Objectives: Impaired attention and language functions are common in psychosis, but have been less explored in subjects with ultra-high risk for psychosis (UHR). The aim of the study was to investigate differences in language lateralization and auditory attention in UHR subjects compared to healthy controls with a dichotic listening paradigm. In addition, symptoms from The Structural Interview for Prodromal Syndromes (SIPS) were explored in relation to performance on dichotic listening. Methods: The UHR subjects (n=46, female=28, mean age=17.9) were compared to (...) a group of healthy controls (n=40, female=20, mean age=16.8). A split-plot repeated measures analysis of covariance was conducted with group as between-subjects factor and attention conditions (non-forced, forced-right, forced-left) and side (right ear, left ear) as repeated measures factors (2x3x2 design) using gender, age and handedness as covariates. SIPS symptoms were subjected to Spearman's r correlations with laterality indexes and attentional gain in each ear. Results: There was a statistically significant three-way interaction of group (UHR, healthy controls) x forced condition (non-forced, forced-right, forced-left) x side (right ear, left ear), p=.048. The effect was due to an interaction between group x side in the forced-left condition. There were no significant differences between UHR subjects and healthy controls in the non-forced condition. Right ear gain correlated with "Perceptual abnormalities/ Hallucinations" (P4), r=0.486, p=.001. Conclusion: UHR subjects demonstrated impairment in top-down attentional mechanisms, but showed no language lateralization abnormalities. Impairment in top-down attentional mechanisms are frequently reported from dichotic listening studies in patients with schizophrenia. Higher levels of perceptual abnormalities and hallucinatory experiences were associated with enhanced report from the right ear in the forced-right condition. (shrink)

Delusional perception is a psychopathological phenomenon in which a self-referential, compulsory, obvious meaning is superimposed on the common meaning of the object or event, which is nevertheless still valid. The essay aims to an analysis of the possibility conditions of the coexistence of two different world-phenomena which share the same hyletic material. Among the variegated features of delusional perception, the essay deals mainly with temporality, as studied by Husserl and Richir, although brief analysis of spatiality and the prodromic phase of (...) delusional perception are also provided. (shrink)

In this article I ask whether elaborated and systematized delusions emerging in the context of schizophrenia have the potential for epistemic innocence. Cognitions are epistemically innocent if they have significant epistemic benefits that could not be attained otherwise. In particular, I propose that a cognition is epistemically innocent if it delivers some significant epistemic benefit to a given agent at a given time, and if alternative cognitions delivering the same epistemic benefit are unavailable to that agent at that time. Elaborated (...) and systematized delusions in schizophrenia are typically false and exemplify failures of rationality and self-knowledge. Empirical studies suggest that they may have psychological benefits by relieving anxiety and enhancing meaningfulness. Moreover, these delusions have been considered as adaptive in virtue of the fact that they enable automated learning to resume after a significant disruption caused by incorrect prediction-error signalling. I argue that such psychological benefits and adaptive features also have positive epistemic consequences. More precisely, delusions can be a means to restoring epistemic functionality in agents who are overwhelmed by hypersalient experiences in the prodromal stage of psychosis. The analysis leads to a more complex view of the epistemic status of delusions than is found in the contemporary philosophical literature and has some implications for clinical practice. 1 Introduction2 Types of Delusions3 What Is Wrong with Elaborated and Systematized Delusions?4 Finding Life Meaningful5 Learning Resumed6 Epistemic Innocence7 Epistemic Benefit8 No Alternatives9 Conclusions and Implications. (shrink)

Consideration is given to some strategies to combat Huntington's disease in the absence of treatment to arrest its progress. Ethical issues for tests such as levodopa loading, to provoke symptoms prematurely in carriers of the gene, are compared with those associated with schemes for delaying the onset of disease. The major drawback of these designs is the uncertainty that prodromal symptoms may be extended unduly and the severity of deferred symptoms worsened. Some attention is also given to the possible use (...) of post-onset plans to reduce illness severity and prolong survival. It is concluded that the characteristics of persons less prone to undesirable consequences of onset-delay should be adequately investigated before attempting to implement such schedules as a practical measure. (shrink)

Our focus in this chapter is to address some of the philosophical issues that arise in the scientific and clinical study of the prodromal phase of psychosis. We discuss issues from both metaphysics and philosophy of science as we all as those related to phenomenological approaches and clinical ethics. A clear challenge arises in considering how models of a continuum of psychosis and of schizophrenia as a neurodevelopmental disorder can be reconciled with a scientific understanding of the prodrome as (...) a discrete constellation of signs and symptoms. Clinical and research work on the prodromal stage of psychosis also highlights ethical concerns. Demarcating a mental disorder and applying therapeutic interventions, based solely on risk estimation, should not be carried out lightly. (shrink)

The papers included in the thesis, and summarized in this covering document, were selected, in discussion with my supervisor, Dr. Roessler, from papers I have published in the philosophy of psychiatry. In parallel to this philosophical work, I have worked clinically as a psychiatrist and academically as a research psychiatrist. My clinical work has largely been working with Early Intervention Services, both in South London and in Coventry and Warwickshire, and this work has been acting as a psychiatrist in clinical (...) teams who work with young people who may either be at risk of developing a psychotic illness, or are in the earliest stages of such an illness. My empirical work has been in the same clinical group and has used functional neuroimaging and cognitive neuropsychology to characterize those at risk of psychosis and to chart the onset of psychosis and the formation of delusions. As required by the university guidelines, a full list of publications, both empirical and philosophical, is detailed in appendix 1. The papers included in the thesis hence parallel many of these clinical and empirical interests: papers 2 and 4, in particular, examine the role neuroimaging may play in studying delusions and relate the prodromal phase of psychosis to both the neurodevelopmental and continuum models of psychosis. Paper 3 is one of two papers written with Lisa Bortolotti drawing on Richard Moran’s work and examining delusions. Paper 1 is perhaps the paper least connected to my empirical and clinical work as has a wider focus and tries to examine what mental illnesses are and to begin to describe a position Lisa Bortolotti and I later expanded on and referred to as ‘psychological realism’, with Paper 2 being a case example of this account being applied to a particular area of psychopathology, namely delusions. The papers form a progression with Paper 1 outlining a general conception of mental disorder, Paper 2 being a case study of this approach specifically in the area of delusion. Paper 3 takes the example of thought insertion and develops ideas from Paper 2 that reason giving is a crucial feature that helps highlight what is pathological about certain experiences. Paper 4 brings together the philosophical concerns regarding a wholly neuroscientific conception of psychopathology, and how this is of clinical and scientific relevance when we use psychopathology to demarcate the various stages of psychotic experience and illness. (shrink)

Traduction commentée de fragments araméens de Qoumrân contenant des restes de légendes sur les temps précédant le Déluge, insistant surtout sur les méfaits des Géants, nés des anges déchus et des filles de l’homme, et leur condamnation. Mis au nombre des écritures saintes du manichéisme, le « livre des Géants » a été traduit en des langues diverses et on en a retrouvé des vestiges à Tourfân. Ils sont rapprochés ici de leur original araméen. Translation and commentary on the Aramaic (...) fragments from Qumran, which include the remainders of legends about the period before the Flood, mainly about the wrongdoings of the Giants who were born from fallen angels and the daughters of men, and their condemnation. Since the « Book of the Giants » was included among the holy scriptures of Manichaeism, it has been translated into several languages. Traces of it have been found, for instance, in Turfan. This paper establishes their connection with the Aramaic original. (shrink)

