Saturday, 10 August 2019

Jaspers’ un-understandability of delusions and the strong psychological model of psychosis


Jaspers’ un-understandability of delusions and the strong psychological model of psychosis 

1.Introduction
The strong psychological psychosis model states that for all the speech, gestures, behaviour etc labelled as functional psychosis we can show how they came about purely in terms of psychological events in a social context in the same way as anxiety or shyness, are continuous with normal psychological processes i.e. are not qualitatively different states and that the meaning of what is communicated can also be understood (Cooke, 2017).  The strong psychological psychosis model applies to ‘functional psychosis’ i.e. where no biological cause is present that is likely to explain the psychosis (such as intoxication with LSD or a brain tumour) (Cooke, 2017).

I will be using Jasper’s phenomenological approach to delusions to critique the strong psychological psychosis model. Jaspers explains “primary delusions” of schizophrenia as the observed manifestation of a global change in awareness of the world with altered meanings of experiences. This differentiates “delusions proper” (also known as “primary delusions” – the terms will be used interchangeably) from “delusion-like ideas” resulting from understandable responses to morbid events e.g. depressive guilt (Jaspers, 1963): 96). In “delusions proper” there is a core to the underlying experience that is not accessible to others understanding as they do not share this changed awareness of the world (Jaspers, 1963: 282). Jaspers describes this phenomenon as a qualitative change from normal or everyday experience that cannot be understood due to lack of shared meanings. This concept if true is problematic for the strong psychological psychosis model that emphasizes continuity with normal experience and that we can understand the meaning of utterances and behaviour in psychosis.

In this essay I will describe initially how the strong psychological psychosis model views understandibility of psychosis symptoms and continuity with normal experience before discussing how Jaspers characterises “delusions proper” as being the external manifestation of an “ununderstandable” experience. I will then discuss this specific meaning of “ununderstandable” for “delusions proper” and why this contradicts the strong psychological psychosis model.  I will then discuss some objections that can be made to Jasper’s ideas by strong psychological psychosis model advocates and how these can be answered.

2. The Strong Psychological Psychosis Model
Now I will briefly summarise the assumptions of the strong psychological psychosis model.

For ‘moral’ reasons including reducing stigma some emphasise continuity between psychological phenomena labelled psychosis and those regarded as normal (David, 2010). Some interpretations of research findings can also be said to demonstrate psychosis being at the severe end of a continuum with normality (Jones et al, 2003; David, 2010 and Linscott and Van Os, 2010). The utterances and behaviour of people experiencing psychosis are said to able to be understood through the joint process of creating a collaborative psychological formulation -
 “assumption is that this process will render even the most unusual or disturbing behaviour and experiences understandable: ‘…at some level it all makes sense’ (Butler, 1998, p.2)” (Division of Clinical Psychology, 2011: 6).
The strong psychological psychosis model asserts that experiences, utterances of behaviour that are labelled as psychosis can be
“understood and treated in the same way as other psychological problems such as anxiety or shyness” (Cooke, 2017: 6)
An example of how psychological formulation is presented as understanding the patient’s psychosis can be found in ‘Understanding Psychosis’ (Cooke, 2017: 51-52). This formulation however demonstrates connections between life experiences  and relevant aetiological factors (such as substance abuse) with the  onset and maintenance of psychotic symptoms as a general class but not why they had such specific experiences such as thought broadcasting through a lump in his throat. It also gave no impression of how did this feel to the person having these experiences. This issue is ignored in ‘Understanding Psychosis’. This contrasts with panic disorder formulations (for example Wells, 1997: 105) where it is easier for me to place myself in the patient’s mind and body and experience what they are going through with increased anxiety leading to physical symptoms such as heart racing and breathlessness and fears of having a heart attack. 

The strong psychological psychosis model holds that in ‘functional psychosis’ there is a continuity between psychosis and normal experience, that the utterances and behaviour in ‘functional psychosis’ can be understood and that the occurrence of psychosis and the content of utterances and meanings behaviour can be explained entirely through psychological processes in a social context.

3. Jaspers Concept of Primary Delusions and Delusion-like Ideas
Now I will describe the phenomenological model of delusions which clashes with the strong psychological psychosis model (Picardi et al, 2018) of which Jaspers is the most renowned exponent.

Jaspers has been influential on psychiatry in general and on psychosis specifically (Stanghellini and Fuchs, 2013) and psychiatry has a substantial influence on the conception and treatment of psychosis despite the objection of strong psychological psychosis model advocates (Cooke, 2017 and Cooke et al, 2019). Jaspers’ phenomenological method consists of
“classifying psychic phenomena” (Jaspers, 1968: 1314), “the sorting out, defining, differentiating and describing of specific psychic phenomena, which are thereby actualized and are regularly described in specific terms” (Jaspers, 1968: 1315-1316) and “must set aside all outmoded theories, psychological constructs or materialist mythologies of cerebral  processes” (Jaspers, 1968: 1316).
This classification of “psychic phenomena” is the essential foundation of further classification, research and clinical practice.  A comparison is made with the histologists describing what they see of the relevant morphological features that others can recognise (Jaspers, 1968; 1316). Jaspers concept of “primary delusions” with global change in awareness of reality with changed meanings permeating many aspects of experience (Jaspers, 1963: 93, 103-104) has a convincing ‘face validity’ for explaining the unusual, baffling enigmatic experiences, behaviour and utterances that clinicians who see patients with psychosis encounter. This is reinforced by the phenomenological descriptions of patients’ experiences in ‘General Psychopathology’ (Jaspers, 1963) of which elements can be readily recognised for clinicians seeing patients in their own practise as Jaspers hoped with his histology comparison. For my own clinical practise in an Early Intervention in Psychosis team I find Jaspers’ concepts of “primary delusions” and “delusion-like ideas” useful as an explanans for why patients that I assess have highly unusual experiences and behaviour whilst also using elements of the weaker psychological psychosis models especially for “delusion-like ideas”.  In my own clinical practice, I find that the claims of strong psychological models of psychosis fall short in helping me to understand why this person is having this particular experience and what it feels like and why are they saying what they are saying (see 2.).

How does Jaspers separate “primary delusions” and “delusion-like ideas”? The “external aspects” used to recognise delusions are “vaguely applied to all false judgements…1…held with an extraordinary conviction…incomparable subjective certainty; 2….imperviousness to other experiences and to compelling counter-argument; 3. Their content is impossible.” (Jaspers, 1963: 95-96). Jaspers is identifying a group of “false judgements” that can be recognised using these “external aspects”  including “delusion-like ideas” or “delusions proper” but could also include some examples of strongly held extreme political or religious beliefs due to “master interpretive systems” (Bentall in Bortolotti, 2018: 79-81 and 87). The “impossible” criterion is discarded nowadays as what is regarded as impossible varies with different cultures and some delusions e.g. of jealousy are possible.

These external aspects are themselves products of “judgments” based on “experience”. These experiences may be morbid events such as depression or hallucinations leading to “delusion-like ideas” but “delusions proper” are caused by “psychologically irreducible” “alien” experiences (Jaspers, 1963: 96).  What is distinctive about the underlying form or mode of experience associated with “delusions proper” that is different from other “false judgements” even if the content is similar (Jaspers, 1963: 58-59)? Jaspers distinguishes between the content of experience and its form which describes the nature of how the experience is presented to consciousness. Jaspers uses “hypochondriacal concerns” to demonstrate the difference – it may be experienced as a recurrent intrusive concern that one is unwell, or it may be a strong belief of being ill despite evidence to the contrary or hearing a voice saying that one is sick. Whilst the content is similar, the mode of its experience is different (and different clinically useful implications for diagnosis, prognosis and treatment).

 In “delusion-like ideas” the mode of experience can be grasped empathically as an understandable consequence of another morbid psychic event (see 5.). For “delusions proper” we cannot achieve “static understanding” (see 4.) of the mode of experience that underlies the delusion producing “judgements” expressed in utterances and behaviour for reasons I shall discuss now.

