Mental disorders as mental

Matthew Broome and Lisa Bortolotti

Disorder in ICD

• they occur as part of a syndrome or pattern;• in the individual they are associated with distress,

disability, an increased risk of suffering, death, pain, disability, or a significant loss of freedom;

• they are not just a culturally sanctioned response to a particular event;

• whatever their original cause, they must be considered as a manifestation of behavioural, psychological or biological dysfunction in the individual.

MAQ: an empirical study into the ideologies of mental illness

• biological, cognitive, psychodynamic, behavioural, social constructionist, social realist, nihilist, spiritual. (8)

• Schizophrenia, Major Depression, Generalised Anxiety Disorder and Antisocial Personality Disorder (4)

• Aetiology, classification, treatment, and research. (4)

Method

• Questionnaires sent by e-mail and post to all psychiatrists in training grades (SHO’s and SpR’s) of all specialities in the Maudsley and Bethlem Royal Hospitals training scheme.

• 120 sent out, 76 returned, 15 never reached recipients.

• Response rate = (76/120-15)*100= 72.4%

Section 2: Examples of statements

• “The disorder results from brain dysfunction (Biological Aetiology).”

• “The disorder is best approached through the study of abnormal behaviour (Behaviorist Research).”

• “There is no universal classification of disorder, only culturally relative classifications (Social Constructionist Classification).”

• “Adherence to religious or spiritual practice is the most effective way of treating the disorder (Spiritual Treatment).”

Attitudes towards mental illness

• 3 most endorsed statements :– Schizophrenia Biological Aetiology: The disorder

results from brain disfunction– GAD Cognitive Treatment: The disorder should be

treated by challenging and restructuring maladaptive thoughts and beliefs

– Schizophrenia Biological Research: The appropriate study of the disorder involves discovery of biological markers and the effects of biological interventions

Attitudes towards mental illness

• 3 least endorsed statements– Schizophrenia Nihilist Treatment: The

management of the disorder is best left to the resources of the individual.

– Schizophrenia Spiritual Aetiology: Neglecting the spiritual or moral dimension of life leads to the disorder.

– Schizophrenia Nihilist Classification: Mental health professionals have no “expertise” of the disorder over and above anyone else.

Interpreting the Principle Components

• Principle components: scales around which individuals orientate their attitudes to mental illness.

• PC1: negative on biology across disorders, positive on everything else (biological vs. non biological)

• PC2: positive on biology, cognitive, behavioural and spiritual with negative tendency on social constructionist (bio-psycho consensus)

• PC3: positive on social constructionist, realist and nihilist negative on psychodynamic (psychodynamic preference amongst non-biological factors)

Results

• 3 dimensions accounted for 56% variance• PC1 33%• PC2 12%• PC3 10%

• Models endorsed differed by disorder. Most conviction for schizophrenia with biological model most endorsed overall.

Current positions

• Essentialist: existing categories of psychiatric disorders as being validated through the discovery a discrete, identifiable ‘essence’, whether that essence be genetic, neural, phenomenological, or cognitive.

• Anti-essentialist: classification as fulfilling certain concerns and disorders do not necessarily have to have a discrete essence or be a natural kind

• Eliminative mindless psychiatry: entities of psychiatry can and should be reduced to their biological underpinnings, and that it is unlikely that such entities will survive the reduction.

• ‘A possible but unlikely scenario is the advent of an eliminativist “mindless” psychiatry which will be driven by biological models and jettison psychopathology. It is much more likely in our view that clinical psychiatry will retain psychopathology … at its core. It is also likely that classification will evolve towards a system with at least two major axes: one aetiological, using neurobiological and genetic organizing concepts, and another syndromal or behavioural-dimensional.’

Jablensky and Kendell 2002 on eliminative psychiatry

Neuroscientific conceptions

• “functional imaging studies … suggest that symptoms of psychiatric disorders, such as those of neurological disorders, can be localized to specific, phenomenologically-relevant brain regions or circuits, despite an absence of gross brain pathology” (Epstein et al., 2002, p. 65-66).

• “our goal is to translate basic and clinical neuroscience research relating brain structure, brain function, and behaviour into a classification of psychiatric disorders based on etiology and pathophysiology” (Charney et al. 2002, p. 70).

The Cognitive Neuropsychiatry Research Paradigm (i)

• Halligan and David (2001) define cognitive neuropsychiatry as ‘a systematic and theoretically driven approach to explain clinical psychopathologies in terms of deficits to normal cognitive mechanisms. A concern with the neural substrates of impaired cognitive mechanisms links cognitive neuropsychiatry to the basic neurosciences’.

The Cognitive Neuropsychiatry Research Paradigm (ii)

• They explain the methodology thus: ‘Cognitive neuropsychiatry (CNP) attempts to bridge this gap by first, establishing the functional organisation of psychiatric disorders within a framework of human cognitive neuropsychology and second, linking this framework to relevant brain structures and their pathology’.

The Cognitive Neuropsychiatry Research Paradigm (iii)

• Such an approach seeks to understand psychopathology through the models and tools provided by cognitive neuropsychology, and in turn relate such an understanding back to the anatomy of the brain.

Neuropsychiatry and Fodor.

• For the cognitive neuropsychiatrist, the entities of psychopathology are real, but further, they can be related back to neuropsychology, and this in turn can be related back to brain structure and function. Fodor offers an elimination of intentionality at the neural level of description (‘it must really be something else…’) whereas cognitive neuropsychiatry suggests a smooth reduction.

• Realist assume that the classification we have should somehow be translatable into neuroscience and cognitive psychology and that this is the only kind of ‘realism’ there is. For them, it seems that all diagnoses are equally likely to be natural kinds, whether one is studying personality disorder, dementia, schizophrenia or hysteria.