"Cette étude est à la fois une révision profonde de la théorie kantienne de l'expérience et une histoire du bouleversement qu'a entraîné, pour la physique, la découverte du calcul différentiel. La méthode qu'en dégage Cohen est destinée à fonder une nouvelle critique de la connaissance. C'est en même temps l'un des piliers philosophiques essentiels de l'idéalisme critique propres à l'École de Marbourg, qui débouchera sur la pierre angulaire du système de Cohen, sa "Logique de la connaissance pure". La réflexion sur (...) l'infinitésimal a pour objectif, dans sa partie historique - des Grecs à la fin du XVIIIe siècle -, de montrer, et bien au-delà de la controverse qui a opposé Newton à Leibniz sur la priorité de la découverte, que c'est bien chez ce dernier qu'on trouve un développement véritablement philosophique des conséquences de cette approche nouvelle de la catégorie de 'réalité'. La reconnaissance du rôle de la physique mathématique va donc au-delà de la "révolution copernicienne" effectuée par Kant, pour s'élever à une conception nouvelle de ce qu'est l'objet même de l'expérience scientifique. Contrairement au verdict kantien, la logique ne s'enferme plus dans sa cohérence systématique qui la condamne à ne plus progresser, voire à rester en quelque sorte à la traîne des progrès scientifiques, mais s'ouvre, au contraire, aux développements ultérieurs de la science en s'adaptant sans distorsions à la théorie de la relativité comme aux prodromes de la théorie des quanta. Léon Brunschvicg, dans son ouvrage sur "Les Étapes de la philosophie mathématique", a souvent suivi l'exposé historique de Cohen, et Bertrand Russel avait aussitôt salué ce "remarquable travail" de reconstruction philosophique où la part de l'histoire n'est nullement contingente puisque c'est précisément à l'intégration de l'évolution scientifique au sein de la critique de la connaissance que tend Hermann Cohen.". (shrink)

Brillant analyste de la vie sociale et culturelle de l’Allemagne des années vingt et trente, Siegfried Kracauer montre dans son essai Le Roman policier comment l’inscription dans une culture de masse du genre littéraire récent qu’est le « roman policier » procède d’une mutation radicale de la rationalité et des conditions « métaphysiques » de la constitution du sens. C’est étonnamment en adoptant une perspective métaphysique que Siegfried Kracauer parvient à faire des transformations du roman policier les prodromes de la (...) terreur totalitaire qui vient. (shrink)

This article defines Themistius’ exegesis of the human intellect as a prodromic noetics, that is, a psychology in which the former psychological function is naturally predisposed, as a matter, to the action of the latter one, which acts as a form. This doctrine, which I claim to stem from Plato’s Timaeus, makes sense of hylomorphism by allowing separate psychological functions both to combine to non-separate ones and to unify cognitive functions and their cognitive objects. At the same time, Themistian exegesis (...) aims at defining the self, which is identified with the active intellect, since this intellect is the ultimate form of this successive prodromic interaction. Concluding remarks are intended to give weight to the thesis that Themistius’ noetics is an original attempt to recognize and reject two other extreme positions: the one which implies that actual intellect is not human but divine, as Alexander of Aphrodisias claimed; the other advanced by Zeno the Stoic, who held that the lower functions of the human soul are defined as perversions of the higher one. (shrink)

Background. Prodromal Alzheimer’s disease (AD) clinical trials enroll patients with mild cognitive impairment (MCI) and their study partners. This study examined trial enrollment decision-making and risk for misunderstanding trial information presented in an informed consent process for prodromal AD trials.Methods. We performed structured interviews with patients with MCI and individuals who could serve as their study partners. We presented details of a hypothetical prodromal AD trial, followed by questionnaires to assess involvement of the study partner in trial decisions, patient capacity (...) to consent, and patient health numeracy skills.Results. Among 65 patient participants, most were male (66%) and non-Hispanic White (88%) with a mean (standard deviation) age of 74.9 (8.4) years. Among 57 study partners, most were spouses (83%), female (74%), and non-Hispanic White (91%) with a mean (standard deviation) age of 70.3 (13.6). Most patient participants (66%) and study partners (72%) reported they would make enrollment decisions in partnership; 28% of patient participants said they would make the decision themselves, with input from a study partner. Twenty-five patient participants (38%) lacked capacity to consent to the trial; 38% demonstrated impaired health numeracy. Seventeen patient participants (26%) demonstrated both a lack of capacity and impaired health numeracy, among whom seven reported they would make enrollment decisions on their own, with input from a study partner.Conclusions. Some patients with MCI demonstrated a lack of capacity to consent, impaired health numeracy, or both, putting them at risk for misunderstanding trial information in the consent process for a prodromal AD clinical trial. (shrink)

The focus is on the intersubjective, narrative and dialogic aspects of the clinical phenomenon of insight in psychosis. By introducing a socio-dialogic model for the clinical production of insight, it can be learned how insight, as a form of self-knowledge, is a product of the clinical interview, namely the dialogic relation between patient and clinical interviewer. Drawing upon the philosophy of Emmanuel Levinas, expressly his notion of the ethical encounter, the production of insight in the clinical interview is elucidated as (...) both a synchronic and diachronic phenomenon—a provisional form of self-knowledge based on historically-produced frames of meaning which are recalled and narrated, i.e., produced at a specific moment in time. The production of insight, based on auto-biographical memory, is ultimately a processual and transactional phenomenon which arises out of the narrative construction of experience and the dialogic negotiation of the individual's "authored" experience. This process may be understood as a synergistic dynamic between intersubjective micro-processes and symbolic macro-processes, which may, when crystallized at the individual level, precipitate a subjectively insightful account of the prodromal illness experience. (shrink)

Comment le jeune Hegel définit-il la notion du positif, ainsi que le concept de positivité? Pour quelles raisons insiste-t-il tellement sur la critique du judaïsme et du christianisme dans ses écrits des années 1790-1800, en se fondant sur une conception novatrice de la positivité? Ce livre essaie de mettre en perspective à travers la lecture de certains textes, que la positivité est pour le jeune Hegel, la perte de la part de l'être humain de la maîtrise de sa propre vie, (...) la privation de l'autonomie du sujet au profit de l'autonomisation du monde des objets, aussi bien que l'asservissement des personnes à des lois et à des forces, lesquelles leur sont étrangères et hostiles. Ainsi cet ouvrage propose de comprendre la positivité, tantôt comme l'extension des rapports mutilés entre l'être humain, le monde et la nature, tantôt comme le prodrome du concept de l'aliénation. (shrink)

