An influential interpretation of phenomenology construes Husserl's project as an attempt to generalize the Fregean notion of sense- an attempt to extend Frege's analysis of the structure of meaningful expressions to a more general account of the structure of meaning in experience . Michael Dummett has articulated a broadly Fregean critique of this Husserlian program, arguing that the project is misguided and retrograde-a relapse into the psychologism and idealism that Frege sought to avoid. A defense of Husserl is offered, based (...) in part on key elements of the theory of meaning articulated in his Logical Investigations . But the main aim is neither to acquit nor to convict Husserl of Dummett's charges; rather it is to use the exchange to investigate some of the philosophical commitments of a broadly Husserlian phenomenology. If we are to understand how Husserl avoids psychologism then we must come to terms with the paradoxical idea of an anti-psychologistic investigation of consciousness (an anti-psychologistic psychology). If we are to understand his complex stance toward idealism then we must not only understand the grounds for his rejection of subjective idealism but also be attuned to the other forms of idealism to which his project is committed. In the course of investigating these matters the author considers how Husserl can reply to the charge of explanatory vacuity, and shows that Frege himself recognizes the legitimacy of something like the Husserlian project. (shrink)

Staphylococcus aureus is an opportunistic pathogen capable of causing a variety of diseases including osteomyelitis, endocarditis, infections of indwelling devices and wound infections. These infections are often chronic and highly recalcitrant to antibiotic treatment. Persister cells appear to be central to this recalcitrance. A multitude of factors contribute to S. aureus virulence and high levels of treatment failure. These include its ability to colonize the skin and nares of the host, its ability to evade the host immune system and its (...) development of resistance to a variety of antibiotics. Less understood is the phenomenon of persister cells and their role in S. aureus infections and treatment outcome. Persister cells occur as a sub‐population of phenotypic variants that are tolerant to antibiotic treatment. This review examines the importance of persisters in chronic and relapsing S. aureus infections and proposes methods for their eradication. (shrink)

BackgroundBeing pregnant is a vulnerable period for women with a history of eating disorders. A central issue in eating disorders is searching control of one’s body and food preferences. Pregnancy implies being increasingly out of control of this. Treatment and targeted prevention start with the patient’s experience. Little is known about how women with a history of eating disorder experience being pregnant.MethodWe interviewed 24 women with a history of eating disorder at the time of pregnancy, recruited from five public pregnancy (...) controls at local family health centers in Norway. Interviews were analyzed by means of ideal type analysis, with a particular focus on how the participants experienced pregnancy and perceived triggers in possible experiences of relapse or worsening during pregnancy. All participants completed the Eating Disorder Examination Questionnaire and were diagnosed by using the Eating Disorder Examination.ResultsOn becoming pregnant, 23 of the 24 participants experienced worsening or relapse of their disorder. This occurred both at first time and after several pregnancies, and either interviewed early or late in pregnancy. Ideal type analyses indicated seven different personal features associated with worsening or relapse: the “chaotic” “rigid” “perfect” “worried” “shameful” “motherhood fearing” and “the mother with lost identity” Perceived triggers of worsening or relapse were: “loss of control” “unpredictability” “competition” “change of appearance” “shame and nausea” and “loss of identity.”ConclusionPregnancy is a vulnerable period for women with a history of eating disorders. A great variation in personal psychological dynamics seems to interact with perceived triggers in worsening or relapse of eating disorder. Our findings have important implications in understanding mechanisms of relapse in pregnancy, preventing relapse and help tailoring adequate intervention. (shrink)

It is universally accepted that informed consent to participate in medical research should be given by subjects. People have the fundamental human right to freely choose, without coercion or withholding of information necessary to make a reasonable choice, whether they will undergo any risks associated with a research project. United States researchers have known for some time that they have the duty to inform potential subjects of the nature of proposed research and the risks and possible benefits, and to seek (...) consent. Investigators also have the duty to design the research so that it will be scientifically valid while minimizing foreseeable and avoidable harms. (shrink)

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BackgroundEvidence suggests that organizational models that provide care interventions including patient support programs may increase patient adherence to multiple sclerosis therapies by providing tailored symptom management, informational support, psychological and/or social support, lifestyle changes, emotional adjustment, health education, and tailored coaching, thus improving patients' overall quality of life across the disease course.ObjectiveThe main objective of this study was to describe MS patients' self-reported experience of a nurse-led, telephone-based PSP and to explore its potential role in improving disease and therapy management (...) skills.MethodsSurvey data were analyzed from a subset of patients relapsing–remitting MS using interferon beta-1a already registered in the adveva® PSP from three Italian multiple sclerosis centers with a consolidated experience in RRMS disease, treatment management, and PSP programs.ResultsIn total, 244 patient data at baseline were analyzed, of which 115 had a follow-up of at least 6 months. Results from this study provide an early view into the role of this PSP in improving the patients reported overall experience regarding disease management and injectable therapy, thus potentially ameliorating treatment adherence and decreasing health care cost. Moreover, study findings confirm the role of providing a patient-focused support by addressing non-medication-related topics in the PSP consultations. Indeed, patients involved in the adveva® PSP program reported a better psychological status in the follow up as demonstrated by an increased optimism regarding their future, tolerance of disease uncertainty, and their perceived ability to benefit from external help and social support.ConclusionsAs such, it is reasonable to conclude that the involvement in the adveva® PSP and the PSP's assistance in guiding patients on proper treatment self-management techniques is of great value to patients as it might contribute to improving engagement in their health care journey in terms of perceived self-care skills, emotional coping toward the future and the unpredictability of the disease course and their general attitudes toward the injection itself, involving pain tolerance. (shrink)

