Time processing is a multifaceted skill crucial for managing different aspects of life. In the current work, we explored the relationship between interoception and time processing by examining research on clinical models. We investigated whether time processing deficits are associated with dysfunction of the interoceptive system and/or insular cortex activity, which is crucial in decoding internal body signaling. Furthermore, we explored whether insular activation predicts the subjective experience of time (that is, the subjective duration of a target stimulus to (...) be timed). Overall, our work suggests that alteration of the interoceptive system could be a common psychophysiological hallmark of mental disorders affected by time processing deficits. (shrink)

ABSTRACT Amygdala is an intensively researched brain structure involved in social processing and multiple major clinical disorders, but its functions are not well understood. The functions of a brain structure are best hypothesized on the basis of neuroanatomical connectivity findings, and of behavioral, neuroimaging, neuropsychological, and physiological findings. Among the heaviest neuroanatomical interconnections of amygdala are those with perirhinal cortex (PRC), but these are little considered in the theoretical literature. PRC integrates complex, multimodal, meaningful, and fine-grained distributed representations (...) of objects and conspecifics. Consistent with this connectivity, amygdala is hypothesized to contribute meaningful and fine-grained representations of intangible knowledge for integration by PRC. Behavioral, neuroimaging, neuropsychological, and physiological findings further support amygdala mediation of a diversity of such representations. These representations include subjective valence, impact, economic value, noxiousness, importance, ingroup membership, social status, popularity, trustworthiness, and moral features. Further, the formation of amygdala representations is little understood, and is proposed to be often implemented through embodied cognition mechanisms. The hypothesis builds on earlier work, and makes novel contributions to understanding the heavy but neglected amygdala-PRC interconnections, and the diversity of amygdala-mediated intangible knowledge representations. Importantly, these illuminate amygdala’s involvement in social processing, and in major clinical disorders. The latter is demonstrated with novel and testable explanations of a number of prominent and unexplained symptoms of autism spectrum disorder. (shrink)

When i was in graduate school, I inadvertently walked in on a fellow student taking his comprehensive exams. He was extremely frustrated because two of the questions asked about conceptual issues in personality and personality disorders. This student was not expecting such questions and considered them to be unfair. I knew other students in that same program who would have considered it a gift to get such “interesting” questions. Those clinical and counseling psychologists with theoretical–philosophical interests are often (...) attracted to the topics of personality and personality disorders. It has, therefore, puzzled me why these same topics are largely ignored by those philosophers who study the conceptual issues of .. (shrink)

Mood disorders, including major depressive disorder and bipolar disorder, are highly prevalent, frequently disabling, and sometimes deadly. Additional research and more effective medications are desperately needed, but clinical trials research in mood disorders is fraught with ethical issues. Although many authors have discussed these issues, most do so from a theoretical viewpoint. This manuscript uses available empirical data to inform a discussion of the primary ethical issues raised in mood disorders research. These include issues of consent (...) and decision-making capacity, including patients’ motivations for participating in research. We also address drug withdrawals, placebo controls, and the overall safety of research. Finally, we examine the extant literature for studies discussing potential indirect benefits of clinical trials research to participants. Taken together, the evidence suggests that clinical trials research incorporating drug withdrawals and placebo controls can be conducted safely and ethically, even in patients with severe or treatment-resistant mood disorders. In fact, given the dearth of effective treatment options for this population, it is our opinion that a moral imperative exists to extend the offer of research participation to severely ill or treatment-resistant groups. (shrink)

Patients with the controversial diagnosis of body integrity identity disorder report an emotional discomfort with having a body part that they feel should not be there. This discomfort is so strong that it interferes with routine functioning and, in a majority of cases, BIID patients are motivated to seek amputation of the limb. Although patient requests to receive the best available treatment are generally respected, BIID demands for amputation, at present, are not. However, what little has been said in the (...) ethics literature on the subject tends to favour doing so in cases of BIID. The general argument is that BIID demands should be respected, first, because of the importance that is already placed on respecting autonomy in medical decision-making contexts and second, because of the potential harm of not providing amputation coupled with the fact that no alternative means of relieving suffering exists. The defence of the right to self-demanded amputation is thus typically supported by the use of analogies with other unproblematical cases in order to show that the denial of BIID patient demands is inconsistent with conventional medical norms and practices. This paper criticises the appropriateness of the particular analogies that are thought to shed light on the allegedly unproblematical nature of BIID demands and argues that a proper understanding of the respect for autonomy in the medical decision-making context prohibits agreeing to BIID demands for amputation. (shrink)

