Psychopharmacology - a remarkable development -- Philosophical questions raised by psychopharmacology -- How to think about science, language, and medicine : classical, critical, and integrated perspectives -- Conceptual questions about psychotropics -- Explanatory questions about psychotropics -- Moral questions about psychotropics.

Members of Division 28 generally appear to agree that empirical demonstrations provide the most valid basis for building the sciences of psychopharmacology, neuropharmacology, and neurochemistry. This article discusses some of the beliefs, interests and concerns among members of Division 28. 2012 APA, all rights reserved).

The availability of a range of new psychotropic agents raises the possibility that these will be used for enhancement purposes (smart pills, happy pills, and pep pills). The enhancement debate soon raises questions in philosophy of medicine and psychiatry (eg, what is a disorder?), and this debate in turn raises fundament questions in philosophy of language, science, and ethics. In this paper, a naturalistic conceptual framework is proposed for addressing these issues. This framework begins by contrasting classical and critical concepts (...) of categories, and then puts forward an integrative position that is based on cognitive-affective research. This position can in turn be used to consider the debate between pharmacological Calvinism (which may adopt a moral metaphor of disorder) and psychotropic utopianism (which may emphasize a medical metaphor of disorder). I argue that psychiatric treatment of serious psychiatric disorders is justified, and that psychotropics are an acceptable kind of intervention. The use of psychotropics for sub-threshold phenomena requires a judicious weighing of the relevant facts (which are often sparse) and values. (shrink)

Psychopharmacological drugs have effects on selfhood in ways that often overlap with the treatment of mental disorders, but the effects also go beyond the domain of disorder into the sphere of enhancement. To what extent this is and will be the case depends, of course, on the definition and understanding of mental disorder. The psychotropic effects on selfhood can be mapped out by distinguishing groups of traits that belong to personality and that form dimensions of selfhood, but they can also (...) be distinguished by acknowledging different layers of selfhood-pre-reflective embodied self, reflective self, and narrative self. The effects of psychopharmacological drugs in some cases normalize the alienating experiences of the breakdown of pre-reflective selfhood, in other cases they rather bring about changes in basic dimensions of selfhood and personality, such as temperament and emotional dispositions. (shrink)

Aldous Huxley’s Brave New World is a famous dystopia, frequently called upon in public discussions about new biotechnology. It is less well known that 30 years later Huxley also wrote a utopian novel, called Island. This paper will discuss both novels focussing especially on the role of psychopharmacological substances. If we see fiction as a way of imagining what the world could look like, then what can we learn from Huxley’s novels about psychopharmacology and how does that relate to (...) the discussion in the ethical and philosophical literature on this subject? The paper argues that in the current ethical discussion the dystopian vision on psychopharmacology is dominant, but that a comparison between Brave New World and Island shows that a more utopian view is possible as well. This is illustrated by a discussion of the issue of psychopharmacology and authenticity. The second part of the paper draws some further conclusions for the ethical debate on psychopharmacology and human enhancement, by comparing the novels not only with each other, but also with our present reality. It is claimed that the debate should not get stuck in an opposition of dystopian and utopian views, but should address important issues that demand attention in our real world: those of evaluation and governance of enhancing psychopharmacological substances in democratic, pluralistic societies. (shrink)

This article will examine how the notion of emotional authenticity is intertwined with the notions of naturalness and artificiality in the context of the recent debates about ‘neuro-enhancement’ and ‘neuro-psychopharmacology.’ In the philosophy of mind, the concept of authenticity plays a key role in the discussion of the emotions. There is a widely held intuition that an artificial means will always lead to an inauthentic result. This article, however, proposes that artificial substances do not necessarily result in inauthentic emotions. (...) The literature provided by the philosophy of mind on this subject usually resorts to thought experiments. On the other hand, the recent literature in applied ethics on ‘enhancement’ provides good reasons to include real world examples. Such case studies reveal that some psychotropic drugs such as antidepressants actually cause people to undergo experiences of authenticity, making them feel ‘like themselves’ for the first time in their lives. Beginning with these accounts, this article suggests three non-naturalist standards for emotions: the authenticity standard, the rationality standard, and the coherence standard. It argues that the authenticity standard is not always the only valid one, but that the other two ways of assessing emotions are also valid, and that they can even have repercussions on the felt authenticity of emotions. In conclusion, it sketches some of the normative implications if not ethical intricacies that accompany the enhancement of emotions. (shrink)

‘Cosmetic psychopharmacology’ is a term coined by Peter Kramer in his 1993 best‐seller, Listening to Prozac. It has come to refer to the use of psychoactive substances to effect changes in function for conditions that are either normal or subclinical variants. In this paper, I ask: What distinguishes an existential ailment from clinical depression, or either of those from normal depressed mood, melancholic temperament, dysthymia or other depressive disorders? Can we reliably distinguish one from the other? Are the boundaries (...) of illness and disorder really so distinct? If not, how can we know that treatment of ‘depression’ with Prozac in any given instance constitutes a cosmetic as opposed to, say, a medical or clinical use of psychopharmacology – a distinction that seems to turn on our ability to clearly differentiate the clinical from the cosmetic. If we cannot reliably distinguish between such conditions, can we even have a cosmetic psychopharmacology that is not a form of malpractice, broadly speaking? What if we unplugged Prozac from all the amplitude and hype that resulted in Listening to Prozac becoming an instant best‐seller and simply asked whether or not we can clearly distinguish an appropriate cosmetic use of Prozac for ‘depression’ from an inappropriate cosmetic use of Prozac, and both of those from Prozac's appropriate clinical, that is, non‐cosmetic uses? If we cannot make these distinctions, perhaps it is too early to say there can be such a thing as a cosmetic psychopharmacology. (shrink)

The long-standing tradition of phenomenological psychopathology has been historically concerned with the nature of mental disorders, with a special focus on their basic experiential core. In the same way, much of the recent phenomenologically-inspired work in psychopathology consists in providing precise and refined tools for diagnosis, classification, and nosology of mental disorders. What is striking, however, is the lack of therapeutic proposals in this tradition. Although a number of phenomenological approaches refer positively to psychotherapeutic practices, psychopharmacological intervention has been mostly (...) neglected as a relevant field of attention. This work aims to fill this gap. We maintain that the convergence of phenomenological psychopathology and psychopharmacology exhibit a rich potential for mutual enlightenment, which unfolds into a more adequate psychopharmacological practice. Initially, after discussing Joanna Moncrieff’s drug-centered model of drug action we review some of the major findings in phenomenological literature regarding psychopharmacological treatment. Next, we suggest that Moncrieff’s drug-centered model can be seen as an important tool for improving clinical decision-making, by elucidating its inherent epistemic advantage when compared to mainstream models of drug action. As a result, the drug-centered model proves to be also patient-centered, by focusing on experiential alterations and helping to improve treatment outcomes. (shrink)

