Tuesday, 2 March 2021

Mental illness is a choice, but who is the agent?

Today's post is by Dan Reardon who is currently an MSc student at the Institute for Mental Health, University of Birmingham. Dan is a medical doctor and an entrepreneur who has founded multiple fitness and nutrition companies, including venture capital funded FitnessGenes. He has been featured in InStyle, The New York Times, Men’s Fitness, Inc, Well+Good, Livestrong and on Fox News, ABC News, Inside Edition, Today, BBC News, and “The Doctors.” Dan has a keen interest in the demedicalization of young people, digital wellbeing and resilience.

Dan Reardon

I have a long-held belief that mental illness is far from something that is “real” in the disease sense, and yet the rate of growth of mental disorders, both the number of potential diagnoses (described by Foucault as being an invention of 19th century reformers), and the number of people suffering, is exponential. I’ve read countless accounts of mental illness being a choice of those that “suffer”, but I’ve realised the statement is wrong. The choice to have a mental illness does not solely reside, if at all, with the person seeking counsel, but with the professional that chooses to either reinforce their career decisions, or simply decide that there is an easy way to palm off the challenges of life of that person. 

These choices are heavily reinforced if not lavishly coerced by drug companies, and within this “therapeutic domain” (Hazemeijer and Rasker, 2003), the normal individual having a challenging life becomes the patient with the diseases “anxiety and depression” (that have no biological basis), requiring medications (that don’t fix any identifiable disease) to feel a bit better about all of their life problems that remain exactly the same.

This is not to say, nor to undermine the suffering of the person seeking help, but the second these life challenges become medicalised rather than understood (Laing 1965), is the second that the sense of responsibility to deal with the problems is lost – and it becomes the responsibility of the state. But the state doesn’t fix these underlying challenges, it merely attempts to use poisons (pharmacology from the classic Greek pharmakon meaning 'poison') to make you feel a bit better about the problem or make someone else’s life a bit better/easier.

Let’s look at a stomach-churning example. In 2002 Miami Dolphins player Ricky Williams (adored by many people of all ages) made an appearance on the Oprah Winfrey Show declaring that he suffered with shyness. That sounds quite innocent given 40% of the Western world (in terms of natural temperament) is shy. But this was no ordinary declaration of shyness because Ricky was being paid by Glaxo-Smith-Klein (GSK) to go on the Oprah Winfrey show and declare his shyness. 

In the months following he would become the poster boy of the new “Social Anxiety Disorder” drug called Paxil®/Seroxat® (Paroxetine). Shyness and introversion were now a bona fide pathology (according to the DSM), with a huge opportunity to get 40-50% of the population medicated using a technique called condition branding, and in 2003 alone, sales of Paroxetine globally reached just under $5B.

Alas as if the waters here are not already murky, let’s introduce the 2004 lawsuit by the New York State Attorney suing GSK for failing to disclose important safety and efficacy data about said drug. This all came to light because a memo from 1998 from inside GSK was leaked, telling employees to withhold clinical trial findings that showed the drugs had no beneficial effects in treating adolescents.

Introverted people know all too well the challenges that they face, not least because of how they are socialized with comments like, “he needs to come out of his shell” or “he needs to participate more”, so this insecurity creates a natural “que” to be receptive to a solution to the fabricated social challenges. If you can find a que, and you can build a drug, you will find your title of stigmatization in the DSM.

In her book Lean In, Sheryl Sandberg talks about how young boys on the playground that show leadership are described as “good leaders”, whereas young girls are described as “being bossy”. This is perhaps one of the many reasons why we often lack females in leadership roles, but it’s an example of the effects of stigma and how it can make outcomes in life inevitable. It’s bad enough that we had previously stigmatised shy children, but we now give them a medical diagnosis of social anxiety disorder, autism, or attention deficit disorder, with the perfect medications to fix this.

In conclusion it is my opinion that the fate of people’s mental wellbeing seems to be in the hands of mental health/healthcare practitioners, incentivized to declare a mental illness, and not to make the now contrarian statement that “your health is fine, but you need some support managing your life”, which would not be best managed by the medical profession.

Tuesday, 23 February 2021

Interview with Federico Bongiorno on Delusions

In this post, I interview Federico Bongiorno who recently completed a doctoral project on delusion formation at the University of Birmingham.

Federico Bongiorno

LB: Philosophers are intrigued by delusions. What interests you about them?

FB: There are several things that interest me about delusions, which is part of the reason why I decided to write a PhD thesis comprising of self-standing papers rather a single book-like package. I will focus on just one, the question of whether delusions can be beliefs despite being only marginally belief-like.

