Deep brain stimulation interventions are novel devices being investigated for the management of severe treatment-resistant psychiatric illnesses. These interventions require the invasive implantation of high-frequency neurostimulatory probes intracranially aiming to provide symptom relief in treatment-resistant disorders including obsessive-compulsive disorder and anorexia nervosa. In the scientific literature, these neurostimulatory interventions are commonly described as reversible and to be used as a last resort option for psychiatric patients. However, the ‘last resort’ status of these interventions is rarely expanded upon. Contrastingly, usages of (...) DBS devices for neurological symptoms have paved the way for established safety and efficacy standards when used earlier in a disease’s timeline. As DBS treatments for these neurological diseases progress to have earlier indications, there is a parallel ethical concern that early implementation may one day become prescribed for psychiatric illnesses. The purpose of this article is to build off contemporary understandings of reversible neurostimulatory interventions to examine and provide clarifications on the ‘last resort’ status of DBS to better address its ethically charged use in psychiatric neurosurgery. To do this, evaluative differences between DBS treatments will be discussed to demonstrate how patient autonomy would be a paramount guiding principle when one day implementing these devices at various points along a psychiatric disease’s timeline. In presenting the clarification of ‘last resort’ status, the ethical tensions of early DBS interventions will be better understood to assist in providing psychiatric patients with more quality of life years in line with their values. (shrink)

Enactivism is an emerging theory for sense-making (cognition) with increasing applications to research and medicine. Enactivists reject the idea that sense-making is simply in the head or can be reduced to neural processes. Instead, enactivists argue that cognisers are embodied and action-oriented, and that sense-making emerges from relational processes distributed across the brain-body-environment. We start this paper with an overview of a recently proposed enactive approach to pain. With rich theoretical and empirical roots in phenomenology and cognitive science, conceptualising pain (...) as an enactive process is appealing as it overcomes the problematic dualist and reductionist nature of current pain theories and healthcare practices. Second, we discuss metaphor in the context of pain and enactivism, including a pain-related metaphor classification system. Third, we present and discuss five paintings created alongside an enactive study of clinical communication and the co-construction of pain-related meanings. Each painting represents pain-related metaphors delivered by clinicians during audio-recorded clinical appointments or discussed by clinicians and patients during interviews. We classify these metaphors, connecting them to enactive theory and relevant literature. The art, metaphors and associated narratives draw attention to the intertwined nature of language, meaning and pain. Of clinical relevance to primary and allied healthcare, we explore how clinicians’ taken-for-granted pain-related metaphors can act as scaffolding for patients’ pain and agency, for better or worse. We visually depict and give examples of clinical situations where metaphors became enactive, in that they were clinically reinforced and embodied through assessment and treatment. We conclude with research and clinical considerations, suggesting that enactive metaphor is a widely overlooked learning mechanism that clinicians could consider employing and intentionally shape. (shrink)

The aims of this paper are to: identify the best framework for comprehending multidimensional impact of deep brain stimulation on the self; identify weaknesses of this framework; propose refinements to it; in pursuing, show why and how this framework should be extended with additional moral aspects and demonstrate their interrelations; define how moral aspects relate to the framework; show the potential consequences of including moral aspects on evaluating DBS’s impact on patients’ selves. Regarding, I argue that the pattern theory of (...) self can be regarded as such a framework. In realizing and, I indicate that most relevant issues concerning PTS that require resolutions are ontological issues, including the persistence question, the “specificity problem”, and finding lacking relevant aspects of the self. In realizing, I identify aspects of the self not included in PTS which are desperately needed to investigate the full range of potentially relevant DBS-induced changes—authenticity, autonomy, and responsibility, and conclude that how we define authenticity will have implications for our concept of autonomy, which in turn will determine how we think about responsibility. Concerning, I discuss a complex relation between moral aspects and PTS—on one hand, they serve as the lens through which a particular self-pattern can be evaluated; on the other, they are, themselves, products of dynamical interactions of various self-aspects. Finally, I discuss, demonstrating novel way of understanding the effects of DBS on patients’ selves. (shrink)

