Sunday, 28 October 2012

Gallagher on Delusional Realities

In his paper Delusional Realities, from the book Psychiatry as Cognitive Neuroscience (ed Broome & Bortolotti), Shaun Gallagher takes issue with both top-down and bottom-up causal accounts of delusional belief, and offers us instead a characterisation of delusion as a matter of inhabiting an alternative reality. What follows is my reading and critique of this chapter.

Against top-down accounts Gallagher comments that they fail (amongst other things) to adequately explain the thematic content of delusion. For example, why does the Capgras patient take himself to have an impostor for a wife, rather than (on the basis of his changed feeling in her presence) maintain that he has simply fallen out of love with her? Or why does the schizophrenic person believe that someone else is responsible for their made actions - rather than a brain malfunction? And if what we have to do with are top-down problems in the formation and maintenance of beliefs, it is not clear why the delusional patient is delusional only about some topics.

Against bottom-up theories Gallagher notes that the extravagant delusional narratives that one sometimes finds espoused by schizophrenic persons appear to outstrip anything that could be provided by aberrant experience alone. Against two-factor theories Gallagher urges that they can still have difficulties with the problem of delusional specificity. Against all such theories: we do not yet have an explanation of occasional schizophrenic double-book-keeping.

Shaun Gallagher
 Gallagher's alternative framework draws on William James' notion of sub-universes. As well as the 'world' of everyday (work, eat, socialise etc) we also have the 'worlds' that open up when we read novels, go to the cinema or theatre, play a video game, dream, or simply sit and fantasise. The affordances in these worlds are utterly different from those of the everyday world. The 'changes are existential involving a transformation of background familiarity and of the sense of reality.' To really engage with one of these worlds I don't just adopt alternative pretend beliefs - rather I get excited and emotional in this other world as I become immersed in it. Re-engaging with the everyday world (e.g. on walking out of the cinema, or when the lights come back on at the end in the theatre) can at first feel quite unreal. For delusional realities, by contrast, the lights do not come back on at the end of the play.

Here is a helpful passage explaining the relevance of the concept of delusional realities for advancing beyond the positions of the cognitivists (p. 257): 'To consider a delusion to be merely a belief is, as Jaspers suggested, to abstract it from something much richer - something that the delusional subject experiences and lives through. To consider a delusion to be a framework belief or the result of a dysfunctional introspection about something in everyday (external or objective) reality, is not just to remain too cognitive; it may also target the wrong world. The delusion may not be about external or everyday reality, but may be tied to an alternative reality, in the same way that events that take place in a play are tied to a fictional reality.' Gallagher goes on to describe the fundamental problem of schizophrenic delusion as the 'failure to suspend belief in the ontological actuality of the delusional reality' (contrast holding onto the knowledge that you are in the cinema).

What explains the delusional patient's failure to recognise the imaginary character of their delusional experience? Gallagher draws on Naomi Eilan's suggestion that it is an idiosyncratic and strong affective attunement that keeps the patient's locked into the delusional reality. What this attunement is is not explored further. Gallagher's alternative realities hypothesis addresses the double-book-keeping problem: if one can sometimes see the delusion from the perspective of everyday reality, it will be possible to have some irony about it, even if when caught in the delusional reality it is impossible to achieve any such reflective space. The complexity of delusional content is managed by the alternative reality hypothesis too: Gallagher does not say as much, but presumably the delusion is elaborated by the imagination in the delusional mode. The problem of delusional specificity is addressed by the notion of emotional reactions to specific persons and objects. The question of why there tend to be certain themes shared between different people's delusions 'may call for the same kind of answer that we would give to the question of why there are typical scenarios developed in pretend games and imaginary play in childhood, or 'universal' literary themes found in novels, plays, and other media.'

Critical evaluation: Gallagher's hypothesis seems eminently plausible to me. Perhaps the main criticism, which he himself makes of it several times, is that it is not itself an explanation, but rather a framework for explanations as yet to be developed. Another criticism pertains to the use of the notion of different 'worlds'. At one point Gallagher talks of the way that different ways of relating to the world involve us with different affordances. And says that a 'delusion that starts out in a prodromal experience as a simple feeling of alien forces can develop in complexity if there is a different way to be-in-the-world, a different experiential framework, an alternative reality where it can grow and find support.' However this seems to involve a different notion of 'world', since the delusional subject is not in-the-world in a different way but, on Gallagher's earlier hypothesis, in fact in a different 'world'. (Perhaps we could square this by invoking two different notions of 'world': being in-the-world1 in a damaged way leads to one being stuck-in-a-different-world2.)

However there is I think a more serious criticism to be levelled at Gallagher's theory. Which is that it is not in fact any kind of a novel theory, but instead a timely yet unacknowledged rediscovery of just a few aspects of the age-old psychoanalytical conception of delusion as (to mix together my Lacanian and Jungian terminology for a moment) a matter of a powerful conflation of the imaginary and the real occurring under the sway of feeling-toned complexes. In fact the principal notion of the theory - that delusion involves a failure of the subject to hold onto the notion that they are in a pretend mode - that the subject is prone to take their imagination for reality - is I suggest such a fundamental part of good-old-fashioned mainstream psychoanalytical psychiatry that in the past no-one really bothered to articulate it as such. (Delusion, on this conception, is basically a kind of peculiarly clear-headed topic-specific delirium.) Freud's notion of the libidinal decathexis of the external world and the hypercathexis of the inner world is surely principally another way of making the same point about which world or 'reality' comes to seem the 'more real' to the patient. And Jung's 100 year old word association experiments and his subsequent theorising of schizophrenic psychosis (and, basically, all the psychoanalytical work on psychosis since then) clearly made the case for the significance of feeling-toned complexes (i.e. emotionally significant topics / networks of associations which overwhelm the deployment of the reality principle) in the formation and maintenance of delusion.

