2nd asia judul fixed_yonico martatino_lali cs_introducing of psychopharmacology executive function, and selfhood
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2nd asia judul fixed_yonico martatino_lali cs_introducing of psychopharmacology executive function, and selfhood 2nd asia judul fixed_yonico martatino_lali cs_introducing of psychopharmacology executive function, and selfhood Presentation Transcript

  • Introducing of Psychopharmacology: Executive Function, and Selfhood Nur Lailatul Masruroh1)2) , Ingga Yonico Martatino3)4) , Andri Frediansyah5 , Gusti Jhoni6 , D. Chandra Purnama7 1 Muhammadiyah University of Malang, Indonesia 2 Faculty of Mursing, Kasetsart University, Bangkok 10900, Thailand Email: faranurlailatul@yahoo.com 3 Faculty of Medicine, Gadjah Mada University, Yogyakarta, Indonesia 4 Department of Psychology, State Islamic University of Sunan Kalijaga Yogyakarta, Indonesia 5 Chulabhorn Graduate Institute, Bangkok, Thailand 6 Muhammadiyah Hospital of Pontianak, Borneo, Indonesia 7 Hospital of Department of Indonesian Police, East Java, Indonesia Abstract— The topic has been argued the approach of psychiatric to psychopharmacology and its emphasis in the treatment of mental disorders is biased by a positivist focus on symptom reduction with no consideration given to pharmacotherapy effects on patient selfhood. As intact executive function, self regulation, and goal-directed actions are critical to selfhood, this paper reviewed studies addressing executive function effects in the context of treating adult and childhood mental illness with antidepressants, antipsychotics, mood stabilizers, stimulants, sedatives, and other substances through the hermeneutic view of selfhood. Findings indicate that a complex relationship exists between pharmacotherapy, executive function, self-regulation, and goal-directed actions, but that these essential functions of self are frequently impaired by pharmacotherapy resulting in a diminished expression of selfhood. While this conclusion is based on a limited review of the research available, the clear implication is that the psychiatric/pharmacotherapy neglect of patient selfhood quietly threatens its foundations as a therapeutic practice. Keywords: psychopharmacology, executive function, selfhood I. INTRODUCTION This scientific paper explained the psychopharmacological influence on the dynamics of executive function as a result of treatment of mental disorders. While it is recognized that mental disorders can adversely impact aspects of executive, it is also important to understand how treatment with psychopharmacological agents impact executive function in the process of treating mental disorders. Intact executive function plays a critical role in a wide range of important life issues such as success in childhood education (Clark, Pritchard, & Woodward, 2010), success in employment (Wolf, 2010), success in financial man- agement (Ball, & Marson, 2006), success in daily living (Vaughan 2010), and health quality of life among the elderly (Najafzadeh, 2010) while impaired executive function can contribute to increased risk of mortality (Amirian, Baxter, Grigsby, 2010). In fact, according to Beahrs (1983), executive function is akin to the “organizing force that gives humans their sense of cohesive selfhood”. Gold and Olin (2009) note that the primary focus of psychopharmacological clinical trials is typically the impact on mental disorder symptoms being targeted with little attention paid to long-term effects on executive function and its role in supporting personhood and the self. Dura (2010) also note that publications such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) do not even consider assessing changes in psychosocial competence or issues of intact self effectively ignoring aspects of individual selfhood and supporting the vacuum of focus on the self within psychiatry, it is supported by a number of studies which show that executive function is typically treated as a marker or indicator of psychopharmacological agency and pharmacotherapy action without attention to issues of selfhood. For example, changes in executive function have been used to determine the psychopharmacological actions of antidepressant medications (Saylor, Adler, Spencer, 2011; McLennan, & Mathias, 2010; Braus, et al., 2011) and stimulants targeting executive function deficits associated with attention deficit disorder (ADD) (Spencer, & Faraone, 2011), and antipsychotic effects on executive deficits concurrent with schizophrenia (O'Grada & Dinan, 2007). Even the intersection of executive function and psychopharmacology is based on the use of neuropharmacological agents in animals and by humans which helped to reveal the neurochemical basis of key behavioral components subsumed under executive function (T.W., 2007). It is there-fore clear that executive function dynamics are important to track, assess, and understand the na-ture of psychopharmacological agent action, but there is little attention given to how pharmacother-apy impacts executive function in ways that either support or detract from selfhood. Executive Function The discussion of “executive functions” described a “dysexecutive syndrome” characterized by impairments in the
