that is worth making and that interestingly corresponds to the distinction generally made between mental disorders and strictly somatic disorders? Brülde and Radovic do not come to any confident or compelling conclusion about this.My answer, based on my harmful dysfunction analysis of disorder (Wakefield, 1992a, 1992b, 1999a, 1999b), is that a mental disorder is a harmful mental dysfunction, where a mental dysfunction is a failure of the capacity of some mental mechanism to perform a function for which it was biologically designed. I argue that, owing to a series of logical missteps, Brülde and Radovic needlessly reject this view. After some preliminary comments and clarifications, I defend the internal dysfunction approach from the objections posed by Brülde and Radovic, and then conclude by elaborating this view in some new ways. Note that Brülde and Radovic critique something they call the "internal cause view" of what makes a disorder mental, and they name others who hold that view. However, my work figures prominently in their discussion, and for expository simplicity, I will presume to simply construe their arguments as aimed at the harmful dysfunction analysis. [End Page 123]Clarifying the QuestionIt is easy to misconstrue the question "What makes a mental disorder mental" as demanding a precise account of the mental, an error to which Brülde and Radovic succumb in their repeated complaints that various writers do not present principled accounts of the mental but rely on lists of prototypical mental states or tentative guidelines to fix the reference of mental. We would need a precise definition of mental if the problem were how to classify cases in which it is ambiguous whether some phenomenon is mental or physical. We might imagine, for example, someone being genuinely puzzled as to whether inability to sleep is failure of a mental function or process. But this sort of puzzle about the boundaries of the mental is not the problem with which Brülde and Radovic are concerned; anyway, ambiguous cases may just be inherently ambiguous. The problem, which a crisp definition of mental will not resolve, is what relation mental states or mechanisms must have to a disorder to make it a mental disorder; must there be mental symptoms, or mental dysfunctions, or either one, and so on? But, even if a precise resolution of the nature of the mental is not needed, some notion of the mental domain is essential in pursuing this discussion. We can pick out the mental ostensively, by pointing to lots of examples (e.g., perception, motivation, emotion, thought, and sensation) much more confidently than we can define it in a principled way. But because Brülde and Radovic find fault in such ostensive reference fixing, let me... (shrink)

While the UK Home Office’s proposals to preventively detain people with what it has called dangerous severe personality disorder have been subjected to debate and criticism the deeply troubling jurisprudential issues in these proposals have not yet entered into public debate in a way that their seriousness deserves.1 It is good that a commentator as well known as Professor Szasz is speaking out on this issue.Professor Szasz focuses upon a crucial question by calling into question the medicalisation of terms like (...) dangerousness and mental illness.2 There is a great temptation for legislators and the public to treat these terms as if they are purely scientific terms and to think of risk assessment as a precise science. I don’t share Professor’s Szasz’s worry about how psychiatry is using these terms but I think there are some important questions about how these concepts function in the public sphere.This issue is important enough to justify the use of some rhetorical claims because such claims can serve to bring out what are neglected and important issues. In raising the following objections I am not attempting to refute the message that is in Szasz’s article or to say that he is not making an important point but rather to attempt to sharpen the issues and to suggest ways that we can respond to Professor Szasz’s challenge.Psychiatry has progressed in a number of ways since Professor Szasz wrote The Myth of Mental Illness.3 The science is much better, we have much better medications, and psychiatrists are acutely aware of the tension between treating their patient and their obligations to the public interest.So when Professor Szasz says: “Psychiatrists offer to relieve the disturbed person of the burden of coping …. (shrink)

Abstract:Many discussions in the philosophy of psychiatry hinge on, among other things, the concepts of disorders, the role of underlying mechanisms, and the merits of various diagnostic models. Yet, some such disputes rest on assumptions about vagueness in the sense of susceptibility to the Sorites paradox as opposed to mere uncertainty in clinical practice. Studying borderline cases of psychiatric conditions—those where it is indeterminate whether applying a diagnosis is appropriate—may shed light on broader debates about the nature and boundaries (...) of these conditions. In this article, I will argue that if psychiatric vagueness exists, then some instances of it stem at least partially from how we describe the world instead of the state of the world or what we know about it. In other words, vagueness in psychiatric terms and concepts is at least in part semantic and neither solely epistemic nor solely ontic. On this view, slight differences in how various linguistic communities apply diagnostic terms modify their referents, making their precise extension indeterminate. This implies that we can sometimes answer questions about diagnosis by settling disagreements about language, which may provide traction in debates about the philosophy of nosology and help inform psychiatric practice. (shrink)

