Towards a New Philosophy of Mental Health : Perspectives from Neuroscience and the Humanities [1 ed.] 9781443884518, 9781443876612

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Towards a New Philosophy of Mental Health

Towards a New Philosophy of Mental Health: Perspectives from Neuroscience and the Humanities Edited by

Drozdstoy St. Stoyanov

Towards a New Philosophy of Mental Health: Perspectives from Neuroscience and the Humanities Edited by Drozdstoy St. Stoyanov This book first published 2015 Cambridge Scholars Publishing Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Copyright © 2015 by Drozdstoy St. Stoyanov and contributors All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-4438-7661-5 ISBN (13): 978-1-4438-7661-2

TABLE OF CONTENTS

Acknowledgements .................................................................................. viii Foreword .................................................................................................... ix Josef Parnas Key Note Chapter One ................................................................................................. 2 Living at the Edge of Compromise: Balkan Pluralism as a Resource for New Philosophy of Mental Health Bill Fulford and Drozdstoy Stoyanov Part I: Methodology of Neuroscience Inquiry Revisited Chapter Two .............................................................................................. 28 Cerebral Cortex Function Wladimir Ovtscharoff Chapter Three ............................................................................................ 35 Emerging Psychiatric Neuroimaging Findings: Translating the Research into Clinical Application Stefan Borgwardt and Drozdstoy Stoyanov Chapter Four .............................................................................................. 41 Cognitive and Brain Markers of Auditory Hallucinations in Schizophrenia Kenneth Hugdahl Chapter Five .............................................................................................. 70 Hughlings Jackson, Neural Connectivity and Mental Disorder Grant Gillet Chapter Six ................................................................................................ 89 Latent Readiness for Psychotic Symptom Formation in Individuals at High Risk for Schizophrenia: Theoretical and Practical Issues Svetlozar H. Haralanov, Evelina S. Haralanova, Georgi Dzhupanov and Diana D. Shkodrova

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Table of Contents

Chapter Seven.......................................................................................... 105 Clinical Applications of the Theory of Translational Validation: Potential EEG and fMRI-derived Markers of Antidepressant Treatment Response Sevdalina Kandilarova and Drozdstoy Stoyanov Part II: Perspectives from Psychology Chapter Eight ........................................................................................... 128 Plato’s Tripartite View of the Human Psyche: Evidence from the Evolution of Human Brain Functions C. Robert Cloninger Chapter Nine............................................................................................ 156 The Range of Plasticity of Personality: Implications for Identity Ada H. Zohar Chapter Ten ............................................................................................. 172 Attachment and Personality Disorders Vania Matanova Chapter Eleven ........................................................................................ 193 Understanding Hostile Attributional Bias: Dodge’s Model Revisited Lilia Gurova, Luiza Schahbazyan and Georgi Petkov Part III: Implications from Phenomenology Chapter Twelve ....................................................................................... 208 Delusional Psychosis in Early Schizophrenia: Existentialism Meets Neuroscience? Aaron L. Mishara and Michael A. Schwartz Chapter Thirteen ...................................................................................... 239 The Empathy for Pain Paradigm in Phenomenology and the Neurosciences: Where Are We? Georgios D. Kotzalidis, Antonella Puzella and Massimiliano Aragona Chapter Fourteen ..................................................................................... 259 Certainty – Uncertainty: Temporal Model of Fear and Anxiety Georgi Popov

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Chapter Fifteen ........................................................................................ 269 Schizophrenia, Embodiment and Intersubjectivity Thomas Fuchs Chapter Sixteen ....................................................................................... 292 The ‘What’ and the ‘Who’ in the Constitution of Psychopathological Phenotypes Giovanni Stanghellini Discussion Chapter Seventeen ................................................................................... 306 Bourdieu and Stanghellini: Socioanalysis and Phenomenological Psychopathology Deyan Deyanov, Svetlana Sabeva and Todor Petkov Contributors ............................................................................................. 329 Index ........................................................................................................ 333

ACKNOWLEDGEMENTS

Stefan S. Kostianev, MD, PhD, DSci, Full Professor of Pathophysiology and Rector, Medical University Plovdiv (MUP), for his constant support Sevdalina Kandilarova, MD, Assistant Professor at the Department of Psychiatry and Medical Psychology (MUP), for her valuable contribution in the preparation of the manuscripts

FOREWORD JOSEF PARNAS MD, DRMED, PROFESSOR OF PSYCHIATRY AND PSYCHOPATHOLOGY UNIVERSITY OF COPENHAGEN

This new volume, edited by Stoyanov et al., contains a very useful and informative collection of papers on psychopathological issues, written by leading figures from neuroscience, psychology, and phenomenology. Over the last decade, we have been witnessing in psychiatry a vibrant (re)-birth of interest in the conceptual, theoretical, philosophical, and phenomenological dimensions of psychopathology. Each year several books on these topics are being published by prestigious publishing houses. Such fervent (re)-examination of the theoretical foundations of psychiatry is an unmistakable sign that our profession undergoes what Thomas Kuhn described as a period of crisis. We may talk about a Kuhnian crisis when the so far dispersed and isolated voices of dissent or discontent, gradually, or more suddenly, coalesce and jointly amplify into an explicit, nearly consensual acknowledgement that the discipline itself is in fundamental trouble. Stated in a simplified way, the crisis of psychiatry, consists in a realization that the theoretical paradigm, so far dogmatically dictating the empirical and pragmatic functioning of our discipline (e.g. choice of research topic, methods, funding and editorial policies etc), suddenly appears glaringly out of touch with the reality of clinical psychiatry while at the same time, the narrow focus of the neurobiological (mainly psychopharmacological) component of this paradigm becomes increasingly out of sync with the rapidly progressing and diversified neuroscience. It is beyond the scope of this preface to articulate that crisis in more detail. Briefly however, the "operational revolution", emblematized by the publication of the DSM-III in 1980, assumed a behavioristic approach to psychiatric description, with symptoms and signs viewed as mutually independent, atomic, thing-like entities, devoid of meaning and constituting

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disease entities by a syndromatic contingency (Parnas and Bovet 2014). Any overall psychological perspective on the human mind (e.g. ɚ la Jaspers) was eliminated. The study of mental pathology was (and sometimes still is) not seen to be dissimilar in kind from the concerns of e.g., hepatology. This conceptual revolution was believed to bring along improved descriptive reliability and thereby clear the road to rapidly forthcoming etiological discoveries "carving nature at its joints." The latter was hoped to constitute the nosological foundations of the future DSM-IV classification. As we know today, this promise did not materialize, not even with the arrival of the DSM-5. Whether reliability, assessed in an ecologically adequate manner, i.e. in a daily clinical praxis, has really improved is an open question; the periodic "epidemics" of mental disorders (e.g. dissociation, Borderline Personality Disorder, autistic spectrum disorders) may suggest otherwise. In the meantime, the psychopathological knowledge among clinicians diminished dramatically. Our profession is increasingly viewed (and not only by a reborn academic anti-psychiatry) as being dehumanized and mainly driven by managerial concerns. In other words, we witness not only a purely Kuhnian crisis of ideas but also face a more mundane question of survival of psychiatry as a medical-academic discipline (Katchnig 2010). Perhaps, a more cynical view would claim that psychiatry always found itself in a kind of larval crisis since its very inception; a crisis of its self-understanding, either as basically medical or basically human science. It is now time to abandon this dichotomy, which is useless and partly false for all practical and theoretical reasons. Psychiatry has been, is, and will remain an interdisciplinary endeavour, even though the notion of interdisciplinarity is a relatively recent invention. This volume, written at the intersection of neuroscience, psychology, and philosophical phenomenology offers the reader a possibility to familiarize herself with a representative selection of crucial themes for psychiatry as a science and as a practical profession. The book should be of interest to a broad variety of professionals engaged in mental health work. Josef Parnas, Copenhagen, November 2014.

References Katschnig H. Are psychiatrists an endangered species? Observations on internal and external challenges to the profession. World Psychiatry, 2010; 9: 21-8.

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Parnas J, Bovet P. Psychiatry made easy: operation(al)ism and some of its consequences. In: Kendler KS, Parnas J (eds). Philosophical issues in psychiatry III: the nature and sources of historical change. Oxford: Oxford University Press, 2014:190-212.

KEY NOTE

CHAPTER ONE LIVING AT THE EDGE OF COMPROMISE: BALKAN PLURALISM AS A RESOURCE FOR NEW PHILOSOPHY OF MENTAL HEALTH KENNETH WILLIAM M FULFORD AND DROZDSTOJ STOYANOV

Abstract This chapter explores the potential for a new philosophy of mental health arising from the uniquely pluralistic values of Bulgaria and other Balkan states reflecting their long periods of colonisation. Balkan people survived these periods by retaining their own values while at the same time evincing where necessary the values of their colonisers. Living at the edge of compromise in this way has left a legacy of values pluralism. Pluralism like monism carries its own challenges. But in a Balkan context we argue it is the basis for distinctively new contributions to that part of philosophy of mental health called values-based practice. An important strength but also a limitation of values-based practice is its basis in a particular kind of shared decision making called ‘dissensus’. But dissensus depends critically on values pluralism whereas our default position in practice, as evidenced by experience at least in the UK, is monism. We illustrate the potential of Balkan cultural pluralism for two key challenges in contemporary mental health: 1) preventing negative abuses of psychiatry, and 2) promoting positive practice. Whether Balkan cultural pluralism will deliver on its potential in these and other areas remains to be tested. But developed like values-based practice itself, within the framework of mid-twentieth century ordinary language philosophy, it could add a key additional resource to the growing tool kit of methods for working with complex and conflicting values in health care.

