Symposium "Psycopathology: back to the future"
F. Resch, P. Parzer, R. Brunner, E. Koch
Dept. of Child- and Adolescent Psychiatry, University of Heidelberg
Developmental psychopathology as a continuously growing field of knowledge provides a new perspective on pathogenetic processes in psychiatry. It provides a conceptual framework for psychopathology, equally based on developmental and clinical psychology and the neurosciences including related disciplines.
Psychiatric Hospital of the University of Heidelberg, Germany
Recent experimental psychopathological work on the pathogenesis of delusion includes the paradigm of Capgras-Syndrome, probabilistic reasoning, and the construction of the interpersonal space investigated by means of the Kelly-grid-technique. However, conclusions for psychotherapeutic intervention remain sparse.
Psychiatric Hospital of Vienna, Vienna, Austria
The paper deals with the conceptual management of psychopathological disorders and tries to compare the pertinent concepts taught in the beginning and the end of the 20th century using the teaching of the school of Vienna as an example. It should be a commentary of a clinician to the basic assumption that these concepts vary not only by the increase of knowledge but by the circular influences between manners to look on, empirical data and the construction of new models. That development happens in a atmosphere which might be more polarizing or more integrative both in general as in particular as well.
O.P. Wiggins, M.A. Schwartz*
Department of Philosophy, University of Louisville, USA; *Department of Philosophy, Tufts University, Boston, Massachusetts, USA
People suffering from schizophrenia lack the capacity to conform to social norms and to enact social roles although they struggle profoundly to come to grips with society's expectations. We call this facet of schizophrenia its "agonomia." We trace this facet to the weakening of the constitution of the world that pervades schizophrenic mental life. The severe weakening of world-constitution undermines the "common sense" of the person with schizophrenia. This loss of common sense entails a loss of the ability to gear into a pre-structured lifeworld that is shared with others.
- Competence to refuse treatment in anorexia nervosa
J.O.A. Tan*, A. Stewart, R.A. Hope
*Department of Child and Adolescent Psychiatry, Berkshire Adolescent Unit, Wokingham Hospital, Barkham Road, Wokingham, Berkshire RG41 2RE; Department of Child and Adolescent Psychiatry, Highfield Unit, Warneford Hospital, Oxford; The Oxford Institute for Ethics and Communication in Health Care Practice, University of Oxford.
The deprivation of an individual of his liberty is a very serious act, but one which is done internationally on a regular basis by mental health professionals using legalised means, the compulsory holding powers. However, due to the seriousness of the removal of a person's freedom, we need to be thoughtful of the basis for this act by psychiatrists, and ask the question: why is mental illness given this unique consideration?
G.A.M. Widdershoven, R.L.P. Berghmans
Dep. Of Health Care Ethics and Philosophy, Maastricht University, The Netherlands
Advance treatment planning for mental illness by way of written advance directives is one of the issues of debate in contemporary psychiatry in a number of western civilised societies. As is well known, there are certain mental illnesses that have periodic features. The most prominent are the manic-depressive psychoses, but we can also think of young chronic schizophrenics.
Senior Research Fellow, Social Sciences Education and Research Centre, Luleå University of Technology, Luleå, Sweden
The aim of this paper is to describe how "home supporters" working in the homes of persons with mental disorder accomplish compliance on behalf of their clients.
Gothenburg University, Sweden
In principle, there seem to be three main ways, in which society can react, when people commit crimes under influence of mental illness.
- Cannabis use correlates with schizotypal personality traits in 232 healthy students.
P. Dumas, C. Gutknecht, M. Saoud, S. Bouafia, J. Dalery, T. d'Amato
EA 1943 Université Lyon I (J. Dalery), CH le Vinatier, 95 boulevard Pinel, 69500 Bron, France
Many reports have evidenced links between cannabis use and schizophrenia and most psychiatrists admit today cannabis use among schizophrenia risk factors. In addition, it has been shown that schizotypal personality disorder [SPD], or even some SPD traits, may be a clinical expression of vulnerability to schizophrenia. The evidence that cannabis use and SPD traits both constitute risk factors for the later development of schizophrenia asks the question of their relationships. The aim of the present study was to examine the association between cannabis use and SPD traits in young healthy French individuals. For this purpose, we have recruited 232 students, aged from 18 to 25 years old, who have completed the Schizotypal Personality Questionnaire [SPQ] and four of the Psychosis Proneness Scales developed by Chapman and colleagues [Magical Ideation Scale: MIS; Perceptual Aberration Scale: PAS; Revised Physical Anhedonia Scale: PhA; and Revised Social Anhedonia Scale: SA]. Subjects were parted into three groups according to cannabis use: Never-Users [NU]; Past or Occasional-Users [POU] and Regular Users [RU].
Mental Health Research Institute Tomsk Scientific Center, Siberian Branch, RAMSci, Russia
For the definitioning of family risk factors and for rendering medical-genetic aid were studied the families of three groups of children. The first group - it's patients of children's mental department of Tomsk psychiatric hospital (126 people). The second group consists on 286 pupils of boarding and secondary schools. The third group is definited in passing of genetical-epidemiological research into schizophrenia in Tomsk region. The age of inspected is 2-17 years. The main part (64%) of patients of children's mental department consists on patients with mental retardation. Among them were differented chromosoming diseases (46,XY, 46 inv 9(p11q12), Turner's syndrome with man's caryotype), monogenical - phenylketonuria, leukodystrophy. Speciality of the family status was in the half of families where parents affected from alcoholism. For these families was taken retrospective medical-genetic counseling (the offspring prognosis). In 40% of researched pupils of school and children of boarding school were found mental disorders - of psychological development, hyperkinetic disorders and other behavioural and emotional disorders with onset specific to childhood or adolescence. The risk factors of there appearing were young age (before 20 years) of parents at their birth, birth of them as the first ones in the family, less number of brother-sisters, incomplete family (more frequently father was absent) and presence of mental disorders in the nearest. More often there were disorders resulting from use of alcohol. "Risk groups" have been formed from brothers-sisters of examined schoolchildren for whom prognosis of appearance of psychopathological signs and conducting of prophylactic measures with the aim of prevention of deviations in health, behavior and learning are possible (the health prognosis). Taking researches of prevalence of schizophrenia in families and population (Tomsk Register of Schizophrenia) showed, that in families of 2850 patients may be 1,5 thousand of children. They are children - "syperphrenycs" and they apply to "risk group". For these children "the health prognosis" is possible with early diagnostics of possible primary symptoms of disease and with taking psychosocial rehabilitation.
P.-A. Tengland, Ph.D.
Department of Health and Society, Linköping university
What mental health is is not an easy question to answer. Is it freedom from mental illness, the ability to think rationally, being self-fulfilled, having a balance between the ego, id and superego, the ability to cope, to feel well, or is it the ability to love and work? The list can be made much longer.
S. Gariboldi, C. Cimmino, C. Balista, M.E. Menini, G. Paulillo, M. Amore, C. Maggini
Institute of Psychiatry, University of Parma
Objective. Results of a one-year-follow up study aimed to find out personality and clinical predictors of response to pharmacological therapy in patients with Panic Disorder are reported.
J.Z. Sadler, M.D.
Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, TX, USA
Heidegger and his students have elaborated the "question of technology" as posing a specifically ontological kind of danger to society. This ontological danger concerns the tendency of technology to shape or unduly influence our ways of thinking, leading to what Heidegger calls "enframing" or the holding of nature in "standing reserve." Technology, from this perspective, tends to assimilate all human action by subjugating all human interests to economic production, material control, and pragmatic problem-solving. Building on Heidegger's, Albert Borgmann's, and other technology theorists ideas, I describe a "technological mode of being" which is characterized, among other ways, as involving a particular and restrictive set of values as ones to live by, and indeed, to assume. These values associated with the technological mode of being include the following (for example): productivity, simplicity, efficacy, efficiency, convenience, economy, disposability. Such values are designed-into technological artifacts, giving us products which make our lives more convenient, productive, efficient, etc. These values can be contrasted with the values characteristic of what one might call the "poietic mode of being"; e.g., values like creativity, tradition, emotional connectedness or intimacy, personal discipline, and the values of nature. The often contradictory nature of technological and poietic values will be noted. The "god" which can "save us" from domination by the technological mode is restitution of the poietic mode and placing technology into its proper role as servant to ultimate human values.
J. Phillips, M.D.
Department of Psychiatry, Yale School of Medicine, USA
Perhaps the most striking feature of contemporary psychiatry is the growing dominance of technical reason in virtually all aspects of the field. This dominance is evident in psychiatric theory, diagnosis, treatment and funding. Several factors have contributed to the technical dominance. One is the recent advances in neuroscience and psychopharmacology. Psychiatry has wanted to identify itself as a medical subspecialty, and advances in neuroscience and psychopharmacology have facilitated the medicalization of the field. Since the rest of medicine has fully embraced technical reason, psychiatry, as it becomes more medical, becomes more technical. Another factor is the predominance of the DSM diagnostic system. The DMS-IV both reflects the technical approach and fosters it. Finally, especially in the U.S. but increasingly in other developed countries, the effort to contain costs has fostered and even demanded a technical approach to psychiatric treatment.
L.S. Berger, Ph.D.
Psychotherapy has been swept along and shaped by the same intellectual, professional, cultural, socioeconomic and political forces that have brought us to a technology-based psychiatry. Yet, although even from its beginnings therapy has mostly succumbed to these various pressures to be conventionally scientific, also since those beginnings there have been signs of a "poietic" counter-force. This humanistic opposition movement, however, while persisting and finding diverse expression within various psychotherapeutic modalities as the field evolved, has been a minority force that has had but scant and fleeting success. A technology-based psychotherapy continues to win the day.
- New Hermeneutic: Clinical Considerations
D. Padro Moreno
Hospital Civil de Basurto (Servicio de Psiquiatría)
This paper focuses in the way hermeneutic 's principles can be translated to clinical praxis. In that sense, it analyze the constructivism social theory of Hoffman, recently appeared in Northamerican psychoanalysis, that presents great similitudes with hermeneutics.
J. Del Meglio
S.S. Psichiatria e Psicoterapia, Università "La Sapienza", Roma
Il rapporto dell'uomo con la natura, con le avversità di una realtà prepotente che lo circondava, è stato fin dalle origini volto a trasformarla. L'uomo ha modificato l'ambiente naturale per adattarlo ai propri bisogni ed alle proprie esigenze. Non si è accontentato del riparo offerto dalla natura agli agenti atmosferici, ma ha pensato di costruirsi una sua casa. Non si è limitato a guardare le stelle, ma ha pensato di andare a staccarle dal cielo. Non si è contentato di credere alle malattie come a manifestazioni di forze soprannaturali incomprensibili, ma ha pensato di poterle conoscere e curare.
G. Di Piazza, M. Nitti, F. Brogi, F. Cernuto, M. Cerretini, M. Del Sole, L. Luccarelli, V. Migliorini., P. Castrogiovanni
Cattedra di Psichiatria, Università degli Studi di Siena
How experience of envie reveals itself at our eyes and how is it possible to delineate an hypotetical typology of the envious man? Since <<typification structures and organizes the field of our experience>> (Schwartz M.A. and Wiggins O.P.), it permits to represent the distinctive features of this feeling as incommunicable, renegaded, rejected as paradoxically evident and not easily hiding. Although the envious man attempts to disguise his feeling, the envie overflows and manifests itself in a "slanting look", in to throw the "evil eye" that now we knock against, now keep us at a distance: the mimic of the envious man is prim, his insincere smile not participated by his eyes is bited between his tooths. His eyes are blushing of hate against the envied person.
Schwartz M.A. and Wiggins O.P.: The first step for clinical diagnosis in psychiatry, J. Nerv. Ment. Dis., 1987
A trip in Japan the author did with a scientific purpose leads him to consider the scientific trip in itself as phenomenon. As a form of scientific trip, the psychiatrist's cultural trip aims to reduce trans-cultural differences to specific symptoms. However, it has its own psychopathology: some travelers become wizened on stereotypes (Gaijin's neurosis), some others bracket their cultural anchorage within the daily life. This kind of reduction changes in depth the observer's point of view. It allows the atmospheric meeting of European and Japanese thoughts by instituting mutual constraint relationships. The traveler questions his/her own culture and find back in his/her Japanese daily-life experience a daily worked-out form of the Westerner phenomenological thought - namely that of Heidegger, Straus, and Merleau-Ponty -. The instituting room of the language within the Freudian unconscious and that of its below are then to be questioned.
GPWP, Landesklinik Teupitz
Concentrating on the aspect of "Pathos" in the term psychopathology and translating it back to "suffering" opens up a field of connections between objective mental symptoms and the more concrete subjective forms of experience. Suffering much more than the meassured pathology is a question for the practical science of therapy. There are growing doubts about the possibility at all to objectify suffering and about the epistemeological status the term "suffering" should gain. Only the subjective ways of individual suffering with mental symptoms are legitimatizing therapeutic actions and as well motivate the patients participation ("Leidensdruck"). On the other hand, psychiatry as a clinical science faces a growing need to develop standardized instruments of objectivation of symptoms and daignoses, especially since the psychiatric community is growing and cannot anymore relate to local traditions and their historical experience. With this, the status of the theory of suffering becomes crucial for the devellopment of moden theoretical psychopathology.
GPWP, Landesklinik Teupitz
What is the relationship between schizophrenia and identity and how does identity change in the course of the illness? - The initial manifestation of schizophrenia, the subsequent treatment in a psychiatric hospital and the breakdown of the social existence demand from the patient initially to formulate a radical redefinition of his/her construction of identity. Aspects of this 'new identity' may be recognized in the contents of higher schizophrenic symptoms (delusions, halluzinations, ego-psychopathology). They represent in some way images of self-other-relationships.
Competing theories try to define mental disorders either as a deviation from functional or behavioral norm, as a loss or reduction of self-determination or free will, or as suffering. We argue that functional deviations cannot by themselves define mental maladies, as they may be irrelevant for everyday life and pose potentially circular question of the ideal norm. A concept of suffering in the absence of a causal outside agent may be a necessary construct to define mental disorders. Problems of the naive and historically contingent empirical foundation of such a concept of suffering are discussed.
Text: There are two models in the scientific understanding of the temporality of melancholy: the first model is the dualism of subjective and objective time, the second the concept of the threefold dimensional time (present, past and future). In my lecture I want to discuss these two models in questioning their efficiency to understand the specific disturbance or disorder the depressive subject is suffering in experiencing time. I want to show that when we prefer the first model for explaining this suffering we have to relate at last to our understanding of natural and social processes of time for "objective time" is the cipher for the specific interrelation of three time conceptions: that of physical, of biological and sociocultural time. So, for example, when we realize or when the patient realizes that he "falls behind" the speed of time (Straus, Gebsattel) we have to ask what time it is he falls behind. But when we prefer the second model for explaining the temporal suffering of the depressive subject we have to relate to our understanding of "biographical time" for this is the space of time in which the subjects time experience is dominated by the past. So when we realize this domination as a "deformation" or even as a "breakdown" of dimensional time (Kraus, Glatzel, Theunissen) we have to ask how we can scientifically describe this deformation as a specific constellation of present, past and future. In my lecture I want to show this specific, "depressive" constellation and, at last, try to explain how this constellation also causes the break between subjective and objective time as ground of the experience of "another time" in melancholical suffering.
- The structure of the communitarian place in a phenomenological view
G. Calvi*, L. Calvi**
*Responsabile della Comunità terapeutica Az. Ospedaliera Fatebenefratelli di Milano
The care, the treatment and the rehabilitation for psychiatric patients, when managed in therapeutic community instead of hospital, they draw the attention not to a clinical place but to a place that can be lived in.
U. O. di Psichiatria di Camposampiero (Pd) AULSS n.15
The Author dwels upon the importance of the henomenological psychopatology as a method necessary to esplore the personal esperiences of the patient.
