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date: 10 April 2020

Introduction: Descriptive Psychopathology

Abstract and Keywords

Following on from Section IV on summoning concepts, this section of the Handbook presents theoretically informed descriptions of psychopathologies. The topics of the chapters range from anxiety, depression, and body image disorders, through emotion and affective disorders, to delusion, thought insertion, and the fragmentation of consciousness. These phenomena call, not only for assessment and diagnosis (see Section VI), but also for understanding on the part of both the engaged clinician and the philosophical commentator. They also provide case studies for general philosophical questions about different levels of description and conceptualisation and the relationships between them, and about the contributions to psychological understanding that are made by phenomenology, clinical expert knowledge, and the sciences of the mind.

Keywords: affectivity, anxiety, body image disorders, cognitive impairments, delusion, depression, emotion, experience of freedom, phenomenology, thought insertion, unity of consciousness

With concepts summoned and at hand, we are ready for theoretically informed descriptions of psychopathologies. This section begins with anxiety, depression, and body image disorders, and moves on through emotion and affective disorders, to delusion, thought insertion, and the fragmentation of consciousness. These phenomena call, not only for assessment and diagnosis, but also for understanding on the part of both the engaged clinician and the philosophical commentator. They also provide case studies for general philosophical questions about different levels of description and conceptualization and the relationships between them, and about the contributions to psychological understanding that are made by phenomenology, clinical expert knowledge, and the sciences of the mind.

In Chapter 35 on anxiety and phobias, Gerrit Glas distinguishes four levels of conceptualization—the level of everyday psychological understanding, and the clinical, scientific, and philosophical levels. Following a brief history of the concept of anxiety, from Hippocrates to the present day, he discusses issues that arise at the interfaces between adjacent levels. At the interface between the everyday and clinical levels of understanding, there are very general issues about the nature of clinical understanding itself and more specific questions about the patient’s and the clinician’s relationships to the patient’s disorder and, particularly, about the way in which the disorder itself and the patient’s own personality influence the patient’s relationship with his disorder. At the interface between the clinical and scientific levels, there are again general issues, concerning the contributions made by clinical expert knowledge and scientific theoretical insight, and the existence of upward explanatory gaps between scientific theory and clinical phenomena. There are also questions about classification and Glas reviews recent discussions of dimensional versus categorical approaches, particularly as these apply to anxiety. At the interface between scientific and philosophical understanding, the major research programs—evolutionary, behavioral, cognitive—in the scientific study of anxiety come into contact with questions in the philosophy of emotion, such as whether emotions are natural kinds. Glas concludes by reviewing recent work on the subjective experience or phenomenology of emotion and commends an “embodied, embedded, and enactive” perspective.

(p. 548) Matthew Ratcliffe offers a phenomenological account of impaired agency in depression in Chapter 36. People with depression describe a change, a diminution, in the subjective experience or phenomenology of free will but, in order to understand this loss, we first need to characterize the normal, intact phenomenology of free will or agency. Ratcliffe argues that the experience of free will is not a quale that accompanies actions of a special kind, such as those preceded by considerable reflective decision-making. Rather, all our actions are experienced as free. Adopting the embodied, embedded, and enactive perspective, and drawing on Husserl and the notion of perceptual expectation, Ratcliffe proposes that normal perception presents possibilities, including possibilities for action, and that this perception of worldly possibility is intertwined with our experience of embodiment. Drawing on Sartre, he proposes that the experience of freedom is integral to the experienced world, shaped by our projects, and inextricable from bodily phenomenology. With this characterization of the normal sense of freedom, it is possible to interpret the change in the experience of free will that is described by people with depression as a change in their experience of the world. Their perceptual experience no longer presents a world of possibilities for action.