  • ability to plan, start and stop actions, utilize abstract thought, successfully adapt to the environment, and act appropriately in social situations (Stirling & Elliot, 2008). While there is still disagreement about the operations subsumed under executive function and some confusion about what distinguishes executive function from cognitive function, there is broad agreement that the key domains of executive function include the ability to control actions (i.e., starting an action, maintaining actions, stopping actions), abstract and conceptual thinking, and the ability to coordinate behavior in pursuit of goals. As indicated above, the knowledge of executive function came from studies of braindamaged patients and animal research (Stirling, et al.) which has been a primary method of investigating the relationship between the brain structures and function as represented by the linkage of prefrontal cortical areas to executive function (Chudasama, 2011) including the dorsolateral prefrontal, orbitofrontal, and medial frontal areas (Ardila, 2008). Animal research has typically correlated the disturbance of neural circuitry with behavioral outcomes and lesion studies using pharmacological agents which have helped to reveal the neurochemical foundations of executive function including the role of dopamine, serotonin, and norepinephrine (Robbins & Arnsten, 2009). Executive function is also intimately linked with self regulation. Executive function and self regulation go hand in hand in areas of human debinge drinking (Mullan, Wong, Allom, & Pack, 2011), and dietary control (Lin, 2011) driving to work, solving a puzzle, or filling out an employee review are key to adaptive behavior and rely on intact executive function which are all broadly associated with adaptive abilities (Buckner, Mezzacappa, & Beardslee, 2009). Theoretically, self regulation, which Brownell (2009) identifies as a key concept in Gestalt therapy, is essential to the subjective realization of self and intentional integration. As described by Baumeister, Schmeichal, and Vohs (n. d.), proper function of self regulation enables an individual to change their behavior in line with societal conventions and rules, follow ideals, and personal standards. When executive function falls short, however, note that “any one of a broad range of human problems and misfortunes can arise. As this paper seeks to consider psychopharmacology impacts on executive function in terms of support or impairment of individual selfhood in contrast to merely as an indicator of pharmacotherapy agent action, it is relevant determine if philosophical support exists for this contrast. Self-Regulation and Goal-Directed Actions. Executive function is also intimately linked with self regulation. Executive function and self regulation go hand-in- hand in areas of human development (Bernier, Carlson, & Whipple, 2010; Friedman, Miyake, Robinson, & Hewitt, 2011), learning (Garner, 2009), binge drinking (Mullan, Wong, Allom, & Pack, 2011), and dietary control (Lin, 2011) which are all broadly associated with adaptive abilities (Buckner, Mezzacappa, & Beardslee, 2009). Theoretically, self regulation, which Brownell (2009) identifies as a key concept in Gestalt therapy, is essential to the subjective realization of self and intentional integration. As described by Baumeister, Schmeichal, and Vohs (n. d.), proper function of self regulation enables an individual to change their behavior in line with societal conventions and rules, follow ideals, and personal standards. When executive function falls short, however, Baumeister, et al., note that “any one of a broad range of human problems and misfortunes can arise.” Philosophy of Psychopharmacology and Self According to Browning (2008), psychiatry in America has moved away from its original focus on mind and consciousness and replaced it with a focus on the physical body and the physical brain as represented by its greater focus on neuroscience and psychopharmacology. The hermeneutic philosophical orientation,according to Stein, is more likely to highlight individual experience of medications and the extent to which they impair or aid an individual‚ Government realization of their own intentional self mediated by the medications impact on executive function and related issues of self regulation and goal directed action. More recently, Aho (2008) has also identified hermeneutic phenomenology as sufficiently capable of challenging the positivist bias of psychiatry and psychopharmacology which is minimizing the relevance of self, and the experience of mental disorder as a thing influenced by the society and culture of the present. The discussion will now turn to an exploration of psychopharmacological agent impacts on executive function through a review of studies examining executive function response to antidepressants, antipsychotics, mood stabilizers, stimulants, sedatives, and hypnotics used to treat mental disorders, as well as studies reporting executive function impacts accompanying the use or abuse of alcohol, vitamins/minerals, and substances including ecstasy, marijuana, and polysubstance users. Based on popular knowledge, it seems obvious to hypothesize that alcohol and substance use will adversely impact executive function and self regulation. Therefore, the primary hypotheses to be evaluated are: 1) treatment with psychopharmacological agents such as antidepressants, antipsychotics, mood stabilizers, and stimulants typically impair executive function and, by association, an individual‚ sense of selfhood, and 2) only vitamins and minerals aid executive functioning. Pharmacotherapy and Executive Function, Antidepressants and Executive Function Evaluating the relationship between patient response to antidepressant medications and pat-terns of cognitive and executive function, McLennan and Mathias (2010) tested a model, the depression executive dysfunction (DED) model, which posited that a patient's response to antidepressant medications is predicted by the patient's levels of cognitive and/or executive dysfunction such that executive dysfunction is associated with poorer response. This study is similar to one reported by A, X., A., C., N., M., S., and A. (2004) who found evidence suggesting that failure to respond to antidepressant pharmacotherapy in late on set depression appears to be related to executive dysfunction. Using meta-analytic methods, McLennan, et al. identified five tests of cognitive function, including one which evaluated