Converging data from different disciplines are showing the role of classical conditioning processes in the elaboration of human and animal behavior to be larger than previously supposed. Restricted views of classically conditioned responses as merely secretory, reflexive, or emotional are giving way to a broader conception that includes problem-solving, and other rule-governed behavior thought to be the exclusive province of either operant conditiońing or cognitive psychology. These new views have been accompanied by changes in the way conditioning is conducted and (...) evaluated. Data from a number of seemingly unrelated phenomena such as relapse to drug abuse by postaddicts, the placebo effect, and the immune response appear to involve classical conditioning processes. Classical conditioning, moreover, has been found to occur in simpler and simpler organisms and recently even demonstrated in brain slices and in utero. This target article will integrate the several research areas that have used the classical conditioning process as an explanatory model; it will challenge teleological interpretations of the classically conditioned CR and offer some basic principles for testing conditioning in diverse areas. (shrink)

_Covert treatment raises a number of ethical and practical issues in psychiatry. Viewpoints differ from the standpoint of psychiatrists, caregivers, ethicists, lawyers, neighbours, human rights activists and patients. There is little systematic research data on its use but it is quite certain that there is relatively widespread use. The veil of secrecy around the procedure is due to fear of professional censure. Whenever there is a veil of secrecy around anything, which is aided and abetted by vociferous opposition from some (...) sections of society, the result is one of two: 1) either the activity goes underground or 2) it is reluctantly discarded, although most of those who used it earlier knew it was needed. Covert treatment has the dubious distinction of suffering both such secrecy and disapproval. Covert treatment has a number of advantages and disadvantages in psychotic disorders. The advantages are that it helps solve practical clinical problems; prevents delays in starting treatment, which is associated with clinical risks and substantial costs; prevents risk of self-destructive behaviour and/or physical assault by patient; prevents relapse; and prevents demoralization of staff. The disadvantages are that it maybe used with malafide intent by caregivers with or without the complicity of psychiatrists; it may be used to force conformity in dissenters; and the clinician may land himself in legal tangles even with its legitimate use. In addition, it may prevent insight, encourage denial, promote unhealthy practices in the treating staff and prevent understanding of why noncompliance occurs in the first place. Some support its use in dementia and learning disorders but oppose it in schizophrenia. The main reason is that uncooperative patients of schizophrenia (and related psychoses) are considered to be those who refuse treatment but retain capacity; while in dementia and severe learning disorder, uncooperative patients are those who lack capacity. This paper disputes this contention by arguing that although uncooperative patients of schizophrenia (and related psychoses) apparently retain capacity, it is limited, in fact distorted, since they lack insight. It presents the concept of insight-unconsciousness in a patient of psychosis. Just as an unconscious patient has to be given covert medical/surgical treatment, similarly an insight-unconscious patient with one of the different psychoses (in the acute phase or otherwise) may also have to be given covert treatment till he regains at least partial insight. It helps control psychotic symptoms and assists the patient in regaining enough insight to realize he needs treatment. Another argument against covert treatment is that people with schizophrenia have the capacity to learn and therefore can learn that they are required to take medications, but if medications are given covertly it may well fuel their paranoia. However, it should be noted that the patient who has lack of insight cannot learn unless he regains that insight, and he may need covert treatment to facilitate this process. Covert treatment can fuel the paranoia, true, but it can also control the psychotic symptoms sufficiently so that regular treatment can be initiated. In a patient who refuses to accept that he is sick and when involuntary commitment is not an option to be considered, covert treatment is the only option, apart from physical restraint. Ultimately, a choice has to be made between a larger beneficence (control of symptoms and start of therapy) and a smaller malevolence (necessary therapy, but without the patient's knowledge and consent). A number of practical clinical scenarios are outlined wherein the psychiatrist should adopt covert treatment in the best interests of the patient. Ethical issues of autonomy, power, secrecy and malafide intent arise; each of these can be countered only by non-malfeasance (above all, do no harm) under the overarch of beneficence (even above that, dare to care). An advance directive with health care proxy that sanctions covert treatment is presented. Questions raised by the practical clinical scenarios are then answered. The conclusions are as follows: covert treatment, i.e, temporary treatment without knowledge and consent, is seldom needed or justified. But, where needed, it remains an essential weapon in the psychiatrist's armamentarium: to be used cautiously but without guilt or fear of censure. However, the psychiatrist must use it very judiciously, in the rarest of rare cases, provided: i) he is firmly convinced that it is needed for the welfare of the patient; ii) it is the only option available to tide over a crisis; iii) continuing efforts are made to try and get the patient into regular psychiatric care; iv) the psychiatrist makes it clear that its use is only as a stop-gap; v) he is always alert to the chances of malevolence inherent in such a process and keeps away from conniving or associating with anything even remotely suspicious; and vi) he takes due precautions to ensure that he does not land into legal tangles later. The need of the hour is to explore in greater detail the need and justification for covert treatment, to lay out clear and firm parameters for its legitimate use, follow it up with standard literature and, finally, to establish clinical practice guidelines by unconflicted authors. The term "covert treatment" is preferable to "surreptitious prescribing"; they should not be used synonymously, the latter term being reserved for those cases where there is malafide intent._. (shrink)

