Empathy or sympathy: a necessary distinction?

As a deeply hybrid discipline, psychiatry demands research that tackles the concepts constituting it and its objects. This is an essential prerequisite to empirical studies, the validity of which are directly dependent on a clear understanding of the underlying concepts. Empathy and sympathy are concepts used variably and inconsistently in clinical practice and research, with ensuing uncertainties around their role and meaning. Using a historical epistemology approach, this paper compares these concepts by examining the structures, intersections, stabilities and factors that shape them. It shows that neither concept is invariant, and, despite overlap, the concepts are essentially different, underpinned by different assumptions, holding different functions and capturing different phenomena. In turn, such differences require apposite approaches to their empirical study.

Empathy: a case study in the historical epistemology of psychiatry.

The hybrid constitution of psychiatry carries important implications for understanding the discipline and the legitimacy of its research approaches. One implication concerns the central role of concepts in forming the knowledge base of psychiatry. Because of this, it is vital to explore the structures and interrelationships of concepts through their historical constitution. Using this approach to compare concepts of empathy as articulated by R Vischer, T Lipps and E Stein shows that, despite overlap, the concepts vary in structure, in meaning and in the aspect of reality they capture. This suggests that the concept of empathy carries an unstable ontology and epistemology. In turn, this carries implications for the concept itself, for psychiatry and for research approaches in this field.

What is Psychiatry? Was ist das, die Psychiatrie?

Drawing on Heidegger's method of analysis, the question of what is psychiatry is explored from within. This leads to a conception of psychiatry as a form of interpersonal interaction in which there is a specific reaching out of one Being to another. It is a 'specific reaching out' because, following the recognition through the interaction between Beings that the other is in some form of distress, there is the corresponding need to assuage. The reformulation of psychiatry in this sense is important because it emphasises the unity with which we communicate and interact, and it also serves as a reminder of the need in psychiatry to develop novel methods to undertake research in this complex and constantly evolving field.

Research in Psychiatry: Concepts and Conceptual Analysis.

Current research in psychiatry is increasingly focused on empirical studies with methods and technologies adopted from medicine. This paper argues that psychiatry has a different epistemological basis from medicine, and it is on account of this that research in psychiatry demands a different approach, one that perforce focuses on the clarification of concepts central to psychiatric practice. This means undertaking conceptual analysis and conceptual history and only then moving on to empirical study. This paper highlights the crucial epistemological differences between the practice of medicine and psychiatry, showing that the latter is enacted at the level of language and communication. Consequently, the structures of psychiatric objects, namely, mental disorders and mental symptoms, are complexes of meaning derived from heterogeneous sources - both organic and semantic. Conceptual analysis of such structures is essential as ultimately the validity of empirical research is directly dependent on the conceptual clarification of its objects of inquiry.

Trajectories of quality of life in early-stage dementia: individual variations and predictors of change.

BACKGROUND: Little evidence is available about how quality of life (QoL) changes as dementia progresses. OBJECTIVES: We explored QoL trajectories over a 20-month period and examined what predicted change in QoL. METHOD: Fifty-one individuals with a diagnosis of Alzheimer's, vascular or mixed dementia (people with dementia (PwD)) participating in the Memory Impairment and Dementia Awareness Study rated their QoL using the QoL-Alzheimer's Disease Scale at baseline and at 20-month follow-up. PwD also rated their mood and quality of relationship with the carer. In each case, the carer rated his or her level of stress and perceived quality of relationship with the PwD. RESULTS: There was no change in mean QoL score. Nearly one-third of PwD rated QoL more positively at 20-month follow-up and nearly one-third rated QoL more negatively. These changes could be regarded as reliable in one-quarter of the sample. Participants taking acetylcholinesterase-inhibiting medication at baseline were more likely to show a decline in QoL score. There were no other significant differences between those whose scores increased, decreased or stayed the same on any demographic or disease-related variables, or in mood or perceived quality of relationship with the carer. Whereas baseline QoL score was the strongest predictor of QoL at 20 months, the quality of relationship with the carer as perceived by the PwD was also independently a significant predictor. CONCLUSIONS: There is a degree of individual variation in QoL trajectories. Use of acetylcholinesterase-inhibiting medication appears linked to decline in QoL score, whereas positive relationships with carers play an important role in maintaining QoL in early-stage dementia.