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Introduction The development of interdisciplinary work between philosophy and mental health in recent decades, although remarkable for the strongly collegial nature of its various programs (Fulford, forthcoming), has been built largely on the resources of Anglo-American Analytic and Continental Philosophy. Impressive as these resources undoubtedly are they represent only some twenty-five percent of the great traditions of thought and practice available across the world as a whole (Fulford et al., 2013). The remaining seventy-five percent thus offers a potential resource for new philosophy of mental health. Values-based practice is a case in point. Developed thus far within the individual-centred analytic philosophical traditions of Britain and North America, it is already being enriched through the more complex individual-cultural concepts of African Batho Pele (Crepaz-Keay, van Staden and Fulford, forthcoming; van Staden and Fulford, forthcoming). In this chapter, we explore the rather different resources for enriching values-based practice offered by a particularly robust form of values pluralism derived from the Balkan experience of living for many centuries under successive colonial administrations. This experience, of living for so long at the edge of compromise, has resulted in a uniquely Balkan capacity for the values pluralism that, as we describe, underpins the dissensual decision making at the heart of values-based practice. The role of this Balkan ‘cultural pluralism’ in strengthening values-based practice remains to be tested in practice. But its importance in principle is evident from the limitations of values-based practice and other positive practice initiatives across a range of current challenges in mental health. We describe these challenges and the potential contribution of Balkan cultural pluralism in addressing them later in the chapter. We start with a (biographically disguised) personal story illustrating Balkan pluralism in action.

The Story of Dr Petrov and His Neighbour, Ivailo Ivailo (not his real name) was a 48 year old psychiatric hospital attendant (orderly) working as a taxi driver on a part-time basis. He had suffered several clinical episodes over the past ten years diagnosed as psychotic mania with associated history of alcohol abuse. His mother left Bulgaria in the early 1990s to immigrate to New Zealand. His father although remaining in Bulgaria had been a major source of various traumatic experiences throughout Ivailo’s life. His father was constantly abusive, with both verbal and physical aggressive behavior, and entering

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into frequent conflicts about property and relationships. He repeatedly threatened to disinherit Ivailo and leave him and his family practically homeless. Ivailo lived in the same house with his father, wife and two adolescent children until July 2011 when his father died from a rapidly progressive cancer. His wife had been unsupportive throughout and now set out to antagonize Ivailo’s two sons against him. In September 2011, Ivailo stopped taking his medication and gradually returned to abusing alcohol. A couple of months later during a brief period of sick leave he turned up at the home of a psychiatrist, Dr Petrov (again, not his real name), who was living nearby, asking for a loan. Dr Petrov was not Ivailo’s physician but recognized that his behavior was unusual: he was struck by his somewhat awkward and untidy appearance and unusual behaviour. After talking with his wife however he came to the view that Ivailo’s presentation was understandable given his complicated family situation and low income. He thus decided to help Ivailo with a loan while encouraging him to take care and to consult his own doctor. Ivailo came back three weeks later asking for a further loan but now in a more obviously disturbed state. On this occasion, Dr Petrov refused the loan but again urged Ivailo as a friend to see his doctor. Ivailo, however, did not seek medical help and over the following eighteen months, his condition deteriorated to the point that his behavior became destructive and dangerous. Following a further period of sick leave he was finally admitted as a patient to the hospital where he had previously worked as an attendant. From this point forward Ivailo’s situation gradually improved. Over three months of in-patient treatment, he restarted his medication and stopped drinking. Within a few months of discharge he was well enough to return to his job as an attendant in the same acute psychiatric ward on which he had been a patient. Ivailo’s family problems continued. However, he now felt more prepared to cope with them while holding down his job. One of the first things Ivailo did after being discharged from hospital was to return Dr Petrov’s loan.

Same Story Different Values We have presented Ivailo’s story here briefly and there are clearly many areas, which the reader may be looking at for further information. The story is short on clinical detail, for example, particularly relevant to Ivailo’s differential diagnosis: was his relapse simply a recurrence of his

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previous illnesses or, perhaps, a pathological grief reaction to the death of his abusive father. We might reasonably want more information about Ivailo’s actual symptoms and indeed about his relationships with his parents, his wife and two sons. Here, though, we want to focus on Dr Petrov and his decision to help Ivailo with a loan in the early stages of his relapse and the effect of this on the course and eventual outcome of his illness. In this context, the relative lack of information (the facts) on which Dr Petrov based his decision is important. It is typically the case that in day-to-day as well as in clinical decision-making we have to make up our minds what to do under conditions of evidential uncertainty. This is why as we discuss further below, the processes of evidence-based practice are an important resource for medical decision-making. Less well recognized, though no less important, are the values in play. Empirical work in areas such as decision analysis (Dowie, 2004) as well as in analytic philosophy (Fulford, 1989) makes clear that all decisions are values-driven as well as evidence-driven. And if the evidence base of Dr Petrov’s decision is uncertain, the values base of his decision is nothing if not controversial. Thus, from one rather negative perspective, Dr Petrov’s decision might be seen as, at best, imprudent. It worked out well in the end (the loan was repaid). But at the time Dr Petrov might well have reflected on the maxim ‘never a lender or a borrower be’. Similarly, negative evaluations might be made from a professional perspective. Dr Petrov as we have said was not Ivailo’s physician. He nonetheless recognized that Ivailo’s behavior was not normal and he accordingly encouraged him to seek medical help. But in not taking a more paternalistic stance, he left himself open to criticism from some of his medical peers. The reaction of one of his senior colleagues when he heard about the loan was ‘you did something quite stupid giving him money and not helping the police to catch him’. Dr Petrov although not ‘thinking values’ at the time was well aware of these negative perspectives. Balanced against them in his mind though was the positive perspective of his role not as a doctor but as a neighbor. Ivailo and Dr Petrov were more acquaintances than friends, though they had known each other for some time. Dr Petrov had been aware of Ivailo’s family problems but he also rated him as a conscientious employee, trustworthy neighbour and open minded and well-mannered person, albeit somewhat vulnerable through lack of family support. As a neighbor then Dr Petrov wanted to help someone who was clearly in trouble and from this humane perspective he felt it was right to give him a loan as he would anyone else who was similarly in trouble.

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Balkan Cultural Pluralism There are clearly many values issues raised by this story. For present purposes, though, the point of the story is to illustrate what in values-based practice is called dissensual decision-making and how this is supported by Balkan cultural pluralism. In this section, we give a very brief description of values-based practice including its basis in dissensus and then show how this is supported by Balkan cultural pluralism, as illustrated by Dr Petrov’s decision.

Values-Based Practice and Dissensus Values-based practice is one of a number of new ways of working with values currently being developed in health care. The most familiar of these is ethics but other tools in the ‘values tool kit’ include health economics, decision analysis and various aspects of the medical humanities (Fulford, Peile and Carroll, 2012, chapter 2). Many of these approaches aim to reduce differences of values with a view to making them more manageable: ethics characteristically seeks to define ‘right outcomes’ emphasizing values such as autonomy of patient choice. Values-based practice by contrast adds to the tool kit a particular focus on diversity of values. The approach to diversity adopted in values-based practice relies on ‘good process’ instead of ‘right outcomes’. Rather than giving us answers as such, values-based practice offers a process that supports us in coming to a decision in a given situation. The process of values-based practice is derived mainly from philosophy (though it has also important empirical support, Colombo et al., 2003). The philosophy in question is the perhaps rather unlikely resources of linguistic-analytic philosophy, as exemplified by Oxford philosophers such as J. L. Austin (1956 - 57), and applied to the language of values by, among others, another Oxford philosopher, R. M. Hare (1952, 1963). The Austin-Hare take on the language of values provides a whole series of theoretical insights into medical concepts of disorder both bodily and mental (Fulford, 1989). These insights in turn generate the practical tools of values-based practice (Fulford, 2004; Fulford, Peile and Carroll, 2012). Although derived philosophically, values-based practice, in relying on good process, is a values-counterpart of evidence-based practice. Evidence-based practice gives us a process that supports decision making where complex and conflicting evidence is in play. Values-based practice gives us a process that supports decision making where complex and

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conflicting values are in play. The processes involved are different of course. Evidence-based practice is based on meta-analyses of the findings from well-conducted research. Values-based practice is based rather on learnable clinical skills together with other practice-oriented process elements. But the principle is the same. Values-based Practice Starting Point is … Mutual respect for differences of values

Process involves … x x x x

Clinical skills Relationships Links between values and evidence Partnership

Outputs are … Balanced decisions in individual situations within frameworks of shared values

Figure 1-1: Diagram of the Process of Values-based Practice

The process of values-based practice is shown diagrammatically in the Figure 1-1. As this indicates the skills and other process elements of values-based practice together support balanced decision-making within frameworks of shared values. It is in the outputs from this, the balanced decision making in the right-hand side of the diagram, that dissensus comes in.