Psychotic-like experiences are a phenomenon that occurs in the general population experiencing delusional thoughts and hallucinations without being in a clinical condition. PLEs involve erroneous attributions of inner cognitive events to the external environment and the presence of intrusive thoughts influenced by dysfunctional beliefs; for these reasons, the role played by metacognition has been largely studied. This study investigates PLEs in a non-clinical population and discriminating factors involved in this kind of experience, among which metacognition, as well as psychopathological features, (...) seems to have a crucial role. The aim of this study was to extend the knowledge about the relationship between metacognition, psychopathology, and PLEs, orienting the focus on metacognitive functioning. The sample consisted of 207 Italian participants voluntarily recruited online, who gave consent to participate in the study. The average age of the sample was 32.69 years. Subjects affected by psychosis, neurological disease, and drug addiction were excluded from the analyses. The following scales were used to investigate PLEs: Peters et al. Delusions Inventory, Launay-Slade Hallucinations Scale-Extended Revised, Prodromal Questionnaire-Brief, and Revised Hallucination Scale. To assess general psychopathological features, the Behavior and Symptom Identification Scale was administrated. The Metacognition Self-Assessment Scale was chosen to evaluate metacognitive functioning. From hierarchical regression analyses, it emerged that the presence of anxiety, depression, and impulsive/addictive symptoms constitute a remarkable vulnerability factor for PLEs, in line with previous evidence regarding the relationship between general psychopathology and PLEs. Metacognition negatively predicts PLEs, and its presence does not affect the significance of psychopathological variables, suggesting that metacognitive abilities seem to play a protective role for the occurrence of PLEs among non-clinical individuals, and such ability operates as an independent predictor along with other variables. These results are explained by the role of metacognitive functions, which allow individuals to operate many mental processes such as interpreting sensorial events as real or illusory, understanding behaviors, thoughts, and drives of others, and questioning the subjective interpretation of facts. (shrink)

Drawing upon core phenomenological contributions of the last decades, the present paper provides an integrated description of the development of auditory hallucinations in schizophrenia. Specifically, these contributions are the transitional sequences of development of psychotic symptoms of schizophrenia as envisioned by Klosterkötter and rooted in the basic symptoms approach, Conrad’s Gestalt-analysis of developing psychosis, and Sass and Parnas’ self-disturbance approach. Klosterkötter’s contribution provides a general descriptive psychopathological approach to the transitional sequence of the development of auditory hallucinations. The key concepts (...) in Conrad’s proposal are discussed, as their role is central as driving forces of the process from non-psychotic symptoms to overt hallucinations. Finally, Parnas and Sass link psychiatry to philosophy and psychology, and provide an in-depth and thorough description of these phenomena in their work on schizophrenia as a disorder of consciousness and self-experience with hyper-reflexivity and diminished self-affection as key aspects. (shrink)

Psychiatric disorders like eating disorders might be underpinned by differences in decision making. However, little previous research has investigated this potential relationship using longitudinal data. This study aimed to understand how components of decision making measured by the Cambridge Gambling Task in the United Kingdom’s Millennium Cohort Study at age 11 might explain clusters/types of ED prodrome involving body dissatisfaction, intention to lose weight, dietary restraint, excessive exercise and significant under/overweight measured in the MCS at age 14. Latent class (...) analysis revealed two groups within the cohort: a non-prodromal eating pathology group, who were more likely to be of “average” weight, according to the UK90, with minimal disordered attitudes and behaviors in relation to eating and weight; and a second group with prodromal eating pathology, who had more body dissatisfaction, a desire to lose weight, were using dietary restriction and exercise to influence weight and were more likely to be “overweight” according to the UK90. Logistic regression showed that, after adjustment for confounding, higher risk-taking scores were associated with a 60% greater probability of being in the prodromal eating pathology group, and higher scores on quality of decision making were associated with a 30% lower probability of being in the prodromal eating pathology group. Helping young people to engage in moderate risk taking and improving decision making might reduce the later presence of ED prodromes. (shrink)

The concept of atmosphere today has raised the interest of various academic disciplines, including phenomenological philosophy and psychiatry. In this chapter, I will first present the phenomenon of atmosphere (from the Greek ‘atmos’ = “vapour”, and ‘sphaire’ = “sphere”), highlighting its main conceptualizations. The concreteness of this phenomenon is evident, but the problem is that every time we theorize it, somehow, we denature its essence. The most reliable way to appraise atmospheres is to rediscover the field of situationality. Then, through (...) the analysis of the main act of the phenomenological method, the epoché, I will illustrate a peculiar affinity with the phenomenon of atmosphere, exploring the psychopathology of prodromal experiences of psychosis. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reifying Relevance in Mild Cognitive Impairment:An Appeal for Care and CautionJanice E. Graham (bio) and Karen Ritchie (bio)KeywordsAlzheimer’s disease, construction, dementia, market forces, mild cognitive impairmentWe thank the reviewers for their thoughtful comments that probe shadowy areas in our argument, and we welcome this opportunity to elucidate our position. First, we are not repudiating the natural and social facts of pathologic brain degeneration and the physical and cognitive impairments (...) that manifest in people affected by dementia disorders. We are, however, questioning the epistemology, politics, and persistence by some to harden the construct of mild cognitive impairment (MCI) prematurely as a "natural" precursor to dementia. We suggested insufficiencies in viewing MCI as prodromal to Alzheimer's disease (AD; Graham and Ritchie 2006, 36), and pointed to evidence for the prognostic irrelevance of some MCI subcategories (35). The commentators have read our manuscript as suggesting that AD and MCI are different kinds, and that a diagnosis of AD is more "real" than that of MCI. But AD is also fraught with classification issues, as we describe in the section of our paper that deals with consensus committees, published practice guidelines, and the determination of treatment efficacy. Like MCI, AD is a heterogeneous condition, but unlike MCI, AD is a constructed practical kind that does some "work" beyond essentialist (neural degeneration, brain atrophy) claims. Its criteria identify people with well-defined dementia symptoms and multiple cognitive and functional impairments who are in need of, and benefit from, support. Even with these criteria, however, there have been great attempts to achieve definitional accuracy in dementia diagnoses. Practical refinements to the differential diagnosis of dementia based on solid research evidence have made way for more specific recognitions of vascular dementias, dementia of the Lewy body type, and other subtypes beyond AD. So AD too has been subject to more careful, more cautious operationalization in recent years, with research supporting multiple factors and the comorbidity of several types (kinds) of dementia in any one individual.Our paper takes up concerns that are not resolved for dementia and suggests that the nascent category of MCI is still so insufficiently defined as to be ambiguous, and as such, is in danger of identifying individuals with what will be, and has [End Page 57] already been, linked to a debilitating and deeply stigmatizing and fatal disorder (AD). We are not contesting the reality that some people begin to display early signs of cognitive loss, nor are we suggesting that symptoms be ignored; as researchers, we stand behind the careful tracking of symptoms and signs in patients and research participants as an essential clinical and research practice. In a era where the public has been made wary of the potentially fatal effects of new treatments whose more careful scrutiny in specific populations would have saved lives (e.g., Fontanarosa, Rennie, and DeAngelis 2004; Psaty and Furberg 2005), and made all the more popular by what Kramer coined "diagnostic bracket creep" (1993, 15), we are questioning the drivers and value of a premature diagnostic classification whose definitional accuracy is neither sufficient nor effective for specific identification of individuals.That matters of fact are constructed does not take away from their natural fact. Some people have subjective reports or show objective evidence of cognitive decline while having preserved activities of daily living—the construction of this evidence indicates they are not normal and they are not demented. Based on such evidence, where then does the balance of probability for MCI lie? A multidisciplinary international group of experts gathered in Stockholm in 2003 to discuss MCI concepts (Winblad et al. 2004). They acknowledged that the heterogeneous etiology of MCI contributes to "some confusion concerning the specific boundaries of the condition", stating that this "not normal, not demented" condition is nonetheless "useful both clinically and as a research entity" (p. 241). Importantly, they concluded that MCI needs "better definition" (p. 246). It was at this stage that we first wrote our manuscript, and in the subsequent two years we have eagerly awaited new studies, and the recognition of flexible, practical subtypes to evolve.We state "that MCI cannot be considered to be a separate clinical entity" (Graham and... (shrink)