Psychological Realism• Must psychiatric disorders be thought of as

strictly analogous to medical disorders?• The concept of ‘mental disorder’ may instead

borrow the conceptual structure of notions of ‘physical disorder’ but re-deploy it in the categorically distinct domain of the mental.

• Many psychiatric disorders may turn out to result from disturbances in evolved neurological processes, but this could be a merely contingent fact, and not stipulative of the very notion of mental disorder.

Players in the game• Only one player in the game of validating

psychiatric categories and that is biology• There is an absence of current debate about

whether disorders can be validated psychoanalytically, cognitively, socially, or even as Kraepelin did, by clinical course.

• Not an anti-science or anti-biology point per se, but rather as with McDowell, equating the natural with the scope of natural physical science, specifically limits and constrains our possibilities for understanding mental illness.

• Can mental illnesses be real diseases without being cashed out in biological terms?

• Can we explore the possibility of a change in the mental, in one’s second nature and ‘space of reasons’? Arguably, this is how mental illness presents to us.

Delusions• The case of delusions, can be considered as one in

which how one investigates it biologically becomes problematic early on.

• delusions are not discrete either temporally or in terms of their demarcation from other mental states

• contemporary accounts of delusion view them as a non-discrete mental state, a symptom when a certain number of differing dimensional attitudes to a belief, and characteristics of that belief, such as implausibility, conviction, being unfounded, distressing, preoccupying, and not being shared by others, are adopted or met

Delusions ii

• Delusions may lead to the subject’s whole experience of themselves and the world to be altered. The meaningful structures of existence are altered and that which was once banal, and beneath conscious attention, becomes salient and self-referential

• The normative, socially conditioned, rules for linking reasons, causes and explanations are disrupted, and we are left with the hallmark of delusion: namely, that the reasons the deluded give for holding their beliefs either do not look like reasons or are not very good reasons when presented to another.

Delusion iii• The effect of an inappropriate dopamine-driven

generation of salience to otherwise neutral representation leads to the private creation of affect-laden meaning and new reason-relations that cannot be shared or recognized by others as valid.

• delusions manifest themselves interpersonally: it is in the process of the giving and asking of reasons that one suspects delusions, not in viewing a brain scan or a genetic sequence.

• what is pathological in delusion cannot be fully captured without referring to normative notions and an interpersonal dimension.

McDowell, 1998

• ‘The therapy I offer is a reminder of the idea of second nature, which tends, I suggest, to be forgotten under the influence of a fascination with modern science. The idea of actualisations of conceptual capacities does indeed belong in a logical space that contrasts with the one in which modern science delivers its distinctive kind of understanding. But we should not allow the logical space of scientific understanding to hijack the very idea of the natural. The idea of actualisations of conceptual capacities belongs in the logical space of reasons, but conceptual capacities are part of the second nature of their

possessors.’

McDowellian thoughts

• McDowell’s diagnosis mirrors the perspectives outlined here: coherentism approximates to the anti-essentialist/pragmatist perspective outlined here; the ‘Myth of the Given’ (empirical foundationalism) to the essentialist and realist views. Lastly, ‘bald naturalism’ (‘the world can be fully described by the natural sciences: the realm of law’

• McDowell reminds us here that one shouldn’t equate the domain of scientific investigation with all that is natural and real.

• There is a conceptual, meaning-laden structure to psychopathology and to our psychiatric classification. This is as real and as objective as anything can be, and it is in this space of reasons that psychopathology exists and is perceived.

• We should not hope to attempt to naturalize or reify our categories wholly into biological entities: in doing so, that in which we are interested and the disorders with which our patients suffer will be lost to us. Conversely, neither should we falsely presume that, because our categories are affected by values, they lack objectivity,

Conclusion• some normative notions play an important role in the

concept of mental illness and in our attempts at classification.

• contribute to a characterisation of delusions as pathologies of beliefs

• Currently psychopathological states and mental disorders use criteria that rely on psycholological terms. These terms themselves are defined normatively. Further, mental illness itself can be thought of the kind of disorder one identifies as when normal reason-giving, all other things being equal, breaks down.

• we would like to suggest that mental illnesses are apparent in the realm of reasons, as abnormal, skewed, or constrained reason-giving. Further, such changes in reason-giving are stereotyped and may map on, or rather, are identical with, the broad categories of mental illnesses we are familiar with. That is not to say that there is no physical aetiology or mechanism but rather, that mental illnesses qua illnesses are manifest at the level of reasons.

• What one sees physically may be changes in receptor function, neurotransmitter metabolism or whatever. But such changes cannot be ‘disordered’ in and of themselves: they require the mental illness as disorder normatively to be detected, and hence, contrary to prevailing trends, the findings of biological psychiatry are dependent upon such shifts in reason-giving.

• Thus, concretely speaking, a brain scan, genetic abnormality, blood test etc. can never a priori serve as the sole criteria for the diagnosis of mental illness.

• However, such tests can serve to diagnose disorders that use those criteria in their definition, or further elucidate physiology. In this respect, neuroimaging has undoubtedly made great advances in the study of the brain. However, to diagnose mental illness, one talks to one’s patients.

• To bring biological investigations into diagnostic use, we can ‘eliminate’ mental illness and choose to redefine psychiatric disturbances using other criteria than that which we now employ.

• leads to a conceptual difficulty: it doesn’t take an expert to recognise that someone is mentally disordered but how would one decide whether dopamine quantal size, functional MRI activations, or repeats of genetic polymorphisms were abnormal in the absence of a disordered person?

• for biological psychiatry to have any validity, and to be anything more than neuroscience, the main object of study needs to be the person. The normal and the abnormal themselves are normatively defined, and are not properties of the brain.