A literature search was conducted on studies of new drugs used with patients with schizophrenia reported by U.S. and non-U.S. researchers from 1966–1993, yielding 41 U.S., and a total of 24 other non-U.S. studies, among them 11 British studies. Results of the U.S. and non-U.S. studies were pooled separately and compared. Among several comparable conditions discussed, the lack of any data on suicides in the U.S. studies was observed. For a second statistical analysis of suicide rates ‘person-years’ were calculated to (...) adjust for differing washout durations. The results obtained include findings that the percentage of patients relapsing in U.S. studies was slightly lower than in non-U.S. studies ; the percentage of patients dropping out in U.S. studies was higher than in non-U.S. studies ; known location of dropout patients in U.S. studies was 1.7%, compared to 2.6% in non-U.S. studies. The most interesting finding was that no suicides were reported in U.S. studies, compared to 0.6% of patients reported in British studies. Some U.S. studies used ‘challenge doses’, such as amphetamines or L-dopa; no non-U.S. studies reported their use. Compared to U.S. studies, those by non-U.S., and particularly British, researchers appeared to report adverse events in their studies. ‘Challenge’ drugs were not used; suicides were reported. It is estimated that the probability that no patients suicided who participated in the U.S. is small—one in 500. (shrink)

The term "hypnozoite" is derived from the Greek words hypnos (sleep) and zoon (animal). Hypnozoites are dormant forms in the life cycles of certain parasitic protozoa that belong to the Phylum Apicomplexa (Sporozoa) and are best known for their probable association with latency and relapse in human malarial infections caused by Plasmodium ovale and P. vivax. Consequently, the hypnozoite is of great biological and medical significance. This, in turn, makes the origin of the name "hypnozoite" a subject of interest. Some (...) "missing" history that is now placed on record (including a letter written by P. C. C. Garnham, FRS) shows that Miles B. Markus coined the term "hypnozoite". While a PhD student at Imperial College London, he carried out research that led to the identification of an apparently dormant form of Cystoisospora (synonym: Isospora). In 1976, he speculated: "If sporozoites of Isospora can behave in this fashion, then those of related Sporozoa, like malaria parasites, may have the ability to survive in the tissues in a similar way." He adopted the term "hypnozoite" for malaria in 1978 when he wrote in a little-known journal that this name would "... describe any dormant sporozoites or dormant, sporozoite-like stages in the life cycles of Plasmodium or other Haemosporina." At that time, the existence of a hypnozoite form in the life cycle of Plasmodium was still a hypothetical notion. In 1980, however, Wojciech A. Krotoski published (together with several co-workers) details concerning his actual discovery of malarial hypnozoites, an event of considerable importance. (shrink)

I argue that addiction is not a chronic, relapsing, neurobiological disease characterized by compulsive use of drugs or alcohol. Large-scale national survey data demonstrate that rates of substance dependence peak in adolescence and early adulthood and then decline steeply; addicts tend to “mature out” in their late twenties or early thirties. The exceptions are addicts who suffer from additional psychiatric disorders. I hypothesize that this difference in patterns of use and relapse between the general and psychiatric populations can be explained (...) by the purpose served by drugs and alcohol for patients. Drugs and alcohol alleviate the severe psychological distress typically experienced by patients with comorbid psychiatric disorders and associated problems. On this hypothesis, consumption is a chosen means to ends that are rational to desire: Use is not compulsive. The upshot of this explanation is that the orthodox view of addiction as a chronic, relapsing neurobiological disease is misguided. I delineate five folk psychological factors that together explain addiction as purposive action: strong and habitual desire; willpower; motivation; functional role; and decision and resolve. I conclude by drawing lessons for research and effective treatment. (shrink)

This paper examines the relation between intuition and concept in Kant in light of John McDowell's neo-Kantian position that intuitions are concept-laden.2 The focus is on Kant's twofold pronouncement that thoughts without content are empty and that intuitions without concepts are blind. I show that intuitions as singular representations are not instances of passive data intake but the result of synthetic unification of the given manifold of the senses by the power of the imagination under the guidance of the understanding. (...) Against McDowell I argue that the amenability of intuitions to conceptual determination is not due some pre-existing, absolute conceptuality of the real but to the "work of the subject."3 On a more programmatic level, this paper seeks to demonstrate the limitations of a selective appropriation of Kant and the philosophical potential of a more comprehensive and thorough consideration of his work. Section 1 addresses the unique balance in Kant's philosophy between the work on particular problems and the orientation toward a systematic whole. Section 2 outlines McDowell's take on the Kantian distinction between intuition and concept in the context of the Kant readings by Sellars and Strawson. Section 3 exposes McDowell's relapse into the Myth of the Given. Section 4 proposes a reading of Kant's theoretical philosophy as an epistemology of metaphysical cognition. Section 5 details Kant's original account of sensible intuition in the Inaugural-Dissertation of 1770. Section 6 presents the transition from the manifold of the senses to the synthesis in the imagination and the unification through the categories in the Critique of pure reason . Section 7 addresses Kant's formalism in epistemology and metaphysics.Esse artigo examina a relação entre intuição e conceito em Kant à luz da posição neokantiana de John McDowell de que intuições estão conceitualmente "carregadas". 1 O foco é sobre o duplo pronunciamento de Kant, segundo o qual pensamentos sem conteúdo são vazios e intuições sem conceitos são cegas. Mostro que intuições como representações singuares não são casos de introdução passiva de dados, mas o resultado da unificação sintética do múltiplo dado dos sentidos pelo poder da imaginação sob a orientação do entendimento. Contra McDowell, defendo que a amabilidade das intuições para com a determinação conceitual não é devida a alguma conceitualidade pré-existente, absoluta do real, mas ao "trabalho do sujeito".2 Num nível mais programático, o presente artigo visa demonstrar as limitações de uma apropriação seletiva de Kant e o potencial filosófico de uma análise mais abrangente e aprofundada de sua obra. A seção 1 aborda o equilíbrio único na filosofia de Kant entre o trabalho com problemas particulares e a orientação em direção a um todo sistemático. A seção 2 descreve a posição de McDowell acerca da distinção kantiana entre intuição e conceito no contexto das leituras de Kant por Sellars e Strawson. A seção 3 expõe a reincidência de McDowell no "mito do dado". A seção 4 propõe uma leitura da filosofia teórica de Kant como uma epistemologia do conhecimento metafísico. A seção 5 detalha a explicação original de Kant sobre a intuição sensível na "Dissertação de 1770". A seção 6 apresenta a transição do múltiplo dos sentidos para a síntese na imaginação e para a unificação por meio das categorias na Crítica da razão pura . A seção 7 aborda o formalismo de Kant na epistemologia e na metafísica. (shrink)