In psychiatry there is no sharp boundary between the normal and the pathological. Although clear cases abound, it is often indeterminate whether a particular condition does or does not qualify as a mental disorder. For example, definitions of ‘subthreshold disorders’ and of the ‘prodromal stages’ of diseases are notoriously contentious. -/- Philosophers and linguists call concepts that lack sharp boundaries, and thus admit of borderline cases, ‘vague’. Although blurred boundaries between the normal and the pathological are a recurrent theme in (...) many publications concerned with the classification of mental disorders, systematic approaches that take into account philosophical reflections on vagueness are rare. This book provides interdisciplinary discussions about vagueness in psychiatry by bringing together scholars from psychiatry, psychology, philosophy, history, and law. It draws together various lines of inquiry into the nature of gradations between mental health and disease and discusses the individual and societal consequences of dealing with blurred boundaries in medical practice, forensic psychiatry, and beyond. -/- Part I starts with an overview chapter that helps readers to navigate through the philosophy of vagueness and through the various debates surrounding demarcation problems in the classification and diagnosis of mental illness. Part II encompasses historical and recent philosophical positions on gradualist approaches to health and disease. Part III approaches the vagueness of present psychiatric classification systems, and the debates concerning their revisions by scrutinizing controversial categories, such as posttraumatic stress disorder, and the difficulties of day-to-day diagnostic and therapeutic practice. Part IV finally focuses on social, moral, and legal implications that arise when being mentally ill is a matter of degree. (shrink)

In psychiatry there is no sharp boundary between the normal and the pathological. Although clear cases abound, it is often indeterminate whether a particular condition does or does not qualify as a mental disorder. For example, definitions of ‘subthreshold disorders’ and of the ‘prodromal stages’ of diseases are notoriously contentious. Philosophers and linguists call concepts that lack sharp boundaries, and thus admit of borderline cases, ‘vague’. This overview chapter reviews current debates about demarcation in psychiatry against the backdrop of key (...) issues within the philosophical discussion of vagueness: Are there various kinds of vagueness? Is all vagueness representational? How does vagueness relate to epistemic uncertainty? What is the value of vagueness? Given the immense social, moral, and legal importance of demarcating the normal from the pathological in psychiatry, what are the pros and cons of gradualist approaches to mental disorders, that is, of construing boundaries as matters of degree? (shrink)

A prevailing issue in clinical research is the duty clinicians have to treat or prevent the progression of disease during a study that they are conducting. While all clinical researchers have a duty of care for the patients who participate in clinical research, intervening at the onset or progression of disease may skew results and have a negative impact on the scientific validity of a study. Extreme examples of failures to intervene can be found in the Tuskegee syphilis study and (...) in an attempt to determine if cervical smears were an accurate predictor of cancer, which was uncovered by the Cartwright Inquiry. However, the issue arises in all research where delay in intervention can cause harm. A current study in Singapore is investigating the significance of an ‘ultra-high risk’ state that may constitute the prodromal phase of psychosis. This project called ‘The Longitudinal Youth at Risk Study’ is potentially contentious because it is recruiting young people who are identified as being ‘at risk’ of developing psychosis. In this paper, the decision to offer treatment to all participants as well as a fast track for those who are assessed to have developed serious mental illness into treatment is discussed. It is argued that this approach is ethically justified because of the duty of care that is owed to research participants, and suggests that the principle of equipoise may be used to guide intervention decisions in other clinical research protocols. (shrink)

