1. In her latest book (Jefferson, 2022), “Are Mental Disorders Brain Disorders?”, Anneli Jefferson (AJ) argues that mental disorders can be considered brain disorders when they involve brain dysfun...

Though addiction is a complex empirical phenomenon, some of the most pressing questions about it concern how we should evaluate agents who are living with it. To that end, a fruitful methodology is to tease out from our best sciences consequences at the level of moral psychology. Taking account of epidemiology, behavioral science, animal studies and, chiefly, neuroscience, I argue for a view according to which addiction involves dysfunctional motivational states (which I call “hybrid intentions”) as well as cognitive distortions. (...) This argument can be made without needing to settle the traditional debate about whether addiction is a disease. (shrink)

In this article, we explore how deep brain stimulation (DBS) devices designed to “close the loop”—to automatically adjust stimulation levels based on computational algorithms—may risk taking the individual agent “out of the loop” of control in areas where (at least apparent) conscious control is a hallmark of our agency. This is of particular concern in the area of psychiatric disorders, where closed-loop DBS is attracting increasing attention as a therapy. Using a relational model of identity and agency, we consider whether (...) DBS designed for psychiatric regulation may require special attention to agency. To do this, we draw on philosophical work on relational identity and agency, connecting it with reports from people using first-generation DBS devices for depression and obsessive-compulsive disorder. We suggest a way to extend a notion of relational agency to encompass neural devices. (shrink)

Psychiatry widely assumes an internalist biomedical model of mental illness. I argue that many of psychiatry’s diagnostic categories involve an implicit commitment to constitutive externalism about mental illness. Some of these categories are socially externalist in nature.

Die forensische Kinder- und Jugendpsychiatrie steht in einem komplexen Spannungsfeld medizinischer, rechtlicher und sozialer Anforderungen. Die ethischen Herausforderungen, die sich daraus für den stationären Maßnahmenvollzug ergeben, sind bisher kaum untersucht, spezifische Hilfestellungen für Behandelnde fehlen. Diese Studie hat zum Ziel, ethische Themenfelder und Probleme in diesem Bereich zu identifizieren und ein Instrument zur Früherkennung und -intervention ethischer Probleme im Klinikalltag zu entwickeln. Methode: Eine systematische Literaturrecherche sowie eine Beobachtungstudie in der Jugendforensik der Universitären Psychiatrischen Kliniken Basel werden durchgeführt. Die Beobachtungsdaten (...) werden mittels qualitativer Inhaltsanalyse ausgewertet. Das Instrument wird auf der Basis der Resultate nach einer neuen Methode entwickelt. In der Literaturrecherche wurden 14 valide Publikationen identifiziert, die hauptsächlich ethische Probleme der Gerichtspsychiatrie thematisieren wie professionelle Rollenkonflikte, ethische Probleme der Diagnostik und Begutachtung oder der Umgang mit vertraulichen Informationen. Empirische oder empirisch-normative Studien fehlen. In der Beobachtungsstudie wurden 24 ethische Themen und spezifische Probleme identifiziert, besonders häufig sind ethische Fragen zu Moralkompetenzen der Jugendlichen, zur Behandlungsqualität, zum Umgang mit Regeln und Sanktionen und zur Freiheits- und Privatsphäre. Das Instrument zur Früherkennung und -intervention ethischer Probleme enthält die vier Kernelemente Risikofaktoren, Indikatoren, Interventionsplanung und Entscheidungsfindung. Der Maßnahmenvollzug der forensischen Kinder- und Jugendpsychiatrie offenbart ein breites Spektrum ethischer Themen mit spezifischen ethischen Problemen, welche in der Literatur bisher nur unzureichend untersucht sind. Das hier entwickelte Instrument FIEP unterstützt Behandelnde dabei, ethische Probleme frühzeitig zu erkennen und effizient zu bearbeiten. (shrink)

Involuntary psychiatric commitment for suicide prevention and physician aid-in-dying (PAD) in terminal illness combine to create a moral dilemma. If PAD in terminal illness is permissible, it should also be permissible for some who suffer from nonterminal psychiatric illness: suffering provides much of the justification for PAD, and the suffering in mental illness can be as severe as in physical illness. But involuntary psychiatric commitment to prevent suicide suggests that the suffering of persons with mental illness does not justify ending (...) their own lives, ruling out PAD. Since both practices have compelling underlying justifications, the most reasonable accommodation might seem to be to allow PAD for persons with mental illness whose suffering is severe enough to justify self-killing, but prohibit PAD for persons whose suffering is less severe. This compromise, however, would require the articulation of standards by which persons’ mental as well as physical suffering could be evaluated. Doing so would present a serious philosophical challenge. (shrink)

Bianchi, Stanley, and Sutander argue in an insightful, cogent manner for the consideration of harm reduction as an ethically-defensible, non-paternal management approach for capable persons...