Recent experiments have shown that when individuals with a substance use disorder are confronted with drug-related cues, they exhibit an automatically activated tendency to approach these cues. The strength of the drug approach bias has been associated with clinically relevant measures, such as increased drug craving and relapse, and activations in brain reward areas. Retraining the approach bias by means of cognitive bias modification has been demonstrated to decrease relapse rates in patients with an alcohol use disorder and to reduce (...) alcohol cue-evoked limbic activity. Here, we review empirical and theoretical literature on the drug approach bias and explore two distinct models of how the drug approach bias may be embodied. First, we consider the “biological meaning” hypothesis, which grounds the automatic approach bias in the natural meaning of the body. Second, we consider the “sensorimotor hypothesis,” which appeals to the specific sensorimotor loops involved in the instantiation of addictive behaviors as the basis of the automatic approach bias. In order to differentiate between the adequacies of these competing explanations, we present specific, predictions that each model should make. (shrink)

The understanding of decision-making systems has come together in recent years to form a unified theory of decision-making in the mammalian brain as arising from multiple, interacting systems (a planning system, a habit system, and a situation-recognition system). This unified decision-making system has multiple potential access points through which it can be driven to make maladaptive choices, particularly choices that entail seeking of certain drugs or behaviors. We identify 10 key vulnerabilities in the system: (1) moving away from homeostasis, (2) (...) changing allostatic set points, (3) euphorigenic signals, (4) overvaluation in the planning system, (5) incorrect search of situation-action-outcome relationships, (6) misclassification of situations, (7) overvaluation in the habit system, (8) a mismatch in the balance of the two decision systems, (9) over-fast discounting processes, and (10) changed learning rates. These vulnerabilities provide a taxonomy of potential problems with decision-making systems. Although each vulnerability can drive an agent to return to the addictive choice, each vulnerability also implies a characteristic symptomology. Different drugs, different behaviors, and different individuals are likely to access different vulnerabilities. This has implications for an individual's susceptibility to addiction and the transition to addiction, for the potential for relapse, and for the potential for treatment. (shrink)

A prominent number of contemporary theories of emotional experience—understood as occurrent, phenomenally conscious episodes of emotions with an affective character that are evaluatively directed towards particular objects or states of affairs—are motivated by the claim that phenomenally conscious affective experience, when appropriate, grants us epistemic access not merely to features of the experience but also to features of the object of experience, namely its value. I call this the claim of affect as a disclosure of value. The aim of this (...) paper is to clarify the sort of assumptions about experience that we ought to avoid if we want to be able to argue that for the claim of affect as a disclosure of value. There are two core arguments in this paper. First, I argue that Mark Johnston’s account of affect as a disclosure of value, due to its naïve realist commitments, relapses into a position that is vulnerable to the same objection put forward by some naïve realists against intentionalist accounts of perceptual experience. Second, I argue that Michelle Montague’s account, due to its phenomenal intentionalist commitments, relapses into a position that is vulnerable to the same objections put forward against qualia theories of the phenomenal character of perceptual experience. The upshot of the paper is that the core assumptions embedded in the three dominant models of experience—namely naïve realism, different versions of intentionalism, and qualia theory—are problematic as found in contemporary accounts of affect as a disclosure of value. (shrink)

This is a technical treatise for the scientific-minded readers trying to expand their intellectual horizon beyond the straitjacket of materialism. It is dedicated to those scientists and philosophers who feel there is something more, but struggle with connecting the dots into a more coherent picture supported by a way of seeing that allows us to overcome the present paradigm and yet maintains a scientific and conceptual rigor, without falling into oversimplifications. Most of the topics discussed are unknown even to neuroscientists, (...) biologists, philosophers, and yet are based on the findings published in their own mainstream peer reviewed literature or on deep insights of the scientific, philosophical and spiritual giants of the past. -/- A scientific, philosophical, and spiritual overview of the relationship between science and spirituality, neuroscience and the mystery of consciousness, mind and the nature of reality, evolution and life. A plaidoyer for a science that goes beyond the curve of reason and embraces a new synthesis of knowledge. The overcoming of the limitations of the intellect into an extended vision of ourselves and Nature. A critique of physicalism, the still-dominant doctrine that believes that all reality can be reduced to matter and the laws of physics alone. A review and reassessment of the old and new philosophical and metaphysical ideas which attempts to bring closer Western and Eastern traditions where science, philosophy, consciousness, Spirit and Nature are united in a grand vision that transcends the limited conventional scientific and philosophical paradigm. A possible answer to the questions of purpose and meaning and the future evolution of humankind beyond a conception that posits a priori a purposeless and meaningless universe. A report of the new scientific discoveries of a basal intelligence in cells and plants, on the question if mind is computational, the issue of free will, the mind-body problem, and the so called ‘hard problem of consciousness’. An essay on ancient as modern philosophical conceptions, from the One of Plotinus, the God of Spinoza until the recent revival of panpsychism or the universal consciousness. A journey into quantum physics from the perspective of philosophical idealism and an invitation to adopt new ways of seeing that might help us to transform our present understanding, expanding it into an integral cosmology, with a special emphasis on the spiritual and evolutionary cosmology of the Indian seer Sri Aurobindo. -/- Not just a philosophical and metaphysical meditation but, rather, an appeal to work towards a change of consciousness, a widening of our perspective towards a new way of seeing beyond a purely mechanistic worldview to avoid a social, environmental and economic collapse. Humans are transitional beings that will have to make a choice: relapse into a pre-rational state or evolve towards a new trans-rational species supported by an ideal of human unity in diversity as the expression of a spiritual evolutionary process, the call of the Spirit on Nature. (shrink)