Humans can consolidate and carry out habits other animals cannot. This statement is mainly sustained by the fact that humans have a unique cognitive control of their actions: we can let our attention fade away to perform automatic tasks more efficiently, we can detect if there has been an unexpected problem in their implementation, and we can regain conscious control of the action if necessary. We tend to dichotomize this cognitive process into two “systems”, namely goal-directed versus habitual (Dickinson, 1985), (...) conscious versus unconscious (Crick and Koch, 1998), or slow versus fast (Kahneman, 2011). If we just put it in those terms, these two ways of tackling the challenges of a changing environment seem to be present in non-human animals. However, all dichotomies imply a difficulty to deal with: the regulation of the transition between the two systems. Is this carried out by a third element, or regulated by one of the systems? Could it be more convenient to view it as a continuum, rather than a dichotomy? In any case, we believe this transition has a level of complexity in humans that makes it qualitatively different from its analogue in animals. In fact, this ‘cognitive bridge’ might be a major feature to characterize a reliable behavior, since a particular task or problem is more efficiently tackled when the transition between the two systems is more adequate. Moreover, the integrity of this link could be an indicator to detect prodromal psychiatric conditions, as it has been suggested for slips-of-action (Gillan et al., 2011). In order to justify these ideas, we will focus first on Kahneman’s distinction between systems 1 and 2 (Kahneman, 2011). On the one hand, System 1 is responsible for making decisions rapidly. The purpose of this system is to give us an assessment of the environment around us as quickly as possible so that we are able to respond as fast as possible. To perform this task, System 1 follows general rules or guidelines (heuristics). In all, System 1 is intended to help us make decisions more quickly, and is very useful (let’s say ‘just fine’) in most cases. However, one of the characteristics of these decisions is the lack of voluntary control, what is a problem considering this system is responsible of many of the decisions and judgments we make. Given to its “automatic” nature, System 1 also has biases and systematic errors that are likely to happen in some situations.On the other hand, System 2 acts when a problem which System 1 has no solution for arises. System 2, apparently, can take control of the whole process at any time. It is somewhat triggered by some external or internal alarm that draws its attention and makes it take “conscious” control of the situation. One of the problems of this system is that it is lazy and can be easily exhausted. Therefore, it usually accepts the decisions of System 1 without monitoring them. One proof of System 2’s negligence is what Kahneman calls WYSIATI ("What You See Is All There Is"), a general rule that “facilitates the achievement of coherence and of the cognitive ease that causes us to accept a statement as true”. System 1 easily gets that coherence, and System 2 usually allows it to jump to conclusions and act. In different sets of experiments, Kahneman demonstrates that humans are not good at all with statistics or handling mathematics; in his opinion, this is because humans simplify judgments to make them more understandable and deal with them just through heuristics that System 1 can handle. This general view of humans as poor rational decision-makers is also supported by other authors (see, for example, Ariely, 2008).In our opinion, this division of human cognition into two systems fits well with the usual opposition between goal-directed versus habitual systems (Dickinson, 1985). In general, goal-directed actions are viewed as conscious, flexible, and sensitive to outcome devaluation, whereas habits are mainly unconscious, rigid and insensitive to changes in the value of the outcome. The features of goal-directed and habit systems were mainly drawn from studies in animals. The typical experiment about this subject consists on teaching the contingency between an instrumental action (for example, a lever press) and a reward to the animal (Adams and Dickinson, 1981). At the beginning, the animal’s behavior is goal directed, and it performs the action to obtain the reward. However, this behavior becomes “habitual” (in this context, a motor routine) after many repetitions. When that happens, the value of the reward is transferred to the lever press itself: even though the outcome is devalued (gets the animal sick) or the animal is sated, it keeps pressing the lever. This is why habits have been opposed to goal-directed behavior.A quick look suggests that habits and goal-directed actions are intimately related to Systems 1 and 2, respectively. This is also supported by the identification of the goal-directed system with a model-based reinforcement learning scheme, since it can be viewed “in terms of sophisticated, computationally demanding, prospective planning, in which a decision tree of possible future states and actions is built using a learned internal model of the environment” (Dolan and Dayan, 2013). The habitual system, on the other hand, follows a model-free scheme, which “is computationally efficient, since it replaces computation (i.e., the burdensome simulation of future states) with memory (i.e., stored discounted values of expected future reward); however, the forward-looking nature of the prediction error makes it statistically inefficient” (Dolan and Dayan, 2013). Following these analogies between systems, we can assume that some actions that at the beginning fall under the domain of System 2 might be transferred to System 1 through learning, like goal-directed actions become habits through experience.Concerning the neural bases of these systems, the striatum and its cortical afferents and –indirect– target areas in the cortex play a major role. It is widely accepted that the cognitive part of the striatum –caudate nucleus and anterior putamen– are involved in the planning and execution of goal-directed actions, together with the prefrontal cortex (Balleine et al., 2007). On the other hand, the sensorimotor striatal aspects –mainly the posterior putamen– and the supplementary motor area of the cortex are particularly active when the agent is performing a well-learned action (Ashby et al., 2010; Miyachi et al., 2002). Furthermore, the activity of the neurons in these areas follows a “chunked” pattern: they are mainly active at certain stages of the motor routine (for example at the beginning and the end of the sequence, when a particular switch or turn is needed, etc), and this activity is reduced in the rest of the motor sequence (Graybiel, 1998). Although some authors question a sharp neuroanatomical basis of Kahneman’s Systems 1 and 2 (Gold and Shadlen, 2007), our train of thought in this manuscript suggests that the more reflective System 2 should be based in the prefrontal cortex –both dorsal and ventral–, and the cognitive regions of the basal ganglia. Likewise, the more automatic System 1 would lie on motor and premotor cortical regions, as well as on the sensorimotor aspects of those subcortical nuclei.This neuroscientific framework identifies the habit system with automaticity, rigidity and unconsciousness; however, we are intending to challenge this view in past and forthcoming contributions (Bernacer et al., 2014; Bernacer and Gimenez-Amaya, 2013). In a nutshell, we propose to view the phenomenon of action from the point of view of the agent as a whole, and not from an isolated movement. Hence, it could be more convenient to understand System 1 –or habits– as a resource of System 2, rather than as opposed systems in competition. Whereas a motor routine (i.e., what is commonly called “habit” in neuroscience) implies the sequential and unconscious performance of movements, they usually pursue the goal set by the agent. In fact, the more engrained the routine is, the easier for the agent to achieve that goal. Furthermore, the agent can consciously stop or correct the movement at any point, since the habit releases the higher cognitive regions of the brain to improve the performance of the action. A very simple example of this is a tennis service, which should be “goal directed” to place the ball wherever the player wants. It involves a set of movements such as throwing the ball upwards, moving the feet, putting the arm back, etc. Only when these motor routines are learned correctly, the player is able to concentrate on other aspects of the service such as the speed, spin, or exploiting the weaknesses of the receiver. This can be also exemplified with other kinds of habits such as driving, playing an instrument, tackling a mathematical problem, and so on. They all suggest that “automatic” routines are governed by higher cognitive functions to better achieve a particular goal.Kahneman’s Systems 1 and 2 allow as well this release of consciousness from everyday decisions to focus on more complicated situations. As Kahneman himself and other authors defend (Ariely, 2008), the problem arises when System 2 is rarely used or either system is applied to inadequate situations. However, we believe that the most effective agent does not exclusively rely on System 2, but efficiently uses all resources of ‘each system’ in the right situation and, more importantly, carries out an appropriate transition between them. That is, in our opinion, a ‘rational’ agent. This could be also said about goal-directed and habitual systems. Moreover, we believe that this transition between systems is subject to learning, and it can be performed more effectively through experience.If we understand these fragmentations of cognition as independent systems in competition, we encounter an important problem: is there an additional mechanism in charge of the transition between systems, or is this regulated by one of the systems itself? If the first option were true, we would find the difficulty of defining the nature –both conceptually and anatomically– of a “third system” qualitatively different than the other two. This would lead us to an ad infinitum process –the need of a fourth element to regulate the activity of the third, and so on–, and therefore we believe this hypothesis should be rejected. Considering the second option, it seems that only the highly cognitive System 2 could be in charge of leading the transition between systems, which in turn dissolves a rigorous separation in two systems. The role of System 2 in leading the transition is clear when the agent decides to regain conscious control of a task generally performed in an unconscious manner. In this sense, the interaction of the orbitofrontal cortex with either the cognitive or sensorimotor aspects of the striatum plays a central role in shifting between goal-directed actions and motor routines (Gremel and Costa, 2013). In other situations, an external cue such as an error may set the alarm for System 2 to retake control of the action. Regarding this, the anterior cingulate cortex has been reported to be active in highly-conflictive decision making situations (Goñi et al., 2011); for that reason, some authors relate this cortical area with error monitoring (Carter, 1998; Botvinick et al., 2004). A recent report suggests a new model of reinforcement learning and conflict monitoring, which involves a wide network including different areas of the cortex (posterior parietal, precentral, anterior cingulate and prefrontal) and the basal ganglia (Zendehrouh et al., 2013).To sum up, this opinion article suggests viewing Kahneman’s systems as analogous to the goal-directed/habits dichotomy in order to improve the understanding of some aspects of human cognition. Further, we believe a strict separation between systems in competition is problematic, since System 2 is always in charge of governing the interplay between systems: therefore, System 1 –or habits– should be understood as a resource of System 2. This view could shed some light on the understanding of habits as a source of learning, plasticity and freedom for the agent. Finally, an inappropriate cognitive control of habits could be an indicator of certain psychiatric conditions. (shrink)

Elucidating distinct morphological atrophy patterns of Alzheimer’s disease and its prodromal stage, namely, mild cognitive impairment helps to improve early diagnosis and medical intervention of AD. On that account, we aimed to obtain distinct patterns of voxel-wise morphological atrophy and its further perturbation on structural covariance network in AD and MCI compared with healthy controls. T1-weighted anatomical images of matched AD, MCI, and HCs were included in this study. Gray matter volume was obtained using voxel-based morphometry and compared among three (...) groups. In addition, structural covariance network of identified brain regions exhibiting morphological difference was constructed and compared between pairs of three groups. Thus, patients with AD have a reduced hippocampal volume and an increased rate of atrophy compared with MCI and HCs. MCI exhibited a decreased trend in bilateral hippocampal volume compared with HCs and the accelerated right hippocampal atrophy rate than HCs. In AD, the hippocampus further exhibited increased structural covariance connected to reward related brain regions, including the anterior cingulate cortex, the putamen, the caudate, and the insula compared with HCs. In addition, the patients with AD exhibited increased structural covariance of left hippocampus with the bilateral insula, the inferior frontal gyrus, the superior temporal gyrus, and the cerebellum than MCI. These results reveal distinct patterns of morphological atrophy in AD and MCI, providing new insights into pathology of AD. (shrink)

