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.
This chapter offers a phenomenological account of impaired agency in depression. It begins by briefly considering some first-person descriptions of how depression affects the ability to act, which point to an altered "experience of free will." Although it is often assumed that we have such an experience, it is far from clear what it consists of. The chapter argues that this lack of clarity is symptomatic of looking in the wrong place. Drawing on themes in Sartre's Being and Nothingness, it is suggested that the sense of freedom associated with action is not-first and foremost-an episodic "quale" or "feeling" that is experienced as internal to the agent. Rather, it is embedded in the experienced world; my freedom appears in the guise of my surroundings. This makes better sense of what people with depression consistently describe-a diminished ability to act that is inextricable from a transformation of the experienced world. In addition to illuminating an aspect of the experience of depression, the chapter aims to illustrate something more general: how phenomenology and psychiatry can interact in a fruitful way.
This chapter aims to address two related challenges the phenomenon of depression raises for theories which present autonomy as an agency concept and an independent source of justification. The first challenge is directed at an intuitive conception of intentional agency as implying a robust though not always direct link between evaluation and motivation, for in depression what appears to be choice-worthy does not get chosen. The second challenge targets the feasibility of a reliable distinction between autonomous and non-autonomous choices, for both value-neutral and value-laden accounts of depressive agency seem open to decisive objections. Drawing on Freud's interpretation of melancholia and Korsgaard's notion of practical identity, the chapter develops a conception of paradoxical identification which helps address the two challenges described and supports a revised value-neutral account of depressive agency as being non-autonomous.
Michael A. Bishop and J. D. Trout
Psychiatric diagnosis and prognosis is fraught with important philosophical and conceptual problems. This chapter focuses on some epistemological issues (What evidence justifies the belief that a course of treatment is effective?) and moral issues (What is a just distribution of scarce psychiatric resources given the many people with psychiatric conditions whose suffering could be alleviated with treatment?) that arise in contemporary psychiatric practice. It examines various clinical and actuarial techniques for psychiatric diagnosis, ordered very loosely in terms of how "structured" or "automated" they are (or, put another way, ordered according to how much freedom the individual clinician has in carrying out the diagnostic method). The chapter makes the case for assessing psychiatric treatments with controlled experiments, raises several epistemological dangers that arise from relying on uncontrolled investigations, and considers some of the unique methodological and ethical issues that arise when trying to assess talk therapy.
Grant Gillett and Rom Harré
The discursive approach to psychiatry, taking as it does an ethological approach to the human organism, directs us to rules and story lines that structure our ways of dealing with the challenges thrown up by particular situated positions in our discursive world. For human beings this means engaging with the sense they are making of the world and the words they use to try and communicate that (to themselves and others). Doing things with words is behavior that draws on certain skills attuned to prompts, cues, expectations, and so on, all of which can go seriously awry in any setting where certain features are unfamiliar or where one of the participants is "impaired" or out of step with prevailing norms and assumptions. Discursive competence and the reality of the human psyche as a mode of being-in-relation-with others crucially depends on intact neural function and brain pathways slowly and cumulatively developed throughout life and is vulnerable to disruption of that substrate. Hysteria (or conversion disorder) and dementia represent two very different situations in which the discursive mismatch between an individual and his or her context of being causes the voice (and soul) of a person to be "lost in translation" so that understanding what is happening and then care and restoration demand a great deal of us not just as biomedical scientists but also as human beings who are reaching out to those who suffer and try to endure (patients) so as to help hold them in being.
Patrick H. DeLeon, Mary Beth Kenkel, Jill M. Oliveira Gray, and Morgan T. Sammons
Involvement in the public policy process is essential to the continued growth of the profession of psychology. The authors posit that five dimensions of involvement in the policy process are fundamental to ensuring the success of advocacy efforts: patience, persistence, the establishment of effective partnerships, emphasizing interpersonal relationships in the policy process, and the adoption of a long-term perspective. These key mediators are described in the context of current major public policy issues affecting psychology: mental health legislation in general, prescriptive authority, provision of psychological services in community health centers, expansion of the available treatments for autistic spectrum disorders, and recasting psychology as a primary health-care delivery profession. The authors suggest that policy makers will value the contributions of psychology only insofar as they are convinced of the profession’s ability to improve the public weal.
