Psychopathology and Philosophy of Mind

What Mental Disorders Can Tell Us About Our Minds

Valentina Cardella, Amelia Gangemi, Valentina Cardella, Amelia Gangemi

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000369199
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

This book explores how the human mind works through the lens of psychological disorders, challenging many existing theoretical constructs, especially in the fields of psychology, psychiatry and philosophy of mind.

Drawing on the expertise of leading academics, the book discusses how psychopathology can be used to inform our understanding of the human mind. The book argues that studying mental disorders can deepen the understanding of psychological mechanisms such as reasoning, emotions, and beliefs alongside fundamental philosophical questions, including the nature of the self, the universal aspects of morality, and the role of rationality and normativity in human nature. By crossing different domains, this book offers a fresh perspective on the human mind based on the dialogue between philosophy, cognitive science and clinical psychology. Mental disorders discussed include schizophrenia, anxiety disorders, major depression, obsessive-compulsive disorder, post-traumatic stress disorder and paranoia.

This book caters to the increasing interest in interdisciplinary approach to solving some of the problems in psychopathology. Since this book treats psychological engagement with empirically informed philosophy of mind, this book is essential reading for students and researchers of cognitive psychology, clinical psychology, and philosophy, as well as being of interest to clinicians and psychiatrists.

PART 1
Cognition in the light of psychopathology

1
A PRELIMINARY STEP

Understanding the mental in mental disorders

Valentina Cardella

1 The challenge of psychopathology

A man is at his first meeting in acute inpatient care. He talks to the psychiatrist about his recent discovery: he is decomposing. During the session, he gives some evidence of this belief (e.g., the strong smell he can perceive, the worms he feels inside his body), and talks about the precautions he’s taking (for example, he puts hydrochloric acid on his skin to kill the worms). Here’s an excerpt of the interview with the psychiatrist:

Psychiatrist (PS): So … do these worms eat organs too?

Patient (PA): I think so.

PS: How do you survive then, when these worms eat your organs? PA: Well, how do I know?

…

PS: Your parents, what do your parents for example say?

PA: They say that it is not true …

PS: Okay, they say that it is not true. And the fact that they say that it is not true, does not make you think that it is possible that it is not true, that it is perhaps rather your perception that you have worms in the body?

PA: I am decomposing (Zangrilli et al., 2014: 3–6).

Another patient, with Parkinson’s disease (Mr I.) is admitted to the department of neurology; during his meeting with the doctor, his wife is present. Suddenly, Mr I asks if it’s alright if he blows in a bottle (something he usually does for his disease). His wife says he can, but adds that it would be better not to do it in public. Then Mr I says: “My wife usually says that too”. Her wife’s attempts to convince him that she is his wife are unsuccessful. Further during the conversation, while his wife is in a different room, he says that the person accompanying him is extremely like his wife and acts like her, but adds: “Even though she looks like her, it doesn’t feel like it’s her” (Alstadhaug, 2019: 85).

A 31-year-old woman starts seeking medical help for her obsessive-compulsive disorder. She is obsessed with cleaning, spends 12 hours a day cleaning her house and objects, washing clothes, and taking care of her personal hygiene. Every time she comes back home, she wipes down her shoes, bag, and cell phone and those of her husband. She would not dirty the kitchen, so she buys ready-to-eat meals. Her overuse of water and cleaning products has provoked physical injury on her skin, hands, and nails. Yet, she can’t help but clean; she just can’t stop (Justo et al., 2015).

Jaspers, the founder of modern psychopathology, cites one of his patients to illustrate thought insertion, one of the most bizarre symptoms of schizophrenia. The patient is perceiving an influence over him, and he’s aware that the thoughts he’s thinking are not his own.

The thought arises and with it a direct awareness that it is not the patient but some external agent that thinks it. The patient does not know why he has this thought nor did he intend to have it. He does not feel master of his own thoughts and in addition he feels in the power of some incomprehensible external force.

