Dan J Stein

Recent years have seen growing public concern about the effects of persuasive digital technologies on public mental health and well-being. As the draws on our attention reach such staggering scales and as our ability to focus our attention on our own considered ends erodes ever further, the need to understand and articulate what is at stake has become pressing. In this ethical viewpoint, we explore the concept of attentional harms and emphasize their potential seriousness. We further argue that the acknowledgment of these harms has relevance for evolving debates on digital inequalities. An underdiscussed aspect of web-based inequality concerns the persuasions, and even the manipulations, that help to generate sustained attentional loss. These inequalities are poised to grow, and as they do, so will concerns about justice with regard to the psychological and self-regulatory burdens of web-based participation for different internet users. In line with calls for multidimensional approaches to digital inequalities, it is important to recognize these potential harms as well as to empower internet users against them even while expanding high-quality access.

The availability of a range of new psychotropic agents raises the possibility that these will be used for enhancement purposes (smart pills, happy pills, and pep pills). The enhancement debate soon raises questions in philosophy of medicine and psychiatry (eg, what is a disorder?), and this debate in turn raises fundament questions in philosophy of language, science, and ethics. In this paper, a naturalistic conceptual framework is proposed for addressing these issues. This framework begins by contrasting classical and critical concepts of categories, and then puts forward an integrative position that is based on cognitive-affective research. This position can in turn be used to consider the debate between pharmacological Calvinism (which may adopt a moral metaphor of disorder) and psychotropic utopianism (which may emphasize a medical metaphor of disorder). I argue that psychiatric treatment of serious psychiatric disorders is justified, and that psychotropics are an acceptable kind of intervention. The use of psychotropics for sub-threshold phenomena requires a judicious weighing of the relevant facts (which are often sparse) and values

Background The rise in genomic and biobanking research worldwide has led to the development of different informed consent models for use in such research. This study analyses consent documents used by investigators in the H3Africa (Human Heredity and Health in Africa) Consortium. Methods A qualitative method for text analysis was used to analyse consent documents used in the collection of samples and data in H3Africa projects. Thematic domains included type of consent model, explanations of genetics/genomics, data sharing and feedback of test results. Results Informed consent documents for 13 of the 19 H3Africa projects were analysed. Seven projects used broad consent, five projects used tiered consent and one used specific consent. Genetics was mostly explained in terms of inherited characteristics, heredity and health, genes and disease causation, or disease susceptibility. Only one project made provisions for the feedback of individual genetic results. Conclusion H3Africa research makes use of three consent models—specific, tiered and broad consent. We outlined different strategies used by H3Africa investigators to explain concepts in genomics to potential research participants. To further ensure that the decision to participate in genomic research is informed and meaningful, we recommend that innovative approaches to the informed consent process be developed, preferably in consultation with research participants, research ethics committees and researchers in Africa.

Cell line immortalisation is a growing component of African genomics research and biobanking. However, little is known about the factors influencing consent to cell line creation and immortalisation in African research settings. We contribute to addressing this gap by exploring three questions in a sample of Xhosa participants recruited for a South African psychiatric genomics study: First, what proportion of participants consented to cell line storage? Second, what were predictors of this consent? Third, what questions were raised by participants during this consent process? 760 Xhose people with schizophrenia and 760 controls were matched to sex, age, level of education and recruitment region. We used descriptive statistics to determine the proportion of participants who consented to cell line creation and immortalization. Logistic regression methods were used to examine the predictors of consent. Reflections from study recruiters were elicited and discussed to identify key questions raised by participants about consent. Approximately 40% of participants consented to cell line storage. The recruiter who sought consent was a strong predictor of participant’s consent. Participants recruited from the South African Eastern Cape, and older participants, were more likely to consent; both these groups were more likely to hold traditional Xhosa values. Neither illness nor education were significant predictors of consent. Key questions raised by participants included two broad themes: clarification of what cell immortalisation means, and issues around individual and community benefit. These findings provide guidance on the proportion of participants likely to consent to cell line immortalisation in genomics research in Africa, and reinforce the important and influential role that study recruiters play during seeking of this consent. Our results reinforce the cultural and contextual factors underpinning consent choices, particularly around sharing and reciprocity. Finally, these results provide support for the growing literature challenging the stigmatizing perception that people with severe mental illness are overly vulnerable as a target group for heath research and specifically genomics studies.