These two companion volumes provide a comprehensive review and critical evaluation of the major DSM-III and DSM-III-R child disorders. Their major goal is to provide diagnostic and assessment guidelines that are based on scientific literature in specific clinical domains. Each chapter contains a discussion of the historical background of a particular diagnosis, definitional issues, a critical but selective review of the literature addressing the diagnosis in question, proposed changes in the diagnostic criteria based on the available literature, and (...) proposed assessment models and methods based on the designated criteria. Given the scientific bases for many of these discussions of diagnostic criteria, these two volumes will serve professionals and graduate students in a wide variety of fields: clinical child psychology, child psychiatry, pediatrics, pediatric and school psychology, special education, social work, and other child mental health specialties. (shrink)

Aims: The Research Diagnostic Criteria for Temporomandi¬bular Disorders (RDC/TMD) Axis I diagnostic algorithms were demonstrated to be reliable but below target sensitivity and specificity. Empirical data supported Axis I algorithm revisions that were valid. Axis II instruments were shown to be both reliable and valid. An international consensus workshop was convened to obtain recommendations and finalization of new Axis I diagnostic algorithms and new Axis II instruments. Methods: A comprehensive search of published TMD diagnostic literature was followed by review (...) and consensus via a formal structured process by a panel of experts for revision of the RDC/TMD. Results: The recommended Diagnostic Criteria for TMD (DC/TMD) Axis I protocol includes both a valid screener for pain diagnoses and valid criteria for the most common pain-related TMDs and for one intra-articular disorder. The Axis II protocol retains selected RDC/TMD screening instruments augmented with new instruments to better assess the interactions between pain and psychosocial functioning. A comprehensive classification system is also presented. Conclusion: The recommended evidence-based DC/TMD protocol is appropriate for use in both the clinical and research settings. Simple Axis I and II screening tests augmented by validated Axis I and Axis II instruments allow for identification of simple to complex TMD patients. (shrink)

The relationship between self- and informant reports of personality using psychometric instruments is constantly the focus of attention for researchers in the field of clinical assessment in psychology. The research shows weak agreement between clinicians and patients’ assessments of personality disorders (PDs). The current study aimed at the convergence of measurement of PDs using the Shedler-Westen Assessment Procedure (SWAP-200), the self-report Character Styles Questionnaire-R (CSQ-R) and Borderline Personality Inventory (BPI). Paper-pencil questionnaires were administered to 102 inpatients (88.2% female, (...) aged 18-64, M = 38.4) in a voivodeship hospital and outpatient health care centre. The SWAP-200 allowed us to gather expert (clinician) personality ratings basing on the intensive contact with patients. Results show that only a few SWAP-200 PD scales showed low positive correlations with corresponding self-reported PD scales from the CSQ-R. With the canonical correlation analysis, we identified two functions (borderline and internalising) that described similarities between the SWAP-200 and CSQ-R. SWAP-200 Obsessive-Compulsive PD correlated negatively with BPI scales. Consistent with previous studies, the self-report and the clinical assessment were only marginally convergent. Furthermore, OCPD stands out from other disorders in that it correlates positively with health indicators and negatively with some of the other personality disorders. The highest agreement was observed in the description of Borderline PD. (shrink)

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

Currently, in England and Wales, Court of Protection’s Practice Directive 9E (PD9E) requires all cases of proposed withdrawal or withholding of life-sustaining treatment in relation to adults in a permanent vegetative state (PVS) or minimally conscious state be referred to the Court. This paper looks at the origins of PD9E and contrasts the routine requirement to refer cases to court with the complex clinical terrain that comprises those suffering from prolonged disorders of consciousness. We look at the role (...) of the court in decision making in these contexts and we ask what role the courts are called on to play in these decisions. We argue that PD9E, as currently drafted, is too imprecise to achieve its purpose. With our focus always on the best interests of patients, we argue that most decisions of this nature should be made according to a strict protocol but without the need for court approval. Court overview should be reserved for cases of disagreement between those involved in the decision that cannot be resolved by other methods, where there are serious doubts about the individual’s best interests or where there are legally untested aspects to the decision. (shrink)