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Dissensus in values-based practice does not mean disagreement. It is perhaps better understood by contrast with consensus. Thus, dissensus and consensus are both ways of coping with difference. In consensual decision making differences are discussed and an agreed position is adopted with other options being dropped or excluded. This is an important process in evidence-based practice for example. The processes of evidence-based practice (meta-analyses etc as above) are used to come to an agreed view on what the evidence in question shows with other views being thereby dropped or excluded. The resulting consensus then becomes a basis for subsequent decision making across all relevant cases. Consensus has a role too in values-based practice: it is by consensus that the framing shared values of values-based decision-making noted in the Figure 1-1 (under ‘outputs’) are defined. But in values-based practice, decisions are made by balancing these shared values on a case-by-case basis according to the particular circumstances presented by a given situation. In contrast to consensus then the shared values framing valuesbased decision making are not dropped or excluded but remain in play to be balanced sometimes one way and sometimes in other ways as the contingencies of the situation demand. This is dissensus.

Dissensus and Dr Petrov’s Decision Dr Petrov, although not trained in values-based practice, shows many of its elements in his interactions with his neighbor, Ivailo. We should not be surprised by this. Values-based practice is about capturing and building on positive practice and this is precisely what we will see Dr Petrov shows. We summarize the elements of values-based practice shown by Dr Petrol in Table 1-1. The left hand column of this table gives the elements of values-based practice: these are the same as in the figure but now set out in more detail. The right-hand column shows how Dr Petrov reflects these elements in his dealings with Ivailo.

Living at the Edge of Compromise ELEMENTS OF VALUES-BASED PRACTICE

POINT

PREMISE

TEN-PART PROCESS

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COMPARED WITH Dr Petrov’s decision

Rather than giving us answers as such, valuesbased practice aims to support balanced decision making within frameworks of shared values appropriate to the situation in question.

Dr Petrov’s decision to give the loan reflects a balance between values that he shares with his wife and Ivailo (acting prudently, and in a clinically responsible way, but also supportively).

The basis for balanced decision making in values-based practice is the premise of mutual respect for differences of values.

Dr Petrov clearly respects Ivailo (he sees him as ‘a conscientious employee, trustworthy neighbour’, etc); he and his wife also share mutual respect (they discuss and agree what to do); although not explicit in the story Ivailo clearly respects Dr Petrov (thus he turns to him for help; and also makes it a priority to repay the loan when he recovers). Many of the elements of the process of values-based practice are evident in this story – as detailed below.

Values-based practice supports balanced decision making through good process rather than prescribing preset right outcomes. The process of valuesbased practice includes four areas of clinical skills, two aspects of professional relationships, three principles linking valuesbased practice with Evidence Based Practice, and partnership in decision making based on ‘dissensus’.

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The four skills areas are Awareness The first and essential skill for values-based practice is raised awareness of values and of the often surprising diversity of individual values.

Dr Petrov is aware not only of Ivailo’s possible clinical deterioration but also of his need for support not as a patient but as a neighbour. This is the basis of his person-centred response in making the loan – see text.

Reasoning

Values reasoning in values-based practice may employ any of the methods standardly used in ethics (principles reasoning, case-based reasoning, etc) but with an emphasis on opening up different perspectives rather than closing down on ‘solutions’.

Values reasoning as such is not employed here but could be used to explore the values in play and our reactions to them further, for example in teaching sessions based on this story.

Knowledge

A key skill for valuesbased practice is knowing how to find and use knowledge of values (including research-based knowledge) while never forgetting that each individual is unique (we are all an ‘n of 1’).

Again, knowledge of values is not used here but could be important in exploring the issues arising – for example, knowing that ‘what matters’ to a person in Ivailo’s situation is often more about people trusting and caring about them than clinical input to control symptoms – see text re recovery later in the chapter.

Communication

Values-based practice communication skills include skills, 1) for eliciting values, in particular StAR values (Strengths, Aspirations and Resources), and, 2) for conflict resolution.

Dr Petrov shows considerable communication skills especially of active listening and observation in coming to understand what help Ivailo needs. Important in this is his understanding of Ivailo’s strengths (his resilience with his family problems, his trustworthiness as an employee,

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etc). It is these strengths in particular that is the basis of Dr Petrov’s positive decision to help. The two aspects of professional relationships are the extended MDT The role of the MDT (multidisciplinary team) in values-based practice is extended from its traditional range of different professional skills to include also a range of different value perspectives. patient-valuescentered-care

In values-based practice patientcentered care means focusing primarily on the patient’s values though other values (including those of the clinician) are important too. . The three principles linking values with evidence are ‘Two Feet’ The ‘two feet’ principle principle of values-based practice is that all decisions are based on values as well as evidence even where (as in diagnostic decisions) the values in question may be relatively hidden.

As this is a personal rather than clinical decision there is no multidisciplinary team involved. But note the key role of Dr Petrov’s wife in providing a balancing perspective.

Dr Petrov’s decision directly illustrates the concept of personvalues-centred-care – his decision to give Ivailo a loan directly corresponds to his understanding of Ivailo’s needs (i.e. for support and etc. rather than just a loan – see text).

Dr Petrov’s decision directly reflects the two-feet principle – the decision could be seen as a clinical decision - based on the facts of Ivailo’s presenting appearance is he or is he not unwell? If not, make the loan; if so, withhold the loan. These clinical facts are clearly important. But Dr Petrov remains throughout fully aware of the key values in play as well.

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‘Squeaky Wheel’ principle

The ‘squeaky wheel’ principle of valuesbased practice is that we tend to notice values when they are conflicting and hence causing difficulties (based on the saying ‘it’s the squeaky wheel that gets the grease’).

As the converse of the two-feet principle, the squeaky wheel principle is also in play. For in remaining fully aware of the values in play, Dr Petrov never loses sight of the relevant clinical facts (to the point that with Ivailo’s deterioration three weeks later he refuses the second loan).

‘Science Driven’ principle

The ‘science driven’ principle of valuesbased practice is that the need for valuesbased practice is driven by advances in medical science (this is because such advances open up new choices and with choices go values).

This principle applies more in high-tech areas of decision making so is not directly relevant here.

Partnership in decision making … based on Consensual decisiondissensus making involves agreement on values with some values being adopted and others not. In dissensual decision making by contrast different values remain in play to be balanced sometimes one way and sometimes in others, according to the particular circumstances of a given case.

In balancing different values that remain in play Dr Petrov’s decision is dissensual – note that balance comes out one way initially (with the loan being made) but differently three weeks later when the clinical facts have changed (with the loan being refused). Dr Petrov’s capacity for dissensual decision making is enhanced by his cultural background of living in a pluralistic society at the edge of compromise – see text.

Table 1-1: Dr Petrov’s Decision as Values-based Practice The standout point that emerges from this is that a majority of valuesbased elements is in play in one way or another in Dr Petrov’s thinking. We should note in particular two of these: first, Dr Petrov’s awareness of

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what really matters to Ivailo in his present situation; and, second, his understanding of Ivailo’s strengths as well as his more obvious difficulties (these are covered between them by skills elements 1 and 4). Both these aspects of the clinical presentation tend to be neglected in clinical assessments: as clinicians we tend to assume we know what matters to our patients rather than actually finding out; and we tend to focus on the negatives (needs and difficulties) while neglecting the positive strengths an individual brings to their situation. Yet both are foundational to positive practice (Ahmad et al., 2014; Fulford and van Staden, 2013). Both are integral also to the balance of values required for Dr Petrov’s dissensual decision to give Ivailo a loan. The balance to be drawn in this instance, as we noted earlier, is between, on the one hand, prudence and clinical concerns, and, on the other hand, the humane values of supporting a neighbor in trouble. These are all values to which Ivailo no less than Dr Petrov and his wife subscribes. They are all in this sense shared values that Dr Petrov has to balance one against another in deciding what to do. When Ivailo first comes to see Dr Petrov, the humane values outweigh the values of prudence and clinical concerns and Dr Petrov decides to give Ivailo a loan. But the values themselves remain fully in play. This is why the decision is a dissensual decision. And the same values indeed are balanced differently three weeks later when Ivailo’s behavior has become more obviously clinically abnormal. On this occasion, prudence and clinical concerns come to the fore and Dr Petrov refuses the loan. With the benefit of hindsight (in particular the knowledge that the loan was ultimately repaid) this may all seem obvious enough. But the balancing of values was much trickier when made for real in all the uncertainties particularly surrounding Ivailo’s first request. Again, Dr Petrov showed well-developed skills for values-based practice in the way he handled this at the time. Many would have ‘played safe’. Many others would have followed Dr Petrov’s senior colleague’s advice and called the police! But Dr Petrov’s balanced approach was vital to Ivailo in affirming his sense of self-worth at this critical point and thus paving the way for his eventual recovery. Again, this may all seem rather obvious with the benefit of hindsight. But experience in the UK at least suggests that in coming to a balanced dissensual decision in this way Dr Petrov succeeded where many others would have failed. We return to the difficulties of dissensual decision making below. But for now, the point is that dissensual decision-making depends on values pluralism which, for reasons we will come to see, seems to be peculiarly difficult to sustain in practice. This is why Dr

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Petrov’s story is important. Dr Petrov succeeded where many would have failed because in coming to a balanced dissensual decision he was able to draw on a resource of values pluralism arising from his background cultural tradition of living for so long under colonial rule at the edge of compromise. We will review this cultural tradition briefly in the next section before coming back to its role in supporting Dr Petrov’s dissensual decision.