The mental health crisis and loneliness epidemic have sparked a growing interest in leveraging artificial intelligence (AI) and chatbots as a potential solution. This report examines the benefits and risks of incorporating chatbots in mental health treatment. AI is used for mental health diagnosis and treatment decision-making and to train therapists on virtual patients. Chatbots are employed as always-available intermediaries with therapists, flagging symptoms for human intervention. But chatbots are also sold as stand-alone virtual therapists or as friends and lovers. (...) There is evidence that these uses of AI and chatbots can provide better quality service, improve accessibility, and lower costs. The systems can reduce the stigma and shame of sharing their problems and leverage a mass of biometric and behavioral data to supplement self-reports. As the systems' intelligence rapidly improves, they will need to be rigorously tested for the accuracy and precision of their diagnoses and the quality of their interactions with patients. As chatbots become indistinguishable from humans and leverage their superhuman capacity to detect affect and draw on knowledge of a patient’s life, patients will be drawn to attribute personality to and relationship with the chatbot. Consequently, it will be essential to study what the “therapeutic alliance” with an actual human counselor provides and the risks of patients attributing such a relationship to a one-sided or “parasocial” relationship. (shrink)

This book takes Edmund Husserl's phenomenology and applies it to help psychotherapy practitioners formulate complex psychological problems. The reader will learn about Husserl's system of understanding and its concepts that point to first-person lived experience, and about the work of Husserl scholars who have developed a way to be precise about the experiences that clients have. Through exploring the connection between academic philosophy of consciousness and mental health, themes of biopsychosocial treatment planning, psychopathology of personality and psychological disorders, and the (...) treatment of complex psychological problems become clear. The author shows that Husserlian phenomenology can be used in the design of interventions for clients in a process called formulation. Once the intentionality of consciousness is understood, by asking simple questions, it becomes possible to define problematic experiences. This is a means of creating informed consent for treatment and it makes it clear to clients what is happening for them, so helping them understand themselves and how they see the world. We also see how Husserl's phenomenology is a vehicle for psychotherapists to present their knowledge about the research literature of what has been found to be effective care. This volume applies the concepts and practices of phenomenology in a concrete way, relating them to the practice of therapy and showing the value of a qualitative approach to understanding mental processes and the nature of human beings as motivated by values, meanings and other conscious experiences. This is a readable text in simple language that condenses key aspects of Husserl's thinking in relation to the theory and practice of psychotherapy, and it is suitable for philosophers and practitioners of psychology, psychiatry, and the psychotherapies, including psychoanalysis. (shrink)

Riassunto: In questo contributo analizzeremo il criterio del danno, presente nella definizione generale di disturbo mentale del DSM. La questione ha rilevanza sia da un punto di vista filosofico, perché il danno è una componente normativa e valoriale, non oggettiva, sia da un punto di vista clinico, perché chi ha difeso il criterio del danno ha spesso sostenuto che in sua assenza avremmo troppi falsi positivi. Infine, ha importanza dal punto di vista socio-sanitario in relazione al rapporto tra la psichiatria (...) e la medicina non psichiatrica, nello specifico tra il DSM e l’ICD. Sosterremo che ci sono buone ragioni per non mantenere il danno come criterio necessario nella definizione generale del disturbo mentale. Dopo una breve introduzione, forniremo una panoramica storica sul ruolo del criterio del danno nelle varie edizioni del DSM. Successivamente si illustrerà la principale obiezione contro l’inclusione del criterio del danno nella definizione generale di disturbo mentale, ossia il problema dei falsi negativi, per poi presentare e discutere ulteriori ragioni – medico-pratiche e concettuali – che depongono a sfavore dell’attribuzione di un forte peso al criterio del danno. In sede conclusiva ribadiamo come la decisione presa dalla task force del DSM-5 di escludere il criterio del danno dalla definizione