Jaspers notes that people’s experiences and perceptions of the world involve meanings – when we perceive an object it is accompanied simultaneously with implications –
“a house is there for people to live in…If I see a knife, I see a tool for cutting” (Jaspers, 1963: 99)…“experiences of primary delusion are analogous to this seeing of meaning, but the awareness of meaning undergoes a radical transformation. There is an immediate intrusive knowledge of the meaning and it is this which is itself the delusional experience” (Jaspers, 1963: 99).
People or everyday objects can acquire new often threatening or otherwise significant meanings. This can occur in several types of experience – such as perceptions, ideas, memories or awareness. The radically changed meanings then spread throughout interpretation of memories, current and recent past experiences and interpretation of current and future experience.
“Later the identical experience of significance is repeated, though in other contexts. The trail is blazed and the preparedness for the significant experience then permeates almost all perceived contents. The now dominant delusion motivates the apperceptive schema for all future percepts.” (Jaspers, 1963: 103-104).
Delusional mood is described as one example where initially subtle then progressively more compelling changes in the meanings of experiences are accompanied by mood changes such as anxiety which result in formation of a “primary delusion” (Sass and Pienkos, 2013).

The incorrigible nature of “delusions proper” is not like the “normal errors” of people reinforced by the values and beliefs of a social group (as would occur for extreme religious or political views that may meet the external characteristics criteria for delusions) nor is it like understandable psychological consequences to a prior morbid event of “delusion-like ideas” but is instead an
 alteration in the nature of personality, the nature of which we are so far unable to describe, let alone formulate into a concept” (Jaspers, 1963: 105).

Jaspers holds that in “delusion-like ideas” there is a connection with other morbid events such as depression but in “delusions proper” there is a global change in awareness of experience with changed meanings of experience but why does this make such states “ununderstandable”?

4. Ununderstandibility of delusions proper
In this section I will outline what Jaspers means by “understanding” of experiences and “ununderstandibility”.

Jaspers separates “genetic understanding” from “static understanding”.  “Genetic understanding” describes
“empathy, of perceiving the meaning of psychic connections and the emergence of psychic phenomenon from another” (Jaspers, 1963: 27). “Psychic events ‘emerge’ out of each other in a way which we understand” (Jaspers, 1963: 302).In terms of the content of the patient’s utterances, “if we understand the contents of the thoughts as they have arisen out of the moods, wishes and fears of the person who thought them we understand the connexions psychologically or empathically…called ‘psychological understanding’…empathic connexions leads us into the psychic connexions themselves.” (Jaspers, 1974, 83).
The “static understanding” of any experience which is not directly visible to the senses of the observer such as a delusion is a
“subjective symptom” that has “to be grasped by transferring oneself… into the other individual’s psyche; that is, by empathy. They can only become an inner reality for the observer by his participating in the other person’s experiences, not by any intellectual effort. .. Then there are all those psychic experiences and phenomena which patients describe to us and which only become accessible to us at secondhand through the patient’s own judgment and presentation. Lastly, subjective symptoms also include those mental processes which we have to infer from fragments of the two previous kinds of data, manifested by the patient’s actions and the way he conducts his life” (Jaspers, 1968: 1313).

When Jaspers refers to “primary delusions” being “ununderstandable” this seems to be referring to “static understanding” rather than “genetic understanding” of meaningful connections and to the underlying experience that leads to the manifestation of the delusion (Gorski, 2012). Jaspers concept of what is “psychologically irreducible” (Jaspers, 1963: 96) in “delusions proper” refers to his concept of
  “irreducible quality of psychic phenomena, which can only acquire identical meaning for numbers of people through the incentive and the multiple clues and leads mentioned previously, may already be found in the case of the simplest sensory qualities, such as red, blue, colour, tone; it comes into play also with spatial awareness, object awareness, perception, imagery, thought, etc.” (Jaspers, 1968: 1317).  “We can have no psychological understanding without empathy into the content (symbols, forms, images, ideas)” (Jaspers, 1963: 311).

Understanding thus requires empathy which in this context requires shared meanings. In the underlying experience all or some experiences may have changed meanings and they are not shared i.e. are not “identical” between the person with the delusion and the person trying to understand them. The basic shared meanings for time, perception or object awareness and so forth may not apply.  An example of these altered meanings as part of the underlying experience has been described by Renee (quoted in Sass, 2003: 130).
“I looked at a chair or a jug, I thought not of their use or function—a jug not as something to hold water and milk, a chair not as something to sit in—but as having lost their names, their functions and meanings; they became “things” and began to take on life, to exist.”
 Note the disjunction between object and typical shared meaning. We can view this experience as a whole description of a world with different/ lost meanings at higher levels but not at the level of shared meanings as every experience or object needs to be checked what the meaning is to the person. Hence “chair” is not a shared meaning between Renee and the person talking to her – the shared meaning would have to be at a higher level – a translation guide for these different experiences/ objects i.e. the “psychologically irreducible” level is the translation guide for this anomalous experience describing the experience in terms of altered meanings. As Sass pointed out Renee is unusual in being able to convey these differences in meanings, in producing a translation guide, often such a guide is absent with the patient saying ‘I don’t have the words to describe it [the experience underlying the delusion].’

One of the key difficulties in understanding the experience that lies behind the “delusion proper” is that it is difficult for other people to “grasp” this experience by “transferring into the other individual’s psyche” because of the changed meaning of experience. The person trying to understand the person with the “delusion proper” is trying to navigate an experiential space where what seems like it could have identical meaning may have a different meaning to the person having the experience unpredictably. This is seen in patients displaying ‘double orientation’ where their behaviour is different from what is suggested by what they say – the classic example of people saying they are royalty but apparently content to stay on psychiatric back wards – which suggests more than one meaning may be held by the same person for the same term.
The patient
 “lives in two worlds simultaneously, the real one …and his psychotic one” (Jaspers, 1963: 150).

 This inconstancy of meanings and difference in meanings mean no easy shared understandings is possible when trying to form “static understanding”. The necessity of using a guide, to continually stop and check whether they have got the meaning right prevents the “grasp” by “empathy” involving a lack of “intellectual effort” that Jaspers describes is the essence of “static understanding”. Even if accurate translation guides are present the resultant staccato “intellectual effort” nature of the exploration of the experience stops the rapid empathic processes. In some cases there is an absence of this guide preventing any sort of “grasp” at all. Since we lack the same meanings we cannot directly perceive them by empathy and require interpretation by the patient these
 “phenomenological elements…. which can in principle never be seen by us,...we term ‘statically ununderstandable’” (Jaspers, 1963: 578).

If one could produce an accurate translation guide that could be applied reliably this may lead to an interpretation of the patient’s “subjective symptoms” but interpretation is not the same as “static understanding” as defined above. Even so, it could be argued that if the rules and meanings of this experience manifesting in “delusions proper” are radically different to everyday commonplace ones then we still may not be able to make sense of these different ways of meanings attached to the world (Thornton, 2004: 223-224). If one could understand through shared meanings of the same experiences i.e. that “static understanding” is possible Jaspers would state that is not a “primary delusion” but is instead a “delusion-like idea”.

Jaspers concept of “un-understandability” does not mean that the contents of utterances or the gestures of behaviours associated with the experiences underlying “delusions proper” are valueless. He noted that
“in psychotic reality we find… fundamental problems of philosophy…the extremest of human possibilities…the philosopher in us cannot but be fascinated by this extraordinary reality and feel its challenge” (Jaspers, 1963: 309).


Jasper’s concept of “ununderstandability” refers to the difference in meanings of experiences caused by the global change in awareness of the environment,
“a mutation in the ontological framework of experience” (Sass and Byrom, 2015),
 and this lack of shared meanings means that “static understanding” is not possible because observers are not able to rapidly grasp empathically what the patient experiences.

5. Delusion-like ideas, genetic understanding and the strong psychological psychosis model
In this section I will focus on delusion-like ideas and where there is compatibility between the strong psychological model and Jasper’s concepts.