In this paper, I explore the questions of how and to what extent new antidepressants (selective serotonin-reuptake inhibitors, or SSRIs) could possibly affect the self. I do this by way of a phenomenological approach, using the works of Martin Heidegger and Thomas Fuchs to analyze the roles of attunement and embodiment in normal and abnormal ways of being-in-the-world. The nature of depression and anxiety disorders — the diagnoses for which treatment with antidepressants is most commonly indicated — is also explored (...) by way of this phenomenological approach, as are the basic structures of self-being. Special attention is paid in the analysis to the moods of boredom, anxiety and grief, since they play fundamental roles in depression and anxiety disorders and since their intensity and frequency appear to be modulated by antidepressants. My conclusion is that the effect of these drugs on the self can be thought of in terms of changes in self-feeling, or, more precisely, self-vibration of embodiment. I present the idea of a spectrum of bodily resonance, which extends from the normal resonance of the lived body, in which the body is able to pick up a wide range of different moods; continuing over various kinds of sensitivities, preferences and idiosyncrasies, in which certain moods are favored over others; to cases that we unreservedly label pathologies, in which the body is severely out of tune, or even devoid of tune and thus useless as a tool of resonance. Different cultures and societies favor slightly differently attuned self-styles as paradigmatic of the normal and good life, and the popularity of the SSRIs can therefore be explained, not only by defects of embodiment, but also by the presence of certain cultural norms in our contemporary society. (shrink)

ObjectiveTo assess the scientific and ethical basis for clinical innovation in psychopharmacology.MethodsWe conducted a literature review, utilizing MEDLINE search and bibliographic cross-referencing, and historical evidence regarding the discovery and development of new medications in psychiatry. Clinical innovation was defined as use of treatments in a clinical setting which have not been well-proven in a research setting.ResultsEmpirical data regarding the impact of clinical innovation in psychopharmacology are lacking. A conceptual and historical assessment of this topic highlights the ethical and (...) scientific importance of clinical innovation. Ethically, it touches a borderline that, in our judgment, is not adequately framed in contemporary mainstream bioethics. Currently, research is viewed as not at all benefiting the patients who participate in it, while clinical care is viewed as being solely for the benefit of patients. Clinical innovation straddles these two worlds, uncomfortably at times. While many argue that clinical innovation should either be avoided or folded into research projects, we argue that clinical innovation is necessary for progress in psychopharmacology research, and that it can prosper best when guided by the following ethical principles: 1.) The treatment should be based on a viable hypothesis. 2.) Whenever possible, one's clinical observations should be reported so they can be evaluated by the scientific community. 3.) One should be willing to report unexpected observations of drug effects. 4.) A high standard of informed consent should be maintained. Again, this proposal goes against the standard view among bioethicists that research and clinical care are categorically opposed activities, as made clear by the either-or dichotomy of the Belmont Report on bioethics. This approach has so polarized our profession into clinicians versus researchers, that many clinicians will not apply new knowledge produced by clinical research until it eventually gets incorporated into formal treatment guidelines, while researchers have little to guide them as to what kind of new knowledge it is most important to provide.SummaryClinical innovation brings out the ambiguities in our current ethical conceptions of research versus clinical care. Yet, historically, clinical innovation has been an important contributor to progress in psychopharmacology. We argue that clinical innovation should not be discouraged, but rather it should occur under certain ethical conditions."Almost everyone can and should do research...because almost everyone has a unique observational opportunity at some time in his life which he has an obligation to record....If one considers the fundamental operations or methods of research, one immediately realizes that most people do research at some time or another, except that they do not call their activity by that name. There are seven operations....In simple language they are counting, sorting, measuring, comparing, nature-study, guess testing, and reappraisal....Guess testing is of course what most people think of when the word research is mentioned; except that it is bad manners to call a guess a guess. It should be called an hypothesis. Let us make one plea. Guessing becomes merely a game unless it is done in the context of a plan for action. It is a waste of time elaborating untestable hypotheses [1]."John Cade. (shrink)

Although psychiatry is interested in what both body and mind contribute to behavior, it sometimes emphasizes one more than the other. Since the early 1980s, American psychiatry has shifted its interest from mind and psyche to body and brain. Neuroscience and psychopharmacology are increasingly at the core of psychiatry. Some experts claim that psychiatry is no longer interested in problems in living and positive goals such as mental health, happiness, and morality but rather has narrowed its focus to mental (...) disorders addressed with psychotropic drugs. In view of this trend, psychiatry needs to confront two questions in social philosophy. If it is no longer directly concerned with health and happiness, how does it relate to these positive goals? And how does it relate as a medical institution to religious institutions, schools, and other organizations that directly promote health, happiness, morality, and the purposes of life? It is not enough for psychiatry to renounce its moral role; its practices still shape cultural values. Psychiatry should take more responsibility for developing a public philosophy that addresses these issues. (shrink)

Bourdieu’s thought is disturbing. Provocative. Scandalous even, at least for those who do not easily tolerate the unmitigated truth about the social. Nonetheless his ideas, among the most important and innovative of our time, are here to stay. This thought has taken form in the course of a career and through works on diverse subjects that have constructed a far-reaching analytical model of social life, which the author calls more readily an anthropology rather than a sociology. In their totality, they (...) constitute today an original and powerful proposal to explain human practices. In the face of criticisms commonly leveled at Bourdieu’s thought (notably the charge that it reduces everything to a single schematic model), it is important to identify the spirit of his enterprise. Early on, it is true, his thought drew on a few fundamental concepts—the trilogy habitus, field (champ), practice (pratique)—to which it constantly returned, and followed a clearly defined trajectory. At the same time, however, he continually reformulated, adapted, and refined his analytical model, depending on the operations to which he subjected new objects of inquiry. The regenerative and transformative force of his thought was supported by two convictions. First, that there being nothing more vain than theory for theory’s sake, it is preferable that theoretical production originate in the study of concrete and occasionally very specific cases. Second, that in order to escape stereotypical classifications, boundaries separating disciplines are best transgressed, thereby favoring new constructions of the object of inquiry. (shrink)

Explores some steps toward non-assimilative encounters in the "global village.".