Abstract: The notion of a self-pattern, as developed in the pattern theory of self, which holds that the self is best explained in terms of the kind of reality that pertains to a dynamical pattern, acknowledges the importance of neural dynamics, but also expands the account of self to extra-neural (embodied and enactive) dynamics. The pattern theory of self, however, has been criticized for failing to explicate the dynamical relations among elements of the self-pattern; as such, it seems to be (...) nothing more than a mere list of elements. We’ll argue that the dynamics of a self-pattern are reflected in three significant and interrelated ways that allow for investigation. First, a self-pattern is reflectively reiterated in its narrative component. Second, studies of psychiatric or neurological disorders can help us understand the precise nature of the dynamical relations in a self-pattern, and how they can fail. Third, referencing predictive processing accounts, neuroscience can also help to explicate the dynamical relations that constitute the self-pattern. (shrink)

Affordances are possibilities for action offered by the environment. Recent research on affordances holds that there are differences in how people experience such possibilities for action. However, these differences have not been properly investigated. In this paper I start by briefly scrutinizing the existing literature on this issue, and then argue for two claims. First, that whether an affordance solicits action or not depends on its relevance to the agent’s concerns. Second, that the experiential character of how an affordance solicits (...) action depends on the character of the concern to which it is relevant. Concerns are conceived of as bodily forms of responsiveness, and solicitations are experienced through this responsiveness. The main aim of this paper is to make clear that an understanding of experiential differences in solicitations has to be based on a phenomenological appreciation of how one experiences one’s responsiveness to those solicitations. In the remainder of the paper I show how such a phenomenological appreciation reveals several characteristics of our responsiveness and I briefly explore three of them: valence, force and mineness. In the final section I discuss the self-referentiality of affordances in light of the current proposal, and argue that this self-referentiality is broader than is typically acknowledged. (shrink)

In this article we move beyond the problematic distinction between ‘higher’ and ‘lower’ cognition by accounting for so-called ‘higher’ cognitive capacities in terms of skillful activities in practices, and in terms of the affordances exploited in those practices. Through ethnographic research we aim to further develop the new notion of skilled intentionality by turning to the phenomenon of the tendency towards an optimal grip on a situation in real-life situations in the field of architecture. Tending towards an optimal grip is (...) an inherently affective and dynamic phenomenon. It has been under explored in philosophy, despite its central place in Merleau-Ponty’s phenomenology. When the architects experience discontent, attention is typically solicited by the affordances through which possible ways of continuing the improvement of the design can be explored. In various ways this tension or disequilibrium - fueling a tendency towards an optimal grip - is encountered in the complex architectural design practices that we observed. Based on our field material we distinguish between: a) grip in visual perception, b) grip on the design, and c) grip on ‘how to design’. The move towards an optimal grip takes shape by joining forces with a landscape of affordances. This landscape includes, for instance, affordances for grasping a cup of coffee, affordances provided by a cardboard model to improve it, as well as for engaging with a person who is not physically present. Because they are skilled, the architects can be responsive to these different affordances in similar ways. Furthermore, in practice the architects are responsive to multiple affordances simultaneously. Through our analysis of the tendency towards an optimal grip we show that our surroundings contribute to skillful action and cognition in a far more complex way than is currently acknowledged in philosophy and cognitive science. (shrink)

The article proposes a theoretical model to account for changes in self due to Deep Brain Stimulation. First, we argue that most existing models postulate a very narrow conception of self, and thus fail to capture the full range of potentially relevant DBS-induced changes. Second, building on previous work by Shaun Gallagher, we propose a modified ‘pattern-theory of self’, which provides a richer picture of the possible consequences of DBS treatment.

