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)

Digital phenotyping will potentially enable earlier detection and prediction of mental illness by monitoring human interaction with and through digital devices. Notwithstanding its promises, it is certain that a person’s digital phenotype will at times be at odds with their first-person testimony of their psychological states. In this paper, we argue that there are features of digital phenotyping in the context of psychiatry which have the potential to exacerbate the tendency to dismiss patients’ testimony and treatment preferences, which can (...) be instances of epistemic injustice. We first explain what epistemic injustice is, and why it is argued to be an extensive problem in health and disability settings. We then explain why epistemic injustice is more likely to apply with even greater force in psychiatric contexts, and especially where digital phenotyping may be involved. Finally, we offer some tentative suggestions of how epistemic injustice can be minimised in digital psychiatry. (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)

Initiating clinical ethics support in psychiatry and maintaining its continuity appear to be easy. This is contradicted by the observed delay or lack of CESiP, e.g. ethics consultation. On the basis of a published literature search and the discussion of practical experiences over 2.5 years 10 tasks and relating challenges of initiating and maintaining CESiP are formulated and illustrated by examples. Referral to experiences is grounded on the systematic documentation of ca. 100 CESiP activities. The tasks and challenges illustrate (...) how CESiP was initiated and maintained in child and adolescent, adult and forensic psychiatry. Each example is followed by a “rule of thumb” that was found useful in our centre. Discussion: Suggestions I–III are of organisational nature, IV–X have explicit ethical content concerning the ethos or professionalism of the ethics consultant and CES practice. Their realisation requires a minimum of stability of CESiP and considerable consultancy experience. (shrink)

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.

Battle Hall Davies' brother Nick ran away from home when she was in high school. Now he has found her and she is going to stay with him for the summer before starting college. Battle discovers that neither she nor her brother is the person she thought they were.

The neurosciences are generating new findings regarding genetic and neurobiological aspects of the pathophysiology of mental disorders. Especially, certain genetic risk factors like neuregulin-1 seem to predispose individuals to a psychotic phenotype beyond the limits of traditional classificatory boundaries between organic psychoses in Alzheimer’s disease, bipolar affective disorder and schizophrenia. Little, however, is known about how such genetic risk factors actually confer an increased risk for psychosis in an individual patient. A gap between neuroscientific findings and psychopathological phenomena exists. The (...) main hypothesis how this gap may be bridged is that mental disorders arise as a consequence of dysfunctions of normal mental functions. Modularity may provide a useful conceptual framework in that temporally and/or spatially stable neural circuits subserve certain physiological functions of the human brain, which become the target of pathophysiological effectors. The idea of a modular construction of the human brain is based on neurobiological evidence regarding the columnar architecture of the cerebral cortex, which provides certain elementary analytical functions. Modular dysfunctions may be assessed with methods of experimental psychopathology, in which subsystems of brain functions are tested with standardized experimental psychological techniques (functional psychopathology). The main questions here are how to define a module, and whether the classical neuroscientific definitions can be used to characterize higher integrative functions of the human brain. (shrink)

In clinical medicine, a diagnosis can offer an explanation of a patient's symptoms by specifying the pathology that is causing them. Diagnoses in psychiatry are also sometimes presented in clinical texts as if they pick out pathological processes that cause sets of symptoms. However, current evidence suggests the possibility that many diagnostic categories in psychiatry are highly causally heterogeneous. For example, major depressive disorder may not be associated with a single type of underlying pathological process, but with a (...) range of different causal pathways, each involving complex interactions of various biological, psychological, and social factors. This paper explores the implications of causal heterogeneity for whether psychiatric diagnoses can be said to serve causal explanatory roles in clinical practice. I argue that while they may fall short of picking out a specific cause of the patient's symptoms, they can nonetheless supply different sorts of clinically relevant causal information. In particular, I suggest that some psychiatric diagnoses provide negative information that rules out certain causes, some provide approximate or disjunctive information about the range of possible causal processes, and some provide causal information about the relations between the symptoms themselves. (shrink)