Participants in this debate are typically non-committal as to what beliefs are over and beyond our folk-psychological practices. So, when they ask whether delusions are or aren’t belief-like, what they want to know are things such as whether delusions play the same role as beliefs in predicting intentional behaviour, or whether they conform to the stereotypical cluster of attributes (cognitive, behavioural, phenomenal) that we would normally expect beliefs to manifest.

An aspect that has so far been largely neglected in the debate is whether delusions really are beliefs, whether there is any robust and unitary psychological entity to simultaneously fill the role set by our folk concepts of ‘belief’ and ‘delusion’. Are beliefs objects that function within scientific theories, or are they merely part of folk psychology? And are delusions belief-like in a scientific psychological sense, strictly in a folk psychological sense, both, or neither?

Addressing this gap is important, I think, for the at least the two following reasons.

First, we need to ensure that the folk concept of belief is not in conflict with the scientific kind at work in psychology and cognitive science. For otherwise, we should allow for the possibility that delusions may be consistent with one but not with the other, or vice versa.

Second, if we can make lawlike generalisations about the ways we normally fix, update, and store beliefs, then we are in a position to really tell whether the surface features of delusions are features of beliefs.

The hypothesis I explored in my PhD thesis was that delusions are the way they are, deviate from rationality in the ways they do, because of how beliefs function cognitively under highly irregular circumstances, such as anomalous sensory experiences and attentional abnormalities.

So, one thing that interests me which very few people seem to be talking about is whether the status of delusions as beliefs can be assessed outside the folk-psychological discourse, and independent of our regular sayings about belief.

LB: Some philosophers claim that delusions are endorsements of experience and other philosophers argue that delusions are explanations of the experience. What is the difference between these accounts? 

FB: One idea that has been very popular in cognitive neuropsychology and neuropsychiatry is that delusions arise as subjectively adequate responses to abnormal sensory experiences, of sight, hearing, or whatever. Call this view ‘empiricism’. Empiricism comes in at least two variants that differ concerning the specific mode in which delusions are grounded in experience: the explanationist account and the endorsement account.

As you said, on the explanationist account, delusions serve an explanatory function, they arise inferentially from one’s reasoned attempt to explain an abnormal experience. On the endorsement account, delusions are acquired immediately, non-inferentially, from experience when one takes that experience at face value.

We can illustrate the difference between these two accounts using the example of Capgras delusion, in which a close relative or spouse is believed to be a stranger and to have been replaced by an identical imposter. Both sides agree that the Capgras delusion involves an abnormal experience in response to seeing a familiar person. What is at issue is the degree of continuity between the representational content of the experience and the content of the delusion itself.

Proponents of the explanationist account will say that the content of the experience is relatively nonspecific. For instance, the experience might be a coarse-grained feeling that something is off about the person being looked at, and one would hit upon the delusional hypothesis to make sense of why the person feels off, e.g., she does because she’s not who she looks like.

By contrast, proponents of the endorsement account will take the content of the experience to be closely linked, if not identical with, the delusional content. For instance, they might think that the reason why a subject believes that the person in front of them is a stranger is because they have in fact an experience representing that person as a stranger. 

LB: Which account do you prefer? 

My preliminary answer would be neither and both. 

What I mean is that we don’t have to choose one: we can use whichever seems most appropriate depending on context. For instance, if someone believes that they are possessed by the devil because they hallucinate voices telling them to kill God, their belief is probably going to be an explanation of experience. On the other hand, if someone believes they have a second head because they hallucinate a second head, that is probably going to be an endorsement of experience.

Something else to keep in mind is that you could in principle have hybrid cases of delusions formed from a combination of endorsement and explanationist processes. Indeed, some think the Capgras delusion might be one such case: the subject would literally experience a person as a stranger at some first moment in time, and later infer that the person is an imposter to explain why she looks so much like a loved one.

So, on balance, there is no reason why we should give up one view and keep the other, given that both potentially help explain delusions.

Tuesday, 16 February 2021

Delusions Beyond Beliefs

This post is by Jasper Feyaerts, who is discussing a paper he co-authored with Mads G Henriksen, Stijn Vanheule, Inez Myin-Germeys, and Louis A Sass, entitled "Delusions beyond Beliefs", and published in The Lancet Psychiatry. With this link, there will be free access to the article for a few weeks.

Jasper Feyaerts

Delusions are commonly conceived as false beliefs that result from epistemic failures to represent reality correctly. This view has been dominant throughout the history of psychiatry, and continues to inform contemporary research and practice. In explanatory research, it underlies (neuro)cognitive attempts to explain delusions in terms of impairments or biases in cognitive reasoning. In clinical practice, it motivates cognitive-behavioral strategies focusing on the rational evaluation of delusional appraisals.

