Philosophical issues with respect to anxiety and its pathological variants arise at the border between everyday and clinical understanding of anxiety, between clinical and scientific approaches and between scientific concepts and the philosophical frameworks they refer to. These four ways of understanding can be seen as epistemic levels that point at different aspects and qualities of anxiety. After a brief historical introduction the three interfaces will be discussed. Philosophical questions at the interface between the first two levels (everyday understanding and clinical knowledge) relate to the issue of where to draw the boundary between normal and pathological manifestations of anxiety and of how to balance the medical view with everyday understandings of anxiety. At the interface between clinical and scientific approaches, the question arises whether scientific theories and models are adequate, more particularly, which aspects of the clinical picture can be explained by scientific theories and concepts. The third interface, between scientific concepts and the philosophical frameworks they presuppose, is the origin of debates about what belongs to science and what should be regarded as meta-theoretical or paradigmatic. To what extent does a particular scientific concept stand on its own and to what extent does it borrow from pre-theoretical and/or philosophical views?
R. Peter Hobson
In order to understand the pathogenesis of autism, one needs to have an adequate framework within which to think about the nature of typical as well as atypical early human mental development. From a complementary perspective, the study of autism may challenge our ways of thinking about the mind itself. For example, are we justified in introducing divisions among cognition, conation, and affect in characterizing early development? What is the epistemological basis for children's understanding of others' minds? How should we think about the origins of and basis for symbolic functioning? This chapter explores the relevance of philosophy for our accounts of autism, highlighting the importance of ideas from Wittgenstein and Strawson in particular, and illustrates fresh ways in which autism might contribute to debates in philosophy of mind.
Katherine J. Morris
This chapter examines so-called body image disorders, focusing on body dysmorphic disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder. These disorders have been studied extensively by psychologists and psychiatrists from both the "body image" and "body shame" research orientations. Body image disorders have also proved, for feminist thinkers mindful of the gender imbalance in many of these disorders, to be an important locus for cultural criticism, including criticism of psychological and psychiatric perspectives. Those philosophers and anthropologists with a phenomenological bent, particularly those with an interest in the lived body and embodiment, have also found a fruitful terrain in body image disorders. These different disciplines and approaches provide multiple perspectives which are often complementary, occasionally in some tension with one another, but always mutually enriching, and all of them are sketched here.
Many psychiatric disorders involve problems with the recognition and preservation of personal boundaries. Philosophy can help to clarify what is at stake, both socially and phenomenologically, in drawing such boundaries. In particular, assignments of responsibility and determinations of loss are deeply implicated in the determination of personal boundaries. Understanding these implications can help make sense of the volatile emotions of borderline personality disorder, for example, and it can clarify what is missing from DSM descriptions more generally.
This chapter contrasts the recent emphasis on operationalism as the route to reliability in psychiatry with arguments for an ineliminable role for tacit knowledge. Although Michael Polanyi popularized the idea of tacit dimension, the chapter argues that two clues he offers as to its nature-that we know more than we can tell and that knowledge is an active comprehension of things known-are better interpreted through regress arguments set out by Ryle and Wittgenstein. Those arguments, however, suggest that tacit knowledge is not inexpressible but merely inexpressible in context-free terms. The chapter suggests instead that tacit knowledge is best understood to be context-dependent practical knowledge. So understood, the regress arguments suggest that the operational approach to psychiatric diagnosis can never free itself from a tacit dimension. Given that claim, then Parnas' opposing view of diagnosis can be seen as a way to embrace, rather than deny, the importance of tacit knowledge and skilled clinical judgment for psychiatry.
Matthew Broome, Paolo Fusar-Poli, and Philippe Wuyts
Our focus in this chapter is to address some of the philosophical issues that arise in the scientific and clinical study of the prodromal phase of psychosis. We discuss issues from both metaphysics and philosophy of science as we all as those related to phenomenological approaches and clinical ethics. A clear challenge arises in considering how models of a continuum of psychosis and of schizophrenia as a neurodevelopmental disorder can be reconciled with a scientific understanding of the prodrome as a discrete constellation of signs and symptoms. Clinical and research work on the prodromal stage of psychosis also highlights ethical concerns. Demarcating a mental disorder and applying therapeutic interventions, based solely on risk estimation, should not be carried out lightly.
