Psychiatric disorders (schizophrenia and other psychotic disorders, personality disorders, neurocognitive disorders, etc.) are based entirely or almost entirely on symptoms. So the criteria for determining e.g., how cognitive, social, & emotional functioning is affected is the disorder. That is, if someone in Europe displays

"(a) callous unconcern for the feelings of others;

(b) gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations;

(c) incapacity to maintain enduring relationships, though having no difficulty in establishing them;

(d) very low tolerance to frustration and a low threshold for discharge of aggression, including violence;

(e) incapacity to experience guilt or to profit from experience, particularly punishment;

(f) marked proneness to blame others, or to offer plausible rationalizations, for the behaviour that has brought the patient into conflict with society."

then they are diagnosed with Dissocial personality disorder. Similarly, if someone in the US is characterized by

"A. A pervasive pattern of disregard for and violation of the rights of others, occurring since age 15 years, as indicated by three (or more) of the following:

1. Failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.

2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.

3. Impulsivity or failure to plan ahead.

4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.

5. Reckless disregard for safety of self or others.

6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.

7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

B. The individual is at least age 18 years.

C. There is evidence of conduct disorder with onset before age 15 years.

D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder."

they are diagnosed with Antisocial personality disorder. Note the incapacity to make responsible decisions; the persistent engagement in antisocial, criminal, or similar behavior; impulsivity, poor judgment, and recklessness; etc., are all components of the disorders. This is also true for intellectual development disorders, psychotic disorders, and every other psychiatric disorder. There is no etiology underlying the diagnoses, and despite the fact that disorders are frequently distinct from one another BY DEFINITION (i.e., in order to be diagnosed with X, the clinician must rule out Y) comorbidity is amazingly high. That's because the diagnostic model was developed mostly out of thin air in the hopes that research would ground claims that each diagnosis represents a pathology distinct from every other. Unfortunately, the neural correlates of many disorders, the neurotransmitters involved in them, and the genetic components identified all overlap significantly but none of them can be used to diagnose, predict, or otherwise identify any psychiatric disorder.

The science is mostly based upon sociocultural and cognitive norms that individuals do not conform to in particular ways for reasons that we don't know and in ways that can vary by culture in fundamental ways (for example, certain disorders are culturally specific; also, most of the research on moral reasoning assumed to be universal was based on applications of game theory to experiments with undergraduates, but it turns out that many "universals" failed to hold true when tested in non-Western cultures- see Henrich, J., Heine, S. J., & Norenzayan, A. (2010). The weirdest people in the world?. Behavioral and Brain Sciences, 33(2-3), 61-83 http://hci.ucsd.edu/102b/readings/WeirdestPeople.pdf). A popular book and movie as well as the recovered memory movement saw a rise in the number of cases of multiple personality disorder (now dissociative personality disorder) from "almost no recorded cases" to an epidemic. Then, when certain high-profile cases revealed that clinicians had helped patients "remember" sexual abuse that couldn't have happened (e.g., memories of being molested by neighbors turned out to be impossible because the neighbor in question wasn't alive at the time or hadn't yet moved to the neighborhood) and "coaxed" personalities using hypnosis and suggestion, suddenly the epidemic died down almost as quickly and completely as it had arisen. This is the disorder that is most often mistaken for schizophrenia, involves a complete disconnect with reality through the adoption of alternate personalities, yet was basically created by media and over-eager clinicians (at least as anything more than a rather nebulous and extremely rare condition). That's the downside of having the criteria written into the definition of the disorders themselves- sure, one can use an inability to function socially as defined by some disorder in order to justify the removal of certain rights, but the sociocultural an epigenetic nature of psychiatric disorders combined with a complete inability to define them other than through symptoms allows for the creation of diagnoses that have no underlying pathology and should not be treated as they are.

Hello Andrew and thank you for your comment.

It is very useful; in fact, I agree with your idea. We could be talking about this hours and hours!!

However, I am afraid you did not answer the core aspect of my question.

For the more mainstream psychology/ psychiatry...What cognitive capacities are necessary for decision making? Who can decide, who cannot?

I am developing my project on this question, so comments or tips are welcome!!!

Hello Xabier,

I think you have to make a difference between the scientific base and how people are treat in their dialy life + the legal component. The last few years laws have changed. Mostly on a scientific base. However the way people are treat did not change in most cases. There is no scientific base why someone should not give anyone enough time to talk with that person about consequences so he/she can make a proper decission. It is more a financial aspect or an aspect of resources.

And then again you cannot put every illness and disorder and disabilities in one huge pot, stir everything up and hope that something usefull comes out here... like a theory of everything that can be reduced to brain functions giving someone a formular into hands why the hell they have the right to treat someone the stereotypical way they do. It is simply not THAT simple.

To be honest: I am a little bit concerned about your question. It just has that specific overtones you are at least looking for some justifications why it is so totally correct the way it already is :S

Thank you Carmen. Great reply.