In spite of the advances in our knowledge of cancer biology, most cancers remain not curable with present therapies. Current treatments consider cancer as resulting from uncontrolled proliferation and are non‐specific. Although they can reduce tumour burden, relapse occurs in most cases. This was long attributed to incomplete tumour elimination, but recent developments indicate that different types of cells contribute to the tumour structure, and that the tumour's cellular organization would be analogous to that of a normal tissue, with a (...) main mass of differentiating cells sensitive to anti proliferative agents, together with a small percentage of quiescent, resistant stem cells responsible for replenishing the tumour: the Cancer Stem Cells (CSCs). Anti‐CSCs targeted therapeutic agents would prevent tumour regeneration. New mouse models tailored to exploit this novel concept will be critical to develop CSC‐based anti‐cancer therapies. Here we review the biological basis and the therapeutic implications of the stem‐cell model of cancer. BioEssays 29:1269–1280, 2007. © 2007 Wiley Periodicals, Inc. (shrink)

Research in the philosophy of addiction commonly explores how agency is impacted in addiction by focusing on moments of apparent loss of control over addictive behavior and seeking to explain how such moments result from the effects of psychoactive substance use on cognition and volition. Recently, Glackin et al. (2021) have suggested that agency in addiction can be helpfully analyzed using the concept of affordances. They argue that addicted agents experience addiction-related affordances, such as action possibilities relating to drugs, drug (...) paraphernalia, and drug-related activities, as aberrantly salient motivations for action. Building on this approach, we present a novel two-tiered affordance model of addiction. In doing so, we suggest that what is significant about the addicted person’s world is not simply what affordances are experienced as salient, but also the way in which the addicted person’s world is shaped by a dominant concern. It is not only that addiction-related affordances become more prominent as addiction progresses but that one’s plurality of concerns become monopolized by and funneled through addiction. Our model endorses Glackin et al.’s idea that addiction-related affordances become aberrantly salient, while proposing why they become and remain so. This way of viewing agency in addiction also brings to light important implications for recovery and treatment. For, if an addicted person adopts a new, even “socially approved”, dominant concern, there is a risk that the shape of addiction is preserved, even though the content changes, leaving an individual at the risk of addiction substitution or relapse. (shrink)

Background Non-adherence to medication is associated with increased risk of relapse in patients with bipolar disorder. Objectives To validate patient-evaluated adherence to medication measured via smartphones against validated adherence questionnaire; and investigate characteristics for adherence to medication measured via smartphones. Methods Patients with BD evaluated adherence to medication daily for 6–9 months via smartphones. The Medication Adherence Rating Scale and the Rogers’ Empowerment questionnaires were filled out. The 17-item Hamilton Depression Rating Scale, the Young Mania Rating Scale and the Functional (...) Assessment Short Test were clinically rated. Data were collected multiple times per patient. The present study represents exploratory pooled reanalyses of data collected as part of two randomised controlled trials. Findings During the study 90.50% of the days were evaluated as ‘medication taken’, 6.91% as ‘medication taken with changes’ and 2.59% as ‘medication not taken’. Adherence to medication measured via smartphones was valid compared with the MARS. Younger age and longer illness duration were significant predictors for non-adherence to medication. Decreased affective symptoms measured with smartphone-based patient-reported mood and clinical ratings as well as decreased empowerment were associated with non-adherence. Conclusions Smartphone-based monitoring of adherence to medication was valid compared with validated adherence questionnaire. Younger age and longer illness duration were predictors for non-adherence. Increased empowerment was associated with adherence. Clinical implications Using smartphones for empowerment of adherence using patient-reported measures may be helpful in everyday clinical settings. Trial registration number NCT01446406 and NCT02221336. (shrink)

Physicians who care for critically ill people with opioid use disorder frequently face medical, legal, and ethical questions related to the provision of life-saving medical care. We examine a complex medical case that illustrates these challenges in a person with relapsing injection drug use. We focus on a specific question: Is futility an appropriate and useful standard by which to determine provision of life-saving care to such individuals? If so, how should such determinations be made? If not, what alternative decisionmaking (...) framework exists? We determine that although futility has been historically utilized as a justification for withholding care in certain settings, it is not a useful standard to apply in cases involving people who use injection drugs for non-medical purposes. Instead, we are welladvised to explore each patient's situation in a holistic approach that includes the patient, family members, and care providers in the decision-making process. The scope of the problem illustrated demonstrates the urgent need to definitively improve outcomes in people who use injection drugs. Increasing access to high quality medication-assisted treatment and psychiatric care for individuals with opioid use disorder will help our patients achieve a sustained remission and allow us to reach this goal. (shrink)

Addiction is increasingly described as a “chronic and relapsing brain disease”. The potential impact of the brain disease model on the treatment of addiction or addicted individuals’ treatment behaviour remains uncertain. We conducted a qualitative study to examine: (i) the extent to which leading Australian addiction neuroscientists and clinicians accept the brain disease view of addiction; and (ii) their views on the likely impacts of this view on addicted individuals’ beliefs and behaviour. Thirty-one Australian addiction neuroscientists and clinicians (10 females (...) and 21 males; 16 with clinical experience and 15 with no clinical experience) took part in 1 h semi-structured interviews. Most addiction neuroscientists and clinicians did not uncritically support the use of brain disease model of addiction. Most were cautious about the potential for adverse impacts on individuals’ recovery and motivation to enter treatment. While some recognised the possibility that the brain disease model of addiction may provide a rationale for addicted persons to seek treatment and motivate behaviour change, Australian addiction neuroscientist and clinicians do not assume that messages about “diseased brains” will always lead to increased treatment-seeking and reduced drug use. Research is needed on how neuroscience research could be used in ways that optimise positive outcomes for addicted persons. (shrink)