Previous research conducted in 1999 highlighted ethical concerns behind challenge studies inducing psychosis with ketamine and made recommendations to enhance ethical standards. Recently, a plethora of clinical trials have evaluated the efficacy of ketamine to treat mood disorders, which lead to complex ethical issues. Pharmaceutical companies and researchers hope to profit by developing patentable variations on ketamine for treating depression. Media have labeled ketamine as a “miracle” antidepressant. Some clinics offer expensive off-label use of ketamine to treat mood (...) disorders. This article examines the ecological validity of ketamine trials, measures to protect patients, informed consent procedures, financial inducements to participants and conflict of interest of researchers, therapeutic misconception, concealment, and deception. Further recommendations are purposed to improve ethical standard of clinical research involving ketamine. (shrink)

This study examined psychopathological correlates of implicit and explicit shame and guilt in 30 clinical and 129 non-clinical youths aged 8–17 years. Shame and guilt were measured explicitly via two self-reports and a parent report, and implicitly by means of an Implicit Association Test (IAT), while a wide range of psychopathological symptoms were assessed with questionnaires completed by children, parents, and teachers. The results showed no differences of implicit and explicit shame and guilt between the clinical and (...) non-clinical group, implying that dysregulation of these self-conscious emotions is not per definition associated with psychopathology. Correlational analyses indicated that self-reported explicit shame was positively associated with a broad range of internalizing psychopathology, while self-reported explicit guilt was associated with higher levels of anxiety and to some extent lower levels of externalizing psychopathology. Correlations with parent-rated shame and guilt revealed the same pattern of results but were in general weaker. Furthermore, implicit shame and guilt did not show significant correlations with the various measures of psychopathology. It can be concluded that the link between shame and guilt and psychopathology is complex, and partly dependent on the disorder under study and context-related factors defining the maladaptive nature of these self-conscious emotions. (shrink)

:Recent neuroimaging research on disorders of consciousness provides direct evidence of covert consciousness otherwise not detected clinically in a subset of severely brain-injured patients. These findings have motivated strategic development of binary communication paradigms, from which researchers interpret voluntary modulations in brain activity to glean information about patients’ residual cognitive functions and emotions. The discovery of such responsiveness raises ethical and legal issues concerning the exercise of autonomy and capacity for decisionmaking on matters such as healthcare, involvement in research, (...) and end of life. These advances have generated demands for access to the technology against a complex background of continued scientific advancement, questions about just allocation of healthcare resources, and unresolved legal issues. Interviews with professionals whose work is relevant to patients with disorders of consciousness reveal priorities concerning further basic research, legal and policy issues, and clinical considerations. (shrink)

Louis Charland has argued that the Cluster B personality disorders, including borderline personality disorder, are primarily moral rather than clinical conditions. Part of his argument stems from reflections on effective treatment of borderline personality disorder. In the argument from treatment, he claims that successful treatment of all Cluster B personality disorders requires a positive change in a patient’s moral character. Based on this claim, he concludes (1) that these disorders are, at root, deficits in moral character, (...) and (2) that effective treatment of these disorders requires a sort of moral education rather than clinical intervention. In this paper, I evaluate the argument from treatment through a critical analysis of two psychotherapeutic interventions that have shown recent effectiveness against borderline personality disorder. I suggest that both Dialectical Behaviour Therapy and Mentalization-Based Treatment indicate that borderline personality disorder is, at root, a deficit in non-moral cognitive and emotional capacities. I suggest that these non-moral deficits obscure the expression of an otherwise intact moral character. In light of this, I conclude that effective treatment of borderline personality disorder requires primarily clinical intervention rather than moral edification. (shrink)

_The Disordered Mind: An Introduction to Philosophy of Mind and Mental Illness, second edition_ examines and explains, from a philosophical standpoint, what mental disorder is: its reality, causes, consequences, and more. It is also an outstanding introduction to philosophy of mind from the perspective of mental disorder. Revised and updated throughout, this _second edition_ includes new discussions of grief and psychopathy, the problems of the psychophysical basis of disorder, the nature of selfhood, and clarification of the relation between rationality and (...) mental disorder. Each chapter explores a central question or problem about mental disorder, including: what is mental disorder and can it be distinguished from neurological disorder? what roles should reference to psychological, cultural, and social factors play in the medical/scientific understanding of mental disorder? what makes mental disorders undesirable? Are they diseases? mental disorder and the mind–body problem is mental disorder a breakdown of rationality? What is a rational mind? addiction, responsibility and compulsion ethical dilemmas posed by mental disorder, including questions of dignity and self-respect. Each topic is clearly explained and placed in a clinical and philosophical context. Mental disorders discussed include clinical depression, dissociative identity disorder, anxiety, religious delusions, and paranoia. Several non-mental neurological disorders that possess psychological symptoms are also examined, including Alzheimer’s disease, Down’s syndrome, and Tourette’s syndrome. Containing chapter summaries and suggestions for further reading at the end of each chapter, _The Disordered Mind, second edition_ is a superb introduction to the philosophy of mental disorder for students of philosophy, psychology, psychiatry, and related mental health professions. (shrink)

Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/uws) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial (...) nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/uws more respondents agreed with treatment withdrawal when they considered that VS/uws patients did not feel pain (77%) as compared to those who thought VS/uws did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments. (shrink)

Traumatic experiences and post-traumatic stress are highly prevalent in people with psychosis, increasing symptom burden, decreasing quality of life and moderating treatment response. A range of post-traumatic sequelae have been found to mediate the relationship between trauma and psychotic experiences, including the “traditional” symptoms of post-traumatic stress disorder. The International Classification of Diseases-11th Edition recognizes a more complex post-traumatic presentation, complex PTSD, which captures both the characteristic symptoms of PTSD alongside more pervasive post-traumatic sequelae known as ‘disturbances in self-organization’. The (...) prevalence and impact of cPTSD and DSOs in psychosis remains to be explored. In the first study of this kind, 144 participants with psychosis recruited from North West United Kingdom mental health services completed measures assessing trauma, PTSD and cPTSD symptoms and symptoms of psychosis. Forty-percent of the sample met criteria for cPTSD, compared to 10% who met diagnostic criteria for PTSD. PTSD and DSOs mediated the relationship between trauma and positive symptoms, controlling for dataset membership. Both PTSD and DSOs mediated the relationship between trauma and affective symptoms but did not explain a significant proportion of variance in negative symptoms. Cognitive and excitative symptoms of psychosis did not correlate with trauma, PTSD or DSO scores. These findings indicate the possible value of adjunct therapies to manage cPTSD symptoms in people with psychosis, pending replication in larger epidemiological samples and longitudinal studies. (shrink)

Transtheoretical integrative decision-making models help clinicians to use patient factors that are known to predict outcomes in order to inform individualized treatment. Patient factors with a strong evidence base include: functional impairment, social support and interpersonal functioning, complexity and comorbidity, coping style, level of resistance, and subjective distress. Among those with binge-eating disorder (BED), patient factors have not been extensively characterized relative to norms or other clinical samples. We used an integrative decision-making model of these six domains of patient (...) factors related to patient outcomes to characterize a sample of 424 adult treatment-seeking patients with BED. Data were from medical charts, a demographics questionnaire, and validated psychometric scales. We then compared these data to published data from normative and other eating disorder (ED) samples. Results showed that the average patient with BED: (1) was significantly more functionally impaired compared to non-clinical norms but somewhat less impaired than other patients with ED, (2) demonstrated clinically significant problems in social support and interpersonal functioning, (3) presented with complex comorbid pathology and high levels of chronicity, (4) used a more internalizing coping style compared to the norm and other ED samples, (5) had low levels of resistance to interventions, and (6) experienced a moderately high level of subjective distress indicating good motivation for treatment. Corresponding recommendations to these findings are that the average patient with BED should be provided higher intensity treatment that is longer in duration, interpersonally-focused, directive in nature, and emphasizing self-reflection and insight. Despite the nomothetic nature of the findings, clinicians are encouraged to assess these patient domains in order to come to an ideographic case conceptualization and to tailor precision treatment to the individual patient with BED. (shrink)

Current management of people with prolonged disorders of consciousness is failing patients, families and society. The causes include a general lack of concern, knowledge and expertise; a legal and professional framework which impedes timely and appropriate decision-making and/or enactment of the decision; and the exclusive focus on the patient, with no legitimate means to consider the broader consequences of healthcare decisions. This article argues that a clinical pathway based on the principles of the English Mental Capacity Act 2005 (...) and using time-limited treatment trials could greatly improve patient management and reduce stress on families. There needs to be early and continuing use of formal best interests meetings, starting between 7 and 21 days after onset of unconsciousness. The treatment options need to evolve as the clinical state and prognosis becomes more certain. A formal discussion of treatment withdrawal should occur when the upper bound of predicted recovery falls below a level the patient would have considered acceptable, and it should always be discussed when the condition is considered permanent. Any decision to stop treatment should be contingent on a formal second opinion from an independent expert who should review the clinical situation and expected prognosis, but not the best interests decision. The article also asks how, if at all, the adverse effects on the family and the resource implications of long-term care of people left in a prolonged state of unconsciousness should be incorporated in the process. (shrink)

