The topic of this Oxford handbook is “4E cognition”: cognition as embodied, embedded, enactive, and extended. However, one important “E” is missing: an E for ecological. We sketch an ecological-enactive approach to cognition that presents a framework for bringing together the embodied/enactive program with the ecological program originally developed by James Gibson, in which affordances are central. We call this framework the skilled intentionality framework. The skilled intentionality framework is a philosophical approach to understanding the situated and affective embodied mind. It is a new conceptual framework for the field of 4E cognitive science that focuses on skilled action and builds upon an enriched notion of affordances. We define skilled intentionality as the selective engagement with multiple affordances simultaneously in a concrete situation. The skilled intentionality framework clarifies how complementary insights on affordance responsiveness from philosophy/phenomenology, ecological psychology, emotion psychology, and neurodynamics hang together in an intertwined way.

Objectives Deep brain stimulation (DBS) is an innovative and effective treatment for patients with therapy‐refractory obsessive–compulsive disorder (OCD). DBS offers unique opportunities for personalized care, but no guidelines on how to choose effective and safe stimulation parameters in patients with OCD are available. Our group gained relevant practical knowledge on DBS optimization by treating more than 80 OCD patients since 2005, the world's largest cohort. The article's objective is to share this experience. Materials and Methods We provide guiding principles for optimizing DBS stimulation parameters in OCD and discuss the neurobiological and clinical basis. Results Adjustments in stimulation parameters are performed in a fixed order. First, electrode contact activation is determined by the position of the electrodes on postoperative imaging. Second, voltage and pulse width are increased stepwise, enlarging both the chance of symptom reduction and of inducing side effects. Clinical evaluation of adjustments in stimulation parameters needs to take into account: 1) the particular temporal sequence in which the various OCD symptoms and DBS side‐effects change; 2) the lack of robust response predictors; 3) the limited sensitivity of the Yale‐Brown Obsessive–Compulsive Scale to assess DBS‐induced changes in OCD symptoms; and 4) a patient's fitness for additional cognitive‐behavioral therapy (CBT). Conclusions Decision‐making in stimulation parameter optimization needs to be sensitive to the particular time‐courses on which various symptoms and side effects change.

Clinical outcome of deep brain stimulation (DBS) for obsessive-compulsive disorder (OCD) shows robust effects in terms of a mean Yale-Brown Obsessive-Compulsive Scale (YBOCS) reduction of 47.7 % and a mean response percentage (minimum 35 % YBOCS reduction) of 58.2 %. It appears that most patients regain a normal quality of life (QoL) after DBS. Reviewing the literature of the last 4 years, we argue that the mechanisms of action of DBS are a combination of excitatory and inhibitory as well as local and distal effects. Evidence from DBS animal models converges with human DBS EEG and imaging findings, in that DBS may be effective for OCD by reduction of hyperconnectivity between frontal and striatal areas. This is achieved through reduction of top-down-directed synchrony and reduction of frontal low-frequency oscillations. DBS appears to counteract striatal dysfunction through an increase in striatal dopamine and through improvement of reward processing. DBS affects anxiety levels through reduction of stress hormones and improvement of fear extinction.

BackgroundDeep brain stimulation (DBS) is an innovative treatment for severe obsessive-compulsive disorder (OCD). Electrodes implanted in specific brain areas allow clinicians to directly modulate neural activity. DBS affects symptomatology in a completely different way than established forms of treatment for OCD, such as psychotherapy or medication.ObjectiveTo understand the process of improvement with DBS in patients with severe OCD.MethodsBy means of open-ended interviews and participant observation we explore how expert clinicians involved in the post-operative process of DBS optimization evaluate DBS effects.ResultsEvaluating DBS effect is an interactive and context-sensitive process that gradually unfolds over time and requires integration of different sources of knowledge. Clinicians direct DBS optimization toward a critical point where they sense that patients are being moved with regard to behavior, emotion, and active engagement, opening up possibilities for additional cognitive behavioral therapy (CBT).DiscussionBased on the theoretical framework of radical embodied cognitive science (RECS), we assume that clinical expertise manifests itself in the pattern of interaction between patient and clinician. To the expert clinician, this pattern reflects the patient’s openness to possibilities for action (“affordances”) offered by their environment. OCD patients’ improvement with DBS can be understood as a change in openness to their environment. The threshold for patients to engage in activities is decreased and a broader range of daily life and therapeutic activities becomes attractive. Movement is improvement.