Nancy Nyquist Potter
This chapter sets out several views of empathy that draw not only on psychology's literature but on philosophical and psychiatric writings. Empathy is a set of complex concepts involving perception, emotion, attitudinal orientation, and other cognitive processes as well as an activity that expresses character traits and, hence, one of the virtues. In other words, an examination of the philosophical and clinical literature reveals empathy to be not one unified concept but instead a set of related characteristics and qualities needed to be an ethical and therapeutically effective clinician. To this end, the chapter offers reasons as to why empathy is important to clinical work: empathy is both epistemically and ethically necessary to good social relations and, in particular, clinical relations. It then distinguishes empathy from a related concept called "world"-traveling and situates its relevance to therapeutic relations. Finally it brings these ideas together by highlighting Iris Murdoch's ideas of "just vision" and "loving attention."
Jennifer Radden and Somogy Varga
This chapter argues that despite the recent, welcome interest in autobiographical writing about depression, its use for research purposes presents an epistemological challenge because the extent to which these descriptions illuminate the true nature of depressive experience cannot be discerned. Contextualized within the genre of autobiography as well as the subgenre of illness memoir (or "autopathography"), the depression memoir exhibits ambiguities, it is shown, imposed by the constraints of its genre, and by the nature of autobiographical memory. Sources of ambiguity distinctive to depression memoirs are next introduced, some tied to cultural meanings, others to the status of depressive states as constituted by moods. Finally, some empirical corroboration for these claims is cited, in findings indicating that depression affects autobiographical memory and writing style. The indeterminacy identified here is not a reason to dismiss depression memoirs, it is concluded, so much as to employ caution in drawing inferences from them.
Rehabilitation psychology is a field in flux. With roots in the early legislation to protect those injured in the course of their job or duty (or both), the field now faces those very same issues again: (welfare) legislation of health care and provision of services to those injured in the course of their job and/or duty. This chapter outlines the path from then to now, and addresses the struggles and milestones the field has faced and crossed. Finally, in an attempt to place the field in a bigger context, a modest review of rehabilitation psychology efforts around the world is presented.
This chapter explores Michel Foucault's contribution to a critical assessment of modern and contemporary psychiatric practice. It focuses firstly on the History of Madness (1961): the social, political, cultural, epistemological construction of the object "psychiatric patient" and "psychiatric pathology"; the gradual historical shift from "madness" to "psychiatric pathology" and its social and epistemological consequences; the horizons and limits of the romantic task Foucault assumes on this basis (namely, the idea of letting the voice of madness come back and speak again, "under" the language and categories of medical knowledge); the critique Jacques Derrida formulated (Writing and Difference, 1967) about this project, and particularly about Foucault's reading of Descartes. Secondly, it examines Foucault's course on Psychiatric Power (1975), focusing on the sociopolitical consequences of this medicalization process: i.e., the construction of the object "psychiatric patient" as "disciplinated bodies", and the general context of this anthropological metamorphosis Foucault studied in his books Discipline and Punish, The Will to Knowledge, and in his course Naissance de la biopolitique (namely, the shift, during the last two centuries, from a disciplinary model to a biopolitical model of power and, more specifically, of administration of mental illness and mental health).
Gail Steketee and Randy O. Frost
The history of research on hoarding behavior has been very brief, spanning only about 20 years. Accordingly, this volume provides the first comprehensive compendium of the most current research and clinical understanding of hoarding and the new formal DSM-5 (American Psychiatric Association, 2013) diagnosis of hoarding disorder (HD). This disorder is remarkable among mental health conditions for its adverse impact on sufferers, on family members, friends and neighbors, and on human service providers trying to address the housing, public health, and other needs of individuals with HD. This chapter provides commentary on recent discoveries and likely next steps in the multiple efforts to better understand, respond, and effectively intervene to resolve this complex condition. In this rapidly moving research field, our goal will be to update these chapters online in the coming years as new research comes on the scene.