Many significant aspects of the various largely complementary psychoanalytic perspectives on delusion are of course missing from Gallagher's theory - their focus on underlying disturbance of ego boundaries and late adolescent failures of individuation which reawaken earlier failures to transition from paranoid-schizoid to depressive functioning, the role of massive projective identification and minus k (reverse alpha function) in the establishing of paranoia, the collapsing of symbolism into symbolic equation, the particular significance of sex (drive, orientation and identity), attachment and aggression, etc. This is not a problem, of course, since Gallagher is only aiming to supply the outline of an explanation, and not to actually explain the derivation of particular delusional content. The real value of Gallagher's paper, however, consists not in its providing any kind of a new theory, but just in it returning us to the fundamental phenomenon of schizophrenic delusionality itself, a phenomenon which those rather thin cognitive / doxastic theories which abound today have rather obscured from our psychopathological vision.

Monday, 22 October 2012

two factors?

Martin Davies, Max Coltheart et al have in recent years outlined the 'two factor' framework for understanding delusions. This framework can seem so utterly reasonable that it might seem perverse or stupid to decline its offer of help in framing the question of how to grapple with psychotic thought. So of course that is just what I'm now going to try to do.

It would of course be more theoretically appealing, especially to fans of Occam's razor, to have a one factor theory. But then as Einstein supposedly said (along with all the other things he supposedly said): if you are out to describe the truth, leave elegance to the tailor. So perhaps it just is the case that a satisfactory explanation of why people have delusions will need to appeal to more than one explanatory pathological factor. Well perhaps, but let's see.

To start with let's recall why we tend to take ourselves to need two pathological factors. First the idea is that, to be deluded, you've got to entertain some rather bizarre idea. Maybe you've had some rather odd perceptual or bodily experiences. OK. But, moving on from the first factor, why on earth would anyone believe that such experiences were better explained by their accurately depicting how things are - rather than, say, by the fact that their perceptual or proprioceptive system had gone up the creek? And so the second factor is there to explain not why delusional beliefs are entertained but why they are then maintained. So there is not only some odd experience or thought process, but also some further odd habit of thought which secures the delusional consideration its home in the storehouse of the subject's beliefs.

 So, what's to complain about? Well, here I want to suggest that this framework will only work if we start from the premise that delusions are failures or disturbances of the processes by which beliefs are formed and maintained. (As Davies has it, 'delusions are pathologies of belief'.) This may of course be true for some beliefs which warrant the epithet 'delusion'. However it is not, I suggest, true for those paradigmatic delusions of paradigmatically delusional 'illnesses' such as schizophrenic conditions. It is also not obvious, in the framework on offer, why such a delusional patient is at least seemingly capable of forming and maintaining other beliefs perfectly well.

I've addressed before this issue of schizophrenic delusional beliefs not being pathologies of believing. To recap: in my opinion, which I reckon is pretty much in line with clinical tradition, delusions arise not from a disturbance in the normal processes of belief formation/maintenance, but rather arise when reality testing (which is not hypothesis testing: that would be a failure of belief!) - ie the capacity to keep reality and fantasy apart - breaks down for some selective area of mental function. An imaginary product then masquerades, as it were, as a bona fide doxastic attitude.  Or, to be clearer: the patient, I reckon, isn't involved in some second-order (metarepresentational) faux pas of mistaking their imaginings for their beliefs (Currie et al) - there is rather a more substantial first-order conflation of the being of these states which confounds our everyday delineations of them, and which is why we have the special qualifier of 'delusional' for delusional belief, delusional mood, and delusional perception. Furthermore, this process is often enough informed by all sorts of fairly everyday 'pathological' tendencies (confirmation bias, wishful thinking, etc), especially the tendency we have to bind intolerable anxiety by producing overly organised narratives.

So: the bottom falls out of your world, and an ersatz world is unconsciously invented to take its place. I'm not sure if this is two factors or one. It is certainly true that a rent in the ego may obtain without receiving a delusional patch. Let us put it this way: the form that delusion takes is a function of the rent; the content and the obtaining of the delusion a matter of the psychological needs of the individual. Not two discrete pathological causes then, not failures in two mechanisms, and not, I would urge, a failure in the normal processes by which beliefs are formed and maintained.

Sunday, 21 October 2012

the hinge

It is sometimes said that people who are psychotic have 'lost touch with reality'. Or that they are 'unhinged'. What do we mean by these terms?

I believe that these terms refer to a specific and deep form of delusional irrationality which needs to be carefully spelled out. However I don't think this is the typical way of understanding them. Which typical way instead, I take it, has it that they are perhaps rather contentless derogatory terms, at best placeholders for a variety of possible everyday epistemic distinctions - to do with consistency or accuracy or willingness to be challenged.

