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Epistemology, Philosophy of Mind and Bioethics
Ego-dystonia: a review in search of definitions
Egodistónico: Una Revisión en Busca de Definiciones
Ignacio Sandiaa,
Corresponding author
i.sandia@ula.ve

Corresponding author.
, Trino Baptistab
a Departamento de Medicina, Facultad de Medicina, Universidad de Los Andes, Mérida, Venezuela
b Departamento de Fisiología, Facultad de Medicina, Universidad de los Andes, Mérida, Venezuela
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The terms &#8220;ego-dystonic&#8221; and &#8220;ego-syntonic&#8221; are commonly used among mental health workers&#44; yet the English version of the 11th revision of the World Health Organization International Classification of Diseases<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> makes no mention of them in any way&#46; The 10th revision &#40;2019&#41; merely assigns the code F66&#46;1 to ego-dystonic sexual orientation&#44; a diagnosis that no longer appears in the latest revision&#46; The Diagnostic and Statistical Manual of Mental Disorders&#44; Fifth Edition &#40;DSM-V&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> made an equivalent change and does not use the term &#8220;ego-dystonic&#8221; in any of its criteria&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">&#8220;Ego-syntonic&#8221; suggests that a subject&#8217;s expressions of their personality are harmonious with their self-concept and goals without sparking heightened anguish or self-recrimination&#46; For example&#44; people may lack the ability to identify their problematic traits&#44; and therefore perceive their dysfunctional traits to be appropriate&#46; &#8220;Ego-dystonic&#8221;&#44; for its part&#44; refers to a subject&#8217;s expressions being inconsistent with their self-concept and goals and accompanied by an increase in anguish or self-recrimination&#46; However&#44; the topic of &#8220;ego-syntonia&#8221; as the subject&#8217;s perception is vast&#44; and more complex than its mere definition&#46; It is not unusual to see somebody describe something as &#8220;ego-dystonic&#8221; at one time and leverage the same characteristic to achieve an end at another&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A response of heightened anguish and self-recrimination in view of the subject&#8217;s own expressions&#44; beyond social&#44; formative and complex aspects of such expressions&#44; is what determines whether they are syntonic or dystonic&#44; and the patient communicating or not communicating them contributes in particular to the diagnosis of obsessive symptoms in patients on the spectrum of schizophrenia&#44; bipolar disorder and obsessive compulsive disorder&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> It would be useful to design an operational definition that distinguishes ego-dystonia from habitual mental phenomena of self-reflection&#44; such as self-criticism&#44; discontent with specific or general aspects of one&#39;s personality or body&#44; etc&#46; Similarly&#44; while ego-syntonia is linked to so-called &#8220;mental illness awareness&#8221;&#44; the differences and similarities remain imprecisely defined&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In general psychiatric practice&#44; ego-dystonia is mentioned in particular in the self-concept of subjects with personality disorders &#40;defining it in terms of its opposite&#44; i&#46;e&#46; ego-syntonia&#41; and subjects with obsessive-compulsive disorder &#40;OCD&#41;&#44; which is the iconic example of ego-dystonia&#46; It has been proposed that OCD be included in a wide range of disorders with the common denominator of &#8220;compulsivity&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which refers to subjects feeling passively forced into behaviours that they themselves consider undesirable&#46; This category would then include subjects with OCD&#44; Tourette syndrome&#44; substance addiction&#44; gaming and Internet use&#44; and compulsive eating&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> According to this proposal&#44; all these individuals would then be ego-dystonic for the symptoms in question&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">On the whole&#44; the latter reflection incites consideration of whether the ego-syntonia&#47;ego-dystonia dynamic might be overused &#40;when any &#8220;mental&#8221; symptom could be defined as ego-dystonic&#41; or underused &#40;when the experience qualifies only if it is accompanied by self-recrimination and intense anguish&#41;&#46; It also prompts contemplation of whether ego-syntonia is overestimated in subjects with personality disorders&#46; In any case&#44; this comment illustrates the need to optimise the definition of ego-syntonia&#47;ego-dystonia&#44; which is the subject of this essay&#46; It is also understood that conceptualisations of the self in the field of phenomenology of mental health are inextricably linked to the concepts that Freud used in 1923 to explain the self&#44; defining its functions of impulse control&#44; self-control&#44; self-recognition&#44; autonomy&#44; etc&#46;&#59; this perennially necessary discussion falls outside the scope of our essay&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Ego-dystonia and psychoanalysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Etymologically&#44; the terms &#8220;ego-syntonic&#8221; &#40;&#8220;in harmony with the