Living at the Edge of Compromise Bulgaria’s history of colonial domination starts with its long period, from 1396 to 1878, was under the Ottoman yoke. During this period many strategies were adopted to make it possible to live together with their oppressors. The Christian population of Bulgaria for example found themselves obliged to build their churches so that they appeared lower than Muslim mosques. Later, in between 1934 and 1944 the governing dynasty of SaxCoburg-Gotha and a number of pro-German politicians brought Bulgaria into alliance with the Axis and National-Socialist Germany. It was at this time that King Boris III captured the idea of ‘living at the edge of compromise’ by famously advising his diplomats to be “always with Germany and never against Russia”. As a further illustration of Bulgarian compromise Boris III was the father of Simeon II who while reigning as King from 1943 to 1946 went on to become Prime Minister of a republican Bulgaria from 2001 to 2005. Bulgaria’s latest period of colonization came as a satellite of the Soviet Union and member of the Warsaw pact from 1944 until the communist regime was deposed in 1989. Interestingly, the regime in Bulgaria was deposed from inside by a party coup d’etat in contrast to other communist regimes in Eastern and Central Europe who were deposed by popular peoples’ uprisings. This is an important further example of Bulgarian “living at the edge of compromise”.

Cultural Pluralism The result of this long history is that Bulgarians are culturally attuned to living within a pluralistic set of values often at odds one with another but requiring a pragmatic balance in the realities of day-to-day living. It is this cultural heritage we believe that supported Dr Petrov in his dissensual decision to give Ivailo a loan.

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This is speculative of course. But note how different Bulgaria is in this respect from the UK. Where the cultural heritage of Bulgaria as a colonised people has been perforce one of pluralistic values the corresponding heritage of the UK, in which values-based practice was first developed, as a dominant power is essentially monistic: the values of a dominant power are by definition dominant. Similar considerations apply to North America and indeed Russia. But the dissensus of values-based practice as we describe further below has been limited by what one of us has called elsewhere the ‘retreat to monism’ (Fulford, Dewey and King, forthcoming). It is from this retreat to monism that Dr Petrov’s cultural heritage protected him. Pluralism particularly as a vassal nation is not to be romanticised. But as the political philosopher Isaiah Berlin pointed out in the aftermath of the Second World War, it is the retreat to monism, not the balance of pluralism that has been at the root of the worst abuses of humanity in much of its history (Berlin, 1958). The moral philosopher Jonathan Glover has made a similar point in his (ironically titled) ‘Humanity’ (Glover, 1999). In the next section we examine the significance of Balkan cultural pluralism both for combating abuses of psychiatry and for promoting positive values-based practice.

Cultural Pluralism and Psychiatric Practice In focusing on the story of Dr Petrol and Avail it might seem that we have been making too much of just one instance. There is though at least negative evidence of the wider influence of Balkan cultural pluralism in the relative absence of political abuses of psychiatry in Bulgaria during the period of Soviet occupation. In this section, we illustrate the possible significance of this with two studies, one of abuses of psychiatry, the other of positive practice. We then return to the potential role of Balkan cultural pluralism respectively in reducing the risks of abuse and in promoting positive practice in psychiatry.

Abuses of Psychiatry in Soviet Russia Political abuses of psychiatry became widespread in Russia during the closing decades of the Soviet Union. These abuses, which were at their height in the 1960s and 1970s, have been well documented elsewhere (Bloch and Reddaway, 1997). What they amounted to was the use of psychiatric diagnoses (such as ‘sluggish schizophrenia’ based on ‘delusions of reformism’) as a means of political oppression. Psychiatry

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seems to be peculiarly prone to sporadic cases of being abused for a variety of non-clinical purposes (van Voren 2010; Van Voren and Keukens, forthcoming).1 However, in Soviet Russia such abuses became institutionally endemic. In the late 1980s, one of us (KWMF) had an opportunity to explore the reasons for this institutionalized abuse of psychiatry using a linguistic analytic methodology similar to that underpinning values-based practice (as above). The opportunity arose from a Russian psychiatrist, Alex Smirnov, arriving in Oxford on a one-year visiting scholarship. We had the further support of a Russian-speaking social worker, Elena Snow. Most of the work on Soviet abuses of psychiatry to that time had focused on documenting cases of abuse and seeking to identify their structural causes (in areas such as professional education). This work was clearly important in its own right. We by contrast wanted to get as it were behind the scenes to look directly at the concepts guiding the Soviet psychiatry of the period. Rather therefore than studying cases of abuse as such, our study took the form of a careful linguistic analysis of a representative sample of the Russian psychiatric literature of the period. The results were a surprise. The assumption among Western commentators had generally been that at the root of Soviet abuses of psychiatry would be found unreliable diagnostic concepts based on unscientific models of disorder. What we found was quite the opposite. The diagnostic concepts and models of disorder evident in the Soviet psychiatric literature were essentially the same as their counterparts in the corresponding British and North American literatures of the day. In both literatures the dominant model was one of descriptively defined symptoms reflecting biological (neuropath logical) disease models. There were indeed close parallels even on the specifics: the ‘sluggish schizophrenia’ of Soviet psychiatry was closely similar diagnostically to the ‘latent schizophrenia’ of British/American psychiatry (Guilford, Smirnoff and Snow, 1993). It is noteworthy also that over this period Soviet paradigm of ‘nosos’ and ‘pathos schizophrenia’ as developed by Andrey Snezhnevsky and others were published in main stream Western European and American peer-reviewed journals and edited books (see Davidovsky and Snezhnevsky, 1966; Snezhnevsky. 1966 and 1968a and 1968b, and Snezhnevsky and Vartanyan, 1971).

1

More extreme forms of abuse should not be forgotten including the socialDarwinist approaches adopted under National Socialism and leading to attempted extermination of the mentally ill under their program of euthanasia (Muller-Hill, 1991).

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These findings thus begged the question, ‘why Soviet psychiatry?’ Why should abuses of psychiatry have become endemic in Soviet psychiatry at this time but not apparently in Britain and America? Various answers are possible. The conclusion we came to in our paper was that while structural factors had indeed been important in allowing abuses of psychiatry to become widespread, the underlying vulnerability of psychiatry arose not from lack of clinical or scientific rigor but rather from a failure to recognize the extent to which values (as well as facts) are important in psychiatric diagnosis. In other Soviet psychiatry, then, so this hypothesis goes, Soviet values were driving the judgment that someone who campaigned to replace the Soviet system was irrational (they had a masked or ‘sluggish’ form of schizophrenia) and, correspondingly, were suffering from delusions (of reformism). This is clearly a large and contentious claim that we do not have space here to discuss in detail. Its justification requires at the very least the finetuning point (made in the original paper) that risks of abuse arise only when totalitarian regimes become (like the Soviet regime in the 1960s and 1970s) partially liberalized: an all-powerful regime simply represses dissidents. The claim rests furthermore on a body of theoretical work in linguistic philosophy about the relationship between evaluative and factual meanings which itself is unresolved (Fulford and van Staden, 2013). However, given the similar institutionalized abuses of psychiatry in other (partially liberalized) totalitarian regimes (such as China, Human Rights Watch/Geneva Initiative on Psychiatry, 2002) it is at least a reasonable working hypothesis. And as a working hypothesis, it leads directly to the need to take the values in psychiatric diagnosis as seriously as we already take the facts. What taking the values in psychiatric diagnosis seriously means for practice is to adopt an open and pluralistically balanced approach of the kind that is supported by the several process elements of values-based practice. Such an approach has been developed in the UK (Fulford et al., forthcoming), though, as we will see from the next study, with variable success.