M. Rossi Monti
In what way did phenomenological psychopathology contribute to the development of community psychiatry in Italy? It certainly didn't do it explicitly. Phenomenological psychopathology's role has always seemed to be quite marginal but, nevertheless, it helped create a setting that actually made the change from a mental hospital-centered to a community-centered model possible. In fact, it's no chance that the father of Italian psychiatric reform (i.e., law 180 passed in 1978), Franco Basaglia, himself had a background in psychopathology. Phenomenological psychopathology, however, didn't appear at the forefront of the anti-institutional ('antipsychiatric') reform movement; rather, it stayed in the background. It was precisely this low-key role that allowed for the opening up of a virtual space between the symptom and the person, based on the analysis of internal experiences. If the socio-genetic/socio-environmental side made up the "manifest content" of community psychiatry in Italy, the psychopathological side was the "latent content" - its profound soul. Refusing to consider mental illness as an inescapable senseless destiny, phenomenological psychopathology advanced that mental illness was, on the contrary, full of sense and, indeed, articulated along a wide range of developing pathways. This was the way that phenomenological psychopathology, begot by Jaspers within the mental hospital system itself, tacitly created the foundations of overthrowing of the mental hospital system in Italy.
Department of Philosophy, University of Warwick, United Kingdom
Important as the ethics of care are in literature, their theoretical structure is insufficiently worked out to engage successfully with some of the key problems in mental health ethics. Philosophy offers various possibilities for extending "care theory", but I favour neo-Aristotelian virtue ethics because recently renewed interest in both classical ethics and in the virtues provide a rich resource for study. I believe that the Aristotelian emphasis on "flourishing" provides a direct link with the ethics of care in a form specifically related to the ethically problematic status of involuntary psychiatric treatment and that Aristotle connects flourishing to proper function in a way which reflects the values by which psychopathological concepts are partly defined, while remaining fully consistent with neuroscientific understandings of the brain.
Department of education and psychology, Linkoping university, Sweden.
This paper concerns the perception of co-operation and work process within psychiatric teams. The main interest concerns the team members' attitudes to and perception of work conditions and co-operation within the teams.
Dept. of Deontology, Ankara Un. Medical Faculty, Ankara, Turkey
By "antiphilosophy", I mean an overall methodological attitude to philosophical activity, in particular towards traditional, for the most part rationalist philosophy. Both conceptually and from a psychological standpoint, the latter is a highly individual-, self- and/or man-centered activity. Considered in connection with such concepts as 'metaphysics', 'speculative philosophy', 'philosophical knowledge claim' and similar others, we must be in a position to psychologically "diagnose" most of philosophical activity as a complex body of rationalizations. Further, philosophy can also be of psychological/psychosocical interest in the light of such concepts as 'wishful thinking', 'utopia' and 'ideology'.
Y. Savenko, L. Vinogradova
Independent Psychiatric Association of Russia, Moscow
We use the concept of antipsychiatry for defining only the nihilistic half of its manifest - its rejection of objectivity of the clinical method, of necessity of biological therapy, of biological nature of psychoses, of psychopathological reality, as well as of the notion of belonging psychiatry and psychiatrists to medicine, but not to police. Although in the 60-80ies psychiatry first of all played the role as social-political couter-reaction to utmost politicized and sociologized image of psychiatry, it was a period of activization of this theme in all its aspects. Antipsychiatry is a particular expression of change of the general scientific paradigm and in its radical form is the expression of antiscientism. Besides direct agressive forms of antipsychiatry there is a huge variety of its latent indirect forms acting in different spheres in non-evident way, so as psychiatrists often condemn their own brain child. Antipsychiatry always acts in the inseparable connection with practice of psychiatric service and the latter - with a definite theory. Shortcomings of psychological, sociological and cultural reductionism and relativism inevitably feed antipsychiaric tendencies. Exclusion from ICD-10 of homosexualism has not been followed by exclusion of other perversions and other forms of psychic pathology. Instead of formation of respectful attitude to mental illnesses and psychic deviation the interests of representatives of individual groups, actually at the expense of others are being "lobbied". As a result, the base of everything that should be opposed, only strengthens. It also refers to re-naming of many psychopathies and even the notion of psychopathy itself. The phenomenological method and the critical ontology of Nikolay Hartman in the most reliable way serve the process of de-mythologization and finding an adequate shape of clinical reality.
Department of Philosophy, University of Warwick, UK
The status of psychopathic disorder has long been a difficult issue for psychiatry. In contrast to the conventional historical analysis of psychopathy, which emphasises a seamless but spurious continuity - thereby supporting a scientifically realist view of the disorder - the work of Foucault anticipates the medicalisation of psychopathy as a means of administrative expediency - a solution to the individual 'not amenable to discipline'. Initially a problem to be transferred from prison to hospital, ostensibly for purposes of 'treatment' the failure of this solution has now brought forth the prospect of a new type of containing institution aiming to deliver sequestration and risk reduction.
J.P. Watson, I. Morris, A. Jefford
South London and Maudsley Mental Health NHS Trust, Guy's Hospital London SE1 9RT UK
This brief report is of the involvement of current service users in the process of appointment of a new consultant psychiatrist whose main responsibility was to be medical responsibility for a milieu therapy unit dealing with 15 inpatients and about 50 daypatients as part of the local acute mental health service.
Institute of Psychiatry, London, U.K.
In the 1960s mainstream psychiatry was subject to penetrating critiques by Foucault, Szasz, Laing, and others. These critiques brought into question the concept of mental disorder that had arisen during the modern age and specifically since the beginnings of the science of psychiatry in the early decades of the present century. They were historical, philosophical, social and political in nature. The paper will discuss these critiques in the light of developments in the theory of disorder and in mental health services in the last few decades and currently, including community care, user involvement, changes in mental health legislation, and the rise of cognitive therapy. Themes in such developments are characteristically post-modern, insofar as they involve questioning of absolute values and power relations, and relativistic approaches to the understanding of order and disorder. The paper will speculate on possible future directions for mental health services.
Towards integration of Euro-American and traditional African therapies: a transcultural exploration of the treatment of psychosis in a post-modern world.
H. Campbell, MRCPsych, E. Burke*, MSc Couns Psych
South East Health Board, Ireland; *Private Practice
Workshop participants will be invited to explore in small groups the role of ritual, spirituality and religious systems in their current therapeutic practice and how this might change as we enter the post modern era, drawing on insights derived from traditional African healing practice. Participants will be given an outline of the historic and pre-historic development of therapeutic systems in a transcultural and evolutionary context. An example of a traditional Tanzanian healing intervention with a sufferer from paranoid schizophrenia will be shown using videotape. Similarities and difference between traditional African therapeutic systems and modern Euro-American systems which have roots in Cartesian philosophy will be outlined.
- Anxiety - animal reactions and the embodiment of meaning
Department of Psychiatry, University Medical Centre Utrecht, The Netherlands, Department of Philosophy, University of Leiden, The Netherlands
In this presentation the question will be raised whether pathological forms of human anxiety are simply remnants of some archaic animal reaction or must be seen as totally distinct from animal physiology, for instance as bearer of existential meaning. I will explore a third position, which suggests that in the human world animal reactions can be enriched with - or opened-up to - social, moral and even existential meanings.
- Origins of Psychotherapy
D. Padro Moreno
Hospital Civil de Basurto (Servicio de Psiquiatria)
Beginning with the shaman as the first practitioner of techniques which we call today psychotherapy, the author studies this figure as a wise man, in the context of ancient classical Greece, the time when mythical conceptions embarked on their journey towards the world of logos. In this transition, the enchantment (epode) of shamanic practise gave rise on the one hand to philosophical logos and hence the word as a curative instrument and, on the other hand, to medicine. This division, presents a clear parallelism with the current dichotomy between the physis and the logos involved in the psychotherapeutic techniques used today. A new paradigm, of New Hermeneutics is proposed which combines the physis and the word at their point of origin.
Department of Psychology, University of Helsinki, Finland
Two broad traditions of psychiatry are presented in this paper. The "romantic" tradition has stressed, beginning from the late 18th and early 19th centuries, the connections of madness to emotions, fantasies, hidden, unconscious "night" sides of the human soul, and to moral factors. Its later ramifications and modifications, for example through psychoanalytic and phenomenological-humanistic views, have brought forth empathic-intuitive understanding and "revealing" depth-interpretation of unique experiences and intrapsychic conflicts. Introspective and idiographical case histories, listening with the "third ear" in psychotherapeutic settings, and subjective symbolic manifestations of personal problems in living have dominated the ethos of this approach.
Head of Incunabula and Western European Books to 1850, Early Printed Collections, British Library, London
The sixteenth-century physician and natural philosopher Girolamo Cardano (1501-1579) presents a number of characteristics which to modern readers of his texts may indicate that he suffered from mental illness. This is partly due to some of his beliefs, which to us seem to be delusions, partly due to his use of language, but also because of his sometimes disconcertingly unusual logic. Despite all his contradictions and all his astonishing arguments, Cardano was not ignored by his contemporaries and undoubtedly made a contribution to the changing approach to natural philosophy in the sixteenth century.
Born in the same year of 1515, Johann Weyer and Teresa of Avila are each regarded - although for very different reasons - as towering intellects and important historical figures. And both wrote extensively about melancholia, Weyer as a physician who treated melancholic patients, Teresa as an abbess in charge of communities of nuns who sufferered melancholia. A comparison of the writing of these two thinkers not only reveals the humanity, subtlety and philosophical sophistication of each, but differences of conceptual frame, purpose, moral psychology and presuppositions about human nature, so great as to require the label of differing, and contrasting, epistemologies. Thus: Weyer begins with a conception of the person which is individualistic and is guided by the goal of curing that individual; Teresa, in contrast, with her more relational conceptions and her differing pragmatic goals, responds to melancholia, from the start, as a social problem. The purpose of my paper is to show the way these fundamental differences of approach affect and shape the accounts of melancholia these authors offer.
J.S. Callender M.D. F.R.C.Psych
Royal Cornhill Hospital, Aberdeen, U.K.
Psychotherapy is an activity which takes many forms and which rests on many theoretical bases. This paper argues that psychotherapy contains paradoxes in relation to free will and rationality and that these can be resolved by the application of Kantian theory.
Youth Specialty Service, Healthcare Otago, Dunedin, New Zealand
As a philosopher, scientist, and psychologist with professional experience outside of psychiatric settings, and with limited contact with psychiatrists, the author found several difficulties when moving to work in a hospital system traditionally dominated by psychiatry. While apparently sharing much of the same literature and terminology it became apparent that many basic assumptions, definitions of terms, and attitudes towards treatment differed, often radically, between psychology and psychiatry. This resulted in misunderstandings and a series of situations where colleagues, believing themselves to be perfectly lucid, were talking past each other. Much of this confusion appeared to stem not only from professional hubris, from both sides, but from a lack of understanding of the theoretical basis and the basic paradigms of the sister profession. In this paper I hope to describe the basic paradigm of cognitive-behavioral psychology (also know as the scientist-practitioner model); a model which is clearly not understood by many mental health professionals. In outlining the essence of the cognitive-behavioral mode of therapy I will describe the history of its development, and illustrate how CBT is often misinterpreted, and misunderstood; Marlatt's relapse prevention model of addiction will be used as one example. In the course of this paper I will describe how CBT, although firmly based in scientific research and practice, is not a set of techniques or models, but rather an eclectic approach to therapy defined by a worldview, or attitude. I will also argue that psychiatry is not only a-scientific, but anti-scientific in its approach, and that this is the crux of much confusion between the professions.
Institute for Psychological Sciences and Systematic Psychotherapy - CESAD - Center for Studies in Dialectical Analisys
K. Jaspers' methodological distinction between an explanatory psychopathology and a comprehensive psychopathology is fundamental in order to define the specific characteristics of the two disciplinar fields of psychiatry and psychotherapy and their dialectical relations. As we know, a psychopathological clinical symptomatology, if imputable to a cerebral disease, is pertaining to psychiatry, whereas if it is to be ascribed to conflicts of the personality is related to psychotherapy. Therefore, this methodological distinction, between explanation (Erklären) and comprehension (Verstehen) is essential, in psychopathology, not only from a theoretical point of view, but also for a clinical differential diagnosis and any consequent therapeutical implication (above all in deciding among a pharmachological or a psychotherapeutical assistance or an integrated therapeutic program as well).It should be considered that a comprehensive psychopathology is founded on a systematic theory of personality as experience of the intimate subjectivity and its historical development; this is also the epistemological basis for a systematic analytic psychotherapy aiming to fill the principles of autonomy and spontaneity of inner subjectivity. The statement is assumed that in a systematical psychotherapeutic perspective the logic of building up and developing of personality, as well as its conflictual positions and their analitical discussion, is dialectically characterized, so that an integration between the phenomenological method of empathy and a dialectical analitic methodology is requested, both in theory and in clinics. For a systematic dialectical analysis of relations among psychopathology, psychotherapy and theory of personality, a reference to the Universal Epistemological Table (UET) is indispensable.
E. Jakobsson, Ph.D.
Department of Social Sciences, Mälardalen University, 63105 Eskilstuna, Sweden
In psychotherapy research the problem of if and how the "talking cures" cures is still a controversial issue. The non-specific factors are often regarded to many to secure a rationale on empirical grounds. Some people, both clinicians and researchers, seem to be content with the fact that psychotherapy on the whole and generally speaking, seems to be effective, while others (e.g. Edward Erwin) claim that this non-specific action should and can be specified according to the scheme "the factors f1, f2, f3... in psychotheraputic intervention P is good for the disturbance D".
SouthWest London and St. George's NHS Mental Health Trust
Objective: Although ADHD has in recent years become one of the most common psychiatric problems in childhood, its status as a medical disorder remains controversial and the medicalisation of hyperactivity is often discussed with critical connotations, especially in Britain. This study examines the experience of parents and doctors dealing with hyperactive children, focusing in particular on the process of medicalisation. It aims at understanding what is at stake for families and doctors and asks about the role of a medical label in the therapeutic process.
Guy's, King's, and St Thomas' School of Medicine, Guy's Hospital, London SE1 9RT UK
The clinical mental state examination taught, examined, and used world-wide has proven validity and reliability when used according to familiar and well-established rules. Nevertheless, the method has limitations, three of which are discussed in this paper.
I.Ya. Stoyanova, V.Ya. Semke, N.A. Bokhan, S.A. Oshayev, D.V. Dobryanskaya
Mental Health Research Institute Tomsk Scientific Centre SB RAMSci
To have an integral idea about personality, attitudinal positions of the man needing psychological, psychiatric or psychotherapeutic care, one should have an idea about primitive mechanisms of the psychological defense manifesting as beliefs and superstitions. Similar to cases of manifestation of the psychological defense studied within psychoanalysis, psychological defense mechanisms (PDM) conditioned by primitive thinking are directed at reduction of anxiety provoked by intrapsychic conflicts and represent specific processes with the help of which self seeks to maintain personality integrative ness and adjustability.
A. Hoeye, V. Hansen, R. Olstad, A. Wifstad
Studying diagnostic practice has traditionally been linked to the evaluation of diagnostic reliability, but can in our opinion be useful when discussing diagnostic validity, and, thereby, concepts of disorder. The diagnostic process includes both the patient, the psychiatrist and the diagnostic systems in use, and a possible cultural bias by clinicians may be reflected in gender differences. A study (in press) of the diagnostic process in a cohort of first episode schizophrenic patients was fulfilled in 1999 in the two northernmost counties in Norway. All first-ever admitted schizophrenic patients with three or more admissions in the period 1980 - 1995 were included. The study shows that females had a significantly longer period than did males from first admission until first given diagnosis of schizophrenia (2.6 years and 3.4 admissions versus 1.6 years and 2.3 admissions). The distribution of diagnoses were also different prior to first schizophrenia diagnosis, females received personality disorder diagnoses (the most frequent being schizoid personality disorder) more often than did males. The total latency period before first schizophrenia diagnosis shortened after the introduction of new diagnostic guidelines with the change from ICD-8 to ICD-9 in 1987, but the gender difference in latency period persisted.
1. Schizophrenia in females is essentially different than in males. On a continuum it may therefore be that females are in the "schizoid end" of the scale while males have more typical "schizophrenic" symptoms.
The heterogeneity of the schizophrenia diagnosis may implicate a lack of diagnostic validity. Pt. 1 and 2 addresses the question of gender linked diversity in the expression of mental disorders, which are not taken into consideration in the diagnostic classification systems. When gender factors in schizophrenia is discussed in relevant litterature it is most often linked to modeling, biological factors associated with femininity, such as estrogen. The possibility that diagnostic heterogeneity linked to gender is also an expression of systematic, cultural bias by the clinicians (pt. 3) has rarely been addressed. The description of mental symptoms throughout history is associated with cultural factors, as well as clinicians' interpretations in the current context. At the conference the study will be presented, with a closer discussion of the question raised in pt. 3. Hopefully this will also include preliminary results from a relevant study performed during spring 2000.
