Search Results

This chapter examines the role of country of origin in relation to psychiatric admission status in Ireland. Data presented in this chapter demonstrate that schizophrenia is a particular problem in individuals born outside Ireland and living in Dublin’s inner-city, and that this is associated with involuntary admission under the Mental Health Act 2001. The chapter also shows much lower levels of voluntary admissions. The chapter argues that these differences in patterns of help-seeking should be considered in future planning exercises in Ireland’s mental health services. In particular, increased emphasis on the cultural competence of health care-providers would be a good first step in recognising and addressing the differing health needs and practices of individuals from different ethnic groups and cultural backgrounds.

This is the first and introductory chapter to the volume entitled Disturbed Consciousness: New Essays on Psychopathology and Theories of Consciousness. Rocco J. Gennaro presents an overview of philosophical psychopathology, specific disorders of consciousness, and philosophical theories of consciousness. Some background on key terminology and a summary of the essays to follow is also included. Some of the theories of consciousness described are the higher-order thought theory, self-representationalism, and the global workspace theory. A fairly lengthy list of disorders, along with their definitions, is also provided.

Myrto Mylopoulos discusses the traditionally neglected phenomenon of action consciousness and its breakdowns in pathological conditions. She introduces a novel framework for understanding action consciousness, which parallels one that is used to discuss state consciousness. In particular, she distinguishes between first-order and higher-order theories of action consciousness, where the former deny, but the latter affirm the claim that an action is conscious only if one is aware of it in some suitable way. Mylopoulos argues that higher-order theories of action consciousness enjoy significant advantages when it comes to making progress on understanding pathological cases in which action consciousness is impaired or disrupted. She focuses on anarchic hand syndrome, utilization behavior, and delusions of control in schizophrenia. Furthermore, while theorizing about action consciousness has typically proceeded independently from theorizing about state consciousness, she highlights some ways in which theorizing about consciousness as applied to these different phenomena, actions and mental states, may be fruitfully merged.

Timothy Lane offers a wide ranging commentary where he responds to Billon and Kriegel, Mylopoulos, and Gennaro. He also clarifies and further develops some of his influential previous work in this area. Subjectivity theories of consciousness take self-reference as essential to having conscious experience but they differ with respect to how many levels they posit and to whether self-reference is conscious or not. But all treat self-referencing as a process that transpires at the personal, rather than at the subpersonal, level. Working with conceptual resources afforded by subjectivity theories, several attempts have been made to explain seemingly anomalous cases, especially instances of alien experience. These experiences are distinctive precisely because self-referencing is explicitly denied by the only person able to report them: those who experience them deny that certain actions, mental states, or body parts belong to self. The relevant actions, mental states, or body parts are sometimes attributed to someone or something other than self, and sometimes they are just described as not belonging to self. The cases under discussion here include somatoparaphrenia, schizophrenia, depersonalization, anarchic hand syndrome, and utilization behavior. The theories discussed include Higher-Order Thought and Self-Representational. He argues that each of these attempts at explaining or explaining away the anomalies fails.

Gerard O’Brien and Jon Opie first present their “vehicle theory of consciousness” which identifies phenomenal consciousness with the brain’s vehicles of explicit representation. Given the distributed nature of neural representation, a vehicle theory is committed to the conjecture that phenomenal consciousness at each instant is a multiplicity: an aggregate of discrete phenomenal elements, each of which is the product of a distinct consciousness-making neural mechanism. This in turn implies that the single, unified, conscious subject (or “self”) is a hard-won computational achievement, in which myriad co-conscious parts are stitched together by the brain to form an integrated and coherent whole. From the perspective of a vehicle theory of consciousness, therefore, it is not surprising that the brain sometimes fails to pull off this remarkable feat. In this chapter, they explore what light a vehicle theory sheds on familiar psychopathologies of the self, especially schizophrenia.