BackgroundCommunity engagement within biomedical research is broadly defined as a collaborative relationship between a research team and a group of individuals targeted for research. A Community Advisory Board is one mechanism of engaging the community. Within genomics research CABs may be particularly relevant due to the potential implications of research findings drawn from individual participants on the larger communities they represent. Within such research, CABs seek to meet instrumental goals such as protecting research participants and their community from research-related risks, as well as intrinsic goals such as promoting the respect of participants and their community. However, successful community engagement depends on the degree to which CABs legitimately represent and engage with communities targeted for research. Currently, there is little literature describing the use of CABs in genomics research taking place in developing countries, and even less in the field of genomics research relating to mental illness. The aim of this article is to describe and consider the contributions made by a researcher-driven, population-specific CAB in a genomics of schizophrenia research project taking place in South Africa, from the perspective of the research team.DiscussionFour broad discussion topics emerged during the CAB meetings namely: 1) informed consent procedures, 2) recruitment strategies, 3) patient illness beliefs and stigma experiences, and 4) specific ethical concerns relating to the project. The authors consider these discussions in terms of their contributions to instrumental and intrinsic goals of community engagement.SummaryThe CAB gave valuable input on the consent processes and materials, recruitment strategies and suggested ways of minimizing the potential for stigma and discrimination. All of these contributions were of an instrumental nature, and helped improve the way in which the research took place. In addition, and perhaps more importantly, the CAB made a unique and important contribution relating to intrinsic functions such as promoting the respect and dignity of research participants and their community. This was particularly evident in ensuring sensitivity and respect of the community’s traditional beliefs about schizophrenia and its treatment, and in this way promoting a respectful relationship between the research team and the participants

Insofar as South Africa underwent a rapid transformation from apartheid to democracy, it may provide a unique laboratory for investigating aspects of revenge and forgiveness. Here we suggest that observations and data from South Africa are partially consistent with the hypotheses generated by MCullough and colleagues. At the same time, the rich range of revenge and forgiveness phenomena in real-life settings is likely to require explanatory concepts other than specialized modules and their computational outputs

Despite the effort on DSM-5 and ICD-11, few appear satisfied with these classification systems. We suggest that the core reason for dissatisfaction is expecting too much from them; they do not provide discrete categories that map to specific causes of disease, they describe clinical syndromes intended to guide treatment choices. Here we review work on anxiety and anxiety disorders to argue that while clinicians draw a pragmatic distinction between normal and abnormal emotions based on considerations such as severity and duration, understanding the evolutionary origins and utility of the emotions, including the adaptive value of adverse emotions, is key for formulating comprehensive assessments of an individual patient’s symptoms and for providing a conceptual foundation for pharmacotherapy, psychotherapy, and public health.

Tilmes concludes his interesting and informative piece with the sentence that “analysis of psychiatric vagueness merits further consideration.” I agree with this point, as well as with his earlier assertion that how one understands psychiatric vagueness may implicate the diagnostic model that one adopts, and the research that one pursues. Fortunately, there has been recent attention to vagueness in psychiatry, addressing both degree-vagueness and combinatorial vagueness. Vagueness in psychiatry is related to a range of nosological debates, including about the...