There are complex considerations when planning to disclose an attenuated psychosis syndrome diagnosis. In this review, we evaluate ethical, legal, and clinical perspectives as well as caveats related to full, non- and partial disclosure strategies, discuss societal implications, and provide clinical suggestions. Each of the disclosure strategies is associated with benefits as well as costs/considerations. Full disclosure promotes autonomy, allows for the clearest psychoeducation about additional risk factors, helps to clarify and/or correct previous diagnoses/treatments, facilitates early intervention and bolsters communication (...) between providers but there are important considerations involving heritability, comorbidity, culture, and stigma. Non-disclosure advances nonmaleficence by limiting stigma and stress, and confusion in a sensitive developmental period but is complicated by varying patient preferences and the possibility that, as new treatments without adverse effects become available, the risk with false positives no longer justifies the accompanying loss of autonomy. Partial disclosure balances ethical considerations by focusing on symptoms instead of labels, but evidence that laypersons may interpret this information as a pseudo-diagnosis and that symptoms alone also contribute to stigma limits the efficacy of this approach. In addition, there are notable societal considerations relating to disclosure involving conservatorship, the reach of insurance companies, and discrimination. We advocate a hybrid approach to disclosure and recommend future research aimed at understanding the effects of stigma on clinical course and a renewed focus on those help-seeking cases that do not transition but remain clinically relevant. (shrink)

Research focused on the prodromal period prior to the onset of psychosis is essential for the further development of strategies for early detection, early intervention, and disease pre-emption. Such efforts necessarily require the enrollment of individuals who are at risk of psychosis but have not yet developed a psychotic illness into research and treatment protocols. This work is becoming increasingly internationalized, which warrants special consideration of cultural differences in conceptualization of mental illness and international differences in health care practices and (...) rights regarding research participation. The process of identifying and requesting informed consent from individuals at elevated risk for psychosis requires thoughtful communication about illness risk and often involves the participation of family members. Empirical studies of risk reasoning and decisional capacity in young people and individuals with psychosis suggest that most individuals who are at-risk for psychosis can adequately provide informed consent; however ongoing improvements to tools and procedures are important to ensure that this work proceeds with maximal consideration of relevant ethical issues. This review provides a discussion of these issues in the context of international research efforts. (shrink)

According to some currents of modern historiography, Galilei's propensity for circular motion would have led him to consider this and not rectilinear motion as “natural motion”; therefore the principle of inertia could not be fully attributed to Galileo, which he would never have formulated. The question of the authorship of the principle of inertia certainly weighs on both nationalistic elements and returns of antigaleleism, while the question of its not explicit formulation as a principle is due to ignorance of the (...) type of organization that Galileo intended to give to the exposition of his physics. The author, after having hinted at possible prodromes of the principle of inertia and having reported the adverse opinions of illustrious historians of science (A. Koyré, I. B. Cohen, P. M. Duhem, P. Rossi, G. Holton), through a careful analysis of the Galilean writings, conducted on the digital versions with the help of text analysis programs, firmly reaffirms Galileo's authorship of the principle of inertia and the consequent principle of classical relativity. (shrink)

Some limitations of ‘category work’ in the history of psychiatry are illustrated via the example of attempts within US alienism and psychiatry since 1889 to identify psychosis and its prodromes. A slowly evolving acceptance of the need for specifiable biological disease concepts, distinct diagnostic categories and defined boundaries of the ‘before and after’ of psychosis among some elite physicians challenged widespread vernacular methods of diagnosis expressed as intuition, feelings or scent as well as local practices of creating novel placeholder terms (...) ‘as needed’ or using question marks to express liminality or confusion. When ‘error of diagnosis’ emerged as a concern circa 1909, the professional transformation of this ‘scientific self of subjectivity’ of the psychiatrist into a ‘scientific self of objectivity’ eventually resulted in the turn to numerical judgments based on rating scales for psychotic symptoms. However, rating scales do not ‘count’ anything at all and exist as instruments of liminality between subjective clinical opinion and the affection of objectivity that quantification symbolizes. (shrink)

In dementia research evidence is mounting that therapeutic strategies that target moderate and even mild Alzheimer's disease may be missing the ‘therapeutic window’. Given that the neuropathology that leads to Alzheimer's disease probably begins somewhere between 10 and 15 years before symptoms manifest, many believe that the optimal therapeutic strategy would target persons in the earliest phases of disease development or even earlier. This would include, for example, persons with prodromal Alzheimer's and even persons who are deemed at risk. Given (...) the nature of research involving the central nervous system, it is conceivable that some therapeutic investigations may involve an increase over minimal risk. This paper examines how, in dementia research, at-risk persons, although healthy, bring multiple and intersecting vulnerabilities to the prospect of research participation even though they are clinically healthy. Current guidelines for research ethics may not provide adequately for the nuances of ‘healthy individuals’ and their possible vulnerabilities. In the context of neurodegenerative disease, the fact of being ‘at risk’ alters the vulnerability profile in significant ways. While healthy persons who are at risk of developing dementia may not appear to warrant placement in the research category of vulnerable participants (alongside prisoners, pregnant women and children) careful regard for the vulnerabilities that arise as a result of the intersecting circumstances of being healthy and at risk of an incurable disease are worthy of increased attention and consideration, particularly as the research effort for the increasingly prevalent disease of Alzheimer's moves forward. (shrink)

The proposal of the new criteria for the diagnosis of Alzheimer’s disease based on biomarker data is making possible a diagnosis of AD at the mild cognitive impairment or predementia/prodromal– stage. Given the present lack of effective treatments for AD, the opportunity for the individuals to personally take relevant decisions and plan for their future before and if cognitive deterioration occurs is one the main advantages of an early diagnosis. Advance directives are largely seen as an effective tool for planning (...) medical care in the event the subject becomes incompetent. Nevertheless, their value has been questioned with regard to people with dementia by scholars who refer to the arguments of personal identity and of patient’s changing interests before and after the onset of dementia. In this paper, I discuss the value of advance directives in Alzheimer’s disease and other kind of dementia. Despite critics, I argue that advance directives are especially advisable in dementia and provide reasons in favor of their promotion at an early stage of the disease as a valuable tool to respect patients’ values and preferences on medical treatment, including participation in research and end of life decisions. I mainly support advance directives that include both decisions regarding health care and the appointment of an attorney in fact. I conclude that patients with AD at a prodromal or early stage should be offered the opportunity to execute an advance directive, and that not to honor a demented individual’s directive would be an unacceptable form of discrimination towards those patients. (shrink)

This book presents an innovative and thought-provoking argument regarding the foundations of politics and its ethical implications, exploring the difference between what politics is (and/or can be) and what it is not (and/or cannot be). It distinguishes between two fundamental forms of political poverty, namely ontological poverty and theoretical poverty. Ontological poverty depicts the negative foundation upon which the political relies—an absence that, paradoxically, underpins the political existence. In contrast, theoretical poverty emerges when this ontological datum is self-delusively denied by (...) politics itself, leading to the loss of political properties of politics, or political poverty, and the resulting dehumanisation of the political subject. Drawing on Aristotelian logic, the volume discloses the aporetic condition of political ontology, deploying phenomenological inquiry through deconstruction. Through close readings of Kafka, Agamben, Derrida, Levinas, and Schmitt among others, it maps the porous threshold between the political and the non-political, illuminating how this tension—between being and becoming—is conditional to politics itself and simultaneously the site of its potential impoverishment. In this context, theoretical poverty is recognised as the prodromic moment when politics ceases to carry its own name, severing its ties to the ethical and ontological relations that sustain it. This work makes a significant contribution to contemporary debates in political philosophy, political theory, political ontology, and ethics. It will particularly appeal to scholars engaged with continental philosophy and literary theory. It opens a new avenue of inquiry into the political foundations by questioning what politics is and what it risks not becoming. (shrink)

