"Never Land": Where do imaginary worlds come from?

We assume "Imaginary worlds" to be unreal and unfamiliar: high fantasy. I argue they are real and familiar to authors because they comprise memory elements, which blend experience, knowledge, beliefs and pre-occupations. These "bits and pieces" from memories can generate a world, which readers experience as pure imagination. I illustrate using J.M. Barrie's "Never Land" and J.R.R. Tolkien's "Middle-Earth."

Correction to: Facilitating the implementation of clinical technology in healthcare: what role does a national agency play?

Upon publication of the original article [1], Gregory Maniatopoulos' name was incorrectly given as 'Greg Maniatopoulous'. This has now been corrected in the original article.

Facilitating the implementation of clinical technology in healthcare: what role does a national agency play?

BACKGROUND: Accelerating the implementation of new technology in healthcare is typically complex and multi-faceted. One strategy is to charge a national agency with the responsibility for facilitating implementation. This study examines the role of such an agency in the English National Health Service. In particular, it compares two different facilitation strategies employed by the agency to support the implementation of insulin pump therapy. METHODS: The research involved an empirical case study of four healthcare organisations receiving different levels of facilitation from the national agency: two received active hands-on facilitation; one was the intended recipient of a more passive, web-based facilitation strategy; the other implemented the technology without any external facilitation. The primary method of data collection was semi-structured qualitative interviews with key individuals involved in implementation. The integrated-PARIHS framework was applied as a conceptual lens to analyse the data. RESULTS: The two sites that received active facilitation from an Implementation Manager in the national agency made positive progress in implementing the technology. In both sites there was a high level of initial receptiveness to implementation. This was similar to a site that had successfully introduced insulin pump therapy without facilitation support from the national agency. By contrast, a site that did not have direct contact with the national agency made little progress with implementation, despite the availability of a web-based implementation resource. Clinicians expressed differences of opinion around the value and effectiveness of the technology and contextual barriers related to funding for implementation persisted. The national agency's intended roll out strategy using passive web-based facilitation appeared to have little impact. CONCLUSIONS: When favourable conditions exist, in terms of agreement around the value of the technology, clinician receptiveness and motivation to change, active facilitation via an external agency can help to structure the implementation process and address contextual barriers. Passive facilitation using web-based implementation resources appears less effective. Moving from initial implementation to wider scale-up presents challenges and is an issue that warrants further attention.

Crossing the invisible line: De-differentiation of wake, sleep and dreaming may engender both creative insight and psychopathology.

Writing about dreaming, the poet Raymond Carver said "I feel as if I've crossed some kind of invisible line". In creative people, the "line" between wake, dreaming and psychopathology may be porous, engendering a de-differentiated, super-critical, hybrid state. Evidence exists for a relationship between creativity and psychopathology but its nature has been elusive. De-differentiation between wake, sleep and dreaming may be the common substrate, as dream-like cognition pervades wake and wake-like neurophysiology suffuses sleep. Chaos theory posits brain states as inherently labile, transient and dynamically unstable. Over and above transient dissociations, an enduring and, sometimes, progressive, de-differentiation may be possible. Evidence indicates that sleep and dreaming facilitate creative insight. In consequence, a mild to moderate form of de-differentiation may enhance creativity but if wake-like neurobiology permeates sleep this may disrupt sleep-dependent memory processing and emotional regulation. If de-differentiation is progressive and enduring, various forms of psychopathology may result.

Reconsolidation or re-association?

The target article argues memory reconsolidation demonstrates how therapeutic change occurs, grounding psychotherapy in brain science. However, consolidation has become an ambiguous term, a disadvantage applying also to its derivative - reconsolidation. The concept of re-association (involving active association between memories during rapid eye movement [REM] dreams followed by indexation and network junction instantiation during non-rapid eye movement [NREM] periods) brings greater specificity and explanatory power to the possible brain correlates of therapeutic change.

Not only but also: REM sleep creates and NREM Stage 2 instantiates landmark junctions in cortical memory networks.

This article argues both rapid eye movement (REM) and non-rapid eye movement (NREM) sleep contribute to overnight episodic memory processes but their roles differ. Episodic memory may have evolved from memory for spatial navigation in animals and humans. Equally, mnemonic navigation in world and mental space may rely on fundamentally equivalent processes. Consequently, the basic spatial network characteristics of pathways which meet at omnidirectional nodes or junctions may be conserved in episodic brain networks. A pathway is formally identified with the unidirectional, sequential phases of an episodic memory. In contrast, the function of omnidirectional junctions is not well understood. In evolutionary terms, both animals and early humans undertook tours to a series of landmark junctions, to take advantage of resources (food, water and shelter), whilst trying to avoid predators. Such tours required memory for emotionally significant landmark resource-place-danger associations and the spatial relationships amongst these landmarks. In consequence, these tours may have driven the evolution of both spatial and episodic memory. The environment is dynamic. Resource-place associations are liable to shift and new resource-rich landmarks may be discovered, these changes may require re-wiring in neural networks. To realise these changes, REM may perform an associative, emotional encoding function between memory networks, engendering an omnidirectional landmark junction which is instantiated in the cortex during NREM Stage 2. In sum, REM may preplay associated elements of past episodes (rather than replay individual episodes), to engender an unconscious representation which can be used by the animal on approach to a landmark junction in wake.