M. van Beinum, H. Connery
Department of Child and Adolescent Psychiatry, University of Glasgow, and Greater Glasgow Primary Care Trust, Glasgow, U.K.
Views of teenagers have rarely been given status in the development of psychiatric services. Where their views have been investigated, quantitative questionnaire surveys have been used. We argue that such positivistic approaches are inappropriate for eliciting the meaning of psychiatric care for clients, and that questionnaire surveys are often based on the assumptions of researchers and not the perceptions of subjects. We therefore used a qualitative study design to probe the views of teenagers about the meaning, for them, of the experience of coming into psychiatric care. Central to our thinking has been a social constructivist approach, both regarding the nature of the psychiatric encounter and the research strategy.
Graduate School of Management, University of Western Sydney-Nepean, Sydney, NSW, Australia
The realities, myths, understanding and expectations of society towards psychiatrists, is explored through interviews with the psychiatrists themselves. A postmodern philosophical perspective is lent to the interview process and transcripts with a selection of Australia's practicing psychiatrists. The interviews center on what it is to be practicing today at the end of one and beginning of a new century. The interviewer becomes the recipient of the questions and answers, allowing the psychiatrists to deconstruct themselves through giving them voice. They question their own 'voice, terrain, purposes, and meaning' (Flax, 1990: 7). The depression, anxiety, stigmatisation and perceptions of loss of control that characterise various mental disorders emerge as also being applicable to the psychiatric profession. A common concern for psychiatry arose in a multiplicity of forms. Will the deinstitutionalisation for the twenty-first century be the removal of the psychiatrists themselves? What will be the place and where will be the space for psychiatrists in the discourse of psychiatry? Alternatively, rather than a deinstitutionalisation of the psychiatrist, will a deconstruction, a questioning of the expectation to practice with levels of utopian ambivalence reveal new spaces for the psychiatrist in the discourse of psychiatry?
Department of Philosophy, University of Louisville, Louisville, USA
According to Derrida, the language of reason is simultaneously the language of order, of the universal rationality of which psychiatry wishes to be the expression, and the language of the body politic--the right to citizenship in the philosopher's city. But this order is always already a disorder, and the objectification that language structures is never total. As Mouffe and Laclau put it, all discourse is subverted by what overflows it.
Department of Philosophy, Erasmus University Rotterdam, The Netherlands
Suppose that there is no real distinction between 'mad' and 'bad.' Suppose that bad-acting agents are simply malfunctioning ones and that this malfunctioning can always be explained either: 1) in terms of the exceptional circumstances (past or present) of the action or, 2) in terms of the impaired (mental) abilities (temporary or more permanent) of the agent. If this is the case: should we not change our ordinary interpersonal relationships in which we blame people for the things they do, are morally indignant about their wrong actions, and hold them responsible for the kind of persons they are? After all, if people literally always act to 'the best of their abilities' nobody is really to blame for the wrong they commit.1
Cattedra di Psichiatria, Università di Udine, Udine, Italia
We are still far from having an unitary psychopathologic model of schizophrenia. At the nosographic-descriptive level it is still open the debate about which are the nuclear, or primary, symptoms of the disease (the positive or the negative symptoms?) and about the role of the subjective symptoms (the basic symptoms) that recently have received new emphasis from the late exponents of the Jasper's school. The knowledge about the factors implicated in the pathogenesis of schizophrenia is even more scanty. It is generally acknowledged the presence of an organic basis, there are many evidences that testify a genetic component and it has demonstrated that the risk is greater in presence of external events of stressful, traumatic or infectious nature. The schizophrenia is currently conceived according to a model where various factors play a predisposing or activating role: the genetics, the trauma of birth or the pathogenic events in pregnancy, the relational style in the infancy, the stressful events and the social support after the development of the disease.
Neuropsicofarmacologia Università di Bari - Italy
When clinical psychopharmacological research began, it also was evident that some logical difficulties arose to face the necessity of comparing the world of clinical symptoms realized by psychiatrists like "perceived" sensations (Praecox Gefühlen e.g.) and the reality of an easy system to describe them. The solution to this problem was the emergent necessity to reduce this complicate world into a synoptical and prevalently behavioral observation of course and outcome of mental illnesses.
Dept of Philosophy, Göteborg University, Box 200, SE-405 30 Göteborg, Sweden
Psychiatry is very good at not remembering its roots. For example, in the recent American upsurge of interest in the Rorschach test, the European tradition is all but ignored, and in John Exner's very influential work "The Rorschach Systems", no European Rorschach system is included. This of course means that a lot of valuable knowledge is lost for the modern scientific community.
Dpt. di Filosofia, Università degli Studi di Milano)
In Eine Schwierigkeit der Psychoanalyse (1917) S. Freud listed the three serious blows dealt to mankind's self esteem by modern science: 1. Copernicus's (The Earth is not at the centre of the Universe), 2. Darwin's (Man has no special privilege in Nature), 3. Freud's (The ego is not its own master). Copernicus's blow was a cosmological one. The animal that the ancients had depicted as keeping his eyes turned upwards to the skies was now a lost creature in the Universe, wrecked on a big rock, as Husserl wrote, on which he crawled aimlessly. This doom was however looming over man well before Copernicus, prepared by Plato's most astonishing invention, the invention of the soul (C. Sini, Passare il segno. Semiotica cosmologica tecnica, 1981). Invention of that unprecedented inner space of experience, the soul, receptacle of logic's and psychology's objects: language, judgement, truth; deception, feelings, opinions. And removal of experience away from where it belonged, the world, and from the meanings and signs of that kosmos. It is not by chance that this immensly powerful and problematic tension between psychology and cosmology, between the emergence of the first and the repression of the second, while achieving its accomplishment, snapped. And that the snapping occurred where in our science's encyclopaedia the tension was highest, where psychology was directly concerned (as Husserl saw in his Krisis, 1954) and also where cosmology was concerned (as Husserl saw in his manuscript Umsturz der koperkanischen Lehre, 1934). Nor it is by chance that the snapping was first recognised by phenomenological psychopathology, that most tormented branch of psychology, which first posed interrogatives about itself and about its object, madness, in terms of its own centuries-old silent alter ego, cosmology (E. Minkowski, Vers une cosmologie, 1936; H. Tellenbach, Melancholie, 1960). Hidden, fragmentary simmetries that are yet absolutely necessary. When cosmological man declined to make room for the man of logic and psychology, the cosmological sense issue declined accordingly; experience was equated with measurement and calculation proceedings. On the contrary, when the man of logic and psychology declines - when he falls into madness, or when his general experience becomes less and less interpretable in psychological terms - the cosmological sense issue comes to surface again: has experience a cosmological meaning? These genealogical, and epistemological connections between cosmology, psychology and psychopathology are as yet, and generally speaking unexplored.
Is it useful to say that pre-twentieth century descriptions of melancholic states refer to the same condition as descriptions of clinical depression from the twentieth century? Part of the answer to this question rests on the degree of similarity between the earlier and later symptom descriptions. And this similarity is striking. On the other hand, the differences are also notable. however, a consideration of the balance between these similarities and differences is not all there is to the matter. At stake in this inquiry are also certain methodological or ontological factors about the sort of thing we understand mental disorder (or at least this particular mental disorder) to be. Adherence to a descriptive analysis will discourage us from identifying early melancholia and depression; but an aetiological account, in contrast, will permit the identity between thw two conditions even in the absence of strong similarities between symptom descriptions (as the case of so-called "masked depression" illustrates.) In my discussion, I explore philosophical and theoretical considerations favouring a descriptive over the aetiological analysis.
E.L. Hersch, M.A., M.D.
Psychiatrist-psychotherapist in private practice; Toronto, Ontario, Canada
Psychotherapy in its various forms is still one of the world's most frequent treatment modalities in the mental health field despite the recent emphasis on pharmacology and "neuroscience." It is also the most directly philosophical of mental health approaches as its basic subject-matter is to deal with the varying "world-views," "belief systems," and "experiential worlds" of its participants, as well as with the interactional "fusings of horizons" which take place in their encounters with each other and within their societies. Perhaps nowhere else in the mental health field are the philosophical questions of epistemology, ontology, and phenomenology so obviously relevant, even if they are often overlooked or ignored. In this sense the practice of psychotherapy might even be seen as a sort of "applied philosophy."
F. Madioni MD, PhD, M. Archinard MD.
Liaison Division ,Department of Psychiatry University of Geneva
What has happened to existential psychotherapy (Daseinanalyse) after Binswanger?
C.R.F. Sherlock MRCPsych
This paper presents a psychological model that proposes new insights into the nature and cause of mood, neurotic and stress-related disorders (depression, anxiety and stress). It is based on extensive clinical experience and observation over the last twenty years. Particular attention is paid to the vicious cycles in which emotions drive us in thoughts, speech and actions.
Psychiatric Clinic, University of Heidelberg
Applying Sartre's "existential psychoanalysis" to mysophobia we are concerned with the existential symbolism of adhesive dirt in compulsive washing. The freedom of the compulsive patient is undermined by the adhesion of dirt, in that part of his being (dirt as a reification of sexual wishes, aggressive tendencies etc.) come to the exterior, starting an expansive, independent existence. The patient is thus caught into an increasingly exterior relationship to himself. Obsessional acts like washing hands are understood as attempts to get rid of this kind of material determination in order to regain his motivational freedom. The question is put if obsessive-compulsive disorders in general - from a phenomenological point of view - are founded in a kind of reification of the self.
Department of Psychiatry, University of Pretoria, South Africa
The distinction between state and trait aspects of dissociation is needed in view of the implicit predominant attention that has been given to trait characteristics despite evidence for state characteristics of dissociation. Evidence for the historical predominant attention to trait characteristics is found in the nature of all dissociative measuring instruments except for the recent State Scale of Dissociation that measures state characteristics.
Philosophy Program, Research School of Social Sciences, Australian National University, Canberra
Philosophy Program, Research School of Social Sciences, Australian National University Haydon Ellis offers a 2-stage cognitive model of delusional belief in which a modularised malfunction produces an anomalous experience which is then rationalised by a malfunctioning central system of belief fixation. Maher offers a 1-stage model, involving only failures of modularised input systems. Others ( Sass, Berrios) think that delusions are not really beliefs at all. Each of these theories captures something important about delusion but, apparently, they cannot all be right. Furthermore, they have different implications for the explanatory role of Cognitive Neuropsychiatry. These cognitive models of delusion are especially interesting and inportant because they offer an explanatory bridge between neurobiological approaches like that of Andreasen and phenomeological ones like that of Sass, to delusional phenomena.
Univeristy of Turku, Finland
This paper deals with the concept of a psychiatric symptom and its development from a historical point of view. Certain psychiatric illnesses (depression, schizophrenia), their symptomatology and the conceptual variation of the symptomatology throughout the history will be discussed.
University of Pavia, Italy
Center for Neurological Diagnosis, Athens, Greece
Introduction: Our aim in this study is to find out the role of the social background and the health insurance programs in the treatment of MS patients in Greece.
A. Romila, V. Marinescu
2nd Department of Psychiatry, Carol Davila University of Medicine, Bucharest, Romania
Despite incontestable technologic progress, the globalization of communications, the rising of economic and standards of life especially in the western world, the entire world is filled with the slogan that the world is mad. However, the psychiatry doesn't see an identity between the world of the psychiatric clinic and the society. There are still some opinions that the clinical psychiatric world is even less mad than the external world.
Khabarovsk Region Railway Hospital, Khabarovsk, Russia.
The growth of depressive disorders has been noticed all over the world .The public demand for high individual achievements and the need to correspond to high social standards promote this problem. Attempts to meet these standards may be demaging to the personal interests and constitutional-biological possibilities of the person. In half of cases these problems appear in the form of somatoform disorders and patients deny the presence of psychological and emotional problems. The majority of them visits general prtactitioners, unwilling to turn to psychiatrists. I have examined 270patiens with somatoform disorders in the neurological department. There were many young people in this group (under 35), 77 % were women. In half of the cases the patients had cranio-cerebrel traumas in the past, encephalopathy or pathological climacterium. Personality disorders have been noted in the 80%. Personal' and family' frustrations provoked somatoform disorders in the majority of cases. So, a combination of biological, psychological and social factors plays an important role in the development of somatoform disorders. Biological therapy and psychotherapy have been given at the neurological department.These patients need further psychoprophylactics and social support in order to achieve positive results and prevent relapses. The psychoprophylactics concludes by self-regulation relaxation strategies, including progressive muscular relaxations, respiratory exercises, meditation, as well as methods of biofeedback. The correction of the small-adaptive characteristics of personality and interpersonal relations is also necessary. As for social factors, its correction can be realized with the help of the following conditions:a) the atmosphere of tough competition existing in society should be replaced by an atmosphere of helping and cooperation, b) attempts to achiev of top social standards in the plan of personal successes and consumptions should be replaced by orientation towards the correspondence of internal criteria to individual, biological possibilities of the person's; c)cooperative circumstances helps to promote person's abilities. Medical co-operative societies may solve the problems of prevention and cure of the somatoform disorders.The state cannot duly guarantee work of psychotherapy seryice, the private practitioners are not interested in this. There were many such organizations in the Far Eastern republic , which existed until the mid-1920s. Regrettably, there are no medical co-operative societies in the Russian Far East at present. There is no information about co-operative activity before the formation of the USSR and about modern coops, acting as members of the International cooperative alliance (IC?).
R.D. Laing's focus in his writings, and therapeutic work, on 'schizophrenia' is consistently on the concept (and reality) of the Person. The conceptual matrix/matrices needed for the study of persons is/are necessarily distinct from that/those used in the study of biological organisms. Human beings can be studied in the two different modes of person and/or organism. In the realm of psychopathology this statement can be 'translated' thus : is psychosis to be understood (solely or exclusively) as the manifestation of biological dysfunction, i.e as the expression of a Kraepelinian disease-entity or as a disorder of the Person?
- Preventing severe mental illnesses: new prospects and ethical challenges
K.F. Schaffner, M.D., Ph.D.
University Professor of Medical Humanities, George Washington University, Washington, DC, USA
Severe mental illnesses devastate millions of lives worldwide. Exciting recent developments in functional psychoses, including schizophrenia and bipolar disorder, are offering hope that such illnesses can be identified and treated early. Early treatment promises better outcomes for both the affected individuals and their families. Such treatment aims at reaching patients during their first "psychotic break" as well as attempts to identify at-risk individuals during the pre-illness or "prodrome" period. These "early intervention" projects also point toward the possibility of true prevention for those at-risk of psychoses from genetic and/or environmental factors.
- Consciousness, awareness and insight in psychopathology
IPSO. Université Bordeaux II. 121 rue de la Béchade, Bordeaux, France
Awareness of disease was central in the conceptualisation of insanity (alienatio mentis), especially among French alienists of the XIX century (T. Hammanaka, 1997). At the turn of the century, with the emergence of psychoanalysis, the interest focused rather on the unconscious (for Freud, man in general has a very little degree of consciousness). Nevertheless, insight became a cornerstone of the theory and psychodynamic treatment of neurosis.
J. Naudin, G. Stanghellini, M.A. Schwartz, O.P. Wiggins, J-M. Azorin
Université de la Méditerranée, Marseille, France; University of Firenze, Firenze, Italy; Case Western Reserve University, Cleveland, USA; University of Kentucky, Louisville, USA
Auditive Hallucinations (Ahs) are here defined as "reports of experiences attributed to an alien voice in direct relation with a self-consciousness' disorder". By its content, AH has to be related to moral insight. As a disorder in the self's feeling about itself, AH implies both misattributions and meta-cognitive beliefs. In AH, Meta-cognitive beliefs had been related to a weak self-esteem. This paper aims to discuss what it happens during voices: are Ahs either palliating or rendering intelligible in trivial terms the deficiency of the self? The authors point out that the hallucinatory content has as its dual object both the modifications in the intentional processes caused by the primary process and the quality of the relation of the self to the surrounding world.