It is often claimed in parts of the psychiatric literature that neuroscientific research into the biological basis of mental disorder undermines dualism in the philosophy of mind. This paper shows that such a claim does not apply to all forms of dualism. Focusing on Kenneth Kendler’s discussion of the mind–body problem in biological psychiatry, I argue that such criticism of dualism often conflates the psychological and phenomenal concepts of the mental. Moreover, it fails to acknowledge that there are different (...) varieties of dualism, and so overlooks the important metaphysical insights of contemporary dualist philosophers. I argue that while the neuroscientific research underpinning biological psychiatry challenges the traditional dualism of René Descartes, it does not pose any problem for the more modern dualism of David Chalmers. It is possible to take seriously the scientific claims of biological psychiatry while holding that this latter form of dualism is true. This has implications for the positioning of the mind–body problem in psychiatry. While the “easy” problem of explaining psychological processes is relevant to the aims of biological psychiatry, psychiatrists need not worry about the “hard” problem of consciousness. (shrink)

:In this article, we consider contexts or domains in which moral bioenhancement interventions possibly or most likely will be implemented. By looking closely at similar or related existing practices and their relevant ethical frameworks, we hope to identify ethical considerations that are relevant for evaluating potential moral bioenhancement interventions. We examine, first, debates on the proper scope of moral education; second, proposals for identifying early risk factors for antisocial behaviour; and third, the difficult balancing of individual freedom and third party (...) concerns in psychiatry. In imagining moral bioenhancement in practice, we observe that unlike other forms of enhancement, moral enhancement fundamentally asks how the interests and preferences of the individual and the interests of others should be weighed. Highly diverse domains such as education, mental health, and the judicial domain might be involved, and moral bioenhancement might challenge existing institutional settings. Given these highly varied contexts and domains, it appears unlikely that there will be a distinct set of practices that will be referred to as “moral bioenhancement.”. (shrink)

This new edition of Mind, Meaning, and Mental Disorder addresses key issues in the philosophy of psychiatry, drawing on both philosophical and scientific theory. The main idea of the book is that causal models of mental disorders have to include meaningful processes as well as any possible lower-level physical causes, and this propsoal is illustrated with detailed discussion of current models of common mental health problems. First published in 1996, this volume played an important role in bridging the gap (...) between philosophy and psychiatry, and introducing those in psychiatry to philosophical ideas somewhat neglected in their field. Completely updated, the new edition of this acclaimed volume draws on the strengths of the first edition, and will be a central text in the burgeoning field of philosophy of psychiatry. (shrink)

Diagnoses are central to the practice of medicine, where they serve a variety of functions for clinicians, patients, and society. They aid communication, explain symptoms, inform predictions, guide therapeutic interventions, legitimize sickness, and authorize access to resources. Insofar as psychiatry is a discipline whose practice is shaped by medical conventions, its diagnoses are sometimes presented as if they serve the same sorts of function as diagnoses in bodily medicine. However, there are philosophical problems that cast doubt on whether the (...) functions of psychiatric diagnoses can legitimately be considered to be equivalent to those of medical diagnoses. The aim of this chapter is to explicate some of these problems, particularly conceptual and epistemological problems pertaining to the roles of diagnoses as explanations. I begin with an overview of the various functions that medical diagnoses normally serve and suggest that many of these functions receive justificatory support from the explanatory roles of the diagnoses. I then present issues regarding the epistemic functions of psychiatric diagnoses and how these issues have featured in the arguments of prominent critics of psychiatry. (shrink)

Volume 19, Issue 10, October 2019, Page W14-W17.

Compulsory psychiatric treatment is the norm in many Western countries, despite the increasingly individualistic and autonomous approach to medical interventions. Community Treatment Orders are the singular best example of this, requiring community patients to accept a variety of interventions, both pharmacological and social, despite their explicit wish not to do so. The epidemiological, medical/treatment and legal intricacies of CTOs have been examined in detail, however the ethical considerations are less commonly considered. Principlism, the normative ethical code based on the principles (...) of autonomy, beneficence, non-maleficence and justice, underpins modern medical ethics. Conflict exists between patient centred commentary that reflects individual autonomy in decision making and the need for supported decision making, as described in the Convention on the Rights of Persons with Disabilities and the increasing use of such coercive measures, which undermines this principle. What appears to have been lost is the analysis of whether CTOs, or any coercive measure in psychiatric practice measures up against these ethical principles. We consider whether CTOs, as an exemplar of coercive psychiatric practice, measures up against the tenets of principalism in the modern context in order to further this debate. (shrink)

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)