(Jaspers, 1963: 122–123)

What exactly happened to those people? We look at them, we listen to them, we read their stories, and we are under the impression that something terribly wrong occurred. How is it possible that they believe impossible things, like that they are decomposing or that their partners have been replaced by a double? How did they end up spending most of their time performing senseless rituals, and being totally absorbed by their obsessions? And, finally, how can they deny such a patent, evident, unmistakable true, as the authorship of their thoughts? To make people act this way, some mental mechanism should have broken down. And then, what happened to their minds? What went wrong with them?

Those questions seem absolutely appropriate. But even a trivial question, when including the word ‘wrong’, is not that trivial after all. ‘Wrong’ implies ‘right’, or also ‘normal’, ‘correct’, ‘common’, ‘proper’. And those are value judgements. Now, common people, when facing mental illness, can sense that ‘wrongness’, in an instinctively, pre-theoretically, ‘a-scientific’ way. But psychiatry is a medical discipline. It has to endorse an objective, impersonal view of abnormal behaviour. It must be so, given that being diagnosed as mentally ill has serious consequences, at the personal, relational, and social levels. One has to be very cautious when a person’s life is at stake.

However, what does it mean, for a discipline that deals with human fragility and suffering, to be ‘objective’? Is a mental disorder something we can detect in an ‘a-theoretic’ way? Furthermore, is it possible, for any science, to be impartial, unbiased, absolutely neutral? Every scientific enterprise, every scientific paradigm (Kuhn, 1962) has its philosophical assumptions. The more implicit they are, the more important it is for a philosopher to detect them. Psychiatry makes no exception. In this chapter, I will first outline some of those assumptions which concern the nature of mental disorders. I will show that, despite the claim of being a practical discipline, which only aims to cure people, psychiatry starts from a series of postulations, i.e., notions and beliefs that are widely shared but largely unwarranted. I will criticize those assumptions, showing that most psychiatrists are committed to a notion of mental disorder that is flawed (or at least unjustified) and that neglects the very role of the mental. I will then show the importance, in defining mental disorders, of both a mentalist vocabulary and the reference to norms that are cultural, social, moral, and evaluative. At the end of the chapter, I will outline the importance of ethics in psychiatry.

2 The strange nature of mental disorders

On the one hand our patients suffer greatly from psychiatric symptoms, and it seems wildly foolish to theorize away their suffering. On the other hand our efforts to organize and classify their suffering can seem arbitrary and confusing. We organize or categorize a symptom cluster and give it a diagnostic name, and it overlaps with another cluster. Or a patient simply has symptoms of both. We start off with the expectation that there will be a match-up between therapeutic agent and diagnostic cluster, and we discover that, at the extreme, most of our pharmacologic agents seem to treat most of our disorders. Finally, we somehow want to resolve this confusion by getting at the underpinnings of the identified disorders, and we discover that the genetics and neuroscience don’t support our groupings.

(Phillips et al., 2012: 4)

The practice of psychiatry, as described earlier, is very hard. But why is it so? Does it all come down to the mental disorder’s label, which is still too elusive, as suggested by Philips and colleagues? Or does the reason lie in the confusion concerning the biological basis of mental disorder, as stated by the same authors at the end of this quote? In other words, is a complete neurobiological framework still to come, and do we only have to wait? I’ll come back to these topics later. For the nonce, let’s start with a simple question. What are mental disorders?

As strange as it may seem, psychiatry has always been more interested to identify the meaning of the word ‘disorder’, in the ‘mental disorder’ label, rather than the word ‘mental’. Many authors (see Brulde and Radovis, 2006; Murphy, 2006; Graham, 2013) noted that what precisely is ‘mental’ in mental disorder remains unclear in the psychiatric literature. The philosopher George Graham, for example, remarks:

The very idea of the mental deployed in psychiatry as well as in the theory of mental disorder typically is unexamined or at least under-examined by psychiatrists and other writing on mental disorder.

(Graham, 2013: 30)

Murphy even claims that “psychiatry contains no principled understanding of the mental” (2006: 61). What does it mean? How is it possible that a medical discipline that has to do with disorders affecting the mind doesn’t clarify properly the meaning of mental? I will elucidate this point later on, and, by now, I will come back to the initial question: what are mental disorders? To answer this question, let’s start from another one, which looks quite trivial: are mental disorders real? That is, are mental disorders out there, existing independently of the observers, entities which psychiatric categories try to match with better and better? If this is the case, a correct nosography has to correspond to these entities, which in turn have to remain much or less the same independently from the historical and social contexts (Patil and Giordano, 2010; Kendler, 2016; Eronen, 2019). In other words, mental disorders should be what they are, regardless of our linguistic practices and social norms.