Hôpital de La Salpétrière and CNRS, Paris, France
Brain mechanisms exist that normally allow us to recognize our thoughts, whether bizarre or unwelcomed, as being self generated. It has been proposed (Feinberg, Frith) that precisely this mechanism was deranged in schizophrenia. Schizophrenic patients are not aware of their inner speech or of moving their arm by their own will when they mention that they are hearing voices or that an alien force cause their arm to move. What is remarkable is that normal subjects are not doing the same mistakes in their attributions. Hence we must hypothesize that normal subjects are informed by their own neural circuits that their motor cortex or that their sensory areas have been self-stimulated. Such an internal monitoring of sensory and motor commands has been considered either as a "feed-forward" control (preparation; Mac Kay) or as an "internal feed-back loop" (Evarts) leading the subject to know that his effectors have been activated. A lot of studies have been conducted to better isolate which neuroanatomical and functional circuits could correspond to this feed back loop. Nevertheless we can not completely identify this self-awareness mechanism to the process of consciousness. Self awareness is only one aspect of consciousness and incidentally it can occur quite automatically. Usually the internal feed back of motor acts is far below the conscious level. The process of consciousness in schizophrenia, if disturbed, is so at a much higher sensory-motor integrated level, where information processing (memory) interfere with motor mechanisms. We must keep in mind that the internal feed back loop does not seem to be dysfunctional for schizophrenic patients during childhood. Consequently the role of non neocortical areas (basal ganglia, hippocampus, thalamus) in information processing must be reconsidered to propose relevant models of alterations of consciousness in schizophrenia.
Hopital Percy. 101 av. H. Barbusse, CLAMART, France
Psychic traumatic stress put the subject at the most primitive level of his personal history and functioning when the infans had not yet acquired the language.
CHU Pasteur, Nice
Phenomenological insight (intuition) is a largely helpful concept for explicating the bases of psychiatric experience. Following Husserl, intuition is not a revealed experience but rather a rigorous method for describing the movement of intentionality. This method allows a better understanding of clinical experience as an intersubjective one (Tatossian). It leads to ground the psychiatric diagnosis on the notion of ideal types (Wiggins & Schwartz). In psychotherapy, it allows a wider horizon of interpretations based on both concepts of taken-for-grantedness and openness of experience. Our definition of insight focuses then on the intentional experience of the Self and the World rather than an exclusively Ego's experience.
Psychiatric Clinic, University of Heidelberg
From a phenomenological point of view, the so-called "first rank symptoms" of schizophrenia may be derived from a fundamental disturbance of intentional mental acts. The structure of intentional consciousness implies self-referentiality, a sense of agency, and the integration of the sequence of moments into an "intentional arc" as outlined by Husserl in his "Phenomenology of the consciousness of internal time". All these characteristics of the acts of perceiving, thinking, willing and acting may be disturbed and altered in schizophrenia. The synthetic and sense-bestowing processes effective in perception are seriously damaged. Thinking and acting occurs without self-referentiality, and the unity of consciousness over time is threatened by the break-down of the intentional arc.
Department of Psychiatry, Ulm, Germany
Current cognitive neuroscience offers new methods and data to explore the neural correlates of agency. I will give a short survey of competing neurocognitive theories based on studies with normal as well as neuropsychiatric patients. I will show that different theories appeal to different levels of explanation, ranging from neurotransmitters up to the contribution of the right versus the left hemisphere. After presenting an integrative account of what the mechanism of agency could consist in I will discuss the question how far such theories can help us to explain schizophrenic experience. I will argue that psychopathology plays a central role for any attempt to formulate a neurobiological theory of agency.
Anglo-American cognitive and Continental phenomenological approaches to schizophrenia converge on certain topics. One of these is that patients with schizophrenia experience alienation with regard to their own agency and a corresponding loss of sensitivity to context, i.e. "common sense," which guides appropriate action. Remarkably, there are similar current debates in both traditions whether this disturbance is due more to an exacerbation or dysfunction of attentional processes (from above, as it were, an Apollonian disturbance) or more a disturbance to automatic processing (from below, a Dyonisian disturbance). In the phenomenological approach, some authors (Sass, Cutting) argue that there is a hyper-concentration which results in the morbid objectivation of experience from above. Other phenomenological authors (Binswanger, Szilasi), however, point to a breakdown in perceptual processing from below as part of prodromal delusional mood. Binswanger describes a "loosening" of the schema formation which normally enables past experience to impact present consciousness of the perceptual object and the transition from perception to movement in an ongoing process of self-transcendence. Along similar lines to the phenomenological debate, cognitive approaches have been divided whether the dysfunction lies more with conscious, explicit processing or more with automatic, implicit processing, for example, in comparator models which enable the distinguishing of self-generated from externally generated movements. The present paper attempts to integrate these different findings and theories by proposing a disturbance to the perception action cycle or Gestaltkreis (von Weizsaecker) between perception and action.
Institute of Psychiatry, University of London
A comparator system, comparing quite generally the current state of the perceived world with its predicted state, was initially proposed as forming part of a suggested neuropsychology of anxiety, and subsequently extended to an account of the positive symptoms of psychosis (the system being functional or hyper-functional in the former case, and dysfunctional in the latter). Recently, it has been further proposed that the contents of conscious experience consist in the outputs of the comparator system (after a second pass through the perceptual systems that provide the initial input to the system), tagged according to their degree of match or mismatch with prediction. This hypothesis is able to account for the lateness with which perceptual experiences enter consciousness, relative to the speed of behavioural response to the initiating stimuli. The hypothesis can also throw further light upon the positive symptoms of psychosis. In this form, the comparator hypothesis resembles earlier suggestions that the relations between automatic and controlled processing are abnormal in schizophrenia.
Persons with schizophrenia often experience certain characteristic alterations of the lived body that undermine normal structures of bodily subjectivity and knowing. Aspects, features, or dimensions of bodily existence that would normally be inhabited lose their natural status as part of the tacit background of awareness, and instead are experienced as existing at a remove or in the outer world. What would normally be experienced as part of the self takes on characteristic of external objects. In this hyper-reflexive state, the planes and cavities of the lived body, or its sensations of solidity and flow, tension and release, come to occupy the focus of awareness. As a result, these phenomena take on qualities that R.D. Laing aptly described as "a kind of phantom concreteness": they seem unreal, distant, dreamlike and unfamiliar, but also (and even simultaneously) somehow exaggeratedly precise, material, electric, or hyper-real. I introduce some concepts from the philosophers Merleau-Ponty and Michael Polanyi that are useful for clarifying these developments.
- Penser la mutation
Docteur en Psychologie Clinique, Hôpital d'Arles (13) France, Département de Psychiatrie
La psychiatrie se propose non seulement d'apaiser les souffrances psychiques mais aussi de provoquer chez le sujet une forme de mutation interne lui permettant de mieux vivre.
Unità Funzionale Psichiatria Adulti, ASL 3 Pistoia - Italy
Psychiatry in modern culture seems to move more and more from an individual to a community approach especially from a psycho-dynamic point of view. In a sense, we should consider that all the theories psychoanalytics derived, have always proposed a dual model (bipersonal model/leader-group) which has been transferred to the group therapies themselves, even if these two techniques have been considered as different fields using different instruments. Actually psychiatry knowledge, according to a close social and thought trends factors implication, is imposing a progressive overcoming of this dichotomy in order to make a synthesis between theory and practice. From this point of view is interesting to review E. Pichon-Revìere studies and works. He was a psychiatrist, social psychologist and psychoanalyst in Argentina (Ginevra 1904-Buenos Aires 1977) though the political contest of his country and personal ideology,(before Bion literature), had already structured his own conception on Groups. The Group Process focused on inner group developing from the birth, but one of the most important aspect is represented by the concept of "Task", coming from social psychology theory, which is the key in the group situation where all the expressed interests and the primary elements of the individual history, of the members converge. The task consists indeed in facing the object of knowledge (anxiety and basic depression), that have become more open to access because of the break down of a dissociative and stereotyped model that functioned as a stop in the reality learning process damaging the communication nets with it.
The author analyses the different possibilities of reading a "clinical text" from the point of view of the most recent developments of the hermeneutics after Heidegger. He investigates the numerous possibility of "listening" to a text and suggests a way that might somehow preserve the words, guarding them with all potential meanings. This "listening"attidude reminds of the hermeneutic considerations of the late Heidegger, aiming at an unexhaustive interpretation of the words, accepting their natural permanent reticence. The refusal of thorough explicitation and the consequent efforts to define what was later called "hermeneutics of listening" aim mainly at defending and guarding the obscure truth contained in the text, fully aware that the blinding light of rational explanations might level ane homologate everything. The late Heidegger is paradoxically intent on never seizing the object of his search (the Truth, the Being), but on defending and guarding it as naturally unspeakable. He opposes a "going around" to the scientific and metaphysical attitude of seizing and revealing the truth. Only renouncing and withdrawing from a claim of possession allow to approach the inexpressible alteritas of a text, core of all hermeneutic problems and of the pshychiatric listening above all.
A. Stewart, T. Hope*
Highfield Adolescent Unit, Warneford Hospital, Oxford; *Oxford Centre for Ethics & Communication Skills in Health Care Practice, University of Oxford.
In working within the area of adolescent mental health, the possible conflict between adolescent autonomy and paternalism is faced on a regular basis at many different levels. In this paper various definitions of autonomy as applied to adolescents will be put forward, including discussion of the components of occurrent and dispositional autonomy and their relevance to adolescents.
Department of Languages and Philosophy, Utah State University, Logan, Utah
The phenomenon of Multiple Personality Disorder (now Dissociative Identity Disorder) has attracted considerable philosophical interest. Typically, philosophers interested in MPD have thought that it raised or clarified issues having to do with the philosophy of mind and personal identity. Furthermore, the controversy about whether MPD is real and, if so, how its reality is to be understood, raises issues within philosophy of science, metaphysics, and epistemology. These issues are not my focus. They focus on the "multiple personality" aspect of MPD, whereas my interest is in the "disorder" aspect. Why is MPD a form of psychopathology, or more broadly, why is it viewed as disorder rather than order? Of course, those with MPD do frequently suffer forms of psychopathology, notably serious depression. But here the pathology is the depression, which may be brought about by the MPD, not the MPD itself. Is there something pathological about MPD itself, even if it does not lead to depression, anxiety, and other unpleasant conditions? Is there something intrinsically pathological about the condition? I shall suggest that MPD in its most common manifestation is in fact a disorder, though not necessarily a disorder of the psyche; rather I shall suggest that it is a moral disorder. In particular, MPD might be considered a form of injustice. Since MPD develops as an initially successful form of adaptation to harsh conditions, it can be considered a mutually beneficial scheme of cooperarion among the "identities or personality states" (DSM-IV) involved, but the "identities or personality states" who benefit from the condition tend to differ from those who bear most of the burdens of the condition. This line of thought leads to two further questions I shall consider, one more philosophical and the other more directly pertinent to psychiatry. First, what sort of entity can be thought to be owed duties of justice? Is a mere personality state, as opposed to a person, such a being? Second, if MPD is considered as a form of moral disorder, what implications would this have for acceptable forms of treatment?
I. Izídio da Costa
Department of Clinical Psychology of the University of Brasília/Brazil and CAPES-Foundation of Brazilian Ministry of Education
In current mental health studies, 'schizophrenia' represents, at the same time, a challenge and a problem. It is a challenge because it demands more and deeper studies and analyses. It is a problem because the complexity of its so-called phenomena and the lack of clarity of its diagnostic criteria have produced imprecision in its treatment, in its understanding and, as a consequence, in its theoretical approach.
Department of Child Psychiatry, Trinity College, Dublin 2
Ludwig Wittgenstein was possibly the greatest philosopher of the 20th century. He met all the Gillberg criteria for Asperger's syndrome (Gillberg, 1991). His difficulties in "affective contact with people" (Kanner, 1943) had a major impact on his philosophical writing and indeed on the course of philosophy in the 20th century. His first book the Tractatus Logico-Philosophicus (Wittgenstein, 1922) focussed on language as a mirror of reality - the 'picture-theory' of philosophy. He believed that only objective facts could be spoken of. In this book he failed to achieve what Hobson (1998) points out an infant can achieve that is a disembedding of "the infant from an immediate, unreflective concrete apprehension of the environment". His research on language was in the 'autistic mode' like the current researchers in autism who focus exclusively on cognitive factors.
Newcastle City Health NHS Trust, Newcastle General Hospital, UK
Prosopagnosia is an inability to recognize faces. It is a symptom that can occur in dementia, as shown by a case history.
II Catedra Of Phenomenologic And Existential Psichology - (Dra. M.L.Rovaletti) Department Of Psichology, University of Buenos Aires, Argentina.
This work points out some of the matters that arise from Kant's statements in reference to reason's caracterization And function in the trascendental dialectic. If it is in the Nature of the reason to escape from the limits of the experience, in its search of the unconditionated and to Originate "illusive objects" or the "trascendental illusion", How to difference the "normal delirium" of the philosopher Or the artist of the "extravagant" or "pathologic" delirium ?
University of Venice, Italy
Starting from a genealogy and a historico-critical epistemology of the science of psyche, the present paper focuses on a theme wich, from the beginning of the nineteenth century, strongly characterized early psychiatry. This theme, sistematically ignored in the subsequent development of clinical psychiatry and psychoanalysis, deals with the relationship between the mind and the world, between the psyche and its socio-historical and cultural context.
- Abolishing subjectivity: generalising Wittgenstein's insights about expression
Georgetown and American Universities, USA and Linacre College, Oxford, UK
Psychology has been framed, explicitly or implicitly in the two structural polarities: inside/outside and subjective/objective. While it is easy to see that behaviourism allowed the legitimacy of only one of each pair current cognitive psychology preserves these distinctions in more subtle ways. The mind, therefore is conceived as hypothetical in the sense that subatomic particles are hypothetical. However Wittgenstein's account of the expressive uses of language shows he holism between the private and public aspects of the mental. Psychological phenomena therefore have their primary mode of being as properties of symbolic exchanges rather than as individual mental states. The argument will develop the joint action point of view through analyses of some commonplace psychological phenomena, such as remembering and classifying.
Department of Philosophy, Åbo Academy University
It is often claimed that the difference between the natural sciences and the study of humanity can be captured in terms of the contrast between explanation and understanding. This way of articulating the difference, however, understates the difference, since it neglects the wide variety of uses of the word "understanding". Sometimes understanding is an intellectual achievement akin to knowledge: thus, one may claim to understand something when one has found the correct interpretation for it. Here understanding is a neutral relation which can be verbally articulated. Failing to understand something, in this sense, means getting the interpretation wrong or giving up the attempt to interpret. However, sometimes understanding and the failure to understand will constitute a more basic relation, more akin to (though not identical with) acceptance and rejection. In these contexts the absence of understanding is not a failure of interpretation but is expressive of one's relation to the purported object of understanding: thus, saying that one does not understand expresses the conviction that there is nothing there to understand, or even a refusal to understand, rather than a failure to interpret. An instance of this use is the classical complaint, "My wife doesn't understand me". This paper explores the relations between understanding as intellectual achievement and as a basic relation. It is argued that non-understanding as a basic relation is relevant in connection with psychiatric disorders, and may even be considered constitutive of them.
A.-H. Siirala, M. Siirala
Therapeia Foundation and Therapeia Society (IFPS)
A report from a therapy:
"Understand" is a key word in clinical psychopathology, since Jasper's' methodological lesson. Among different possible hermeneutic models of understanding, psychopathological tradition is based on an understanding that intends to find the "lived world" in individual experience (in the form of experience) which is possible to approach through identification with the other person (Einfuhlung). But, as we know, from the observer's point of view the failure of understanding is just the brand of delusional experiences. Where there is true delusion there is no understanding; where it is possible understand there is no delusion, as K. Schneider and G. Huber write in a conclusive manner. However, it is useful to keep in mind not only the "static understanding" but also the "genetic understanding", i.e. how the delusional experiences are tied to each other and to a persona's life history.
V. Räkköläinen, M.-L. Heinonen
In DSM III-R there were given nine items, i.e. specific modes of behaviour, in order to identify the "prodromal" stage of schizophrenia before proper diagnosis could be justified. The list is a collection of behaviours seen on the border of what is considered as "normal", but with the common denominator "without understandable reason".
How an acute psychosis turns to chronic schizophrenia? According to Roger Barrett treatment of acute psychosis serves as an initiation ritual to otherness, being maybe less human than humans although living among them. No ritual leading back to original status seems to exist, but schizophrenics-to-come are caught in a liminal position, having lost their former status and not getting anything instead.