generale di disturbo mentale debba essere sostenuta. Parole chiave: Danno; Disabilità; Disagio; Disturbo mentale; DSM “Harm” as Criterion for the Definition of Mental Disease in DSM. Some Epistemological Reflections: In this paper, we analyse the harm requirement in the general definition of mental disorder in the Diagnostic and Statistical Manual for Mental Disorders. This issue has both philosophical and clinical relevance: on the one hand the harm requirement is a normative, value-laden, non-objective component in the definition of mental disorder; on the other hand, the harm requirement has often been defended on the grounds that it prevents an increase in false positives. The issue is also important in assessing the relationship between psychiatry and somatic medicine, more precisely, between the DSM and the International Classification of Diseases. We argue that there are good reasons not to maintain the harm requirement in the general definition of mental disorder. After a brief introduction, we overview the history of the harm requirement across the various editions of the DSM. Then, we examine the main objection to the inclusion of the harm requirement in the general definition of mental disorder, that is, the problem of false negatives, and also present several other points – both practical and conceptual – that help demonstrate why the harm requirement is inadequate as a definiens of mental disorder. To conclude, we stress that the decision of the DSM-5 task force not to regard the harm requirement as a necessary component of mental disorder should be endorsed. Keywords: Harm; Disability, Distress; Mental Disorder; DSM. (shrink)

Over the last several years, predictive processing approaches to computational neuropsychiatry have been gaining explanatory traction. According to these accounts, some of the positive symptoms of schizophrenia arise from aberrant precision-weighting during hierarchical Bayesian inference. In contrast to computational approaches, the phenomenological tradition in psychiatry holds that disruptions or alterations of the self (Ichstörungen) lie at the core of schizophrenia. In this article, we aim to integrate these approaches. We align ourselves with the phenomenological insight that self-disturbances lie (...) at the core of schizophrenia and with the hierarchical conception of the self-model that emerges from the predictive processing architecture. We suggest that disruptions of the “hard core” of the narrative self-model might be partially involved in the generation of aberrant experiences and hyperreflexivity, and in some aspects of the sense of self-alienation and ambiguity that is characteristic of the phenomenology of schizophrenia. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Commentary on “Psychopathy, Other-Regarding Moral Beliefs, and Responsibility”R. A. Duff (bio)AbstractI make four criticisms of Fields’s account of one type of psychopathy as a responsibility-negating personality disorder which involves an incapacity to form other-regarding moral beliefs. First, his account of what it is to hold moral beliefs (in terms of accepting universal practical principles) actually specifies neither a necessary, nor a sufficient, condition for holding a moral belief. Second, (...) he is too quick to dismiss the suggestion that what psychopaths suffer from is an inability to understand moral concepts and values. Third, he does not show why we should ascribe an incapacity to accept moral beliefs to the psychopath, rather than a culpable failure to do so. Fourth, he suggests too weak a criterion of criminal liability, as requiring only the capacity to act for prudential reasons.KeywordsMoral beliefs, moral understanding, incapacity, criminal liabilityFields argues that we can properly count at least one type of psychopathy as a personality disorder which negates moral responsibility. This is not because, as others have argued, such psychopaths cannot understand moral concepts and moral values, but because they suffer an incapacity to form other-regarding moral beliefs, i. e., to accept practical moral principles; we cannot hold them morally responsible for failing to accept or obey moral principles which they lack the capacity to accept. Nor, he also argues, should we hold them criminally liable, since they lack that capacity to act for prudential reasons to which a deterrent system of law appeals.His paper rightly emphasizes the interdependence of psychiatry and philosophy, in this as in other contexts. A psychiatric account of psychopathy as a disorder involving some kind of moral incapacity must depend for its precise sense on an adequate account of the concepts of moral capacity and incapacity: an account which should draw on the resources of moral philosophy. Philosophers who aim to understand those concepts will do well to attend, as Fields does attend, to psychiatric discussions and case histories: not only because this is necessary if their comments on mental disorder or on psychopathy are to be adequately informed, but also because careful attention to the problematic phenomena of mental disorder can also illuminate our understanding of the rational powers and capacities which are lacking or distorted in the disordered, and which philosophers hope