While principle-based ethics is well known and widely accepted in psychiatry, much less is known about how decisions are made in clinical practice, which case scenarios exist, and which challenges exist for decision-making. Protocols of the central ethics committee responsible for four psychiatric hospitals over 7 years (N=17) were analysed. While four cases concerned suicide risk in the case of intended hospital discharge, the vast majority (N=13) concerned questions of whether the responsible physician should or should not initiate the (...) use of coercion in patients lacking mental capacity. The committee’s recommendations were non-uniform. Forced feeding and electroconvulsive therapy were endorsed in each one case. In two cases of intermittent loss of capacity due to heavy drinking or intermittent severe suicidal ideation, a self-binding contract was recommended and the use of coercion was considered as justified for a very limited period. In all other cases, most of which involved involuntary treatment, the use of coercion was not endorsed. Without exception, the recommendations were accepted with relief by the physicians and their treatment teams, who feared liability in the event of harm to the patient. Eventually, a model of a decision algorithm was derived from the ethical arguments in the protocols. (shrink)

Eating disorders can be viewed as “embodied acts” that help to cope with internal and external demands that are perceived as overwhelming. The maintenance of EDs affects the entire identity of the person; the lack of a defined; or valid sense of self is expressed in terms of both physical body and personal identity. According to attachment theory, primary relationships characterized by insecurity, traumatic experiences, poor mirroring, and emotional attunement lead to the development of dysfunctional regulatory strategies. Although the (...) literature shows an association between attachment style or states of mind, trauma, behavioral strategies, and various EDs, the debate is still ongoing and the results are still conflicting. Therefore, we believe it is important to examine and treat EDs by understanding which narrative trajectory intercepts distress in relation to narrative and embodied self-concept. Drawing on clinical observation and a narrative review of the literature, we focus on the construction and organization of bodily and narrative identity. Because bodily representations are the primary tools for generating meaning, organizing experience, and shaping social identity from the earliest stages of life, we focus on the role that bodily interactions and sensorimotor and proprioceptive patterns have played in the development of EDs. We consider the role that lack of attunement, insecure attachment, and relational trauma play in mentalizing, affecting self-representation and emotion regulation strategies. The paper also considers a semantic mode of trauma in EDs that involves a top-down pathway through beliefs and narratives about oneself based on lack of amiability, on devaluation, and on humiliation memories. Finally, we would like to highlight the proposal of an integrated model with multiple access model to psychotherapy that takes into account the complexity of ED patients in whom aspects related to dysregulation, body image disintegration, and post-traumatic symptoms are associated with a suffering sense of self and a retraumatizing narrative. (shrink)

Introduction. Eating Disorders (EDs) are serious psychiatric disorders, impacting physical and psychosocial functioning, often with a chronic course and high mortality rates. The two continua model of mental health states that mental health is a complete state, that is not merely the absence of mental illness, but also the presence of mental health. This model was studied among ED patients by comparing the levels of well-being to the Dutch general population and by examining the of well-being and psychopathology. (...) Method. A total of 468 female ED patients participated in this study during application and intake at a specialized ED treatment centre in the Netherlands. They filled out questionnaires about well-being (MHC-SF), general psychopathology (OQ-45), and ED psychopathology (EDE-Q). Categorical and mean well-being levels were calculated. Also, the correlates of these variables were examined with Pearson correlation and multiple hierarchical regression analysis. Results. ED patients showed lower levels of emotional, psychological and social well-being on average compared to the general population. About 26% of the ED patients experienced low levels of well-being (languishing). However, also 13% experienced high levels of well-being (flourishing), varying between 9% in Anorexia Nervosa to 25% in Binge Eating Disorder. ED psychopathology and general well-being showed a moderate negative correlation. For patients with Bulimia Nervosa and Binge Eating Disorder however no such correlation was found. Lower general psychopathology, not having a history of hospitalization for the ED, and adaptive personal functioning were correlated with well-being among ED patients. Conclusion This study shows initial support for the two continua model of mental health among ED patients. Psychopathology and well-being should be considered as related, but distinct dimensions of mental health in ED patients. Further research should focus on the possible reciprocal relationships between psychopathology and well-being during recovery. It is recommended to monitor well-being during treatment and to implement interventions for well-being to realize complete recovery for those patients with inadequate levels of well-being. (shrink)

