Medical professionals, including mental health professionals, largely agree that moral judgment should be kept out of clinical settings. The rationale is simple: moral judgment has the capacity to impair clinical judgment in ways that could harm the patient. However, when the patient is suffering from a "Cluster B" personality disorder, keeping moral judgment out of the clinic might appear impossible, not only in practice but also in theory. For the diagnostic criteria associated with these particular disorders (Antisocial, (...) Borderline, Histrionic, Narcissistic) are expressed in overtly moral language. I consider three proposals for dealing with this problem. The first is to eliminate the Cluster B disorders from the DSM on the grounds that they are moral, rather than mental, disorders. The second is to replace the morally laden language of the diagnostic criteria with morally neutral language. The third is to disambiguate the notion of moral judgment so as to respect the distinction between having morally disvalued traits and having moral responsibility for those traits. Sensitivity to this distinction enables the clinician, at least in theory, to employ morally laden diagnostic criteria without adopting the sort of morally judgmental (and potentially harmful) attitude that results from the tacit presumption of moral responsibility. I argue against the first two proposals and in favor of the third. In doing so, I appeal to Grice's distinction between conventional and conversational implicature. I close with a few brief remarks on the irony of retaining overtly moral language in an ostensibly medical manual for the diagnosis of mental disorders. (shrink)

Moral considerations do not appear to play a large role in discussions of the DSM-IV personality disorders and debates about their empirical validity. Yet philosophical analysis reveals that the Cluster B personality disorders, in particular, may in fact be moral rather than clinical conditions. This finding has serious consequences for how they should be treated and by whom.

I was delighted to be asked to comment on Peter Zachar’s paper, partly because he presents an elegant proposal for how personality disorders (PD) might be considered to fit into a broadly medical conception of disorder, but also because the overlap between moral and clinical elements of disorder, and more broadly moral and clinical psychiatric kinds, seems to me to be a question central to the theory and practice of psychiatry. The moral context of diagnosis and treatment is (...) a question not just in the PD field (Pearce and Pickard 2009, 2010). The fact that over half of prisoners in the United Kingdom have a PD and a similar number can be diagnosed with a neurotic disorder (Singleton, Meltzer, and Gatward 1998) .. (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)

Should we let personal responsibility for health-related behavior influence the allocation of healthcare resources? In this paper, we clarify what it means to be responsible for an action. We rely on a crucial conceptual distinction between being responsible and holding someone responsible, and show that even though we might be considered responsible and blameworthy for our health-related actions, there could still be well-justified reasons for not considering it reasonable to hold us responsible by giving us lower priority. We transform these (...) philosophical considerations into analytical use first by assessing the general features of health-related actions and the corresponding healthcare needs. Then, we identify clusters of structural features that even adversely affected people cannot reasonably deny constitute actions for which they should be held responsible. We summarize the results in an analytical framework that can be used by decision-makers when considering personal responsibility for health as a criterion for setting priorities. (shrink)

In this paper we argue that autobiographical memory can be conceptualized as a mental state resulting from the interplay of a set of psychological capacities?self-reflection, self-agency, self-ownership and personal temporality?that transform a memorial representation into an autobiographical personal experience. We first review evidence from a variety of clinical domains?for example, amnesia, autism, frontal lobe pathology, schizophrenia?showing that breakdowns in any of the proposed components can produce impairments in autobiographical recollection, and conclude that the self-reflection, agency, ownership, and personal temporality are (...) individually necessary and jointly sufficient for autobiographical memorial experience. We then suggest a taxonomy of amnesic disorders derived from consideration of the consequences of breakdown in each of the individual component processes that contribute to the experience of autobiographical recollection. (shrink)

Disturbed identity is one of the defining characteristics of Borderline Personality Disorder manifested in a broad spectrum of dysfunctions related to the self, including disturbances in meaning-generating self-narratives. Autobiographical memories are memories of personal events that provide crucial building-blocks in our construction of a life-story, self-concept, and a meaning-generating narrative identity. The cultural life script represents culturally shared expectations as to the order and timing of life events in a prototypical life course within a given culture. It is used (...) to organize one’s autobiographical memories. Here, 17 BPD-patients, 14 OCD-patients, and 23 non-clinical controls generated three important autobiographical memories and their conceptions of the cultural life script. BPD-patients reported substantially more negative memories, fewer of their memories were of prototypical life script events, their memory narratives were less coherent and more disoriented, and the overall typicality of their life scripts was lower as compared with the other two groups. (shrink)

The current assessment of behaviors in the inventories to diagnose autism spectrum disorders (ASD) focus on observation and discrete categorizations. Behaviors require movements, yet measurements of physical movements are seldom included. Their inclusion however, could provide an objective characterization of behavior to help unveil interactions between the peripheral and the central nervous systems. Such interactions are critical for the development and maintenance of spontaneous autonomy, self-regulation and voluntary control. At present, current approaches cannot deal with the heterogeneous, dynamic and (...) stochastic nature of development. Accordingly, they leave no avenues for real-time or longitudinal assessments of change in a coping system continuously adapting and developing compensatory mechanisms. We offer a new unifying statistical framework to reveal re-afferent kinesthetic features of the individual with ASD. The new methodology is based on the non-stationary stochastic patterns of minute fluctuations (micro-movements) inherent to our natural actions. Such patterns of behavioral variability provide re-entrant sensory feedback contributing to the autonomous regulation and coordination of the motor output. From an early age, this feedback supports centrally driven volitional control and fluid, flexible transitions between intentional and spontaneous behaviors. We show that in ASD there is a disruption in the maturation of this form of proprioception. Despite this disturbance, each individual has unique adaptive compensatory capabilities that we can unveil and exploit to evoke faster and more accurate decisions. Measuring the kinesthetic re-afference in tandem with stimuli variations we can detect changes in their micro-movements indicative of a more predictive and reliable kinesthetic percept. Our methods address the heterogeneity of ASD with a personalized approach grounded in the inherent sensory-motor abilities that the individual has already developed. (shrink)