Phenomena of awareness in dementia: heterogeneity and its implications.

Despite much research on the relationship between awareness and dementia little can be concluded concerning their relationship and the role of other factors. It is likely that studies capture different phenomena of awareness. This study aimed at identifying and delineating such variation by analysing data from three questionnaires obtained during the longitudinal study of awareness in 101 people with early-stage dementia. The data concerned awareness in relation to memory, activities of daily living and socio-emotional function. Significant differences in patterns of discrepancies were obtained. This suggests that the awareness phenomena involved were structurally different; and that, in turn, this may reflect variation in the intrinsic linking between awareness and its 'object' (different 'objects' determining different kinds of judgements). The identification of such differences is necessary so that appropriate methodologies can be applied to the study of awareness in different contexts.

Memory awareness profiles differentiate mild cognitive impairment from early-stage dementia: evidence from assessments of performance monitoring and evaluative judgement.

BACKGROUND: Measures of memory awareness based on evaluative judgement and performance monitoring are often regarded as equivalent, but the Levels of Awareness Framework suggests they reflect different awareness phenomena. Examination of memory awareness among groups with differing degrees of impairment provides a test of this proposition. METHOD: Ninety-nine people with dementia (PwD), 30 people with mild cognitive impairment (PwMCI), and their relatives completed isomorphic performance monitoring and evaluative judgement measures of memory awareness and were followed up at 12 and (PwD only) 20 months. In addition to the resulting awareness indices, comparative accuracy scores were calculated using the relatives' data to establish whether any inaccuracy was specific to self-ratings. RESULTS: When making evaluative judgements about their memory in general, both PwD and PwMCI tended to overestimate their own functioning relative to informant ratings made by relatives. When monitoring performance on memory tests, PwD again overestimated performance relative to test scores, but PwMCI were much more accurate. Comparative accuracy scores indicated that, unlike PwD, PwMCI do not show a specific inaccuracy in self-related appraisals. CONCLUSIONS: The results support the proposition that awareness indices at the levels of evaluative judgement and performance monitoring should be regarded as reflecting distinct awareness phenomena.

Self-concept in early stage dementia: profile, course, correlates, predictors and implications for quality of life.

OBJECTIVE: Although it is increasingly accepted that people with dementia retain a sense of self, there is a need for empirical evidence regarding the nature of the self-concept in early stage dementia, how this changes over time and how it relates to quality of life. METHODS: Self-concept was assessed using the short form of the Tennessee Self-concept Scale in 95 individuals with early stage dementia; 63 were reassessed after 12 months, and 45 were seen again at 20 months. Participants also completed measures of mood, cognitive functioning and quality of life. Caregivers provided proxy ratings of self-concept, completed measures of symptoms and distress at symptoms and rated their own levels of stress and well-being. RESULTS: Self-ratings of self-concept were close to the average range for the standardization sample, and the distribution did not differ significantly from expected values. Although caregiver ratings were slightly lower, discrepancies were small. There were no significant changes over time in self-ratings or informant ratings or discrepancies. At Time 1, self-ratings were predicted by anxiety, depression and memory, caregiver ratings were predicted by caregiver distress and by depression in the person with dementia and discrepancies were predicted by caregiver distress. These models remained predictive at later time points. Self-rated self-concept predicted quality of life, with the relationship only partially mediated by depression and anxiety. CONCLUSIONS: Self-concept appears largely intact in early stage dementia, but in view of the association between self-concept and quality of life, a preventive approach focused on supporting self-concept may offer benefits as dementia progresses.

Exploring longitudinal changes in implicit awareness of dementia: An investigation of the emotional Stroop effect in healthy ageing and mild dementia.

The aim of the study was to investigate responses to dementia-relevant words in healthy older people and to investigate changes in response over 20-months in people with early-stage dementia. An emotional Stroop task, using colour-naming dementia-relevant words, was used as an indicator of implicit awareness of dementia. Overall, 24 people with dementia and 24 healthy older people completed an emotional Stroop task (T1). People with dementia completed the same task again after 12 (T2) and 20 (T3) months. For people with dementia emotional Stroop performance was contrasted with ratings of explicit awareness based on a detailed interview at T1 and at T2. For healthy older people and people with dementia response times to dementia-relevant words were significantly longer than those for neutral words. The effect was absent for people with dementia at T3. This decline in the emotional Stroop effect was not associated with cognitive decline as measured by the MMSE. Ratings of explicit awareness showed no significant change over time. There was no association between explicit awareness and implicit awareness. Implicit awareness of the condition is evident in early-stage dementia and can be elicited even where there is reduced explicit awareness. The emotional Stroop effect for dementia-relevant words in people with dementia appears to decline over time, independently of changes in MMSE score, suggesting that implicit awareness fades as time progresses.