Yet despite being the standard view of delusion in psychosis research, this conception has not gone entirely unchallenged. Most notably in the tradition of phenomenological psychopathology (Sass & Pienkos, 2013; Stanghellini et al., 2019), less emphasis has been put on the erroneous or belief-like nature of delusions, than on adequately identifying the specific experiential context within which delusions occur, with a particular focus on what ‘sort’ of reality delusional individuals may ascribe to them. 

Karl Jaspers in General Psychopathology, for example, already emphasized how certain types of delusions – i.e., which he called ‘primary’ or ‘true’ delusions, and considered specific for schizophrenia – are not mere ordinary empirical beliefs, but may involve global ontological changes that affect our most basic experience of reality. “Delusion proper”, Jaspers wrote, “implies a transformation in our total awareness of reality” (page 95); “reality [for the patient] does not always carry the same meaning as that of normal reality” (page 105).

In our review paper, we discuss how this phenomenological emphasis on the overall experiential context of delusions can be used to critically revisit and to enhance contemporary diagnosis, explanation and treatments for delusions. In diagnostic research, we show how claims regarding the existence of a so-called ‘continuum’ between ordinary irrational beliefs and delusions may have more to do with the vagueness and selectivity of criteria and measures used in assessing these phenomena, than with the continuous nature of delusional experience itself. 

In explanatory research, we discuss how one/two-factor-accounts and predictive models could benefit from accommodating global ontological transformations in their accounts. This could offer more specificity to the nature of anomalous experience in schizophrenia, while it also challenges the idea that delusion is always a matter of (rational or irrational) belief explaining or endorsing experience. We emphasize in particular that alterations in reality experience also alter the cognitive status of delusions. It is unclear, for example, whether straightforward believing is actually possible in a delusional world that is experienced as entirely unreal or sometimes even as somehow mind-dependent.

In therapeutic research, we suggest that the limited therapeutic benefits of current cognitive-behavioral treatments for delusions (see Jauhar et al., 2014) may be the result of applying an ordinary framework of reality experience in emphasizing rational evaluation of delusional beliefs. We argue that treatments should shift away from narrowly targeting delusions themselves (via attempts, eg., to refute or challenge them) towards altering the experiential conditions that inspire and sustain them. From a phenomenological perspective, effective treatments are most likely those that help to reduce feelings of self-alienation and uncertain embeddedness in everyday reality that are conducive to delusional experience.

Yet we also emphasize that delusions are not always experienced as a simple affliction or deficit. Indeed, for some individual with delusions, the common-sense perspective can look flat, uninspiring, and utterly constrained by conventionality, closed off from what they consider the true sources of originality and truth. As such, delusions are not only a psychopathological or psychiatric issue, they also seem to confront us with the possible contingency or ungroundedness of our ordinary reality experience.

Tuesday, 9 February 2021

Motivated Reasoning in Science

Today's post is by Josh May (University of Alabama, Birmingham). In this post, he talks about one of his papers published in Synthese and entitled "Bias in Science".

Josh May

Much discussion of the replication crisis in science has focused on the social sciences, particularly psychology. A common narrative is that the social sciences are particularly susceptible to powerful biases, such as moral and political ideology. I argue instead for a parity thesis: all areas of science are subject to bias, through the general psychological mechanism of motivated reasoning. This provides a unified framework for understanding how values influence the entire scientific enterprise.

The scientific process involves numerous decisions that can be influenced by one's values--including moral, political, and prudential values--which manifest as goals or motivations. A researcher wants badly, say, to publish in a prestigious journal in order to either advance her career or maintain her status and recognition among colleagues. Or she wants badly to maintain her industry funding, or to promote a pet theory, etc. 

These motivations can then influence her reasoning about which hypotheses to test, how to operationalize variables, how to interpret the data, whether to report certain measures, and so on. Commonly this involves wishful thinking and confirmation bias, but these are just instances of the general phenomenon of one's reasoning being influenced by one's motivations---typically ante hoc, not post hoc (see May 2018: Ch 7).

So what motivates most scientists? Drawing on case studies and surveys of scientists, I highlight four ultimate goals: knowledge, ideology, credit, and profit. Of course many scientists are motivated to produce knowledge and to acquire or maintain a job ("profit"). Researchers are also motivated to promote favored ideologies---such as libertarianism, theism, and environmentalism---for which the natural sciences also have implications (think e.g. of climate change, intelligent design, vaccines). 