_341_ _Objectives: _In patients with multivessel disease both the detection of the culprit lesion and the exact allocation are important preconditions for sufficient treatment and improved outcome. In a vessel based approach the combination of quantitative coronary angiography and fractional flow reserve measured by a pressure wire should be advantageous compared to myocardial SPECT, as morphological and functional information is delivered simultaneously. Therefore our aim was to evaluate MS in the detection and allocation of hemodynamically significant stenoses obtained by the (...) combined gold standard QCA plus FFR in patients with multivessel disease. _Methods: _FFR and QCA of 95 vessels in 80 patients have been evaluated. Hemodynamically significant target lesions were defined as intermediate stenoses between 50 and 75% with an FFR. (shrink)

The Collective Unconscious in the Age of Neuroscience brings the connection between C.G. Jung's theory of a collective unconscious, neuroscience, and personal experiences of severe mental illness to life. Hallie B. Durchslag uses narrative analysis to examine four autobiographical accounts of mental illness, including her own, and illuminate the interplay between psychic material and human physiology that Jung intuited to exist. Durchslag's unique study considers the links between expressions of the collective unconscious, such as myth, fairy tales, folk tales, and (...) 'big dreams', and the experiences of those diagnosed with severe mental illnesses, such as schizophrenia and bipolar disorder. The author's personal narrative account of a psychotic episode is at its heart, bringing both an intimate foundation and exceptional insight to the book. With reference to neuroscientific and genetic research throughout, The Collective Unconscious in the Age of Neuroscience highlights the gap between depth psychological notions of etiology and treatment, highlights patterns of collective material in the qualitative experience of these genetic and biological disorders, and explores how the efficacy of pharmacological treatment sheds light on Jung's theoretical model. The Collective Unconscious in the Age of Neuroscience will be essential reading for academics and students of Jungian and post-Jungian studies, consciousness, neuroscience and mental health. It will also provide unique insight for analytical psychologists interested in severe mental illness and the collective unconscious. (shrink)

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

The advent of digital cameras has provided photographers, with varying levels of expertise, the opportunity to accumulate large repositories of digital images. However, this expansion has also brought the attendant difficulty of image retrieval. This paper reviews the considerable work already carried out on image retrieval and identifies critical constraints in attempting to handle the underlying semantics of photographic images. The authors address the issue of how an amateur photographer, storing several thousand images a year, can effectively and efficiently manage (...) a personal collection. A number of surprisingly simple techniques are proposed utilising a sparse lexical ontology alongside iconic visual clues to identify key representative events in the collection. The photographer’s associated knowledge and experience, often shared by others who are attuned to the context of the collection, are critical to the effective management of the images. The authors recommend the use of existing browsers and a simple keyword table to facilitate concise and effective image storage and retrieval. Photographers can further enrich the representation of their collection by clustering images in accordance with their perceived relevance and aesthetic qualities. The authors argue that these properties can also be exploited to enhance retrieval. (shrink)

Endosex, in contrast to intersex, refers to innate physical sex characteristics judged to fall within the broad range of what is considered normative or typical for ‘binary’ female or male bodies by the medical field, or to persons with such characteristics1 (p. 437). In this short contribution, we explain the origins and increasing use of this little-known term and discuss its practical and ethical relevance to medicine as well as to scholarship from a range of disciplines concerned with individuals’ sexed (...) embodiment. There is growing awareness in many quarters of the term intersex— used within some discourses to refer to clusters of bodily attributes (as in ‘intersex traits’, also termed differences of sex development or variations of sex characteristics)1 or more broadly to persons (as in ‘intersex persons’) whose bodily attributes differ from the dominant clinical, biological, or legal paradigms that categorise and differentiate female and male bodies. Intersex traits have historically been stigmatised as monstrous, morbid or tragic, justifying surgical and hormonal ‘fixing’.2 Persons born with the attributes named with these terms, even if physically healthy, therefore risk unnecessary pathologisation and medicalisation, prompting interventions, often non-voluntary, into their bodies to make them appear or function in ways that are deemed more typically female or male. In addition, some legal and social systems automatically associate persons with these traits with third categories of sex—neither female nor male—which may or may not align with their sex designation at birth, sex of rearing, personal experience or self-conception (see Coda). Being seen as intersex or being judged to have …. (shrink)

Vacillating and mixed emotional experiences are often difficult to explore and understand because they confront the limits of our language's ability to capture private experiences in extreme or abnormal circumstances. In this paper, we build upon remarks by Wittgenstein (1953) to present a conceptual-discursive perspective based on naturalistic examples of individuals vacillating between pride and other emotions. This perspective is used to show how relevant emotion theories contain conceptual errors of the sort identified by Wittgenstein. The “assembled reminders” of shifts (...) between pride and other emotions are presented in contrast to analyses that focus on people's identification of causes of emotions, an approach which leads to theoretical speculation about underlying appraisal set changes or discussion of the empirical justification of cognitive ontology. We bypass a direct confrontation on these issues by examining how people's talk about the content of vacillating and mixed emotional experiences (i.e., aspect shifts) augments a shared “emotionology” with creative expressions and poetic comparisons. This last point is illustrated by the emotional instability experienced by individuals with Borderline Personality Disorder (BPD). Support for the conceptual-discursive perspective is provided by the success of a particular therapeutic approach, the Conversational Model, in ameliorating the developmental disruption of BPD by encouraging participation in empathic conversations. We conclude that a conceptual-discursive perspective undermines the cognitive appraisal “picture” of vacillating emotions and adds to our understanding. (shrink)

