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Are MD Continuous with Healthy Functioning?

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Valentina Petrolini

on 3 April 2017

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Transcript of Are MD Continuous with Healthy Functioning?

Valentina Petrolini (University of Cincinnati)
Are Mental Disorders Continuous
with Healthy Functioning?

Core questions of my project
§2. Thesis a):
Mental disorders can be seen as
extreme variations of non-pathological phenomena.


Four dimensions of mental functioning and their disruption
. Pathological case studies.


§3.

Thesis b):
There are
non-arbitrary criteria
that can be used to distinguish between healthy and pathological cases.

Notions of
vulnerability, risk and protective factors.
Intermediate case studies and their relation to pathological ones.
Cases of
local imbalances
that are similar to the pathological ones as they approximate one extreme of a given dimension.

They represent situations of
vulnerability
to mental disorders and are thus crucial to explain the
transition from health to pathology
.

Argument for quantity
against categorical approach: These intermediate forms are both frequent and relevant.

Cut-off point between health and pathology becomes harder to pin down.
HYPO
HYPER
Salience
Confidence
Familiarity
Agency
Anhedonia

Interrogative
attitude
Fregoli
delusion
Capgras
delusion
AVH
Pathological
guilt
Grandiosity
delusion
Neuroticism
Sadness
Lack of interest
Estrangement
Dissociation
PBHE
False
confessions
Impostor's
Syndrome
Dunning-Kruger
effect

Meditation,
Mind-wandering
Engagement
Flexibility
Self-confidence
Self-attribution
Self-knowledge
Other-knowledge
Self-loathing
"A
logician
would have started by
defining what he meant by disease as a whole
and then produced individual diseases by sub-dividing the territory whose boundaries he had thus defined.

Medicine
, being essentially practical and opportunist, proceeded the other way and started with
individual diseases
.

As a result, many of these overlap with one another, and the
outer perimeter between disease and health is based on different criteria in different places
."
[Kendell 1975, p. 307]
Are there
boundaries
around the pathological?

What is the relationship between
normality

and
pathology
?

Which
approach
is better suited to explain
this relationship?
Two Approaches
Categorical
:
Disorders are seen as
discrete phenomena, qualitatively different from normal states
in virtue of pathological causal histories.
Dimensional
:
Disorders are seen as falling between points on an axis, or as a location in multidimensional space, and
not as discontinuous categories
.
[Murphy 2006, p. 345]
Dimensional Approach:
Empirical Defenses

Dimensional Approach:
Philosophical Resistances

AVH
(n = 375 college students): "71% of the subjects reported some experience of at least brief, occasional hallucinated voices during periods of wakefulness; and 39% reported hearing their thoughts spoken aloud"

Hallucinations (
n = 18,572 US residents): "The lifetime prevalence of hallucinations in this sample was 10% for men and 15% for women, and the overall rates were similar for visual, auditory, and tactile hallucinations."
[Johns & van Os 2001]
In the past thirty years, growing evidence for the presence of
psychiatric symptoms in non-clinical populations
. Taken as a support for the notion of a
continuum
between normality and pathology.
Obsessions and intrusive thoughts:
Clinical practitioners unable to reliably detect abnormal obsessions by looking at cards describing their content – i.e. only 55.8% of the assessments were correct.

[Rachman & De Silva 1978]
Arbitrary cut-off
point between mental health and pathology.
Analytic tradition
Phenomenological tradition
Incompatible with mental disorders being
natural kinds (i.e. discrete, homogeneous categories with clear boundaries from the normal)
.

Risk of leaving psychiatry out of the medical model.
Tendency to
typification (i.e. things are experienced as belonging to a certain type or kind)
.

Ideal type

or
prototype

approach
: classification should start
from exemplars of a
particular category
(e.g. schizophrenia)

[Murphy 2006; Samuels 2009]
[Fernandez 2016]
My Proposal:
I outline a
dimensional model of mental disorders
in order to
make space
for such a view in philosophy of psychiatry.
Road Map
§2.
Four Dimensions
and their
Disruptions

§2. Four Dimensions of Functioning
Ways of
modulating our relationship with the environment
.

Appraisals
or assessments on whether something is interesting, difficult, safe, controllable.

Not a complete list, but a
methodological sketch
.

Disrupted in
two opposite directions
:
Salience - Confidence - Familiarity - Agency
Ability that allows us to allocate
significance
in our environment according to our goals, preferences and dispositions - e.g "X appears interesting and worth exploring".
Tracking what matters to us
.
Nothing seems interesting or worth exploring
§2. Salience
Hypo
Hyper
Too many aspects of reality appear significant and crying for explanation
Engagement, flexibility
§2. Confidence
Ability that allows us to assess our
performance
with respect to a variety of tasks - e.g "X appears easy/difficult/beyond grasp".
Tracking what is doable
.