Philip Gerrans first explains the “predictive coding conception of cognition” which treats the mind as a hierarchy of cognitive systems devoted to the cancellation of error signals. Although the deep consequences of this theory for understanding consciousness have not been fully explored, Andy Clark has suggested that the logical consequence of the predictive coding view is that intuitive distinctions between higher and lower level cognitive systems need to be rethought. This suggests that conscious experience itself produced by very low level sensory and perceptual processes should be at the mercy of beliefs, since those beliefs can ultimately cancel the prediction errors generated by those systems. Gerrans explores this idea in the context of explanations of the “sense of agency,” the phenomenologically-elusive experience of being the agent of an action. Much of the relevant data comes from the study of schizophrenic delusions of alien control that use predictive coding models to explain the role of correlated neural activation. Garrans argues that the sense of agency is not as vulnerable to context effects as Clark and others have argued.

This chapter explores the politics in the works of Gilles Deleuze. There is no political treatise nor political programme in Deleuze's work and his political orientation is very basic. However, in his Anti-Oedipus: Capitalism and Schizophrenia, Deleuze and his co-author Félix Guattari dealt with political themes. The question of fascism is analysed in it and a universal vision of history is proposed. The same pre-occupations characterise A Thousand Plateaus, where these notions are revised and corrected.

We begin this second chapter where we left off in the preceding one, with the question of what is involved in the work of recovery and how practitioners can best support this work. On one hand, we understand the answer to this question to be very much a work in progress. There is much still to learn about recovery and recovery-oriented care, and we consider the field—including our own efforts in this regard—to be in the very early stages of its development. On the other hand, we have begun to learn some things about what processes of recovery entail and what the provision of recovery-oriented care looks like in practice, as well as about some of the structural conditions necessary for this kind of care to be implemented. In this chapter, we share some of these lessons by describing components and processes of being in recovery that we have integrated into a model that can then serve as the foundation for developing recovery-oriented practices. The assumption of this approach, as we mentioned in the previous chapter, is that this form of recovery is primarily the responsibility of the person with a serious mental illness. What practitioners do should thus be oriented to supporting and facilitating the person’s own efforts. We describe this perspective as a “bottom up” approach to service development, as it begins with the needs, preferences, and goals of the person in recovery— not only at the individual level of a person’s “recovery plan” but also at the collective level of the system as a whole. What services and supports should a mental health system offer? Those, we suggest, that will enable persons with serious mental illness to lead safe, dignified, and gratifying lives beyond the illness—when possible— or, when that is not possible, within the boundaries imposed by the illness. Before turning to the question of what services and supports we need to offer to promote and sustain recovery, we need to understand better what being in recovery entails. To frame the question in this way is not to ignore the other form of recovery (i.e., recovery from mental illness).

The second chapter begins with descriptions of some of the many ways in which people with serious mental illness are key agents in their own recovery. In these descriptions, we fi nd that the cornerstones of recovery are both the hope that a better life is possible and the desire the person has to pursue such a better life once this hope has taken root. For an individual, both hope and action appear to be required to make recovery a reality. As we begin to understand more fully the role of systems of care and of the practitioners within those systems in facilitating recovery, we suggest that achieving, in the words of the New Freedom Commission report, “profound change—not at the margins of a system, but at its very core” also will require both hopeful attitudes and concerted efforts. While the remaining chapters in this volume will deal more explicitly with the kinds of concerted efforts required to achieve transformation, this chapter focuses primarily on attitudes toward recovery and the kinds of concerns systems and practitioners have raised (to date) as they have gone about the process of understanding and implementing recovery principles in practice. It has been our experience, however, that the federal mandate to transform systems of care to promote recovery has left many policy makers, program managers, practitioners, and even the recovery community itself under increasing pressure to move to a recovery orientation without fi rst examining the concerns of stakeholders within those systems about this new notion of recovery and its implications. As a result, we are all at risk of overlaying recovery rhetoric on top of existing systems of care, failing to effect any real or substantial—not to mention revolutionary—changes due to our urgency to just “get it done.” In this chapter, we pause to consider some of the more common concerns we have encountered in attempting to introduce and implement care based on the vision of recovery that we have articulated thus far. Addressing these concerns, we believe, is a necessary fi rst step in changing the attitudes that underlie current practices in the process of replacing these attitudes with the more hopeful, empowering, and respectful attitudes demanded, and deserved, by people in recovery.