Comparative political theory is at best an embryonic and marginalized endeavor. As practiced in most Western universities, the study of political theory generally involves a rehearsal of the canon of Western political thought from Plato to Marx. Only rarely are practitioners of political thought willing (and professionally encouraged) to transgress the canon and thereby the cultural boundaries of North America and Europe in the direction of genuine comparative investigation. Border Crossings presents an effort to remedy this situation, fully launching a (...) new era in political theory. Thirteen scholars from around the world examine the various political traditions of West, South, and East Asia and engage in a reflective cross-cultural discussion that belies the assumptions of an Asian "essence" and of an unbridgeable gulf between West and non-West. The denial of essential differences does not, however, amount to an endorsement of essential sameness. As viewed and as practiced by contributors to this ground-breaking volume, comparative political theorizing must steer a course between uniformity and radical separation--this is the path of "border crossings.". (shrink)

Medicalization in contemporary psychopharmacology is increasingly dominated by commercial interests that threaten the scientific and ethical integrity of psychiatry. At the same time, the proliferation of new social media has altered the manner in which the social groups and institutions that have stakes in medicalization interact. Consumers are at once more powerful than ever before, but also more vulnerable. The upshot of all these developments is that medicalization is no longer simply the professed enemy of anti-psychiatry and its supporters. (...) It is now also an enemy of psychiatry. Once a welcome ally of psychiatry, medicalization appears to have turned into a fearsome enemy. (shrink)

Since the ages of the Old Testament, the Homeric myths, the tragedies of Sophocles and the ensuing theological speculations of the Christian millennium, the theme of loneliness has dominated and haunted the Western world. In this wide-ranging book, philosopher Ben Lazare Mijuskovic returns us to our rich philosophical past on the nature of consciousness, lived experience, and the pining for a meaningful existence that contemporary social science has displaced in its tendency toward material reduction. Engaging key metaphysical discussions on causality, (...) space, time, subjectivity, the mind body-problem, personal identity, freedom, religion, and transcendence in ancient, scholastic, modern, and contemporary philosophy, he highlights the phenomenology of loneliness that lies at the very core of being human. In challenging psychoanalytic and neuroscientific paradigms, Mijuskovic argues that isolative existence and self-consciousness is not so much of a problem of unconscious conflict or the need for psychopharmacology as it is the loss of a sense of personal intimacy. The issue of the criteria of "personal identity" in relation to loneliness has long engaged and consumed the interest of theologians, ethicists, philosophers, novelists and psychologists. This book will be of great interests to academics and students of the humanities, and all those with an interest in the philosophy of loneliness.. (shrink)

The purpose of this paper is to use neuroscientific evidence to address the philosophical issue of intertheoretic reduction. In particular, we present a literature review and a new experiment to show that the reduction of cognitive psychology to neuroscience is implausible. To make this case, we look at research using object exploration, an important experimental paradigm in neuroscience, behavioral genetics and psychopharmacology. We show that a good deal of object exploration research is potentially confounded precisely because it assumes that (...) psychological generalizations can be reduced to neuroscientific ones. (shrink)

Contemporary mental health professionals exhibit interest in integrating spirituality into the services they provide to clients. This clinical integration raises questions about both the goals of mental health services and the professional relevance of mental health providers’ spiritual competency. Drawing on the Christian anthropology of St. Thomas Aquinas, Benedict Ashley’s approach to psychotherapy differentiates psychopharmacological, psychotherapeutic, and spiritual approaches on the basis of the different domains of a client’s personality. These domains are the focus of different professions, and Ashley’s account (...) suggests that mental health providers who lack additional spiritual-moral training should adopt a clinical model that recognizes their work is spiritually oriented but not spiritually directive. (shrink)

Arguments in the neuroenhancement debate are sometimes based upon idealistic scenarios involving the assumption of using a drug that has no or negligible side effects. At least it is often implicitly assumed – as technology and scientific knowledge advances - that there soon will be a drug with no or negligible side effects. We will review evidence from neuroscience, complex network research and evolution theory and demonstrate that - at least in terms of psychopharmacological intervention – on the basis of (...) our understanding of brain function it seems inconceivable that there ever will be a drug that has the desired effect without undesirable side effects. We will illustrate this by reference to enhancing edge detection in V2 in monkeys and demonstrate that even for this localised single neuron coded function there would be numerous side effects. Taking the more realistic case of pharmacological enhancement that is inevitably associated with side effects will change consequentialist arguments for neuroenhancement and have implications for the conception of autonomy, specifically in the case of performance enhancement. We conclude that a neuroethics debate that aims to inform policy decisions should take these findings into account. We hope that our article will precipitate more interdisciplinary research in neuroscience and philosophy. (shrink)

Moral enhancement proposals struggle to be both plausible and ethically defensible while nevertheless interestingly distinct from both cognitive enhancement as well as (mere) moral education. Brian Earp (_Royal Institute of Philosophy Supplement_ 83:415–439, 12 ) suggests that a promising middle ground lies in focusing on the (suitably qualified) use of psychedelics as _adjuncts_ to moral development. But what would such an adjunctive use of psychedelics look like in practice? In this paper, I draw on literature from three areas where techniques (...) for moral development have been discussed: psychotherapy (e.g., Overholser 2010; Burns 1980) education (e.g., Uhl and Lütge, 2018), and AI-assisted enhancement (e.g., Lara and Deckers, _Neuroethics_ 13(3):275–287, 17 ) in order to propose more concrete ways in which to use psychedelics as adjuncts to moral development. It is shown that in each of these areas, we can see that _trusting_ relationships (e.g., Baier 1986; Hawley 2019) between the facilitator and the agent will very plausibly maximize the success of this type of moral enhancement. Finally, I appeal to literature on informed consent for use of psychedelics (e.g., Smith and Sisti, _Journal of Medical Ethics_, 22 ; Johnson et al., _The Journal of Psychopharmacology_ 22(6):603–20, 23 ) and on the therapeutic relationship in psychotherapy (e.g., Dryden and Reeves 2013; Horvath et al. 2011) to outline concrete suggestions for facilitating dimensions of trust most likely to maximize the benefits of (adjunctive) psychedelic moral enhancement. The result is a newly detailed practical proposal for how we might best facilitate moral enhancement by using drugs as adjuncts to moral development. (shrink)

