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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.

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.

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.

The status of schizophrenia as a disorder has been controversial since its original description by Kraepelin and Bleuler. This chapter critiques a prominent theory of schizophrenia espoused by Meehl in 1962 that spurred a great deal of research into its genetic origins and subthreshold manifestations. In particular, a decade of findings on the meta-structure of mental disorders, the development and course of at-risk youth, and genetic epidemiology can be understood as direct challenges to the idea of a specific etiology for the disorder. Instead of a well-mannered diagnostic entity, schizophrenia and thought disorder more generally delineate a psychosis spectrum linked to a number of other psychiatric outcomes, including, but not limited to, bipolar affective disorder. In addition, studies of the cognitive impairments associated with the disorder show that a generalized deficit is a prominent behavioral feature of the disorder. This chapter concludes by noting that spectrum constructs do not preclude generating and testing falsifiable hypotheses. The use of a fault tree analysis, as employed in reliability engineering, may be helpful in delineating such hypotheses explicitly. This perspective gives rise to a new set of priority questions. Published in the Strungmann Forum Reports Series.

Schizophrenia is best viewed as a clinical syndrome, without compelling evidence of a homogeneous disease. Most investigations over the past century, however, have been designed without addressing heterogeneity, thus impeding knowledge acquisition. Recent paradigm shifts in the schizophrenia construct are intended to provide more valid and more robust approaches to discovery. These include: 1) Identifying patient subgroups to enrich study cohort homogeneity on causal pathway and pathophysiology; 2) Identifying key domains of psychopathology and using each domain as the pathology of interest; 3) Investigating molecules, genes, and pathways related to known neural circuits and behavioral constructs which, in turn, are related to psychopathology domains; and 4) Using stages of vulnerability development as study targets, to conceptualize causal pathways to early vulnerability that are not specific to schizophrenia, as well as later stages associated with pathological variables which have greater disorder-outcome specificity. The first paradigm shift can be informative for a form of schizophrenia that may not generalize to all forms of the disorder. The last three provide for more specific study targets but address pathologies that will cut across current disorder boundaries. The fourth paradigm, in particular, calls attention to preventive and resiliency factors as well as causal factors. Published in the Strungmann Forum Reports Series.

Schizophrenia is a disorder, or a class of disorders, of cognition. Defining features include a loss of coordination in core perception, attention, memory, and executive functions together with the dysregulation of emotion. These features are the strongest contributors to burden of illness. Diagnostic criteria, clinical trials, and popular conceptions typically focus, however, on the more florid positive symptoms of psychosis, such as hallucinations. As a result, impairments in cognitive–emotional function remain largely undiagnosed and untreated, with no current treatments in routine use that target these impairments. The evidence base for developing new treatments requires cognitive–emotional measures that link to functional capacity as well as to brain changes involved in schizophrenia pathophysiology. This chapter looks at five aspects of cognitive–emotional function in schizophrenia: Which cognitive–emotional impairments characterize schizophrenia patients at first onset? Are functional capacities predicted by these impairments at first onset? What brain systems are involved? How do cognitive–emotional impairments, and their relationships with functional capacity and brain function, progress over time? What are the implications for treatment outcomes? Focus is on the first episode of schizophrenia, since early intervention is likely to have the best impact for improving outcomes. Published in the Strungmann Forum Reports Series.

This chapter reviews the definitions of resilience with respect to psychological disorder and to schizophrenia, in particular. Alternative meanings of resilience emphasize innate characteristics and the steeling effect of experiences; these are not mutually exclusive and both could be harnessed in terms of treatments for the disorder. The implications of resilience are already well known in the sphere of psychosocial interventions and recent developments in cognitive therapies. The notion of building structural or physical resilience of the brain to prevent the onset of schizophrenia is not new: Kraepelin discussed such an approach in the conclusion of his most definitive description of dementia praecox a century ago. To do this successfully, however, remains a challenge, but much could be done if studies on risk modifiers and causes were reformulated toward public health intervention. Finally, new domains for inquiry into developmental resilience are explored, with a focus on neural connectivity and healthy brain growth. Published in the Strungmann Forum Reports Series.

Genetic and epidemiological studies have begun to identify specific “vulnerability” genes and environmental risk factors that, together, may contribute to neurodevelopmental abnormalities and the emergence of psychosis. Neuroimaging and electrophysiological studies also demonstrate altered developmental trajectories and evidence of compensatory changes, which perhaps reflects a period of neurotoxicity coinciding with emerging psychosis. These occur at a time of increased brain plasticity. There is therefore an opportunity to provide interventions that may disrupt the neuropathological processes and remediate cognitive and functional deficits to alter the progressive trajectory of the illness. Adequately powered clinical trials that utilize information gained from biomarker studies are now needed to determine the most effective individualized interventions. A synergistic treatment approach that offers precision pharmacologic intervention combined with remediation techniques is likely to have the greatest impact during the early course of illness. Published in the Strungmann Forum Reports Series.

Schizophrenia research encompasses many different categories of observation: (a) genetic research, which examines variants in single base pairs, (b) cellular and applied neuroscience, including animal models, (c) clinical research representing a broad spectrum of patient-centered research, and (d) population-based epidemiology and health services research. Each field of research has a natural tendency to become more specialized and, as a consequence, more inward looking. Meta-research, the study of the process of research per se, shows that creativity tends to occur at the boundaries of disciplines and research areas. This chapter examines ways to facilitate this type of cross-disciplinary translational research. Examples are provided of collaborative scientific programs that have used clues from fields such as epidemiology and genetics, and these clues are explored via the prism of various neuroscience platforms. Published in the Strungmann Forum Reports Series.

This chapter addresses the question of how knowledge of risk and resilience in relation to the etiology of schizophrenia can be leveraged to optimize discovery of preventive and therapeutic approaches. It explores the challenges and gaps in knowledge that have emerged as a result of significant progress in understanding factors conferring risk for schizophrenia. The fuzzy boundaries of schizophrenia and overlap in risk factors with other mental disorders are highlighted, as is the predominant focus on risk rather than on resilience. Research in genetics (including epigenetics) and neuroimaging which examines putative mechanisms and pathways can be leveraged to develop novel interventions. Implications for prevention and intervention are considered from the point of view that heterogeneity and nonspecificity in schizophrenia present opportunities both to disentangle shared pathways that underpin a wide range of disorders and to develop novel approaches to prevention and intervention. Published in the Strungmann Forum Reports Series.

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.