 In the strong psychological psychosis model there is a core assumption that delusions are wholly   understandable through psychological formulation (Division of Clinical Psychology, 2011: 6) and for this to happen then the form of experience underlying “delusions proper” has to be eliminated and replaced with analysis of the content. The form of “primary delusion” involves disjunction not continuity with everyday psychological phenomena which is emphasised in the strong psychological psychosis model. For “delusion-like ideas” the mode of the experience has continuity with everyday psychological phenomena so this form does not have to be rejected. Jaspers says that
“the  psychologist  who looks  for  meaning  will  find  content  essential  and  the  form  at times unimportant” (Jaspers, 1963: 59).
Jaspers drew a distinction in understandability between “delusions proper” and “delusion-like ideas”.
“The most profound distinction ….between what is meaningful and allows empathy and what…is ununderstandable, ‘mad’ in the literal sense…Pathological life of the first kind we can comprehend…as an exaggeration or diminution of known phenomena…Pathological psychic life of the second kind we cannot adequately comprehend in this way. Instead we find changes…for which we have no empathy but which…we try to make comprehensible from an external point of view” (Jaspers, 1963: 577).
 For “delusion-like ideas” they are an “exaggeration or diminution” of psychological phenomena we can grasp at with empathy through shared meaning – if someone was depressed we can grasp they may feel guilty and then form delusions of guilt that their family is ruined–something that can be grasped by us and is not a disjunction with normal psychology in contrast to “delusions proper”. Here we can see common ground between the strong psychological psychosis model and “delusion-like ideas” in that they are regarded as being at the extreme end of continuum with normal psychology that we can achieve “static understanding” of.

Further common ground also exists in the strong psychological psychosis model’s assertion that if we knew a patient’s life history and their personality then we can appreciate why they experience “delusion-like ideas” in the same way we can for anxiety or shyness (Cooke, 2017). The DCP guidelines on formulation (Division of Clinical Psychology, 2011: 6) emphasise how the utterances and associated behaviour that are called delusions should be framed in terms of the person’s context, life experiences and psychological processes continuous with normality and that if we do it “makes sense”.  This is what Jaspers refers to as “genetic understanding” (see section 4.) using empathy in a specific sense
 “We sink ourselves into the psychic situation and understand genetically by empathy how one psychic event emerges from another.”(Jaspers, 1963: 301) “When we understand how thoughts rise from moods, wishes and fears we are understanding the connections in the true psychological sense, that is by empathy (we understand the speaker)” (Jaspers, 1963, 304).
This could easily apply to the part of the psychological formulation (see 2.) as to how a clinical problem came about. For “delusions proper” there may be some aspects from a patient’s life history and previous morbid psychological events that we can see linking together as part of “genetic understanding” but at some point this fails as we are unable to follow the psychological connections to the experience underlying “delusions proper” as we cannot achieve “static understanding” of important aspects of this state (Sass and Pienkos, 2013 in Fulford et al, 2013: 644) for reasons explained in 4. We may see a patient with a history of childhood trauma then a triggering life event that we can grasp as generating vulnerability for mental health problems but understanding is lost when they talk about Martians are passing electricity through their body.

Psychological Formulations also include ‘maintenance factors’ i.e. why does the problem not resolve itself. In the cognitive model of delusions several maintenance factors are outlined including anomalous states (Freeman, 2016). There is often also a diagram showing a variety of thoughts, feelings and behaviour in an environment interact with each other. Jaspers may refer to this interlocking system of beliefs and processes as “rational understanding” and “relational understanding” (how mental contents relate together).
 “Rational…understanding…is a purely cognitive understanding of rational content, common to all (e.g. we can understand the logical structure of a delusional system in which an individual lies submerged)” contrasting with “empathic understanding - is the proper psychological understanding of the psyche itself” (Jaspers, 1963: 307).

Jaspers conception of “delusions proper” does not necessarily rule out one contention of the strong psychological model of psychosis – that the aetiology of ‘functional psychosis’ is always due to psychosocial causes so long as a mechanism for these causes to cause this disjunctive state can be demonstrated.

The strong psychological psychosis model would not recognise the distinction between “delusion-like ideas” and “delusions proper” and just view them all as delusions. The definitions of delusions in classification systems used in research - for example, DSM-V (American Psychiatric Association, 2013: 87) - or rating scales used to measure delusions in research - for example, PANNS (Kay et al, 1987) – are based on the external characteristics of delusions which are shared between “delusions proper” and “delusion-like ideas”. As these are lumped together in classification and measurement then advocates of the strong psychological psychosis model will often not be presented with research that contradicts their view. On the other hand the research demonstrating continuity with normal psychology often fails to convince in the clinic when faced with examples of “delusions proper” due to failure to achieve “static understanding”.   

In summary, some elements of the strong psychological psychosis model is compatible with Jaspers especially for “delusion-lie ideas” but the disjunction with every day experience and psychology and inability to achieve “static understanding” which Jaspers proposes as underlying “delusions proper” is not.

6. How can the Strong Psychological Psychosis Model deal respond to Jaspers?
I will now discuss how one prominent strong psychological psychosis model advocate Bentall questions the phenomenological method. Bentall states the difficulties of people reporting on their own experiences, whether phenomenologists can “bracket out” preconceptions completely and the problems of trying to understand what people are communicating about private experience often using metaphor (Bentall, 2015). The second concern seems to be about the true objectivity and reliability of the method but any observation is impacted upon by preconception, the important matter is whether like the histologist the resultant description allows recognition by others and Jaspers’ vivid descriptions and subsequent classifications passes this test. The first point also refers to what Jaspers refers to as “subjective symptoms” and his answer may be that it relies on the skill of the phenomenologist but to ignore “subjective symptoms” for “objective symptoms” would seriously impair understanding what patients experience by focussing on measuring external aspects  Jaspers, 1968: 1313). The third point would be used by Jaspers to say Bentall has proved Jaspers’ point – the patient is forced to use inadequate metaphor because of the lack of shared meaning. People in the same culture often use common metaphors for inner experience such as “butterflies in the stomach”.  These descriptions are sound odd but because they are shared metaphors we can at the least come close to what they feel like or mean unlike experiences underlying “delusions proper” which are so different from everyday experience that shared descriptions seem impossible – how does it feel to have one’s thoughts be broadcast or withdrawn and how to communicate this to somebody not having these experiences?

Bentall could point to phenomenological theories on understanding “delusions proper” such as from Minkowski, Blankenburg and Kimura (Sass, 2001), Maher,(Maher, 1974), Sass and various colleagues (Sass and Byrom, 2015 and Sass and Pienkos, 2013), Rhodes and Gipps (Rhodes and Gipp, 2008) but they all involve complicated mental steps that preclude “effortless” static understanding and in any case are based on qualitatively different experiences discontinuous from normal psychology.

7. Conclusion
Jaspers concepts of “delusions proper” and “delusion like ideas” with former term used to describe experiences that are qualitatively different from normal experience (and are “ununderstandable” due to the subsequent lack of shared meanings) with the latter term used for delusions that can be understood as responses to prior morbid mental events These concepts seem closer to the reality of psychosis encountered in the clinic than the strong psychological psychosis model which regards all psychosis as continuous with normal psychology and is always able to be understood.


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Thursday, 8 August 2019

Should psychiatry abandon "natural science" methods as critical psychiatry says we should?


Should psychiatry abandon “natural science” based methods?

Introduction

Critical psychiatrists claim that natural science methods are of little use in studying humans and their problems that form the subject matter of mental health  due to their ignoring important factors such as intentionality, meaning and being embodied in social contexts and that social science methods such as hermeneutics  are preferred (Middleton & Moncrieff, 2019).
I will argue that natural science methods include descriptions such as observation of outcomes of interest to provide the information on causes, complications and treatment responses needed for medical practice. Natural science techniques even in unquestioned natural sciences such as physics may also struggle to discover universal laws because of the effect of multiple interactions, yet we still use them to explain relationships between observable entities hence this is no reason to disbar them in mental health. They can be used to establish causations of organic mental disorders.  Even for functional mental health problems where natural science methods are not used to explain causation these problems are negatively defined using natural science methods. Finally, it may be possible to use natural science methods to study relationships between social contexts and mental health problems. Psychiatry should still use natural science methods.