This thesis provides an ethical analysis of imprisonment as a mode of punishment. Consisting in an introduction and four papers the thesis addresses several important questions concerning imprisonment from a number of different perspectives and theoretical starting points. One overall conclusion of this thesis is that imprisonment, as a mode of punishment, deserves more attention from moral and legal philosophers. It is also concluded that a more complete ethical assessment of prison conditions and prison management requires a broader focus. It (...) must include an explicit discussion of both how imprisonment directly affects prison inmates and its negative side-effects on third parties. Another conclusion is that ethical discussions on prison conditions should not be too easily reduced to a question about how harsh or lenient is should be. Paper 1 argues that prisoners have a right to privacy. It is argued that respect for inmates’ privacy is related to respect for them as moral agents. Consequently, respect for inmates’ privacy is called for by different established philosophical theories about the justification of legal punishment. Practical implications of this argument are discussed and it is argued that invasion of privacy should be minimized to the greatest extent possible, without compromising other important values or the rights to safety and security. It is also proposed that respect for privacy should be part of the objective of creating and upholding a secure environment. Paper 2 discusses whether the collateral harm of imprisonment to the children and other close family members of prison inmates may give rise to special moral obligations towards them. Several collateral harms, including decreased psychological wellbeing, financial costs, loss of economic opportunities, and intrusion and control over their private lives, are identified. Two perspectives in moral philosophy, consequentialism and deontology, are then applied in order to assess whether these harms are permissible. It is argued that from either perspective it is hard to defend the claim that allowing for these harms are morally permissible. Consequently, imprisonment should be used only as a last resort. Where it is deemed necessary, it gives rise to special moral obligations. Using the notion of residual obligation, these obligations are then categorized and clarified. Paper 3 focuses on an argument that has figured in the philosophical debate on felon disenfranchisement. This argument states that as a matter of democratic self-determination, a legitimate democratic collective has the collective right to decide whether to disenfranchise felons as a way of defining their political identity. Yet, such a collective’s right to self-determination is limited, since the choice to disenfranchise anyone must be connected to normative considerations of political significance. This paper defends this argument against three charges that has been raised to it. In doing so it also explores under what circumstances felon disenfranchisement can be permissible. Paper 4 explores the question of whether prison inmates suffering from ADHD should be administered psychopharmacological intervention for their condition. The theoretical starting point for the discussion is the communicative theory of punishment, which understands criminal punishment as a form of secular penance. Viewed through the lens of the communicative theory it is argued that the provision of pharmacological treatment to offenders with ADHD need not necessarily be conceived of as an alternative to punishment, but as an aid to achieving the penological ends of secular penance. Thus, in this view offenders diagnosed with ADHD should have the option to undergo pharmacological treatment. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Subjective Knowledge, Mental Disorders, and MedsHow to Parse the EquationMark D. Rego (bio)Keywordspsychopathology, antidepressants, suicidality, subjective experience, pre-reflectiveA few weeks, ago I was walking down the hall to my office when I spotted my brother-in-law coming the other way. This was odd on two accounts. First, he lives in Kentucky (I am in Connecticut) and second, he is at least a foot taller than the man in my hallway. (...) Nonetheless, I struggled to figure out why he was there. The resemblance was so striking it took me a minute or two to convince myself it was not him. Even after such convincing, the feeling that it was him remained.Later, I imagined that had I just returned from a crack cocaine den I would have been hypervigilant, if not paranoid, and consequently would be certain that my brother-in-law had arrived unannounced. Furthermore, I would probably assume that he was up to no good.How did I retain a strong feeling of recognition, the feeling that maybe it was really him, when I already concluded otherwise? And why, were I on crack cocaine, would the obvious facts be useless in rendering a decision about the identity of the man in the hall? Last, why would the post-cocaine man in the hall become a nefarious brother-in-law rather than a benign one?If I just computed some symbols to figure this out, wouldn't the feeling have gone away? If I activated a brother-in-law neural network, how did I come to acquire an evil brother-in-law neural network? And why wouldn't that go away either?In his article in this issue of Philosophy, Psychiatry, & Psychology, Hadreas looks at questions like these through the prism of before and after effects of people treated with selective serotonin reuptake inhibitors (SSRIs). Hadreas investigates the implications of a straightforward recomputation of self-awareness when treated with these medicines and finds such approaches unsatisfying and incomplete in their explanatory power. (My example looks at a type of awareness, but not specifically self-awareness, as does Hadreas. Furthermore, my paradigm asks about computational conclusions using language more common in psychiatric literature, whereas Hadreas uses standard philosophical terms. Although not isomorphic, I believe the interchange of the two remains true to the issues Hadreas is addressing). [End Page 57]In my example, there is clearly something else going on than the incorrect arrangement of symbols or the misfiring