IntroductionThis study aimed to evaluate, in adults with mild cognitive impairment, the brain atrophy that may distinguish between three AT biomarker-based profiles, and to determine its clinical value.MethodsStructural MRI was employed to evaluate the volume and cortical thickness differences in MCI patients with different AT profiles, namely, A−T−−: normal AD biomarkers; A+T−−: AD pathologic change; and A+T++: prodromal AD. Sensitivity and specificity of these changes were also estimated.ResultsAn initial atrophy in medial temporal lobe areas was found in the A+T−− and (...) A+T++ groups, spreading toward the parietal and frontal regions in A+T++ patients. These structural changes allowed distinguishing AT profiles within the AD continuum; however, the profiles and their pattern of neurodegeneration were unsuccessful to determine the current clinical status.ConclusionsMRI is useful in the determination of the specific brain structural changes of AT profiles along the AD continuum, allowing differentiation between MCI adults with or without pathological AD biomarkers. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mild Cognitive Impairment Is RelevantRonald C. Petersen (bio)Keywordsaging, Alzheimer’s disease, dementia, mild cognitive impairment, pharmaceutical industryGraham and Ritchie (2006) have contributed a scholarly document that implores us to reexamine nosological categories and certain diagnostic outcomes. They have chosen mild cognitive impairment (MCI) as the target of their scrutiny and have raised several interesting issues. I would like to comment on their approach and suggest that MCI is a useful (...) clinical entity that does serve a practical function and hopefully will lead to a better quality of life for aging persons.There are several clarifications concerning the construct of MCI that need to be emphasized. Graham and Ritchie have asserted that all persons with MCI eventually evolve to Alzheimer's disease (AD) and have claimed that this is the inevitable outcome of the disorder. Although it is true that many of the early studies on MCI focused on the amnestic subtype as a precursor to AD (Bennett et al. 2002; Ganguli, Dodge, Shen, and DeKosky 2004; Lopez et al. 2003; Petersen et al. 1999), subsequent work has expanded the construct to include prodromal forms of other disorders (Petersen 2004; Winblad et al. 2004). As such, the construct of MCI has become flexible in recent years to account for alternative types of intermediate cognitive impairment.The authors state that MCI addresses those individuals speculated to have an inevitable dementia. Certainly, we do not presume that dementia is inevitable in the aging process; rather, we posit that if certain criteria are fulfilled in persons who are aging, the likelihood of a person progressing to a certain type of dementia is quite high. As such, this is an important precondition about which to learn, because interventional strategies may be available.Graham and Ritchie argue that some cognitive changes with aging are "normal" and trying to classify these individuals as "abnormal" is performing a disservice to much of the aging population. We draw an important distinction between the cognitive changes of normal aging, as they are recognized to exist, and what we feel constitutes the pathologic changes of MCI. We believe that the abnormal cognitive function found in MCI has a high probability of progressing to a greater degree of cognitive dysfunction in a relatively short period of time and these behavioral changes are accompanied by pathologic brain changes that are manifested on magnetic resonance imaging scans, positron emission tomography scans, cerebrospinal fluid biomarkers, and autopsy studies (Hampel et al. 2004; Jack et al. 1999; Markesbery et al. [End Page 45] 2006; Petersen et al. 2006). This type of progression is in contradistinction to other individuals who are experiencing cognitive changes of normal aging. These individuals do not progress rapidly to greater degrees of impairment and autopsy studies reveal that their brains do not harbor the pathologic changes found in the MCI population (Knopman et al. 2003).The cognitive and behavioral changes accompanying persons with MCI are devastating and cannot be ascribed to "senility" or "He is just getting old." It is a mistake to imply that by labeling people with a condition such as MCI we are doing them a disservice. Most of these individuals are seeking medical attention for their perceived difficulties. Consequently, addressing these concerns and educating the individuals on the implications of their symptoms are important services. Although we may not have adequate therapies at present, this does not imply that we should ignore the symptoms.We cannot treat many conditions at present, yet we do not avoid the opportunity to characterize the condition and make a diagnosis. Even if this were part of the aging process, this does not mean that we should ignore the disability and refuse to treat it. Most individuals develop an inflexibility of their optical lenses as they age, yet corrective lenses of one type or another are believed to be extremely beneficial at alleviating this disability associated with the aging phenomenon. No one would argue that it is inappropriate to treat this condition because it is "just a part of aging."It should be noted that I have stressed the situation in which individuals are seeking medical attention for their cognitive concerns. It is quite a different situation if an... (shrink)

The semantic fluency task is a widely used clinical tool in the diagnostic process of Alzheimer's disease. The task requires efficient mapping of the semantic space to produce as many items as possible within a semantic category. We examined whether healthy volunteers and patients with early Alzheimer's disease take advantage of and travel in the semantic space differently. With focus on the animal fluency task, we sought to emulate the detailed structure of the multidimensional semantic space by utilizing word2vec-method from (...) the natural language processing domain. To render the resulting multidimensional semantic space visually comprehensible, we applied a dimensionality reduction algorithm, which enabled a straightforward division of the semantic space into sub-categories. Moving in semantic space was quantified with the number of items created, sub-categories visited, and switches and returns to these sub-categories. Multinomial logistic regression models were used to predict the diagnostic group with these independent variables. We found that returning to a sub-category provided additional information, besides the number of words produced in the task, to differentiate patients with Alzheimer's dementia from both amnestic Mild Cognitive Impairment patients and healthy controls. The results suggest that the frequency of returning to a sub-category may serve as an additional aid for clinicians in diagnosing early Alzheimer's disease. Moreover, our results imply that the combination of word2vec and subsequent t-SNE-visualization may offer a valuable tool for examining the semantic space and its sub-categories. (shrink)

Youths at risk for psychotic disorders present with indistinct clinical syndromes in the setting of functional difficulties. They frequently seek help from clinical services and possess compelling individual narratives. Clinical outcomes however usually only become clear after a year or two of longitudinal intensive clinical follow-up, as young individuals have diverse and dynamic trajectories, even from seemingly similar starting points. Here, the experience of use of a novel diagnostic method based upon functional MRI in addition to intensive clinical follow-up are (...) described during the time I served as medical director of a prodromal psychosis clinical service in an urban medical center. By combining clinical observation with imaging technology, prediction of longitudinal outcomes, along with opportunity to apply tailored individual clinical intervention, appears feasible. (shrink)

In the hope of future treatments to prevent or slow down the disease, there is a strong movement towards an ever-earlier detection of Alzheimer's disease. In conjunction with scientific developments, this has prompted a reconceptualization of AD, as a slowly progressive pathological process with a long asymptomatic phase. New concepts such as "preclinical" and "prodromal" AD have been introduced, raising a number of conceptual and ethical questions. We evaluate whether these new concepts are theoretically defensible, in light of theories of (...) health and disease, and whether they should be understood as disease or as an at-risk state. We introduce a pragmatic view on disease concepts and argue that an evaluation of the reconceptualization of AD should also take its aims and effects into account, and assess their ethical acceptability. The reconceptualization of AD is useful to coordinate research into preventive strategies, and may potentially benefit future patients. However, in the short term, early detection and labelling of "preclinical AD" can potentially harm people. Since there is no treatment available and the predictive value is unclear, it may only create a group of "patients in waiting" who may suffer from anxiety, uncertainty and stigmatization, but will never actually develop dementia. We conclude that only if the promise of preventive medication materializes, will the reconceptualization of AD turn out unequivocally to be for the better. Otherwise, the reconceptualization may do more harm than good. (shrink)