ego&#8221;&#41;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and &#8220;ego-dystonic&#8221; &#40;&#8220;impulses&#44; desires and thoughts that are unacceptable or repugnant to the ego and the self&#8221;&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> are related to &#8220;ego&#8221; and &#8220;self&#8221;&#44; this term being perhaps the most Freudian in medical&#47;psychological semiology given that he coined it when he postulated his second topic&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The use of this root would seem to have its origins in the works of Johann Gottlieb Fichte&#46; In 1794&#44; taking Kant&#39;s second critique as a starting point&#44; this German philosopher stated that every being is posited by the ego&#44; which posits itself by establishing that &#8220;one whose being &#40;essence&#41; consists simply of the fact that one posits oneself as existent is the ego as an absolute subject&#46; As stated&#44; so it is&#59; and as it is&#44; so it posits itself&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> According to Lenin&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> &#8220;The world is the not-I&#44; created by our &#8216;I&#8217;&#44; said Fichte&#8221;&#46; While the dictionary of the American Psychological Association asserts that Freud coined the term &#8220;ego-syntonic&#8221; in 1914&#44; a review of the Spanish versions of the works published by Sigmund Freud in that year was inconclusive in this regard&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;13</span></a> Freud&#8217;s notion of the self &#40;<span class="elsevierStyleItalic">Selbst</span>&#41; is defined as &#8220;a restricted set of representations that make up for the subject an archaic model of the self and that functions as an actual object of love of the Self&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> As explained by the Uruguayan psychologist Lagomarsino&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> the self then refers to narcissistic object choice&#58; &#8220;The process of identification with the object produces a set of representations that the subject has of himself or herself&#59; this model will be sought in the object and dressed in narcissistic libido&#46; The beloved in the object will be the model&#44; the Self&#44; what oneself was&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> In Klein&#39;s view&#44; &#8220;&#8230;the self exists in a rudimentary form from birth&#44; but the notion of self involves the capacity to feel oneself as an animated totality&#46; This&#44; then&#44; is linked to the elaboration of the depressive position&#46; A good structuring of the self involves the possibility of recognising oneself in one&#39;s different object relationships and defence mechanisms&#44; as well as a decrease in pathological projective identification and tolerance of depressive and persecutory anxieties&#8230;&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Of course&#44; the study of the self has a long tradition in psychoanalysis&#44; but the name and postulates of Heinz Kohut are of particular importance&#46; Lagomarsino continued&#58;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> &#8220;Regarding the origin of the self&#44; Kohut suggests that every person consists of a &#8216;virtual&#8217; self which will be consolidated as a core self based on the empathetic response of the core &#39;selves&#39; of the primary self-objects&#44; which can be differentiated as follows&#58; the object-self&#44; which fulfils a mirror function&#44; and the idealised omnipotent object-self&#46; The experience of a cohesive core self is determinant of an enduring sense of identity&#46; The two poles of the &#8216;self&#8217; are determined by&#58; <span class="elsevierStyleItalic">a&#41;</span> ambitions conceived in the period of the predominance of the archaic grandiose self and <span class="elsevierStyleItalic">b&#41;</span> ideals conceived in the period of the idealised parental &#8216;imago&#8217;&#46; A stable sense of identity over time&#44; an attribute of the healthy self&#44; is established early as a result of a constant gradient of action-promoting tension between the two elements that constitute the core self&#46; In economic terms&#44; then&#44; if the tension between ambitions and ideals is properly balanced&#44; sufficient energy will be available for healthy output in the different fields of life&#46; The cohesive strength of the self will depend on two points&#58; a first point featuring a process of selective inclusion and exclusion of structures through a specific mechanism that Kohut called &#8216;transmuting internalisation&#8217;&#44; and a second point that might compensate for the failings of the first&#8230;&#8221;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">It has been seen&#44; then&#44; that for the core of psychodynamic knowledge ego-dystonia &#40;by opposition&#44; disharmony of the ego&#41; manifests with a self-response of heightened anguish and self-recrimination in view of the subject&#8217;s very individual thoughts and behavioural expressions&#44; offering evidence that ego-dystonia and ego-syntonia are situated in the self&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">From the same point of view&#44; ego-dystonia could be said to fit within the definition of guilt&#58; &#8220;a self-conscious emotion characterised by a painful evaluation of having done &#40;or thought&#41; something wrong