Marital relationship quality in early-stage dementia: perspectives from people with dementia and their spouses.

Spouse caregivers of people with dementia (PwD) report relatively poor marital relationship quality (RQ), but few studies have obtained the perspective of the PwD, examined discrepancies between spouses, or considered changes in RQ over time. This study explored caregiver and PwD perceptions of RQ, identified associated factors, and examined changes over an 18-month period. Participants were 54 couples where one spouse had early-stage dementia and 54 were control couples. RQ was assessed with the Positive Affect Index. Measures of mood, stress, and quality of life (QoL) were also administered. The clinical couples were followed up after 9 and 18 months. Caregivers gave significantly lower RQ ratings than controls. PwD ratings did not differ significantly from those of caregivers or controls. Dyadic discrepancies were significantly greater in the clinical than in the control group. Caregiver ratings were associated with stress, whereas PwD ratings were associated with depression and QoL. Discrepancies were associated with caregiver stress and with PwD mood, QoL, and age. Caregiver ratings declined significantly over time; PwD ratings did not decline significantly, but showed different trends for men and women. It is important to consider RQ when considering how to support couples where one partner has early-stage dementia.

Longitudinal trajectories of awareness in early-stage dementia.

Although it is often assumed that awareness decreases as dementia severity increases, there is limited evidence regarding changes in awareness over time. We examined awareness in 101 individuals with early-stage dementia (PwD) and their carers; 66 were reassessed after 12 months and 51 were seen again at 20 months. Awareness was assessed in relation to memory, everyday activities, and socio-emotional functioning using discrepancies between PwD and carer ratings on parallel questionnaires. PwD completed neuropsychological tests and measures of mood and quality of life. Carers completed measures of mood and stress. At initial assessment, discrepancies were greatest for activities of daily living, moderate for memory, and least pronounced for socio-emotional functioning. Discrepancy scores did not change over time. PwD self-ratings indicated perceived poorer functioning in everyday activities over time, but no change for memory and socio-emotional functioning. Carer ratings indicated perceived decline in everyday activities and socio-emotional functioning, but no change for memory. PwD declined in neuropsychological functioning, but self-ratings of depression, anxiety, and quality of life remained stable over time. Carer mood and stress levels also remained stable. At least in the earlier stages of dementia, it should not be assumed that awareness will inevitably decrease as dementia progresses.

The influence of psychological, social and contextual factors on the expression and measurement of awareness in early-stage dementia: testing a biopsychosocial model.

BACKGROUND: Insufficient attention has been paid to the influence of psychological and social factors on discrepancy-based measures of awareness. OBJECTIVES: The present study tested a biopsychosocial model of awareness in early-stage dementia by gathering evidence regarding the relative contributions of neuropsychological, individual psychological and social factors to the level of scoring on measures used to index awareness. METHOD: Awareness was assessed in relation to memory, activities of daily living and social functioning in 101 individuals with early-stage dementia participating in the Memory Impairment and Dementia Awareness (MIDAS) Study. People with dementia (PwD) and carers also completed measures of individual psychological and social variables, and PwD completed measures of neuropsychological functioning. RESULTS: Scores on discrepancy-based indices of awareness and on the self-ratings and informant ratings contributing to these indices were associated with a range of factors including neuropsychological functioning of PwD, individual traits and dispositions and current affective functioning of PwD, socio-demographic characteristics of PwD and carers, carer well-being and carer perceptions of PwD and of quality of relationship with PwD. Patterns of association varied across domains of functioning. CONCLUSIONS: The findings support the relevance of a biopsychosocial approach to understanding the factors that influence unawareness of impairment in dementia.

Epistemology of psychiatry.