T. Schevelenkova, PHD, vice-professor
Institute of Psychology, Russian State University for Humanities, Moscow, Russia
The paper describes the phenomenon of personal identity, with clinical illustrations, and indicates its significance for abnormal psychology. It notes the difference between modern psychoanalysis and existential-phenomenological modes of thinking in abnormal psychology and indicates their significance for the study on personal identity. It argues that personal identity can be seen as a kind of existential a priori, which create a type of inner personal wold, a mode of interpersonal relations and a special body-image. Some conceptual difficulties entailed in formulating such alternative are discussed and nontraditional suggesting for addressing this problem are offered.
Moscow Research Inst. for Psychiatry Russia
The term "Clinical reality" (CR) is a widely spread international psychiatric cliche implying that the idea that CR is something objective, independent of our consciousness reality and sometimes even materialized reality.(The "objectivity" is supposedly granted through the "clinical method"). For such a clinician diseases seem to exist apart from our consciousness, and the history of knowledge formation is perceived as a gradual but unavoidable approach to the truth. But "objective reality" is not available to us in an "objective" state. Clinical observation is always receded by the knowledge of what should be observed. That is an exogenetical inheritance transmitted through the school. The illusion of the "objective knowledge" of a disease is supported by: 1) an unwritten convention that psychiatric deviations must exist - a class of issues that in any system of reasoning have to be accepted a priori; 2) Mutual consent of most psychiatrists acknowledging the presence of a mental illness, in some "crude" clinical cases. All disagreements and arguments concerning the name of disease arise are later put down to the "defects" of observation. Such conviction is also a derivative of senses, perceptions, certain intuitions (e.g. "Vigor vitalis" by old author's etc.). For psychiatrists it is a perception of a certain distinction "unlikeness" of patients e.g."Gefuhl"), which being blended with its logical comprehension (e.g. "Praecox") i.e. is significated and creates a phantom of CR. "Objective knowledge" is no more than "packed", "archived" perceptive probes, unconscious patterns of well digested, hence subjective, theoretically loaded knowledge. Languages and reactions schemes they contain are form-creating matrices of thinking, behavior and perception(F. Bacon. Whorf. CR like any other classification built on its foundation is a variety of subjective reality. Moreover: ossification as a form of conventional notion once arisen will form this reality. However, all these assertions make sense only when you oppose objective reality and subjective one. In the mental space there exists only one reality - reality of the cognizing mind and it is always true.
The Russian State Medical University, Independent Psychiatric Association of Russia
The all-round learning of mutual relation between spiritual experiences and mental disorders has become possible in Russia only from time of Perestroyka. At a constantly operating seminar " Psychiatry and the problems of spiritual life " (the name has been denizen from the book of D. Melehov), joining the psychiatrists, psychotherapeutists, psychologists, people of church and representatives of public organizations problems "Doctrine and mind", "Sin and fault", "What the mental disorder is", "Patient and it illness" etc. are discussed. On these questions the course of the lectures is read, the conferences will be carried out. A ultimate goal of such activity is to open potential of the man (patient, client), suffering by mental disorder (or having a psychological problem) or/and inclined to spiritual search (in particular - of the believer) more full.
Graduate Student, Russian State Medical University
Corporality has been treated in a different way in the history of human self-knowledge. There has always been a desire to do without this category using other concepts. Transformation of philosophy into a classical science with its tendency towards general objectification resulted in Corporality being outside. Philosophy reduced Corporality to biological and sociological analysis. Corporality turned out to be ignored by psychology either, as it treated Corporality as an archaic form of vital activity. Corporality acquired another meaning in Vygotsky's cultural and historical conception. Corporality is included into a broad context of human knowledge. Corporal phenomena are socialised through adoption of the system of signs. The satisfaction of the vital needs by the mother in ontogenesis has a function of interpersonal communication. The stage when the communicative meaning of corporal phenomena prevails coincides with the symbiosis period. Later the communicative meaning starts to weaken but it may be actualised and even cause development of conversion disorders. Next comes the period of the psychosomatic development that is characterised by appearance of another type of activity. It is imitation activity. The child imitates ill adults that later may result in actualization of learned symptoms in chronicle disease. Acquisition of speech skills is a major task in a third period. The child starts considering his body through the meanings that a word has. Corporal phenomena of an adult person are most complicated. In case of a disease ?orporal sensations do not only mean perceptive tissue but a disease as well. Formation of the secondary meaning of corporal sensations is connected with adoption of the cultural views on the disease. According R.Bart ideas can be interpreted as classical myths. In this system sign (corporal sensations) which is an association of perceptive tissue and corporal structure becomes a denotative in the myth of the disease and is transformed into a symptom. The same mechanisms are the basis of the treatment. Treatment is a process of turning myth inside, from the secondary semiological system (the myth of treatment) to the original one (body language). Any treatment is a sign process and a doctor working in the system of myth has to posses the qualities that are defined by his understanding of the disease. The tendency of medicine towards demythologization should be considered wrong. One should learn to decipher secret myths and create necessary mythological systems.
The Moscow State Medical University
Each psychiatrist, basing his experience not only on the obvious symptoms or categories, which with the course of practice became obvious and definite to him, finally comes to the philosophic orientation on the aggregate existence of man. We need the concept of completeness and desire to interpret our object of research as a unity: biological, personal, living in peace with the others and at the same time indefinitely spiritual. The empiric studies of the definite material lead us to the conclusion, that there is no definite "Structure of Human". The contemporary psychiatry needs methods, allowing to maximally approach the essence of human, the existence of man.
Adelaide, Meath and National Children's Hospital, Tallaght, Dublin 24, Ireland
In the past, "clinical vampirism" was used as a diagnostic category in psychiatry. Review papers were devoted to the topic in journals such as The Archives of General Psychiatry and the Journal of Nervous and Mental Disease. A recent case is described, concerning an East European male with schizophrenia, who believed he was turning into a vampire and needed to drink blood in order to stay alive. He did not want to harm anybody, so he presented to a general hospital in search of the hospital's supply of blood for transfusion. Classical and contemporary literature on vampirism is reviewed, providing numerous clinical examples of psychotic illnesses featuring vampiric delusions and vampiric behaviour. The importance of transcultural factors in determining the content of delusions is emphasized. Many authors have linked "clinical vampirism" with schizophrenia. The attack of the vampire reflects many of the psychodynamic theories of schizophrenia. For example, the schizophrenic has considerable needs to be fed by people who may have deprived him in the past, reflected in the vampire's craving for oral nourishment in blood. Following the attack of the vampire, the victim becomes a vampire too, reflecting a significant loss of ego boundaries. According to mythology, vampires do not cast reflections in mirrors, and schizophrenics commonly have sensations of reduced visibility. In these and other ways, the myth of the vampire provides a valuable psychodynamic and phenomenological model of schizophrenia.
Psychologist; C.H.U. Sainte Marguerite, Marseille, France
DSM IV defines hallucinations as "a sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of relevant sensory organ". This definition fails to distinguish pathological and mystic experiences. Moreover, it does not give adapted consideration of cultural beliefs. M.Liester (1998) reserves the term hallucination to pathological experiences by adding two criteria for including medical context and excluding religious experiences. However a relative perspective implies to consider both cultural and pathological voices as meaning process.
D. Pringuey M.D., F.S. Kohl M.D., S. Thauby M.D.
Academic Department of Psychiatry and Psychological Medecine, CHU Pasteur BP69 06002 Nice cedex 1 France
Collège International de Philosophie
An article was published recently in Nature Medecine about the possibility of anticipating Epileptic Seizures (Cf. " Epileptic Seizures can be anticipated by non-linear analysis " by J. Martinerie, C. Adam, M. Le Van Quyen, M. Baulac, S. Clémenceau, B. Renault & F.J. Varela, Nature Medicine, volume 4, number 10, octobre 1998, p. 1173-1176.)
Department of Communication, Aalborg University, Denmark
By the application of Merleau-Ponty's phenomenology, it is aimed in this paper to contribute to the illumination of intentionality in psychosis. In his close investigations of intentionality in perception, the body, and language Merleau-Ponty laid open a structuring of meaning which, however incoherent it may be, is sociocultural structuring and which we never escape in our own experience and practice.
Dept. of Psychiatry and Psychotherapy, Technical University of Aachen, Aachen, Germany
The paper will focus on the theoretical and epistemological foundations of what is usually called "biological psychiatry". In the first part, the historical perspective is discussed, especially the emergence of biological hypotheses on the etiology and pathogenesis of mental disorders in the 19th century, exemplified as well by concepts (e.g. degeneration theory) as by authors (e.g. Emil Kraepelin). The second part will outline the development up to the year 2000, focussing on the problems that do result from the manifold meanings of the term "biological" in a psychiatric context. The range of meanings includes clear-cut empirical laboratory studies, questions of clinical psychopathology and nosology and even an anthropological framework. Before using it, it is necessary to clarify the meaning of this important term in order to avoid severe misunderstandings.
Dept. of Phenomenological and Existential Psychology, University of Buenos Aires, Buenos Aires, Argentina
Taking Heidegger's "The question concerning technology" as a starting point we are in a position to wonder about the meaning that both the technological development, and the advance of science have in today's world, and how 'the human'(menschlich) may express itself within this frame of reference.
R. Vizioli, L. Orazi
VI Chair of Neurology University "La Sapienza", Rome
In line with one of the topics of this congress (history of ideas) the authors devote their contribute to the scientific personality of F. W. Sperry, Nobel prize for Neurophysiology. In his classic paper of 1980: "Mentalis yes, dualism no" Sperry made some revolutionary statements considering is long background of neurophysiologist and used for the first time the word "interactionism" stating that mind is a production of matter but acts on matter. in other words as neurophysiologist he has no doubts that brain is the basic structure of mind but, and this point is revolutionary, he, as philosopher of mind accepts that mind play a leading role in modifying brain.
Before him another Nobel prize for Neurophysiology: Sir John Eccles said that the brain caused in the scientiphic world some unrespectful gossip about the hypothesis that Sir John Eccles had a "mystic involution" in his old age.
The authors stress the difference between the unrealistic hypothesis of Sir Eccles and the ideas of Sperry and will try to give some example of the fact that Nobel Sperry is the most authoritative rapresentant of a possible integration between mind philosophy and Neurophysiology
D. Sullivan MBBS MBioeth MHealthMedLaw MACLM
Honorary Research Associate, Monash University, Australia
Putative genetic and biological aetiologies for various mental illnesses and behaviours dominate research literature and popular media. New techniques for imaging the brain and mapping the human genome have focussed attention on the structural anomalies and functional brain-states of abnormal behaviour.
Senior Clinical Lecturer in Psychiatry, University of Sheffield, The Longley Centre, Sheffield, UK
In this paper we present data from a series of related brain imaging experiments, using positron emission tomography (PET). These studies examined the functional anatomy of volition in neuropsychiatric disorders (including schizophrenia, depression, Parkinson's disease, hysteria and deliberately 'feigned' dysfunction).
- A naturalistic interpretation of the concept of delusion
Dept. of Philosophy, Goteborg University, Sweden
This paper discusses the part of the DSM-IV definition claiming of delusion that it is "[a] false personal belief based on incorrect inference about external reality".
J. Zislin MD
Kfar Shaul Mental Health Center, affiliated with the Hebrew University Medical School, Jerusalem, Israel
As strange as it may seem, psychiatrists contrary to psychoanalytic have seldom made attempts to analyze the significance of language in mental illness. This is particularly surprising in view of the fact that language is their principal instrument in attempting to assess the condition of patients. Psychiatrists tend to interpret language in a phenomenological manner. But here the following should be noted: when language is looked upon as an instrument/symptom the linguo-philosophic principle is being ignored. Clearly, another approach to the understanding of psychotic speech is needed, one that takes into account the role of language in the generation of psychosis. Our idea that the speech act theory makes it possible to realize it. According to the illocutionary acts theory (J. Austin), a distinction should be made between utterances that constitute statements or descriptions, and utterances that constitute acts of creation. It is assumed here that psychotic discourse should be viewed as an illocutionary act and that language itself is able to create a new psychotic reality. The peculiarities of this approach are the following: Psychotic discourse can be defined ignoring true-false dichotomy.
C.W. Van Staden
Department of Psychiatry, University of Pretoria, South Africa
A report is given on the synergistic utilisation of philosophical and empirical methods in a study of first person pronoun usage by recovering patients. The philosophical component was an extension of the work by Frege and the logic of relations. It distinguished semantic usage from syntactic and pragmatic usage of first person pronouns. Semantic usage of first person pronouns was described analytically according to the expression of occupancy of distinct semantic positions in relations, called the alpha and the omega positions. Criteria were proposed to identify the alpha and the omega positions as, respectively, positions of the owner and the accidental of a (Fregean) relation.
University of Glasgow, Scotland
The concept of piety was the issue in the Socratic dialogue titled Euthyphro. Piety was not clearly established. The dialogue is typically aporetic. The concept was important because it had social importance in Athens at that time. I argue in this paper that we have a similar situation with concepts of mental and physical illness. They are both important for individuals and for the societies they live in. But our concepts of mental illness (as a failure of action) and physical illness (as a failure of function) do not seem to hold in many situations, just as Euthyphro's concept of piety as doing as the gods do, did not hold in many situations of fourth century (BC) Athens. Socrates made the point that the gods did some very different things and that the young Euthyphro had to do some reasoning for himself if he was to establish what activities really could count as pious, and therefore just, in the actions of the gods. There can be no evading this kind of reasoning in each case that is open to interpretation. So I argue that there can be instances of mental illnesses that are a failure of function (whatever that is taken to be) and physical illnesses that are a failure of action. Does all this then mean that physicians and psychiatrists should abandon their different concepts of illness because they are loose and only of use in the more social or non-professional contexts? In following Socrates I argue that caution should be taken with these concepts. I ask about the role of these concepts in the physicians and psychiatrist's work with particular cases of mental and physical illness. Is the psychiatrist or physician to work with the disorder as it presents itself in the ambiguities of the patient, or is she to start with the relative clarity of concepts of mental or physical illness? I argue for neither but cite the two recent cases in Scotland of the apotemnophilia ('imagined ugliness') that gained treatment in leg amputations as complicating the issue and something that should be reflected upon with great care.
D. Padro Moreno
Hospital Civil de Basurto (Servicio de Psiquiatría)
If certainly wisdom was before philosophical knowledge, it's from the latter where our actual procedures comes from. Astonishingly for nowadays, one of the concepts more developed in the Modern Age, was not known in the Classical Age. Depending on the subject's notion we manage in our clinical work we will take different relationship approaches between doctor and patient. We will analyze Gadamer's proposition of the subject's notion realized by him in his New Hermeneutics. Based on hermeneutical's circle, relation process is in a symetrical and reciprocal basis. In an opposite sense for Lacan relationship betweeen subject and the Other though in the circle is never reciprocal, but clearly asimetrical. The consequences of both types of approaches will be analized around a delitious tail from Saramago. In this way we can appreciate that knowledge's philia in reality praxis is always developed by love's
- Form and content, the role of discourse in mental disorder.
Any mental disorder is given form by a set of factors which often make it recognisable as a pattern of manifestations in terms of behaviour, neurological symtpoms, and conversational activity. It is plausible that the form of a psychiatric disorder is, in many cases, a causal result of a certain disease process. But in addition to this and in parallel with it there is content to a psychiatric disorder which may take the form of genuine llife problems contributing to stress or depression, or some meaningful constellation of life events that can only be dealt with by adopting the solution available through a disorder. I will examine two cases, the one case concerns a person with bipolar disorder who commits suicide, almost certainly for reasons to do with a dysfunctional life relationship and its effects on him. The second case is a young woman with anorexia where we are forced to take seriously the meaning of food and eating to her in order to understand her suffering from this disorder. I will use the insights generated from these two examples to explore the ways we can conceptualise the relationship between the causal structure of the mind and the discourse which the mind inhabits. The result is a profound synthesis of the nature of psychiatric disorder as it is seen from within the framework of discursive psychology.
Department of Psychiatry, UT Southwestern, Dallas, TX, USA
Kenneth Schaffner has characterized biomedical theory as built around overlapping and interacting "levels of aggregation" which in turn are characterized by particular varieties of "ontological reduction." Ontological reduction is the simplifying of complex phenomena into descriptions apropos to a particular research theory, procedure, or program, or "level of aggregation." Ontologically-reductive statements can be generally described as reflecting the form "the phenomenon is little more than an example of general explanation Y." As a specific example: "Schizophrenia is little more than the consequence of a collection of variant, and suboptimal, alleles."