This paper utilizes the enactivist notion of ‘sense-making’ to discuss the nature of depression and examine some implications for treatment. As I understand it, sensemaking is fully embodied, fundamentally affective, and thoroughly embedded in a social environment. I begin by presenting an enactivist conceptualization of affective intentionality and describing how this general mode of intentional directedness to the world is disrupted in cases of major depressive disorder. Next, I utilize this enactivist framework to unpack the notion of ‘temporal desituatedness,’ and (...) maintain that the characteristic symptoms of depression result from a disruption to the future-directed structure of affective intentionality. This can be conceptualized as a loss of “online intelligence” and a shrinking of the field of affordances. Then, I argue that two of the standard modes of treatments for depression, medication and cognitive behavioral therapy, are not fully sufficient means of restoring online intelligence, and that these limitations stem partly from the approaches’ implicit commitment to a brain-bound, overly cognitivist view of the mind. I recommend expressive arts interventions such as dance-movement therapy and music therapy as important supplementary treatment methods that deserve further consideration. Insofar as they revitalize subjects’ bodies and emotions, cultivate an openness to the future, and promote self-insight and social synchrony, these treatment modes not only reflect key insights of enactivism, but also offer great potential for lasting healing. (shrink)

Questions about the nature of self and self-consciousness are closely aligned with questions about the nature of autonomy. These concepts have deep roots in traditional philosophical discussions that concern metaphysics, epistemology and ethics. They also have direct relevance to practical considerations about informed consent in medical contexts. In this paper, with reference to understanding specific side effects of deep brain stimulation treatment in cases of, for example, Parkinson’s Disease, Obsessive Compulsive Disorder, and Major Depressive Disorder, I’ll argue that it is (...) best to frame discussions of informed consent in terms of relational autonomy and a pattern theory of self. (shrink)

This thesis proposes a perspective on language and its development by starting from two approaches. The first is the ecological-enactive approach to cognition. In opposition to the widespread idea that cognition is information-processing in the brain, the ecological-enactive approach explains human cognition in relational terms, as skilful interactions with a sociomaterial environment shaped by practices. The second is the metalinguistic approach to language, which holds that reflexive or metalinguistic language use – talking about talking – is crucial for understanding language (...) and its development. In particular, I defend two theses: 1. A child’s initial communicative behaviour can be explained in terms of attentional actions: social actions that function by directing someone else’s attention. 2. In order for the child’s communicative behaviour to be sensitive to key properties of language, such as semantic content and normativity, she needs to learn metalinguistic skills. The development of this ecological-enactive perspective on language serves two functions. First, the ecological-enactive approach started by considering basic behaviour, su. (shrink)

One important concern regarding implantable Brain Computer Interfaces is the fear that the intervention will negatively change a patient’s sense of identity or agency. In particular, there is concern that the user will be psychologically worse-off following treatment despite postoperative functional improvements. Clinical observations from similar implantable brain technologies, such as deep brain stimulation, show a small but significant proportion of patients report feelings of strangeness or difficulty adjusting to a new concept of themselves characterized by a maladaptive je ne (...) sais quoi despite clear motor improvement. Despite the growing number of cases in the DBS literature, there is currently no accepted or standardized tool in neuroethics specifically designed to capture the phenomenological postoperative experience of patients implanted with DBS or BCI devices. Given potential risks of postoperative maladaptation, it is important for the field of neuroethics to develop a qualitative instrument that can serve as a shared method for capturing postoperative variations in patient experience of identity and agency. The goal of this article is to introduce an instrument we have developed for this purpose and call for further neuroethical efforts to assess the phenomenology of implantable brain device use. (shrink)

Despite growing evidence that a significant number of patients living with Parkison’s disease experience neuropsychiatric changes following Deep Brain Stimulation treatment, the phenomenon remains poorly understood and largely unexplored in the literature. To shed new light on this phenomenon, we used qualitative methods grounded in phenomenology to conduct in-depth, semi-structured interviews with 17 patients living with Parkinson’s Disease who had undergone DBS. Our study found that patients appear to experience postoperative DBS-induced changes in the form of self-estrangement. Using the insights (...) from patients’ subjective perceptions of postoperative self-change provides a potent explanation of potential DBS-induced self-estrangement. (shrink)