Background Research on the impact of ethics reflection groups (ERG) (also called moral case deliberations (MCD)) is complex and scarce. Within a larger study, two years of ERG sessions have been used as an intervention to stimulate ethical reflection about the use of coercive measures. We studied changes in: employees’ attitudes regarding the use of coercion, team competence, user involvement, team cooperation and the handling of disagreement in teams. Methods We used panel data in a longitudinal design study to measure (...) variation in survey scores from multidisciplinary employees from seven departments within three Norwegian mental health care institutions at three time points (T0–T1–T2). Mixed models were used to account for dependence of data in persons who participated more than once. Results In total, 1068 surveys (from 817 employees who did and did not participate in ERG) were included in the analyses. Of these, 7.6% (N = 62) responded at three points in time, 15.5% (N = 127) at two points, and 76.8% (N = 628) once. On average, over time, respondents who participated in ERG viewed coercion more strongly as offending (p < 0.05). Those who presented a case in the ERG sessions showed lower scores on User Involvement (p < 0.001), Team Cooperation (p < 0.01) and Constructive Disagreement (p < 0.01). We observed significant differences in outcomes between individuals from different departments, as well as between different professions. Initial significant changes due to frequency of participation in ERG and case presentation in ERG did not remain statistically significant after adjustment for Departments and Professions. Differences were generally small in absolute terms, possibly due to the low amount of longitudinal data. Conclusions This study measured specific intervention-related outcome parameters for describing the impact of clinical ethics support (CES). Structural implementation of ERGs or MCDs seems to contribute to employees reporting a more critical attitude towards coercion. Ethics support is a complex intervention and studying changes over time is complex in itself. Several recommendations for strengthening the outcomes of future CES evaluation studies are discussed. CES evaluation studies are important, since—despite the intrinsic value of participating in ERG or MCD—CES inherently aims, and should aim, at improving clinical practices. (shrink)

Brings together and interprets previously hard-to-find texts, new translations and passages detailing the interplay between philosophy and psychopathology.

The need for a model -- Currently available models in psychiatry -- Introduction to enactivism -- Body and mind - and world -- The existential dimension and its role in psychiatry -- Enriched enactivism : existential sense-making, values, and socio-cultural worlds -- Enactive psychiatry : psychiatric disorders are disorders of sense-making -- An enactive approach to causes, diagnosis and treatment of psychiatric disorders.

If a patient complies voluntarily with a certain proposal, we generally regard the treatment as legitimate. But a competent patient may also assent to a certain treatment only because he was compelled to do so. Influences on the formation of his decision may render his choice contrary to his will. It is my aim to focus on these particular forms of coercion which are often neglected in discussions of informed consent.

Some critics argue that the types of psychiatric diagnosis found in the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Disease are superfluous and should be abandoned. These are known as categorical polythetic psychiatric diagnoses. To receive a categorical polythetic psychiatric diagnosis an individual need only exhibit some, rather than all, of the symptoms on the diagnostic criteria. Consequently, categorical polythetic psychiatric diagnoses only associate an individual with a range of symptoms rather than specify which symptoms they (...) have. Drawing on Giere’s account of scientific models, I portray categorical polythetic psychiatric diagnoses as abstract models that guide the building of less abstract models. These models can specify which symptoms a particular individual has. Additionally, categorical polythetic psychiatric diagnoses can guide investigation of symptoms towards difficult to spot symptoms, guide investigation towards changing symptoms, and guide investigation towards how symptoms manifest. These important roles mean categorical polythetic psychiatric diagnoses should not be abandoned. (shrink)

Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder, and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient’s autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical (...) practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient’s and the therapist’s perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist’s approach, who used motivational interventions with a view to appealing to the patient’s responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions. (shrink)

In a clinic-wide approach to establish liberal policies, a closed psychiatric ward was planned to be opened. The leaders of the multi-professional team of this ward requested continuous ethics support during the first few months after the transition from their previously closed ward into an open one. During the process of accompanying the team through this ethically sensitive period of institutional change, several variations of ethics consultation were developed: the ‘context-adjusted’ clinical ethics support. Some ethics consultations focused on a retrospective (...) evaluation of a patient case, in other ethics consultations consolidation of a previous case discussion was worked out, and/or reflections on fundamental ethical issues were included. Based on our experiences and the feedback of the team, we consider this context-adjusted clinical ethics support as feasible and effective. (shrink)

