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.

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.

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.

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.

Translational neuroscience and psychiatry: A conceptual analysis.

As rapidly developing research disciplines and enterprises, the translational sciences have made significant impact on research direction in medicine. Psychiatry has likewise been affected, and in this regard, the translational neurosciences have been the major drivers. This paper explores the conceptual underpinnings of this enterprise in relation to psychiatry. It shows that translation is used in a metaphorical sense in this context but that this can be misleading because of the resultant connotation that there is equivalence between neurobiological states and mental states. Furthermore, this equivalence is reinforced by the unidirectional flow or bottom up approach of the translational process. Given that the epistemological basis to psychiatry is fundamentally different to that underlying medicine, questions are raised concerning the application of the translational neurosciences approach to mental symptoms and mental disorders. The hybrid structure of mental symptoms and mental disorders demands that attention is paid to the "semantic" as well as the neurobiological constituents. Neglect of the former would carry implications for the validity of research findings as well as have ethical consequences for treating patients. Translational neurosciences may have greater validity in those mental disorders and mental symptoms whose constitution and sense are carried by the neurobiological elements.

Historical and conceptual aspects of motor disorders in the psychoses.

Historical epistemology is a useful method to understand the longitudinal construction of the movement disorders in psychiatry. Four periods can be identified in such a process. The first, extending from Classical times to the work of Griesinger, included disorders such as catalepsy, crocidism, epilepsy and paralysis. The second period, stretching from Griesinger to Kahlbaum, concentrated on the study of melancholia attonita, stupor and catatonia. The third period, covering the time from Kahlbaum to WWI, witnessed important conceptual shifts such as: the transformation of madness into psychoses; the redefinition of movement and motility in psychiatry; the appearance of self-contained syndromes as dyskinesias, tics, akathisia, complex disorders like the cases of encephalitis lethargica, etc.; the advent of functional and psychodynamic explanations; and the description by Wernicke, Kleist and others of the motility psychoses. The fourth period stretches from WWI to the present and since it corresponds to the views and work reported in the rest of this Special issue it has not been touched upon in this paper. In spite of an increasing methodological refinement, empirical research is yet to clarify what is the clinical meaning of the movement disorders in the context of the psychoses and to explain whether such disorders are primary (i.e. issuing directly from the brain and parallel to the rest of psychotic symptomatology) or secondary (i.e. mediated by cognitive and emotional phenomena characteristic of the psychoses).

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.

The hermeneutics of mental symptoms in the Cambridge School / A hermenêutica de sintomas mentais na Escola de Cambridge / L’herméneutique de symptômes mentaux selon l’École de Cambridge / La hermenéutica de los síntomas mentales en la Escuela de Cambridge / Die Hermeneutik der psychischen Symptome gemäß der Schule von Cambridge / 精神症状在剑桥学派的解释学

Current Psychiatry is in crisis. Decades of neuroscientific research have not yet delivered adequate explanations or treatments. One reason for this failure may be the wrongness of its central assumption, namely that mental symptoms and disorders are natural kinds. The Cambridge School has proposed that a new Epistemology must be constructed for Psychiatry, and that this should start with the development of a new model of mental symptom-formation. ‘Mental symptoms’ should be considered as hermeneutic co-constructions occurring in a intersubjective space created by the dialogue between sufferer and healer. Subjective experiences (caused either by neurobiological or psychosocial upheaval) penetrate the awareness of sufferers causing perplexity and/or distress. To understand, handle and communicate these experiences, sufferers proceed to configure them by means of templates borrowed from their own culture. Importantly, however, the same neurobiological information can be configured into different symptoms; and different neurobiological information into the same symptom. Therefore, ‘mental symptoms’ are dissimilar hybrid combinations of neurobiological and cultural information. To be ethical, therapeutic interventions must take into account such dissimilarities. Blind manipulation of the brain in all cases should be considered as counterproductive.