Moving beyond local practice: reconfiguring the adoption of a breast cancer diagnostic technology.

This paper explores the ways in which technological innovation becomes adopted and incorporated into healthcare practice. Drawing upon the notion of 'field of practices', we examine how adoption is subject to spatially and temporally distributed reconfigurations across a multi-level set of practices, ranging from the policy level to the micro-level setting of individual action. The empirical backdrop is provided by a case study of the adoption of Breast Lymph Node Assay (BLNA), a diagnostic technology innovation for the treatment of breast cancer patients. Our aim is to contribute to the development of a more comprehensive analysis of the processes surrounding the adoption and incorporation of complex healthcare technologies into routine practice.

Dream to Predict? REM Dreaming as Prospective Coding.

The dream as prediction seems inherently improbable. The bizarre occurrences in dreams never characterize everyday life. Dreams do not come true! But assuming that bizarreness negates expectations may rest on a misunderstanding of how the predictive brain works. In evolutionary terms, the ability to rapidly predict what sensory input implies-through expectations derived from discerning patterns in associated past experiences-would have enhanced fitness and survival. For example, food and water are essential for survival, associating past experiences (to identify location patterns) predicts where they can be found. Similarly, prediction may enable predator identification from what would have been only a fleeting and ambiguous stimulus-without prior expectations. To confront the many challenges associated with natural settings, visual perception is vital for humans (and most mammals) and often responses must be rapid. Predictive coding during wake may, therefore, be based on unconscious imagery so that visual perception is maintained and appropriate motor actions triggered quickly. Speed may also dictate the form of the imagery. Bizarreness, during REM dreaming, may result from a prospective code fusing phenomena with the same meaning-within a particular context. For example, if the context is possible predation, from the perspective of the prey two different predators can both mean the same (i.e., immediate danger) and require the same response (e.g., flight). Prospective coding may also prune redundancy from memories, to focus the image on the contextually-relevant elements only, thus, rendering the non-relevant phenomena indeterminate-another aspect of bizarreness. In sum, this paper offers an evolutionary take on REM dreaming as a form of prospective coding which identifies a probabilistic pattern in past events. This pattern is portrayed in an unconscious, associative, sensorimotor image which may support cognition in wake through being mobilized as a predictive code. A particular dream illustrates.

Such stuff as dreams are made on? Elaborative encoding, the ancient art of memory, and the hippocampus.

This article argues that rapid eye movement (REM) dreaming is elaborative encoding for episodic memories. Elaborative encoding in REM can, at least partially, be understood through ancient art of memory (AAOM) principles: visualization, bizarre association, organization, narration, embodiment, and location. These principles render recent memories more distinctive through novel and meaningful association with emotionally salient, remote memories. The AAOM optimizes memory performance, suggesting that its principles may predict aspects of how episodic memory is configured in the brain. Integration and segregation are fundamental organizing principles in the cerebral cortex. Episodic memory networks interconnect profusely within the cortex, creating omnidirectional "landmark" junctions. Memories may be integrated at junctions but segregated along connecting network paths that meet at junctions. Episodic junctions may be instantiated during non-rapid eye movement (NREM) sleep after hippocampal associational function during REM dreams. Hippocampal association involves relating, binding, and integrating episodic memories into a mnemonic compositional whole. This often bizarre, composite image has not been present to the senses; it is not "real" because it hyperassociates several memories. During REM sleep, on the phenomenological level, this composite image is experienced as a dream scene. A dream scene may be instantiated as omnidirectional neocortical junction and retained by the hippocampus as an index. On episodic memory retrieval, an external stimulus (or an internal representation) is matched by the hippocampus against its indices. One or more indices then reference the relevant neocortical junctions from which episodic memories can be retrieved. Episodic junctions reach a processing (rather than conscious) level during normal wake to enable retrieval. If this hypothesis is correct, the stuff of dreams is the stuff of memory.

The practice of commissioning healthcare from a private provider: learning from an in-depth case study.

