Mental disorders as mental

1
Mental disorders as mental

• Matthew Broome and Lisa Bortolotti

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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.

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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)

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Method

• Questionnaires sent by e-mail and post to all
  psychiatrists in training grades (SHOs and
  SpRs) 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

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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).

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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

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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.

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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)

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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.

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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.

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Jablensky and Kendell 2002 on eliminative
psychiatry

• 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.

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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).

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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.

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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.

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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.

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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.

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• 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.

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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.

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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.

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• 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 ones second nature and space of
  reasons? Arguably, this is how mental illness
  presents to us.

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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

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Delusions ii

• Delusions may lead to the subjects 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.

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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.

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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.

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McDowellian thoughts

• McDowells 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

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• McDowell reminds us here that one shouldnt
  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.

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• 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,

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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.

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• 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.

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• 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.

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• 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
  ones patients.

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• 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 doesnt 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?

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• 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.