This study explored drug users’ attitudes toward and understanding of randomized controlled trials testing addiction therapies. A video portraying a fictional consent conference for a randomized controlled trial with placebo arm was shown to poor male and female drug users of diverse ethnic status and sexual orientation. The video stimulated focus group discussion in which participants’ comments often reflected “experimental realism”—a realistic view of the trial—and adequate understanding of the uncertain efficacy of the treatment being tested, as well as the (...) concepts of randomization and placebo control. However, participants’ comprehension of the nature of placebos was compromised by the widespread view that placebos are a way of testing a subject’s willpower and personal control over his or her addiction. Comments also showed a mistrust of the video investigator’s integrity and competence and signs of therapeutic misconception and misestimation. The study’s findings underscore the importance of tailoring informed consent encounters to the personal and sociohistorical context of participants’ lived experiences. (shrink)

Each year, millions of individuals in the United States are treated for a variety of serious medical conditions with prescription drugs whose therapeutic benefits are well known. The vast majority of these medications are used to treat medical and psychiatric illnesses. Generally, they are used as prescribed, and contribute to a better quality of life for persons suffering from debilitating or life-threatening disorders.The fact that a small portion of these medications is diverted by those who seek their psychoactive effects (...) raises the important policy issue: how to make drugs easily available for medical use while limiting access for purposes of abuse.Such a responsibility poses challenges very different from those of the so-called “war” on illicit drugs, because this control must be achieved without impeding patients’ access to medical care. A rational public policy would attempt to achieve a balance between the need to minimize abuse and the need to provide relief. (shrink)

Each year, millions of individuals in the United States are treated for a variety of serious medical conditions with prescription drugs whose therapeutic benefits are well known. The vast majority of these medications are used to treat medical and psychiatric illnesses. Generally, they are used as prescribed, and contribute to a better quality of life for persons suffering from debilitating or life-threatening disorders.The fact that a small portion of these medications is diverted by those who seek their psychoactive effects (...) raises the important policy issue: how to make drugs easily available for medical use while limiting access for purposes of abuse.Such a responsibility poses challenges very different from those of the so-called “war” on illicit drugs, because this control must be achieved without impeding patients’ access to medical care. A rational public policy would attempt to achieve a balance between the need to minimize abuse and the need to provide relief. (shrink)

We propose the “microbiota‐inflammasome” hypothesis of major depressive disorder (MDD, a mental illness affecting the way a person feels and thinks, characterized by long‐lasting feelings of sadness). We hypothesize that pathological shifts in gut microbiota composition (dysbiosis) caused by stress and gut conditions result in the upregulation of pro‐inflammatory pathways mediated by the Nod‐like receptors family pyrin domain containing 3 (NLRP3) inflammasome (an intracellular platform involved in the activation of inflammatory processes). This upregulation exacerbates depressive symptomatology and further compounds gut (...) dysbiosis. In this review we describe MDD/chronic stress‐induced changes in: 1) NLRP3 inflammasome; 2) gut microbiota; and 3) metabolic pathways; and how inflammasome signaling may affect depressive‐like behavior and gut microbiota composition. The implication is that novel therapeutic strategies could emerge for MDD and co‐morbid conditions. A number of testable predictions surface from this microbiota‐gut‐inflammasome‐brain hypothesis of MDD, using approaches that modulate gut microbiota composition via inflammasome modulation, fecal microbiota transplantation, psychobiotics supplementation, or dietary change. (shrink)

Children with developmental language disorder (DLD) have significant deficits in language ability that cannot be attributed to neurological damage, hearing impairment, or intellectual disability. The symptoms displayed by children with DLD differ across languages. In English, DLD is often marked by severe difficulties acquiring verb inflection. Such difficulties are less apparent in languages with rich verb morphology like Spanish and Italian. Here we show how these differential profiles can be understood in terms of an interaction between properties of the input (...) language, and the child's ability to learn predictive relations between linguistic elements that are separated within a sentence. We apply a simple associative learning model to sequential English and Spanish stimuli and show how the model's ability to associate cues occurring earlier in time with later outcomes affects the acquisition of verb inflection in English more than in Spanish. We relate this to the high frequency of the English bare form (which acts as a default) and the English process of question formation, which means that (unlike in Spanish) bare forms frequently occur in third‐person singular contexts. Finally, we hypothesize that the pro‐drop nature of Spanish makes it easier to associate person and number cues with the verb inflection than in English. Since the factors that conspire to make English verb inflection particularly challenging for learners with weak sequential learning abilities are much reduced or absent in Spanish, this provides an explanation for why learning Spanish verb inflection is relatively unaffected in children with DLD. (shrink)

Food images are useful stimuli for the study of cognitive processes as well as eating behavior. To enhance rigor and reproducibility in task-based research, it is advantageous to have stimulus sets that are publicly available and well characterized. Food Folio by Columbia Center for Eating Disorders is a publicly available set of 138 images of Western food items. The set was developed for the study of eating disorders, particularly for use in tasks that capture eating behavior characteristic of (...) these illnesses. It contains foods that are typically eaten, as well as those typically avoided, by individuals with eating disorders. Each image has now been rated across 17 different attributes by a large general United States population sample via Amazon’s Mechanical Turk. Ratings included subjective attributes as well as estimates of nutrient content. Each participant rated a subset of stimulus set food items on all 17 dimensions. Additional description of the image set is provided in terms of physical image information and accurate nutritional information. Correlations between subjective ratings were calculated and an exploratory factor analysis and exploratory cluster analysis completed. Outcomes of the factor analysis suggested foods may be described along three latent factors of healthiness, tastiness, and umami taste; the cluster analysis highlighted five distinct clusters of foods varying on these same dimensions. Descriptive outcomes indicated that the stimulus set includes a range of foods that vary along multiple dimensions and thus is likely to be useful in addressing various research questions surrounding eating behavior and cognition in healthy populations, as well as in those with eating disorders. The provision of comprehensive descriptive information allows for stimulus selection that is optimized for a given research question and promotes strong inference. (shrink)