BACKGROUND: The direction of health service policy in England is for more diversification in the design, commissioning and provision of health care services. The case study which is the subject of this paper was selected specifically because of the partnering with a private sector organisation to manage whole system redesign of primary care and to support the commissioning of services for people with long term conditions at risk of unplanned hospital admissions and associated service provision activities. The case study forms part of a larger Department of Health funded project on the practice of commissioning which aims to find the best means of achieving a balance between monitoring and control on the one hand, and flexibility and innovation on the other, and to find out what modes of commissioning are most effective in different circumstances and for different services. METHODS: A single case study method was adopted to explore multiple perspectives of the complexities and uniqueness of a public-private partnership referred to as the "Livewell project". 10 single depth interviews were carried out with key informants across the GP practices, the PCT and the private provider involved in the initiative. RESULTS: The main themes arising from single depth interviews with the case study participants include a particular understanding about the concept of commissioning in the context of primary care, ambitions for primary care redesign, the importance of key roles and strong relationships, issues around the adoption and spread of innovation, and the impact of the current changes to commissioning arrangements. The findings identified a close and high trust relationship between GPs (the commissioners) and the private commissioning support and provider firm. The antecedents to the contract for the project being signed indicated the importance of leveraging external contacts and influence (resource dependency theory). CONCLUSIONS: The study has surfaced issues around innovation adoption in the healthcare context. The case identifies 'negotiated order', managerial performance of providers and disciplinary control as three media of power used in combination by commissioners. The case lends support for stewardship and resource dependency governance theories as explanations of the underpinning conditions for effective commissioning in certain circumstances within a quasi marketised healthcare system.

If waking and dreaming consciousness became de-differentiated, would schizophrenia result?

If both waking and dreaming consciousness are functional, their de-differentiation would be doubly detrimental. Differentiation between waking and dreaming is achieved through neuromodulation. During dreaming, without external sensory data and with mesolimbic dopaminergic input, hyper-cholinergic input almost totally suppresses the aminergic system. During waking, with sensory gates open, aminergic modulation inhibits cholinergic and mesocortical dopaminergic suppresses mesolimbic. These neuromodulatory systems are reciprocally interactive and self-organizing. As a consequence of neuromodulatory reciprocity, phenomenologically, the self and the world that appear during dreaming differ from those that emerge during waking. As a result of self-organizing, the self and the world in both states are integrated. Some loss of self-organization would precipitate a degree of de-differentiation between waking and dreaming, resulting in a hybrid state which would be expressed heterogeneously, both neurobiologically and phenomenologically. As a consequence of progressive de-differentiation, certain identifiable psychiatric disorders may emerge. Ultimately, schizophrenia, a disorganized-fragmented self, may result.

In two minds? Is schizophrenia a state 'trapped' between waking and dreaming?

This paper proposes that schizophrenia is a state of mind/brain 'trapped' in-between waking and dreaming. Furthermore, it suggests that both waking and dreaming are functional. An in-between state would be disordered; neither waking nor dreaming would function properly, as the mind/brain would be attempting two, ultimately incompatible, sets of tasks simultaneously. In support of this hypothesis, evidence is synthesised across four different domains: the chemistry of the dreaming state; work on dreaming as functional for memory; the membrane theory of schizophrenia; and chaos theory. The brain produces itself; self-organizing through its modulatory systems. Differentiation between dreaming and waking is achieved through aminergic/cholinergic/dopaminergic reciprocity. Chaos theory indicates that self-organizing systems function most creatively on the 'edge of chaos'; a state which lies between order and disorder. In the mind/brain 'order' represents rigid differentiation between waking and dreaming, whereas 'disorder' results from their interpenetration. How could the latter occur? In sum, the causal sequence would be as follows. Genetic susceptibility to schizophrenia is expressed through fatty acid deficiencies which precipitate neuronal cell membrane abnormalities. In consequence, all neurotransmitter systems become disrupted. Ultimately, the reciprocal interaction between aminergic/cholinergic neuromodulation breaks down. Disrupted cholinergic input interferes with the reciprocal relationship between mesolimbic and mesocortical dopaminergic systems. Loss of reciprocity between aminergic, cholinergic and dopaminergic neuromodulation results in chronic interpenetration; a 'trapped' state, in-between waking and dreaming results. This would be 'schizophrenia'. Currently, imaging techniques do not capture dynamic neuromodulation, so this hypothesis cannot yet be tested inductively. However, the paper suggests that further evidence would be gained through a closer attention to the phenomenology of schizophrenia in the waking and dreaming states.

Is 'bipolar disorder' the brain's autopoietic response to schizophrenia?

Evidence is accumulating that schizophrenia and bipolar disorder are related conditions. This paper proposes a particular form of relatedness. If 'schizophrenia' is a mind/brain 'trapped' between waking and dreaming, in a disordered in-between state, then bipolar 'disorder' could actually be an attempt to restore order. The mind/brain is a self-producing, self-organizing system. Autopoiesis applies to such systems. Neuromodulation accomplishes self-organization in the mind/brain. If schizophrenia is a state in-between waking and dreaming, characterized by aminergic/cholinergic interpenetration and dopaminergic imbalance then bipolar 'disorder' could be a modulatory response. This autopoietic reaction may take the form of either aminergic hyperactivity aimed at producing a purer waking state, (precipitating mania in the waking state), or cholinergic hyperactivity aimed at producing a purer dreaming state, (producing depression in the waking state), or both, resulting in rapid cycling bipolar disorder. Thus bipolar activity may be an autopoietic response aimed at restoring differentiation to the in-between state of schizophrenia.