Hypo
Hyper
Self-doubt,
sense
of inadequacy,
underestimation
Grandiosity,
sense of
omnipotence,
overestimation
Self-confidence, self-worth
§2. Familiarity
Hyper
Hypo
Something
that is familiar appears strange or unknown
Something
that is unknown appears familiar
Ability that allows us to assess people and situations with respect to how much we feel at ease with them - e.g "X appears safe/known".
Tracking what is comfortable
.


Self-knowledge, other-knowledge
§2. Agency
Ability that allows us to assess our degree of responsibility or control over a situation - e.g "X appears within my control/beyond my control".

Tracking what is controllable
.


Hyper
Hypo
Loss of control with respect to things/events for which we are responsible
Sense of control over things/events for which we are not responsible
Self-attribution
§3.
Intermediate
Cases

§2. Disorders of Salience
“When I have to go to the bathroom, I first check the time in order to not stay too long.
It takes a certain amount of my time to look at my watch; I check exactly how the hands are placed
[…] I now find that the feather duster seems longer than usual.
I know that an object that has been seen repeatedly ends up looking less remarkable than at first
, but I nevertheless wonder whether the duster has become longer or shorter.
Every time, I look at it and ask myself this question
."

[Paul, reported by Minkowski 1923, p. 273]

I was supposed to be having the time of my life
. I was supposed to be the envy of thousands of other college girls just like me all over America […] Only
I wasn't steering anything, not even myself.
I just bumped from my hotel to work and to parties and from parties to my hotel and back to work
like a numb trolleybus.
I guess
I should have been excited the way most of the other girls were, but I couldn't get myself to react."


[Plath 1963, pp. 2-3 & 11-12]
§2. Disorders of Confidence

I began believing that I had a great future as an architect
[…] Teachers in my other classes were likewise paying a great deal of attention to me. I had discovered how to charm people into liking me using
my color theory
[…]
By using people’s natural sensory biases toward these colors, I could control them
, to the extent that I could give people a favorable view of myself.
I believed that these new powers were some type of magic.

[Reina 2009, pp. 3-4]
Depression & Self-loathing
: pervasive underestimation of one's abilities and talents, belief that one is not worthy of anything.

“Did I ‘intend’ to lose the money?
Recently I had been deeply bothered that I was not deserving of the prize.
I believe in the reality of the accidents we subconsciously perpetrate on ourselves, and so how easy it was for this loss to be not loss but a form of repudiation, offshoot of that
self-loathing
(depression’s premiere badge) by which I was persuaded that
I was not worthy of the prize, that I was in fact not worthy of any of the recognition that had come my way in the past few years.


[Styron 1991, p. 19]
§2. Disorders of Familiarity
Delusion of Capgras:
the patient believes that a loved one has been replaced by an impostor.

“She looked at her daughter carefully, inspected her facial characteristics, asked her to turn around and take off her shoes and walk.
After a few minutes’ hesitation she decided that ‘this person’ was only the double of her real daughter


"The patient’s behavior was remarkably consistent with the delusion, as
she put on black dressing in mourning of her ‘late’ husband, refused to sleep with his ‘double’ and angrily ordered him out of the house, shouting ‘go to your own wife
’”

[Christodoulou 1977, pp. 557-558]
A woman obsessed with theater starts to believe that
her two favorite actresses are taking the form of other people she encounters in everyday life
– e.g. bystanders, doctors, or employers

A woman developed Fregoli
after her fiancé had refused to marry her:
after this event, she
“misidentified strangers with an ex-friend who in the past had asked her to marry her but she denied his proposal”


[Courban & Fail 1927]
[Papageorgiou et al. 2002, p. 806]
§2. Disorders of Agency
Pathological guilt:
The patient feels responsible for actions she has not committed or that are trivial from other people's perspective.

"The patient tends to be overly hard on herself and to
feel directly responsible for the least signs of neglect.
If the towels for the massage are not in their usual place or if the newspaper for me to read when she is asleep is not instantly ready to hand” [...] “
Is it not a sign of worthlessness what I did yesterday?”
Freud cannot recall what happened to justify such a “damning verdict



[Freud 1893, pp. 65-70]
AVH:
internally generated speech is experienced as external and alien.

The first voice makes its appearance while Eleanor is going home after a class:
she characterizes it as neutral, similar to her own voice but narrating all her actions in third person, like a running commentary
– e.g. “She is leaving the room”; “she is opening the door”.


[Longden 2013]
§3. Intermediate Cases
§3. Two Kinds of Vulnerability
Increase of risk factors
(stress-inducing)

- Duration

- Frequency

- Intensity
(strength & depth)

- Urgency

- Scope
Weakening of protective factors
(stress-reducing)

- Control

- Energy (m&p)

- Humor

- Discharge

- Abreaction
§3. Vessel or Fortress?
A vessel struggles to stay above water during a storm.

