Luca Casartelli PhD Student Université de Genève casartelli.lc@gmail.com
A good vision for a better comprehension: the psychiatric syndromes topic through phenomenology and neuropathology In this poster I present a synergetic and multidisciplinary approach to psychiatric syndromes (Capgras Syndrome, Fregoli Syndrome and Cotard Syndrome) trying to clarify the connexion between neuropathology and phenomenology and showing the philosophical implications. I also expose how neuroethics field can be involved in this topic (I.). Considering Bayne&Pacherie perspective I present some psychiatric delusions interpretative models (II.). Following Kendler&Parnas I underline the role of neurological perspective in psychiatric syndromes (“bio-psychiatric model”) and the philosophical reformation necessity. In particular I propose a phenomenological approach that aims to overcome the psychiatric’s narrow conception of self and its naturalistic view (III.). I suggest a phenomenological exemplification from husserlian tradition in order to underline the engagement with phenomenological approach: in this perspective I make reference to the phenomenologically different experiences based on common hyletic data (IV.). Considering these presuppositions I synthesize in this way the contribution of phenomenology to neuropsychiatry: “a good vision for a better comprehension” (V.). Therefore I conclude showing that a phenomenologically severe and scientifically rigorous analysis of neurophysiological data about Capgras Delusion, Fregoli Delusion and Cotard Delusion can be supported by a phenomenological comparative approach (VI.).
III. The Philosophical Reformation Necessity of Psychiatry
I. A Multidisciplinary Approach Between Neuropsychiatry and Phenomenology Leon Kass says that neuroethics is the discipline connected with the ethical implications linked with
- The Bio-Psychiatric Model
neurosciences and neuropsychiatry progress (Baertschi 2009). Adina Roskies speaks about neuroethics
Kendler&Parnas point out the philosophical reformation necessity of psychiatry and specially they underline the dominant role of neurological perspective in the treatment of
as multitask domain: it involves an “ethical approach to neurosciences” (“ethic of neuroscientific practice” and “ethical implications of neurosciences studies”) and a “neuroscientific approach to
psychiatric delusions (Kendler&Parnas 2008). From DSM-III (1980) to DSM-IV-TR (2000) we can find a specific interpretation of mental illness as “brain chemical imbalances” or
ethics”. Here I propose not an experimental research project, but I adopt a theoretical and
“neurological impairment” (genetical or traumatic nature) of cerebral activity. We can define this perspective as “bio-psychiatric model”: it is characterized by historical context minimization, by instrumental control, by causal explication emphasis and by adoption of mechanistic picture of the world as an aggregate of quantifiable material objects in causal
multidisciplinary approach among neuropathology, ethics, neuropsychiatry and phenomenology.
interaction (Aho, 2008).
My topic is a broad ethical approach to neuroscience: it has to be considered as a “meta-reflexion about neuroscientific practice”; in a particular way I pose my attention on neuropsychiatric sphere.
Nevertheless the “bio-psychiatric model” implications are not without important consequences: in this perspective non-medical aspects of human condition are increasingly being “medicalized” under diagnostic labels as brain dysfunctions (Aho, 2008). The problem is not “bio-psychiatric model” but the reductionist view of “bio-psychiatric model” as the only possible modality of comprehension of mental disorder. Therefore bio-psychiatric model has to be rethought: I propose a phenomenological reformation.
II. The Clinical Cases: Capgras Syndrome, Fregoli Syndrome, Cotard Syndrome I try to point out my topic making reference to three several psychiatric delusions associated with Capgras Syndrome, Cotard Syndrome, Fregoli Syndrome. Usually they manifest themselves in unusual experiences connected with delusional beliefs. In these syndromes we observe a visual recognition deficit that has to be attribute to an impairment of affective response. - Capgras delusion is the belief that a know person has been replaced by an impostor; it is triggered by an abnormal affective experience in response to seeing a know person (Ellis&Young, 1990). -Cotard delusion involves the belief that one is dead or unreal in some way; it may stem from a general flattening of affective responses to external stimuli (Ellis&Young, 1990) -Fregoli delusion is the belief that one is being followed by known people who are in disguise; it may lie in heightened affective responses to unfamiliar faces (Davies&al., 2001). Bayne&Pacherie distinguish an “endorsement model” (the unusual experience comprises the very content of the delusion) and an “explanationist model” (the delusion is adopted in an attempt to explain an unusual experience) (Bayne&Pacherie 2004a, 2004b).