Take what Lisa Bortolotti writes about the irrationality of delusion in her pleasingly clear Delusions and  Other Irrational Beliefs. 'What makes delusions pathological?' Lisa asks (pp. 259-260). 'Whatever it is' she says 'it is not their being irrational, because the irrationality of delusions is not different in kind from the irrationality of everyday beliefs.' (Lisa also has a helpful Youtube video here in which she makes some similar claims about psychotic delusion.)

And consider why Lisa says this. Delusions, she amply demonstrates (you will have to take my word for this) in chapters 2 - 4, are not all that different from non-delusional irrational beliefs in terms of their procedural, epistemic, or agential ir/rationality. (Procedural rationality: a belief is procedurally rational if it is well integrated, consistent, with the believer's other beliefs. Epistemic rationality: a belief is epistemically rational if it is supported by and responsive to evidence. Agential rationality: agentially rational beliefs guide actions appropriately (actions here including speech acts).)

Well yes, but this would only entail that delusions are not to be considered pathological because of their  irrationality if ir/rationality were exhausted by the above three forms. And it is my contention here that there is a more fundamental form of un/reasonableness. And that this form is aptly described by terms such as 'un/hinged', 'out of / in contact with reality'. (I now take leave of Bortolotti to describe this foundational source of intelligibility before returning to her argument at the end.)

There is, it seems to me, a picture of our relation with reality that can far too easily guide yet also constrain work in epistemology. In this picture the mind is an inner domain and reality an outer domain. In the inner domain there are 'representational states', beliefs say, which come in networks. There are (or are not) relations of rational entailment etc. between these states and between them and the subject's actions and utterances. And then there is the further question of their representational fit, singularly and together, with the outer world.

Now I have no quarrel with this as a picture of certain aspects of the relationship between some of our beliefs and other beliefs or thoughts or the facts. But as a picture of the essentials, and especially the foundations, of our reality contact it seems, to me, to be rather hopeless. In fact I would instead want to urge that the obtaining of those beliefs that are aptly characterised as obtaining as a network of inner representations presuppose that the subject is already related to reality in a more fundamental way. So let me now sketch another picture.

In this other picture our fundamental comprehending grasp of our situation is not considered a matter of representation but rather of a living bodily practical immersed engagement with our environment ('being-in-the-world'). We can start to grasp its character by contrasting it with our 'representational' beliefs which are characterised, one could say, by a division of labour between meaning-grasping and truth-speaking; for such beliefs we can be said to know what we mean by what we say when we articulate them even when they are false. But there is (contra the sceptic and her epistemological opponent), when what we are having to do with is our most basic comprehending relation with our world, not obviously any such thing as my possibly being regularly mistaken that I have two hands, that the world is aged, that humans mainly live in families, that the world is populated with trees and flowers and insects, etc etc. Why? Because my knowing these things is not something supplementary to my grasp of the meaning of the relevant terms: meaning and truth are for me here of a piece. At the point of our engaged immersed reality contact, before mind has lifted apart from world to be its representing mirror, meaning and truth are inseparable. I cannot be mistaken because my grasp was not a take in the first place.

At the point of our reality contact, in which the mind is of a piece with reality, and in which reality itself grace-fully constrains and structures our understanding and is not being asked to answer to representations, we find what I will call 'the hinge'. The hinge is what embeds us - it is (to use the existential-phenomenological idioms) the locus of our 'originary transcendence' (Heidegger), the moment of our 'flesh' (Merleau-Ponty) - this fleshly juncture is itself the prior condition of possibility of our holding true or false beliefs. The hinge is our rootedness in the world, a rootedness which then makes for the logically later possibilities of representing and inference making. Making putative truth claims at said juncture of the hinge is accordingly either to be spouting nonsense or nothing more than our unwittingly showing off that we know how to use our words (sarcastic response to Moore's 'This is 'one hand'' ... 'Very good little fellow, well done...!'). Doubt at this juncture is simply narcissistic (since it tacitly supposes that we can muster up the meanings of those of our words used to articulate the doubt by ourselves, without a prior reliance on the embedding regularities of our ownmost natural and social environment to provide content from - as one could misleadingly put it (falling back momentarily into the misguided representationalist inner/outer conception of our basic epistemic situation) - without.[1]

I said the hinge - but in fact there are I suggest many hinges, many junctures from which we are anchored to yet pivot off from within the world into the domain of representational thought where we can then ponder or imagine possibilities and get things right or wrong. Colour hinges, body hinges, passion hinges, animal hinges - different hinges for all the different sui generis domains of discourse (for all the different 'language games' (Wittgenstein) as we might put it)...

In psychotic delusion one or more hinges collapse. The mind accordingly becomes, well - unhinged. And it now starts to become impossible for the clinician - for any Other - to 'find their feet' with the psychotic subject. This is the psychotic 'break' as we call it.