and&#44; often&#44; by a disposition to take measures designed to undo or mitigate this wrong&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Freud&#44; Klein and many of their followers wrote about guilt&#46; Klein theorised about the existence of very early-onset guilt&#44; thus laying the groundwork for conceptualising guilt as of two types&#58; depressive guilt &#40;requires an integrated self&#41; or paranoid guilt &#40;weak and immature self&#41;&#46; In her view&#44; this paranoid guilt was mostly instinctual&#46; Perhaps the one to best illustrate the psychoanalytic approach to guilt was Leon Gringberg&#46; Chapter seven of his book <span class="elsevierStyleItalic">Culpa y depresi&#243;n&#46; Estudio psicoanal&#237;tico &#91;Guilt and Depression&#58; A Psychoanalytic Study&#93;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> distinguishes two types of guilt&#58; depressive guilt&#44; characterised by being conscious&#44; with concern for the object and the ego&#44; and manifested through feelings of grief&#44; longing and responsibility&#59; and persecutory guilt&#44; governed by the &#40;unconscious&#41; primary process and characterised by resentment&#44; despair&#44; fear and self-reproach&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ego-dystonia and cognitive psychology</span><p id="par0060" class="elsevierStylePara elsevierViewall">Cognitive psychology distinguishes two types of mental processes&#58; cognitive and metacognitive&#46; The former are&#44; in general&#44; automatic and unconscious&#44; consisting of&#44; for example&#44; how information is stored in one&#39;s memory and how one remembers such information&#46; Metacognitive mechanisms are the set of processes through which people are able to supervise&#44; manage and consciously reflect on the cognitive processes that they use to perform a given task&#46; Some metacognitive mechanisms are&#58; asking questions internally during a given procedure&#44; meditating&#44; reflecting&#44; conducting a self-assessment of strengths and weaknesses in performance&#44; being self-aware about the type of learning that one uses best &#40;visual&#44; auditory&#44; tactile or kinaesthetic&#41;&#44; using mnemonics and applying study strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the case of OCD&#44; it has been argued that deficits are present in the following cognitive processes&#58; response inhibition&#44; cognitive flexibility&#44; planning and goal-directed behaviours&#44; working memory&#44; and error monitoring&#46; Ego-dystonia in subjects with OCD&#44; as it is an evaluation of cognitive mechanisms themselves&#44; is conceived of as a sign that metacognitive processes are preserved&#44; since the subject feels that his&#47;her obsessions and&#47;or compulsions are strange and incongruous with him&#47;herself&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ego-dystonia and evolution of the species</span><p id="par0070" class="elsevierStylePara elsevierViewall">Daniel Dennet&#39;s <span class="elsevierStyleItalic">Consciousness Explained</span><a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> proposed an evolutionary pathway towards the constitution of the ego&#44; starting with the sum of two perspectives &#8212; heterophenomological and memetic &#8212; which complement one another to delineate a coherent image of the nature of the self called a &#8220;Joycean machine&#8221;&#44; understanding therefore that consciousness is composed of simple and complex elements that form a programming which incorporates the vast capacities derived from the circuital interconnection of the various brain structures&#46; What Dennet&#39;s work did not explain was why this virtual machine also produces self-recrimination in view of actions and thoughts raised only therein&#46; The answer would seem to lie in Dennet&#39;s conceptualisation of the self as feedback in this same programming&#46; However&#44; if&#44; as proposed by the North American philosopher following Robyn &#40;p&#46; 416&#41;&#44; the self is a biologically constructed network of discourses like any other construction found in the animal world&#44; what is the origin of the ego-dystonia that a subject feels when faced with thoughts or actions that are only bothersome to that subject&#63;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In 1958&#44; Spitz<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> proposed that the organisation of the Freudian mental apparatus &#40;which nothing precludes from considering analogous to Dennet&#39;s Joycean machine&#41; features an evident parallelism between the biological and the psychological and that the three moments of organisation of the psyche &#40;the social smile&#44; fear of the unknown and the appearance of language&#41;&#44; whose emergence is characterised by dependent differentiation&#44; may account for the onset of psychiatric disease based on the deformation generated in the failure of early integration of the ego&#44; but also does not raise the issue of self-recrimination in stages in which the psyche is more developed&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Individuals&#8217; interactions with themselves would seem to be key to understanding the problem of harmony or disharmony of the ego&#46; A concept intimately linked to the subject at hand is that of self&#44; which according to Owens et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> is an organised&#44; interactive