- Phenomenological Reformation of Bio-Psychiatric Model A phenomenological approach can be very useful because it underlines the “naturalistic risk” of “bio-psychiatric model” assumptions (Aho, 2008). Vittorio Gallese says: “We should phenomenologize the neurosciences rather naturalize the phenomenology”; I can add: “We should phenomenologize the neuropsychiatry rather naturalize the phenomenology”. Karl Jaspers believes that familiarity with the methods and viewpoints of philosophy (especially phenomenology) is indispensable for psychiatry. He says: “Above all I appreciated Husserl’s unceasing demand to clarify unnoticed presuppositions. In Husserl I found confirmed what was already working within me: the drive to press to the things themselves. And at that time -in a world full of prejudices, schematisms, and conventions- this was like a liberation” (Jaspers, 1963). Another important claim of Jaspers perspective exposes the idea that the interdisciplinarity was not an option, a possible path out of many, but an essential condition of psychiatry. With Jaspers, the phenomenological position in psychiatry assumes the sense of “study of experience”: “We should picture only what is really present in the patient’s consciousness” (Jaspers, 1963). I can add that in a phenomenological investigation above psychiatric delusions the emphasis is on the form of experiencing rather than its content alone. Thus, for example, it is not sufficient to note that a patient is excessively preoccupied with jealousy as a theme dominating his mind (content). What is crucial for the psychopathologist is to recognize the particular mode of his jealous experience (for example, whether it presents as an obsession, an overvalued idea, a delusion, or a hallucination), and each of these modes would need to be grasped in terms of the distinctive subjective attitude that it involves (Kendler&Parnas 2008). A phenomenological approach aims also to overcome the psychiatric narrow conception of the self as an enclosed, biological individual (A); psychiatry should begin to understand the patient not as a static, material body with a clearly defined brain dysfunction. Psychiatry has to consider the patient as an unfolding, situated existence already involved in an irreducibly complex social world, an involvement that allows the patient to experience, feel, and make sense of their emotional suffering (B) (Aho, 2008). I can repropose this distinction in the phenomenological language: the measurable, biophysical body is defined as körper (A) and the lived-body is defined as leib (B). This claim is significantly
Even if we can not argue that all delusional states are beliefs, it is correct to suppose that many
linked with an important philosophical distinction in biomedical studies: the difference between “disease” and “illness”. In Aho’s view “bio-psychiatric model” is focused on the
delusions are qualified as beliefs. For this reason I support an “endorsement model” because it seems
medical disease, where disease is understood as a biophysical condition that can be treated with specific drugs or chemical treatments; disease makes reference to the idea of self as biophysical body, self as körper (A). A phenomenological approach to mental health would challenge this “disease model” by remaining faithful to the illness, where illness is
more compatible with empirical datas and phenomenological descriptions of patient’s experiences (Bayne&Pacherie, 2005). Anyway the category “belief” is far from homogeneous: unfortunately, dominant models of belief obscure the multi-dimensional nature of belief. Trying to overcome this classical perspective Bayne&Pacherie distinguish “simple imagination”, “counterfactual imagination” and “indicative imagination”. These distinctions show that “indicative imagination” and belief seem to be on a continuum, insofar as both are attitudes to the way the world actually is; “simple imagination” and “counterfactual imagination”, by contrast, are not on a continuum with belief. In Bayne&Pacherie perspective when they speak about belief they also distinguish “first-order belief”
understood as the lived-experience of the patient and how she or he exists with, makes sense of, and responds to the symptoms of given anxiety, depressive, or impulse disorder (Toombs, 2002). We can also point out that from the perspective of the lived-body, the phenomenological evidence of mental disorder in not objective and quantifiable. As Aho exposes clearly the phenomenological account of the lived-body reminds us that whatever neuroimaging reveals as a brain abnormality is experienced and understood in different ways through the ongoing, situated life of the patient (Aho 2008). In my view concerning Capgras Syndrome, Cotard Syndrome and Fregoli Syndrome the reference point which I suggest in my above interpretations are unusual experiences. On the phenomenology of experience topic I propose to clarify the manifestness of unusual experiences in order to discover the sources and the etiology of the delusional beliefs.