The understanding of decision-making systems has come together in recent years to form a unified theory of decision-making in the mammalian brain as arising from multiple, interacting systems (a planning system, a habit system, and a situation-recognition system). This unified decision-making system has multiple potential access points through which it can be driven to make maladaptive choices, particularly choices that entail seeking of certain drugs or behaviors. We identify 10 key vulnerabilities in the system: (1) moving away from homeostasis, (2) (...) changing allostatic set points, (3) euphorigenic signals, (4) overvaluation in the planning system, (5) incorrect search of situation-action-outcome relationships, (6) misclassification of situations, (7) overvaluation in the habit system, (8) a mismatch in the balance of the two decision systems, (9) over-fast discounting processes, and (10) changed learning rates. These vulnerabilities provide a taxonomy of potential problems with decision-making systems. Although each vulnerability can drive an agent to return to the addictive choice, each vulnerability also implies a characteristic symptomology. Different drugs, different behaviors, and different individuals are likely to access different vulnerabilities. This has implications for an individual's susceptibility to addiction and the transition to addiction, for the potential for relapse, and for the potential for treatment. (shrink)

What triggers the execution of actions? What happens in that moment when an action is triggered? What mental state is there at the moment of action-execution that was not there a second before? My aim is to highlight the importance of a thus far largely ignored kind of mental state in the discussion of these old and much-debated questions: motor imagery. While there have been a fair amount of research in psychology and neuroscience on motor imagery in the last 30 (...) years or so, it is only recently that we start to understand the important role motor imagery plays in action initiation. And if, as these findings suggest, motor imagery plays an important role in action initiation, we can make progress not only in understanding action initiation in general but also in understanding what goes wrong in akratic actions and in relapse actions. Finally, this new picture of action-initiation also has far-reaching consequences for the relation between motivation and causation in naturalistic action-explanations. (shrink)

This paper presents four arguments in favour of respecting Ulysses Contracts in the case of individuals who suffer with severe chronic episodic mental illnesses, and who have experienced spiralling and relapse before. First, competence comes in degrees. As such, even if a person meets the usual standard for competence at the point when they wish to refuse treatment, they may still be less competent than they were when they signed the Ulysses Contract. As such, even if competent at time 1 (...) and time 2, there can still be a disparity between the levels of competence at each time. Second, Ulysses Contracts are important to protect people’s most meaningful concerns. Third, on the approach defended, the restrictions to people’s liberty would be temporary, and would be consistent with soft paternalism, rather than hard paternalism: the contracts would be designed in such a way that individuals would be free to change their minds, and to change or cancel their Ulysses Contracts later. Finally, even if one rejects the equivalence thesis, this is still consistent with the claim that, in particular cases, it can be as wrong to allow a harm as to do a harm. Nevertheless, controversies remain. This paper also highlights several safeguards to minimise risks. Ultimately, we argue that people who are vulnerable to spiralling deserve a way to protect their autonomy as far as possible, using Ulysses Contracts when necessary. (shrink)

Since the early seventeenth century of Bacon, Gallileo and Descartes, the relations between science and religion as well as mind and body have remained volatile fault lines of conflict. The controversies surrounding these relations are as alive and pressing now as at any point over the course of the past four centuries. Adrian Johnston's transcendental materialism offers a new theoretical approach to these issues. Arming himself with resources provided by German idealism, Marxism, psychoanalysis, the life sciences and contemporary philosophical developments, (...) Johnston formulates an account of subjectivity that, although being both materialist and naturalist, does full justice to human beings as irreducible to natural matter alone. At the same time he argues against relapses into idealisms, dualisms and spiritualisms. Adventures in Transcendental Materialism elaborates Johnston's position through critical engagements with some of today's most important thinkers including Slavoj Žižek, Alain Badiou, Catherine Malabou, Jean-Claude Milner, Martin Hägglund, William Connolly, and Jane Bennett"--Back cover. (shrink)