You are totally right about the distinction on daily life and resources vs. law.

My question is more related to the legal aspect in institutions and the person-centred approach (which I firmly support), and also from an ethical or "good practices" point of view, but each person does what they want with their disabled people.

Regarding the pot you refer to, that is exactly what I intend, although I know it will be difficult. Try to integrate cognitive, neuropsychological, neuroimaging, etc. studies and propose a test or heuristic for decision making.

If you are interested in this project, do not hesitate to write!!

The trouble is not that it will be difficult but either whatever you intend to do will simplify the topic. I guess you underestimate the problem that each simplification means an alteration of the object you want to describe. And based on that very, very altered object (which in fact consists of many objects/illnesses/disorders) you want to come to ethic claims? I fear this will end up in a bunch of stereotypical statements in which some of your readers might belief that the world you are describing is not just a simplified model but reality. Especially when it comes to ethic suggestions, to suggestions pointing torwards practitioners who work with people one should really show more respect.

Thank you, Carmen.

I am aware that this is an ambitious project and I face it with all the possible humility; in fact I will start with a literature review and see where it goes; then, I will try to use this info. in my PhD project, so I am thinking of a long-time project.

I am opened to any interpretation of the literature, and if it is inevitable to conclude that the topic is too complex (which in cognitive neurosciences it is too often), I will be more than happy to embrace it.

Actually, I have worked as a practitioner for some years and I realized about the gap that exists in this topic. That is why I want to shed some light.

Thank you again for your comments,

Best Wishes

Any more tips??

For the past ~30 years, two rather fundamentally incompatible theories of cognition have existed side-by-side despite thousands of experimental results from fields as diverse as linguistics and systems neuroscience using everything from functional neuroimaging to analyses of classical languages. The problem isn't so much a matter of complexity. It's the vast amount of contradictory literature that, for your question, means the answer to "who is qualified to use what methods to determine whether x individual is capable of y set of cognitive functions?" depends fundamentally on who you ask. Ask Lakoff, Chao, Gibbs, Pulvermüller, etc. and you will be told that the higher cognitive function is domain-general, embodied, and intricately linked to culture, language, etc. Ask Chomsky, Pinker, Caramazza, Foder, etc., and you will be told that higher cognitive processes are domain-specific, that the mind is functionally massively modular, that it is a symbol processing machine, etc. Something as fundamental as severe brain damage that results in aphasia or similar cognitive deficits is interpreted fundamentally differently by perhaps half of those in the cognitive sciences. That's just the issue of how the mind works and what the foundations of decision-making processes are (and how they can go wrong or be improved); go into clinical issues and you are faced with fundamental disagreements over what clinical issues actually are, let alone how they relate to the divides over the nature of the basis for cognitive functions. Add to this the desire to communicate a non-existent collective body of research to political, legal, and non-profit organizations involved in mental health, institutional commitment, etc., and you are essentially taking on the question "if there were an agreement within the cognitive sciences over the nature of cognition and higher cognitive functions, then if this were translatable into a non-existent body of clinical literature sufficiently explanatory and empirically based, then how could these non-existent frameworks be combined to inform policy and policy makers who are not scientists nor equipped to evaluate scientific literature?

Alternatively, you could set your sights a bit lower. For example, it doesn't really matter if seeing one's recently departed loved one's is a cultural phenomenon that is therefore normal in one context but not another or if it is necessarily indicative of either mental disorders or poor decision making/judgment capabilities. Where it is a normative reaction nobody is going to admit someone for such behavior, and where it is aberrant the extent to which cognition is culturally-based or embodied and/or to which disorders fit the biomedical model are mostly irrelevant- such behaviors are then by definition indicative of an inability to function within society. Likewise, it doesn't matter if something as severe as multiple personality disorder/dissociative personality disorder fits a sociocognitive model or a biomedical model- being unable to remember large portions of your life because you have more than one "alter" that for all intents and purposes means you act like fundamentally different people at different times means you are incapable (again) of normative behavior, risk assessment, etc. In other words, you don't need to understand the brain so much to get to the heart of the issue. The real issue is not whether there is some scientifically valid diagnostic criteria for whether someone has a disorder that interferes with their social, cognitive, emotional, or other brain functions to such an extent that warrants removing certain rights they have over their own person. It's whether or not a person can function in the society in which they live. Like mental disorders in general, this is not a matter of criteria based upon neuronal models, neurophysiological dynamics, or even neurocognitive measures per se, but rather the much simpler question "given that we know how most people behave, and given that X individual does not conform to this pattern, are they therefore a danger to themselves and/or others? Someone who believes that the moon landing was faked, dinosaur bones were planted as part of a conspiracy, the Knights Templar hid information about Jesus' descendants, and similar theories, but who goes to work every day, pays the bills, perhaps has a stable relationship, and is neither prone to violent outbursts nor in general known to be more than "odd" by acquaintances shouldn't be committed. It could be that there are all kinds of interesting reasons underlying such a worldview, and indeed there is extensive literature on this kind of question. It's irrelevant, however. Likewise, someone habitually runs into trouble, with the law, is prone to violent outbursts, has justified harming others for trivial reasons, etc., could have be suffering from neurological damage (this goes back all the way to Phineas Gage) or from some psychiatric condition and it couldn't matter less (for treatment, it absolutely matters, but not for any evaluation of whether the individual should have the rights over their own person limited or autonomy denied).