In the 20th century, the boundaries of psychosis emerged as an area in which psychiatric judgement faced numerous and profound uncertainties. Between obvious neuroses and personality and reactive disorders on the one hand, and unquestionable psychoses on the other, psychiatrists faced a world of suspected cases of schizophrenia, doubtful personality disorder diagnoses or probable cases of psychosis constituting a garden of equivocal clinical presentations in which both individual psychiatrists and the discipline as a whole were confronted with the limits of (...) their knowledge. This article examines how psychiatrists from two German university clinics managed the multiple uncertainties involved in diagnosing cases of early psychosis between 1950 and 1980. Based on the analysis of a sample of records, we propose a pragmatic interpretation of the ways in which these uncertainties were recorded by psychiatrists. How were uncertainties and doubts expressed in the records and managed by clinicians? What means were used to dispel doubt? What were the consequences for patients of these diagnostic uncertainties? The article defines an uncertainty diagnosis as a diagnosis expressed with reservations by its author and recorded as such in a medical file. Depending on the nature of the uncertainty, the types of evidence used by the professionals and how this evidence was dealt with, we have identified three types of uncertainty diagnoses: suspicion, plausibility and probability diagnoses. The article then reflects on the role of the patients themselves in shaping these uncertain situations. (shrink)

_Choice Recommended Read_ _What Psychiatry Left Out of the DSM-5: Historical Mental Disorders Today_ covers the diagnoses that the _Diagnostic and Statistical Manual of Mental Disorders_ failed to include, along with diagnoses that should not have been included, but were. Psychiatry as a field is over two centuries old and over that time has gathered great wisdom about mental illnesses. Today, much of that knowledge has been ignored and we have diagnoses such as "schizophrenia" and "bipolar disorder" that (...) do not correspond to the diseases found in nature; we have also left out disease labels that on a historical basis may be real. Edward Shorter proposes a history-driven alternative to the DSM. (shrink)

Volume 19, Issue 10, October 2019, Page 68-70.

Common mental health disorders are rising globally, creating a strain on public healthcare systems. This has led to a renewed interest in the role that digital technologies may have for improving mental health outcomes. One result of this interest is the development and use of artificial intelligence for assessing, diagnosing, and treating mental health issues, which we refer to as ‘digital psychiatry’. This article focuses on the increasing use of digital psychiatry outside of clinical settings, in the following (...) sectors: education, employment, financial services, social media, and the digital well-being industry. We analyse the ethical risks of deploying digital psychiatry in these sectors, emphasising key problems and opportunities for public health, and offer recommendations for protecting and promoting public health and well-being in information societies. (shrink)

In recent years, phenomenologically informed philosophers, psychologists and psychiatrists have attempted to import philosophical notions associated with the self into the empirical study of pathological experience. In particular, so-called ipseity disturbances have been put forward as generative of symptoms of schizophrenia, and several attempts have been made to operationalize and measure kinds and degrees of ipseity disturbances in schizophrenia. However, we find that this work faces challenges caused by the fact that the notion of ipseity is used ambiguously, both in (...) the philosophical and in the empirical discussion, and the methods employed to operationalize ipseity often portray a rather different understanding of the notion from that found in the literature that is cited as providing the philosophical foundation for the studies in question. In particular, according to the definitions found in the philosophical literature, while being phenomenologically available, the self is not represented in ipseity. However, when it comes to the empirical study of ipseity and its disturbances, the object of investigation is often a kind of explicit self-representation. As a result, it is unclear whether different researchers are really talking about the same thing. Future progress in this area will require more careful conceptual distinctions; the present article aims to contribute to this task. (shrink)

There is an apparent epidemic of mental illness. At the end of 2011, untreated mental disorders accounted for 13% of the total global burden of disease, and for 25.3% and 33.5% of all years lived with a disability in low-and middle-income countries, respectively. Depression affects 350 million people globally and is the leading cause of disability. One in five U.S. adults takes psychiatric medication. One study found that by age 32, 50% of people surveyed qualified for an anxiety disorder, more (...) than 40% for a mood disorder, and more than 30% for substance dependence. Another study reported that... (shrink)

Patient competence, defined as the ability to reason, appreciate, understand, and express a choice is rarely discussed in patients with obsessive compulsive disorder, and coercive measures are seldom used. Nevertheless, a psychiatrist of psychologist may doubt whether OCD patients who refuse treatment understand their disease and the consequences of not being treated, which could result in tension between respecting the patient’s autonomy and beneficence. The purpose of this article is to develop a notion of competence that is grounded in clinical (...) practice and corresponds with the experiences of patients with obsessions and/or compulsions. We present a naturalistic case study giving both the patient’s and the therapist’s perspective based on in-depth interviews and a narrative analysis. The case study shows that competence is not merely an assessment by a therapist, but also a co-constructed reality shaped by the experiences and stories of patient and therapist. The patient, a medical student, initially told her story in a restitution narrative, focusing on cognitive rationality. Reconstructing the history of her disease, her story changed into a quest narrative where there was room for emotions, values and moral learning. This fitted well with the therapist’s approach, who used motivational interventions with a view to appealing to the patient’s responsibility to deal with her condition. We conclude that in practice both the patient and therapist used a quest narrative, approaching competence as the potential for practical reasoning to incorporate values and emotions. (shrink)