A Psiquiatria atual está em crise. Décadas de pesquisa neurocientífica ainda não resultaram em explicações ou tratamentos adequados. Uma das razões para esse fracasso pode ser sua hipótese central equivocada, ou seja, de que os sintomas e desordens mentais são tipos naturais. A Escola de Cambridge propôs a construção de uma nova epistemologia para a Psiquiatria, que deve começar com o desenvolvimento de um novo modelo de formação de sintomas mentais. “Sintomas mentais” devem ser considerados uma coconstrução hermenêutica que ocorre em um espaço intersubjetivo criado pelo diálogo entre paciente e médico. Experiências subjetivas (causadas por convulsão neurobiológica ou psicossocial) penetram na consciência dos pacientes, causando perplexidade e/ou sofrimento. Para entender, manipular e comunicar essas experiências, os pacientes seguem para configurá-las por meio de modelos emprestados de sua própria cultura. É importante notar, no entanto, que a mesma informação neurobiológica pode ser configurada em diferentes sintomas e diferentes informações neurobiológicas, no mesmo sintoma. Portanto, “sintomas mentais” são combinações híbridas diferentes de informações neurobiológicas e culturais. Para serem éticas, intervenções terapêuticas devem levar em conta essas diferenças. A manipulação cega do cérebro deve, em todos os casos, ser considerada contraproducente.

La psychiatrie contemporaine est en crise. Des décennies de recherche neuroscientifique n’ont pas été capables de produire ni des explications, ni des traitements appropriés. Cet échec est peut-être partiellement dû à l’ambiguïté de son hypothèse centrale, selon laquelle les symptômes et les troubles mentaux sont des types naturels. L’École de Cambridge propose la construction d’une nouvelle épistémologie pour la psychiatrie, à commencer par l’élaboration d’un nouveau modèle de formation de symptômes mentaux. Ceux-ci doivent être considérés comme des co-constructions herméneutiques qui se produisent dans un espace intersubjectif créé par le dialogue entre le patient et le médecin. Des expériences subjectives (qui résultent de bouleversements neurobiologiques ou psychosociaux) pénètrent la conscience des patients et causent la perplexité et/ou la souffrance. Pour comprendre, gérer et communiquer ces expériences, les patients les configurent à l’aide de modèles empruntés à leur propre culture. Cependant, il est important d’observer qu’une unique information neurobiologique peut être configurée par de différents symptômes et que des informations neurobiologiques différentes peuvent à leur tour être configurées par un seul symptôme. Par conséquent, « les symptômes mentaux ¼ sont des combinaisons hybrides différentes, composées d’informations neurobiologiques et culturelles. Pour pouvoir respecter l’éthique, les interventions thérapeutiques doivent prendre en compte ces différences. La manipulation aveugle du cerveau doit, dans tous les cas, être considérée comme solution contre-productive.

La Psiquiatría actual está en crisis. Décadas de investigación neurocientífica aún no han entregado explicaciones o tratamientos adecuados. Una de las razones a las que se le atribuye este fracaso puede ser la injusticia de su supuesto central, es decir, que los síntomas y desórdenes mentales son tipologías naturales. La Escuela de Cambridge ha propuesto que una nueva epistemología debe ser construida para la Psiquiatría y que esto debería empezar con el desarrollo de un nuevo modelo de formación del síntoma mental. Los “síntomas mentales” deberían ser considerados una co-construcción hermenéutica que se da en un espacio intersubjetivo creado por el diálogo entre el paciente y quien cura. Las experiencias subjetivas (ya sean causadas por trastornos neurobiológicos o psicosociales) penetran la consciencia de los pacientes causando perplejidad y/o angustia. Para entender, controlar y comunicar estas experiencias, los pacientes proceden a configurarlas a través de plantillas tomadas de su propia cultura. Cabe destacar, sin embargo, que la misma información neurobiológica puede ser configurada en diferentes síntomas y diferentes informaciones neurobiológicas en el mismo síntoma. Por lo tanto, los “síntomas mentales” son combinaciones híbridas disímiles de informaciones neurobiológicas y culturales. Para ser éticas, las intervenciones terapéuticas deben tener en cuenta tales disimilitudes. La manipulación del cerebro debería ser considerada, en todos los casos, contraproducente.