We have defined and discussed the nature of various notions of recovery, grappled with the implications of a recovery vision for mental health system transformation, and begun to draw the outlines of a transformed system. Now we can turn to the question of how such services and supports can actually be offered to people who need them. Here we propose what we call the recovery guide model. Analogous to the role currently played by case management, the recovery guide model is an organizing vehicle by which practitioners can offer a range of services and supports to people, either directly or through others. As with case management, the intensity, scope, focus, and duration of a recovery guide’s work with a person will depend on that person’s needs, preferences, life circumstances, and goals at a given point in his or her unique recovery journey. In this chapter we describe the basic aims, tenets, and tools of this approach. First, though, we offer a brief review of advances in mental health case management that preceded and led up to the concept of recovery guides, including the present recognition that, in a recovery-oriented system of care, people with serious mental illness can no longer be considered “cases” that others manage (Everett & Nelson, 1992). With the failure of a combination of Thorazine and psychotherapy to achieve the aims of deinstitutionalization (Johnson, 1992), case management became the predominant service that mental health systems offered their clients with serious mental illness (Sledge, Astrachan, Thompson, Rakfeldt, & Leaf, 1995). In addition to being inadequately funded, community-based systems of care that were developed to enable people with serious mental illness to leave state hospitals were fragmented and uncoordinated “non-systems” of care (Hoge, Davidson, Griffith, & Jacobs, 1998). As it was practically impossible for people seeking care to navigate these complex and unintegrated health and social service systems on their own, the case manager role was created to identify and coordinate the provision of services to meet their multiple needs in the community (Hoge, Davidson, Griffith, Sledge, & Howenstine, 1994; Sledge et al., 1995). Case managers’ primary responsibility was to assess people’s needs, link them to services, and monitor their service use and outcomes.

Epidemiology is often described as the basic science of public health. A mainstay of epidemiologic research is to uncover the causes of disease that can serve as the basis for successful public-health interventions (e.g., Institute of Medicine, 1988; Milbank Memorial Fund Commission, 1976). A major obstacle to attaining this goal is that causes can never be seen but only inferred. For this reason, the inferences drawn from our studies must always be interpreted with caution. Considerable progress has been made in the methods required for sound causal inference. Much of this progress is rooted in a full and rich articulation of the logic behind randomized controlled trials (Holland, 1986). From this work, epidemiologists have a much better understanding of barriers to causal inference in observational studies, such as confounding and selection bias, and their tools and concepts are much more refined. The models behind this progress are often referred to as ‘‘counterfactual’’ models. Although researchers may be unfamiliar with them, they are widely (although not universally) accepted in the field. Counterfactual models underlie the methodologies that we all use. Within epidemiology, when people talk about a counterfactual model, they usually mean a potential outcomes model—also known as ‘‘Rubin’s causal model.’’ As laid out by epidemiologists, the potential outcomes model is rooted in the experimental ideas of Cox and Fisher, for which Neyman provided the first mathematical expression. It was popularized by Rubin, who extended it to observational studies, and expanded by Robins to exposures that vary over time (Maldonado & Greenland, 2002; Hernan, 2004; VanderWeele & Hernan, 2006). This rich tradition is responsible for much of the progress we have just noted. Despite this progress in methods of causal inference, a common charge in the epidemiologic literature is that public-health interventions based on the causes we identify in our studies often fail.

Translational research has become one of the key concepts of medical science in the 21st century, with academics and clinicians coming together in a joint effort to bring findings from basic research into the clinical setting so that they can benefit patients. Channi Kumar may not have recognized this phrase, but his work was truly translational. Indeed his perinatal research programme was bi-directional in its translation. As a clinician and an academic, Channi’s research was informed by his clinical work with mothers suffering from severe mental illness (SMI) following childbirth. He recognized the importance of treating a mother’s mental illness, while at the same supporting her in the care of her baby. His clinical work on the Mother and Baby Unit at the Bethlem Royal Hospital gave rise to research into the understanding of antenatal and postnatal mental illness and its effects on the child as well as into improving services and treatment for women and their babies. In this chapter we will show how two of Channi’s flagship studies, the South London Child Development Study (SLCDS) and a video feedback intervention programme on the Mother and Baby Unit, continue to gather evidence and to inform perinatal guidelines in the 21st century. The SLCDS is unique in that it is one of the first longitudinal studies of women’s mental health and its impact on the children to begin during pregnancy. Specifically, families from two inner-city London General Practice sites were initially recruited into a longitudinal prospective study of emotional disorders related to childbirth when the women were pregnant between 1 January and 31 December 1986. It has followed the lives of 151 families through pregnancy and the index child’s first year, with 86% participating when the index child was 4 years, 89% at 11 years, and 83% at 16 years. At the outset of the study, the mean age of the women was 25.9 years (range 16–43 years); 60% were married, 32% had a regular partner, and 8% were single; 78% were of white British origin; 86% were working class; 30% had no educational qualifications.