What is the attitude of critical psychiatry to the use of natural science techniques?

An article describing critical psychiatry (Middleton & Moncrieff, 2019) stated one key attitude was the applicability of scientific methodology in psychiatry. This is quoted in full to avoid any summarising on my part being misleading about their position.

“Medical knowledge is identified with the scientific approach that was developed to study the natural world; systematically investigating assumed-to-be immutable truths by measurement and manipulation of particular elements in a controlled environment. The application of this form of knowledge-seeking to the world of human affairs is referred to as ‘positivism’, an approach that has been criticised for oversimplifying human affairs. Earlier scholars distinguished between Geisteswissenschaften, human or moral sciences, and Naturwissenschaften, natural sciences. The distinction remains a core feature of social science, where it is argued that the study of human beings is irreducibly different from the study of the natural world. Human behaviour is intentional, interactive and inextricable from its social setting. It has meaning, rather than causes, that can only be discerned by reference to its context.

Therefore, if mental disorders are to be understood as human reactions rather than as physical diseases, a positivist perspective cannot provide adequate or comprehensive knowledge. Different approaches are needed that can study social phenomena appropriately.” (Middleton & Moncrieff, 2019: 49)

Alternative social science approaches such as hermeneutics and social constructivism are suggested as alternatives (Middleton & Moncrieff, 2019: 49)

The article summary stated:
“Critical psychiatry does not reject science, but questions the applicability of positivist research paradigms to the study of complex human responses, suggesting that other epistemologies may often be more enlightening.” (p. 53)
An article on the ‘Critical Psychiatry Network’ also described the views of critical psychiatry (Double, 2019) including their view on the role of “natural science” methods.
“However, critical psychiatry’s challenge to reductionism and positivism, including mechanistic psychological approaches, does create a framework which focuses on the person and has ethical, therapeutic and political implications for clinical practice. It also has consequences for psychiatric research, which has become too focused on speculative neurobiological notions” (p.62)

These articles particularly the former promulgate the view that “natural science” methods  
“systematically investigating assumed-to-be immutable truths by measurement and manipulation of particular elements in a controlled environment” (Middleton & Moncrieff, 2019 p.49).
are not suitable for “the study of human beings” (Middleton & Moncrieff, 2019 p.49).   

Critical psychiatry regards the subject of psychiatric research and clinical practice – what problems people present with and are seen by psychiatrists– as “human reactions” or “meaningful responses” (Middleton & Moncrieff, 2019 p.49). The article by Double places a limit on what is referred to is mental health problems not clearly linked to somatic disease such as hypothyroid induced depression or Alzheimer’s disease
“the essential position of critical psychiatry is that functional mental illness should not be reduced to brain disease...Functional mental illness is a personal experience that does not have an underlying brain pathology. No definite biomarkers have been linked to functional mental illness” (Double, 2019 p. 62).
 “Natural science” techniques are described here as controlling for potentially confounding variables whilst altering the experimental variable with results being used to produce “immutable laws”. For the problems that come to psychiatrists this method is regarded as not being able to provide “adequate or comprehensive knowledge” because they are “human reactions” and as such are driven by intentions and are meaningful in response to multiple contexts. Thus, controlling for these contextual factors – regarded as confounding by the “natural sciences” – in order to examine the effects of a single experimental factor (even if it is a social factor such as class) cannot explain why the behaviour happened. There is also a view that meaningful intentional behaviour belongs to the “space of reasons” and may not conform to the “realm of laws” (McDowell, 1994) and hence natural science methods cannot thus provide explanations.

What kinds of information do psychiatrists need for clinical practice?

To address the question of which type of scientific methodology is best for psychiatry we need to know why they need science.
“The link between psychiatry and medicine confers legitimacy on psychiatry as a professional enterprise because its practitioners are seen to hold and exploit expert medical knowledge” (Middleton & Moncrieff, 2019. P. 48-49).
Science is thus used to gain information – for critical psychiatry this is to cement psychiatry’s professional status. Another reason, which may still apply with the previous reason, is that doctor’s professional role to advise on, coordinate, or deliver interventions for health improvement should be based on the best possible evidence gained from science (Shah & Mountain, 2007).

The type of information doctors need for clinical practice can be ascertained by descriptions of ‘clinical utility’ that is stated to come from diagnostic constructs. Diagnostic constructs are used as containers of information – the question of their suitability as carriers of information in psychiatry is not relevant here but given the centrality of making a diagnosis is to medical practice, the purported information attached to a diagnosis is clearly thought to be essential.
Examples of the type of information include
“nontrivial information about prognosis and likely treatment outcomes, and testable propositions about biological and social correlates” (Kendell & Jablensky,2003. P.9)
A more exhaustive list of useful information is listed below
“1.  Conceptualizing diagnostic entities
2.  Communicating   clinical   information   to   practitioners, patients and their families, and health care systems administrators
3.  Using diagnostic categories and criteria sets in clinical practice (including for diagnostic interviewing and differential diagnosis)
4.  Choosing effective interventions to improve clinical outcomes
5.  Predicting future clinical management needs” (First et al, 2004. P.947)
In this list points 2 and 3 relate more to the use of diagnosis in other functions so will be ignored.

Therefore, the types of information that doctors including psychiatrists require include information on likely outcomes (prognosis), the effectiveness of various interventions for this type of problem, what problems may occur in future (complications) and what possible causative mechanisms may be involved (aetiology). The other important thing to note is this type of information is in the form of a range of probabilities not binary information. Even with conditions with almost certain mortality, it is important to know the likely range of possible survival time.

What is the best way to acquire this information?

Doctors can use the patient’s history to provide some of this information in an idiographic fashion. If they have had episodes of low mood in the past in response to interpersonal stressors then you can predict that an upcoming family wedding mixing with hated in-laws may trigger low mood; if they found that a certain type of medication helpful then it may be helpful in the future. If patient had an abscess and they were allergic to penicillin in the past then even If the microscopy culture and sensitivity showed penicillin was the most effective antibiotic you would not prescribe penicillin. This relies on the patient’s past predicting the future – so long as the patient has all the relevant experience.
Often though this information is not available – the patient may not have experienced this type of health problem before to provide guidance on treatments or prognosis, the patient may not be able to recall accurately the information, the patient may be at risk of a complication or problem they have never experienced so cannot be guide in themselves as to the risk of this problem (they may have never had a heart attack but the doctor may be interested in their risk of a heart attack or whether vaccination to prevent a disease is advisable) or they may not have tried a potential treatment so cannot tell you whether it will be effective or if they experienced any side effects.
The commonest way in current medical practice to get this useful information is research on people whose problems resemble the problems of the patient in the clinic in front of them in some way (Kendell in Shepherd & Zangwill (1983): 191-198). This type of research may be simple observation by a clinician that is recorded or remembered in some fashion all the way up to multi-million pound projects involving many researchers. The information gained from this research can then be used to give some idea of probabilistic information of the types described in the previous section.
The natural scientific method is described as a method of investigation to ascertain laws (Middleton & Moncrieff, 2019) but scientific methods are used to describe phenomena as well as explain what is described using laws (Hempel in Sadler et al, 1994: 317-18). Descriptive goals can be achieved by observation and use of standardised terminology to facilitate communication, replication and application by others such as doctors in their clinical practice. For medical practice, important information can be gained by observation of participants with some commonality of their problems - at repeated intervals if necessary – of classified events to gain knowledge on prognosis/ complications of mental health problems, effectiveness and side-effects from treatment.
For this nomothetic approach from research to be useful it relies on several possible mechanisms. One is that the similarities between research participants and the patient in the clinic increases the chances of making successful inferences - the probabilities of recovery or rates of response to treatment -as they have an increased chance of sharing some fundamental quality even if it is unknown. Practical kinds that perhaps share external features such as similarities in symptoms rather than common mechanisms or causes have a greater degree of uncertainty making inferences from research to the clinic. Another possibility is that even if the mechanisms are unknown and the participants are heterogenous there maybe some common elements of mechanisms (mechanistic property clusters) allowing greater degrees of certainty. For natural kinds with common mechanisms and/or causes the certainty is greater still (Kendler et al, 2011). The knowledge gained from research has a degree of uncertainty, greatest when relying on “practical kinds” but also influenced by the effect of multiple contextual factors (such as participants in research differing markedly from patients seen in clinical practise) but information even with great degrees of uncertainty is still better than no information at all so long as this degree of uncertainty is taken into account in decision-making.
If general laws are demonstrated that can offer explanation of observed descriptive data – such as increase in neurochemical x leads to increase in symptom y then this can allow a greater degree of explanation and extrapolation from research participants to the patient in the clinic. With this higher degree of explanation comes increased predictive ability – it can lead to increased understanding and explanation of the patient’s situation; an increased knowledge of the mechanisms can allow increased predictive ability for complications and prognosis and more rational choices in treatment and development of more effective treatments in future.
It is important to recognise that there are certain limitations to using natural science methods in mental health. The information gained even if only descriptive uses classifications varying from a “black box” type where we have little explanation to types with a great degree of explanation. There is always a degree of uncertainty but even in the most uncertain cases, information with high degrees of uncertainty is better than no information at all so long as one is aware of the degrees of uncertainty (see evidence pyramid and subsequent strengths of recommendation).