to analyze. Fields is also clearly right to emphasize that the criteria of moral responsibility might not be the same as the appropriate [End Page 283] criteria of criminal liability: that the question of whether psychopaths should be criminally liable cannot necessarily be answered simply by determining whether they are morally responsible.However, I do not think that he has provided an adequate account of psychopathy as a personality disorder which negates moral responsibility and criminal liability. I will comment on four aspects of his discussion.First, as Fields recognizes, one who wants to argue that psychopaths lack the capacity to form moral beliefs owes us an account of what it is to form, or hold, a moral belief. Fields’s account is familiar, but arguable. To hold a moral belief is to accept, and to be motivated by, a universal practical principle: a principle which one regards as providing very strong reasons for action, and breaches of which arouse such responses as (third-person) disapproval or (first-person) guilt. It could be plausibly objected, however, that accepting some universal practical principle is neither a necessary nor a sufficient condition for holding a moral belief.It is not a sufficient condition, partly because not any universal practical principle which an agent treats as being important can intelligibly count as a moral principle. The principle “One should never split an infinitive” cannot, by itself, count as a moral principle; and if someone treated it as if it were a moral principle, we would judge his moral understanding, and his rational capacities, to be seriously impaired. This suggests that a purely formal account of the “moral,” like Fields’s (an account that pays no attention to the content of what could count as a moral principle) cannot be adequate (see Foot 1978). A further, related reason for the... (shrink)

Body integrity identity disorder (BIID), formerly also known as apotemnophilia, is characterized by a desire for amputation of a healthy limb and is claimed to straddle or to even blur the boundary between psychiatry and neurology. The neurological line of approach, however, is a recent one, and is accompanied or preceded by psychodynamical, behavioural, philosophical, and psychiatric approaches and hypotheses. Next to its confusing history in which the disorder itself has no fixed identity and could not be classified under (...) a specific discipline, its sexual component has been an issue of unclarity and controversy, and its assessment a criterion for distinguishing BIID from apotemnophilia, a paraphilia. Scholars referring to the lived body—a phenomenon primarily discussed in the phenomenological tradition in philosophy—seem willing to exclude the sexual component as inessential, whereas other authors notice important similarities with gender identity disorder or transsexualism, and thus precisely focus attention on the sexual component. This contribution outlines the history of BIID highlighting the vicissitudes of its sexual component, and questions the justification for distinguishing BIID from apotemnophilia and thus for omitting the sexual component as essential. Second, we explain a hardly discussed concept from Maurice Merleau-Ponty’s Phenomenology of Perception (1945a), the sexual schema, and investigate how the sexual schema could function in interaction with the body image in an interpretation of BIID which starts from the lived body while giving the sexual component its due. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 8.4 (2001) 317-322 [Access article in PDF] On Wolfgang Blankenburg, Common Sense, and Schizophrenia Aaron L. Mishara Introduction In its increasing openness to neuroscience (Cowan, Harter, and Kandel 2000) and other of its neighboring disciplines, mainstream biological psychiatry has allowed psychopathology, philosophy, and philosophical approaches to psychopathology to play an increased role in current research interests. Given this new openness, and the acknowledgment (...) of the severity of one of psychiatry's most debilitating, costly, and intractable disorders, 1 the translation of W. Blankenburg's 1969 article concerning the psychopathology of common sense does not merely serve historical interest. It is an exceptional example of a not well-known trend in German- and French-speaking psychiatry to apply philosophical phenomenology and existentialism to psychopathological research. This trend, which reached a peak in the late 1950s and was strong well into the 1970s, has dwindling, but nevertheless, current representatives in Heidelberg and Zurich and is scattered in a few other places in Europe, Japan, the United States, and South America. The view of the Zeitgeist—which may sound astonishing, even antiquated to contemporary readers—was highly ambitious: Conceptual approaches, such as philosophical ("transcendental") phenomenology, were expected to supply knowledge about the structure of consciousness and its disturbance in various mental disorders.Following the lead of Binswanger and Szilasi, who viewed schizophrenia as an "experiment of nature" that enables us to view underlying processes otherwise hidden to "natural, everyday consciousness," Blankenburg believed that it may be possible to map the