of nodes in a network that influences how I feel and what I think. Neither reason nor empiricism seem to serve me well here. Hadreas utilizes Husserl to begin to unpeel the layers of self-awareness and self-states that intermix to form the shifts and contradictions which are so common in psychiatric treatment (and in common experience as I describe).This is a welcome reckoning; the psychiatric literature is overflowing with unquestioned premises about the neuropsychiatric correlates of reason and empirical approaches (described more as computation and neural networks in the literature—again, not strictly analogous, but the same criticisms apply) Hadreas is critical of. Unfortunately, Hadreas has navigated through a sea of highly questionable assumptions about the psychopharmacology of depression to illustrate his points. This is due in large part to the common practice of consulting literary narratives and critics rather than one of immersion in the literature as a whole and the daily life of patients and active clinicians. He arrived at his destination despite this, because many of these details did not affect his particular analysis. However, to look forward to a continuation of this work and clarify some important issues I devote most of my commentary to these issues. The points I raise are more extensively discussed in a previous edition of this journal (Rego 2005).Affect to Reason ShiftLet's begin with the idea that SSRIs work by dampening emotions. An extension of this idea is that they dampen negative emotions and strengthen positive ones like assertiveness, confidence, and optimism. An even further development in this direction is that, by dampening strong emotions, cognitive enhancement takes place with SSRI treatment. A summary observation then is that SSRIs facilitate... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.3 (2002) 255-259 [Access article in PDF] On the Evolution of Depression Mike W. Martin Keywords: Depression, morality, mental disorders, psychobiology, evolutionary psychiatry. In "Depression as a Mind-Body Problem," Walter Glannon outlines a psychosocial-physiological explanation of depression as a psychological response to chronic stress—today, especially social stress—in which cortisol imbalances disrupt neurotransmitters. Accordingly, treatment for depression should combine psychopharmacology and psychotherapy—a valuable reminder in (...) light of the current restrictions on funding for health care (Hobson and Leonard 2001). My comments focus, however, on Glannon's objections to evolutionary theorists who explain our capacity for depression as adaptive to the natural and social environment. His objections are implausible because he fails to distinguish depression as a mood and a disorder. What Is Depression? Explaining the psychology, sociology, physiology, and evolution of depression presupposes knowing what depression is and hence what is being explained. As a blunt but important distinction, let us contrast depression as a mood and as a mood disorder.As a mood, depression is a state of low spirits, typically involving painful and low affect (of a kind needing further specification). Not all negative low moods are depressions. It is notoriously difficult to distinguish depression from grief, sadness, gloom, and a host of additional ways to feel down—especially because today many people use "I'm depressed" as a blanket expression for virtually any low mood. For the purposes of this paper, it is not necessary to attempt a full-blown analysis of depressed moods (and emotions). I would emphasize, however, that depressed moods involve values. They involve negative evaluations of ourselves, major events in our lives, life in its entirety, or the values that have been guiding us. Typically, to be depressed is to experience such things as feelings of worthlessness, dejection about failures, despair and hopelessness, and loss of caring and commitment. Thus, we might be sad or grieving but not depressed because we retain a solid grip on what is valuable and worthwhile. In any case, there should be no general presumption that depressed moods are all bad or undesirable. Instead, we should be prepared to appreciate the importance of depressed moods in connection with questions of value, identity, and even moral insight (Martin 2000). Depressed persons are not necessarily sick.In contrast, depression as a mood disorder is, by definition, pathologic. Moreover, usually it is not a depressed mood, although it involves depressed moods. On the one hand, depression as a disorder is defined as pathologic, a notion that is itself understood in terms of values—the values of health and, indirectly, moral values that define what is culturally acceptable. Thus, even severe [End Page 255] grief can be nonpathologic, even though it involves depressed moods, when it is within the range of "culturally-sanctioned responses" (APA 2000, xxxi). On the other hand, only sometimes is depression a single pathologic mood, as in major depressive episodes that can strike with a terrifying and suicidal severity (APA 2000, 375). Usually, however, the pathology is not a single depressed mood, but instead a longer-term state involving recurring depressed moods and additional features, such as poor concentration, insomnia, poor appetite or overeating, and so on. For some purposes, such as research funding and billing insurance companies and government health providers, these pathologies can be equated with what is currently in the DSM. Yet, there are many additional states of suboptimal health, in which the DSM criteria are only partly met.What does Glannon mean by depression? He does not define it, but he makes it perfectly clear that he intends depression as a disorder. Or rather, it is a set of mental disorders, including the "depressive disorders" of major depressive disorder, dysthymic disorder, depressive disorder not otherwise specified, and a variety of bipolar disorders and some anxiety disorders. Glannon sometimes indicates his primary topic is "severe depression," which of course is not a DSM category (nor always a mark of pathology). For the most part, however, he says his topic is "chronic depression," which might suggest dysthymia, "a chronically depressed mood for most of... (shrink)