Incapacitated adults with a legally appointed guardian or conservator may be recruited for or involved with medical, behavioral, or social science research. Much of the research in which such persons participate is aimed at evaluating medical interventions for them, or contributing to general knowledge about disorders from which they may suffer. In this paper we will consider how the appointment of guardians for patients with disorders of consciousness —severe brain injuries that affect a patient’s level of arousal and (...) ability to interact —impacts such patients’ access to research.Such persons may be under guardianship because they have lost decisional capacity (i.e., those in a coma or... (shrink)

Popular and neurobiological accounts of addiction tend to treat it as a form of compulsion. This contrasts with personality disorder, where most problematic behaviours are treated as voluntary. But high levels of co-morbidity, overlapping diagnostic traits, and the effectiveness of a range of comparable clinical interventions for addiction and personality disorder suggest that this difference in treatment is unjustified. Drawing on this range of clinical interventions, we argue that addiction is not a form of compulsion. Rather, the misuse (...) of drugs and alcohol is like many of the problematic behaviours associated with personality disorder: it is typically a way of coping with psychological distress. We suggest that a satisfying explanation of why many addicts struggle to control their use can be given without departing from concepts employed in our basic folk psychological understanding of agency. In particular, we appeal to five rough-and-ready folk psychological factors to explain addiction: (i) strength of desire and habit; (ii) willpower; (iii) motivation; (iv) functional role; and (v) decision and resolve. (shrink)

Many individuals who have mental disorders often report negative experiences of a distinctively epistemic sort, such as not being listened to, not being taken seriously, or not being considered credible because of their psychiatric conditions. In an attempt to articulate and interpret these reports we present Fricker’s concepts of epistemic injustice (Fricker, 2007, p. 1) and then focus on testimonial injustice and hermeneutic injustice as it applies to individuals with mental disorders. The clinical impact of these concepts (...) on quality of care is discussed. Within the clinical domain, we contrast epistemic injustice with epistemic privilege and authority. We then argue that testimonial and hermeneutic injustices also affect individuals with mental disorders not only when communicating with their caregivers but also in the social context as they attempt to reintegrate into the general society and assume responsibilities as productive citizens. Following the trend of the movement of mental health care to the community, the testimonies of people with mental disorders should not be restricted to issues involving their own personal mental states. (shrink)

Background: although cognitive behavioural therapy is the gold standard treatments for bulimia nervosa (BN) and binge eating disorder (BED), evidence for its long-term efficacy is weak. Empirical research support the efficacy of brief strategic therapy (BST) in treating BN and BED symptoms, but its statistical significance still need to be investigated. Objective: to statistically test the long-term efficacy of the BST treatment protocols for BN and BED through one-year post-treatment. Methods: a two-group longitudinal study will be conducted. Participants will be (...) sequentially recruited for inclusion in a state-funded community psychotherapy clinic. Multilevel growth curve modeling will be used to estimate the average growth trajectories from baseline to one year after treatment termination for the severity of the BN and BED features as measured by the Eating Disorder Examination Questionnaire. Discussion: findings from this study will clarify the impact of BST in treating BN and BED symtoms. Conclusions: translating research into practice may inform how to ensure high-quality patient care. (shrink)

The paper by Bergnar and Bunford in this edition of Philosophy, Psychiatry, & Psychology is a sophisticated examination of a central question that has lacked consensus in the philosophy of psychiatry, namely, what is “the key aspect of the meaning of this fundamental term, mental disorder”? To settle this question, the authors use an empirical approach by surveying graduate students in clinical psychology. In this way, they attempt to invoke the Wittgensteinian method of determining the meaning of a term (...) by seeing how it is used. The empirical results, the authors argue, serve as strong evidence in support of the position that the term ‘mental disorder’ designates disability... (shrink)

Häftets samlingstitel: Unveiling the feminism of Islam. AnA society for Feminist Analyses.