Completing this first trio of chapters, Katherine Morris (Chapter 37) examines body image disorders, particularly body dysmorphic disorder, anorexia nervosa, bulimia nervosa, and binge eating disorder. She focuses on attempts to understand these disorders from three perspectives: psychology and psychiatry, feminism, and phenomenology. First, Morris briefly reviews research in the “body image” tradition, where body image is conceived as individuals’ own subjective experiences of their appearance, and she notes that, consistent with this conception, this research downplays social and cultural factors. Research in the “body shame” tradition, in contrast, accords a central role to social and cultural factors and, in this respect, it promises a better understanding. Second, many body image disorders exhibit a strong gender asymmetry and feminists go beyond the “body shame” tradition, to provide critiques of cultures. These critiques contribute to understanding of the social and cultural conditions in which body image disorders thrive but, in common with work in the “body image” and “body shame” traditions, they do not contribute as much to an understanding of the embodied experience of individuals suffering from these disorders. Third, that deficit is made good by phenomenological philosophers who describe body dysmorphic disorder in Sartrean terms, with particular attention to shame and alienation, and anorexia in terms of abjection. Overall, Morris judges that the body image approach is in the grip of scientism and unlikely to contribute to understanding, that the body shame approach is an improvement and provides models that shed some light on the persistence of body image disorders, and that the feminist cultural critical and phenomenological approaches are potentially complementary and together contribute to understanding of individuals with body image disorders.

In Chapter 38, Thomas Fuchs is concerned that understanding of affective disorders is impeded by the lack of an adequate account of affectivity itself. Rejecting traditional psychodynamic approaches, contemporary cognitive models, and the heritage of Cartesian dualism, he offers a phenomenological account of emotions and the field of affectivity more generally. The dominant idea is that affectivity is an ineliminable aspect of our embodied experience, giving meaning to our environment. Fuchs begins with the example of vital feelings—the feeling of being alive, the loss of which may lead to the conclusion that one has died, the Cotard delusion—and then moves on to existential feelings, which are divided into three categories. Elementary existential feelings include the feeling of being alive, and feelings (p. 549) of meaningfulness and significance; general existential feelings include feeling healthy or ill, strong or weak, alert or indifferent; and social existential feelings include the feeling of connectedness and the feeling of familiarity, the loss of which may lead to the conclusion that familiar people have been replaced by impostors, the Capgras delusion. The chapter continues through affective atmospheres and moods to emotions. Here, Fuchs describes four aspects of emotions: affective intentionality, which is a distinctive kind of intentionality in being evaluative; bodily resonance; action tendency; and functions and significance—emotions interrupt us, inform us, give meaning to a situation, and make us ready to act, and also have an expressive function. These aspects are brought together in an “embodied and extended” concept of emotions, in line with a general view of affects as connecting body, self, and world.

In Chapter 39 on the phenomenological approach to delusions, Louis Sass and Elizabeth Pienkos focus on what Karl Jaspers called the “true delusions” of schizophrenia. They begin by highlighting five features of the approach: the phenomenologist is interested in understanding what it is like to have a delusion; emphasizes the form, rather than the content, of the experience; appreciates the heterogeneity of delusional experience; questions the assumption that a delusion is best understood as a false belief; and recognizes the inherent difficulty in describing delusion in schizophrenia. Sass and Pienkos propose that, although Jaspers regarded true or primary delusions as un-understandable and beyond the scope of empathy, the phenomenological approach offers, not only description, but also understanding and even explanation. They begin with the delusional mood or pre-delusional state, which is characterized by feelings of change, strangeness, and elusive meaning and the sense that objects have become detached from their natural perceptual context. In this state, the patient may experience the external world both as inauthentic and as referring to himself. These changes in the patient’s experience of the world are accompanied by changes in his experience of himself, his body, his thoughts, and his stream of consciousness, such as feelings of estrangement from his body. Sass and Pienkos describe how delusions of persecution, alien control, or non-existence or, as they put it, “entry into a delusional world,” develop as making some sense of the patient’s anomalous experience of self and world. Later in the chapter, they explore the idea of double bookkeeping—that delusions do not involve straightforwardly false claims about shared external reality and that the patient experiences his delusional world as having a status analogous to an imagined or dreamt world.