I think you might be looking in the wrong place for the answers. Not that I don't understand the desire to take on ambitious projects, mind you, it's just that unless you personally solve fundamental divides in two sets of fields (the cognitive sciences and clinical/psychiatric sciences), you won't really have a place to start. If you do happen to solve such problems, don't tell anybody just email me the results so that I can take all the credit. :)

HI Xabier

Really interesting question, and something that I do come across at times in my research on dementia.

There is a decent literature on decision-making processes in psychology, such as decision making in regards to whether to chose a small reward now or wait a certain time and increase that reward, which may however be less likely to actually be given in the end. I did quite a bit on this during my undergraduate, and this may be helpful in ascertaining a relationship to cognitive processes, as there surely should be some imaging studies/ relationship data to neuropsychological test performance.

Hope that helps!

Thank you again andrew. I guess your surname is not really Messing;)

Once I understood your discourse, I can only accept the fact that there are basic conceptual problems to be solved related to the idea itself of capacity-incapacity. By the way, what is a disorder in the end, but a score in a test? So according to a test one person could be unimpaired but another person who scored one more point would be impaired.

Regarding the functionality in everyday life, what is to function?

These questions have been in my mind for a long time and are essential to psychology, but I am afraid that are not solvable with the current pathological framework.

Anyway I consider that improvements can be made from advances in basic research. This is better than nothing.

I really appreciate your excellent analytical point of view.

Thanks Clarissa.

Decision making in dementias and especially in AD is interesting given that it provides evidence on the influence of self awareness. Patients with mnemonic anosognosia show impairments in decision making due to an inability to incorporate autobiographical information to their life, therefore making poor judgements about their capacities and consequently about risks.

Good morning, Shafig. Thank you for your answer. Could you please develop your idea?

Hi Xavier,

De la integridad del funcionamiento ejecutivo de la persona depender'a la capacidad para la toma de decisiones. Cierto es que es dificil basarse 'unica y exclusivamente en lo que la persona puede hacer cuando se le aplican pruebas de laboratorio, pero si se pueden generar inferencias de qu'e ocurriria si las funciones que se han puesto en marcha durante la realizacion de las pruebas lo hicieran en contextos reales. Incluso con dominios tan importantes como el lenguaje alterados se podrian tomar decisiones de un modo correcto (en segun que casos). En AD es dificil saber cu'ando el paciente a superado esa linea tras la cual la toma de decisiones sea quizas conducida por el medio, apoyada (pero solo parcialmente) por los recursos que el paciente aun conserva, etc. Lo ideal seria establecer unos estandares, eso si con metodos de medida lo mas ecologicos posibles, y aunque sea esa una empresa complicada es mejor intentarla que basare solo en aspectos meramente clinicos, tan suceptibles de error por exceso o defecto.

Oh, sorry. I had written this in spanish!

Muy buenas, Salmantino (qu'e gran ciudad, hice alli un m'aster en neuropsicolog'ia)

Te respondo en ingl'es:

First of all, thank you for your response.

Secondly, I agree with you that executive functions are one of the most important in Decision Making, but I am not sure what you refer to when talking about Executive Functions because, in my opinion, it is a very messy concept.

It is said in some papers that both more "executive" functions, like reward-related learning, dependent on the OFC, and more "cognitive-deliberative" functions, like the evaluation and comparation of options, dependent on the DLPF, are used in Decision-Making. On the other hand, it is said that executive functioning is predictive of Decision Making ability.

Regarding Executive functioning and Decision Making, I think it is important to distinguish between capacity (the minimum ability necessary to do something) and competence (to do this right in a given situation), for which executive functioning is essential.

I also think that memory and other cognitive abilities are important, depending on what type of decisions we are talking about.

This is such a complex topic!

If you are interested:

2000_Krawczyk_Neuroscience and Biobehavioral Revs_Contribution of the prefrontal cortex to the neural basis of human DM

2005_Ernst_Biol.Psych_Neurobiology of Decision Making: A Selective Review

from a Neurocognitive and Clinical Perspective

There is a very very extensive literature on DM, so these are only a few papers.

I am currently doing a project on the DM in disabilities, and I would like to find people to collaborate, so I would like to talk with you about it. Wold you give me your email account?

Thanks