This article analyzes how the recent call for accounting in health care interferes with daily care practice and raises the question of how accounting practices relate to the aim of good care. The most influential accounting methods in the Netherlands suggest ways for professionals to legitimize their activities. The analysis of washing patients in long-term mental health care shows that different styles of accounting evaluate and legitimize care while structuring notions of what good care is. A specific style of accounting (...) enforces certain values but does not tell about the tragic or unexpected effects that come with it, nor does it provide a repertoire to deal with these. Thus, care practices incorporating specific styles of accounting remain dependent on forms of care that are not accountable or ask for new forms of reflexivity. (shrink)

A brief critical notice of Dan J Stein's new book _Problems of Living: Perspectives from Philosophy, Psychiatry, and Cognitive-Affective Science_.

Wakefield's (2000) responses to our paper herein (Murphy and Woolfolk 2000) are not only unsuccessful, they force him into a position that leaves him unable to preserve any distinction between disorders and other problems. They also conflate distinct scientific concepts of function. Further, Wakefield fails to show that ascriptions of human dysfunction do not ineliminably involve values. -/- We suggest Wakefield is analyzing a concept that plays a role in commonsense thought and arguing that the task of science is to (...) identify the natural processes that accord with that commonsense concept. We argue that this represents an attempt to use conceptual analysis to legislate what should be acceptable science. We conclude that this constraint on science is unacceptable and that therefore Wakefield's overall position should be rejected. (shrink)

Background: The magnitude of bullying and harassment among psychiatrists is reportedly high, yet no peer-review published studies addressing this issue could be found. Therefore, it was decided to conduct a pilot study to assess the degree of the problem, the types of bullying/harassment and to provide some insights into the situation.Methods and Principal Findings: Following multiple focus group meetings, a yes/no response type questionnaire was developed to assess the degree and type of bullying and harassment experienced by psychiatrists. Over a (...) 3-month period the questionnaire was administered to a random sample of 60 psychiatrists. 57 out of the 60 psychiatrists reported harassment and bullying. Frequencies of the following response variables are presented in descending order: rumours 40% ; defamation 20% ; passing remarks 20% ; false accusations 15% ; threats 13.3% ; verbal abuse 13.3% ; unjustified complaints 13.3% ; promotion blocked 13.3% ; humiliation 13% ; bad reference given 10% ; credentials questioned 8.3% ; physical attacks 5% ; termination 5% ; derogatory remarks 1.7% and 1.7% were subjected to personal work. As a result of being subjected to harassment, 66.7% of the psychiatrists did not take any action, whereas 33.3% confronted the person they believed responsible. Asked whether the bullying and harassment caused distress, 18.3% of the psychiatrists did not report any effect, 30% reported mild distress, 40% moderate distress and severe distress was reported by 11.7%.Conclusions: It was concluded that the magnitude of bullying and harassment among psychiatrists may be quite high, as evidenced by this pilot study. There is a need for extensive systematic studies on this subject and to establish strategies to prevent and address this issue at a national and regulatory level. (shrink)

I am grateful to the editor for asking me to comment on this interesting article about interdisciplinary work between a philosopher and a psychiatrist, with which I found much to agree. As a medical student, I had no exposure to bioethical reasoning in medicine, and even now, I think it is the case that junior doctors in the UK have variable exposure to good quality ethical reasoning in clinical practice. I also agree that lectures are a poor way to learn (...) about ethical reasoning, especially in psychiatric practice; and I have been part of a special interest group at the Royal College of Psychiatrists that has tried to develop and enhance bioethical awareness in mental health. We do this by a) ensuring that ethical... (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)

The idea behind this article is to discuss the importance and to develop the concept of reciprocity in asymmetric professional relationships. As an empirical starting point for an examination of the possible forms of reciprocity between patients and nurses in psychiatry, we chose two qualitative in-depth interviews with two different patients. The manners in which these two patients relate to medical personnel—one is dependent, the other is independent—show that this presents challenges to nurses. The theoretical context is provided by (...) the notion of mature care as it has been developed by feminist-oriented ethics of care, in contrast to the notion of altruistic care. In relation to the concept of mature care, we discuss how nursing can be perceived in demanding relationships with patients in psychiatry. Reciprocity implies that, in principle, the interests of the nurses also matter in a nurse-patient relationship. We show that reciprocity—in practice—is complicated and challenging in a number of different ways. Mature care—with its systematic inclusion of relationships and reciprocity—provides an alternative understanding of what takes place between patients and nurses compared with an altruistic notion of care. As such, mature care can be regarded as an useful paradigm for nurse-patient relationships in psychiatry. (shrink)