formal properties of the psychopathology of schizophrenia—precisely in the loss of common sense—as a disturbance to the basic organization of conscious experience. Any attempt to summarize this rather abstract and complex approach in a brief commentary would be ill advised. In passing, rather, I will remark that such efforts could have profound relevance to the current research of schizophrenia and its underlying neurobiology. This research has gradually acknowledged the importance of taking the patient's subjective experience of the disorder into account (Mishara, Parnas, and Naudin 1998). In this commentary, I will first give an account of the biographical and clinical reasons that led Blankenburg to turn to the problem of common sense and its relevance for schizophrenia. I will then explore what implications [End Page 317] his work may have for more recent findings concerning schizophrenia. Blankenburg's Intellectual Development Born in 1928, W. Blankenburg, the son of a Lufthansa pilot who pioneered transatlantic commercial flights, began his studies in Freiburg im Breisgau in 1947. While at Freiburg, Blankenburg heard lectures in philosophy given by E. Fink (the former assistant to Husserl) and Max Mueller, and in psychology, by R. Heiss and others. After three years, Blankenburg turned to the study of medicine, producing a dissertation in 1956 on an application of Daseinsanalysis (Heidegger and Binswanger) to a case of paranoid schizophrenia. Binswanger wrote the forward to the publication. Between 1956 and 1958, Blankenburg studied internal medicine in Heidelberg with the accomplished phenomenologist of bodily experience (Leibphaenomenologer) and student of V. von Weizsaecker Herbert Pluegge. He spent one semester in Goettingen where he attended lectures by the ontological philosopher Nicolai Hartmann, who provided for Blankenburg a more useful approach to the problem of nature and natural science than Heidegger's primary emphasis on the question of Being. During his Freiburg years, Blankenburg attended small seminars led by Heidegger in the Schwarzwald forest. (Heidegger had been forbidden to teach after the end of World War II.) Blankenburg recalls that the participants would sit on logs in an open field as if to invoke Heidegger's concept of the clearing (Lichtung) of Being. While not entirely sympathetic with Heidegger's philosophy, Blankenburg learned to carefully "listen"—as Heidegger would repeatedly emphasize—to language, not merely poetic or philosophical language, but the language of the patients he would meet in clinical practice.During this time, Blankenburg heard lectures by W. Szilasi, the philosopher-scientist who held Husserl's and Heidegger's chair in the department of philosophy. Szilasi collaborated with the phenomenological psychiatrist, L. Binswanger. Their effort to apply concepts from Husserl's... (shrink)

This essay provides an analysis of the clinical problems that arise at the borderline between neurology and psychiatry. We postulate that psychopathological and neuropathological constructs have distinct referents and conceptual fields, but they are not mutually exclusive categories. After establishing criteria for defining neuropsychiatric constructs, we outline rules for identifying cases where a significant relationship exists between neuropathological and psychopathological patterns. We propose three approaches to establishing this relationship: a clinical epidemiology approach, a clinical neuroscience approach offering a mechanistic (...) model, and a longitudinal study of individual cases incorporating idiographic perspectives. We discuss the logic of brain-behavior relationships and emphasize the need for closer academic feedback between neuroscientific research and clinical practice to better understand the causality of psychopathological phenomena in the context of neuropsychiatry. While precise demarcation may be challenging in some cases, we provide two types of examples: first, straightforward cases where neuropathology explains psychopathological patterns; second, complex cases that require studying the causal interactions between neuropathological factors, psychological factors, and sociocultural contexts, leading to intricate clinical patterns that demand cognitive neuropsychiatry resources, and a multidisciplinary approach to clinical care. (shrink)

This article explores negotiations over the humanistic versus mechanized components of care through an ethnographic account of digital phenotyping research. I focus on a US-based team of psychiatric and engineering professionals assembling a smartphone application that they hope will analyze minute changes in the sounds of speech during phone calls to predict when a user with bipolar disorder will have a manic or depressive episode. Contrary to conventional depictions of psychiatry as essentially humanistic, the discourse surrounding digital phenotyping positions (...) the machine as a necessary addition to mental health care precisely because of its more-than-human sensory, attentional capacities. The bipolar research team likewise portrays their app as capable of pinpointing sonic signs of mental illness that humans, too distracted by semantic meaning, otherwise ignore. Nevertheless, the team members tasked with processing the team’s data must craft and perform a selectively attentive machinic subject position, which they call “listening like a computer”: a paradoxical mode of attention and inattention. By tracing the team’s discursive and on-the-ground enactments of care and attention as both humanistic and machinic, I tune a critical ear to the posthuman promises of digital phenotyping. (shrink)