What is less often recognized is that, as humans, scientists are deeply social and hierarchical creatures and thus powerfully motivated to acquire, maintain, and improve their status among peers by earning "credit" for scientific advances and achievements. Thus, even when researchers are unmoved by ideology or profit, there is always the concern to impress one's peers and move up the social ladder, even if that requires questionable research practices that conflict with the knowledge motive.

Philosophers of science have long emphasized that values influence scientific practice, in both pernicious and productive ways. I similarly do not assume that motivated reasoning is always problematic. Sometimes it produces knowledge by, say, opening up neglected avenues of inquiry (e.g. Anderson 2004) or leading to an invisible hand that guides the marketplace of ideas toward knowledge (e.g. Solomon 2001; Bright 2017).

My analysis within the motivated reasoning framework argues that the natural and social sciences are more alike than different. All domains of science are subject to motivated reasoning and often the more powerful "non-epistemic" motive is social credit, not ideology, which might seem more prevalent in the social sciences. I hope this illuminates how pervasively values influence all areas of science, whether in pernicious, productive, or even benign ways. 

Motivated reasoning is a fact of human life and thus (all) of science.

Tuesday, 2 February 2021

Psychiatry and Anti-Psychiatry in the 70s in Italy

Today's blog is by Matteo Fiorani (University of Rome, Tor Vergata) and it is the last in a series of posts associated with the special issue of the European Journal of Analytic Philosophy on Bounds of Rationality. Matteo's paper (open access) is entitled: "Rationality, Irrationality and Irrationalism in the Anti-institutional Debate in Psychiatry around the Second-Half of the 1970s in Italy".

Matteo Fiorani

The 1968 movements overwhelmed psychiatry with anti-authoritarian and anti-institutional criticism. The young protesters demanded, first of all, the rights of madness and, provocatively, of unreason. At the same time, they dismissed the dominant normality, represented by bourgeois common sense. They also affirmed the need not to repress contradictions and suffering. Emotions and affectivity were indeed part of the social and political world. From these premises it was possible to develop a deep political and cultural reflection on the boundary between reason and madness. The so-called official psychiatry and the scientific criteria that sought to distinguish with certainty between insanity and mental health, were radically challenged.

In Italy, psychiatric discourse was politicized as in no other Western country. Starting in the 1970s, in a scenario characterized by a profound cultural and political transformation within the left, anti-psychiatry became a word that was used, abused, mythologized and misunderstood. It was at the center of a veritable battle of ideas. The traditional concept of rationality and its very connection to irrationality were challenged, as was the idea of classical reason. The attempt was to redefine limits. Did madness really exist? Was it, in a perspective of overthrowing the bourgeois order, a manifestation of freedom and creativity? Or was it illness and suffering produced by life's experiences?

In my article I tried to give an account of all this. Not without difficulty, especially in the interpretation of the sources. On the one hand, in fact, the reviews of the movement, the writings of anti-establishment psychiatrists and the militants of the so-called New Left gave a sensation of hopeless desolation, made up of irrationalist drifts that simplified psychiatric discourse. They also left unresolved the many important questions about normality and madness raised since 1968. On the other hand, oral sources and individual experiences of psychiatric renewal, less visible and less recounted (and for this reason present in the paper as suggestions), warned me of the danger of excluding the positive legacy of those years, probably crushed by the depressed look of today. 

The hyper-politicization of the psychiatric and scientific question certainly struggled to find a synthesis and a direction. Especially since the mid-1970s, the irrationalist drifts can be interpreted as the failed attempt to affirm a new rationality that was even more rigid, even if directed against the system. In this sense, even Marxism, in its various interpretations, proved unable to find a way out. However, it was not only psychiatrists who approached anti-psychiatry texts, but also students and intellectuals (an Italian peculiarity) in search of alternative tools to interpret reality.

These people wanted to free themselves from the decades-long devaluation of science, typical of Italy (in the footsteps of the neo-idealism of Benedetto Croce and Giovanni Gentile) and to open up to foreign countries, especially the United States, where science was not devalued, but complicated, and where it was possible to criticize Galilean rationality without being accused of relativism. In short, the answer to the rationality of the system was not only an aimless flight into irrationalism (which it was). It was also an attempt to hold together rationality and irrationality, intellect and affects (reason and sentiment, we could say), to build a new free and vital subjectivity.

Tuesday, 26 January 2021

Against Defining Delusion

Today's post is by Sam Wilkinson. You can read Sam's recently published paper, Expressivism about Delusion Attribution, in the European Journal of Analytic Philosophy. It appeared in a special issue on the Bounds of Rationality.