from “second-order belief” (“distinction of content”) and “explicit-beliefs” from “implicit-
IV. How the Phenomenological Approach Works? What Does It Suggest to Do?
belief” (“distinction of role”) (Bayne&Pacherie, 2005).
I want to suggest a phenomenological exemplification from husserlian tradition in order to underline my engagement with phenomenological approach. Phenomenology is the “science of phenomena”, it is the “science of phenomenical description”. Quoting Toombs: “A phenomenological approach thus involves a type of radical disengagement, a ‘distancing’ from our immediate ongoing experience of everyday life in order to make explicit the nature of such experience and the essential intentional structures which determine the meaning of such experience” (Toombs, 1992). What does it mean to propose a phenomenological description of a consciousness experience? What does it involve “to describe an experience” (a “normal experience” or a “delusional experience”) ? In a famous passage of Analysen zur passiven Synthesis Husserl presents an interesting phenomenological description trying to clarify the contrast between two perceptual apprehensions based on the same hyletic elements; these perceptual apprehensions are mutually superimposing. While I am walking in the street I catch sight of a silhouette: firstly I think that it is a man in flesh and blood but successively, coming nearer and verifying the circumstances and the connexions, I realize that it is a mannequin (Husserl, 1966). The important husserlian intuition shows us a way: it is necessary to distinguish the phenomenologically different experiences based on common hyletic data. This exigence is
Capgras Syndrome
very significative in psychiatric field where the role of unusual experience rigorous description is decisive in order to propose a genuine global interpretation of a syndrome. A genealogically rigorous description of a patient’s behaviors (that is: a phenomenologically attentive to phenomena description) can offer a fundamental instrument of interpretation
Fregoli Syndrome
Cotard Syndrome
for neuroimaging data; in this way, the visual recognition deficit is brought back to impairment of affective response. This is the way to clarify unusual experiences connected to Capgras Delusion, Fregoli Delusion and Cotard Delusion.
References • Aho K. (2008). Medicalizing Mental Health: A Phenomenological Alternative, J Med Hum, 29: 243-259. • American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM- IVtr). Fourth Edition. Washington DC, APA. • Baertschi B. (2009). La Neuroéthique, Paris, Edition la Découverte. • Bayne T. & Pacherie E. (2004a). Bottom up or top down?, Philosophy, Psychiatry, & Psychology, 11 (1). • Bayne T. & Pacherie E. (2004b). Experience, belief, and the interpretive fold, Philosophy, Psychiatry, & Psychology, 11 (1). • Bayne T. & Pacherie E. (2005). In defence of the doxastic conception of delusion, Mind & Language, 20 (2). • Cushman, P. and Gilford, P. (2000). “Will Managed Care Change Our Way of Being?,” American Psychologist 55, 9: 985–996. • Davies&al. (2001). Monothematic Delusions: Towards a Two-Factor Account. Philosophy, Psychiatry, and Psychology, 8/2, 3. • Ellis H.D & Young A. (1990). Accounting for delusional misidentifications. British Journal of Psychiatry, 157. • Gallese V. (2009). Motor abstraction: a neuroscientific account of how action goals and intentions are mapped and understood, Psychol Rev, Jul;73(4):486-98. • Heidegger M. (1987). Zollikoner Seminare, Frankfurt, Von M. Boss. • Husserl E. (1950). Die Idee der Phänomenologie, Martinus Nijoff, The Hague. • Husserl E. (1966). Analysen zur passiven Synthesis, Dordrecht, Kluwer. • Jaspers K. (1963). General Psychopathology, Manchester, University Press. • Kendler K. & Parnas J. (2008). Philosophical Issues in Psychiatry: explanation, Phenomenology and Nosology, Baltimore, The John Hopkins University Press. • Pacherie E. (2008). Perception, Emotions and Delusion Revisiting the Capgras Delusion, in Bayne T. & Fernandez J., Delusions and Self-Deception: Affective Influences on Belief Formation, Hove, Psychological Press. • Toombs S.K. (1992). The Meaning of Illness: a Phenomenological Account of the Different Perspectives of Physician and Patient, Norwell (MA), Kluwer. • Toombs S.K. (2002). The Body in Multiple Sclerosis: a Patient’s Perspective, in The Body in Medical Thought and Practice, London, Kluwer.