Clearly the majority of people who use marijuana do not develop schizophrenia. Yet, the human literature suggests that there is a modest association between cannabis exposure (particularly in adolescence) and later development of schizophrenia--whether or not this association is causal is hotly debated. This chapter reviews some of the evidence for and against such a causal relationship. The chapter concludes with the suggestion that individuals with a family history of schizophrenia, with prodromal symptoms, or who have experienced discreet episodes of psychosis related to cannabis use, may be best served not using THC-predominant marijuana.

This chapter begins with the assumptions of the present volume that a crisis exists in psychiatric research and that research concerning mental illness has entered a period of “extraordinary science.” After clarifying certain key features of both the crisis and extraordinary science, we examine the reasons for the crisis so as to identify some major challenges facing mental illness research during this period. We identify four broad classes of challenge: ideological, methodological, clinical, and transitional. We then articulate a version of the innovative research program of computational psychiatry that introduces novel representational and methodological resources and holds promise for meeting some of the various challenges. Finally, we demonstrate this promise using some concrete examples of research in this area concerning Parkinson’s Disease and Schizophrenia.

The target of this chapter is a set of six commonly held assumptions in the biomedical approach to schizophrenia, a highly regarded view in mainstream American psychiatry. A careful examination of the available research literature reveals that these widely accepted assumptions are, at best, questionable and, in many cases, refuted by empirical data. In this chapter I argue that the endurance of the biomedical schizophrenia concept in the face of mounting evidence of its inadequacy is a testament to the power that scientific paradigms hold over the minds of researchers, and of the failure of the normal process of empirical refutation that ensues.

Psychiatric research on schizophrenia is currently undergoing a period of extraordinary science, with many alternative research programs investigating the illness using different assumptions and methodologies. As the struggles the DSM-led research faces are now “more generally recognized as such by the profession,” trust in the dominant DSM-led research paradigm is shaken, and “numerous partial solutions to the problem” are made available (Kuhn 1962, 82-83). I use philosophical tools in this chapter to evaluate one of these alternative research approaches that I call “phenomenology-neuroscience partnership” (PNP). In part II, I lay out the phenomenological approach to schizophrenia that is critical of the DSM-led research. In part III, I focus on the phenomenology-neuroscience partnership (PNP) that takes this phenomenological approach as a starting point to investigate schizophrenia, and address its shortcomings. In part IV, I conclude by pointing out the strengths of the PNP and offer prescriptions for its improvement.

What is schizophrenia? What are its causes? Can it be cured? Can it be prevented? These fundamental issues have confronted the field of schizophrenia research and treatment for over 100 years. Our ability to improve the lives of people with the disorder, however, has not improved at nearly the same rate as the accumulation of new knowledge about it and technological advances to study it. Paradigm shifts may thus be needed to accelerate progress. This was the aim of the Ernst Strü;ngmann Forum, “Schizophrenia: Evolution and Synthesis,” to which a group of leading researchers were invited to explore novel ways of conceptualizing the disorder, integrating data across levels of analysis, and accelerating advances in treatment development and prevention efforts. In this introductory chapter, we introduce the questions and issues that motivated the Forum, in terms of fundamental problems facing the field of schizophrenia research and treatment, and discuss the specific issues identified for debate and the questions which served as starting points for deliberation. We briefly summarize the debate and conclusions of each of the four thematic groups and highlight issues that emerged during the final plenary discussion. Published in the Strungmann Forum Reports Series.