The claim that mental disorders are real phenomena is the ground for realism in psychiatry. And realism is one of the dominant conceptions of psychiatry; according to this perspective, mental disorders are discrete entities, existing independently of the way we study them, they are, in other words, natural kinds. The strong realist position is both ontological and epistemological (Pouncey, 2005): it has an ontological commitment about the existence of abstract entities called mental disorders, and an epistemological commitment about our possibility to genuinely know them. However, there is also a weaker realism, where the commitment is ontological only; in other words, one can believe that mental disorders exist in nature, but can doubt our capacity to know them as they are. This seems to be a more plausible position, because it is hard to deny that psychiatric categories are constructs, viz., the best attempts to describe mental disorders’ abstract entities based on manifest symptoms alone. Thus, the vast majority of psychiatrists probably share this last position; maybe we aren’t able to accurately characterize them, but mental disorders really exist out there. After all, does it make sense for a physician to doubt the reality of his patient’s disease? The same should be valid for a psychiatrist.

But is this ontological commitment justified? For instance, is there, in nature, something like depression, a category with essential and specific features, that can be described with objectivity and is clearly distinct from other mental disorders? The answer is no, for several reasons. First of all, psychiatric disorders don’t have sufficient and necessary conditions. To give an example, the DSM-5’s criteria for major depression involve five or more symptoms among a list of nine; thus, no single symptom is sufficient, and, as strange as it may seem, the depressed mood is not even necessary (APA, 2013a). Secondly, the boundaries among psychiatric categories are fuzzy and blurred. For example, despite the claim, that dates back to Kraepelin (1883), that affective disorders and schizophrenia are two distinct categories, experience has shown that there are many hybrid cases (the schizo-affective disorder, see Jablensky, 2016), and the same can be said of affective disorder and personality disorders, or depression and anxiety disorders, or addiction and psychiatric disorders. In other words, comorbidity, that is, the presence of more mental disorders in a single person, is very common (Maj, 2005; Roca et al., 2009; Teesson et al., 2005). As pointed out by Jablensky “It is not surprising that disorders, as defined in the current versions of DSM and ICD, have a strong tendency to co-occur, which suggests that fundamental assumptions of the dominant diagnostic schemata may be incorrect” (2016: 28). It is not surprising, then, that the last edition of DSM shifted from a categorical to a dimensional approach, giving up the aim to identify distinct mental diseases, as one can read in the highlights of changes between DSM-IV and DSM-5:

Because the previous DSM approach considered each diagnosis as categorically separate from health and from other diagnoses, it did not capture the widespread sharing of symptoms and risk factors across many disorders that is apparent in studies of comorbidity. … Indeed, the once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders. The historical aspiration of achieving diagnostic homogeneity by progressive subtyping within disorder categories no longer is sensible.

(APA, 2013b: 12)

However, it is worth noticing that, in DSM-5, this dimensional model often remains a declaration of intent, rather than being an actual paradigm shift, especially when the Manual has to deal with what makes a behaviour abnormal. A clear cut-off among the different mental disorders is often really hard to find, but, and this is also more striking, the same issue regards the boundary between clinical normality and abnormality, too. Evidence has started to show that the line between normality and insanity is not a sharp one, and that mental disorders are extreme variants of normal continua (Poulton et al., 2000; van Os et al., 2009; Freeman et al., 2005; see also Chapter 7 in this book). In the general population, psychotic-like experiences are more common than expected, and it is sometimes hard to divide ‘normal’ and pathological anxiety, or ‘normal’ grief and depression. But the DSM largely ignores those evidence supporting the dimensional approach. Actually, the last edition expands the concept of mental disorder, ‘pathologizing’ normal reactions to distress or loss, like normal grief (major depressive disorder can now include people who are grieving the loss of a loved one if a patient’s distress and impairment last more than two months after the death), and including syndromes like premenstrual dysphoric disorder, caffe...