Johannes Roessler begins Chapter 40 about thought insertion by setting out an inconsistent triad, three plausible claims that cannot all be true. The first is a claim about introspective awareness: to be introspectively aware of a current episode of thinking that p is to be aware of oneself thinking that p (Transparency). The second is a claim about thought insertion: patients with the delusion of thought insertion believe that someone else is the thinker of an episode of thinking of which they are introspectively aware (Alienation). And the third is a claim about the rational intelligibility of beliefs: reports of thought insertion express rationally intelligible coherent beliefs (Intelligibility). In the philosophical literature on thought insertion, the standard response to the tension between these three claims has been to weaken Transparency by distinguishing between two concepts of the ownership of one’s own thoughts. In principle, one can be introspectively aware of an episode of thinking as occurring in one’s own mind without being aware that one is the agent or author of the thought. Thus, what patients believe is not beyond the bounds of rational intelligibility. Roessler rejects this standard response and, in particular, rejects recent proposals for developing a notion of agentive ownership for which Transparency would not hold. He argues (p. 550) that, instead of questioning Transparency, we should question the idea that schizophrenic delusions are to be understood as patients’ rationally intelligible descriptions of abnormal experiences. Nevertheless, Intelligibility should not be discarded altogether and the delusion of thought insertion can be understood as the delusional transformation of a rationally intelligible precursor belief.

In Chapter 41 on the disunity of consciousness, Tim Bayne addresses the question whether consciousness is fragmented, rather than unified, in psychiatric disorders. He begins by distinguishing three aspects of the unity of consciousness: intentional, subjective, and phenomenal. Intentional unity is the integration of conscious mental states with each other; subjective unity is a subject’s capacity to be aware of her conscious mental states as her own; phenomenal unity is the existence of a single total conscious state that encompasses each of a subject’s conscious states at a time. Are any of these aspects of unity lost in psychiatric disorders? Bayne considers anosognosia, schizophrenia, and dissociative identity disorder. In anosognosia, the patient does not make appropriate use of available evidence to revise her belief that she can still move her arm (which is, in fact, paralyzed). This is a failure of integration or intentional unity. Since some of the available evidence is provided by her own experience of the consequences of motoric failure, it is also plausible that there is a breakdown of subjective unity. But, Bayne argues, even the phenomenon of “dim knowledge” (a patient’s implicit appreciation of her impairment) does not show that anosognosia involves a breakdown of the phenomenal unity of consciousness. This pattern generalizes. Thought disorder involves a breakdown of intentional unity and it is plausible that thought insertion compromises subjective unity. But there is no reason to deny that phenomenal unity is preserved in patients with schizophrenia. Even in the case of dissociative identity disorder, there is no compelling case for the claim that it involves phenomenal disunity. Overall, even in psychiatric disorders, the phenomenal aspect of the unity of consciousness is preserved.

In the final chapter in this section, Chapter 42 on cognitive approaches to delusion, Martin Davies and Andy Egan focus on the two-factor framework for explaining delusions, which has mainly been applied to monothematic delusions of neuropsychological origin. The first factor in the etiology of a delusion is a neuropsychological deficit from which the content of the delusion arises in some plausible way. The second factor is supposed to explain why the delusional belief is not rejected, but Davies and Egan point to some unclarity surrounding its role. Does it explain why a hypothesis that is related to the neuropsychological deficit is initially adopted as a belief, rather than being rejected, or why the initially adopted belief persists, rather than being subsequently rejected? They show that it is difficult to find a role for a pathological factor in an explanation of persistence because, on standard Bayesian assumptions, persistence of an adopted belief (until new evidence is available) is the normal case. Davies and Egan do not regard this difficulty as revealing a problem for the two-factor framework, for a Bayesian approach, or for the idea that the second factor explains the persistence of the delusional belief. Instead, they recommend relaxing the standard Bayesian idealizing assumption that subjects have a single coherent assignment of credences, and allowing that newly adopted beliefs should be compartmentalized until they can be evaluated in the light of pre-existing beliefs. A newly adopted delusional belief would then be compartmentalized and could, in principle, be subsequently rejected on the grounds of its implausibility. Cognitive impairments of executive function or working memory would make critical evaluation of the belief difficult and, more dramatically, failure of compartmentalization would eliminate the very considerations in the light of which the belief was implausible.