When some particular domain of mind is hinged then, as I have been describing, we not only have the possibility of originary transcendence/being-in-the-world (the juncture at which truth and meaning are of an embodied piece) but also the derivative possibility of representational thought, of imagining things as or as other than they are - this possibility that much of the epistemological tradition mistakes as the fundamental situation for our reality contact. But when the mind is unhinged, that which was hinged - the representational mind - starts to float free. And as it floats free it accordingly denatures. The uprooted representational tree can no longer take up from the soil structure of being-in-the-world the vital normative water and nutrients it needs to inform and constrain its thought from underneath.

So what we are left with, in the end, is a domain of quasi-thought in which the distinction between the ideal and the real, the imaginary and the empirical, collapses inwards. The imaginary and the real start to bleed back into one another; genuinely representational thought falters as 'reality testing' (itself not to be confused with the far more developed, representation-presupposing capacity for 'hypothesis testing') fails. We may be tempted to say things like 'reality becomes subjectivised' or the 'inner world becomes objectified' (Sass) but really these formulations presuppose once again that what is broken is intact. For at this juncture what we really have is an unmooring of the mind from its embodied roots, an unmooring which, because of what the hinge provided towards the normativity of thought, impoverishes thought itself. Thought becomes unconstrained and accordingly becomes denatured. 'Ego boundaries' break and this now unhinged aspect of our world-relation is no longer 'libidinally cathected': these psychoanalytic formulations are ways of referencing the same fact.

To finish lets return to the question of the unreason of delusion. The options canvassed and rejected by Bortolotti would have it that delusional irrationality is a matter of having badly behaving beliefs. The kind of irrationality that I am considering here instead refers us to the intelligibility made possible by our rootedness in our world. A failure of rootedness cuts loose parts of the canopy of belief. There is no doubt that this uprooting will lead to knock-on effects in the relations of beliefs to one another, to the believer's thoughts and actions and to their worldly situations. Delusional beliefs will, accordingly, be irrational in just the kinds of ways achieved by many of our better rooted thoughts. Yet as Bortolotti concludes, psychotic delusions are not in this sense radically different from other irrational beliefs. But what I have been urging here is that there is a deeper form of reasonableness or intelligibility constituted by our basic epistemic relation - that of originary embeddedness - to our world. Bortolotti concludes that there is no distinctive irrationality to delusion; what I have instead been proposing is that the irrationality that is a distinctive feature of becoming unhinged is a result of a disturbance of our hinged installation in our worlds.

One form of rapprochement between Bortolotti's and my own position would be to save the term 'ir/rationality' for the kinds of procedural, epistemic, and agential considerations she canvasses, and to discuss un/hinged reality contact in other terms. I don't terribly mind if that's how things go. But more turns on this than the right name; after all, as I understand it, the point of Bortolotti's concerns with promoting a conception of delusions as a) beliefs which are b) irrational in ordinary ways is to offer an optimistic normalised conception of them to the clinician. And part of what I am claiming is that the unreason of delusion is more severe than is estimated by this optimistic conception. But perhaps some kind of compromise could be reached? Maybe, for example, we could make a distinction between irrationality and unreason, thereby saving the traditional conception of delusions as manifestations of profound unreason whilst yet ceding that their irrationality is not of a particularly damning sort.

Monday, 15 October 2012

neither top down nor bottom up

Reading the cognitive neuropsychiatric literature on delusion one is often offered the following two choices, nicely summarised by Lisa Bortolotti in her Delusions and Other Irrational Beliefs (p. 29).
Empiricists argue that the direction of causal explanation is from the experience to the belief. Delusions involve modifications of the belief system that are caused by 'strange experiences', in most cases due to organic malfunction (Bayne and Pacherie 2004a; Davies et al 2001). These accounts are also referred to as bottom-up (from experience to belief).
Contrast the:
Rationalists about delusion formation [who] argue that delusions involve modifications of the belief system that cause strange experiences. This [top-down] thesis, where the direction of causal explanation is reversed, has been proposed for monothematic delusions such as Capgras (Campbell 2001; Eilan 2000; Rhodes and Gipps 2008) and for delusions of passivity, in which the subject experiences her movements, thoughts or feelings as controlled or generated by an external force (Sass 1994; Graham and Stephens 1994; Stephens and Graham 2000).
No doubt these could be perfectly reasonable options for explaining why sometimes certain people come to maintain, at least passingly, some rather strange things. (I don't however think that Campbell, Eilan or Rhodes & YoursTruly are best characterised as being concerned primarily to explain atypical monothematic delusions (although the first two do touch several times on these, perhaps because they have been discussed so extraordinarily frequently in the philosophical cognitive science literature) - we all seem interested mainly in more (proto/)typical schizophrenic delusions - but  this doesn't matter for now; what follows can however be read in part as querying whether my own views are best described as 'rationalist' or 'top down'.) But it is, I think, pretty hard to see how either of them is supposed to work in understanding schizophrenic delusion. Because this discussion about top-down and bottom-up has become somewhat hegemonic, it can often seem that we simply must choose one of these two options, or offer some kind of hybrid account. In this post I will be suggesting that the discussion presupposes too much about the nature of delusion - in particular that it involves some kind of a problem in belief formation and maintenance - and that we need to look elsewhere to understand it adequately.