Both individuals with diagnosed with Autism Spectrum Disorder and individuals high in psychopathic traits show reduced susceptibility to contagious yawning; that is, yawning after seeing or hearing another person yawn. Yet it is unclear whether the same underlying processes are responsible for the relationship between reduced contagion and these very different types of clinical traits. College Students watched videos of individuals yawning or scratching while their eye movements were tracked. They completed the Interpersonal Reactivity Index, the Autism-Spectrum Quotient, the Psychopathy (...) Personality Inventory-Revised, and the Adolescent and Adult Sensory Processing Disorder Checklist. Both psychopathic traits and autistic traits showed an inverse relationship to contagious yawning, consistent with previous research. However, the relationship between autistic traits and contagious yawning was moderated by eye gaze. Furthermore, participants high in autistic traits showed typical levels of contagious itching whereas adults high in psychopathic traits showed diminished itch contagion. Finally, only psychopathic traits were associated with lower overall levels of empathy. The findings imply that the underlying processes contributing to the disruptions in contagious yawning amongst individuals high in autistic vs. psychopathic traits are distinct. In contrast to adults high in psychopathic traits, diminished contagion may appear amongst people with high levels of autistic traits secondary to diminished attention to the faces of others, and in the absence of a background deficit in emotional empathy. (shrink)

The treatment of persons who frequently present to the healthcare system following repetitive foreign body ingestion has been addressed in the psychiatric literature. However, there has been little exploration of the ethical considerations regarding the treatment of these patients. The complexity of their medical and psychiatric presentation raises fundamental ethical questions regarding the duty to treat, patient autonomy, justice, and futility. Careful ethical analysis is particularly important in this context, since the frustration that medical professionals may feel in response may (...) lead to false assumptions that can negatively impact patient care. A careful exploration of these questions can increase awareness and understanding, which in turn can lead to improved treatment of patients who repetitively ingest foreign bodies. Care for patients who inflict self-harm, particularly by repetitive foreign body ingestion, is not futile. The patients have a right to treatment and are entitled to resources. Efforts should be made to provide a more comprehensive treatment approach to these patients. (shrink)

Delays in early language development are characteristic of young autistic children, and one of the most recognizable first concerns that motivate parents to seek a diagnostic evaluation for their child. Although early language abilities are one of the strongest predictors of long-term outcomes, there is still much to be understood about the role of language impairment in the heterogeneous phenotypic presentation of autism. Using a person-centered, Latent Profile Analysis, we first aimed to identify distinct patterns of language and social communication (...) ability in a clinic-based sample of 498 autistic children, ranging in age from 18 to 60 months. Next, a multinomial logistic regression analysis was implemented to examine sociodemographic and child-based developmental differences among the identified language and social communication profiles. Three clinically meaningful profiles were identified from parent-rated and clinician-administered measures: Profile 1 “Relatively Low Language and Social Communication Abilities,” Profile 2 “Relatively Elevated Language and Social Communication Abilities,” and Profile 3 “Informant Discrepant Language and Relatively Elevated Social Communication Abilities.” Overall, young autistic children from the lowest-resource households exhibited the lowest language and social communication abilities, and the lowest non-verbal problem-solving and fine-motor skills, along with more features of attention-deficit/hyperactivity disorder and atypical auditory processing. These findings highlight the need for effective community-based implementation strategies for young autistic children from low-resource households and underrepresented communities to improve access to individualized quality care. (shrink)

Music-based interventions (MBI) have become increasingly widely adopted for dementia and related disorders. Previous research shows that music engages reward-related regions through functional connectivity with the auditory system, but evidence for the effectiveness of MBI is mixed in older adults with mild cognitive impairment (MCI) and Alzheimer’s disease (AD). This underscores the need for a unified mechanistic understanding to motivate MBIs. The main objective of the present study is to characterize the intrinsic connectivity of the auditory and reward systems (...) in healthy aging individuals with MCI, and those with AD. Using resting-state fMRI data from the Alzheimer’s Database Neuroimaging Initiative, we tested resting-state functional connectivity within and between auditory and reward systems in older adults with MCI, AD, and age-matched healthy controls (N = 105). Seed-based correlations were assessed from regions of interest (ROIs) in the auditory network (i.e., anterior superior temporal gyrus, posterior superior temporal gyrus, Heschl’s Gyrus), and the reward network (i.e., nucleus accumbens, caudate, putamen, and orbitofrontal cortex). AD individuals were lower in both within-network and between-network functional connectivity in the auditory network and reward networks compared to MCI and controls. Furthermore, graph theory analyses showed that the MCI group had higher clustering and local efficiency than both AD and control groups, whereas AD individuals had lo... (shrink)

A recent legal case involving an ambiguous diagnosis in a woman with a severe disorder of consciousness raises pressing questions about treatment withdrawal in a time when much of what experts know about disorders of consciousness is undergoing revision and refinement. How much should diagnostic certainty about consciousness matter? For the judge who refused to allow withdrawal of artificial nutrition and hydration, it was dispositive. Rather than relying on substituted judgment or best interests to determine treatment decisions, he ruled (...) that withdrawal was categorically prohibited, even as he concluded that Hannah Capes was more likely than not in a permanent vegetative state. In many jurisdictions, his decision would likely be consistent with existing law. Evolving technological advances have demonstrated that biologically distinct diagnoses incorporated into state laws may be difficult to establish even under ideal conditions. We offer the Capes case for purposes of examining the consequences of enshrined legal distinctions between permanent vegetative state and other severe disorders of consciousness. Insistence on proof of the permanent absence of consciousness before treatment withdrawal is allowed fails to respect the rights of persons with disorders of consciousness. Even the well-established rights to treatment withdrawal for those in a permanent vegetative state may be in jeopardy if reform is not undertaken. (shrink)