Do natural science techniques have limits for explaining and establishing causation in mental health problems?

Middleton and Moncrieff state that human beings cannot be studied by natural science but later specifies “behaviour” and “human reactions”. It makes the case that behaviour, thoughts, emotions and so forth cannot be studied in a natural science way because this ignores context, personal history, meaningfulness that do not apply to the subjects of natural sciences such as subatomic particles and animals.
Middleton and Moncrieff describe natural science’s “immutable truths” derived from “controlled” “manipulation” of “particular elements”. It is true that scientific practice often tries to generate observations from experiments aiming to minimise the effects of confounding variables to clarify the role of the experimental variable. Are these experiments in natural sciences such as physics or chemistry producing “immutable truths”? No, they provide results that operate under certain conditions. For example, determining the state of water as a liquid depends on certain conditions of temperature and external pressure. Even what we may regard as relatively stable phenomenon in physics such as the passage of time are changed by near-relativistic speeds and the laws of physics were different at the time of the big bang and continued to evolve even during tiny fractions of a second afterwards.
We cannot expect “immutable truths” very often, if at all, in the hard sciences. What we get is contextual-influenced observations. Hacking suggests that whilst proving that theories (these explanatory underpinning “laws”) are real may be an ultimate goal of scientists but in practice most scientific work is concerned with manipulations of observable entities and the relationships between them (Hacking in Boyd et al, 1999: 247-260). So in psychiatry we natural scientific methods may be used to observe interactions between say giving an antidepressant and effects on depression without necessarily proving an underpinning law predicting the entire effects of the antidepressant on speech and behaviour (it might demonstrate a relationship between a reduced tendency to have less negative thoughts but not the exact content of the negative thought).
In terms of explanations of human behaviour and speech there is always going to an effect of culture, history and environment. Delusions in the 19th Century were often religious due to the importance of religion in culture; nowadays people often have delusions around technology such as television or the internet which were not around in the 19th Century. Now if we posit a biological causation for delusions then a purely biological model cannot explain this variation – it may say delusions around available technology have a biological basis but not why the patient talks about being controlled by wifi now and emissions from natural gas used in lighting in the 19th Century - that is due to historical contingent factors as to what technology is available.
Psychiatric symptoms and signs have been described as ‘hybrid objects’ (Markova and Berrios in Zachar et al, 2015) where this model leaves aside the question of causation. The term ‘objects’ describes constructs that are used to depict or explain aspects of the world. The generation of psychiatric symptoms as signs are said to be ‘hybrid’ because they involve combinations of biological and semantic elements—a biological element/kernel is contained within two layers of configurating envelopes.
The cause of the biological element is not depicted in this model. The biological element refers to the brain activity associated with the symptom or sign. This might be, for example, nervous activity that is a corollary of the patient’s thoughts.

C4.P4
 The two configurating envelopes describe the semantic and contextual elements that act to configure and modify the interpretation and expression of the biological element successively. The first envelope involves individual and sociocultural forces (such as personality traits and culture) whilst the second envelope consists of interactional forces (e.g. between doctor and patient or within a broader social context) (Markova and Berrios in Zachar et al, 2015)).The second type of  configurating envelope describes interactions including that between the patient discussing their experiences with somebody else.
Thus, any explanation of a patient’s behaviour or speech will necessarily include contextual social and interpersonal factors. This means any explanation from laws derived natural scientific methods will also need to explain these contextual and interpersonal factors in order to claim a full explanation of the mental health problems expressed in behaviour and speech.  For laws derived from natural science methods to be able to explain the entire reasons for behaviour they have to be able to explain these contextual social and interpersonal/ interactional factors.
Even in what seem paradigmatic natural sciences such as physics it has been argued that laws derived from the uncontested use of natural science methods fail to explain as much as people think. They often have certain assumptions such as “all things being equal” which in practice is hard to achieve to control for all contextual factors absolutely even in experiments let alone in naturally occurring situations (Cartwright, 1983). Cartwright puts forward the argument that natural science methods even in physics only allow us to make predictions about relationships between observable events rather than hidden laws. Interestingly, Cartwright makes a direct comparison between the behaviour of particles and people.
“I imagine that natural objects are much like people in societies. Their behaviour is constrained by some specific laws and by a handful of general principles but is not determined in detail, not even statistically. What happens on most occasions is dictated by no law at all.” (Cartwright, 1983: 49).
 Even in physics it is also hard to establish causality.
“All the counter examples I know to the claim that causes increase the probability of their effects work in this same way. In all cases the cause fails to increase the probability of its effects for the same reason: in the situation described the cause is correlated with some other causal factor which dominates in its effects. This suggests that the condition as stated is too simple. A cause must increase the probability of its effects; but only in situations where such correlations are absent” (Cartwright 1983: 25).
Given these problems with uncontested use of natural science methods in paradigmatic natural sciences such as physics in being able to establish laws that can explain everything and to establish causation, it would be reasonable to infer that for the experiences/behaviours patients have that are disvalued that result in them receiving psychiatric care may not be able to have laws discovered that predict and explain them totally or establish causation using natural science methods. There may be at least a gap where different types of methods may be useful, a “space of reasons” perhaps where the social science methods advocated by Moncrieff and Middleton may be advantageous.

Can we really do without natural science methods at all in psychiatry?

There may be certain situations or certain areas when natural science methods may fail to explain fully the speech, thoughts or behaviour of people with mental health problems. It is possible that in all patients the contextual broader sociocultural factors and interpersonal factors that affect speech/ thought/ behaviour (as described by Markova and Berrios in Zachar et al, 2015) are the “space of reasons” requiring different methods than the natural science methods. On the other hand, it is well recognised there are cases when mental health problems are at least in part “the psychological consequences of cerebral disorder” such as general paralysis of the insane, hypothyroid induced depression or the dementias (Lishman, 1997). It is untenable that in cases of what would be regarded as ‘organic mental disorders’ that natural science techniques would be of no use. As Berrios & Markova suggests yes the exact content of speech and behaviour is affected by broader contextual factors but surely the presence of neurosyphilis is germane to the patient talking of their fantastical schemes or an underactive thyroid in a patient with depressed mood and paranoid psychosis? Natural science surely has a role to play when clear-cut biological factors seem to be strongly related to the mental health problems – not only for judging aetiology but also prognosis and treatment even if they cannot fully explain all the details of someone’s speech or behaviour.
Double suggests that ‘critical psychiatry’ is only referring to ‘functional’ mental health problems. But what is a ‘functional’ mental health problem? It is a negatively defined state – one where there is an absence of a biological cause that has been demonstrated in the research to cause the defined problem. How do know what biological causes cause these problems? By using natural scientific methods to demonstrate an absence of a demonstrated biological cause. So even if we adopt the position of only using the social science methods suggested for functional mental health problems these need to be defined by using natural science methods to confirm they are functional mental health problems. Furthermore, one cannot state that with further advances in scientific techniques we will not identify in future biological causes for some cases of mental health problems that are not apparent now. We already have an example in antiNMDA encephalitis that in the time of Szasz he would describe as a ‘problem in living’ as the ability to detect the relevant antibodies was unavailable.
It may be possible to use natural science methods to study the effects of social contextual and interpersonal factors on a variety of outcomes such as the relationship of employment to ethnic minority status. In line with Hacking’s view, Brown and Harris used a standardised interview with reasonable reliability – the Life Events and Difficulties Schedule – to measure the relationships between described observable entities:  social contexts, life events and interpersonal difficulties and the risk of developing depression in women (Brown & Harris, 1978). This demonstrated that social contexts and interpersonal factors (three or more life events, lack of social confidants) and their effects on depression (an increased risk in women) could be measured and a relationship demonstrated even though the full meanings and a satisfactorily predictive law of all resultant phenomena were not demonstrated.