The empiricist top-down option is usually cashed out as: the patient is either automatically 'endorsing' their odd experience, or they are going on to further 'explain' it using their reason. Endorsing by itself won't explain why anyone cleaves to what their wonkified experience seems to be telling them. Hence the 'two factor' approaches of Max Coltheart and Martin Davies who suggest that we need to supplement naively believing in weird experiences with continuing to reflect weirdly on this experience. The weird reflection that Anne Aimola Davies and Martin Davies propose amounts to a failure of working memory and/or executive function caused by right frontal damage.

One objection to this is that this failure seems too highly selective (to the delusional scheme). Given that the patient spends a lot of time and energy preoccupied by their delusion one might think that only selective deficits would be less, rather than more, likely to show up here. Another is that schizophrenic patients have of course not at all inevitably suffered lesions in their right frontal cortex. But my main objection draws on something I remember Matthew Broome saying to me about 10 years ago when we were talking about those probabilistic reasoning experiments (to do with proportions of coloured beads in a bag) that used to be popular in this field. 'But, after all, why would someone believe in such wonkified experiences?' I asked. 'Well, perhaps it is because they are mad', Matthew said. And something like this seems intuitively right to me. 'You would have to be mad, unhinged, to believe that!' is our intuitive response to the question of why someone with schizophrenia buys into their unusual experiences with their unusual beliefs.

The point of saying this, of course, is not to thoughtlessly throw round derogatory words like 'mad' or 'unhinged', but rather to urge that, if we are honest, we must admit to still being as puzzled about the delusionality of the delusion as ever. Odd experiences and deficits in working memory and executive function are all very well, but 'how can someone really believe something as odd as that!' is the question that still seems to me to remain after the empiricist bottom-up explanations have run their course. (Of course there's a difference between a phenomenological explication of the delusionality of the delusion, and a causal explanation of how it arises, but the latter explanation must be an explanation of how it - this thing with these properties - arises.)

What about the 'top-down' alternative? Well: what is this alternative? The idea that our beliefs shape our experiences is, stated like that, far too vague to really mean anything at all. In one form or other it will be self-evidently true, blatantly false, or just nonsense. So here is one reading of it which I think captures something of what is typically meant. The idea (Campbell 2001) is that we have a set of basic framework beliefs which partly constitute the meanings of the associated terms whilst not themselves facing the tribunal of experience. (I believe that the world has been here for a jolly long time; my believing this is not to be taken as dependent on a separable grasp of the meaning of 'world'.) We need them in order to formulate testable hypotheses, but they are not themselves up for test (at least, not normally). (Philosophers: think of Wittgenstein's On Certainty run through Quine's epistemological mangle and you pretty much get the picture.) Now consider that delusions function as framework beliefs: the reason the patient so intransigently believes something this weird is that they have a deviant framework belief.

The problems with this kind of approach (the problems with the very idea of nonsensical framework propositions) are already well known (Thornton 2008). I'm not going to rehearse them here. Instead I just want to point out the obvious fact that whilst this 'top-down' approach aims to explain why the delusion is maintained, and how it is that certain affects and meanings find their way into the subject's experience, it does nothing to say how delusions come about. Campbell suggests an unspecified brain disorder, and wards off the criticism that appeals to brain disturbance are better at explaining disrupted experience than disrupted belief. But nothing in the top-down 'rationalist' theory itself leads to this neurological suggestion. (Point of interest: Campbell himself appears to ultimately endorse neither the bottom-up nor the top-down approach, instead applauding Gerrans' view that disturbances of belief and experience are effects of a common cause, rather than either being the cause of the other.)

Both Campbell and Rhodes & YoursTruly draw on Wittgenstein's On Certainty to explicate the essential disturbance of delusion. Whilst Campbell refers to the notion of framework propositions, Rhodes & I instead draw on the notion of a non-propositional dispositional bedrock of sensibilities. Disturbances in this subdoxastic background or bedrock throw the subject out of his automatic kinship with others, disrupting his going-on-being-in-the-world. We don't draw on the dubious idea of an unfathomable framework proposition (although note that Campbell only says that delusions are akin to framework beliefs), but instead promote the idea that delusions are compensations for disturbances in the bedrock which are so radically unchallengeable because the subject no longer enjoys a non-psychotic place to stand from which to mount any critique. There is surely something right, however, in what Campbell says: the fact is that the delusional patient tends to take their delusion as an axiom, and the system of their delusional thought is built around it. It itself is not, on the whole, up for grabs, but instead becomes the filter through which other thought and experience is processed. Yet whether we draw on Wittgenstein to explicate the absence (damaged background) or the presence (quasi-framework beliefs) of certainty, in neither case are we offering any kind of causal hypothesis. In this sense the top-down theories are not to be considered theories of how delusions are formed. And in a sense this ought to have been obvious from the get go: top-down theories tell us that the direction of explanation is to be from delusion to manqué delusion-confirming experience - and it is obvious that this presupposes that we already have to do with a delusion.