Plus qu'un ouvrage concernant les rapports ombrageux et controversés de l'art et de la pathologie, ce recueil est d'abord une rencontre, un creuset entre des champs, la clinique et la théorie qui, pour s'y confronter, excèdent les limites du " prêt-à-penser ". C'est pourquoi ici les divergences de méthodes et de perspectives entre des approches phénoménologique et psychanalytique ne dressent pas de strictes délimitations, mais font résonner des dissonances capables de laisser penser l'écart entre l'art et la pathologie comme établi (...) sur une entr'appartenance plus essentielle, ne livrant rien de son secret à celui qui s'en tient à des distinctions de principe. Encore faut-il entendre pathologie en son sens grec, au sens où la rencontre avec le monde ouvre, dans le réel, une brèche incolmatable dont seul l'art peut authentiquement rendre compte et dans laquelle la psychose s'engouffre si aucune mise en œuvre ne vient l'endiguer ou la ressourcer. " Aussi ne faut-il pas s'étonner que penser l'art et penser la folie puissent converger dans la mesure où ni l'un ni l'autre ne sont conceptualisables. Finalement, penser l'art ou penser la folie, c'est avoir ouverture à eux, à travers les œuvres, à travers les êtres malades et cela n'est possible précisément que dans une rencontre. Qu'est-ce qu'une rencontre? C'est cette situation qui n'a pas d'antécédent, qui n'a pas d'espace ni de temps qui puisse la précéder. L'épiphanie de quelqu'un dans le regard d'un autre implique nécessairement l'autophanie de celui-ci. L'échec de la rencontre, récusant tout passage lucide à l'ouvert, rejette le thérapeute sur sa facticité. C'est pour se dérober à l'épreuve sans partage de cette absence de soi, que la psychiatrie médicale, scientifico-médicale fait l'impasse sur la présence de l'autre, en objectivant tout ce qui touche à l'homme, en faisant de lui un cas particulier de cette objectivation universelle qui est la caractéristique de la culture de notre époque. ". (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Eclecticism and Adolf Meyer’s Functional Understanding of Mental IllnessD. B. Double (bio)KeywordsAdolf Meyer, eclecticism, functionalism, biopsychosocial modelGhaemi’s Commentary and Meyer’s ‘Eclecticism’I am not against humanism. How could anyone be against the humanistic wisdom rooted in the worthy writings of Socrates, Hippocrates, Shakespeare, Cervantes, Osler, and the others listed by Nassir Ghaemi? Psychiatry should recognize the dignity and value of all people. The problem is that it may not (...) always do so, coming from a reductionist paradigm as it so often does.Ghaemi appreciates that Meyer’s compromising attitude meant that he was “unable to inoculate psychiatry from biological dogmatism.” My emphasis is on the challenge of Meyer’s psychobiology to biomedicine. In the same way, Engel’s biopsychosocial model acknowledged the need to neutralize the power of an impersonal and mechanical medicine. Doctors tend to overemphasize physical abnormalities at the expense of dealing with difficult personal issues.At the risk of oversimplification, I am juxtaposing biopsychosocial and biomedical models in psychiatry. Or in other terms, for our modern understanding, I am asserting a neo-Meyerian approach in contrast to neo-Kraepelinianism. Merely restating the Meyerian perspective will not do, because of Meyer’s ‘give and take,’ and his consequent failure to follow through the implication of his position. At least the ethical ramifications of his conceptual framework need to be acknowledged.Neo-Meyerianism also needs to be realized in the context of the reaction to anti-psychiatry. After anti-psychiatry’s attack, our modern understanding of mental illness has tended to be been subsumed into the binary opposition of ‘pro-psychiatry’ and ‘anti-psychiatry.’ But neo-Meyerianism is as much pro-psychiatric as biomedical psychiatry. It is in this sense that biopsychological approaches have been undermined by the biomedical reaction to anti-psychiatry. [End Page 355]I also agree with Ghaemi that there is a way in which the failures of the biopsychosocial model allowed the development of anti-psychiatry. For example, even though Laing quoted favorably from psychologically minded psychiatrists such as Manfred Bleuler, as far as I know he never made any reference to Meyer. There was never a systematic Meyerian theory to which Laing could refer. In fact, Laing wished to move beyond an interpretative understanding to abandon the metaphor of pathology (Double 2006). Perhaps if the biopsychosocial model had been more clearly defined, Laing would not have felt he needed to take this step. Or, at least in doing so, he would have been clearer about where he stood on this issue. When labeling Laing’s views as ‘anti-psychiatry,’ biomedical psychiatry would have had to state more precisely how Laing’s position was anti- rather