Background: Fetal alcohol spectrum disorder (FASD), a complex diagnosis that includes a wide range of neurodevelopmental disabilities, results from exposure to alcohol in the womb. FASD remains poorly understood by Canadians, which could contribute to reported stigma faced by both people with FASD and women who drink alcohol while pregnant. Methods: To better understand how information about FASD is presented in the public sphere, we conducted content analysis of 286 articles from ten major English-language Canadian newspapers (2002-2015). We used inductive (...) coding to derive a coding guide from the data, and then iteratively applied identified codes back onto the sample, checking inter-coder reliability. Results: We identified six major themes related to clinical and scientific media content: 1) prevalence of FASD and of women’s alcohol consumption; 2) research related to FASD; 3) diagnosis of FASD; 4) treatment of FASD and maternal substance abuse; 5) primary disabilities associated with FASD; and 6) effects of alcohol exposure during pregnancy. Discussion: Across these six themes, we discuss three instances of ethically consequential exaggeration and misrepresentation: 1) exaggeration about FASD rates in Indigenous communities; 2) contradiction between articles about the effects of prenatal alcohol exposure; and 3) scientifically accurate information that neglects the social context of alcohol use and abuse by women. Respectively, these representations could lead to harmful stereotyped beliefs about Indigenous peoples, might generate confusion about healthy choices during pregnancy, and may unhelpfully inflame debates about sensitive issues surrounding women’s choices. (shrink)

Pain, suffering and positive emotions in patients in vegetative state/unresponsive wakefulness syndrome (VS/UWS) and minimally conscious states (MCS) pose clinical and ethical challenges. Clinically, we evaluate behavioural responses after painful stimulation and also emotionally-contingent behaviours (e.g., smiling). Using stimuli with emotional valence, neuroimaging and electrophysiology technologies can detect subclinical remnants of preserved capacities for pain which might influence decisions about treatment limitation. To date, no data exist as to how healthcare providers think about end-of-life options (e.g., withdrawal of artificial (...) nutrition and hydration) in the presence or absence of pain in non-communicative patients. Here, we aimed to better clarify this issue by re-analyzing previously published data on pain perception (Prog Brain Res 2009 177, 329–38) and end-of-life decisions (J Neurol 2010 258, 1058–65) in patients with disorders of consciousness. In a sample of 2259 European healthcare professionals we found that, for VS/UWS more respondents agreed with treatment withdrawal when they considered that VS/UWS patients did not feel pain (77%) as compared to those who thought VS/UWS did feel pain (59%). This interaction was influenced by religiosity and professional background. For MCS, end-of-life attitudes were not influenced by opinions on pain perception. Within a contemporary ethical context we discuss (1) the evolving scientific understandings of pain perception and their relationship to existing clinical and ethical guidelines; (2) the discrepancies of attitudes within (and between) healthcare providers and their consequences for treatment approaches, and (3) the implicit but complex relationship between pain perception and attitudes toward life-sustaining treatments. (shrink)

We used Nunez's physiologically based dynamic theory of EEG to make predictions about a clinical population of children with Attention Deficit Hyperactivity Disorder (ADHD) known to have neuronanatomical abnormalities. Analysis of high-density EEG data (long-range coherence) showed expected age-related differences and surprising regional specificity that is consistent with some of the literature in this clinical area.

A brief theoretical review of the current state of the art of embodiment research in clinical psychology has been expounded in order to highlight the key role that embodied conceptualization has on the understanding and explanation of several mental disorders, such as eating disorders, schizophrenia and depression. Evidence has suggested that mental disorders may be explained as disturbances of embodiment, from the disembodiment to the hyperembodiment. In order to understand how some clinical conditions are affected (...) by cultural models, we propose and define a new framework called Exbodiment, complementary to the Embodiment approach to cognition. Mental disorder is strictly related to the subject-culture interaction that may be explained as a two way process in which embodiment and exbodiment are complementary points of view. In this perspective, embodiment may be seen as the “top-down” process, while exbodiment the “bottom-up” one. The introduction of exbodiment conceptualization highlights how subject is both receiver and interpreter of social influence. Subject is the target of a cultural pressure and, at the same time, enacts its own embodied culture in world. Exbodiment conceptualization may help clinicians to better understand and explain the role of culture in the onset and maintenance of mental disorders. (shrink)

We describe our clinical experience in treating patients with Tourette syndrome and other tic disorders using infra-low frequency neurofeedback, often in conjunction with cognitive behavior therapy. Following a narrative description of our approach, we present outcome data for 100 successive cases. Many of the children and adolescents that we have treated since 2005 did not derive sufficient benefit from standard treatment for Tourette syndrome and other tic disorders. In our clinical experience, based on extensive before- and (...) after- testing and symptom tracking, this patient group derived significant additive benefit from complementary neurofeedback treatment. The majority of trainees attained a higher level of functioning and were able to live up to their potential in a way they were not able to prior to neurofeedback treatment. (shrink)