Martin Heidegger has been one of the most influential but also criticized philosophers of the XX century. With Being and Time (1927) he sets apart his existential analytic from psychology as well as from anthropology and from the other human sciences that deny the ontological foundation, overcoming the Cartesian dualism in search of the ontological unit of an articulated multiplicity, as human being is. Heidegger’s Dasein Analytic defines the fundamental structures of Dasein such as being-in-the-world, a unitary structure that discloses (...) the worldhood of the world; the modes of being (Seinsweisen), such as fear (Furcht) and anxiety (Angst); and the relationship between existence and time. In his existential analytic, anxiety is one of the fundamental moods (Grundbefindlichkeit) and it plays a pivotal role in the relationship of Dasein with time and world. The paper firstly focuses on the modes of being, underling the importance of anxiety for the constitution of human being; secondly, it is shown the relationship between anxiety and world, and anxiety and time: rejecting both the Aristotelian description of time, as a sequence of moments that informs our common understanding of time, and the Augustine’s mental account of inner time, Heidegger considers temporality under a transcendental point of view. Temporality is ek-static, it is a process through which human being comes toward and back to itself, letting itself encounter the world and the entities. The transcendental interpretation of time provided by Heidegger may give its important contribution in psychopathology. (shrink)

This paper aims to explore the validity of phenomenology in the psychiatric setting. The phenomenological method - as a mode of research, a method of engagement between self and other, and a framework for approaching what it means to know - has found a legitimate home in therapeutic practice. Over the last century, phenomenology, as a philosophical endeavour and research method, has influenced a wide range of disciplines, including psychiatry. Phenomenology has enabled an enrichment of such practice through deepening (...) the way in which we can come to know the experiences of the other. This knowing-of-the-other is explored here within the context of psychiatric and clinica assessment. The question asked is: How best can we come to know those we work with? What method of engagement can be used to most completely come to understand and narrate the experiences of the individual, and how can this be applied in the context of an assessment aimed at psychiatric or psychological intervention? Elements of phenomenological praxis are presented as definitive of the most integral way of approaching the human subject. Husserlian and Heideggerian notions are explicated and related to phenomenological conceptions of intersubjectivity, in an effort to describe a phenomenology that can be used effectively within the psychiatric setting. Indo-Pacific Journal of Phenomenology , Volume 7, Edition 1 May 2007. (shrink)

The three essays reprinted in this book were first published in 1963 as individual chapters of a psychiatric treatise entitled Psychiatrie der Gegen wart (Psychiatry of the Present Day). The editors, W. H. GRUHLE (Bonn), R. JUNG (Freiburg/Br. ), W. MAYER-GROSS (Birmingham, England), M. MUL LER (Bern, Switzerland), had not planned an encyclopedic presentation; they did not intend to present a "handbook" which would be as complete as possible in details and bibliographic reference. Their intention was to "raze the (...) walls" separating Continental and Anglo-Saxon psychiatries and to offer a synopsis of developments in psychiatry during the last decades on an international basis. The editors requested, therefore, cooperation of scholars from many foreign countries, large and small, on both sides of the Atlantic. A section entitled "Borderlands of Psychiatry", in which MARGARET MEAD (New York) discusses the relation of "Psychiatry and Ethnology", HANS HEIMAN (Bern), the relation of "Religion und Psychiatrie", and ROBERT VOLMER (Paris), "Art et Psychiatrie", is a good illustration of the trilingual character of the whole work. Two of the editors, GRUHLE and MAYER-GROSS, died before the publi cation had been completed. In a kind of posthumous eulogy, Professor JUNG and Professor MULLER praised the initiative and accomplishments of MAYER-GROSS, "who during the last five years of his life had given a great deal of his time to this work. He had set his mind on a synthesis of German and Anglo-Saxon psychiatry. (shrink)

We generally agree with Burt's thesis. However, we note that the author did not discuss epigenetics, the study of how the environment can alter gene structure and function. Given epigenetic mechanisms, the utility of polygenic risk scores (PRS) is limited in studies of development and mental illness. Finally, in this commentary we expand upon the risks of reliance upon PRSs.

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)