The emergence of new technologies has had a significant impact on the development of modern psychiatry. Brain scanning, biochemical analysis, the search for genetic markers, and the development of psychopharmacology have had a great influence on the way we understand the nature of mental disorders and the role and place of mental health specialists. The article aims at presenting the consequences of a technical approach in psychiatry, giving examples of such an approach and proposing a critical attitude to this (...) approach and the role of technical expertise in psychiatry. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:In Defense of My Reading of Husserl and a Final NotePeter Hadreas (bio)KeywordsSSRI, Prozac, Fluoxetine, Zoloft, Sertraline, Paxil, Paroxetine, Husserl, phenomenologyI want to acknowledge Dr. Mark D. Rego and Professor Marilyn Nissim-Sabat for the care they put into the responses to my paper "Husserlian Self-Awareness and Selective Serotonin Reuptake Inhibitors." One of the abiding strengths of Philosophy, Psychiatry and Philosophy is its debate format.Thanks to the debate format, I (...) am not constrained from openly (and sincerely) contesting Marilyn Nissim-Sabat's reading of my paper. In my opinion, Marilyn Nissim-Sabat remarks suffer from many misconceptions. I'll respond in some detail to these misconceptions and misapprehensions. Contrastingly, I am largely in agreement with Mark Rego's commentary. After discussing Nissim-Sabat's misconceptions, I'll use the remaining space to propose how some of Mark Rego's suggestions might be filled out for further psychological research using the model of prereflective awareness.Nissim-Sabat brings many misunderstandings to my paper. They extend to the paper's purposes, its manner of evidence, as well as its consequences for psychotherapy. I respond to each of these issues.First about the paper's purpose. She writes: "I share with Hadreas the conviction that Husserlian phenomenology is the best philosophical approach to understanding, and indeed, possibly improving the treatment of mental disorders" (54). Nissim-Sabat and I do not share the same point of view regarding Husserlian philosophy and mental disorders. I am keen on Edmund Husserl's theories of pre-reflective awareness inasmuch as they provide a model for understanding mental disorders. Given the space limits, I focus my paper on puzzles emerging from case histories of people treated with SSRIs. Even so, I think it is a mistake to make Husserl's philosophy into a Rosetta stone for decoding this topic. This may mislead the reader as well as misrepresent the history of philosophy. As I point out in the section of the paper titled, "Husserl on Self-Awareness," Husserl is not the only well-known philosopher or psychologist who proposes a pre-reflective account of self-awareness. William James proposes an analogous notion of self-awareness. G. W. Leibniz, at the and of the seventeenth and the beginning of eighteenth centuries, worked out a very sophisticated understanding of pre-reflective awareness, which he applied to a multitude of psychological, epistemological, and ethical topics (Leibniz 1996, 53, 11, 164, 194). Husserl's account of pre-reflective awareness is 'better' inasmuch as it is systematically connected to an epistemology that can enable a researcher to understand how pre-reflective awareness fits both personal self-understanding and empirical psychological [End Page 61] experimentation. But James' and Leibniz 's accounts also have their strengths. Their descriptions of pre-reflective awareness are less burdened with technical language than Husserl's and, in the case of Leibniz, broadly applied to topics outside of psychology and epistemology.Perhaps in keeping with Husserl's philosophy as "the best," Nissim-Sabat argues that I am unfaithful to Husserl's true mission as she sees it. I fail to uphold the essence of Husserlian philosophy. She reminds us: "… Husserl's view that the raison d'etre of phenomenology is to develop an attitude that 'overcomes naturalism once and for all' …" (55–56). She quotes from Husserl's "Vienna Lecture," in support of the claim that overcoming naturalism is the raison d'etre of Husserl's phenomenology. Nissim-Sabat picks out one theme of Husserl's philosophy and makes it into its "raison-d'etre." Those familiar with Husserlian philosophy, and circumspect of its application to current issues in psychiatry and psychotherapy, would find her position worrisome. Specifically, as regards the application of Husserlian philosophy to current issues, a more specific obstacle than a looming naturalism is the prospect that researchers in the empirical sciences will doubt the efficacy of Husserlian philosophy for establishing causal relations through statistical correlations. Because Husserlian philosophy is intentionality based, it might seem (falsely) that it cannot handle the rigorous quantitative analysis of after and side effects that psychopharmacology requires.There should be little worry that anyone who would apply Husserlian philosophy to current psychological or psychiatric issues might... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 10.1 (2003) 63-66 [Access article in PDF] The Pragmatics of Psychiatry and the Psychiatry of Cross-Cultural Suffering Jennifer Radden I AM IN SUBSTANTIAL AGREEMENT with many of the conclusions David Brendel draws in his thoughtful discussion. Misleading language aside, I particularly applaud his use of my plea for ontological descriptivism to support clinical practice, which respects, as he puts it, the subjectively "melancholic" person living (...) behind the objectively "depressed" clinical presentation.Brendel offers two main critiques of my discussion about the relationship between today's depression and melancholia of past eras. First, he asserts that I neglect the relevance of causal reasoning in my preference for a descriptivist over a causal ontology. Second, arguing that pragmatic considerations ought to be, as he says, front and center when philosophers and psychiatrists "grapple with the complexities of psychiatric explanation," (Brendel 2003, 54) he questions what he sees as my too ready dismissal of pragmatism in this discussion. Allegiance to pragmatism seems to me to sit strangely with support for a causal ontology, as I shall try to demonstrate. But first let me comment on these two sides of Brendel's commentary.The case of Van Gogh's alleged melancholia is particularly well chosen because there has been continuing debate about Van Gogh's condition, including scholarly work attributing it to an inherited metabolic disorder (Arnold 1992). Brendel's suggestion that a causal ontology might allow us to use historical evidence to throw light on the relation between depression and melancholia is an interesting and fruitful one that I had overlooked. Brendel also holds hope for drug cartography as a means of determining the causes of mental disorders. I admit to the initial plausibility of the approach to classification employed by drug cartography, of course. Diagnostic maps must be evaluated according to their effectiveness for the purposes they serve, and cannot—or should not—be seen as mere descriptions of natural phenomena. And maps based on psychopharmacological effects will serve one of the most important purposes we can have in relation to mental disorders: their successful treatment. Nonetheless, as I indicated in my essay, there are conceptual limitations to drug cartography. That several different syndromes respond to the same drug is suggestive, but it does not tell us anything definitive about structural similarities or differences between those different disorders. Nor, from the fact that a condition is alleviated by drugs, does it follow that a particular brain state was the initiating cause of that condition.My dismissal of a pragmatic approach in the foregoing discussion may have been overly hasty. [End Page 63] But in trying to make good this omission, I find myself struck by the complexity of the task. There appear to be at least five different places where a pragmatic response might be called for: (1) in deciding what to say about the relationship between depression and melancholia; (2) in determining the structure of any given psychiatric classification; (3) in choosing between what I have called descriptivist and causal ontologies; (4) in electing a course or method of treatment in the clinical context; and (5) in evaluating psychiatric explanations.With regard to (1), I have sketched in a note one pragmatic consideration in favor of equating melancholia and depression: by so doing, we might reinvest depressive states with some of the glamorous associations from the past and so diminish the stigma and provide some compensation and consolation for the suffering attaching to depression. Pragmatic reasoning may be perfectly appropriate here. I beg to point out that pragmatic considerations let me neglect it.With regard to (2), I recognize that psychiatric classifications are not so much identifications of natural kinds as responses to our various purposes; indeed, this point is offered as one drawback of adopting a causal analysis, because there is little reason to expect our purposes, which are a product of culture, to correspond to natural arrangements, which are not.With regard to (3), if there were overriding pragmatic considerations that favored accepting one or the other of these ontologies, then perhaps this would be... (shrink)