Many of Rose's criticisms of determinism in biology have clear relevance to modern cognitive and psychiatric science; too narrow a focus on the brain as an information processing machine runs the risk of neglecting the context in which information processing takes place, and too narrow a focus on the neuroscience of psychopathology runs the risk of neglecting other levels of explanation for these phenomena. It should be emphasized, however, that animal and genetic studies of phenomena of interest to cognitive and psychiatric science (e.g., Alzheimer's disorder, schizophrenia, attention deficit/hyperactivity disorder, and violence), while perhaps only providing a partial perspective, may be useful in understanding these phenomena and in leading to appropriate psychiatric interventions.

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 12.3 (2005) 261-263 [Access article in PDF] The Philosophy of Evil Dan J. Stein Keywords philosophy, evil, self-deception, psychopathy, narcissism, sadism Kubarych (2005) first draws on Peck (1983) to suggest a distinction between psychopaths who have no conscience and therefore no need for self-deception, and evil narcissists who use self-deception to keep the emotional consequences of their crimes out of awareness. He then draws on Davidson (1985) to emphasize a parallel between self-deception (or weakness of the warrant) where an irrational belief conflicts with the evidence, and akrasia (or weakness of the will) where an irrational intention is in conflict with one's values.Although self-deception has long been de-scribed and debated (Fingarette 2000; McLaughlin and Rorty 1988; Mele 2001), a cognitive-affective neuroscience of self-deception has become possible only recently. Such an approach includes several strands. First, contemporary information processing constructs (e.g., schemas) have been used to reframe the early insights of writers like Freud and James, and to emphasize how inattention to painful truths provide a shield against anxiety (Goleman 1997). Second, the theoretical framework of evolutionary psychology has been used to emphasize the adaptive advantages of self-deception (Lockard and Delroy 1988). Third, functional brain imaging studies have noted increased activity in executive regions (e.g., prefrontal and anterior cingulate cortices) during attempted deception but not during truthful responding, suggesting that the former requires active effort (Spence et al. 2004). The functional imaging of memory suppression suggests similar processes (Anderson et al. 2004). To date, however, there has been little functional imaging work on self-deception.Similarly, although evil has always been a key concern of philosophical thought, a cognitive-affective neuroscience of evil has emerged only in recent years (Stein 2000). Evil actions are not homogenous, and this area of research again comprises a number of different strands. First, there are actions where the primary aim is not necessarily to hurt, but where harm is in fact inflicted. (A contested, but perhaps useful example, is the battery-raising of animals for human consumption [Singer 2001]). Second, there are actions where the aim is to hurt, and where harm to the other may even be enjoyed. (During normal altruistic punishment, for example, reward circuitry is activated [de Quervain et al. 2004]). Third, there are actions characterized by impulsive aggression, and a relative absence of executive control. (There may be psychobiological distinctions between reactive aggression in response to frustration or threat, and instrumental aggression that is more goal directed [Blair 2004]).What are the implications of these two sets of cognitive-affective neuroscience literature for a philosophical consideration of evil and of narcissism? [End Page 261] It may be useful to differentiate healthy processes (e.g., having sufficient frontal cortical activity to be able to deceive others) from psychopathologic processes (e.g., not having the necessary frontal-amygdala circuitry required for empathic processing of emotions in social interaction). Similarly, it may be useful to differentiate between normal healthy narcissism (Taylor and Brown 1988) and pathologic malignant narcissism (Kernberg 1985), and between normal altruistic punishment (Hamilton 1963) and pathologic sadistic personality (Kaminer and Stein 2001). In addition, it is perhaps the case that some cognitive-affective processes that do not seem to involve psychopathology may nevertheless be seen as evil (e.g., arguably, the processes that allow a human to eat a battery-raised chicken), whereas some cognitive-affective processes that are clearly psychopathologic may not be viewed as evil (e.g., impulsive aggression in the context of a frontal lobe tumor may be viewed as excusable, as "mad" rather than "bad").Taken together with recent work on the cognitive-affective neuroscience of psychopathy, narcissism, and sadism, these considerations may lead to somewhat different approaches from those taken by Peck and Davidson. In his work on psychopathy, for example, Blair emphasizes a dysfunction in cognitive-affective processing resulting in abnormalities in the weighing up of social emotions (Blair 2004). This account is not inconsistent with a view that in psychopathy there is a disturbance in moral processing that is evil (contra Peck). Furthermore, this...