Positive Practice: Values-Based Involuntary Treatment Our example of positive practice comes from a series of policy and practice initiatives developed under the auspices of the UK’s Department of Health where one of us worked for a period as Special Advisor for Values-based Practice (Fulford, Dewey and King, forthcoming). The particular initiative we have chosen to describe is not in diagnosis as such

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but the assessments involved in involuntary (or coercive) psychiatric treatment. This might perhaps seem an unlikely source of positive practice. There are after all those who would say that the very possibility of involuntary psychiatric treatment puts psychiatry and psychiatric patients at a stigmatizing disadvantage relative to their bodily medicine counterparts (Sayce, L., 1998 responding to Szmukler et al., 1998). Values-based practice nonetheless has the clear consequence that involuntary no less than voluntary psychiatric treatment demands a positive approach (Fulford, King and Dewey, 2009). Positive practice in involuntary treatment is important moreover as a ‘proof of product’: if values-based practice can support positive practice in the uniquely challenging decisions involved in involuntary treatment, it surely has a role across psychiatry as a whole. The initiative in question furthermore had every chance of success in that the key elements needed to support values-based involuntary treatment (a set of Guiding Principles operating as a framework of shared values) were embodied in a new Mental Health Act, that practitioners were required to have regard to these elements in any decisions they made under the powers of the Act, and that they were supported in this by an extensive training program rolled out by the Department of Health to support implementation. Yet in the event, despite successful pilot projects, the approach failed to take hold across psychiatric practice as a whole (Fulford, King and Dewey, forthcoming). Values-based involuntary treatment we should add is not alone among positive practice initiatives in failing to generalize from successful local pilots to mainstream practice: recovery, person-centered care, and latterly co-production, have all suffered similar problems of generalization (Ahmad et al., 2014). Again, we do not have space here to discuss the many possible reasons for this. A key factor though in the case of valuesbased involuntary treatment, has been what we called earlier the ‘retreat to monism’. Positive practice in involuntary treatment, on the model developed in the UK, requires a dissensual approach that, as we saw earlier, in turn depends critically on values pluralism. Values pluralism proved to be relatively easy to sustain in the context of local pilots and training programs. But what happened as the program moved out into the wider world of everyday practice was a dramatic and more or less complete retreat to monism. In place of the required dissensual approach balancing key shared values, decision making under the Act became dominated by one or another single value (notably risk and resources, Fulford, Dewey and King, forthcoming).

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Abuses of Psychiatry, Positive Practice and Values Pluralism Values pluralism, therefore, is at the heart of meeting the challenges of positive practice, as illustrated here by value-based involuntary treatment, as it is of resisting the negative practices represented by Soviet abuses. In both cases, a key factor in meeting their respective challenges is to find ways of sustaining pluralism in the face default retreats to monism. This is where the cultural pluralism of Bulgaria and other Balkan states could have a role to play. Cultural pluralism clearly did have a role to play in Dr Petrov’s dealings with his neighbor Ivailo. Instead of a risk-averse refusal to help Ivailo, Dr Petrov took a balanced positive decision to help him with a loan. But this was a dissensual decision in which the relevant values remained fully in play. This is why as we saw, once Ivailo’s condition became clearly clinically abnormal the balance of values shifted to refusing a further loan and pushing Ivailo more firmly towards seeking medical help from his own doctor. Importantly, Dr Petrov’s handling of this difficult situation was positive at both stages: his initial help indicated in a personal and humane way his care and concern for Ivailo not as a patient but as a neighbor: this personal engagement and the trust Dr Petrov put in Ivailo would have been crucially supportive to him in his undoubtedly demoralized state at the time and almost certainly contributed to his eventual recovery (as evidenced not least by his prompt repayment of the loan). But the later refusal of a second loan actually built on this. For in the context of his earlier support, it showed Ivailo that Dr Petrov was still caring for him as a person and (‘tough love’ though it was) advising him very much in his best interests. Balancing these conflicting values in this way came naturally to Dr Petrov with his cultural heritage of living at the edge of compromise. Just how widespread this might be among Balkan people in general we do not have the data to say. Nor do we have the data to say whether in other similarly colonized countries their peoples like the people of Bulgaria have learned to live pluralistically at the edge of compromise. But as already indicated the fact that abuses of psychiatry never became endemic in Bulgaria during the period of Soviet domination is at least consistent with their cultural capacity for sustaining values pluralism. Consistent too is the difficulty that in countries like Britain we have with sustaining values pluralism (as evidenced by the retreat to monism in the use of the Mental Health Act, above). For of course Britain in contrast with Bulgaria has historically been a colonizing rather than colonized country. As a colonizer, monism rather than pluralism serves well. Therefore, in Britain we have no cultural heritage to support us in

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sustaining pluralism. This could turn out to be important in preventing abuses as well as in promoting positive practice. It is relevant here to note the continuing much higher rates of involuntary psychiatric treatment among young black men in the UK than their white peers (up to 17 times, Care Quality Commission, 2009). There are as ever many possible explanations for this. But as the black researcher and activist Colin King has pointed out (King et al., 2009) it is not inconceivable that it has something to do with values. So we have much to learn at least in the UK from Balkan experience. Just how we learn is yet a further question. As with African Batho Pele the dependence of Balkan cultural pluralism on particular historical contingencies means that there can be no simple transfer of learning. Even the requisite words defy direct translation: the ‘togetherness’ of BosnianSebian and Bulgarian ‘zaednost’ (‘ɡɚɟɞɧɨɫɬ’), like the ‘culturalindividual’ connotations of the African Sesotho ‘Batho Pele’ and isiZulu ‘indaba’, carry meanings unique to their own cultural contexts (van Staden and Fulford, forthcoming). In this, they are not unique of course. One of the key insights of twentieth century philosophy (in the work of Ludwig Wittgenstein, J. L. Austin and others) is the extent to which meanings in general are learned through shared use in a social context. Correlatively therefore an important part at least of what is required for shared learning between cultures is a shared project. It is this that in the coming century the philosophy of mental health with its international reach and strongly collegial nature could help to supply.

Conclusions In this chapter, we have explored the potential of a particular form of Balkan cultural pluralism to drive new philosophy of mental health. We started with the story of a real (though biographically disguised) doctor, Dr Petrov, in his dealings with his (again biographically disguised) neighbor, Ivailo. Dr Petrov succeeded where, as we saw later in the chapter, most of us fail in coming to a balanced dissensual decision in deciding whether to give Ivailo a loan. In succeeding in this way, we suggested, Dr Petrov drew on background resources of Balkan pluralism arising from Bulgaria’s long history of being ruled by a succession of colonizing powers. Corresponding resources we further suggested are not available to historically colonizing countries like Britain. Given therefore, the importance of pluralism both in preventing abuses of psychiatry and promoting positive practice, Balkan cultural pluralism, we argued, has the

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potential to make an important contribution to driving future developments in values-based practice and related areas of philosophy and psychiatry. We have emphasized throughout the challenges both theoretical and practical of realizing this potential in practice. There is no contradiction here. There is no place in philosophy and psychiatry any more than there is in the sciences of psychiatry for mere theorizing. In the one as in the other, the twin constraints of logical rigor and of empirical testing apply. Equally, though, in the one as in the other, the twin constraints of logical rigor and empirical testing should serve to drive, not limit, our ambitions. Science as the twentieth century philosopher Karl Popper memorably pointed out thrives on conjectures as well as refutations (Popper, 2004). In our perhaps overly-regulated contemporary scientific funding environment, politically-motivated priorities for instant ‘results’ are at risk of restricting the imaginative leaps on which the conjectures that drive real science crucially depend. So understood, then, science itself has become yet another victim of the default retreat to monism. The widely recognized failures of translation of psychiatric science (Fulford, Bortolotti and Broome, 2014), discussed elsewhere and in this book (Stoyanov et al., 2013; Stoyanov, Borgvardt and Varga, 2014., and Kandilarova and Stoyanov, forthcoming, this book), could well be a symptom of this values-monism-based failure of the conjectural leap. Which if so, would give a completely new edge to the potential importance of Balkan cultural pluralism as a resource for new and practically relevant philosophy of mental health.

Acknowledgements The story of Dr Petrov and Ivailo was first presented by one of us (DS) at a conference of the International Network for Philosophy and Psychiatry held in 2013 at St Catherine’s College, Oxford, on ‘Making Change Happen’. The figure and table are based on similar illustrations in van Staden and Fulford (forthcoming). We are grateful to the authors and publisher (Oxford University Press) for permission to publish these versions here.