system of thoughts&#44; feelings&#44; identities and motives borne of self-reflection and language that people attribute to themselves and that characterises specific human beings&#46; However&#44; this raises a problem for cognitive psychology&#44; as it is not possible to objectively distinguish as true cognitive elements the set of representations that reflect a person&#39;s personality traits&#44; organised by links&#44; through representations created by personal experience or biography because they remain forever on the subjective plane&#44; which cannot be distinguished within developmental psychology methodology&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Spitz&#44; with his psychodynamic roots&#44; was able to sidestep this problem&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Evolutionary biology&#44; for its part&#44; describes guilt as the operating mechanism in &#8220;reciprocal altruism&#8221;&#46; According to this&#44; guilt is advantageous&#44; as it limits and controls opportunistic behaviours involved in maintenance of social relationships&#59; thus&#44; guilt is adaptive and protects humans from one another&#46; According to Trivers&#44; guilt &#8220;&#8230;evidences a more enduring commitment to altruism&#44; either because guilt teaches or because the cheater is unlikely not to feel the same guilt in the future&#8230;&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Guilt has been defined by psychologists&#44; psychiatrists and clinicians as an unpleasant emotional condition associated with transgression of personal or moral rules or customs&#46; By this definition&#44; guilt can be resolved with reparation&#44; restitution or confession and forgiveness&#46; According to Shapiro et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> definitions of guilt include&#58; self-reproach and remorse for one&#39;s behaviour&#59; an impulse&#44; such as fear or anxiety&#44; that motivates compulsive responses&#59; the dysphoric feeling resulting from the realisation that one has breached a personally important moral or social standard&#59; and chronic self-blame and obsessive rumination about some objectionable or harmful behaviour&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Persecutory guilt in psychoanalysis appears to correspond to theoretical constructs closer to biological guilt versus depressive guilt&#46; In this regard&#44; Takashi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> found that certain structures are activated in evaluation with functional magnetic resonance imaging associated with the process of evaluating the moral emotions of guilt and shame&#59; these structures are the medial prefrontal cortex &#40;MPFC&#41;&#44; left superior &#40;posterior&#41; temporal sulcus &#40;STS&#41; and visual cortex&#46; It was striking that&#44; since the experiment was conducted in normal subjects presented with standardised stimuli compared to the guilt condition&#44; the shame condition caused greater activation in the right &#40;anterior&#41; temporal cortex&#44; bilateral hippocampus and visual cortex&#44; approaching the normal masochism described by Kernberg &#40;&#8220;the price paid for the integration of normal superego functions is the disposition to develop unconscious feelings of guilt when repressed childhood instinctual derivatives are activated&#8221;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#41;&#44; and did not persist as self-reproach or cause excessive distress in the experimental subjects&#46; They were feelings of guilt or shame&#44; but they were not ego-dystonic feelings&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Another feeling to take into account along with guilt as an example of ego-dystonia is shame&#44; a very unpleasant self-conscious emotion that arises from the feeling that there is something dishonourable&#44; immodest or unseemly about one&#8217;s behaviour or circumstances&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Palmero<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#44; following Damasio&#44; included shame among the secondary emotions&#44; referring to them as&#58; &#8220;chemical and neural response patterns whose function is to contribute to maintaining life in an organism by providing adaptive behaviours&#8221;&#46; It must be considered ego-dystonic&#44; since it is inconsistent with the self-concept and objectives of those who feel it accompanied by heightened anguish or self-recrimination and&#44; strikingly&#44; it must be distinguished from social shame&#44; since it is more conscious and less physiological in nature&#8221;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In an extensive review&#44; Weingarden et al&#46; found that&#44; in OCD&#44; symptom-based shame may be particularly triggered by violent&#44; sexual&#44; or blasphemous obsessions&#44; whereas in other obsessive-compulsive spectrum conditions&#44; it is triggered by compulsions&#44; beliefs or guilt&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The ego-dystonic nature of OCD raises intriguing questions about the relationship between observed behaviour and its subjective and metacognitive correlates&#46; Ego-dystonia remains unexplained within the &#8220;modal hypothesis&#8221; of deregulation of cortico-striatal-thalamo-cortical pathways and within the advances that have been made by including other structures&#44; which has broadened knowledge of these networks&#8217; essential