Conclusion

Critical psychiatry states that natural science methods should be replaced by social science methods such as hermeneutics because such techniques cannot explain the speech and behaviour of people with mental health problems as this requires understanding of social contexts and interpersonal interactions. The critical psychiatry view ignores that natural science has descriptive and explanatory aims. Descriptive methods can be used to gain information on information that is important to medical practice including psychiatry such as probabilistic information on prognosis, complications, and treatment responses.
Natural science methods can struggle to establish laws that fully explain behaviours of bodies and particles in physics due to the difficulty of fully accounting for contexts and this may apply to establishing laws that can fully explain speech and behaviour due to the effect of social contexts.  Natural science methods can have some explanatory value in ‘organic’ mental disorders. Even if we accept that natural science methods cannot be used to explain speech and behaviour at all  in ‘functional’ mental health problems then we still need natural science methods to negatively define these ‘functional’ mental health problems and in the future scientific advances may allow us to identify biological cases of what seemed to ‘functional’ mental health problems  for which natural scientific methods could be applied to. Natural science methods can still be used to establish relationships between reliably described and observed contextual and interpersonal factors even if the full meanings cannot be described or explanatory laws established.
In conclusion, natural science methods should not be abandoned by psychiatry.


Bibliography

Boyd, R., Gaspar, P. and Trout, J.D., 1999. The Philosophy of Science. Cambridge, MA: MIT Press
Brown G.W. and Harris T. (1978). Social Origins of Depression: A Study of Psychiatric Disorder in Women. London; Tavistock
Cartwright, N., 1983. How the laws of physics lie. Clarendon.
Double, D.B., 2019. Twenty years of the Critical Psychiatry Network. The British Journal of Psychiatry214(2), pp.61-62.
Fine NOA
First, M.B., Pincus, H.A., Levine, J.B., Williams, J.B., Ustun, B. and Peele, R., 2004. Clinical utility as a criterion for revising psychiatric diagnoses. American Journal of Psychiatry161(6), pp.946-954.
Hacking
Sadler, J.Z., Wiggins, O.P. and Schwartz, M.A., 1994. Philosophical perspectives on psychiatric diagnostic classification. Johns Hopkins University Press.
Kendell, R. and Jablensky, A., 2003. Distinguishing between the validity and utility of psychiatric diagnoses. American journal of psychiatry160(1), pp.4-12.
Kendler, K.S., Zachar, P. and Craver, C., 2011. What kinds of things are psychiatric disorders? Psychological medicine41(6), pp.1143-1150.
Lishman W.A. (1997). Organic Psychiatry. The Psychological Consequences of Cerebral Disorder, 3rd edn. Oxford: Blackwell Science.
McDowell, J., 1994. Mind and world. Harvard University Press.
Middleton, H. and Moncrieff, J., 2019. Critical psychiatry: a brief overview. BJPsych Advances25(1), pp.47-54.
Shah, P. and Mountain, D., 2007. The medical model is dead–long live the medical model. The British Journal of Psychiatry191(5), pp.375-377.
Shepherd, M. & Zangwill. O.L. (eds) (1983). Handbook of Psychiatry 1: General Psychopathology. Cambridge: Cambridge University Press.


Tuesday, 5 February 2019

What influence do value judgements have in making in evaluating disease status?



Introduction
Szasz claimed mental illness is an expression of ethical disapproval of a behaviour involving a covert negative moral evaluation (Szasz (1960): 114-115). Examining psychiatry’s role in the abuse of political prisoners by diagnosing them as having schizophrenia with ‘reformist delusions’ it was suggested that both physical and mental disease concepts are evaluative but that the role of values is greater for mental illness (Fulford et al (1993): 806-807) because values underlying designation of states as physical disease are said to be more commonly shared and thus less problematic for physical illness compared to mental illness (Fulford in Boch & Chodoff (1991): 80-82).

Defining disease and illness in a biologically based value-free manner still contained implicit value judgements ((Boorse (1975) & Kendell (1975)). More recent propositions have dealt with the issue of values in different ways. Wakefield acknowledged the role of values in judging if a factual dysfunction is harmful and should qualify as a disorder (Wakefield (1992): 374)). This proposition also relied on value judgments to decide if there was a supposedly factual value-free dysfunction present (Murphy & Woolfolk (2000): 245-7). Fulford presented the argument that it was identifying illness that was crucial based on a ‘failure of doing’ (Fulford (1989)) and that disease was what was associated with producing illness (Fulford in Bloch & Chodoff (1991): 85). The values associated with the designation of illness were described as medical values as opposed to moral or aesthetic values (Fulford (1989): 109)) though to me the distinction is not clear.

The aim of this essay is to discuss how commonly values are involved in evaluating if states are diseases.

How often do different groups of people agree on the disease status of problems?
A survey in Finland of a randomly selected representative sample of 3000 laypeople, 1500 doctors, 1500 nurses and all 200 MPs asked the respondents about 60 relevant states (chosen by expert consensus) were asked if they regarded these states as diseases (Tikkinen et al (2012)) on a Likert scale with 5-points from strongly agree to strongly disagree. The paper’s definition of disease was not given explicitly but was implied by an additional question - the state should entitle the affected person to tax-funded healthcare. The states covered a wide variety of conditions including those commonly thought of as physical and mental health conditions. Strongly agree and agree answers will be combined into a single agreement category. Answers for some conditions will be discussed to highlight the potential role of values in deciding if states are diseases including discussions if the conditions could be viewed as clear dysfunctions (Wakefield (1992) or failures of doing (Fulford (1989) or biological disadvantages (Kendell (1975)).

Doctors were more likely to regard states as diseases but there were some exceptions – for example age-related muscle loss was regarded as a disease by 50% of lay people and MPs and 40% of nurses but just over 20% of doctors. Mental health conditions were more likely to be regarded as diseases by doctors than other groups. I will discuss some of the results in further details to discover if value judgements influenced disagreements as to disease status

Anorexia nervosa is a severe mental health condition - with high rates of mortality (Chesney et al (2014)) and in women amenorrhea reducing fertility meeting Kendell’s criteria of biological disadvantage (Kendell (1975): 310) – was regarded as a disease by only just over 60% of lay people and MPs but over 90% of doctors and 80% of nurses. Given the combination of increased mortality, physical complications and reduced fertility and the markedly different associated thoughts/ behaviour it is interesting that over a third of lay and MP respondents do not regard anorexia as a disease (there is higher agreement for depression even though depression’s mortality is much less than that for anorexia (Chesney et al (2014)). Thinking about possible reasons for this discrepancy between lay/ MP respondents and doctors it may be that the general public and MPs may not be fully informed about anorexia’s high mortality or what people in this state experience in terms of distress and impaired functioning. Another possibility may be that anorexia involves a disorder of eating – a disorder of appetite (similar to appetites in the broad sense – see later discussion of substances and sexual functioning). In this case it is a restriction not perceived over-indulgence. An additional possibility is the association with thinness which may be regarded as a physical feature conveying sexual attractiveness and that in some people anorexia is regarded as trying to achieve a desirable feature, a form of vanity that is regarded negatively and undeserving of disease status. In terms of evolutionary dysfunctions (Wakefield (1992): 383) that may be causing anorexia it is possible there may be functions to suppress appetite in terms of food shortage or to adopt body shapes regarded as attractive to potential mates but this does not explain to me why these functions become so awry to produce the severe distress of anorexia nervosa and its associated biological disadvantage. In any case even if these evolutionary functions have become dysfunctional their nature – of perceived wilful suppression of appetites when unnecessary to achieve thinness - may be subject of moral judgement as vanity and not deserving of the exemptions of criticism of such behaviour conferred by disease status (Boorse (1975): 61) which is a value judgement (Wakefield (1992): 383-4).