Recent years have witnessed an intensification of historical and philosophical research on the link between psychotropic drugs and psychiatric theories. For example, Kendler and Schaffner detailed how the dopamine hypothesis of schizophrenia was intimately linked to the dopamine theory of antipsychotic drug action. Here, a related case is explored: the use of antidepressants' neurochemical effects to speculate about the pathophysiology of depression.This rationale was central to American psychiatrist Schildkraut's landmark article on the catecholamine hypothesis of affective disorders. Accordingly, the paper's (...) hypothesis—that depressions may relate to decreased... (shrink)

Background: Psychedelics are known for their powerful mental effects due to the activation of 5HT-2A receptors in the brain. During the 1950s and 1960s, research was conducted on these molecules until their criminalization. However, their clinical investigation as therapeutic tools for psychiatric disorders has revived the deontological ethics surrounding this subject. Questions arise as research on their therapeutic outcome becomes a reality. We aim to explore deontological ethics to understand the implications of psychedelics for the clinician, patient, and society. Results: (...) A total of 42 articles were considered for this review. Methods: A methodological search of psychedelic studies from 2017 to 2022 was conducted in PubMed, Scopus, EBSCOhost, and ScienceDirect to address the deontological ethics of clinical psychedelic use. Conclusion: Psychedelics need to be culturally contextualized, epistemic harm minimized and represented to ensure informed consent. Open data and commissions are needed to ensure safe and equal distribution. (shrink)

Jonathan Y. Tsou examines and defends positions on central issues in philosophy of psychiatry. The positions defended assume a naturalistic and realist perspective and are framed against skeptical perspectives on biological psychiatry. Issues addressed include the reality of mental disorders; mechanistic and disease explanations of abnormal behavior; definitions of mental disorder; natural and artificial kinds in psychiatry; biological essentialism and the projectability of psychiatric categories; looping effects and the stability of mental disorders; psychiatric classification; and the validity (...) of the DSM's diagnostic categories. The main argument defended by Tsou is that genuine mental disorders are biological kinds with harmful effects. This argument opposes the dogma that mental disorders are necessarily diseases that result from biological dysfunction. Tsou contends that the broader ideal of biological kinds offers a more promising and empirically ascertainable naturalistic standard for assessing the reality of mental disorders and the validity of psychiatric categories. (shrink)

The dominance of the medical-model in American psychiatry over the last 30 years has resulted in the subsequent decline of the “talking cure”. In this paper, we identify a number of problems associated with medicalized psychiatry, focusing primarily on how it conceptualizes the self as a de-contextualized set of symptoms. Drawing on the tradition of hermeneutic phenomenology, we argue that medicalized psychiatry invariably overlooks the fact that our identities, and the meanings and values that matter to us, (...) are created and constituted by our dialogical relations with others. While acknowledging the importance of medical and pharmaceutical interventions, we suggest that it is only by means of the dialogical interplay of the talking cure that the client can both recognize unhealthy and self-defeating ways of being and be opened up to the possibility of new meanings and self-interpretations. (shrink)

Just over a decade ago, I began teaching medical students in the required preclinical course ethics and professionalism. The point of the course was to introduce basic ethical and professional norms through a small number of large group sessions, but mostly small group tutorials of 10 or 12 students engaging in weekly sessions combining readings from the literature and case scenarios highlighting real-life ethical tensions they either had, or would most likely, encounter in the future. The students wrote perceptively and (...) thoughtfully each week, and class was topical and lively. Some students went on to complete longer essays for a school-wide ethics competition and even to win. By all accounts a resounding... (shrink)

Preview: Where should we look for an answer to the question whether a psychiatrist is an expert? In analyses of the concept of “expert”? In sociological studies? Or perhaps in opinions formulated by psychiatrists themselves? The subject is not as simple as it might first seem and the answer cannot be obvious. Certainly, psychiatrists are considered to be experts when they are called in by the court to act as expert witnesses. They are also deemed experts when they make a (...) diagnosis, prescribe medication, or write out a sick note – similarly to other doctors. We typically trust that, just like other healthcare professionals, they will help us to recover or at least that they can alleviate our suffering. (shrink)