Most metazoan organisms have evolved a mildly acidified and calcium diminished sorting hub in the early secretory pathway commonly referred to as the Endoplasmic Reticulum‐Golgi intermediate compartment (ERGIC). These membranous vesicular‐tubular clusters are found tightly juxtaposed to ER subdomains that are competent for the production of COPII‐coated transport carriers. In contrast to many unicellular systems, metazoan COPII carriers largely transit just a few hundred nanometers to the ERGIC, prior to COPI‐dependent transport on to the cis‐Golgi. The mechanisms underlying formation and (...) maintenance of ERGIC membranes are poorly defined. However, recent evidence suggests an important role for Trk‐fused gene (TFG) in regulating the integrity of the ER/ERGIC interface. Moreover, in the absence of cytoskeletal elements to scaffold tracks on which COPII carriers might move, TFG appears to promote anterograde cargo transport by locally tethering COPII carriers adjacent to ERGIC membranes. This action, regulated in part by the intrinsically disordered domain of TFG, provides sufficient time for COPII coat disassembly prior to heterotypic membrane fusion and cargo delivery to the ERGIC. -/- . (shrink)

DBS Think Tank IX was held on August 25–27, 2021 in Orlando FL with US based participants largely in person and overseas participants joining by video conferencing technology. The DBS Think Tank was founded in 2012 and provides an open platform where clinicians, engineers and researchers can freely discuss current and emerging deep brain stimulation technologies as well as the logistical and ethical issues facing the field. The consensus among the DBS Think Tank IX speakers was that DBS expanded in (...) its scope and has been applied to multiple brain disorders in an effort to modulate neural circuitry. After collectively sharing our experiences, it was estimated that globally more than 230,000 DBS devices have been implanted for neurological and neuropsychiatric disorders. As such, this year’s meeting was focused on advances in the following areas: neuromodulation in Europe, Asia and Australia; cutting-edge technologies, neuroethics, interventional psychiatry, adaptive DBS, neuromodulation for pain, network neuromodulation for epilepsy and neuromodulation for traumatic brain injury. (shrink)

In previous literature, ethicists mention several goals of Clinical Ethics Support (CES). It is unknown what key persons in healthcare institutions see as main–—and sub-goals of CES. This article presents the goals of CES as perceived by board members and members of ethics support staff. This is part of a Dutch national research using a mixed methods design with questionnaires, focus groups and interviews. Quantitative and qualitative data were analyzed and combined in an iterative process. Four main clusters of goals (...) were found: 1) encouraging an ethical climate, 2) fostering an accountable and transparent organization, 3) developing professionalism and a final goal, overarching the previous three, 4) good care. Most important sub-goals of CES were: attention for ethical issues, raising awareness of ethical issues, fostering ethical reflection and supporting employees. The article ends with a discussion on the desirability to further operationalize the general goal of good care, the context-boundedness of our findings and the need to relate goals of CES to the features of organizational cultures to further improve the integration of CES in healthcare institutions. (shrink)

Variant Creutzfeldt–Jakob disease is a fatal, transmissible, neurodegenerative disorder for which there is currently no effective treatment. vCJD arose from the zoonotic spread of bovine spongiform encephalopathy. There is now compelling evidence for human to human transmission through blood transfusions from presymptomatic carriers and experts are warning that the real epidemic may be yet to come. Imperatives exist for the development of reliable, non-invasive presymptomatic diagnostic tests. Research into such tests is well advanced. In this article the ethical implications of (...) the availability of these tests are elaborated and comparisons drawn with predictive genetic testing for Huntington’s disease and screening for HIV. Paramount to considerations is the issue of whom to test, weighing up respect for personal autonomy against obligations to benefit and protect society. A paradigm is proposed similar to that used for HIV screening but with unique features: compulsory testing of all blood/organ donors and individuals undergoing surgery or invasive procedures who have a significant risk of disease transmission. (shrink)

I am delighted that Zachar and Potter have chosen to refer to my work on the DSM-IV cluster B personality disorders in their very interesting and ambitious target article. Their suggestion that we turn to virtue ethics rather than traditional moral theory to understand the relation between moral and nonmoral factors in personality disorders is certainly original and worth pursuing. Yet, in the final instance, I am not entirely sure about the exact scope of their (...) proposed analysis. I also worry whether they may have inadvertently presented a slightly inaccurate account of my views on the cluster B personality disorders, as they seek to formulate and defend their own views, which seem to be far wider in scope. I .. (shrink)

The DSM-IV-TR (American Psychiatric Association 1994, 689) defines personality disorder (PD) as: An enduring pattern of experience and behavior that deviates markedly from the expectations of an individual’s culture. This pattern is manifested in two (or more) of the following areas: 1 Cognition (i.e., ways of perceiving and interpreting self, other people, and events); 2 Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response); 3 Interpersonal functioning; and 4 Impulse control. B The enduring ..