How long will the storm last? (
duration
)

When will the next storm be? (
frequency
)

How strong will the storm be in comparison to others? (
intensity
)

How soon will it start damaging the vessel’s vital components (
urgency
)?

How widespread is the damage? (
scope
)

Breaking point = overflow
A medieval fortress is under siege.

What can be done about the attack? (
control
)

How can the citizens preserve various kinds of resources? (
energy
)

How can the citizens draw attention away from the threat, or release some tension?

(
Humor -
e.g. telling jokes about the siege;
abreaction -
e.g. venting;
discharge
- e.g. getting drunk)

Breaking point = defeat
§3. Neuroticism & Hypersalience
Instances of neuroticism include
mild obsessions
("This is what Bogart would do")
paranoid thoughts
("What if she's disappointed? What if she laughs or screams?") as well as various
idiosyncrasies
(talking to Bogart before going out on a date).

Neurotic individuals exhibit an
exaggerated attention to details
that are usually overlooked by others and
act upon them in ways that are unreasonable or irrational
.
§3. Neuroticism vs Interrogative Attitude


Over-attribution of salience
to objects and events that are trivial from other people’s perspective
(e.g. Bogart's outfit and lines; feather duster).

Obsessions as sources of anxiety


Protective factors
: humor used as a buffer against pathology.

Risk factors
: scope appears more restricted (romantic life vs everything)

§3. Impostor's Syndrome vs
Self-loathing

§3. Impostor's Syndrome and Hypoconfidence
Feelings and beliefs about one’s
inadequacy
that tend to
persist even in the face of contrary evidence
. Widespread among successful and over-achieving individuals, and especially among
women
.

“I
did not really deserve
the promotion I got"; "
I am not sure I am the best person
to run this new project"; "If I made it, anyone can"; "Deep down
I feel like an impostor
, fake and fraud" [Kay & Shipman 2014]



Recurring sense of
inadequacy
,
feeling
not worthy of recognition
.

“I feel like a complete failure”; “I do not deserve any of the recognition I am getting”; “It is just a matter of time before I am exposed as a fraud”.


Protective factors
: detachment and humor as strategies to regain control.

Risk factors
: scope (professional life vs everything), and possibly duration, frequency and intensity

§3. PBHE and Hyperfamiliarity
PBHE are often experienced by family members or close friends during the
mourning period
, and may take the form of
visual or auditory hallucinations, felt presence of the lost person, and attempts to communicate with her.

“One widow was resting in her chair on a Sunday afternoon when she
saw
her husband,
quite clearly
, digging in the garden with only his trousers on; another
saw
her husband coming in through the garden gate; a third
saw
her dead father standing by her bed at night” [Parkes 1972]
§3. PBHE vs Fregoli


Episodes of
misidentification
, where perception remains intact but the relevant judgment is altered.
Loved ones are involved.

“I don’t see him or hear him”; “I know he’s physically present” (PBHE); “He looks different”; “I know they are the same person” (Fregoli)

Protective factors
: control appears higher in PBHE; appraisal is positive as opposed to distressing

Risk factors
: duration and frequency are actually similar (or even more severe for PBHE), intensity is similar with opposite valence
§3. False confessions and Hyperagency
False confessions are cases in which
an individual confesses to a crime that s/he has in fact not committed,
often due to a process of suggestion or persuasion following police interrogation.

Reilly's case: 18-year-old from Connecticut who found his mother dead upon returning home and came to believe to have murdered her. “Now there is doubt in my mind.
Maybe I did do it
”; “The polygraph thing didn’t come out right.
It looked like I’ve done it
” [reported by Connery 1977, p. 66].
§3. False confessions vs Pathological Guilt




Subjects falsely – although sincerely –
come to believe to have committed an action that falls beyond his control
and takes responsibility for it.

Pervasive feeling of guilt


Protective factors
:
strength and control
(physical & psychological stress)

Risk factors
: duration (retraction time), urgency and intensity ("I did it" vs "I must have done it")
Wrap-up
New
dimensional model of mental disorders

where psychiatric symptoms and ordinary states are seen as
points along four axes - i.e. salience, confidence, familiarity, agency.


Harder to identify a
cut-off point
between normality and pathology (vs categorical approach).

Notions of
vulnerability
,
risk

and
protective factors

could be easily applied to clinical practice (prevention & prognosis).
Hyper

(excess, overload)
Hypo

(deficit, loss)
Depression & Anhedonia:
nothing appears exciting or worth exploring even when in-tune with one's goals and interests.
Schizophrenia & Interrogative Attitude:
Too many aspects of reality are puzzling or in need of an explanation.
Delusion of grandiosity
: sense of omnipotence, pervasive overestimation of one's abilities and talents.
Fregoli delusion:
the patient believes that everyone she encounters is in fact the same person.
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