Understanding Eating Disorders is an original contribution to the field of healthcare ethics. It develops a new theory concerning the moral basis of eating disorders, and places such disorders for the first time at the centre of philosophical discourse. The book explores the relationship that people have with food and their own body by looking at genetics and neuro-physiology, sociology and family studies, clinical psychology and psychiatry, and frames abnormal eating at the extreme of a spectrum (...) of normal behaviours, directed by moral values. Giordano argues that abnormal eating is not a psycho-pathological phenomenon, but the coherent implementation of ordinary moral values with a long tradition in Western culture. The book also contains a detailed analysis of UK legislation, accompanied by a timely critique of the law on treatment of mental disorders in general and of eating disorders in particular. (shrink)

Current psychiatric classification adopts a disorder-focused diagnostic approach, as exemplified within ICD-11 and DSM-V. Although this approach has improved reliability of categorization, its validity and utility has been questioned (Harvey, Watkins, Mansell, & Shafran, 2004; Insel et al., 2009; Sanislow et al., 2010). Limitations include high comorbidity between supposedly distinct disorders; heterogeneity within diagnoses; limited treatment efficacy; and similarities across disorders in aetiology, latent symptom structure, and underlying biology. There is also evidence of transdiagnostic cognitive-behavioural processes (Harvey et (...) al., 2004). An alternative approach is therefore to focus on fundamental underlying mechanisms of psychopathology rather than observed symptom clusters. This article considers the possible benefits, hurdles, and steps towards implementation of this transdiagnostic mechanistic approach, using the example of repetitive negative thought. (shrink)

Eating disorders are evolutionarily novel conditions that lead to some of the highest mortality rates of all psychiatric disorders. Several evolutionary hypotheses have been proposed for eating disorders, but only the intrasexual competition hypothesis is extensively supported by evidence. We present the mismatch hypothesis as a necessary extension to the current theoretical framework of eating disorders. This hypothesis explains the evolutionarily novel adaptive metaproblem that has arisen when mating motives and readily available food rewards conflict with (...) one another. This situation is exacerbated in contemporary environments characterized by sedentary lifestyles, caloric surplus and the ubiquity of social comparisons that take place via social media. Our psychoneuroimmunological model connects ultimate-level causation with proximate mechanisms by showing how the adaptive metaproblem between mating motives and food rewards leads to chronic stress and, further, to disordered eating. Chronic stress causes neuroinflammation, which increases susceptibility to OCD-like behaviors that typically co-occur with eating disorders. Chronic stress upregulates the serotonergic system and causes dysphoric mood in patients with restricting-type anorexia nervosa. Dieting, however, reduces serotonin levels and dysphoric mood, leading to a vicious serotonergic-homeostatic stress/starvation cycle whereby cortisol and neuroinflammation increase through stringent dieting. Between-individual and within-individual variation in eating disorders partially arises from (co)variation in gut microbiota and stress responsivity, which influence neuroinflammation and the serotonergic system. In binge-related eating disorders, even a short period of fasting drops serotonin levels, a state alleviated by binge eating. Eating disorder treatments should aim to reduce the chronic stress, neuroinflammation, stress responsivity and gut dysbiosis that fuel the disorders. We review the advances that have been made in recent years in understanding how to best treat eating disorders, outlining directions for future clinical research. Connecting ultimate causes with proximate mechanisms and treating biopsychosocial causes rather than manifest symptoms will enable more effective and sophisticated long-term interventions for the millions of people who suffer from eating disorders. (shrink)

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the National Institute of Mental Health’s Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, and the general psychopathology factor, as well as a revival of interest in phenomenological psychopathology. The question naturally emerges as to what the relationship between these new approaches is – are they mutually exclusive, competing approaches, or can they be integrated in some way (...) and used to enrich each other? In this opinion piece, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology, such as selfhood, embodiment, affectivity, etc., can be overlaid on clinical stages in order to enrich and deepen the phenotypes captured in clinical staging (‘high resolution’ clinical phenotypes). This approach may be useful both ideographically and nomothetically, in that it could complement diagnosis, enrich clinical formulation, and inform treatment of individual patients, as well as help guide aetiological, prediction, and treatment research. The overlaying of phenomenological domains on clinical stages may require that these domains are reformulated in dimensional rather than categorial terms. This integrative project requires assessment tools, some of which are already available, that are sensitive and thorough enough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging may be enriched by introducing greater depth to phenotypes; phenomenological psychopathology may be enriched by introducing stages of severity and disorder progression to phenomenological analysis. (shrink)