Philosophers have long been involved in the pursuit of a goal shared by researchers in psychiatry and the cognitive sciences: understanding the relationship between the functioning of the human mind and human well-being or suffering. For this reason there is a very large area of overlap between philosophical and psychiatric research. The overlap is particularly significant in the domain of practical ethics, which is concerned with understanding the moral dimension of policies and actions in the real world. This chapter reviews (...) two distinct domains in which psychiatry and practical ethics overlap. First, issues in practical ethics arise out of new advances in psychopharmacology, including clinical and non-clinical use of new antidepressants drugs, the clinical use of placebo medications, and psychiatric drugs which enhance human cognition; these issues are frequently grouped under the banner of "neuroethics." Second, the understanding of fundamental questions in moral philosophy is being driven forward by evidence from psychology and psychiatry. Evidence from autism and the personality disorders is shedding light on the nature of moral motivation, while evidence from addiction and compulsion is generating progress in understanding moral responsibility. Finally, some areas are highlighted in which the science of psychiatry may benefit from the application of existing work in moral philosophy and practical ethics. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 12.3 (2005) 239-242 [Access article in PDF] The Uses of Borrowed Knowledge: Chaos Theory and Antidepressants Stephen H. Kellert Keywords chaos, metaphor, rhetoric, values Ever since the popularization of chaos the-ory in the 1980s, there has been an explo-sion of interest in work in nonlinear dynamics generally and the study of strange attractors in particular. From law to economics to theology, researchers in the social (...) sciences and the humanities have sought to make use of the concepts, methods, and results of chaos theory. Previous generations have seen similar attempts to explore the consequences of relativity theory or quantum mechanics for their own areas of inquiry. In examining the implications of chaos for the treatment of mental illness, Douglas Heinrichs provides an example of this phenomenon, which I call "borrowed knowledge." Lacking expertise in the areas of psychotherapy or psychopharmacology, I view his suggestions as a case study in the ways that knowledge gets used across disciplinary boundaries. In these remarks, I examine some of the different functions that borrowed knowledge can serve in order to argue that although cross-disciplinary borrowing can be a fruitful source of new insights, it is not without its dangers. I look at the persuasive function that borrowed knowledge can serve in making one's ideas plausible candidates for further exploration, as well as in motivating methodological change. I look at the conceptual work performed by metaphors, paying special attention to the question of how we can judge whether or not a nonliteral use of knowledge from the natural sciences is fruitful. And finally, I look at the ways in which borrowed knowledge can be used to address evaluative questions—in this case, questions about autonomy and appropriate therapeutic practice. I do not mean for these various functions to be thought of as exclusive categories. Instead, they overlap, interact, and combine in various ways. Rhetorical Functions, Disciplinary Prestige, and Methodologic Change In examining the persuasive uses of chaos theory, I should make it clear that by "persuasive" I do not mean illegitimate or deceptive. When Heinrichs points out that what he calls the traditional model of brain function is used to [End Page 239] present and explain the use of antidepressants (ADs) to clinicians and the general public, it becomes clear that he believes an alternative model can be useful for explicating and justifying the use of ADs for clinicians and patients. This descriptive function of the metaphorical appeal to a chaotic "attractor landscape" shows up where Heinrichs discusses the use of the chaotic model for patient education and the "rationale for pharmacotherapy," giving patients "appropriate expectations."But the rhetorical functions of chaos theory also come into play with audiences other than patients; they apply to the audience for the scholarly article itself, perhaps attracting attention because of the novelty or promise of a new field of research, but also harnessing the considerable disciplinary prestige that the natural sciences wield in our culture. All of these functions are useful in directing attention to the author's suggestions for further research, especially where he suggests that it would provide the clinician with guidance in working with an individual patient. Here I take it that Heinrichs has made fruitful use of the work of Thelen and others on the variability of individual developmental trajectories. This proposal for methodological change suggests that focusing on the dynamics of system and its evolution through time may be important in addition to focusing on equilibrium states. The disciplinary prestige of the natural sciences can provide a valuable and legitimate resource for the persuasive task of encouraging one's colleagues to explore a new methodological approach.A further rhetorical use is found in the appeal to the unpredictability of chaotic systems to account for the variability of results in the application of ADs. We see this where Heinrichs says, "a meaningful science of persons is possible even in the face of their ultimate unpredictability" (2005, 221). The disciplinary prestige of the natural sciences, which in studying chaotic systems are able to achieve genuinely "scientific" status without being able... (shrink)