In historical and epistemological terms, psychiatry is a new discipline born during the 19th century. Rooted in both the natural and social sciences, psychiatric objects of inquiry, namely mental symptoms and mental disorders, are hybrid, constituted by the blending of components arising from disparate sources of knowledge ranging from the biological to the semantic in its widest sense. This poses problems for psychiatric research and therapy. Whilst conventional pluralism may be a convenient approach to manage aspects of psychiatric practice, it lacks the capacity to analyse psychiatric objects in their entirety. For the latter, psychiatry demands a new, tailored regional epistemology. This paper outlines the main features of an epistemology specific to the needs of psychiatry. It highlights the relational approach that needs to be taken and illustrates the usefulness of this approach by analysing the structure of psychiatric objects, exploring the manner in which they may be inscribed in the brain, and identifying the need to periodically recalibrate the language of psychiatry.

'She might have what I have got': the potential utility of vignettes as an indirect measure of awareness in early-stage dementia.

OBJECTIVES: In early-stage dementia, awareness at the meta-representational level involving a person's appraisal of his/her own condition and its implications has usually been assessed by interview, but contextual factors may influence responding. We examined the utility of an indirect, vignette-based method of eliciting awareness. METHOD: Three vignettes describing early-stage dementia, established dementia and healthy ageing were used to elicit views of the problem and the kinds of advice that might be helpful for the characters depicted. Responses were obtained from 91 people with early-stage Alzheimer's, vascular or mixed dementia, 87 carers and 80 older controls. For the participants with dementia, awareness was assessed in separate in-depth interviews and rated on a five-point scale for comparison purposes. RESULTS: Participants with dementia were often able to correctly identify the problems described in the vignettes, although scoring lower than carers or controls. Participants with dementia were also able to offer advice for those depicted, although to a lesser extent than carers or controls. Ability to offer advice was greater where MMSE scores were higher. For participants with dementia, vignette scores were moderately correlated with ratings derived from interviews, and those showing limited or no awareness offered fewer items of advice than those showing some or good awareness. In addition, 29% of participants with dementia spontaneously pointed out similarities between their own condition and that of the person depicted. CONCLUSIONS: The vignette method may be useful where resources preclude the use of in-depth interviews, and may supplement in-depth interviews as part of a multi-dimensional assessment of awareness.

Multidimensional assessment of awareness in early-stage dementia: a cluster analytic approach.

BACKGROUND/AIMS: Research on awareness in dementia has yielded variable and inconsistent associations between awareness and other factors. This study examined awareness using a multidimensional approach and applied cluster analytic techniques to identify associations between the level of awareness and other variables. METHODS: Participants were 101 individuals with early-stage dementia (PwD) and their carers. Explicit awareness was assessed at 3 levels: performance monitoring in relation to memory, evaluative judgement in relation to memory, everyday activities and socio-emotional functioning, and metacognitive reflection in relation to the experience and impact of the condition. Implicit awareness was assessed with an emotional Stroop task. RESULTS: Different measures of explicit awareness scores were related only to a limited extent. Cluster analysis yielded 3 groups with differing degrees of explicit awareness. These groups showed no differences in implicit awareness. Lower explicit awareness was associated with greater age, lower MMSE scores, poorer recall and naming scores, lower anxiety and greater carer stress. CONCLUSION: Multidimensional assessment offers a more robust approach to classifying PwD according to level of awareness and hence to examining correlates and predictors of awareness.

Dissociation between implicit and explicit manifestations of awareness in early stage dementia: evidence from the emotional Stroop effect for dementia-related words.

OBJECTIVE: To determine whether people with dementia (PwD), and carers of PwD, show a processing bias to dementia-related words in an emotional Stroop task, and if so, whether the presence of such a bias is related to level of explicit awareness of the condition. METHOD: Seventy-nine people with early stage Alzheimer's disease (AD), vascular or mixed dementia, and their carers, completed an emotional Stroop task. Time taken to colour-name dementia-related and neutral words was compared within and between groups. Additionally, as a comparison, ratings of the awareness of the condition shown by PwD were made on the basis of a detailed interview with each PwD and his/her carer. RESULTS: PwD and carers showed the same level of increase in response times to salient compared to neutral words. In the PwD this effect was unrelated to the degree of awareness that they demonstrated regarding the condition. CONCLUSIONS: The emotional Stroop effect in response to dementia-related words in PwD indicates that preserved implicit awareness of the condition can be elicited even where there is reduced explicit awareness.