_Treating Dissociative and Personality Disorders_ draws on major theorists and the very latest research to help formulate and introduce the Relational/Multi-Motivational Therapeutic Approach, a new model for treating such patients within a clinical psychoanalytic setting. Supported by her fellow contributors, Antonella Ivaldi provides an overview of existing theories and evidence for their effectiveness in practice, sets out her own theory in detail and provides rich clinical detail to demonstrate the advantages of the REMOTA model as applied in a clinical (...) setting. The narratives in this book show how it is possible to integrate different contributions within a multidimensional aetiopathogenic treatment model, which considers the mind as a manifestation of the relationship between body and world. From a conceptual perspective, according to which consciousness emerges and develops in the interpersonal dimension, this book shows how it becomes possible to understand, in the therapeutic space, what stands in the way of sound personal functioning, and how to create the conditions for improving this. Treating Dissociative and Personality Disorders will be highly useful in addressing the particular clusters of symptoms presented by patients, stimulating therapists of different backgrounds to explore the complexity of human nature. On reading this book, it will become clear that theories can truly become useful instruments, if approached with a critical mind and with humbleness, in order to venture into what we do not know and will never know completely: the relationship with the other, unique and irreplaceable. Treating Dissociative and Personality Disorders provides an integrative and comparative new approach that will be indispensable for combining relational clinical knowing and motivational theories. It_ _will appeal to psychoanalysts and psychotherapists, especially those in training, clinicians of different backgrounds interested in comparative psychotherapy, as well as social workers and graduate and postgraduate students. (shrink)

In this article, I argue for a reconsideration of the taxonomy of the Histrionic Personality Disorder. First, HPD does not carry the negative ethical implications of the other Cluster Bs, which are Anti-Social, Borderline, and Narcissistic. Using Aristotelian notions of character as a heuristic device, I argue that ontologically HPD is not a personality disorder, but instead a cultural disorder, a result of attitudes toward traditionally feminine styles of interaction. This explains the confusion in the research between (...) HPD and hysteria and also the curious paucity of literature on HPD itself in contrast to the other Cluster Bs. (shrink)