Die zeitgenössische Psychiatrie befindet sich in Krise. Jahrzehnte neuro¬wissen¬schaftlicher Forschung haben weder angemessene Erläuterungen, noch Behandlungen geliefert. Einer der Gründe für dieses Versagen könnte die Ambiguität ihrer zentralen Hypothese sein, nämlich dass psychische Symptome und Störungen natürliche Typen sind. Die Schule von Cambridge schlägt nun vor, eine neue Erkenntnistheorie für Psychiatrie zu erstellen, die mit der Entwicklung eines neuen Modells der psychischen Symptombildung beginnen müsste. „Psychische Symptome“ sind demnach hermeneutische Co-Konstruktionen, die sich in einem intersubjektiven Bereich manifestieren, der durch den Dialog zwischen Arzt und Patient geschaffen wird. Subjektiven Erfahrungen (die entweder durch neurobiologische oder psychosoziale Änderungen verursacht werden) dringen in das Bewusstsein des Patienten und verursachen Verwirrung und/oder Leiden. Um diese Erfahrungen zu verstehen, zu verarbeiten und mitzuteilen, konfiguriert sie der Patient mit Hilfe von Modellen, die aus seiner eigenen Kultur entlehnt werden. Es muss hier jedoch beachtet werden, dass die gleiche neurobiologische Information in unterschiedliche Symptome konfiguriert werden kann und dass andererseits verschiedene neurobiologische Informationen mittels eines einzigen Symptoms konfiguriert werden können. Daher sind „psychische Symptome“ abweichende hybride Kombinationen, die aus neurobiologischen und kulturellen Informationen bestehen. Um der Ethik gerecht zu werden, müssen therapeutische Interventionen diese Unterschiede berücksichtigen. Blinde Gehirnmanipulation muss in allen Fällen als kontraproduktiv angesehen werden.

当前精神病学正处于危机之中。几十年神经科学的研究还没有提供足够的解释或处理。其中一个可能导致此失败的原因是其核心假设的不正确性：精神症状和疾病是自然种类。剑桥学派提出了需要构造精神病学的一个新认识论，而这应该开始于发展精神症状形成的一个新模式。对于“心理症状”的考虑应由患者和医者在对话时共同建设的一个主体间的空间。主观经验（由任何神经生物学或心理状态所产生的）穿透患者的意识而导致困惑和/或痛苦。为了理解，处理和交流这些经验，患者会借鉴自己文化的内容设置此经验的意义。可是重要的是，同样的神经...

The hermeneutics of mental symptoms in the Cambridge School / A hermenêutica de sintomas mentais na Escola de Cambridge / L’herméneutique de symptômes mentaux selon l’École de Cambridge / La hermenéutica de los síntomas mentales en la Escuela de Cambridge

Current Psychiatry is in crisis. Decades of neuroscientific research have not yet delivered adequate explanations or treatments. One reason for this failure may be the wrongness of its central assumption, namely that mental symptoms and disorders are natural kinds. The Cambridge School has proposed that a new Epistemology must be constructed for Psychiatry, and that this should start with the development of a new model of mental symptom-formation. ‘Mental symptoms’ should be considered as hermeneutic co-constructions occurring in a intersubjective space created by the dialogue between sufferer and healer. Subjective experiences (caused either by neurobiological or psychosocial upheaval) penetrate the awareness of sufferers causing perplexity and/or distress. To understand, handle and communicate these experiences, sufferers proceed to configure them by means of templates borrowed from their own culture. Importantly, however, the same neurobiological information can be configured into different symptoms; and different neurobiological information into the same symptom. Therefore, ‘mental symptoms’ are dissimilar hybrid combinations of neurobiological and cultural information. To be ethical, therapeutic interventions must take into account such dissimilarities. Blind manipulation of the brain in all cases should be considered as counterproductive.(AU)

A Psiquiatria atual está em crise. Décadas de pesquisa neurocientífica ainda não resultaram em explicações ou tratamentos adequados. Uma das razões para esse fracasso pode ser sua hipótese central equivocada, ou seja, de que os sintomas e desordens mentais são tipos naturais. A Escola de Cambridge propôs a construção de uma nova epistemologia para a Psiquiatria, que deve começar com o desenvolvimento de um novo modelo de formação de sintomas mentais. “Sintomas mentais” devem ser considerados uma coconstrução hermenêutica que ocorre em um espaço intersubjetivo criado pelo diálogo entre paciente e médico. Experiências subjetivas (causadas por convulsão neurobiológica ou psicossocial) penetram na consciência dos pacientes, causando perplexidade e/ou sofrimento. Para entender, manipular e comunicar essas experiências, os pacientes seguem para configurá-las por meio de modelos emprestados de sua própria cultura. É importante notar, no entanto, que a mesma informação neurobiológica pode ser configurada em diferentes sintomas e diferentes informações neurobiológicas, no mesmo sintoma. Portanto, “sintomas mentais” são combinações híbridas diferentes de informações neurobiológicas e culturais. Para serem éticas, intervenções terapêuticas devem levar em conta essas diferenças. A manipulação cega do cérebro deve, em todos os casos, ser considerada contraproducente.(AU)