This chapter briefly discusses the history of the notion of "cure" in relation to serious mental illnesses from Pinel to the present day, including both theories on the nature of the illnesses and the nature of presumed therapeutic agents and mechanisms. The chapter then gives a brief overview of the notion of "recovery" in relation to serious mental illnesses, also from Pinel to the present day, and describes various definitions and forms of recovery as they have emerged over time. With this historical and conceptual background in place, the chapter then takes up the present state-of-the-art in psychiatry in relation to both concepts of cure and recovery, considers the empirical and neuroscientific evidence available relative to each concept, and then suggests several directions for research and philosophical reflection as the field continues to evolve. Two guiding principles that shape this discussion are that mental illnesses are not one-dimensional phenomena, but may be made up of several loosely related components which each have their own natural course, and that mental illnesses do not typically take over the entirety of a person's functioning, but also leave other aspects of functioning relatively intact. The combination of these principles suggests that cure and recovery are not likely to be binary functions in relation to serious mental illnesses (i.e., yes or no), but will more likely be more a matter of degree across multiple domains.
Louis A. Sass and Elizabeth Pienkos
This chapter offers an overview of the phenomenological approach to delusions, emphasizing what Karl Jaspers called the "true delusions" of schizophrenia. Phenomenological psychopathology focuses on the experience of delusions and the delusional world. Several features of this approach are surveyed, including emphasis on formal qualities of subjective life (e.g., mutations of time, space, causality, self-experience, or sense of reality) and questioning of standard assumptions about delusions as erroneous belief (the traditional doxastic view, or "poor reality-testing" formula). The altered modalities of world-oriented and self-oriented experience that precede and ground delusions in schizophrenia, especially the experiences of revelation that Klaus Conrad termed the outer and inner apophany, are then discussed. The chapter first considers the famous "delusional mood" (feelings of strangeness and tension, and a sense of tantalizing yet ineffable meaning ), then the role of ipseity-disturbance (altered minimal or core self, of the basic, pre-reflective sense of existing as a unified and vital subject of experience). In both cases it is explained how delusions can develop out of these distinctive alterations of perception and feeling. The classic question of the understandability or comprehensibility of schizophrenic delusion, together with the related issues of wish-fulfillment and rationalizing motives are then considered. The chapter addresses the crucial but neglected issue of the felt reality-status of delusions or the delusional world, discussing derealization, "double bookkeeping" (in which the patient experiences delusional reality as existing in a different ontological domain from everyday reality), and "double exposure" (merging of two perspectives on reality, with the potential for confusion this implies). The chapter concludes by discussing delusions typically found in paranoid and affective psychoses, and monothematic delusions found in certain organic conditions.
Martin Davies and Andy Egan
Cognitive approaches contribute to our understanding of delusions by providing an explanatory framework that extends beyond the personal level to the sub personal level of information-processing systems. According to one influential cognitive approach, two factors are required to account for the content of a delusion, its initial adoption as a belief, and its persistence. This chapter reviews Bayesian developments of the two-factor framework.
Julian C. Hughes
Dementia is dead, long live aging! This chapter sets out the philosophical sources for understanding working with "dementia." The concept, "dementia," serves no useful purpose. Even "Alzheimer's disease" turns out to be problematic. This is because there is a lack of precision around the boundaries of these notions. The messiness that surrounds these notions, in terms of facts and values, is made obvious when we consider mild cognitive impairment, which is said to be a pre-dementia state. It makes more biological sense to think in terms of the ageing brain, rather than to search for discrete disease entities. We need to think in terms of dementia-in-the-world. Ageing is not something that we do solely at the end of our lives: it is a part of our lives, to be celebrated. We must look more broadly at dementia-in-the-world as a (biological, psychological, social, and spiritual) feature of our ageing lives.