functions&#44; interactions and regulation&#44; thus yielding the cognitive triad&#44; psychotropic drugs and surgical treatment which have demonstrated efficacy in the symptomatic treatment of the disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">However&#44; when obsessive symptoms improve with the greater or lesser success of various therapeutic strategies&#44; ego-dystonia persists as a symptom that constantly emerges in normal life&#59; this contributes to the need to delve ontologically and biologically into the problem raised&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">Ego-dystonia or a lack of harmony in the self is a complex situation characterised by a heightened response of anguish and self-recrimination that subjects feel towards themselves in view of their very much individual thoughts and behavioural expressions&#46; It takes place in what has been come to be called the self&#44; and when in a given subject it lacks an accessible psychosocial correlate that a valid interlocutor can perceive as suitable&#44; it appears to be related to deficiencies in the early organisation of the self&#46; According to this conceptualisation&#44; ego-dystonia would respond better to pharmacological interventions than to psychological interventions&#46; Cognitive analysis indicates&#44; at least in subjects with OCD&#44; that mechanisms of self-appraisal and metacognitive mechanisms are relatively intact&#44; but corrective interaction is deficient&#46; We have established a clear relationship between ego-dystonia&#44; guilt and shame&#46; The latter two emotions have been appraised from the perspective of evolutionary theory as adaptive traits&#44; since they enable social cohesion and incorporate reparative mechanisms that appear to be absent in the phenomenon of ego-dystonia&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">From a psychotherapy point of view&#44; ego-dystonia has not been addressed directly&#59; rather&#44; in general&#44; it is expected to change as the primary elements of each specific mental disorder are addressed&#46; Psychiatry and psychology will benefit from developing definitions of ego-dystonia that are operational&#44; reliable&#44; reproducible and valid&#44; such that hypotheses with respect to pathogenesis and treatment can be tested&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The ego-dystonic experience refers to the negative assessment that the subject makes of some of their thoughts or emotions&#44; in the context of a conserved state of consciousness&#44; as well as other aspects of their social and intrapersonal life that are relatively intact&#46; Ego-dystonia is a widely used construct&#44; but one that has not been defined in reasonably operational terms&#46; Perhaps this explains why it is no longer used in contemporary classifications of mental disorders such as the ICD-11 and DSM-5&#46; It is related to the awareness of the mental illness&#44; with feelings of guilt and shame&#44; but intuitively we perceive relevant differences between all these experiences&#46; Psychoanalytic theory conceives the ego-dystonic as an alteration in the early structuring of the ego&#46; Cognitive psychology conceives it as a dysfunction of the corrective mechanisms that harmonise the cognitive and the metacognitive&#46; Evolutionary theory has not addressed the issue directly&#44; but through the analysis of guilt&#44; to which it attributes a high adaptive value&#44; since it limits aggression and promotes reparative behaviours&#46; Given the importance of the concept of self-attunement&#44; it is surprising how little theoretical and empirical research there is on the subject&#44; the clarification of which could represent a considerable advance in the field of mental health&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La vivencia egodist&#243;nica se refiere a la valoraci&#243;n negativa del sujeto sobre algunos de sus pensamientos o emociones&#44; en el contexto de un estado de conciencia conservado&#44; al igual que otros aspectos de su vida social e intrapersonal que se encuentran relativamente intactos&#46; La egodiston&#237;a es un constructo ampliamente utilizado&#44; pero que no ha sido definido en t&#233;rminos razonablemente operativos&#46; Tal vez ello explica por qu&#233; ha dejado de utilizarse en la clasificaciones contempor&#225;neas de los trastornos mentales&#44; como la ICD-11 y el DSM-5&#46; Lo egodist&#243;nico se relaciona con la conciencia de enfermedad mental&#44; con los sentimientos de culpa y la verg&#252;enza&#44; pero intuitivamente percibimos diferencias relevantes entre todas estas vivencias&#46; La teor&#237;a psicoanal&#237;tica concibe lo egodist&#243;nico como una alteraci&#243;n en la estructuraci&#243;n temprana del Yo&#46; La psicolog&#237;a cognitiva lo concibe como una disfunci&#243;n de los mecanismos correctivos que armonizan lo cognitivo y lo metacognitivo&#46; La teor&#237;a evolutiva no ha abordado el tema directamente&#44; sino a trav&#233;s del an&#225;lisis de la culpa&#44; a la cual atribuye un alto valor adaptativo&#44; dado que limita la agresi&#243;n y promueve conductas reparativas&#46; Dada la importancia del concepto de egosinton&#237;a&#44; es sorprendente la escasa investigaci&#243;n te&#243;rica y emp&#237;rica sobre el tema&#44; cuyo esclarecimiento podr&#237;a representar un avance considerable en el campo de la salud mental&#46;</p></span>"
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