A central methodological innovation in cognitive science has been the development of connectionist or neural network models of psychological phenomena. These models may also comprise a theoretically integrative and methodologically rigorous approach to psychiatric phenomena. In this paper we employ connectionist theory to conceptualize obsessive-compulsive disorder . We discuss salient phenomenological and neurobiological findings of the illness, and then reformulate these using neural network models. Several features and mechanisms of OCD may be explicated in terms of disordered networks. Neural network modeling appears to constitute a novel and potentially fertile approach to psychiatric disorders such as OCD

Glas's article is one of several in an interesting special issue focused on applying concepts from enactivism to psychiatry; his focuses on anxiety in particular. Given ongoing developments in work on enactivism, and ongoing debates about how to progress psychiatry, this application is timely. Here, I make three general points about the application of enactivism to psychiatry; I exemplify these with occasional comments on social anxiety disorder.First, as de Haan notes in her introduction, the term enactivism encompasses a number of authors and ideas. Wilson and Foglia note that enactivism falls within a broader literature on "embodied cognition." This literature is partly conceptual, but also relies on...

Psychiatric disorders present distinct clinical challenges which are partly attributable to their multifactorial aetiology and the absence of laboratory tests that can be used to confirm diagnosis or predict risk. Psychiatric disorders are highly heritable, but also polygenic, with genetic risk conferred by interactions between thousands of variants of small effect that can be summarized in a polygenic risk score. We discuss four areas in which the use of polygenic risk scores in psychiatric research and clinical contexts could have ethical implications. First, there is concern that clinical use of polygenic risk scores may exacerbate existing health inequities. Second, research findings regarding polygenic risk could be misinterpreted in stigmatising or discriminatory ways. Third, there are concerns associated with testing minors as well as eugenics concerns elicited by prenatal polygenic risk testing. Fourth, potential challenges that could arise with the feedback and interpretation of high polygenic risk for a psychiatric disorder would require consideration. While there would be extensive overlap with the challenges of feeding back genetic findings in general, the potential clinical use of polygenic risk scoring warrants discussion in its own right, given the recency of this possibility. To this end, we discuss how lay interpretations of risk and genetic information could intersect. Consideration of these factors would be necessary for ensuring effective and constructive communication and interpretation of polygenic risk information which, in turn, could have implications for the uptake of any therapeutic recommendations. Recent advances in polygenic risk scoring have major implications for its clinical potential, however, care should be taken to ensure that communication of polygenic risk does not feed into problematic assumptions regarding mental disorders or support reductive interpretations.

Psychiatric genetic research investigates the genetic basis of psychiatric disorders with the aim of more effectively understanding, treating, or, ultimately, preventing such disorders. Given the challenges of recruiting research participants into such studies, the potential for long‐term benefits of such research, and seemingly minimal risk, a strong claim could be made that all non‐acute psychiatric inpatients, including forensic and involuntary patients, should be included in such research, provided they have capacity to consent. There are tensions, however, regarding the ethics of recruiting psychiatric inpatients into such studies. In this paper our intention is to elucidate the source of these tensions from the perspective of research ethics committee interests and decision‐making. We begin by defining inpatient status and outline some of the assumptions surrounding the structures of inpatient care. We then introduce contemporary conceptions of vulnerability, including Florencia Luna’s account of vulnerability which we use as a framework for our analysis. While psychiatric inpatients could be subject to consent‐related vulnerabilities, we suggest that a particular kind of exploitation‐related vulnerability comes to the fore in the context of our case study. Moreover, a subset of these ethical concerns takes on particular weight in the context of genetic research in low‐ and middle‐income countries. At the same time, the automatic exclusion of inpatients from research elicits justice‐related vulnerabilities.