Throw in a dynamic hypothesis: that delusions are anxiety-reducing compensations for a loss of pre-reflective certainty and we have the beginnings of (what could be called) a causal explanation (so long as explanations in terms of motivation, character and function are allowed to be called 'causal' - alongside those ?perhaps more prototypical examples of 'efficient' precursor-referencing forms of causal explanation).  At the same time we may also reference the traditional idea that delusionality involves an influx of imagination into reality, a local collapsing of the domains of inner (dream/phantasy) and outer (e.g. perceptual) experience (a failure in 'reality testing' as the analysts say). As Sass describes it, the inner world becomes objectified; as the analysts describe it, the outer world becomes subjectified; as it seems to me, these are more complementary than competing notions. In this collapsing, 'symbolic equation' replaces symbolism (Hanna Segal). An anxiolytic purge of intolerable (self-splitting) inner conflict becomes solved for. The lure of paranoia - to locate the conflict outside, even at the expense of depleting the self (cf the major losses of parts of the self to itself in what is called 'massive projective identification') - grows strong.

The 'rationalist' version of 'top-down' theories of delusion, just like the empiricist version of the 'bottom up' approach, want to put the subject's rational sense-making at the heart of the mechanism of delusional thought. This ever-so-innocent and widespread, but to my mind utterly pernicious, idea of the human subject as located in the world fundamentally as a sense-maker takes us further away from, not closer to, an understanding of the delusionality of delusional belief.1 Sense-making takes place under the aegis of the 'reality principle'; delusion, I want to say, precisely does not.

How are we to understand these evasions of madness in psychological theories of delusion? My own hunch is that they constitute largely unconscious motivated deflections from the unbearableness of psychosis. The phantasy may be that if we could explain the delusional condition in terms, say, of a matter of an isolable pathology of belief, then we can reduce the phenomenon. And by reducing (assimilating) it, the hope is that one would not have to accommodate to it, or better - not be frustrated or pained or disturbed by it in our thwarted attempts at such accommodation. But reduction, here, is just what doesn't work; instead it amounts to changing the topic (changing it to that of dealing with various odd intransigent mistakes that people make). Far too many cognitively oriented theories simply carry almost none of the quality of the psychotic mind. And it is not as if we could say 'well the authors are philosophers rather than clinicians', for the dreadful sound of schizophrenic delusion and of the terror it hides is amply available for those with ears to hear in the hundreds of first person and other accounts that are widely available. Instead of the schizophrenic world, theorists offer us tidy accounts of the relation of beliefs to experiences, failures in hypothesis testing, inferential reasoning, and so on. The terror and tragedy of the experience of true madness - and, in case it's not obvious, the terror and tragedy I am thinking of here are precisely those that the patient is often not feeling when they are deluded; the terror being what the delusion displaces, and the tragedy being the ethical assault of all of this on their personhood - is just nowhere on the table.

I don't want to be taken  the wrong way; this is just a hunch of mine, and the value or lack of value of it will depend on what the cognitive theorist has to say by way of acknowledgement: does honest reflection incline you at all to self-ascribe this deflective disposition? Well: does it?

 Take Kelly's 'people are like scientists' cognitivist trope. On the one hand, the obvious retort is that, well, some of them are like scientists; some of them even are scientists. Then again one wants to ask, rhetorically, if the reverse is true: ... but are scientists like people? (one can only hope). There are of course various times in which I am puzzled in my goings about; my situation stops making sense to me; I stop seeing the sense in it that is there to be found. At these times I may pause and have to try to make sense of it. But an iota of phenomenological reflection tells us that this is hardly the normal case: I am not normally having to make sense of the situations I am in: they already make sense. 'Ah', says the cognitivist, 'I'm not saying that sense-making is a conscious activity; instead it takes place subconsciously, or perhaps even subpersonally'. Well, now what we need are criteria for the application of the term 'subconscious sense-making'. It had better not turn out (on pains of circularity) that such grounds for attributing subconscious sense-making are the exercising of those very capacities which that sense-making is posited to explain - my capacity to automatically see the sense in what I encounter, for example. Referring to brain functions at this point would be fine by way of causal explanation, so long as (again to avoid circularity) they are identified independently of the said functions - fine so long as we also acknowledge that we've now left epistemology way behind.

Monday, 1 October 2012

are delusions pathologies of belief?

I've not previously devoted much time to cognitive neuropsychiatric theories of delusion, and I really need to put this right. What follows considers the cognitive neuropsychiatric theorisation of delusion offered by Anne Aimola Davies & Martin Davies (henceforth: Davies) in their Explaining Pathologies of Belief which appears as chapter 15 of Matthew Broome & Lisa Bortolotti's (eds) Psychiatry as Cognitive Neuroscience  -  Mary Warnock's 'book of the year' in 2009. A value of this paper is that it aims to provide a general theory, or at least theoretical framework, for delusion in psychiatric disorders, rather than restrict itself, as much of this tradition has done, to the somewhat obscure monothematic delusions found in rather rare conditions such as Capgras or Cotard syndromes.

Davies' approach is firmly rooted in the methods and assumptions of cognitive neuroscience, and as such belongs to a tradition (call it the 'cognitive tradition') which aims to build the psychological theory required to understand psychopathological phenomena by drawing both on general psychological models of cognition and on empirical investigation of specific neurological impairments, so that this rather rigorously developed theory can then be applied to clinical cases. One could say that it's an attempt to grasp the psychopathological phenomena 'from the outside', and is of a piece with the 'scientist-practitioner' model in clinical psychology.