Subjectivity is a methodological keyword in the understanding of recent and important trends in Italian historiography: microhistory and gender history, which are connected by the rejection of structural determinism (olism). One way of developing this category (the traditional method of historicism) is to underline the qualitative idea of the unity and centrality of human nature. At the same time, the debate among social scientists about the possibility of methodological individualism and neoclassical rationality offers an alternative pathway. Following the work of philophers like Elster, of economists like Sen, and sociologists like Giddens, the paper focuses on the main historiographical consequences of that debate: the connections and contradictions between macrostructural and microindividualist explanation, the growing complexity of individual rationality and the varying influence of social norms.
Soggettività è un termine chiave per comprendere le tendenze più recenti ed importanti della storiografia italiana: la microstoria e la storia di genere, che sono accomunate dal rifiuto del determinismo strutturalistico (olismo). Un modo di sviluppare questa categoria (quello dello storicismo tradizionale) consiste nel sottolineare l'idea qualitativa dell'unità e della centralità della natura umana: lo storico e gli uomini che formano il suo oggetto di studio appartengono allo stesso genere umano, il che permette di rivivere e comprendere (che è cosa diversa dallo spiegare) il passato. Ma il dibattito degli scienziati sociali attorno alla possibilità di un individualismo metodologico e di una razionalità neoclassica offre una strada alternativa. Seguendo l'opera di filosofi come Elster, economisti come Sen, sociologi come Giddens, il paper si concentra sulle principali implicazioni storiografiche di tale dibattito: i nessi e le contraddizioni tra spiegazione macrostrutturale (clima, demografia, economia) e spiegazione microindividuale (razionalità, legami comunitari, culture), la crescente complessità della razionalità individuale e l'influenza variabile delle norme sociali.
The main goal of the scientific method is to create hypothesis, models and theories suitable to comprehend the Universe. We talk about mass, energy or time because they help us face the comprehension of the complexity of our experiences. There is an issue as old as Science: do scientist make up or discover the laws of Physics?
Reductionism is an epistemological theory whose clearest formulation was given by those logical empiricists who defended physicalism. Among the privileged examples of reductions of theories one can mention the reduction of thermology to classical mechanics through thermodynamics and the reduction of chemistry to physics through Bohr's theory of the atom. Following the example of the different opinions that one can have with regard to the relationship between biology and chemistry also the so called 'mind-brain problem' has been seen according to all the possible combinations of ontological/methodological reductionism/antireductionism: ontological and methodological antireductionism (dualism or pluralism); ontological and methodological reductionism (materialism, identity theory); ontological reductionism and methodological antireductionism (functionalism); ontological antireductionism and methodological reductionism (scientific emergentism). To sum up, the ontological and methodological reductionism of the identity theory has been rejected either completely by dualists or partially by functionalists. However, there is a third way to reject methodological reductionism though accepting ontological reductionism: eliminativism. This theory is an extreme contemporary form of materialism and naturalism according to which, although it is true that mental states are not reducible to brain processes, that is not due to the fact that mental states are not physical or to the fact that they are functional states that can be implemented by different brain processes but to the fact that mental states do not exist under the description given to them by folk psychology. This does not mean that the mental does not exist at all but simply that concepts like for example belief, desire, intention, passion etc. are too crude if one wants to found a scientific psychology on them. The most striking objection that has been advanced against naturalism and materialism in all its forms is that there is an aspect of every subjective experience that cannot in principle be reduced to a natural (physical) process. If I see and smell a rose no neural process in my brain can be identical to the experience that I have of seeing its redness and smelling its flavour. However, materialists and naturalists have replied that the consciousness of 'qualia' might not be the knowledge of immaterial phenomena but the way in which the brain monitors some of its own processes. The possibility of reducing mental states to brain processes and substituting psychology by neurosciences is still very disputable. However, whereas forty years ago the discussion between the identity theorists and their opponents was developed only by means of arguments a priori and conceptual analysis and was devoted to establish the mere logical possibility or impossibility of such a reduction, nowadays neuroscientists give philosophers - by means of their 'brain images' (P.E.T., functional magnetic resonance etc.), EEG layouts, theories on the sensorimotor-coordination of animals and human beings, clinical cases that show a certain correlation between psychopathologies and brain lesions etc. - many examples of the kinds of neural activity that might be identical to phenomena which in our everyday language we usually describe as mental.
Psychopaths lack the normal capacity to feel moral emotions such as guilt based on empathy with the victims of their actions. They also apparently can't keep track of their own interests consistently over time and therefore are unable to learn from punishment. In effect, they fail to empathize with themselves at other times, and in that sense lack an emotional prerequisite for full rationality.
There is a tension in our pretheoretic views about the evil person. On the one hand, we find it almost incomprehensible that a fellow human being could consistently violate moral rules, often take pleasure in doing so, and evince no subsequent guilt or remorse. This makes it tempting to think that the evil person is simply beyond the moral pale; he is not a member of the moral community and thereby cannot be held morally responsible for his wrong-doing. On the other, we are bothered by the evil person. We do not think that he escapes our censure and we are reluctant to entirely exclude him from blame. In sum, we think of the evil person simultaneously as one of us and as not one of us. But this is not a coherent position. If we seek rational and effective medical and legal strategies for dealing with evil, we will need some framework within which this fundamental tension can be resolved.
Psychoanalytic Institute for Social Research, 11, Passeggiata di Ripetta, Rome, Italy
"Suppose that someone says his lust is irresistible when the desired object and opportunity are present. Ask him whether he would not control his passion if, in front of the house where he has this opportunity, a gallows were erected on which he would be hanged immediately after gratifying his lust." (I.Kant, PrR 30)
"Ich bin alt und will für ihn sterben, denn er hat Frau und Kirner" (I'm elderly, I want to die in his place, because he is married and he has sons). These were the words with which the polish priest, Maximilian Kolbe, saved Francis Gajowniczeck, taking his place in the list of prisoners destined to be executed by the SS in July 1941, in the concentration camp of Auschwitz. "Ihr werden eingehen wie die tulpen" (We shall dry them as tulips) said the guards to the prisoners. Two weeks after only four prisoners on ten still survived, between them Maximilian Kolbe. They were killed on August 14, by an injection of phoenic acid.
Assistant Professor, Department of Philosophy, Dowling College, Oakdale, Long Island, NY, USA
It is difficult to find a satisfying account of how an action can be performed by a person with full knowledge of relevant information and under no physical constraint or coercion from another person, and yet fail to be autonomous. Yet in many cases of psychopathology, such as addiction, compulsive rituals, mania and possibly even personality disorders, we are often inclined to describe a person as not in control of her actions, in contrast to the way a healthy person normally acts autonomously. Some libertarian and existentialist antipsychiatrists have suggested that the notion of non-autonomous intentional action is confused. They have argued that it is a conceptual truth that intentional action, at least when performed without coercion from another person, is autonomous.
Department of Psychiatry, Rotherham District General Hospital
A hypothesis is presented for eating disorders, based on Darwinian theory, that contends that these syndromes, together with the phenomenon of the pursuit of thinness, are manifestations of female intra-sexual competition. It is suggested that eating disorders originate in the human female's psychological adaptation of concern about physical attractiveness which is an important component of female 'mate attraction' and 'mate retention' strategies. It is argued that present-day environment of Western countries presents a range of conditions which have led to the overactivation or the disruption of the archaic female sexual strategy of maximizing 'mate value'. The present hypothesis deals with the ultimate level of causation and is, therefore, compatible with a range of theories of proximate causation. Although the present hypothesis is not directly testable, it makes predictions that are testable and refutable. Arguments and evidence is presented in favour of a range of predictions that arise from this hypothesis. It is suggested that the sexual competition hypothesis has more explanatory power than existing evolutionary theories of eating disorders.
British Journal of Medical Psychology (1998), 71, 525-547
Department of Psychiatry, Warneford Hospital, Oxford, UK
In society we are continually adapting to new technology, customs, laws, roles in life, and most importantly of all, to one another. Following Daniel Dennett and other writers, four methods of adaptation will be described: inherited instincts; trialanderror learning; cognitive learning and the use of language and other symbols.
V. Murray*, J. Barnes
*Department of Psychiatry, University of Edinburgh, Morningside Park, Edinburgh EH10 5HF; Drs Barnes & Graham, The Surgery, 14 Hillington Road South, Glasgow G52 2AA
While intelligence and language are generally held to be the major components of human uniqueness, the marked capacity for altruism may have been the key to the evolutionary success of modern humans. Altruism in evolutionary terms describes an individual acting to increase another's survival fitness at the expense of their own fitness. Thus the origin of altruism is difficult to account for in evolutionary theory, but once established, altruism is advantageous. Reciprocal altruism, whereby reciprocal acts are repaid, demands that individuals meet repeatedly, can remember who helped them in the past, and can recognise and guard against cheaters. Indirect reciprocal altruism supposes that being perceived as being altruistic increases the likelihood that the individual will be in receipt of altruism from a third party in the future. Evolutionary altruism provides the foundation of human society, and the need for rules to punish cheaters. Altruistic behaviour can be considered a complex trait with an underlying genetic basis and a large environmental component.
Psychosis is also a complex trait, and many different theories have been proposed to account for its persistence across all human cultures despite a likely evolutionary disadvantage. Kraepelinian division of the psychoses pervades modern psychiatry, compartmentalising research and obscuring features common to people with psychosis as a whole. Research involving people with a broad range of primary psychoses has permitted clinical observations which would otherwise be overlooked. The authors have noted, both in psychiatry and general practice, as a group people with psychosis and their relatives appear to be more altruistic than usual. If the trait of psychosis and altruism co-evolved, this may account for the persistence of psychosis. Genetic advances make identification of predisposing psychosis genes likely, but it would be dangerous to alter the balance of such genes in the population, if this also affected the tendency to altruism. Of more immediate relevance, an association between psychosis and altruism could profoundly change society's perception of people with psychosis, and perhaps redress the stigma associated with these illnesses.
S. KarakaB1*, Y. Örs,2*
1 Department of Experimental Psychology, Hacettepe University, Ankara, Turkey* ; 2Department of Deontology Ankara University, Turkey*;
A paradigm change has been declared in brain electrophysiology. This change involves the renaissance of the oscillatory activity as the valid response of the brain. Contemporary research repeatedly shows that the electroencephalography (EEG) and the event -related oscillations of the brain have a higher explanatory value than time-domain event-related potentials (ERP).
- The negative and positive element of delusion - a new Jacksonian concept
Ph. Portwich, A. Barocka*
Department of Psychiatry, University of Erlangen; *Hohe Mark Hospital, Oberursel (Germany)
This contribution presents a new psychopathological concept of the structure of the psychiatric phenomenon delusion in terms of John Hughlings Jackson's (1835-1911) model of cerebral disorders.
F-S. Kohl, D. Pringuey, F. Cherikh, S. Thauby
Clinique Universitaire de Psychiatrie et de Psychologie Médicale, France
Mary-Magdalene is a young patient referred by the police to our department for a psychotic episode. She was founded wandering in the city not even remembering her name. Slowly she revealed pieces of the history of her existence. Six months after our first meeting, she was able to express her understanding of what happened to her. She expressed a wide mystical delusional experience. She had the intuition that she came from another planet, that her family was a fake one and that God and the saints imposed on her this experience for redemption of her sins.
Husserl E. Méditations cartésiennes. Librairie philosophique J. Vrin: Paris, 1996. 256p.
Consultant Psychiatrist, Private Practice, Burwood NSW Australia
Objective: To use a multi-axial approach to characterise and manage 'madness' more efficiently and yet more humanely; as it demands and allows such a course.
Method: Philosophical conceptualisation, using both its analytic and synthetic functions and considering ontological, epistemological and methodological aspects to achieve a more comprehensive, critical and concise diagnosis and therapy.
Results: The 3 Categories of Consciousness in which we normally perceive the 'realities' of our world are mixed in madness:
Diagnostically, 'madness' (this ataxia of the mind) must be analysed parallel as
Conclusion: Therapeutically alientation is the most in-sane approach to madness. The self has to be supported and Integrated by: A Multi-Axial Dynamics (M.A.D.) based on Phenomenology, Personality and (Human) Ecology using the Morphogenetic Metaphor of Mind in a New Paradigm of Psychiatry.
Seminar "Philosophers on madness. The dialogue between philosophy and psychopathology III"
Department of Philosophy, University of Southampton, United Kingdom
If in life we are surrounded by death, so too in the health of our understanding by madness. (Culture and Value, p50)
International Institute for Interpersonal Communication, Liechtenstein
Family roles are: parental roles of motherhood and fatherhood, spousal roles of husband and of wife, and the role of a child.
Psichiatra, C.S.M. di Arona, ASL 13 Regione Piemonte
Intentionality is a theme upon which philosophers of the mind have discussed since the beginning of time, and the roots of this problem spread way back to the down of human thought. The attempts made to reach an unequivocal and operational definition of the concept - through the different points of view - have probably run into the constituent feature of intentio that is its dynamic aspect borne from the interaction, and the continuous relation between man and the world, between man and his personal history, between the ambitions and the possibility of fulfilling them in the world-of-the-life that is his own.
BLANKENBURG W., (1971), La perdita dell'evidenza naturale, tr. it. Raffaello Cortina Editore.
- Phenomenology and Psychosomatics
CONICET and Dept. of Phenomenological and Existential Psychology, University of Buenos Aires, Buenos Aires, Argentina.
By dividing the field of the human, the psyche-soma dualism ended in sectorizing diseases into organic illnesses, and psychic illnesses. Eventually, however, the so-called 'psychosomatic disorders' that, apparently, had broken up such a pattern have been converted to a new corpus pineale just as Descartes would have done. The body is reduced to a mere instrument of psyche, and the subject is reduced to a mere onlooker of illness he or she tries to remove one way or the other.
- Mental disorder as an excuse
Department of Philosophy, University of Aberdeen, UK
The "insanity defence" is a familiar part of most legal systems, but "insanity" is a legal, rather than a psychiatric concept. How far can we use the concept of "mental disorder", which is more typical of psychiatry, in a similarly exculpatory fashion? That depends largely on how far we can map the latter concept on to the former in relevant respects. The insanity defence is often supported by reference to Aristotelian conceptions of involutariness, which at first sight involve two criteria: lack of knowledge of relevant features and lack of control over one's own behaviour. But Aristotle's examples do not suggest that ignorance and lack of control in themselves excuse, but only when they are themselves exusable, and this seems to be the case also when they are applied to the example of insanity (as seen, for instance, in the famous case of M'Naghten). Different sorts of examples of typical mental disorder often cited as diminishing responsibility are examined to see in what ways, if at all, they meet the Aristotelian criteria so interpreted. It is concluded that only some of them in fact do so, and that the relevance of psychiatric expertise to legal decisions is more complex and subtle than it is often thought to be.
Department of Psychiatry, University of Turku & Department of Philosophy, Åbo Akademi University, Turku, Finland
This presentation belongs to a series of papers that investigate the logic of some central psychiatric concepts like "psychosis", "delusion", "insight" and "understanding". The key theme of these investigations is the importance of the grammar of "understanding" and concepts related to its demise ("incomprehensibility") in describing these psychiatric concepts. In this paper, the logic of incomprehensibility is investigated with reference to Ludwig Wittgenstein, Cora Diamond and Peter Winch. It is shown that incomprehensibility is not a stable attribution on which we could build either psychopathology or psychiatric activity. The implications of these findings to our understanding of psychiatric conceptualisations are drawn.
- Moral reasoning in individuals with personality disorder
G. Adshead, S. Nicholson, E. Skoe
Personality disorder is a medical term denoting significant interpersonal dysfunction, and failure at social relationships. There are categories of personality disorder, such as antisocial personality disorder, which are characterised by rule breaking behaviour, and sometimes violence towards others. It has sometimes been argued that individuals with antisocial personality disorder are less able to reason morally, and it is this failure in their capacity to reason morally which contributes to their unpleasant and antisocial behaviour towards others. We present the results of a pilot study looking at moral reasoning in men and women with personality disorder in a maximum security hospital in England. We hope to show that there is a range of levels of moral reasoning. Moral reasoning is assessed using the Ethic of Care Interview (Skoe 1993) which we will argue is more appropriate for individuals with personality disorder, than other tools for assessing moral reasoning.