than pro-psychiatric.My main disagreement with Ghaemi is his view of Meyer as eclectic. Meyer’s willingness to allow ‘anything goes’ in psychiatry meant that he did not oppose or challenge too much the views of those with whom he disagreed. Nonetheless, he did not combine together different sources to create an unintegrated philosophical and conceptual understanding. His theoretical position is internally consistent.Modern American psychiatry studied by participant observation is “of two minds,” in that there is a divided consciousness created between the practices of drug therapy and psychotherapy (Luhrmann 2000). In this sense, it is eclectic because there is no consistent theory that combines the two practice modes. True, psychiatry often claims that the foundation for this mixture is the biopsychosocial model. It asserts that everyday psychiatry is not as purely biomedical as is often maintained because it takes into account psychosocial factors that may precipitate mental disorders. It, therefore, says that it bring together the biological and psychosocial. This compromise avoids the adoption of any one model and was proposed to neutralize the dogmatism engendered by the anti-psychiatry debate (Clare 1980). I agree with Ghaemi that such eclecticism has outlived its usefulness.Where I think Ghaemi is mistaken is that he sees Meyer and Engel as the originators of this eclecticism. I regard the Meyerian approach as more genuinely pragmatic than Ghaemi suggests. Meyer’s dynamic psychology sought an integration of mind and brain as a way of dealing with the philosophical dilemma of the mind–body... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 8.4 (2001) 327-329 [Access article in PDF] Husserlian Comments on Blankenburg's "Psychopathology of Common Sense" Osborne P. Wiggins, Michael Alan Schwartz, and Jean Naudin In this essay, Wolfgang Blankenburg sketches his influential view that some of the disturbances of schizophrenia in particular can be interpreted as a pathology of common sense. We think it important at the outset, however, to avoid possible misunderstandings of (...) Blankenburg's point. It is perhaps unfortunate that this point is expressed by use of the phrase, "common sense." As Blankenburg's own essay shows, even among the learned, "common sense" has no definite or univocal meaning. Therefore, it is entirely possible to find many people who, under some conception of "common sense," appear to lack common sense and yet should not be deemed schizophrenic. Consequently, it is probably best to avoid the ambiguous phrase "common sense" altogether and seek to comprehend Blankenburg's point in other terms. That is precisely what we shall attempt here. We do endorse Blankenburg's view. Moreover, we shall pursue his suggestions that a Husserlian phenomenology of our experience of the life-world may provide the basis for developing the kind of psychopathology he seeks. Our ultimate aim, however, is for this phrase "common sense" to vanish into the Husserlian phenomenology we offer, so that all the other meanings of common sense will not threaten Blankenburg's position with misunderstandings.Our comments must remain a mere sketch. Since, however, Husserl's phenomenology is not well known, we shall have to devote some time to outlining those features of it that we deem relevant here.For Husserl, every mental process is an awareness of something. In his terminology, it is "intentional." No mental process occurs in isolation, however. It rather occurs within a concatenation of many other mental processes. Some of these co-occurring mental processes intend the same object; they intend other aspects of the object. For example, a woman may be aware of the color of a dress she is considering wearing. Hence, one process in her mental life is (visually) aware of the brown color. But another process in her mental life may be intending it as a "party dress." And yet another process in her mental life may be (tactually) intending the texture of the cloth. Because all of these mental processes (and many others) intend the same object, namely, the dress, Husserl says that they are synthesized with one another. "Synthesis," then, connotes a multiplicity of mental processes united with one another through intending the same object.Now Husserl believed that it is because the many processes occurring in our mental lives [End Page 327] synthetically intend the many objects we encounter that we experience ourselves as inhabiting a world of objects. If these syntheses failed to occur, we would not experience the world or ourselves as parts of this world. These syntheses make it possible for us to experience objects and events as related to one another in the manifold spatial, causal, temporal, social, political, religious, and other relationships that we do in fact experience. Husserl thus contends that our mental lives "constitute" the world for us. Mental life can accordingly be viewed as "world-constituting." Mental life is thus the condition for the possibility of there being a world of objects for us, to modify Kant's phrase. Husserl thought his notion of world-constituting consciousness sufficiently similar to Kant's for him to appropriate the latter philosopher's concept of "transcendental." Husserl also then spoke of "transcendental consciousness" and the study of this consciousness as "transcendental philosophy."Husserl made many distinctions among kinds of mental processes and their correlative objects. We shall here explicate only one such distinction. Mental processes must be distinguished as those that are actively generated by an ego and those that are not produced by an ego. The latter kind of mental process occurs automatically or, as Husserl writes, "passively." Husserl calls the first kind of mental process "active." Having mentioned him, however, we should also briefly characterize the "ego... (shrink)