Davies with Yeti
Davies with Chalmers
This can be contrasted with (call it) the 'clinical tradition' which I would say has been generated mainly by clinicians out of an immersion in psychopathological phenomena, with an attempt to do justice to the phenomenology and dynamics of the phenomena they encounter there. This often rather less rigorously developed tradition has flowered intellectually principally in phenomenological and psychoanalytical forms, but mainly ticks along in more intuitive and less articulated forms in much clinical psychiatric practice. At times the clinical tradition uses theory and science to help refine or validate its own deliverances, but it is primarily experience- rather than science- led. In the UK I think it's fair to say that the cognitive tradition has a place in certain universities (in London and Oxford for example) and to some degree in their associated clinics, and the clinical tradition more or less ticks along all over the place, although fairly often in rather impoverished (e.g. in excessively procedural or medicalised or legalised or target-obsessed) forms that sap out of it much of its wisdom.

At any rate, I ought to own that I have so far found my happy home in what I'm calling the clinical rather than the cognitive tradition. (En passant: Risks of the clinical tradition: bad science, introversion, confirmation bias, failure to distinguish expert clinical judgement from inherited prejudice. Risks of the cognitive tradition: unwittingly attending to the wrong phenomena, lack of a feel for the material, theorisation unconstrained by intuition born of engaged encounters, importing of dubious epistemological and metapsychological assumptions from cognitive science into psychopathology, etc.) And so what follows is something of an attempt to peer over the garden wall at the rather different flowers growing on the other side.

Davies' first sentence has it that 'In a case of delusion, belief goes wrong.' They continue 'Delusions are pathologies of belief.' The rest of their investigation - and, also, we might note, the investigations of other cognitive tradition delusion theorists - follows from this point. I think it is fair to say that they take it completely for granted. The thing is, though, that the clinical tradition really hasn't taken this for granted at all. I myself don't take it for granted; in fact I am at present intuitively inclined to disagree with it.

To be sure, everyone would agree that delusions are at least sometimes (e.g. when they're not moods or perceptions) pathological forms of belief (well - excepting those who find delusions so wanting by way of the allegedly normal and essential properties of belief (Davidson's constitutive principle of rationality etc.) that they are reluctant to label them as such - although even in these cases they would, one imagines, be happy to talk about 'delusional [i.e. in some way totally knackered] beliefs'). But just because delusions are pathological beliefs does not mean that they are pathologies of belief. It does not entail, that is, that delusion must be understood as consequent on or as maintained by disturbances in the processes by which beliefs are normally formed and maintained. Maybe delusions often have their home in a quite different set of mental functions, functions that are not geared up to making sense of the world around one, and that what drops out the end of these functions merely masquerades as a belief of the normal sort. Perhaps, for example, delusions are ersatz beliefs formed by dreaming, and the delusional mind has become unable, in some specific domain or topic, to distinguish dreaming from thinking. I'm not sure that this would be quite right, but you get my drift: it doesn't have to be about wonky attempted grasps of the world, wonky attempted sense-makings of or uncritical uptake of one's also possibly wonky experience. I've no doubt that having various cognitive deficits in the faculties which support normal veridical belief formation and maintenance may be a big help to the delusional subject aiming, as it were, to cleave to their delusion. Whether the origin of your typical schizophrenic delusion can be understood in such general cognitive terms is, however, a different matter.

Let me just provide a nutshell summary of Davies' theory. It is a two factor, three stage theory. Or rather it is a theoretical framework, since it is suggested that different delusions will have different causes - they will find their own home somewhere in this two factor three stage account. The first factor: how do delusions come about? The second: how are they maintained? (The consideration here is that there will be a different explanation in the two cases.) The first stage: experience. The second: hypothesis generation about what is experienced. The third: endorsement of a hypothesis and creation of a belief. Delusions may involve the straightforward endorsing uptake of abnormal experience, or they may represent manqué attempts to explain abnormal experience. In the second stage attributional biases, jumping to conclusions, a failure of pre-existing beliefs to constrain the uncritical uptake of abnormal experiences, ignoring alternative explanations and so on are offered as explanations of what the first factor could consist in. These are largely presented as personal-level phenomena but Davies also accept that subpersonal processes can also find a place in the same (now really rather broad) framework. The second factor includes the following 'Some patients may fail to reject their false belief because they do not make proper use of available disconfirming evidence, others because they do not take proper account of the belief's implausibility' (15.5.1). A Capgras patient (spouse impostor delusion) fails to notice their belief's implausibility; a Cotard patient ignores what we would normally think of as evidence of life. Working memory and inhibitory executive processes are required for the evaluation of beliefs. An Anosognosic patient, for example, may continue to have illusions of movement in their paralysed arm. If they also have right frontal damage then they may also struggle to hold on to the idea that this really is illusory, and be left with delusional beliefs about their capacity to move it.