This paper is a product of serendipity. It explores how ward based psychiatric nurses in one Special Hospital attribute the notion of 'evil' to deviant activities. Staff were asked to read and make comments about a series of vignettes, abbreviated offence scenarios, from which emerged the construction of a taxonomic order of evil. These explanations of evil were then juxtaposed alongside their counterparts from theodicy. Deviancy attributed to extreme psychoticism is not credited with being an evil act, such individuals having a primordial contract of innocence. In contrast, extreme crimes committed by those with a psychopathic disorder are considered evil. An evil act is seen to be one which transgresses a `natural boundary'; the product of purposeful action after the accumulation of stages of `reality testing'; and, finally, a consequence of the extinction of moral bonding leading to residual instinctive behaviour.
The fact that there is a right way to behave and a wrong way to behave is one of the rare universals of Human society. Anthropologists have studied the similarities and differences of the rules that structure human behaviour - and what happens to those that break the rules - in many different places. Common themes emerge of taboos, witchcraft and evil contrasting with other, harmony and social cohesion.
On Friday, March 6, 1999, at 11:08 a.m., the police department in Naperville, Illinois, an upper middle-class suburb of Chicago, received a chilling phone call. The caller was Marilyn Lemak, estranged wife of a local physician, who had just learned that her husband was dating another woman. "My three kids are dead and I wanted to be dead too, but it didn't work. I did it." On the night of November 4, 1997, in Little Rock, Arkansas, Christina Marie Riggs, a single mother abandoned by her husband injected a large dose of potassium chloride into one of her children's neck, gave him an injection of morphine and smothered him to death. Shortly thereafter, she smothered her second child to death with a pillow. She then wrote a suicide note and attempted suicide but failed.
On July 12, 1995, in Spartanburg, South Carolina, Susan Smith was sentenced to life in prison. On February 14, 2000, the mothers of Naperville, Illinois picketed the courthouse where Marilyn Lemak had been charged with first degree murder, demanding that she be found innocent by reason of insanity and get proper treatment for her mental illness. On May 2, 200, in Little Rock, Arkansas, Christina Marie Riggs, 28 years old, was executed by lethal injection.
How can these three cases whose similarities are so striking have such different outcomes? This paper will attempt to deal with this question as well as with the uniquely American tendency to transform a moral dilemma into a medicolegal issue with scientific trappings. It will also attempt to show that though the psychological motives of these three women were remarkably similar, the moral perspectives of the communities in which they lived, were quite different.
Assistant Professor of Political Philosophy, Memorial University of Newfoundland, Canada
Much contemporary analytic work in philosophy of psychiatry has focused on defining mental disorder (Clare 1980, Fulford 1989, Wakefield 1995, Clark 1999) and in doing so has done much to clarify the evaluative as well as factual dimensions of normal and abnormal thought, feeling, and action. Recognizing the importance of intentionality and values in judgements of normality and abnormality has lead to broad notions of mental illness which (as Fulford has argued) are best seen not as putting psychiatry at odds with general medicine but rather as creating the model of understanding of illness in general. In this essay I shall argue (a) that this contemporary view of mental illness, conceived as dysfunction of intentional and normative rationality, is conceptually highly defensible; and, at the same time, (2) that this view raises highly complex, perhaps irresolvable empirical problems in terms of distinguishing cases of mental illness from idiosyncratic or unethical behaviour. The analysis of mental illness or madness in terms of a failure of reason is fairly well established, though irrationality regarding norms and values is less readily accepted as a component of mental illness. The reason for scepticism regarding the latter is obvious: including unreasonable values in the definition of mental illness threatens to conflate illness and badness of an ethical sort; doing so would jeopardize the scientific standing of psychiatry. Yet it is to such an impasse that recent work regarding definitions of mental disorder has brought us. The impasse has been dealt with differently. Some, e.g., Wakefield, include values in disorder but conceive of them as subjective harms distinct from scientifically conceived dysfunctions. Others, e.g., Fulford, incorporate normative malfunction in their analysis of illness and defend such views by resort to notions of the 'ordinary' or 'normal' state from which illness may be reasonably distinguished. Neither of these strategies succeeds, I shall argue: the first accepts a subjective view of norms that is philosophically weak and the second accepts an uniform notion of the ordinary that is historically and culturally weak. Including the value dimension in mental illness and illness in general is an important conceptual advance in philosophy of medicine; at the same time, the difficulties in distinguishing between certain illnesses and different or unethical behaviour should not be played down. The challenge for views of mental illness now lies in a general consideration of the relation between physical, psychological, social, ethical, and political dimensions of normality and abnormality in personal life and conduct. The complexity of such inquiry shows the need for new methods of thought and the dangers of philosophical and scientific complacency. The analytic tradition in philosophy of psychiatry may here benefit from views in what has, up to now, been a radically divergent tradition, e.g., the social and political philosophies of madness (e.g., Foucault 1954, 1965; Deleuze and Guattari 1972, 1980). How such an encounter may be beneficial will be suggested in closing.
Central Sydney Area Health Service
The question of whether human beings can reasonably be considered responsible for their actions in a deterministic universe has occupied philosophers for millennia. This paper discusses philosophical theories of responsibility, from Aristotle to the present day. The issue is of particular relevance to psychiatry, as psychiatrists often encounter patients who appear unable to behave responsibly. I will consider the nature of responsibility and the function of this concept in our society, in order to examine the question of whether people with severe personality disorders should be held responsible for their actions.
University of Sheffield, Institute of General Practice & Primary Care, Community Sciences Centre, Northern General Hospital, Herries Road, Sheffield, S5 7AU, England
The aim of this paper is to challenge one notion of agency that existential psychotherapists propound. To put it very simply, this notion of agency suggests that we are free agents who choose to create, and are responsible for, our own destiny. In this paper, I argue that this notion of agency in fact reflects the Socratic paradox in which agents cannot knowingly choose the worse of two available alternatives. Rather, they always choose what they think best. I then follow by arguing that the notion of agency is problematic because the possibility of "akratic actions", i.e. weakness of will, has been ignored. I argue that akratic actions should not be optional in therapeutic practice. As the possibility of akratic actions is considered, one can make dubious the existential psychotherapeutic framework of agency. I argue that to do so would bear important implications for therapeutic practice.
A.O. Brundusino, G. Longo
University of Pavia, Italy
Being able to feel the others' sufferings arises from the meaning of acting as psychiatrists. Ethics consists in being called to give account of ourselves, of our values, of the projects for our lives; psychiatry will live "the others" only by giving right to different, but anyway righteous, ways of life. The deepest requirement is that of reciprocity, which states that the other one is similar to myself and to the others; the phenomenologic path which was given room by a suffocating psychiatry states the respect for the other, without distinction between healthy and ill subjects. Every psychiatrist should start from himself; knowing this could be an answer to the questions and worries rooted in the lack of care to the other one, who is different from me, but similar to me.
Shame is an abnormal predominance of the interpersonal world over the Self. The centre of gravity of life is shifted outside: the other person's judgement rules the Self. The Mitwelt dominates subjectivity. This is the essential aspect of "social phobia" that expresses the insecurity of the Self. But the vulnerability to shame, like the insecurity of the Self, is possible at different levels. One level concerns the ontological foundation of the Ego (trascendental Ego), the deficiency of which could be the matrix of psychotic experiences. Another level is the ontic position of the Ego (empirical Ego) in the context of "natural experience", and it could be the level in which "social phobia" appears.
F. Brogi, M. Cerretini, G. Di Piazza, M. Del Sole, L. Luccarelli, V. Migliorini, M. Nitti
University of Siena, Department of Psychiatry (Direttore Prof. Castrogiovanni P)
Human psychic suffering often takes the form of a somatic symptom. Physical pain, which can be found in every psychiatric diagnosis, is sometimes the only symptom of a disorder. In that case the soma asserts itself as an experienced-body (Leib) and the somatic perception became private communication through the body image. That kind of pain seems to be functional if compared to more "mental" conditions, such as depression. Patient suffering psychogenic pain follows different courses: fantastic metaphors describe a symptom absorbing the human being and his being-in-the-world; or an indefinite feeling unwell winds through important life events. By a few psychopathologic considerations we think possible to set the phenomenon into the field of the delusional experiences, at least in some respects. This suggests a defensive function as to more severe psychopatologic developments.
M. Cerretini, F. Brogi, G. Di Piazza, M. Del Sole, L. Luccarelli, V. Migliorini, M. Nitti, P. Castrogiovanni
University of Siena, Department of Psychiatry
In case of algic disorder, clinicians pay few attention to psychopatological course from mental contents to algic somatization. Studies on the personality, found out conflicts between an ego-ideal being independent versus precocious needs of dependence (1). The psychoanalitic school uses terms as "psychotic core" of personality to indicate residues of symbiotic contents associated to presymbolic mental activity and primitive defense mechanisms; psychopatology connected with physical suffering may be splitted and crowned in the above-mentioned areas; alexytimic trends could be an epiphenomenon linked to a lack of symbolization and to a confusion between Self and object (2). Psychopatological research about basic symptoms, individuated transition sequences toward delusion of somatic control; first stage's features are circumscribed and migrating algic sensations, motor weakness and stiffness (3); these symptoms may be phenomenically similar to those of algic disorder. Our aim is the study of psychotic dimension in a sample of patients with algic disorder using questionnaires as the italian version of "Experimental World Inventory" (EWY) (4) and of "Bonner Skala fur die Beurteilung von Basissymptomen" (BSABS) (5).
Institute of Psychotherapy and Medical Psychology, University of Wuerzburg, Germany
The phenomenon of symptom shift is well known since a long time. In "Beyond the Pleasure principle" Freud for instance states: "We also know (...) that severe disturbances in the distribution of Libido like in melancholia may be lifted temporarily by an intercurrent organic illness (...)". Among many others Kerman described a shifting between asthma and affective disorders. The phenomenologic pioneer of psychosomatic medicine v. Weizsäcker was speaking of an "alternation" or "mutual representation" between mental and somatic disorders. Schur regarded organice diseases as "somatic equivalents" expressing severe mental disorders. These examples suggest a similarity in the structure of psychosis and psychosomatic illness. Such a structural connection is also supposed by Lacan who states a defiency in the emergence of the "paternal metaphor" and an unsymbolized relationship with reality in both conditions. The 'concretistic' thought and the absence of a genuine 'transitional object' in both, the psychotic and the severely ill psychosomatic patient, appear to point to a comparable 'basic fault' in the function of symbolisation. Why the reaction to this primary symbolisation "defect" takes the form of a psychosis in the one case and that of a severe psychosomatic disorder in the other and why these responses can alternate in one and the same patient is very much the question. Case reports as the history of a young female patient who originally suffered from schizoaffective psychosis, who later on under therapy developed gastric ulcer, then neurodermitis and finally showed features of an neurotic-depressive emotional state can illustrate these theoretical considerations.
G.G. Beskrovny, MD; G.N. Khandourina, MD
Khabarovsk Region Railway Hospital, Khabarovsk, Russia
Pseudosomatic disorders often prevalent in general medical settings. There is a kind of patients with physical complaints meet diagnostic criteria of ICD-for affective (cyclothymia, dysthymia), anxiety, adaptation impairment, conversional and somatoform (somatized, hypochondriac and steady painful) disorders. Routine therapeutic management results in the chronic course of the disease, unreasonable hard-to perform and expensive labs and treatment. Further, the primary disorder accompanied by iatrogenic anxieties leads to long-term disability.Patiets fail to respond to treatment either at the mental hospitals or somatic centers. They need care combining pharmacology and psychotherapy. Over the last 12 years we have been managing such patients in general hospital. They are mainly middle aged females having middle or low social status.The majority of the disordes are psyhogenic. But the patients are unable to recognize their true causes. The psychogenic character resembles a reflexive response to a stressful situation. This mechanism seems to be close to "reflex arch" term. The fixation of the disturbances is likely to result from minor socialization, insufficient self-comprehension and self-regulation. Along with drug therapy modified narcopsyhotherapy aimed at motivation such as autogenic training and meditation, activation to change the situation. The state of trance coursed purposely with medication enables the patient to feel his own resource. Getting beyond the limits of common consciousness inhibits the left hemisphere where logic and estimation predominate. A woman faced to live in compliance with males, logic regulations is unable to solve her problems with reasonable means. Gaining access to the right hemisphere known for its intuition. It is possible to change the scale of values. The work with active imagination enables the patients to experience inner phenomena at fantasy level, to comprehend the symbolic sense of the symptom, "the vital scenario" (E.Bern). The sense of safety and altered world outlook give new perspectives to solving existencial problems and putting forward definite goals.What is the sanogenic mechanism of simbolic virtual examination of the problem situation? Whether it is insight, catharsis, reframing or behevioral investigation is not clear. However, an altered mind is of benefit in breaking emotional set capsule, that makes these emotions more accessible to both the patient and the therapeutist. An altered mind allows these emotions to be taken as a bridge to a real life.
- Psychological Dimension of a Sociological Problem: Stigmatization
Depts. of Psychiatry and Consultation-Liaison Psychiatry, Cerrahpasa Medical Faculty, University of Istanbul/Turkey
Today, much of the attention is not on the psychotherapeutic and/or pharmacotherapeutic advances in psychiatry. It is the stigmatization that has a pivotal role in the practice and theory on this respect.
Department of Medical Ethics, Cerrahpasa School of Medicine, University of Istanbul/TURKEY
Stigmatization has been a long lasting discussion subject of psychiatry without reaching a clear resolution on the issue.
1Department of Psychiatry, University of Heidelberg
The suffering of the schizophrenic patient is mainly determined by psychotic content. From delusions and hallucinations the patient develops strong feelings of anxiety and danger. This experience is almost ununderstandable outside the context of the schizophrenic distortion. A fast and effective neuroleptic and anxiolytic treatment of psychotic symptoms is generally recommendable. In addition, a specific psychotherapeutic management of delusion has been proposed. Nevertheless, suffering doesn't end after acute psychotic symptoms have disappeared. In many cases, with the development of so-called deficits as a result of the disease process a new career of suffering starts. But this suffering is of a different nature. It results from a clash with non-schizophrenic experience and cognition. A precise analysis of different aspects of suffering in the course of schizophrenia, can help us understand why schizophrenic patients are often unable to follow therapeutic instructions optimistically. Poor compliance often develops on the background of newly experienced deficits in social skills and social communication. Apart from the individuality of suffering, we understand suffering as a function of environment. In this context, an anthropological and ecological perspective is helpful to elucidate how we should communicate with schizophrenic patients after acute episodes, to reduce suffering and to promote the individual's specific abilities.
E. Bezzubova, M.D.
Russian State Medical Institute/ University of California, Irvine
Each epoch, culture, society brings its own image of the mad person, expressed as a constellation of clinical signs and social stigma that lie outside of normality. This paper considers so-called "sluggish schizophrenia " (SS) The nosology here is emblematic of the "soviet type" of science-society relationship. Beyond political oversimplification the story of SS opens the way to see multidimensional interweavings and tragic conflicts between science and propaganda, personal authenticity and state regulations, moral ideals and autocratic reality. On the one hand SS was developed in the context of and rooted in Grundstimmung Stoerungen and Bleuler's "latent schizophrenia" schizophrenic-spectrum, covering developmental distortions, disorders of personality, pseudoneurotic states and mild schizophrenia. On the other hand the social dimension of SS can be examined in terms of totalitarian suppression of individuality, of any personal properties under a monoideological stamp. Methodologically the SS-conception substituted "mad" for "bad," replacing clinical categories by social-cultural notions. Oddity, bizareness and withdrawal are at the core of the schizophrenic spectrum. At the same time they are close to social terms designating a variety of asocial or antisocial behavioral patterns. The next step leading to political abuse of SS is different from substitution, and is based on the old slogan: Those who are not with us are against us. The image of the patient with SS and the image political dissident were quite close. "Heboid schizophrenia" (HS), claimed in the late 70s in Russia as a special type of SS is a clear example of intellectual deficiency, cultural confusion and political provocations around clinical-social misunderstanding. Its diagnostic criteria, clinical descriptions and social expression are discussed. Clinical-social analysis of the three most popular personages of soviet underground literature meeting the criteria of three subtypes of HS are presented. It is concluded that the SS-story shows the contradictory drama of clinical-social interference and deficiencies in psychiatric methodology and ontology.