V. The Contribution of Phenomenology to Neuropsychiatry: a Good Vision for a Better Comprehension I assume that a phenomenological approach to neuropsychiatry can be very useful in phenomenical description of unusual experiences and specially in etiological description of Capgras Delusion, Cotard Delusion and Fregoli Delusion. I want to underline some general considerations about the use of phenomenology in neuroscientific topic: my conviction is based on the idea that the conceptual severity of phenomenological approach and its purpose to “back to the things themselves” can offer an important interpretative tool in order to clarify empirical sciences and in particular way neuropsychiatry. The phenomenological vision is the claim aspect of my topic; it involves seeing the phenomena as they appear to us, permitting genealogically attentive descriptions without intellectualistic or naturalistic edifications. In a neuropsychiatric topic this consideration would mean that in order to explain unusual experiences (I do not recognize my wife, I think to see my wife even if she is not my wife, etc.) I conceal the effectiveness of dative of experiential phenomena re-conducting to simple visual recognition deficit. I have seen that Husserl suggests to distinguish phenomenologically different experiences based on common hyletic data: in my topic regarding psychiatric syndromes it is important to point out the necessity to report the visual recognition deficit (namely the “common hyletic data” in husserlian terminology) to two phenomenological different experiences: in Capgras Delusion patient manifests an affective response deficit whereas in Fregoli Delusion patient manifests an hyperactive affective response that bring the patient to recognize his wife in another woman visage. On the contrary Cotard Delusion is connected with a (quasi)total annulation of affective response that involves the delusional belief to be dead.
VI. Conclusion My purpose was to show that a phenomenologically severe and scientifically rigorous analysis of neurophysiological data about Capgras Delusion, Fregoli Delusion and Cotard Delusion can be supported by a phenomenological comparative approach. The attention in the description of several experiences (the good vision) permits ourselves not to make naturalistic misunderstands: the husserlian model pictured in the mannequin example represents the point of reference in order to obtain a “genuinely attached to dative of phenomena approach”. For this reason I think that in this way it is possible to find a significative examination of my topic (better comprehension) based on the simple assumption that a “genealogically rigorous” and “attentive to manifestness of delusional experience” description is the claim point in order to obtain a deeper understanding of unusual experiences in psychiatric delusions. The neuroimaging data are the empirical elements to root this approach. In conclusion my argument is directed to underline the idea that not only the “bio-psychiatric model” is possible during the study of Capgras Delusion, Cotard Delusion and Fregoli Delusion; rather I have tried to present synergistically a phenomenological approach. Furthermore my proposal of trying to overcome the naturalistic position about objective and measurable standards of the DSM: from the perspective of phenomenology, the patient is not a “case” to be measured and diagnosed but a being who is uniquely human, who is tacitly aware of his own finitude and who makes sense of life in terms of relations with others.