Psychotropic and other drugs can alter brain mechanisms regulating the formation, storage, and retrieval of different types of memory. These include “off label” uses of existing drugs and new drugs designed specifically to target the neural bases of memory. This paper discusses the use of beta-adrenergic antagonists to prevent or erase non-conscious pathological emotional memories in the amygdala. It also discusses the use of novel psychopharmacological agents to enhance long term semantic and short term working memory by altering storage and (...) retrieval mechanisms in the hippocampus and prefrontal cortex. Although intervention in the brain to alter memory as therapy or enhancement holds considerable promise, the long term effects of experimental drugs on the brain and memory are not known. More studies are needed to adequately assess the potential benefits and risks of these interventions. (shrink)

The theoretical implications of equating the melancholic states of past eras with today's depression are explored. These include the presuppositions of the descriptive psychiatry so influential in twentieth century classification, which attempts to identify and describe mental disorders without reference to underlying causes. It also includes claims made about different forms of masked, and non-Western depression, and the new "drug cartography" assigning psychiatric categories based on psychopharmacological effect. An evaluation of the relative merits of descriptivist and causal ontologies, together with (...) an assessment of the similarities and differences between melancholia and depression, suggest the conclusion that these two conditions are misleadingly equated. (shrink)

This paper offers a panoramic assessment of the significant changes experienced by psychiatric care in Western Europe and North America in the course of the last decades of deinstitutionalization and reform. Drawing on different comparative studies and an own review of relevant data and reports, the main transformations in the mental health field are analyzed around seven major topics: the expanding scope of psychiatry; the decline and metamorphosis of the asylum; the introduction of alternative and diversified forms of care; the (...) new challenges posed by chronic mental illness; the emergence of modern psychopharmacology; the deployment of subspecialization; and the new forms of coercion implemented with community mental health practices. Following a renewed diagnosis on the essential features of the reformed mental health systems based on the pattern of social inclusion inherent to the new devices and philosophies of care, some major challenges for the future such as the overburdening of services or the overt exclusion of a significant part of potential users are also identified and briefly discussed. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Diagnostic Criteria, Psychological Tests, and Ratings Scales: Extending the HistoryPeter Zachar, PhD (bio)Le moigne narrates a history of the development of psychiatric ratings scales as hybrids between psychological tests and diagnostic categories. In his telling, psychological tests seek to quantify population-based traits on which every person has a position and which tend to be conceptualized as being stable. Personality traits are often conceptualized as dispositions. Diagnostic categories represent not (...) trait-like properties of populations but episodic states consisting of clusters of symptoms experienced by individuals with disorders. Ratings, scales, he notes, are hybrids between the two. They are used to quantify psychiatric symptom clusters so that change over time can be measured. Le Moigne argues that these distinctions were initially suggested during the development of measures that could assess outcomes in psychopharmacological treatment studies.With respect to depression, Le Moigne writes that in the 1970s and 1980s something akin to depressive personality was reconceptualized as a temperament. A key move, somewhat reflective of Kraepelin’s notion of a depressive temperament, was to view a dysthymic temperament as both a predisposing factor and an attenuated form of depression. Thus, an episodic state commandeered the predisposing–dispositional role that was assigned to stable personality traits.This conceptual shift allowed test-like ratings scales to be seen as useful for quantifying not just stable traits, but salient features of episodic states that are potentially subject to change in response to interventions. To put it another way, in the development of a psychological test, one goal is to have high test-retest reliability (i.e., stability of measurement). With rating scales used to measure change, one wants the scores to not be as stable; ideally the scores on the later assessments will be lower. According to Le Moigne, when dysthymia was subsequently placed on axis I of the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III (as a syndrome) and segregated from personality disorders which were placed on axis II, personality traits were evicted from the conceptualization of depressive disorders.One perennial feature of psychiatry and psychology is that even if an older idea is superseded [End Page 253] in the view of some thinkers, it can still attract adherents. Indeed, interest in understanding a relationship between personality and attenuated states did not fully disappear. For example, based on research in genetics, the schizophrenia spectrum concept included not only schizophrenia, but also milder conditions such that were conceptualized as personality disorders; that is, schizotypal personality disorder and paranoid personality disorder (Kety, Rosenthal, Wender, & Schulsinger, 1971).During the development of the DSM-IV, some people wanted to add depressive personality disorder to the manual (Phillips, Hirschfeld, Shea, & Gunderson, 1995). It seems to have become a territorial dispute between mood disorder specialists and personality disorder specialists The mood disorders specialists challenged the personality disorder specialists to differentiate depressive personality disorder from early onset, chronic dysthymia. They were able to do so by using criteria such as critical, blaming, and derogatory toward self. After the mood disorders work group proposed incorporating some of those criteria into a revised criteria set for dysthymia, the two sets overlapped. The result was the old criteria for dysthymia were printed in DSM-IV and criteria for depressive personality disorder and the revised criteria for dysthymia were both placed in the appendix.In the DSM-5, Axis II was eliminated and personality disorders were placed alongside all the syndromic symptom clusters at the same level. Even so, interest in attenuated presentations as personality-related lingered still. During the development of the DSM-5 there was some thought to using diagnostic spectra as a meta-structure for organizing the manual (Andrews et al., 2009). One idea was to move some personality disorders into a best fitting spectrum, akin to attenuated forms. This did occur with schizotypal personality disorder which is both in the DSM-5 chapter on schizophrenia and in the chapter on personality disorder. In the schizophrenia chapter it is positioned as the earliest emerging disorder on the spectrum. There was also some interest in grouping avoidant personality disorder with the anxiety disorders, but the evidence supporting such a change was not available.These issues may... (shrink)

When the first edition of Pediatric Psychopharmacology published in 2002, it filled a void in child and adolescent psychiatry and quickly establishing itself as the definitive text-reference in pediatric psychopharmacology. While numerous short, clinically focused paperbacks have been published since then, no competitors with the scholarly breadth, depth, and luster of this volume have emerged. In the second edition, Christopher Kratochvil, MD, a highly respected expert in pediatric psychopharmacology, joins the outstanding editorial team led by Dr. Martin (...) and Dr. Scahill. In the new edition, the editors streamline the flow of information to reflect the growth in scientific data since the first edition appeared. The overall structure of the book remains the same, with major sections on underlying biology; somatic interventions; assessment and treatment; and special considerations. (shrink)

Biological psychiatry has been dominated by a psychopharmacologically-driven neurotransmitter dysfunction paradigm. The objective of this paper is to explore a reductionist assumption underlying this paradigm, and to suggest an improvement on it. The methods used are conceptual analysis with a comparative approach, particularly using illustrations from the history of both biological psychiatry and molecular biology. The results are that complete reduction to physicochemical explanations is not fruitful, at least in the initial stages of research in the medical and life sciences, (...) and that an appropriate (non-reducible) integrative principle - addressing a property of the whole system under study - is required for each domain of research. This is illustrated in Pauling's use of a topological integrative principle for the discovery of the functioning of proteins and in Watson and Crick's use of the notion of a genetic code as an integrative principle for the discovery of the structure of genes. The neurotransmitter dysfunction paradigm addresses single molecules and their neural pathways, yet their interactions within the CNS as a whole seem most pertinent to mental disorders such as schizophrenia. The lack within biological psychiatry of an integrative principle addressing a property of the CNS as a whole may be responsible for the empirical failure of orthomolecular psychiatry, as well as for the central role that serendipity has played in the study of mental disorders, which is dominated by the neurotransmitter paradigm. The conclusion is that research in biological psychiatry may benefit from using, at least initially, some integrative principle(s) addressing a property of the CNS as a whole, such as connectionism or a hierarchical notion. (shrink)

Many drugs have therapeutic off-label uses for which they were not originally designed. Some drugs designed to treat neuropsychiatric and other disorders may enhance certain normal cognitive and affective functions. Because the long-term effects of cognitive and affective enhancement are not known and may be harmful, a precautionary principle limiting its use seems warranted. As an expression of autonomy, though, competent individuals should be permitted to take cognition- and mood-enhancing agents. But they need to be aware of the risks in (...) chronic use of these agents and to take responsibility for their effects. A reasonable middle ground between these positions is to warn those who choose to enhance that doing so entails risks. (shrink)

This article discusses the way how change in depressed patients included in clinical trials was both conceptualized and measured in the 1970s to decide on the efficacy of the first candidate drugs for the treatment of depression. Understanding how this issue was resolved is of major interest as the protocol designed to distinguish the diagnosis of the depressive syndrome from the measurement of its evolution over time built the contours of the methodological device to which the whole of standardized evaluation (...) in psychiatry has since referred. This paper draws on the debates in nascent psychopharmacology in both the United States and Europe and examines the protocols and findings of the research programs on depression the National Institute of Mental Health (NIMH) has developed in the United States at the same time, as well as on the writings of the main authors of the standardized evaluation. This investigation suggests that measurement of patients’ improvement could not be characterized on the basis of psychiatric inventories that were not well-suited to quantification, nor on the basis of psychometric tests which were intended for the evaluation of psychological invariants. This is why the answer given to the characterization of change in depression under therapy rather reveals a syncretism both conceptual and technical, mixing classificatory and psychometric traditions, a syncretism that the distinction endorsed by the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition,between syndromes and personality disorders no longer allows us to perceive. (shrink)