  • an executive function, which demonstrated the ability to discriminate between patients who showed good and poor response to antidepressant medications. An additional review of studies which focused on response to selective serotonin reuptake inhibitors (SSRIs) also found the same pattern where poor response was associated with executive and cognitive function deficits, offering evidence that as-sessments of executive function and cognitive function are associated with differential patterns of favorable or unfavorable response to antidepres-sants and suggesting that intact executive and cognitive function is a factor determining adequacy of response to antidepressants. II. DISCUSSION In the case of use of antipsychotics, their application in the treatment of euthymic/bipolar I disorder contributed to the impairment of planning aspects of executive function, while the positive effects of second generation antipsychotics among schizophrenics, like SSRIs, appeared dependent on healthy levels of executive function. Thus, the use of antipsychotics to treat euthymic/bipolar I disorders appears to move these individuals farther away from the meaning inherent in selfhood and diminishes their opportunity for self agency. Additionally, the use of second generation antipsychotics in the treatment of schizophrenics can also not be expected to move a schizophrenic patient closer to selfhood and phenomenological meaningfulness in that its positive action is dependent upon intact self agency. However, the antipsychotic, aripiprazole, positively impacted planning aspects of executive function without apparent dependence on pre existing patterns of healthy executive function, thus its use should enhance the prospects for selfhood and realization of self agency. As Beahrs (1983) identified healthy executive function as critical to selfhood, this paper has explored how use of psychopharmacological agents in the treatment of mental disorders which typically impair executive function further influences aspects of executive function, self regulation, and goal directed actions critical to the expression and realization of selfhood. The primary hypothesis; namely, that the use of antidepressants, antipsychotics, mood stabilizers, and stimulants typically impair executive function is only partially supported. In fact, the evidence reviewed highlights the complex nature of pharmacotherapy relationships to executive function based on both the class of medication and individual medications. For example, it appears that the use of atomoxetine benefits executive functioning among children with ADHD, but the proper functioning of antidepressant pharmacotherapy using SSRIs actually dependents on healthy executive function. Thus, it can be expected that the application of atomoxetine among children with ADHD should improve their chances of developing a sense of balanced selfhood and meaningful self agency. In contrast, the same benefit cannot be expected from the use of SSRIs as it appears their action and agency depends on intact selfhood and self agency. The second hypothesis stating that only vita-mins and minerals aid executive functioning is also not supported because, as noted above, stimulants have been consistently shown to improve executive function. However, the single study re-viewed wholeheartedly supported the positive benefits of B vitamin and mineral consumption to mental functioning, energy, vigor, and executive function. Thus, the regular consumption of vita-mins and minerals is an essential aid to the realization of healthy intact self agency and full ex- perience of phenomenal selfhood. The final hypothesis stating that the use of alcohol and substances will adversely impact executive function is supported in the context of adverse impacts on self regulation and goal directed actions. As alcohol consumption was shown to impair attention to contextual cues resulting in improper goal directed actions, improperly stimulate goal commitment and impair goal directed follow through, and disrupt prospective memory and executive function, it is clear that the consumption of alcohol is a serious existential threat to selfhood and a serious detractor of healthy self agency. The same conclusion can be applied to cocaine, marijuana, ecstasy, and polysubstance use because they all impair several aspects of cognitive and executive function (e.g., misdirection of goal directed actions, impaired planning and working memory, impaired inhibition, inhibitory switching errors, impaired self- regulation) indicating that their use, like alcohol, can disrupt user self agency, impair the phenomenal world experience of the user, and damage a user’s expression of self. III. CONCLUSIONS AND IMPLICATIONS This scientific paper has presented evidence show-ing that as pharmacotherapy is applied in the treatment of mental disorders it can, in some cases, represent an additional existential threat to the full intact expression and realization of individual self-hood based on the hermeneutic phenomenological view. As psychiatrists or medical practitioners, whose perceptions of reality are defined by the positivist view, equate mental disorder symptom reduction with successful treatment, the hermeneutic view reveals the potential for harm to individual selfhood, harm to self agency, the diminishing of self in the eyes of fellow phenomenal selves, and a diminishing of the meaning of one’s own existence. This diminishment of meaning is adequately illustrated in the association between treatment with SSRIs and love. According to Meyer (2007), individuals being treated with SSRIs may experience diminished relationship satisfaction due to impaired functioning of neurotransmitters (e.g., oxytocin, dopamine, GABA) as a result of increasing levels of serotonin. If the ability to love is affected by treatment with SSRIs, then, according to Gold, et al., how can psychiatry keep itself separate and cut off from the bigger issues of individual meaning and patient selfhood? And if it does keep itself apart, then it can only do so by disregarding the actual welfare of patients (Gold, et al.), and thus begin the steady erosion of its own identity as a health and therapeutic discipline.
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