Awareness in Alzheimer's disease and associated dementias: theoretical framework and clinical implications.

BACKGROUND: Awareness can be defined as a reasonable or realistic perception or appraisal of a given aspect of one's situation, functioning or performance, or of the resulting implications, expressed explicitly or implicitly. Disturbances of awareness have significant implications for people with dementia and their caregivers. The construction of awareness has been extensively studied in dementia, but a lack of conceptual and methodological clarity in this area means that few clear findings have emerged. AIMS: This article presents a framework for conceptualizing awareness in people with Alzheimer's disease and associated dementias that can guide research and influence practice. OVERVIEW: This article begins by considering the general concept of awareness and the ways in which neurological damage can place constraints on awareness. Within an integrative biopsychosocial model that acknowledges the influence of neurocognitive, psychological, and social variables on awareness, challenges for empirical research on awareness in dementia are addressed, and a 'levels of awareness' framework is presented within which awareness operates at four levels of increasing complexity, providing a means of differentiating among awareness phenomena. Approaches to mapping awareness phenomena are discussed, and directions for future research and clinical practice are outlined. CONCLUSIONS: The levels of awareness framework should act as a stimulus to further research in this area, resulting in a more coherent understanding of the nature of awareness deficits, the implications of these for people with dementia and their caregivers, and the possibilities for targeted and effective interventions.

Historical Epistemology: a Research Approach in Psychiatry.

Drawing on a key issue raised in the paper by Scardigno and Mininni (2021), this commentary explores the question of historical research in psychiatry. Firstly, the importance of historical research is highlighted for both psychiatry as a medical discipline, and for descriptive psychopathology, the language of psychiatry. Of significance has been the construction of psychiatry as a hybrid discipline formed through the deep participation of both the natural and the social sciences. This in turn brings to light the fundamental difference in epistemological basis to psychiatry and medicine, with ensuing consequences for our understanding of mental disorders and for the development of further research methodology. Likewise conceptually hybrid, the special role carried by mental symptoms in psychiatry places them, as concepts, in the position of crucial research tools. Secondly, given some of the complexities raised in carrying out historical research in this area, the issue of how this should be approached is examined. The method proposed here is that of historical epistemology. This is an approach that focuses on concepts, on mapping their biographies in order to clarify their structures, their roles, their discontinuities, their relationships and interactions with other concepts and so on. Given the central role of concepts in psychiatry and descriptive psychopathology, this approach to their study is most likely to provide valid and meaningful results.

Epistemology of mental symptoms.

BACKGROUND AND METHODS: Psychiatric diagnosis is dependent on the identification of mental symptoms. On the assumption that they are 'natural kinds', the latter are routinely entered as correlational variables in empirical research. Published work on the philosophy of psychiatry has tended to concentrate on the concept of mental disorder or on individual symptoms but has given less attention to mental symptoms as a class. This paper deals specifically with the epistemology of mental symptoms, that is, with focusing on the nature of mental symptoms as a class of 'objects' and how the clinician gets to know them. In order to do this, mental symptoms can be explored from various perspectives, namely: (i) as types of objects, (ii) as structures, (iii) as definitions, (iv) as pockets of meanings, (v) as comprising constituents, (vi) as attractors in specific dialogical contexts, etc. In this paper, on account of space constraints, we deal only with the former 4 perspectives. RESULTS AND CONCLUSION: Our analysis shows mental symptoms to be unstable constructs with implications for both correlational research and further theoretical exploration.

Insight and obsessive-compulsive disorder: a conceptual analysis.

Analysis of insight in obsessive-compulsive disorders (OCD) raises conceptual problems that need addressing before meaningful empirical work can be undertaken. Insight and OCD are locked within a definitional contradiction relevant both to the nosological boundaries of OCD and the meaning of insight itself. Given that it is a form of self-knowledge, it is proposed here that insight is best conceived as a mental state rather than symptom or symptom-dimension. As an aspect of this mental state, the clinical phenomenon of insight should be understood as independent of any underlying disease albeit influenced by it and by other factors. As the focus of empirical research, the phenomenon of insight is dependent on the concept of insight, the measure by which it is assessed and on the 'object' of insight assessment. Explication of these factors allows for the delineation of specific insight phenomena whose respective usefulness can be determined by empirical research.