References Ahmad, N., Ellins, J., Krelle, H., and Lawrie, M. (2014) Person-centred care: from ideas to action - bringing together the evidence on shared decision-making and self-management support. London: Health Foundation

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Austin, J.L. (1956-7) A plea for excuses. Proceedings of the Aristotelian Society 57:1-30. Reprinted in White, A.R., ed. (1968). The Philosophy of Action. Oxford: Oxford University Press, pps 19-42. Berlin, I., (1958) Two Concepts of Liberty. Oxford: Clarendon Press. Bloch, S., and Reddaway, P., (1997) Russia's Political Hospitals: The Abuse of Psychiatry in the Soviet Union. London: Gollancz; also published in the USA as Psychiatric Terror, New York: Basic Books, 1997. Care Quality Commission (2009) Count Me In 2009: The National Mental Health and Learning Disability Ethnicity Census. Care Quality Commission and the National Mental Health Development Unit, London. Colombo, A., Bendelow, G., Fulford, K.W.M., and Williams, S. (2003) Evaluating the influence of implicit models of mental disorder on processes of shared decision making within community-based multidisciplinary teams. Social Science & Medicine, 56: 1557-1570. Crepaz-Keay, D., Fulford, K.W.M., van Staden, W., (forthcoming, 2015) Putting both a person and people first: interdependence, values-based practice and African Batho Pele as resources for co-production in mental health. Ch 4 in Sadler, J.Z., van Staden, W., and Fulford, K.W.M., (Eds) The Oxford Handbook of Psychiatric Ethics. Oxford: Oxford University Press Davidovsky, I. V., & Snezhnevsky, A. V. (1966). Concerning the social and biological factors in the aetiology of mental disturbances. British Journal of Social Psychiatry, 1, 16-21. Dowie, J. (2004) Research Implications of Science-Informed, Value-Based Decision Making. International Journal of Occupational Medicine and Environmental Health, 17 (1) 83-90. Also appears in Human Ecological and Risk Assessment (2005) 11:115-124. Fulford, K.W.M. (1989, reprinted 1995 and 1999) Moral Theory and Medical Practice. Cambridge: Cambridge University Press. —. (2004) Ten Principles of Values-Based Medicine. In Radden, J. (Ed) The Philosophy of Psychiatry: A Companion. New York: Oxford University Press. —. (forthcoming, 2013) Particular Psychopathologies: Lessons from Karl Jaspers’ General Psychopathology for the new Philosophy of Psychiatry: Introduction to Stanghellini, G., and Fuchs, T., (Eds) One Century of Karl Jaspers’ General Psychopathology. Oxford: Oxford University Press

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Fulford, K.W.M., Smirnov, A.Y.U. and Snow, E. (1993) Concepts of Disease and the Abuse of Psychiatry in the USSR. British Journal of Psychiatry, 162, 801-810. Fulford, K.W.M., Peile, E., and Carroll, H (2012) Essential Values-based Practice: clinical stories linking science with people. Cambridge: Cambridge University Press Fulford KWM, Davies M, Gipps R, Graham G, Sadler J, Stanghellini G, Thornton T. (2013) The Next Hundred Years: Watching our Ps and Q’: chapter 1, pps 1 – 11 in Fulford KWM, Davies M, Gipps R, Graham G, Sadler J, Stanghellini G, Thornton T (eds). The Oxford Handbook of Philosophy and Psychiatry. Oxford: Oxford University Press. Fulford, K.W.M., van Staden, W., (2013) Values-based practice: topsyturvy take home messages from ordinary language philosophy (and a few next steps) chapter 26, pps 385 – 412 in Fulford, K.W.M., Davies, M., Gipps, R., Graham, G., Sadler, J., Stanghellini, G., and Fulford, K.W.M., King, M. and Dewey, S. (2009) Values Based Practice and Involuntary Treatment: A new training programme in the UK. Advances in Psychiatric Treatment, Volume 3 (Editors: G.N. Christodoulou, M. Jorge, J.E. Mezzich), Beta Medical Publishers, 2009, pp 185-195 Fulford, K. W. M., Bortolotti, L., and Broome M. (2014) Taking the long view: an emerging framework for translational psychiatric science. Special Article for World Psychiatry. 13/2, 108 – 117. Fulford, K.W.M., Dewey, S., and King, M.(forthcoming, 2015) Valuesbased Involuntary Seclusion and Treatment: Value Pluralism and the UK’s Mental Health Act 2007. Ch 60, in Sadler, J.Z., van Staden, W., and Fulford, K.W.M., (Eds) The Oxford Handbook of Psychiatric Ethics. Oxford: Oxford University Press Fulford, K.W.M., Duhig, L., Hankin, J., Hicks, J., and Keeble, J.(forthcoming, 2015) Values-based Assessment in Mental Health: The 3 Keys to a Shared Approach between Service Users and Service Providers. Ch 73, in Sadler, J.Z., van Staden, W., and Fulford, K.W.M., (Eds) The Oxford Handbook of Psychiatric Ethics. Oxford: Oxford University Press Kandilarova S, Stoyanov D. (forthcoming) Clinical application of the theory of translational validation: potential EEG- and fMRI-derived markers of antidepressant treatment response. In: Stoyanov D, editor. Towards new philosophy and mental health: perspectives form neuroscience and humanities. forthcoming. New Castle: Cambridge Scholars Publishing; forthcoming

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Glover, J. (1999) Humanity: A Moral History of the Twentieth Century. London: Jonathan Cape. London: Pimlico Human Rights Watch/Geneva Initiative on Psychiatry. (2002) Dangerous Minds: Political Psychiatry in China Today and its Origins in the Mao Era. New York: Human Rights Watch. Hare, R.M. (1952) The language of morals. Oxford: Oxford University Press. —. (1963) Descriptivism. Proceedings of the British Academy 49: 115134. Reprinted in Hare, R.M. (1972) Essays on the moral concepts. London: The Macmillan Press Ltd. King, C., Bhui,, Fulford, K.W.M., Vasiliou-Theodore, C and Williamson, T. (2009) Model Values? Race, Values and Models in Mental Health. London: The Mental Health Foundation. Muller-Hill, B. (1991). Psychiatry in the nazi era. Psychiatric ethics (2nd edn). Oxford: Oxford University Press. Popper, Karl (2004). Conjectures and refutations : the growth of scientific knowledge (Reprinted. ed.). London: Routledge. Sayce, L., (1998) Commentary on Szmukler, G and Holloway, F., Mental Health Legislation is now a Harmful Anachronism. Psychiatric Bulletin. 22. 669-670. Stoyanov, D., Machamer, P., & Schaffner, K. F. (2013). In quest for scientific psychiatry: Toward bridging the explanatory gap. Philosophy, Psychiatry, & Psychology, 20(3), 261-273. Stoyanov D, Borgvardt S, Varga S. The problem of translational validity across neuroscience and psychiatry. In: Zachar P, Stoyanov D, Aragona M, Jablenski A, editors. Alternative perspectives on psychiatric validation. Oxford: Oxford University Press; 2014. p. 128. Snezhnevsky, A. V. (1966). The prognosis of schizophrenia. International journal of psychiatry, 2(6), 635. —. (1968a). The symptomatology, clinical forms and nosology of schizophrenia, pps., 425-447 in Modern Perspectives in World Psychiatry. Edinburgh and London: Oliver & Boyd, Ltd. —. (1968b). The Symptomatology, Clinical Forms and Nosology of Schizophrenia, Brunner-Mazel, New York, NY. Snezhnevsky, A. V. and Vartanyan Ɇȿ (1971)The Forms of schizophrenia and their biological correlates, pps., 1-28 in Himwich, H.E. (ed) Biochemistry, Schizophrenias and Affective illnesses. Baltimore: The Williams and Wilkins Company. Szmukler, G., and Holloway, F., (1998) Mental Health Legislation is now a Harmful Anachronism. Psychiatric Bulletin. 22. 662-665.

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Thornton, T. (Eds). The Oxford Handbook of Philosophy and Psychiatry. Oxford: Oxford University Press van Staden, W and Fulford, K.W.M., (forthcoming, 2015) The Indaba in African Values-based practice: respecting diversity of values without ethical relativism or individual liberalism. Ch 28, in Sadler, J.Z., van Staden, W., and Fulford, K.W.M., Eds The Oxford Handbook of Psychiatric Ethics. Oxford: Oxford University Press van Voren, R., (2010) Cold War in Psychiatry: Human actors, Secret Actors. Amsterdam, Netherlands and New York, USA: Editions Rodopi van Voren, R., and Keukens, R., (forthcoming, 2015). Ch 48: Political abuse of psychiatry, in Sadler, J.Z., van Staden, W., and Fulford, K.W.M., Eds The Oxford Handbook of Psychiatric Ethics. Oxford: Oxford University Press

PART I METHODOLOGY OF NEUROSCIENCE INQUIRY REVISITED

CHAPTER TWO CEREBRAL CORTEX FUNCTION WLADIMIR OVTSCHAROFF

Abstract The cerebral cortex contains an enormous number of different types of neurons, about 100 billion, which have about one quadrillion synapses. Thinking about this basic structure of the cerebral cortex, we must take into consideration about over 20 types of mediators and that each one of these transmitters has between 2 and 25 different types of receptors. The connecting neurons form neuronal chains, circuits and networks. The cerebral cortex is bidirectionally connected with other parts of the CNS. Different functions are located in the numerous cerebral cortex areas. These areas consist of smaller areas that differ from one another according to the form, size, distribution and density of their neurons. On the other hand, these areas could be subdivided into much smaller distinct fields. Having in mind that the human brain is a self-organizing system, many of these cerebral cortex interconnected areas must be activated simultaneously. This brain activity cannot be centralized and there are several spontaneously activated areas. The result of the respective brain activity would probably be greater than the sum of the activated cerebral cortex areas. All these events in the cerebral cortex are the morphological basis of the human intellectual capability, including creativity and other brain functions. The optimal educational environment at home and school is extremely important to reach higher intellectual potential. *** The operational activity and the function of the cerebral cortex depends on the precise organization of numerous cerebral gyri, sulci and areas, as this includes the arrangement of neurons and the suitable interconnection between them. This is the precision of the brain wiring. To be realized this highly sophisticated structure, the steps during development of the brain