Alcoholism is regarded as a disease by about 50% of lay people and over 60% of doctors; drug addiction by about one third of lay people and just under 60% of doctors and smoking as disease by under 10% of all four groups. Nicotine is a highly addictive substance so alcoholism, drug addiction and smoking can all be regarded as forms of addiction caused by a biological substance with biological effects contributing to addiction. Alcohol problems have been defined as a clinical syndrome to allow further research into psychobiological causes (Edwards & Gross (1976)). The concept involves the biological consequences of alcohol – such as increasing tolerance to its effects and the withdrawal signs/ symptoms – interacting with psychological phenomenon such as negative conditioning promoting using the substance to ameliorate unpleasant withdrawals to create the constellation of increased use with subsequent problems.  This has formed the basis of other addiction syndromes. Tolerance and withdrawal can both viewed as a result of evolutionary functions (Wakefield (1992): 383) – tolerance is mediated by the body reacting to increasing exposure to a bioactive compound by increasing its ability to metabolise the compound and reduce its pharmacodynamic effect on the body; withdrawal represents what happens when the body is no longer being exposed to this bioactive compound when it may have reduced production of its own compounds that have similar effects and/or reduced sensitivity of systems to this compound’s effects. These bodily responses can be seen as evolutionary functions to maintain homeostasis. Psychological mechanisms – such as conditioning- can be viewed similarly as evolutionary functions to increase an organism’s adaptation to its micro-environment. Therefore addiction to a biological substance inducing tolerance and withdrawal could be seen to involve dysfunction and therefore achieve part of the criteria for disease status (Wakefield (1992): 383).Smoking, alcoholism and drug addiction are associated with increased mortality though smoking to a lesser extent than severe forms of alcoholism and drug addiction (Chesney et al (2014)) and could be seen as biological disadvantages conferring disease status (Kendell (1975): 310).

Both smoking and alcohol are legal as are some drugs that can be addictive for certain purposes (e.g. opioids for pain relief). Smoking, even with passive smoking, may be regarded as less harmful to other people than alcoholism and drug addiction with their associations with crime, aggressiveness and other antisocial behaviours. The marked difference for smoking compared to alcohol/drugs may reflect a reluctance to confer disease status on smokers for several possible reasons: unwillingness to medicalise a much more prevalent group than alcoholism or drug addiction or that people are not ‘sold’ on a disease model of addiction that applies logically to smoking. Doctors have similar rates for regarding alcoholism and drug addiction as diseases but lay people are less likely to confer disease status on drug addiction than alcoholism – this may reflect an unwillingness to confer disease status on drug addiction (and entitlement to tax funded health care) which may reflect that they personally disapprove of drug use compared to use of alcohol.

It seems likely to me that the difference in assigning disease status to these different addictions represents differences in personal attitudes to the substances involved in the particular addiction. These different attitudes are likely to be influenced by personal values. These values may be influenced by various factors such as experience with their own or others with addiction, training and education (such as doctors taught the medical model of addiction as exemplified by the alcohol syndrome), the media, cultural attitudes and so forth. It may also be that “familiarity breeds contempt” – people have experience of wanting to use and actually have used cigarettes, alcohol and illegal drugs. Their personal experience of unproblematic use and desire for these substances makes it harder for them to see why people should have problematic use and cannot stop using it to that degree and may impute personal failing as a reason why people become addicted. The public may be more likely to see drug addiction as immoral as it involves either illegal substances or legal substances for limited purposes being abused for pleasure. This appetite for pleasure out of control seems to attract varying degrees of moral censure and disbarring from disease status depending on the perception of the substance’s legality or perversion of purpose. Doctors may be indoctrinated by their training to regard it as a disease. They may also see people in their clinic with highly problematic use and regard their experience as different from non-problematic use – it may appear “syndromal” to them or even if an excess on a dimension with everyday use (“quantity has a quality of its own”).  

Gambling addiction was regarded as a disease by 25% of lay people, 50% of doctors and about 40% of MPs and nurses. Gambling addiction as its’ name suggests has adopted the substance addiction model for problematic gambling behaviours in the absence of a biological substance. This absence of a biological substance means that the addiction model relies on dysfunctional psychological functions (including impulsivity) so may be less likely to meet evolutionary dysfunction criteria for disease status. To my knowledge there is less evidence for increased mortality for gambling addiction than the other addictions mentioned above and it would be hard to demonstrate reduced fertility that was not socially mediated so is unlikely to meet biological disadvantage disease status either (Kendell (1975): 310).. Gambling may be regarded as more harmful to others in the gambler’s social network than smoking due to its financial effects. In Finland gambling is legal but under a government monopoly (alcohol was also strictly regulated at the time of the survey).  There may be a reluctance, particularly amongst lay people but also about half of doctors, to regard a problematic behaviour as a disease in the absence of a biological substance causing an effect on the brain leading to tolerance and withdrawal effects. This may reflect values indicating reluctance to assign disease status in the absence of biological causes for a behaviour that is regarded as an appetitive disturbance or indulgence. Gambling may be regarded as an immoral indulgence not deserving of disease status.

Erectile dysfunction is regarded as a disease by less than 50% of all groups. Erectile dysfunction presumably reduces chances of reproduction thus meeting Kendell’s biological disadvantage criteria for a disease (Kendell (1975): 310). The dysfunction of erectile function would meet criteria for a failure of doing - of difficulty in performing penetration (Fulford (1989)) and a dysfunction in the sense of having difficulty in its’ evolutionary function of penetration (Wakefield (1992):310). Despite this, less than half of respondents regard it as a disease which makes little sense according to me especially as doctors are likely to view states as diseases (Tikkinen et al, 2012). Possible reasons could include that it is often regarded as a psychological problem caused by anxiety and that as such is regarded a nervous problem not a disease. This ignores it is often associated with medical conditions such as diabetes or as a medication/ surgical side-effect or can be caused directly by disease processes such as vascular disease and is coded in ICD10 both as a mental and a urological disorder. Another possibility could be that it is a state that affects sexual functioning it is regarded as an appetitive problem, a dysfunction of sexual enjoyment/ activity that may influence people’s value judgement of it. This may lead them to viewing this state not as a disease entitled to tax funded healthcare but a problem of lifestyle or desired state (the desire linked to activities either regarded as base or immoral).

There is inconsistency around the allocation of disease status to adult-onset diabetes (over 80% all groups), elevated blood pressure (70% or more in all groups) and elevated cholesterol (about 50-60% in all groups). These conditions are all aspects of metabolic syndrome and share many features such as a complex aetiology involving multiple genes of small effect (often shared between these different conditions) interacting with environmental factors such as exercise, diet and alcohol intake. Given these are different aspects of a broader condition why the difference in rates of according disease status to them? They share many common factors with an evolutionary function – blood pressure to circulate blood and maintain renal function, cholesterol and glucose metabolism to provide immediate energy whilst also storing energy and providing building blocks to produce important molecules such as steroids. The dysfunction element arises from the consequences of these functions (at high levels of blood pressure for instance) to lead to a variety of processes, for example atheroma, with several adverse consequences like cardiovascular disease (Wakefield (1992):310). The resultant increased mortality would meet biological disadvantage criteria for disease (Kendell (1975): 310). It may be that the lower rates of elevated cholesterol being regarded as a disease is because of its closer association with diet in people’s minds and specifically overeating of sinful foods like cream cakes and English breakfasts that is it attracts negative moral judgements affecting people’s willingness to accord it disease status.