It is well established by psychopathological research that disorders of self-experience are among the main features of schizophrenic prodromes in a pathogenetic sense. Disorders of the phenomenal self, as "lack of ipseity" (the vanishing of the feeling of being embedded in oneself and of distinctiveness between the self and the outer world) and "hyper-reflexivity" (the monitoring of one's own life entailing the tendency to objectify parts of one's own self in an outer space) are considered key phenomena of schizophrenic vulnerability. (...) In this paper, I argue that the analyses of the disorders of phenomenal self catch only some dimensions of schizophrenic vulnerability, since they mainly focus on the pathological changes in subjective experience of an isolated self and disregard the fact that the self is not purely personal. Because our existence is fundamentally tied to a social existence, the feeling of one's own self and the sense of "reality" of an experience are products of intersubjectivity and not only a private process based on introspection or reflexivity in which one is engaged in an idiosyncratic way. Building on, and extending, contributions of the phenomenological tradition, I attempt to demonstrate that intuitive attunement is the basic prerequisite for establishing one's sense of "reality" (feeling familiarly related to one's environment) and for establishing one's sense of "ipseity" (the sense of existing as a subject of awareness). In the last part of the paper, I show the importance of the concepts "lack of attunement" and "antagonomia" (the rejection of conventional knowledge and intuitive attunement, experienced as dangerous sources of loss of individuality) to establish a comprehensive theory of schizophrenic vulnerability. I finally discuss the implications of this view for empirical research and clinical management of schizophrenic vulnerability. (shrink)

Delusional mood is a well-recognized psychological state, often present in the prodromal stage of schizophrenia. Various phenomenological psychopathologists have proposed that delusional mood may not only precede but also contribute to the later formation of schizophrenic delusion. Hence, understanding experiential abnormalities involved with the delusional mood have been considered central for the understanding of schizophrenic delusion. Ranging from traditional and contemporary phenomenological and neurobiological accounts, it has been often mentioned that the peculiar affective saliency of the world experience may underpin (...) the emergence of delusional mood. In this paper, I employ Edmund Husserl’s account of affection and affective syntheses to clarify the nature of such an experience and illuminate how this experiential abnormality contributes to the emergence of the delusional mood. I conclude by relating the phenomenological account I advance here with a neurobiological account of aberrant salience hypothesis and chart out a possible way toward mutual enlightenment for both approaches. (shrink)

The Covid-19 pandemic has affected not only the health of populations but also their everyday social practices, transformed by orienting to risks of contagion and to health prevention discourses. This paper emanates from a project investigating the impact of Covid-19 on human sociality and more particularly the situated and embodied organization of social interactions. It discusses how Covid-19 impacts the design of ordinary actions in social interaction, how this is made publicly accountable by the participants orienting to the pandemic in (...) formatting their actions and in responding to the actions of others. Adopting an ethnomethodological and conversation analytic perspective, the analyses focus on a particular social activity: paying. The organization of payments in shops and services has been affected by the pandemic, not only by official regulations, favoring some modes of payment over others, but also in how sellers and customers situatedly adapt their practices to imperatives of prevention. On the basis of a rich corpus of video-recorded data, which spans from the pandemic’s prodromes to and after its peak, we show how money transfer is methodically achieved – imposed, negotiated, and readjusted – while variously taking into account possible risks of contagion. Thus, we show not only how pandemics affect social interaction, and how prevention is incarnated in social actions, but also how, in turn, situated solutions implemented by people during the pandemic reveal fundamental features of human action. (shrink)

Individuals diagnosed with conduct disorder (CD) in childhood and adolescence are at risk for increasingly maladaptive and dangerous behaviors, which unchecked, can lead to antisocial personality disorder (ASPD) in adulthood. Children with CD, especially those with the callous unemotional subgroup qualifier (“limited prosocial emotions”/dsm‐5), present with a more severe pattern of delinquency, aggression, and antisocial behavior, all markings of prodrome ASPD. Given this recognized diagnostic trajectory, with a pathological course playing out tragically at the individual, familial, and societal level, (...) and lack of effective remediation via current standards of care, we posit an alternate treatment approach; case‐specific compulsory moral habilitation aimed at rectifying the undeveloped affective domain of adolescents and young adults suffering from these disorders. We begin with a brief historical overview of response to mental illness, review CD and ASPD diagnostic criteria and treatment limitations, and posit a unique neurohabilitative approach that focuses on the absent affective moral development of these populations. Next, we invoke a public health safety argument to justify case‐specific compulsory moral habilitation, discuss neurotechnologies to be considered in treatment, and conclude with ethical considerations and suggestions for further research. (shrink)

Background: Today, many healthcare or dementia organizations, clinicians, and companies emphasize the importance of detection of Alzheimer’s disease in an early phase. This idea has gained considerable momentum due to the development of biomarkers, the recent FDA and EMA approval of three amyloid tracers, and the failure of a number of recent therapeutic trials conducted in the early dementia phase. On the one hand, an early etiological diagnosis can lead to early and more efficacious intervention. On the other hand, it (...) is questioned how early an etiological diagnosis is beneficial to the patient. Here we consider ethical issues related to the process of biomarker testing and the impact on the diagnostic disclosure to patients with mild cognitive impairment due to prodromal Alzheimer’s disease. Methods: A systematic review of the theoretical bioethics literature was performed by using electronic databases. The review was limited to articles published in English between 2003 and 2016. Results: A total of twenty articles were included in our effort to make an analysis of the ethical challenges. One of the biggest challenges was the uncertainty and the predictive value of the biomarker-based diagnosis where patients can be amyloid positive without full certainty whether or when they will develop symptomatic decline due to Alzheimer’s disease. Another challenge was the tension between the right to know versus the wish not to know, the limited efficacy of currently available treatment options, and the opportunities and consequences after receiving such an early diagnosis. Conclusion: Based on the results and the additional comments in the discussion, several unanswered questions emerged. Therefore, careful consideration of all these ethical issues is required before the disclosure of a biomarker-based diagnosis to the patient with mild cognitive impairment due to Alzheimer’s disease. (shrink)

Psychotic and prodromal states are characterized by distortions of intersubjectivity, and a number of psychopathologists see in the concrete I-You frame of the clinical encounter the manifestation of such impairment. Rümke has coined the term of ‘praecox-feeling’, designated to describe a feeling of unease emanating in the interviewer that reflects the detachment of the patient and the failure of an ‘affective exchange.’ While the reliability of the praecox-feeling as a diagnostic tool has since been established, the explanation and theoretical framing (...) of the phenomena is still lacking. By drawing on enactivist approaches to social cognition, the paper will attempt to provide such an explanation. This is relevant, since such an explanation could contribute to a more precise understanding of the phenomena in question and possibly add to our knowledge regarding the link between experiential vulnerability to psychosis and disturbed I-Thou intersubjectivity. (shrink)