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are the generation of neurons – the process of cell proliferation, the neuronal migration, neuronal differentiation and formation of the interneuronal synaptic contacts and the following elimination of neurons and interneuronal synaptic contacts (Squire et al. 2003, p. 363). It is accepted that all these events of development are under genetic control, but also depend on environmental factors during pregnancy. This is the organization of the “basic” cytoarchitectonic and wiring of the cerebral cortex. The formation of neuronal chains and networks by means of cellto-cell neuronal communication mostly occurs during the prenatal cerebral cortex development. After the birth, intensive modification of interneuronal synapses starts, including elimination and formation of new synaptic contacts. These processes lead to reorganization of neuronal circuits and networks in the cerebral cortex. These events in the cortical areas occur during the postnatal life, as well. This process, which exists in the course of human life, is called synaptic plasticity. One important base of the complexity of the brain is the number of neurons and synapses. It was estimated that the cerebral cortex contains 100 billions of neurons - 1011. If each neuron has approximately 1000 up to 60000 synapses, the synaptic capacity of the respective nerve cell, the number of neurons could be multiplied by the number of synapses per neuron and we would get the incomprehensible synaptic number of about 1015 or 1016. It should be assumed that the number of neurons and synapses is a tiny part of brain complexity. The different structures of the neural chains, circuits and networks have a very important role in brain function. The neurons are interconnected in different ways – chains, circuits and networks. The neural chains are two or more neurons successively connected end-to-end by means of synaptic connection. For example, the simplest neuronal chain is formed by one sensory and one motor neuron – patellar or “knee-jerk” spinal reflex. The three-neuron chain is principally formed by one sensory or afferent neuron, one interneuron and one motor or efferent neuron. The chains could be divided in several types: simple, diverging and converging. The last could be included into the circuits. A simple chain has a neuronal interconnection in which the number of interconnected neurons is equal or almost equal to the number of afferent neurons, interneurons and efferent neurons respectively. A diverging chain is characterized by an increasing number of the consecutive parts of the chain. The number of neurons in a converging chain is decreasing as compared to the previous type of chain.

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The second main type or level of connection between the neurons is the neural circuit. Their structure and organization include a different number of neurons dependent on the intended function. Having in mind the enormous ability of each neuron to receive information from thousands of neurons by means of synapses and to send information to thousands of other neurons by means of synaptic connectivity, it is easy to accept that neural networks with different complexity are formed in this way. Thinking about the complexity and plasticity of the human brain, it must be assumed that brain circuits and networks are in a state of constant change. They are constantly active, even when resting or sleeping. The number, localization and distribution of synapses are genetically coded; others are formed and disintegrated in the course of postnatal life. The synapses send excitatory or inhibitory signals. This is relatively simple. However, brain function is much more complex – there are more than 200 neurotransmitters and neuromodulators, some of them excitatory and others inhibitory. The activity of the synapses is much more sophisticated, having in mind that for each mediator there are 2 to more than 20 types and subtypes of receptors (Bear, Connors and Paradiso, 2007, p. 133). The function of the cerebral cortex is based on the neuronal types, different transmitters, neuromodulators, neurosteroids, different transmitter receptors, hormones, as well as other substances and chemical compounds from the environment,. The main neuronal type in the cerebral cortex is the pyramidal neuron. These neurons comprise about 75 – 76% of the neuronal population. Very important for the sophisticated structure of the cerebral cortex are the interneurons, the number of which increases during phylogeny. These interneurons or granular neurons comprise about 24 – 30% of the cerebral cortex neuronal population. There are 9 types of interneurons: bipolar cells, stellate cells, double bouquet cells, chandelier cells, fusiform cells, basket cells, gliaform neurons, horizontal Cajal cells and Martinotti cells. Most of the pyramidal neurons are glutamatergic. The class of excitatory transmitters includes L-glutamate, L-aspartate and perhaps L-cysteate, Lhomocysteate, L-cystein sulfinate and less likely N-acetyl-L-aspartyl-Lglutamate. Very small number of pyramidal neurons is cholinergic. Most of the granule neurons or interneurons are GABAergic with coexistence: parvalbumin – 40% (basket and chandelier cells), somatostatin – 30% (Martinotti cells and other neurons), Vasoactive Intestinal Polypeptide (gliaform and other interneurons). There are glutamatergic and cholinergic interneurons, as well. It is believed that there are glycinergic

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and taurinergic cerebral cortex interneurons. Numerous pyramidal and granule neurons use NO, as an additional transmitter. Trying to explain the cerebral cortex function, the cortical afferents must be taken into consideration, which use several types of mediators: serotonin, norepinephrin, dopamine, acetylcholine, histamine and glutamate. The large number of transmitter receptors is very important for cerebral cortex activity. There are 24 types and subtypes of glutamate receptors: ionotropic – 16 types and subtypes, metabotropic – 8 types, AMPA – 4 types, kainite – 5 types and NMDA – 7 types. The GABA receptors are 2 types – GABAA – inotropic and GABAB - metabotropic. The serotonin receptors are 17 types and subtypes, the norepinephrin receptors – 4 types and 2 subtypes, dopamine receptors – 5 types, acetylcholine receptors – 2 types, histamine receptors – 4 types, somatostatin receptors – 5 types, VIP receptors – 2 types, neuropeptide Y receptor – 4 types and so on. Environmental factors like alcohol, tobacco and many drugs and medicines influence the activity of the cerebral cortex. In the cerebral cortex, there are functional areas, which could be divided into three main types: motor, sensory and association. The motor areas are involved in the voluntary control of the skeletal muscles. The sensory areas receive different types of sensory information – common sensation, visual, olfactory, taste, equilibrium and hearing. The association areas integrate the sensory information with learning, memory processes, emotions and thoughts. The different cerebral cortical functions are closely connected with the Brodmann areas. These areas were originally described by Brodmann (1909) on the basis of cytoarchitectural organization of nerve cells in the laminar structure of the cerebral cortex. The cerebral functions, sensory, motor and association are closely related to the respective structural organization of the cerebral cortex. Here Broca’s area (motor speech area) must be mentioned, which is involved in the production of language as well as Wernicke’s area (sensory speech area) linked to understanding speech and producing coherent speech. Another level of structure and function of the cerebral cortex are the lobes: frontal, parietal, occipital, temporal, insula and the cortical part of the limbic system. A number of different functions are located in the frontal lobe: intellect, attention, abstract thought processes, behavior, problem solving, consciousness, judgment, initiative. Creative thoughts, judgments of daily activity, coordination of movements, some emotions and their control, sexual urges, some eye movements, motor skills, and olfaction are formed

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in this lobe. The parietal lobe is involved in orientation, recognition, and movement. The occipital lobe is associated with visual processing and reading, while the temporal lobe is responsible for memory, auditory stimuli, speech, music, fear, some emotions and behavior as well as sense of identity. Visual processing is located in the occipital lobe, while the temporal lobe is responsible for recognition and perception of auditory signals. The insula is involved together with other brain structures in consciousness, self-awareness and psychopathology but it is also associated with emotions and homeostasis. The limbic system encompasses the limbic lobe, the hippocampus, the entorhinal area and several other structures such as the amygdaloid complex, indusium griseum, mamillary bodies, septum, and several other brain structures (Duus, 1998). This system is responsible for many functions – defensive reactions, sexual and grooming behavior, memory, autonomic reactions (Waxman, 2013, 236). Having in mind the structure and functions of the cerebral cortex, the main question is how the human brain works. Nowadays, we know much more about the brain structure, including the brain chemistry. We know about many brain processes and mechanisms as well. For better understanding of the cerebral cortex function, it should be assumed that our brain is one self-organizing system, which can make new connections in milliseconds. Different cerebral cortex areas are simultaneously involved in the respective activity – motor, sensory and limbic areas, prefrontal cortex, auditory and visual areas, and many others. This cerebral cortex activity has been demonstrated by means of functional magnetic resonance imaging and with positron emission tomography. So, this self-organizing system is theoretically not centralized (Andreasen 2005, p. 61). Such systems could be observed in human societies, schooling of fish, swarming of bees, or flocking of birds. The difference in the structure, in the different level – cellular, synaptic contacts, genetic regulation of neuron wirings and environmental factors, molecular mechanisms in different brain areas - could probably explain the respective capacity and creativity in different human beings. Let us presume that the number, types and arrangement of neurons, the brain wiring, the number of synapses, their location and their transmitters in the course of brain development are genetically regulated, without excluding the respective role of prenatal and postnatal environmental factors (Squire et al. 2003, p. 363). Having in mind the plasticity of the brain, we must strive to stimulate the formation of a “better” brain during the periods of childhood and adulthood and to preserve the respective degree of the mental capacity of aged people.