Patients with borderline personality disorder (BPD) are overrepresented in compulsory inpatient care for suicide-protective reasons. Still, much evidence indicates negative effects of such care, including increased suicide risk. Clinical guidelines are contradictory, leaving clinicians with difficult ethical dilemmas when deciding on compulsory care. In this study, we analyse the arguments most commonly used in favour of compulsory care of BPD patients, to find out in what situations such care is ethically justified. The aim is to guide clinicians when deciding (...) on compulsory care for BPD patients and reduce the use of potentially harmful care. The arguments analysed are (a) the patients lack decision competence, (b) the patients lack authenticity, (c) compulsory care saves the patient from suicide, (d) compulsory care safeguards against litigation, complaints, or doctor's anxiety, (e) compulsory care is a practical solution in emergencies, and (f) it is better for the caregiver to ‘err on the safe side’. We conclude that compulsory care is not ethically justified in most cases unless the clinician has probable reason to believe that the patient lacks decision capacity by suffering from a severe mental co-morbidity and stands to benefit from such care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Why Narcissists Are Morally ResponsibleAleksandar Fatic, PhDIn his insightful commentary of ‘Narcissism as a moral incompetence,’ Professor Pies proposes several principal objections to my line of argument. First, Pies mentions that I embrace a Platonic essentialism and a ‘binary’ view of narcissism, whilst in fact narcissistic traits present themselves in degrees, within a continuum of pathology.Let us clarify the meaning of essentialism. When applied to the phenomenology of narcissism, (...) Platonic essentialism would imply that there is an idea, or ideal, of ‘pure’ narcissism, which governs our cognition of narcissistic phenomenology. Without an ‘essentialist’ understanding of what narcissism as a more or less pure phenomenon would look like, it would make no semantic or logical sense to speak of various ‘types’ or ‘degrees’ of narcissism. In the 1940s, in The Concept of Mind, Gilbert Ryle offered the now infamous logical analysis of ‘false’ and ‘true coins’: if there were not true coins of which we had some idea, it would be logically impossible to speak of counterfeit coins (McDermid, 2004; Ryle, 1949, pp. 94–99). There are shoddily produced coins that bear only a vague resemblance to the original idea or mint of the real coin, however, for each we would ultimately have to decide whether the resemblance is sufficient for it to be considered a real coin. Shoddily produced coins represent various ‘degrees’ of resemblance of the idea, or form, of a coin, but to call them coins, and to decide whether they are true coins or not, it is a logical presupposition that we must first have an ‘idea’ of what an ‘ideal’ real coin is like. This, at its core, is essentialism.There is no escape from this type of essentialism in any rigorous argument, because Platonic essentialism is the foundation of the very meanings of the concepts we use. Plato’s ideas are paradigms, where the particular instantiations of their qualities are called ‘phenomena’ (Sedley, 2016; Taylor, 2016). Thus, the nuanced expression of ideas or forms in their various phenomena is the very substance of the essentialist theory of ideas. It appears that Professor Pies is also a Platonic essentialist, as am I.So why is it often impossible in clinical practice to ascribe necessary and sufficient conditions to narcissism? Well, let us remember Rosenhan’s experiments (1973). Rosenhan illustrates how the same individuals were diagnosed with very different disorders by different clinicians at roughly the same time, and how healthy individuals, once they had been instructed to ‘fake’ psychotic symptoms, remained under the same or more serious [End Page 177] diagnoses even when they stopped pretending and behaved completely normally. The reason for the arbitrariness of psych-diagnoses is the insufficiency of the psych-diagnostic language, including the actual diagnostic criteria, a kind of Lacanian ‘lack’ that is built into the very structure of psychodiagnostics (Ruti, 2008), and not a metaphysics behind such use of diagnostic language, whether it is essentialist or non-essentialist. Whether a particular patient actually has NPD or not in practice comes down to a consensual judgement—one that has been notoriously lacking in the history of psychiatry (Verhaeghe, 2008, pp. 71–125).Second, Pies suggests that empathy is ‘a complex, multidimensional construct comprising cognitive and affective components.’ I do not think this is a correct understanding of empathy. In fact, it is a conceptual revision of the original concept of empathy, which is one of a moral emotion (Kauppinen, 2014). What Pies calls ‘cognitive empathy,’ namely the ability to recognize and influence the emotions of others is an entirely different quality capacity that has recently been called ‘emotional intelligence’ (e.g., Conte, 2005). Many Cluster B personality disorders are characterized by an exceptionally high emotional intelligence and an almost complete lack of empathy, which allows them to use their emotional intelligence to manipulate and mistreat others. Surely such emotionally intelligent, but highly malignant strategies would not be considered ‘empathy.”Relatedly, Pies objects to Slote’s alleged view that only actions arising from factual empathy are morally justifiable. This is a ‘naturalist fallacy’ in reading Slote. The natural fallacy is a confusion between the ‘is’ and the ‘ought.’ Slote actually argues that only actions that are consistent with... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:A Third Way: Social Disability and Person-Centered AssessmentChristopher Heginbotham (bio)Keywordsimpaired functioning, psychopathic, personality disorder, neurological damage, psychotherapyJohn Sadler’s Fascinating Paper identifies a significant problem with existing diagnostic classifications. But in doing so he raises further unresolved philosophical, nosological, and practical problems. Although he is undoubtedly right in showing that the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV (and International Classification of Diseases [ICD]-10) do not provide (...) an adequate categorization, he is I believe wrong to use the term “vice” to describe the cluster of wrongful acts.“Vice” conjures up images of Miami, drugbusting police, prostitution, and other activities that are characterized by one thing—by and large, these are actions undertaken knowingly, usually for financial gain. These are not the actions of people with impaired mental functioning as a result of mental disorder or neurological damage. It is of course true that human trafficking and enforced prostitution may mean women forced into prostitution against their will, but rarely are these women considered mentally disordered solely as a result of their prostitution. Yet it is capacitated, premeditated wrongdoing that is normally considered to be “vice.”By contrast, all the cases cited in the paper describe conditions that are almost certainly the result of some form of impaired functioning, either owing to early childhood experiences (Case A), familial culture and conditioning (Case B), or neurological damage (Case C). The common thread in these cases is impaired capacity—in Case A this could be described as due to psychopathic or personality disorder (I distinguish the two separately rather than describe the phenomenon as “psychopathic personality disorder”) as a result of multiple childhood traumas. Their presentation is not unexpected given the person’s history and, although the condition may have become refractory, it might be amenable to treatment with psychoanalytically oriented psychotherapy, given sufficient time and a nurturing environment (Bateman and Fonagy 2006, 2008; Cordess and Cox 1996; Levy 2008).The description of Case B leaves a lot of room for doubt and uncertainties. Did Ms A really try to smother her child? She confessed to one occasion, but was this under duress? Did she feel that if she agreed she would be treated more leniently? And if she was guilty, does it suggest “vice,” a premeditated act, or is there another explanation—attention [End Page 31] seeking because of low self-esteem or a personality disorder as a result of some abuse that had not been identified? Almost certainly from the description given this would not count, for me at any rate, as vice. Her actions may be odd, bizarre, or dangerous, but did they demonstrate a mens rea? Was Ms A making adequate evaluative judgments of her situation and that of her child? We know from clinical work with very damaged women in forensic mental health services that early physical, emotional, or sexual abuse leads in turn to women harming both themselves and their children (Bland et al. 1999; Cordess and Cox 1996; see also for example, Jeffcote and Watson 2004). Or perhaps, speculatively, her condition was Munchausen’s by proxy?Case C is horrendous but does not lend itself readily to the forms of psychiatric classification available. Indeed there is no easy way to describe such actions other than those of someone who is either incapable of understanding the nature and consequence of the actions that he has undertaken, or is simply “mad” in a folk sense. Prima facie this seems to be the result of permanent and little understood neurological damage. However, this case comes closest to the evil that is implied in the term “vice”; and might be diagnosed similarly to a celebrated English murderer, that of Peter Sutcliffe, the so-called Yorkshire Ripper. Sutcliffe was diagnosed as suffering from paranoid schizophrenia, although the jury at his trial found that he was fit to plead, and he was initially sent to prison, where he deteriorated. He is now, and has for some time, been in Broadmoor high secure hospital.The result of these comments is that I agree fully with John Sadler’s conclusions, but for rather different reasons. DSM-IV categories try and fail to offer a symptomatology for... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Narcissism A Focal Point for Examining the Interrelatedness of Psychology and PhilosophyLydia Amir, PhD (bio)In a groundbreaking article, Aleksandar Fatic challenges the view that mental health is to be dissociated from morality or ethics. His argument targets cluster B personality disorders, such as Borderline and Narcissistic Personality Disorders, but focuses mainly on narcissistic disorders, whether diagnosed or not. Although these persons are not (...) exempt of moral and legal responsibility, they are diagnosed by and relegated to the mental health system, which is often ineffective in treating them. Fatic suggests that addressing their faulty morality is the best policy. In my commentary of his article, I further probe the viability and desirability of doing so. I point to narcissism as a focal point for examining the necessary impact of psychology and philosophy insofar as psychologists may be considered experts in emotions and philosophers in normative ethics. I question the interest in any ethics that does not also supply the means of its implementation and suggest that narcissists may have a morality of their own, ethical egoism.As psychiatrist Bennett Simon notes, Socrates did not inquire into the mental health field; his presence is missed as the questions, “what is mental illness?” and “what are psychiatry and psychiatrists?” are not addressed. It follows that it is up to us, as Simon attempts to do in the first chapter of Mind and Madness in Ancient Greece: The Classical Roots of Modern Psychiatry (1978), to define the psychiatrist’s proper area of professional competence (p. 28). That which makes matters even more confusing, he notes, is that psychiatrists are only one group of professionals who deal with the “mentally ill” and that they are “far from unanimous” about which problems “pertain to their particular sphere” (Simon, 1978, p. 29). He thus lists a variety of problems which “a glance at both popular and professional literature…reveals that at one time or another, psychiatrists have claimed [End Page 169] (sometimes by public demand) for their proper sphere” (Simon, 1978, p. 29). Among them is the issue that Fatic’s break grounding article tackles: “Psychiatrists at times consider it their proper task to deal with people who are excessively selfish and self-centered (narcissistic personality disorder)” (Simon, 1978, p. 29).Thus, Simon sees as a matter of controversy whether narcissism is a psychiatric issue, and defines the disorder in moral terms (“selfish,” “self-centered”). Fatic broadens the argument: he questions the validity of the psychological approach not only to narcissism as a personality disorder, but also to narcissistic traits, and the effectivity of this approach given that this is an area in which therapists usually do not have much success even if the patients look for help, which is rare. Fatic suggests that these personalities, either those with narcissistic traits or those with full-fledged narcissistic personality disorder, should be better understood (and maybe also addressed, although this point is not explicitly made) when viewed through moral lenses. In doing so, Fatic not only questions the validity of one form of personality disorder––still a controversial category––but re-kindles the view that correlates aspects of mental health with virtue, a view that was valid up until the nineteenth century and that made of philosophers (and priests) doctors of the soul.1That which made of philosophers’ teachings an important part of one’s life before the advent of scientific psychology has been often associated with this view, that the virtuous are also the healthy. Without going as far as to suggest that philosophers should teach virtue to narcissists, which could be a further argument in favor of the new field of philosophical practice and a broadening of its legitimate concerns, Fatic notes that moral categories are better suited to approach those who are plagued by narcissism.One way to explain the historical role that psychology played in relation to the traditional one upheld by morality is that psychology stepped in to explain the origins of failures in morality. If the narcissist is to be judged according to moral categories (a judgment that he necessarily fails in so far as right emotions as relevant to morality), what might be the consequences?Ascribing... (shrink)