Addiction: A Philosophical Approach CHAPTER ABSTRACTS “Introduction: Dismantling the Catchphrase” by Candice Shelby Shelby dismantles the catchphrase “disease of addiction.” The characterization of addiction as a disease permeates both research and treatment, but that understanding fails to get at the complexity involved in human addiction. Shelby introduces another way of thinking about addiction, one that implies that is properly understood neither as a disease nor merely as a choice, or set of choices. Addiction is a phenomenon emergent from a complex (...) dynamic system that is at once physical, psychological, social, and more. “A Philosophical Analysis of Addiction” by Candice Shelby Shelby brings much-needed clarity to the discourse surrounding the topic of addiction. Arguing that addiction can neither properly be understood as a disease nor as merely a set of choices, Shelby exposes the weaknesses of both approaches. She shows that addicted persons do not exhibit the elements characteristic of compulsion, nor does an account of addiction in terms of weakness of will, or irrational choosing, provide a satisfying explanation. Instead, by replacing traditional substance ontology with process ontology, and accepting the reality of emergent entities, a coherent account of persons, minds, and addiction can be provided. A fundamental philosophical shift is necessary to see that bodies, minds, values, and addictions are all part of the natural world. “Addiction at the Individual Level” by Candice Shelby Shelby discusses the most influential accounts of addiction as it is understood at the purely individual level. From hedonic theories to incentive sensitization, to habit theories of addiction, to behavioral theories and the ego depletion theory, Shelby considers a variety of approaches to understanding addiction in individuals, as framed in both psychological and in neuroscientific terms. She notes some important caveats that should be considered before accepting the research regarding addiction at the individual level, namely that the scanning studies that are so popularly used to characterize addiction in neurobiological terms are ambiguous, and rely on numerous assumptions that may be false, and that certainly mislead. Shelby provides much-needed critique of both disease and choices models as they characterize addiction at the individual level. “Addiction and the Local Environment” by Candice Shelby Shelby argues that human addiction cannot be understood without serious consideration of the individual’s local environment, her home and family. From the gestational environment to interactions with caregivers during post-natal development to the adult environment in which people become addicted, Shelby shows that no one becomes an addict in a vacuum. Stress is a major influence in the environment throughout life, and has serious consequences for addictive vulnerability. Genetic influences as well are important to addictive vulnerability, but genes always express in interaction with their environment. Social acceptance or rejection is another particularly important factor in the local environment with respect to both coming to be addicted and transitioning out of it. “The Relation Between Addiction and Culture” by Candice Shelby Shelby provides a groundbreaking analysis of the relation between addicts and the cultures that breed them. In this cultural critique, Shelby shows that addictions to certain substances have historically been both the solution to the problem of how to grow economies and control people, and a problem for economic productivity and controlling citizens. Not all cultures have even the concept of addiction, while others, such as the contemporary Western world, and the U.S. in particular, seem to foster it. Shelby shows that addiction is both a cultural construct and, from another way of thinking about it, the result of conditions created by particular cultures. Social inequities, alienation, driving capitalism, and in particular the power of pharmaceutical companies, all contribute to the spiraling endemic of addiction. “Addiction and Meaning” by Candice Shelby Shelby provides a unique argument that understanding how meanings work is essential to a complete analysis of addiction. Individuals experiencing addiction and those who care about and for them often utterly fail to communicate. This is because their respective systems of meanings come to be significantly different. Meanings are not, Shelby argues, best understood in the symbolic terms that characterized the theory of language in the 20th century, but are better apprehended as emotion-rich prototypes carved from repeated interaction with the world. Becoming addicted essentially changes one’s entire system of meanings. Requisite to transitioning out of addiction is a Gestalt-type shift in one’s system of meanings. This holistic way of understanding meanings also provides one level of explanation of what happens when an addict relapses. “The Phenomenology of Addiction and its Implications” by Candice Shelby One way of judging theories of addiction is by how well they capture the phenomenal descriptions that addicts give of their own experiences. Shelby considers variations on 5 basic patterns of addictive experience through the eyes of particular individuals who lived through addictive periods, and shows how even the most influential theories of addiction fail to capture all of them. She argues that an important implication of taking the details of individuals’ addictive stories seriously is that addiction must be understood as a personal phenomenon emergent from a particular complex dynamic system. As her theory of addiction would lead one to expect, no two addicts are the same, and no single-focus theory can explain why not. “Possibilities for Transitioning Out of Addiction” by Candice Shelby Shelby provides numerous strategies for transitioning out of addiction. Given that the vast majority of addiction treatment programs currently available are 12-step based and only successful about 5-8% of the time, it is essential that other approaches be undertaken. Shelby canvasses a variety of options for helping addicted individuals to make the transition out of their troubled pattern of thinking and behaving. From direct brain interventions to drugs to trauma therapy to exercise and nutrition to habit reformation to use of narrative and changing one’s social context as ways of redefining the self, Shelby shows that the possibilities for transitioning out of addiction are legion. Perhaps the best approach is to understand addiction treatment in terms of providing physical, psychological, and social tool kits. “Addiction Emerges from a Complex Dynamic System” by Candice Shelby Shelby considers whether there truly exists such a thing as “an addict” or “addictive thinking” in the universal sense. She concludes that within the context of disruptive substance use or repetitive engagement in certain activities, ordinary human cognitive biases and behavior patterns are categorized as addictive. Addiction, she argues, is best understood as an irreducible human reality, emergent from a sufficiently complex dynamic system (an organism with self-awareness, within a particular cultural milieu) that is both shaped by and contributes to the shaping of its environment. Attempts to simplify addiction into one or a few dimensions may create a solvable problem, but by doing so they fail to solve the real one. (shrink)

Normative thinking about addiction has traditionally been divided between, on the one hand, a medical model which sees addiction as a disease characterized by compulsive and relapsing drug use over which the addict has little or no control and, on the other, a moral model which sees addiction as a choice characterized by voluntary behaviour under the control of the addict. Proponents of the former appeal to evidence showing that regular consumption of drugs causes persistent changes in the brain structures (...) and functions known to be involved in the motivation of behavior. On this evidence, it is often concluded that becoming addicted involves a transition from voluntary, chosen drug use to non-voluntary compulsive drug use. Against this view, proponents of the moral model provide ample evidence that addictive drug use involves voluntary chosen behaviour. In this paper we argue that although they are right about something, both views are mistaken. We present a third model that neither rules out the view of addictive drug use as compulsive, nor that it involves voluntary chosen behavior. -/- . (shrink)

In this two-part analysis, I analyze Marc Lewis’s arguments against the brain-disease view of substance addiction and for a developmental-learning approach that demedicalizes addiction. I focus especially on the question of whether addiction is a medical disorder. Addiction is currently classified as a medical disorder in DSM-5 and ICD-10. It is further labeled a brain disease by NIDA, based on observed brain changes in addicts that are interpreted as brain damage. Lewis argues that the changes result instead from normal neuroplasticity (...) and learning in response to the intense rewards provided by addictive substances, thus that addiction is not a brain disease and by implication not a medical disorder at all. I argue that even if one accepts Lewis’s reinterpretation of the brain evidence, his conclusions do not follow. Relying on my harmful-dysfunction analysis of medical disorder, I defend the view that substance addiction is in fact a medical disorder and a brain disorder. In Part 1, I identify five arguments Lewis puts forward against the brain-disease view and evaluate them as arguments that addiction is not a disorder: Addiction is not a chronic, relapsing condition; There is no clear boundary between addiction and other strong desires; Negative consequences are not unique to disorders; The brain disease model does not account for behavioral addictions; and, Addiction is like love. I argue that Lewis’s arguments are invalid because they fail to take account of the context of addiction and its relation to biological design. (shrink)