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The brain of a newborn, the formation of which is mainly genetically predetermined, is actually not “tabula rasa.” If we want to develop its inborn capacity, it is necessary to train the mental capacity of the child. Reading to the children is very important and it must start as early as possible (Andreasen, 2005, p.170). Speaking, that is, active verbal interaction with the child is of great importance for the stimulation of brain development. Choose toys which are suitable for the child’s age, such as puzzles, which could contribute to the mental development of the children. Try to involve children in music education, which will stimulate the development of the respective cerebral cortex areas. There is no unanimous opinion regarding TV for children, but educational and other suitable for children TV programs must be intensively used to stimulate the formation of better brains. Highly advisable for the children is the intensive contact with nature. Optimal kindergarten environment and intensive teaching at a suitable school later will be an important basis for the formation of creative brains. To develop better brain creativity, it is important to study in the high-ranking schools and universities. In some cases, this is not true, but the intensive study, good teachers and university are very important for the development of a more creative brain. Suitable family atmosphere will contribute to the formation of a better brain in the respective degree. The striving to build better brains must continue in adults by means of mind gym and as Andreasen (2005) advised, mental exercises must become daily routine. One important rule is to be optimistic or realistic. This will stimulate your brain training. Take a sheet of paper and try to describe buildings, cars or people that you have seen or met this day or this morning coming to your working place or at official diner. To observe and describe is good for your brain, or when you are alone try thinking intensively about something. Personally, I have a keen interest in and knowledge of world history, which is a totally different area of cognition, having in mind that I am a physician, but this was a very important brain exercise for me. Everybody could choose another field of knowledge, which is quite different from their profession, to exercise their brain with. Protecting the brain in aged individuals is another important task. There are three main factors for protection against brain aging: mental activity, physical activity and social contacts. All these activities must be in combination. Mental activity means to engage the brain in a new way: to interrupt the old routine and to study something new or to do the old things in a new way. Physical activity, like walking at least 30 minutes daily or working in the garden, is necessary for life during aging, Maintaining the social contacts with friends, family

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members and colleagues, making new friends as well as traveling with friends are very useful for the protection of brain function. There are many other important activities for supporting the structure and activity of the brain like, for example, body mass control, avoidance and control of stress, positive thinking, cholesterol levels, blood pressure, blood glucose, and a healthy diet. In the years to come, we will learn more and more about how to stimulate the formation of better brains and how to protect the brain's capacity because brain plasticity exists from the prenatal brain formation to the end of a person's life.

References Andreasen, N.C. (2005) The Creative Brain. A Plum Book, Published by Penguin Group. Bear, M.F., Connors, B.W., Paradiso, M.A. (2007) Neuroscience. 3rd Ed. Lippincott Williams & Wilkins. Brodmann, K. (1909) Vergleichende Lokalisationslehre der Grosshirnrinde in ihren Prinzipien dargestellt auf Grund des Zellaufbaus. Bart, Leipzig. Duus, P. (1998) Topical diagnosis in Neurology. 3rd Ed. Thieme. Squire, l.r. et al. (2003) Fundamental Neuroscience. 2nd Ed. Academic Press. Waxmann, S.G. (2013) Clinical Neuroanatomy. 27th Ed. McGraw Hill Medical.

CHAPTER THREE EMERGING PSYCHIATRIC NEUROIMAGING FINDINGS: TRANSLATING THE RESEARCH INTO CLINICAL APPLICATION STEFAN J. BORGWARDT AND DROZDSTOJ ST. STOYANOV

Abstract Psychopathological criteria currently employed to define a high-risk state for psychosis have low validity and specificity. Consequently, there is an urgent need for reliable biomarkers linked to the core pathophysiological mechanisms that underlie schizophrenia. Neuroimaging techniques such as structural and functional neuroimaging techniques including whole brain gray and white matter analyses, resting state and effective connectivity functional analyses, have rapidly developed into a powerful tool in psychiatry as they provide an unprecedented opportunity for the investigation of brain structure, function and connectivity. This presentation aims to show that neuroimaging studies of the prodromal phases of psychosis have the potential to identify core structural and functional brain imaging markers of an impending risk to psychosis. Moreover, it will be shown that psychiatric imaging needs to move away from simple investigations of the neurobiology underlying schizophrenia to translate imaging findings in the clinical field. Clinical outcomes including transition, remission and response to preventive interventions, as well antipsychotic treatment, need to be targeted.

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Introduction Much hope in psychiatry has been directed towards functional neuroimaging approaches, which promise to identify core neurobiological alterations. A non-invasive technique that can be used repeatedly in a clinical population, neuroimaging could in principle support diagnosis and effective interventions in psychiatry. Functional brain imaging methods such as functional magnetic resonance imaging (fMRI), which allow the in vivo investigation of human brain function, have been increasingly employed to examine the neurophysiological substrate of cognitive processes and psychopathological features. As the signals of the human brain functions are universal, fMRI studies exploring the neural substrates of psychopathology theoretically no longer rely on subjective measures, resulting in numerous publications of fMRI studies employing task and non-task related paradigms. However, despite the growing literature, the neural networks underlying the different psychopathological features are not clarified. Despite the impressive growth of neuroimaging studies and methods, neuroimaging has yet to become an established instrument of diagnostics, let alone prognostics. This is, partly due to the significant heterogeneity across the findings from research studies. Interestingly, no consistent or reliable functional brain alterations could unequivocally be associated with any mental disorder, and no clinical applications have been developed in psychiatric neuroimaging. Apart from the exclusion of disorders due to other medical/neurological conditions (e.g. brain tumor), there is a gap between the use of psychiatric neuroimaging research and its translational relevance into clinical practice. Methodological factors may account for the considerable heterogeneity in the findings across fMRI studies. These factors include differences in relevant acquisition design, lack of statistical power due to small sample sizes, different methods of image analysis (i.e. parametric versus nonparametric), differences in the demographic and socio-demographic group characteristics, and confounding effects of antipsychotic or generally psychotropic medication or illness chronicity and severity. Analysis of the consistency and comparability of the results obtained using different fMRI acquisition and analysis methods on the same set of neuroimaging data is a crucial prerequisite for the accurate localization of various brain functions. To reliably apply fMRI in clinical settings, stable and consistent results irrespective of particular image acquisition and analysis methods used are needed.

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To address validation procedures MRI data acquisition parameters need to have demonstrated discriminative power at group or better at singlesubject level. Moreover, MRI modalities have to be available across different MRI scanners, provide good test-retest, inter-subject and crossscanner reliability. MRI calibration studies allow cross-centre studies and computation of voxel-wise intra-class correlation coefficients (ICC) to quantify test-retest reliability. A number of methodological problems may underlie the inconsistencies across neuroimaging studies and the difficulty of identifying reliable results. Heterogeneity in psychiatric neuroimaging originates from multiple differences across the studies: in conceptual issues underlying psychiatric diagnoses and psychopathology, the clinical characteristics of psychiatric samples; the use of different paradigms and designs, and the use of different forms of image acquisition and image analysis. Because of multiple comparisons across different brain regions, reporting of regions of interest (ROIs) can be guided by post-hoc significance of the results, with the whole brain results remaining unpublished. These problems limit the localization of the potential brain abnormalities, which should be based on a whole-brain analysis of the differences between patients and controls. However, voxel-based meta-analyses have the potential to overcome the limited sample size of individual studies revealing functional abnormalities at specific brain coordinates rather than differences in volumes of pre-specified ROIs. A meta-analytic method, Signed Differential Mapping (Radua et al., 2010, Radua et al., 2011), allows also for the consideration of null findings and mitigates the excessive influence of single study data sets. In this context it has been suggested that imaging data contain information for predicting progression across different psychiatric disease stages. Multivariate pattern recognition methods as support vector machines (SVM) are able to categorize individual brain scans by separation of images from different groups taking into account the interregional dependencies of different pathologies. SVMs use information from all voxels to reflect differences between groups in order to create models that allow predictions of clinical outcomes in individual patients, i.e. prediction of subsequent conversion to psychosis with an accuracy of 82% (Koutsouleris et al., 2012, Koutsouleris et al., 2014, Borgwardt et al., 2013) In much of this neuroimaging field research, there is the implicit assumption that structural abnormalities are linked to functional abnormalities in the affected brain regions or in the functional circuits in

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which they take part. However, this is not necessarily the case since volumetric changes can occur without clear functional correlates (Radua et al., 2012).. They can occur, for example, as a consequence of nutritional or hydration status, or for other reasons (Weinberger and McClure, 2002). To arrive at a reliable account for clinical applicability it is therefore important to know which brain regions show conjoint structural and functional abnormalities. In this context, voxel-based meta-analytical methods to multimodally examine the relationship between structural and functional brain abnormalities were recently developed (Radua et al., 2012). This method may be useful to sustain multimodal imaging applications in broad fields of clinical psychiatry. By overcoming some of the discussed issues, the results of psychiatric neuroimaging can become more reliable and have a translational impact on clinical practice. The following overview aims to provide practical guidelines to conduct or evaluate functional neuroimaging studies and ultimately help to improve the reliability of psychiatric neuroimaging (Borgwardt et al., 2012). (i) With an increasing number of ways of pre-processing the data becoming available; (ii) ROIs studies (employing preselected masks or adopting Small Volume Corrections) should first report standard whole brain results and acknowledge if no significant clusters were detected at whole brain level before presenting the ROI findings; (iii) Both ROIs and whole brain studies should first report the results significant at p