Now this is all intriguing stuff. My first (psychological) thought however is that it would be nice to see how it applies to typical (i.e. schizophrenic, manic and depressive) delusions, and not just to the 'more neurological' cases. As yet I'm also more persuaded by the second factor than by the first. My second (philosophical) thought is that I'm somewhat unsettled by the epistemology that appears to be embedded in this framework. What I have in mind, in particular, is the rather 'empiricist-theory-of-the-mind-ish' set of ideas that maps various human capacities onto stages of an inner process. The notion, for example, that forming perceptual beliefs involves the having of experiences, followed by the entertaining of various hypotheses, and then the plumping for one or other of these hypotheses in the creation of a belief, strikes me as phenomenologically rather implausible. I don't, for example, think it happens to me very often. It is of course always open for the cognitivist to say: well the hypothesis formation etc. are either descriptively unconscious personal-level phenomena, or are subpersonal phenomena. But then it is surely incumbent on them to now provide the distinct criteria for such unconscious hypothesis formation - and it is my sense from the literature, and from this chapter, that this provision of criteria very rarely happens. (Options such as 'well it's just like conscious hypothesis formation, only unconscious' ('an imaginary egg is just like a real egg except there's no egg there': thank you so much), or 'the model is an inference to the best explanation' (but we're wanting to understand what the explananda are so that we can then understand the explanation), or 'the causal relations between neurological states map onto the inferential relations in the model' (according to which mapping rules chosen why?) are I suspect unlikely to convince many of us these days.)

Davies do say that they are happy with the idea that a patient may simply endorse rather than explain their experiences, and they also say that, for them, 'seeing is believing'. But this it turns out is not to be taken literally. Rather what we are offered is the suggestion that there is (293) a 'prepotent doxastic response of treating a perceptual experience as veridical'. Perception and belief are still positioned as stages of a process with cognitive mechanisms intervening. (To clarify: it is not that we are being offered a rule of grammar which says: someone is just to be said to believe what they see unless they are baulking. Rather we are offered an empirical proposition of the form: perception tends to automatically give rise to belief unless inhibitory mechanisms are working.) There is a 'processing stage that leads from experience to belief' (15.4.4). So: 'A delusion is a belief, but having a deficit or experience is not yet having a belief; it is not even having a hypothesis that could be adopted as a belief. A complete answer to the question will have to appeal to a processing stage that leads from deficit or experience to belief. This is the idea that the two-factor framework is also a three-stage framework' (290).

Again, in my experience I don't tend to treat my perceptual experiences as veridical, since I don't really treat them at all. I am instead, in my perceptual experience, open to parts of the world, (hopefully) taking in the facts. I am not, apart from in some of my more as-it-were schizoid moments, set back from the world inspecting the deliverances of perception and either admitting them or otherwise. Perception, it seems to me, really is believing (when what we have to do with are perceptual beliefs!) - or better, it is usually knowing (which I guess isn't obviously to be taken as a species of, or as implying the presence of, belief).

Anyway, lets move back from the epistemology to the psychology. Within the clinical tradition the failure in 'reality contact' or 'reality testing' which is seen to be manifest in primary (core schizophrenic) delusion is not typically understood as a disturbance in belief formation. The concept of 'reality testing', one could say, is just not the concept of 'hypothesis testing'. Rather what has happened is that a 'part of the mind' has become 'autistic' (in Bleuler's rather than Kanner's sense) or 'psychotic'. In this lifeworld-retreated part of the mind the distinction between fantasy and reality, imagination and world-directed thought, has broken down. And delusion crystallises. Which crystallisation, to anticipate, is not explanation...

Davies consider cases in which psychotic experiences less than fully encode the content of the delusion (e.g. perhaps the experience is just a sense of unfamiliarity or diffuse threat). In these cases, we are told, 'the processing stage that leads from experience to belief must involve substantive explanatory processes of hypothesis generation and confirmation.' (290) From the standpoint of the clinical tradition I don't see why this must be the case. Let us imagine that someone shifts from a state of prodromal tréma to one of delusional stability. 'Something is going on, I don't know what' becomes 'The wardens are planning to irradiate the hospital'. On the cognitivist hypothesis what has happened is that the patient has made sense of why they felt the way they did. On the clinical hypothesis what has happened is that a more manageable belief has been substituted for a less manageable terror, and is maintained because of its powerful restorative function. Diffuse threat becomes focal and thereby thinkable. Thinkable terrors are more bearable, because we get some of our agency back. When Freud wrote that delusions were 'patches over rents in the ego', his writing was not, it seems to me, unnecessarily poetic. Instead he was talking about the restoring of the patient's self-identity, their recovery of their going-on-being, through their 'invention', by projection of threat into the environment, of the delusional belief. (The rub is that then you have to live with the persecuting irradiating wardens, but this is still better than falling apart.) Once again, what seems to me to be happening is akin to an insurgence of fantasy to bind over ruptures in the delusional subject's self-identity - and it is not at all obvious that this 'must involve substantive explanatory processes of hypothesis generation and confirmation.' Far from it, I want to suggest: it rather seems to me that the patient is playing a different game altogether.

What I've been calling the clinical tradition also has at least some resources for explaining some of the other moves of this different game - such as double bookkeeping. The cognitive tradition will unsurprisingly have little to say about this: if delusions are best understood as pathologies of belief formation and maintenance, then it is hard to see how the patient can both succeed and fail at these tasks at one and the same time. The clinical tradition, on the other hand, sees delusion as growing out of, and being sustained by, quite different soil than belief - as different as dream and unconscious phantasy are from our formation of beliefs (and even more so from hypothesis testing). I can after all have a fantasy about a horse and see a horse at the same time.The autistic enclave is not only governed by different rules, but is also a quite different regime.