In this article, we present for the first time Schelling’s early critique of absolute idealism within his middle metaphysics (1804–1820), which has great relevance and influence on the subsequent course of German philosophy, and, more broadly considered, on later systematic thinking about the categories of unity and duality. We aim to show how Schelling defends a form of metaphysical duality, from 1804 onwards, without relapsing into a stronger Kantian dualism. In this sense, our author rejects both the dualism between nature (...) and spirit, necessity and freedom, as well as the monist-immanent metaphysical stance later associated with Hegelian panlogism. Against Hegel, Schelling increasingly vindicates the reality of the finite and degrades the infinite to mere ideality in a movement that resembles later existentialism. Furthermore, we defend Schelling against the accusation of irrationalism that sections of Hegelianism formulated against him and present the concept of infinity without the notion of totality, which he thinks of, much like Fichte, in the light of the concept of an ‘infinite task’. Schelling’s later criticisms of Hegel are shown to be influenced by his early idealist critique of the period at hand. (shrink)

Philosophical critiques are prone to relapse into a sort of entrenchment in which the basic elements of a philosophy are kept from exposure, so that instead of advancing, philosophy easily becomes compartmentalized into specific trends. This article thus seeks the conditions of a non-entrenched, open-field philosophical critique in general and, in particular, of an open-field critique of Harman’s OOO (object-oriented ontology). For that purpose, the idea of precariousness is introduced, which is then confronted with some ideas concerning philosophical critique and (...) practice, in particular those of François Laruelle. Since we can find in Harman’s OOO an outline of what we call here an open-field critique, the field of combat against Harman will be the one concerning the idea of an open field itself. (shrink)

A woman from the Republic of Ireland has successfully challenged the country's restrictive abortion legislation at the European Court of Human Rights. 1 The woman was in remission from cancer and believed that she was at increased risk of relapse due to her unintended pregnancy. She believed that continuing with the pregnancy would have put her life at risk. She travelled to England for an abortion in 2005 and subsequently experienced medical complications when she returned to Republic of Ireland. Abortion (...) in the Republic of Ireland is permitted if the life of the pregnant woman is at risk, but given the uncertainty around interpreting the legislation and the fear of criminal sanctions, the provision is not always effective in practice. The woman argued that her right to an abortion had been denied because there was no law or procedure through which she could have her clinical entitlement established. The ECtHR was unanimous that her right to private and family life had been violated but did not uphold her challenge under Articles 2, 3 and 14. The woman was joined by two other women in the challenge but the other women were unsuccessful as their circumstances differed; their lives had not been at risk if they had continued with their pregnancies. 2The Court concluded ‘that neither the medical consultation nor litigation options, relied on by the Irish government, constituted effective and accessible procedures which allowed [her] … to establish her right to lawful abortion in Ireland’.3At the time of writing, the Irish government was considering how to implement the judgement.Review of arm's-length bodiesAs previously reported here, in July 2010 the UK Government announced plans to reform and abolish a large number of arm's-length bodies. 4 …. (shrink)

Expressed emotion is a measure of the family environment that has been demonstrated to be a reliable, cross-culturally valid psychosocial predictor of relapse in patients with schizophrenia, mood disorders, and other — also somatic — illnesses. Assessed during the Camberwell Family Interview CFI, relatives are classified as being high in EE if they make more than a specified threshold number of critical comments or show any signs of hostility or marked emotional overinvolvement. In schizophrenia, the median relapse rate for patients (...) returning after hospital discharge to a high EE environment is 48%, compared with 21% in a low EE-environment. In this article, the history of EE research will be outlined, and the evidence for the association between family EE and the course of schizophrenia and mood disorders will be presented. Conclusions about the treatment of major mental disorders are discussed as well as the directions of future studies. (shrink)

Poor medication adherence in patients with a psychosis is associated with relapse. It has been proposed that outcomes might be improved by using financial incentives for treatment adherence (FITA). However, a strong moral intuition against this practice has been found. This paper examines the ethics of FITA. Three arguments are presented, which if accepted would severely restrict or even prohibit the practice. These are based on (1) “incommensurable values”, where FITA denigrates an aspect of “respect for the person”, (2) “exploitation”, (...) where unfair advantage is taken of the patient, and (3) “fairness”, where it is difficult to draw a line between those who should and should not be offered payment. A number of practical impediments are also considered. (shrink)

One of the most recent controversies to arise in the field of bioethics concerns the ethics for the Groningen Protocol: the guidelines proposed by the Groningen Academic Hospital in The Netherlands, which would permit doctors to actively euthanise terminally ill infants who are suffering. The Groningen Protocol has been met with an intense amount of criticism, some even calling it a relapse into a Hitleresque style of eugenics, where people with disabilities are killed solely because of their handicaps. The purpose (...) of this paper is threefold. First, the paper will attempt to disabuse readers of this erroneous understanding of the Groningen Protocol by showing how such a policy does not aim at making quality-of-life judgements, given that it restricts euthanasia to suffering and terminally ill infants. Second, the paper illustrates that what the Groningen Protocol proposes to do is both ethical and also the most humane alternative for these suffering and dying infants. Lastly, responses are given to some of the worries expressed by ethicists on the practice of any type of non-voluntary active euthanasia. (shrink)