In this paper, we set out to develop a theoretical and conceptual framework for the new field of Radical Embodied Cognitive Neuroscience. This framework should be able to integrate insights from several relevant disciplines: theory on embodied cognition, ecological psychology, phenomenology, dynamical systems theory, and neurodynamics. We suggest that the main task of Radical Embodied Cognitive Neuroscience is to investigate the phenomenon of skilled intentionality from the perspective of the self-organization of the brain-body-environment system, while doing justice to the phenomenology (...) of skilled action. In previous work, we have characterized skilled intentionality as the organism's tendency toward an optimal grip on multiple relevant affordances simultaneously. Affordances are possibilities for action provided by the environment. In the first part of this paper, we introduce the notion of skilled intentionality and the phenomenon of responsiveness to a field of relevant affordances. Second, we use Friston's work on neurodynamics, but embed a very minimal version of his Free Energy Principle in the ecological niche of the animal. Thus amended, this principle is helpful for understanding the embeddedness of neurodynamics within the dynamics of the system “brain-body-landscape of affordances.” Next, we show how we can use this adjusted principle to understand the neurodynamics of selective openness to the environment: interacting action-readiness patterns at multiple timescales contribute to the organism's selective openness to relevant affordances. In the final part of the paper, we emphasize the important role of metastable dynamics in both the brain and the brain-body-environment system for adequate affordance-responsiveness. We exemplify our integrative approach by presenting research on the impact of Deep Brain Stimulation on affordance responsiveness of OCD patients. (shrink)

In this article, we sketch how theoretical neuroethics can clarify the concept of autonomy. We hope that this can both serve as a model for the conceptual clarification of other components of PIAAAS and contribute to the development of the empirical measures that Gilbert and colleagues [1] propose.

One important concern regarding implantable Brain Computer Interfaces is the fear that the intervention will negatively change a patient’s sense of identity or agency. In particular, there is concern that the user will be psychologically worse-off following treatment despite postoperative functional improvements. Clinical observations from similar implantable brain technologies, such as deep brain stimulation, show a small but significant proportion of patients report feelings of strangeness or difficulty adjusting to a new concept of themselves characterized by a maladaptive je ne (...) sais quoi despite clear motor improvement. Despite the growing number of cases in the DBS literature, there is currently no accepted or standardized tool in neuroethics specifically designed to capture the phenomenological postoperative experience of patients implanted with DBS or BCI devices. Given potential risks of postoperative maladaptation, it is important for the field of neuroethics to develop a qualitative instrument that can serve as a shared method for capturing postoperative variations in patient experience of identity and agency. The goal of this article is to introduce an instrument we have developed for this purpose and call for further neuroethical efforts to assess the phenomenology of implantable brain device use. (shrink)

Gilbert et al. argue that the concerns about the influence of Deep Brain Stimulation on – as they lump together – personality, identity, agency, autonomy, authenticity and the self are due to an ethics hype. They argue that there is only a small empirical base for an extended ethics debate. We will critically examine their claims and argue that Gilbert and colleagues do not show that the identity debate in DBS is a bubble, they in fact give very little evidence (...) for that. Rather they show the challenges of doing research in a field that is stretched out over multiple disciplines. In that sense their paper is an important starting point for a discussion on methodology and offers valuable lessons for a future research agenda. (shrink)

The idea that deep brain stimulation induces changes to personality, identity, agency, authenticity, autonomy and self is so deeply entrenched within neuroethics discourses that it has become an unchallenged narrative. In this article, we critically assess evidence about putative effects of DBS on PIAAAS. We conducted a literature review of more than 1535 articles to investigate the prevalence of scientific evidence regarding these potential DBS-induced changes. While we observed an increase in the number of publications in theoretical neuroethics that mention (...) putative DBS-induced changes to patients’ postoperative PIAAAS, we found a critical lack of primary empirical studies corroborating these claims. Our findings strongly suggest that the theoretical neuroethics debate on putative effects of DBS relies on very limited empirical evidence and is, instead, reliant on unsubstantiated speculative assumptions probably in lieu of robust evidence. As such, this may reflect the likelihood of a speculative neuroethics bubble that may need to be deflated. Nevertheless, despite the low number of first-hand primary studies and large number of marginal and single case reports, potential postoperative DBS changes experienced by patients remain a critical ethical concern. We recommend further empirical research in order to enhance theoretical neuroethics work in the area. In particular, we call for the development of better instruments capable of capturing potential postoperative variations of PIAAAS. (shrink)