Finally, few considered dental caries a disease (about 30-40%) except over 60% of doctors despite being a clear disease with resultant pain and even loss of teeth indicating dysfunction (Wakefield (1992):310) but perhaps not increased mortality/ reduced fertility of biological disadvantage (Kendell (1975): 310). The association of dental caries with indulgently eating sweets and chocolates may induce negative moral judgements or views about not restricting appetites.


How do moral judgements affect decisions about disease status?
It is important to note that this survey asked different groups of people (the public, doctors, nurses, MPs) whether states should be conceived as diseases and entitled to tax funded health care but their opinion could be wrong (Wakefield (1992): 377). These different groups are likely to have had different levels of knowledge of the different conditions and under the pressure of completing the survey their thinking processes in deciding whether to allocate disease status may have been different than if they had time to research the condition and form reasoned judgments. 

The allocation of disease status to various conditions is often to my mind illogical. Hypertension, type 2 diabetes and elevated cholesterol are similar conditions yet elevated cholesterol is less likely to be regarded as disease. Erectile dysfunction is often not regarded as a disease despite often being a result of pathological processes and medication effects. Nicotine addiction despite involving a highly addictive substance is rarely considered a disease. Alcohol addiction is more likely to be considered a disease than drug addiction. Dental caries is often not considered a disease.

The reasons why conditions which seem to have legitimate claims to disease are disregarded as such seems to rely on value judgements about their perceived nature. Anorexia may not be regarded as a disease – despite its high mortality for a mental health condition and a diagnostic biomarker which is rare for mental health conditions – because it is a disorder of eating, an appetite, and possibly because it may be regarded as a form of vanity with its association with thinness.  

The association of cholesterol with eating and in particular eating foods regarded as sinful (high fat foods) may explain why elevated cholesterol is less likely to be regarded as a disease than type 2 diabetes and hypertension. It may be more likely to regarded as a moral failing – not restricting oneself from eating badly, a poorly regulated appetite.

If one regards all addiction to a biological substance – whatever the substance – as a similar phenomenon the varying answers about disease status of alcohol, drugs and nicotine are confusing. The different answers for alcohol and drugs may reflect greater moral disapproval on the use of drugs as compared to alcohol and subsequent reluctance to extend disease status and tax-funded help to people with drug addiction problems. For nicotine another value judgment may apply – since smoking is so common so everyday there may be a value judgement that ubiquitous phenomenon should not be regarded as diseases and especially if involve pleasure-seeking activities with smoking as a vice.  In gambling addiction the link to vice and pleasure seeking is more obvious in the absence of a biological substance.

All these conditions described do not have associated differences of structure/ anatomy or physiological causative processes or mechanisms. Addiction may have induced nerve receptor changes as a result of the biological addiction but this is as a result of the substances involved not a cause of the problems. Yet even where seem obvious differences in structure or physiological process and biological disadvantages such as erectile dysfunction a minority regard it as disease possibly because it’s a dysfunction of a sexual activity and hence linked to appetite and morality.

Turning to what may be described as mental illness what are the relevant points? The frequent absence of biomarkers and differences in structure/ processes leading to the clinical features can weaken the claim to disease status especially if the value issues outlined later casts further doubt. Of course one can point out that these differences in structure/ process only counts as a disease marker AFTER we have already decided that the condition is a disease (Fulford (1989). If a biological difference in structure or process was found in all people with the condition that explained its clinical features many would accept that as ‘proof’ of disease status yet biology is not the sole hurdle for what is described as mental illness achieving disease status. These judgement as to whether a condition is a disease if it involves behaviour regarded as immoral or even if involves appetites or drives will involve mental illnesses more than physical illness as behaviour is more frequently an associated or central component of mental illness.

Many impulse control or ‘addiction’ type problems or conditions involving sexual desires involve an additional value judgement as to whether this is best viewed as an immoral behaviour not worthy of the excuses and exemptions of a disease (Boorse (1975): 61). The person judging may reflect that if the person is taking illegal drugs why should they be given the exemption of criticism of behaviour that disease status confers (Boorse (1975): 61) for something they view as morally wrong.  Imagine the discomfort and clash with personal values that would arise from trying to describe paedophilia as a disease? Even if a biological difference in structure or process was discovered that was likely to be causative of paedophilia the moral revulsion that paedophilia evokes would make people reluctant to see it as a disease.

The inconsistencies in allocating disease status to the different states in the survey suggests that moral judgements are integral to the decisions made. There may also be a folk version of stoic beliefs that temperate and mild affectations are unhealthy but excessive appetites (and by implication) over-denial is mentally unhealthy ((Nordenfelt (1997)).  Disease status entitling tax-funded healthcare is likely to mean that moral judgements of deserving help and support are involved. Moral judgements of the type that somebody has contributed to their problem in a blameworthy manner -by not denying appetites or immoral behaviour – is undeserving of such help and associated excuses (Boorse (1975): 61). In these cases, a negative moral judgement is an obstacle to being allocated disease status but this happens less often in doctors decision-making as they are more likely to recognise states as diseases (Tikkinen et al (1975)). The reasons for this could be multiple and more than one reason may operate in each doctor.

Doctors
·       are taught about states in the same medical/ disease paradigm so may be more likely to not distinguish between diseases and non-diseases.
·       may wish to extend their claim to professional expertise and thus generate work for themselves by allocating disease status even when it is not warranted
·       may possess vague concepts of what disease is and allocate disease status haphazardly
·       may see patients presenting with problems caused by these states and wish to help and by allocating disease status helps justify medical help being given
·       experience and knowledge of these states may allow them to put less weight on moral judgements and focus on other factors relevant to disease status.

In contrast to the above discussion, negative moral judgments may increase the chance of behavioural states being allocated mental disease status. Schizophrenia may be readily conceived as disease despite the attempts to emphasise continuity between psychosis and typical human experience/ behaviour to reduce stigma whilst ignoring the evidence for discontinuity (David (2010)) because this continuity view induces uncomfortable feelings (Thibodeau & Peterson, 2018). A view of schizophrenia as a disease and separate from health may help resolve this uncomfortable feeling. Black slaves were viewed as trying to deprive their masters of their labour may be viewed as immoral by white American doctors and facilitated viewing them as suffering drapetomania (Wakefield (1992): 373-4). Perhaps Soviet dissidents were viewed by their psychiatrists as decadent for trying to oppose the proletarian dictatorship which then led to their views described as ‘reformist delusions’ and need for treatment (Fulford et al (1993): 806-807)). These negative moral judgements leading to disease status allocation may be enhanced when the consequences are negative such as confinement and unpleasant/ unnecessary treatments. To prove this would require careful questioning of the people making the judgements whether this statement is true. It may be that different doctors – with different training or cultures of value judgements – would be less likely to regard these states as diseases. Pre-civil war US black doctors for instance may be less likely to have regarded black slaves escaping white masters as immoral or bad and thus less likely to view them as mentally diseased.


Conclusion
Value judgments around morality and appetites are involved when people judge whether states are regarded as diseases. Examples where what seem clear diseases are commonly not regarded (especially by the public) as diseases include dental caries and erectile dysfunction. This suggests value judgements around morality and appetites can trump what appear to be factual dysfunctions/ biological disadvantage.  Since the value judgements are of behaviours these value judgments are more likely to be found in mental illness than in physical illness. Value judgments that reduce the chances of states being regarded as disease include if it involves behaviours regarded as immoral or if it involves appetites/ drives and disease status leads to favourable consequences such as tax funded healthcare to help. If the consequences of disease status are negative (such as confinement) then negative value judgements may make it more likely for states to be regarded as diseases. There seems to be disagreement between individuals as to whether value judgments prevent allocation of disease status to states. Different groups and individuals may place different weights on these value judgments. Doctors for a variety of reasons may be more likely to regard states as diseases.


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