The fast-developing field of neuroscience has given philosophy, as well as other disciplines and the public broadly, many new tools and perspectives for investigating one of our most pressing challenges: addressing the health and well-being of our mental lives. In some cases, neuroscientific innovation has led to clearer understanding of the mechanisms of mental illness and precise new modes of treatment. In other cases, features of neuroscience itself, such as the enticing nature of the data it produces compared to previous (...) behavioral methods, together with its costliness and “coldness” have complicated understanding of mental illness and decision making about mental illness. Taking neuroscientific information into account can leave practitioners in psychiatry and law with difficult questions, stemming not only from the complexity of these fields, but also from our rapidly evolving understanding of and facility with neuroscience. In this chapter, we will review several examples of the insights and dilemmas that have unfolded as mental illness has been examined through the lens of neuroscience, covering diagnoses such as obsessive-compulsive disorder (OCD), schizophrenia, addiction, and severe mood disorders. (shrink)

Synchronicity IIn the summer of 2006, I read several books by well-known existential psychiatrist and insightful novelist Irvin Yalom.2 They were all thought-provoking and mightily entertaining. Dr. Yalom sustains lively interests in philosophical aspects of psychiatry, as well as in psychiatric aspects of philosophy. Among other works, he has written two profoundly philosophical novels, namely The SchopenhauerCure and When Nietzsche Wept, in which he has delved deeply and creatively into the psyches of these two outstanding thinkers via the refracting (...) media of literary and historical fiction, and through lenses of eclectic existential psychiatry.Yalom’s fictive excursions are not confined to philosophical realms—far from it. In a delightfully ironic novel entitled Lying on the Couch Yalom takes to task some perennially unfinished business of psychoanalysis, namely analysts’ perpetual struggles with counter-transference issues. Even the most seasoned psychoanalysts, so Yalomartfully reveals, have not yet had their own egos sufficiently shrunk. In consequence, they are apt to experience all kinds of problems with patients, and not always of the patients’ making. To be sure, patients are wont to deceive their analysts at times, whether subconsciously, diffidently, or maliciously. And analysts themselves are prone to all the vanities catalogued by Ecclesiastes in antiquity,3 egoisms and egotisms alike that appear innately rooted in the human psyche, and which inevitably contribute to self-deception. If an analyst’s vanities, self-deceptions, and unresolved counter-transferences were skillfully exploited by a professional con-artist posing as a patient, personal and professional mayhemwould result. This is one of the conspicuous threads in the rich tapestry of untruths, vanities and self deceptions that Yalom weaves in Lying on The Couch.One particular episode in Yalom’s novel rather jarred me when I encountered it in August 2006, because it coincided with an uncannily similar episode that was unfolding in my own life at precisely the same time. (shrink)

Sleep has long been a topic of fascination for artists and scientists. Why do we sleep? What function does sleep serve? Why do we dream? What significance can we attach to our dreams? We spend so much of our lives sleeping, yet its precise function is unclear, in spite of our increasing understanding of the processes generating and maintaining sleep. We now know that sleep can be accompanied by periods of intense cerebral activity, yet only recently has experimental data started (...) to provide us with some insights into the type of processing taking place in the brain as we sleep. There is now strong evidence that sleep plays a crucial role in learning and in the consolidation of memories. Once the preserve of psychoanalysts, 'dreaming' is now a topic of increasing interest amongst scientists. With research into sleep growing, this volume is both timely and valuable in presenting a unique study of the relationship between sleep, learning, and memory. It brings together a team of international scientists researching sleep in both human and animal subjects. Aimed at researchers within the fields of neuroscience, cognitive neuroscience, psychiatry, and neurology, this book will be an important first step in developing a full scientific understanding of the most intriguing state of consciousness. (shrink)