La psychiatrie contemporaine est en crise. Des décennies de recherche neuroscientifique n’ont pas été capables de produire ni des explications, ni des traitements appropriés. Cet échec est peut-être partiellement dû à l’ambiguïté de son hypothèse centrale, selon laquelle les symptômes et les troubles mentaux sont des types naturels. L’École de Cambridge propose la construction d’une nouvelle épistémologie pour la psychiatrie, à commencer par l’élaboration d’un nouveau modèle de formation de symptômes mentaux. Ceux-ci doivent être considérés comme des co-constructions herméneutiques qui se produisent dans un espace intersubjectif créé par le dialogue entre le patient et le médecin. Des expériences subjectives (qui résultent de bouleversements neurobiologiques ou psychosociaux) pénètrent la conscience des patients et causent la perplexité et/ou la souffrance. Pour comprendre, gérer et communiquer ces expériences, les patients les configurent à l’aide de modèles empruntés à leur propre culture. Cependant, il est important d’observer qu’une unique information neurobiologique peut être configurée par de différents symptômes et que des informations neurobiologiques différentes peuvent à leur tour être configurées par un seul symptôme. Par conséquent, « les symptômes mentaux » sont des combinaisons hybrides différentes, composées d’informations neurobiologiques et culturelles. Pour pouvoir respecter l’éthique, les interventions thérapeutiques doivent prendre en compte ces différences. La manipulation aveugle du cerveau doit, dans tous les cas, être considérée comme solution contre-productive.(AU)

La Psiquiatría actual está en crisis. Décadas de investigación neurocientífica aún no han entregado explicaciones o tratamientos adecuados. Una de las razones a las que se le atribuye este fracaso puede ser la injusticia de su supuesto central, es decir, que los síntomas y desórdenes mentales son tipologías naturales. La Escuela de Cambridge ha propuesto que una nueva epistemología debe ser construida para la Psiquiatría y que esto debería empezar con el desarrollo de un nuevo modelo de formación del síntoma mental. Los “síntomas mentales” deberían ser considerados una co-construcción hermenéutica que se da en un espacio intersubjetivo creado por el diálogo entre el paciente y quien cura. Las experiencias subjetivas (ya sean causadas por trastornos neurobiológicos o psicosociales) penetran la consciencia de los pacientes causando perplejidad y/o angustia. Para entender, controlar y comunicar estas experiencias, los pacientes proceden a configurarlas a través de plantillas tomadas de su propia cultura. Cabe destacar, sin embargo, que la misma información neurobiológica puede ser configurada en diferentes síntomas y diferentes informaciones neurobiológicas en el mismo síntoma. Por lo tanto, los “síntomas mentales” son combinaciones híbridas disímiles de informaciones neurobiológicas y culturales. Para ser éticas, las intervenciones terapéuticas deben tener en cuenta tales disimilitudes. La manipulación del cerebro debería ser considerada, en todos los casos, contraproducente.(AU)

The construction of anosognosia: history and implications.

The construction of anosognosia as a clinical 'disorder' resulted from the convergence (in the work of various writers and culminating in Babinski) of a name, a concept, and a clinical phenomenon. During the early stages of this convergence, unawareness of neurological dysfunction was not considered as an independent clinical phenomenon. Started in the work of Anton, the process of separating it as a differentiable clinical state is completed by Babinski who reaffirmed the semiological independence of 'unawareness'. The history of the construction of 'anosognosia' parallels the late 19th century debate on the nature and brain inscription of the concept of 'consciousness'.

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.

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.

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.

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.

Verbal fluency and awareness of functional deficits in early-stage dementia.

Assessment of activities of daily living is an important element in the diagnosis of dementia, with research suggesting a link between functional ability and cognition. We investigated the relationship between self- and informant ratings of instrumental activities of daily living (iADL) and verbal executive functioning in early-stage dementia. A total of 96 people with early-stage Alzheimer's disease or vascular or mixed dementia and their carers completed the Functional Activities Questionnaire; people with dementia also completed a test of letter fluency. Letter fluency was associated with self-ratings of iADL, while informant ratings of iADL were associated with the age and Mini-Mental State Examination score of the person with dementia. Self-ratings of perceived functioning suggested significantly less impairment than informant ratings. Those with impaired letter fluency rated themselves as having greater difficulties in iADLs than those who performed better. People with early-stage dementia vary in their subjective level of awareness of their iADL functioning, and difficulties with language production may contribute to better awareness of iADL impairments.

'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.

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.