The comorbidity of personality disorders and mental disorders is commonly understood through three types of theoretical models: either a) personality disorders precede mental disorders, b) mental disorders precede personality disorders, c) mental disorders and personality disorders share common etiological grounds. Although these hypotheses differ with respect to their idea of causal direction, they all imply a latent variable perspective, in which it is assumed that either personality and (...) mental disorders are latent variables that have certain causal relations [models a) and b)]; or that, as in model c), the common etiology is in fact a latent variable that causes symptomatology of both personality and mental disorders. We aim to provide another perspective on the comorbidity between personality and mental disorders, namely a network perspective. To this end, we investigated Major Depression and Borderline Personality Disorder and hypothesized that symptoms of BPD and MD could interact with one another rather than being caused by a latent variable. To illustrate this theoretical network conceptualization of the comorbidity of BPD and MD we analyzed a cross-sectional clinical dataset of 376 patients who were asked to complete the Structured Clinical Interview for DSM-IV Axis II Disorders and the Beck Depression Inventory II. The results identify direct associations between symptoms of MD and BPD. If we take the links in this empirical network to be ‘substantive', this suggests a radical shift of our current conceptualization of the comorbidity of mental disorders and personality disorders. (shrink)

Introductory remarks about the problem of the self -- The epistemological self : the self of neural instantiation -- The ontological self : the self of first-person subjectivity -- The epistemological and ontological selves : a brief "summing up" -- Empirical evidence and the ontological and epistemological selves -- Some final thoughts.

In her paper, Robinson asserts that if one is convinced by the arguments assigning personhood according to a threshold criterion, one should also be open to the potential for a secondary personhood threshold, satisfied when one is pregnant, which confers temporary enhanced moral status. Rather than grounding such a claim on a fetus’s possession, or lack thereof, of personhood, Robinson argues that the pregnant person’s status as a ‘unique being’ is enough to satisfy the requirements of such an additional personhood (...) classification. 1 She justifies her claim via three arguments: (1) that the pregnant person is, in fact, more than a singular individual; (2) that pregnant people play a critical role in the human race’s continuation and (3) that the significant harms and burdens to which pregnant people have been exposed to historically and contemporary requires counterbalancing with enhanced protections. Unfortunately, despite Robinson’s best efforts, she does not... (shrink)

This is a critical exposition and limited defence of a theory of first- person belief transiently held by Roderick Chisholm after giving up the early haecceity theory of Person and Object and before adopting the late self-attribution theory of The First Person. I reconstruct that 'middle' theory as involving what I call a 'hard-core' approach to de re belief and I rebut objections concerning epistemic supervenience and abnormal consciousness. In my rebuttals, I sketch a variant of the middle theory according (...) to which first- person belief essentially involves the believer's introspective acquaintance with herself. (shrink)

A dominant strand of philosophical thought holds that natural kinds are clusters of objects with shared properties. Cluster theories of natural kinds are often taken to be a late twentieth-century development, prompted by dissatisfaction with essentialism in philosophy of biology. I will argue here, however, that a cluster theory of kinds had actually been formulated by William Whewell (1794-1866) more than a century earlier. Cluster theories of kinds can be characterized in terms of three central commitments, all (...) of which are present in Whewell’s work on classification. Like contemporary cluster theorists, Whewell claims that kinds are united by similarity, that many kinds do not have essences, and that there are “gaps” between kinds. Moreover, Whewell advises taxonomists to look for consilience (roughly, convergence) between different classificatory schemes, a recommendation that reinforces the identification of natural classes with property clusters. Thus Whewell was not only an early cluster theorist, but one with important insights into what a cluster theory of kinds means for the practice of classification. (shrink)