- Towards a psyche for psychiatry
Department of Psychological Medicine, The University of Sydney, Australia
The notion that a disruption of the sense of personal existence is the basis of mental illness is a fundamental one. Nevertheless, it has been neglected in the disciplines of psychiatry, psychology, and even psycho-analysis, for most of the 20th century. This deficiency leaves a vacuum at the heart of these disciplines. A clear idea of what we mean by the sense of personal existence, or self, is necessary in making theoretical formulations, of a more than trivial kind, which might provide a framework for the understanding of various mental illnesses.
- Phenomenological-anthropological approach to diagnosis and classification
Psychiatric Clinic, University of Heidelberg
Modern diagnostic systems in current use such as ICD-10 and DSM-IV rely upon operational criteria and decision-making algorithms, features that have resulted in significant changes for clinical diagnostic practice. With this modern diagnostic approach, new clinical entities have been created while other diagnostic categories have been abandoned. What have been the benefits and drawbacks of this modern approach to diagnosis? Diagnosis has always involved a more comprehensive, holistic consideration of the patient and not just a simple assessment of symptoms. The phenomenological-anthropological approach in psychiatry seeks to make scientifically accessible the intuitive grasping of the patient as a whole being in relationship with the world and others.
Psychiatric Clinic, University of Heidelberg
Starting from psychopathological analyses of lived time in melancholia, the paper first examines the continuous processes of synchronization effective in biological as well as social life. These processes enable the individual to compensate for states of shortage, to adapt to changed circumstances, finish with past events and reconnect with the present. Examples of such resynchronizing processes are regeneration, sleeping, dreaming, forgetting, remorse or grief.
Institute of Psychotherapy and Medical Psychology, University of Wuerzburg, Germany
In empirical therapy research the notion of 'empathy' plays a central role as a basic factor of the therapist's attitude. It has been introduced and emphasized in psychotherapy especially by Carl R. Rogers' client-centered-therapy. Rogers means by it the therapist's capacity to accurately receive the client's emotions and to understand them in their personal significance. By using the concept of 'precise sympathetic understanding', Rogers explicitly refers to existential and dialogical philosophy. There is no doubt that phenomenology, hermeneutics and existential philosophy have provided the essential framework for the concept of empathy. So, for instance, for Husserl the notion of 'empathy' revealed to be important to achieve an understanding of the Other. In the sense of Scheler, Heidegger and Buber's philosophy of encounter the concept of empathy would be misleading if it presupposes the idea of a monadic subject which tries to throw a bridge to another equally monadic subject. These authors argue that the Other is already present by virtue of the fundamental structure of human existence as one's being with others. From that point of view empathy is not considered as an instinctive or merely intuitive capacity, but as a phenomenon which includes man's insertion into an universal community of language (Gadamer) as a necessary prerequisite. A similar position is held by structuralist writers like the ethnologist C. Lévi-Strauss or the psychoanalyst J. Lacan. For the latter, like for Hegel, it is the experience of the Other which constitutes human subjectivity.
U.O. Sperimentale di Psichiatria, Dipartimento di Salute Mentale, Università di Firenze, Florence, Italy
It is well established by psychopathological research that disorders of self experience are among the main features of schizophrenic prodromes in a pathogenetical sense. Disorders of the phenomenal self, as "lack of ipseity" (the vanishing of the feeling 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.
Centre de Logique, Université Catholique de Louvain
The purpose of this paper is to exemplify the usefulness of the dialogue between the psychological sciences and speculative philosophy. Although it argues from a broad phenomenological perspective, its technicalities belong to the field of process thought, as carved by the later Alfred North Whitehead (1861-1947). It proceeds in two main epochs.
R. Dalle Luche
Servizio Psichiatrico Diagnosi e Cura ASL 1 MASSA CARRARA
The modifications of the sense of Self (self awareness, self experience) are ubiquitarious in the different psychotic conditions: in early phases of schizophrenic and schizophreniform disorders they reveal themselves as feelings of estraneity of psychic acts and functions, dissociation in an observing and observed ego, loss of personal identity, and in an increasing introversion and a compensatory iperryflexivity (depersonalization states); in full blown psychotic conditions, acute or chronic, the impairment of reflexivity and insight sustains delusional misidentifications of Self or a complete loss of a true I, which becomes a mere grammatical figure (depersonation states). In depressive disorders depersonalization concerns affective and volitional aspects of I (feeling of having no feelings, inconsistency of projects and achievements); in manic states the lack of reflexivity is pointed out by impulsivity and diminished self-control.
Key Words: Self experience, I, Myself, Ipseity, Identity, Psychosis, Depersonalization, Depersonation
A. Faulkner, V. Nicholls
The Mental Health Foundation
The 'strategies for living' project is a user-led programme of research, training and dissemination, focusing on:
The project has been going for three years now, and our own research is completed and reported in: 'Strategies for Living: a report of user-led research into people's strategies for living with mental distress'. We have also been supporting six service users/user groups to conduct research in their own local areas, through providing training and support as well as small grants for costs and materials. Throughout this process, we have endeavoured to ensure that our research is user or survivor-led, and have given considerable thought to what this means to us in practice, and to the ethics of user-led research. Our session would address the following issues:
. Why conduct user-led research? including such issues as: having the power to ask the questions, asking different questions?, independence, defining outcomes, person-centred, taking a wider view of mental distress and mental health treatments
The presentation would address these issues from the perspective of the Strategies for Living project research, as well as the research we have supported.
Moscow Institute of Psychology and Pedagogy, Moscow, Russia
Retaining great variety of schools in psychotherapy reflects its immature stage of development. The natural base of psychotherapy is the philosophic anthropology and the theory of personality. The legal development of those themes in the Soviet Union had not been possible for a long time. The theory of psychotherapy had been substituted by the naturalistic mythology of quasi-Pavlov physiology and practice had been limited by authoritarian hypnosis and suggestion. The leading psychiatric school of the country had rejected psychotherapy.
F.E. Vasilyuk, Ph.D., O.V. Filippovskaya, Ph.D.
Moscow Institute of Psychology and Pedagogy, Moscow, Russia
A doctor puts his hopes ultimately not in drugs themselves, but rather in the response of a patient's body to them. A teacher does not believe that his explanations alone will create knowledge in a student's head, but hopes for a responsive process of understanding. In what do professional psychotherapists put their hopes? That is, what is the productive process which will ultimately be responsible for the psychotherapeutic effect?
N. Voskresenskaya, M.D.
Independent Psychiatric Association of Russia, Scientific Center for Mental Health of the Academy of Medical Science of the RF
Advanced age - the time for summing up, the time for suffering, illnesses and losses. Only the system of spiritual values can oppose growing failing of body and spirit. However, character's changes, depressions and failing of memory and intellect hamper this work.
B. Voskressensky, M.D.
Independent Psychiatric Association of Russia, Russian State Medical University
Clergyman and psychiatrist is different even if two specialists are combines in one person. Clergyman deals with spiritual matters (proceeding from trichotomy spirit - soul - body), saves the soul of a sinful layman. Doctor-psychiatrist treats patient (here we mean the faithful patient) and mental disorders. That is why there is no ground to talk of orthodox, catholic or protestant psychiatry.
M.S. Radionova, Ph.D.
Moscow City Center for the Prevention of Drug Dependence, Moscow, Russia
Not only are drugs ruinous to the brain, but they render the dependent culturally disadapted. Drug dependents are distinguished by emotional immaturity, alexitymia, diffuse identity, and ethnofunctional discordances. Preventive measures must be taken beginning in infancy. The normal development of a child replicates the philogeny of a respective culture, including the mythological, religious-ethical, and technotronic-scientic stages. When this succession is upset violently, ethnofunctional disontogenesis ensue. The child suffers emotional shock due to failure of the ethnocultural filter. Such children are computer-literate, but are not familiar with fairy tales, which play a harmonizing psychotherapeutical role (B. Bettelheim, 1980): fairy tales are replaced by surrogates in the form of television soap operas and Barbie dolls.
A. Sosland, Ph.D.
Independent Psychiatric Association of Russia
1. There is a hidden medical model According to L. Wittgenstein: Philosopher treats a question like a physician - an illness.
A. Bondarenko, Ph.D.
Kiev State Linguistic University, Chair of Psychology
Love is a complex personal relationship, whose value seems to be considered essential in the cross-cultural context. At the same time love is a special concept, which belongs to the so-called non-distinctive concepts, i.e. it may have an indefinite number of definitions. Neurotic or traumatic love with a certain obsessive or addictive tendency to suffer from the non-satisfied need of being needed is also a complex experience with its own phenomenology and myth. In a well-known Sternber`s triangle theory (1986) love has three main components: passion, intimacy and commitment. In case of neurotic love the configuration of this symbolic figure is being deformated and a personal myth, a behavior pattern, an intrusive symbol or fixated image of the beloved object form the center of gravity which supports the neurotic fixation. Our controlled studies show that in descriptions of the personal myths, done by victimized with the traumatic love subjects some principal symbolic incarnations of the beloved figure are reproduced. These are the images of the animals (i.e. a cat, a dog); the archetypal images of Artist, Poet, Hero etc. which are attached to core predications "I am afraid (to lose him/her)", "I am suffering without him/her", "I am living for him(her)". These self-programming core predications together with emotionally, sensorically or visually feedbacked memories are fused into indivisible syncretic cognitions which structure drives and behavior in a certain dysfunctional style. In its turn this dysfunctional style is self-presented as a meaningful myth of "Great Love", "Eternal Love", "Tragic Love" etc. So the viceous circle is formed. Females are inclined to experience traumatic love much more than males.
- The importance of the concept of relational agency in psychiatric care
Faculty of Philosophy, Erasmus University Rotterdam
The principle of respect for autonomy of persons in terms of respect for the right of self-determination has been the dominant value in caring relationships and has been expressed in several medical laws for the last fifteen years in the Netherlands. The Law on Contract of Medical Treatment (WGBO) in 1995 and the Law on Special Admission of Psychiatric Hospitals (Wet bopz) in 1994 are two important examples of such medical law. The WGBO defines patients rights in professional health-care situations, such as the right of informed consent and the right to refuse medical treatment. The Wet bopz defines the legal position of the psychiatric patient who faces possible coercive institutionalisation. In contrast to the past, coercive institutionalisation and coercive treatment is no longer justified for paternalistic reasons. The right of self-determination overrules considerations of protecting the well-being of patients. Coercive interventions are legally and morally justified, only in cases of severe risk or danger to society and patient. Nowadays a discussion has been started about the dominance of the right of self-determination, particularly in the context of psychiatric health care. It seems that current care practices cannot answer sufficiently to the needs of patients, precisely because of the dominant value of non-interference and self-determination. Sometimes, patients are left to themselves in respect for these values, whereas at the same time they do need help for flourishing and viable relationships. For this reason, 'self-binding' contracts or 'compassionate interference' are introduced as forms of good psychiatric care. For the justification of these forms of good care , other justifying reasons than the right of self-determination and autonomy as non-interference are put forward. Values such as trust and commitment are also important values in good caring. In this paper I want to develop a more relational model of agency, in which interventions in care can be shown to be in the interest of patients, that is, they can be seen as interventions for attaining relational autonomy, instead of threatening autonomy and in which values such as trust and connectedness do get a place in caring relationships..
Department of Psychological Medicine, University of Sydney at Nepean Hospital, Australia
Heidegger's conception of being a "person-in-the-world" and of being "thrown into" a complex environment are taken as a starting point for a model of mind that is irreducibly interpersonal in nature. Mind cannot be separated from environment and therefore cannot be equated to brain, which can be conceived of as separate from environment. Nor, however, can mind be separated from brain.
Psychoanalytic and psychological literature have problems in trying to formulate biological understanding of psychological processes when focus is maintained on internal mechanisms. Although it is possible to talk in terms of "having a mind of one's own", this statement includes an irreducible environmental component. In contrast, feelings arise within the individual person. Feelings, a product of the interaction of the person-in-the-world, are more truly identifiable as existing only within individuals.
It is therefore proposed that a rational approach to the study of the biology of psychological processes would be advanced by considering the bodily / mental feelings that arise out of interactions with the environment as a "basic" unit for examination in research. Of particular importance in this regard will be the feelings that arise out of interpersonal interaction.
M. Ballerini, G. Stanghellini
In the DSM-IV, the concept of social dysfunction is a fundamental diagnostic feature of schizophrenia. Social dysfunction in schizophrenia has been considered the consequence of the disease process (i.e. defict state, as in the classical kraepelinian model), social stigma (chronicity as a social artifact) or a specific domain of psychopathology (e.g. in the model of J.S. Strauss) .
Waitemata Mental Health Services and Department of Psychiatry, School of Medicine, Auckland, New Zealand
Traditional medical ethics were based on professional characteristics and ideals. Trends in philosophical thought have moved from Aristotelian conceptions towards a debate between Kantianism and utilitarianism. The growth of consumerism in the later part of the twentieth century reinforced the rejection of professional elitism, and a growth in universalist principles in the codes of ethics for professionals, often at the expense of the specifics. The author contends that this ignores the value which comes from the recognition that being a professional involves having a certain identity or character; being a person of a particular sort.
P. Mannoni, C. Bonardi
A number of daily life situations are characterized by the presence of danger, in the more or less direct and imaginative environment of subject people. This danger can be substantialized in different ways : it can appear as of comparatively little account with a relatively moderate intensity but it can also take the shape of dangerous exogenous factors bearing a high degree of emotional stress. In the first case, subjects people usually resort to run away or to install defensive means, which corresponds to an adpatative, in most cases satisfactory strategy (classic fight or flight).
M. Marzanski MD, M. Phil, MA, MRCPsych
Coventry Health Care NHS Trust
30 patients with dementia had been asked what they thought was wrong with them, what they were told about the disease and by whom, and what they wished to know about their illness. Analysis of their answers has shown that the quality of received information was poor and many patients had no opportunity to discuss their illness with anybody. Despite that almost half of the participants in the study had adequate insight and majority declared that they would like to know more about their predicaments. The results have been discussed in the context of current psychiatric practice in the UK and views of patients' relatives on telling dementia sufferers their diagnosis. Ambivalent attitudes among clinicians and carers seem to reflect different values in medical practice and various beliefs regarding dementia itself.
T. Kitamura, F. Kitamura, H. Higuchi, A. Tomoda, N. Kijima, M. Kato, M. Mimura, K. Matsubara, T. Hayakawa, H. Koishikawa, K. Tsukada
Department of Sociocultural Environmental Research, National Institute of Mental Health, Japan
Patients' right to autonomous decision-making can be embodied only when their competency is measured with a reliable and valid instrument. The Structured Interview for Competency and Incompetency Assessment Testing and Ranking Inventory (SICIATRI) is a product of such an effort of ours. The SICIATRI is a semi-structured interview guide applicable to many clinical situations. Using the SICIATRI for 103 newly admitted inpatients (23 medical and 80 psychiatric), we confirmed the inter-rater agreement of the interview items. A factor analysis of the SICIATRI yielded three factors interpretable as reflecting "insight and evidencing a choice", "awareness of legal rights", and "understanding of treatment". The score for these three SICIATRI subscales were differentially linked to patients' diagnosis, legal status, demographic features, and disclosure of medical and legal information by the attending physician. Information disclosed by the attending physician prior to the SICIATRI interview was crucial for patients with schizophrenia. Thus, in a two-way analysis of variance, they performed more poorly for "insight and evidencing a choice" when they were not informed of the fact that they had a right to decide and when they were not asked to decide, in comparison with patients with other diagnoses. Ethical issues will be discussed in terms of the use of competency testing prior to informed consent.
J.M. Vile, K.W.M. Fulford, M.D. Beer
Kent Institute of Medicine and Health Sciences, University of Kent, Canterbury, Kent, UK
In this report we integrate the techniques of history, philosophy and sociology to examine the ethical, legal and social consequences of the changes in psychiatric classification which are likely to result from developments in brain imaging, genetics and psychopharmacology (collectively the "New Technologies" in brain research).
School of Medicine, Queen's University, Belfast
'We are fascinated by all forms of rivalry, by so-called love, by fighting, by violence, by chaos. These are all aspects of the mimesis of desire which is all around us and in us.' .
 1 Kaptien R. Freedom in Relationships. Queen's University , Belfast. 1993.
1Which is not to claim that we need or are able to abandon our so called moral sentiments.