Sam Wilkinson

What is delusion? While we can point to paradigmatic cases, we have struggled to produce an uncontentious definition of delusion. In my paper, I argue that we shouldn’t have been trying to define delusion in the first place, and that it becomes clear why, once we reflect on the sort of concept that delusion is.

Delusion attribution, e.g. saying “This person is delusional”, is not (fully) fact-stating. It is not like saying “This person is 6ft tall”. It is fundamentally an evaluation. Some evaluations involve failing to adhere to an objective benchmark, while others are more fundamentally, irreducibly evaluative. One way of thinking about these fundamental kinds of evaluations is as expressive, rather than descriptive.


To simplify somewhat, delusion attributions are more akin to expressions of folk-epistemic bafflement. Why think that this is so? And what are the consequences of this?

First of all, it seems like delusion expresses a negative evaluation. Consider a hyperbolic use among friends (“You’re delusional if you think Manchester Utd. will win the Premiership!”). Now, one might object that, while this is an expressive use of “delusion”, this is not at all how psychiatrists use the term. Nevertheless I would insist that the calm, institutional use of the term only masks its true nature.

Secondly, as with expressivists in meta-ethics, who are motivated by a metaphysical unease with postulating moral properties we might be similarly reluctant to countenance properties of “delusionality”.

What are the consequences of the view?

First, an inability to define is to be expected. Why think that all of the many things that arouse negative reactions from our folk-epistemic sensibilities can be regimented under a strict definition?

In a related manner, if you try to characterize the sorts of things that get called delusions, you get a sort of disjunctive norm pluralism. Put simply, there are different kinds of folk-epistemic badness, but once a threshold is reached, you call that thing a delusion. Contrast, for example, reverse Othello syndrome with a bizarre delusion in the context of psychosis. You might, for example, think about the implausibility of the content. Here, the bizarre delusion (“I am the left foot of God”) scores highly, so highly in fact that you don’t even need to ask yourself about the individual’s grounds for the claim. (Though interesting, it wouldn’t remove delusional status.) In contrast, if somebody said “My wife is being faithful to me”, this is true (one hopes) of many people, and it could only be an examination of their personal situation, their resistance to evidence, etc. that would then tip them into delusional territory.


Since delusion attribution is an expression of bafflement, understandability takes precedence over rationality. A mother who is reluctant to believe that her son is a murderer may exhibit profound levels of epistemic irrationality, but we understand that people are reluctant to admit the guilt of loved ones. Indeed, we’d find an impartial acceptance of the evidence more troubling!

What does this mean for delusions researchers? Not much. Keep up the great work on paradigm cases of delusion. Just don’t worry about defining it.

Tuesday, 19 January 2021

Disorders of Agency on a Spectrum

Today's post is by Valentina Petrolini (University of the Basque Country – UPV/EHU). Here she talks about a recent paper she wrote, “Too Much or Too Little? Disorders of Agency on a Spectrum” published open access in a special issue of the European Journal of Analytic Philosophy on Bounds of Rationality.

Valentina Petrolini


“Rock You like a Hurricane” has been playing on repeat in my head since yesterday. I am unsure where it came from, although I am afraid a binge session of Stranger Things might have something to do with it. Despite my attempts, getting rid of the song proves surprisingly difficult. In my paper I characterize these episodes as mild cases of hypoagency. An action – in this case a mental one – is attributed to an agent, who is unsure about having initiated it and lacks a robust sense of control over it.

Some instances of hypoagency – such as having an 80’s song stuck in your head – strike us as relatively innocent. We may even imagine circumstances in which similar mind-wandering episodes may be beneficial. Assume that I have an important interview coming up and I cannot concentrate because my thoughts keep drifting away. Although my fantasizing might take a pessimistic turn, it might also allow me to come up with original ideas that help me succeed in the interview.

In an interesting study, Baird and colleagues show that some forms of mind-wandering might indeed support problem-solving. Other experiences of hypoagency are undoubtedly less benign. Think about phenomena such as auditory verbal hallucinations (AVH), in which a person loses grip over her own thoughts and experiences them as alien. Longden describes her voice-hearing experience along these lines: the first voices sound like “a running commentary”, but over time they grow in number and intensity and start issuing threats and commands over which she has no control.

However, there are also situations in which people experience hyperagency. A clinically-relevant example concerns cases of pathological guilt, commonly experienced by people diagnosed with schizophrenia. For instance, Saks talks about being filled with anxiety when reading the newspaper, because she would blame herself for every violent crime reported in the area. Some cases of hyperagency do not qualify as pathological. 

An interesting phenomenon in this sense is false confessions, in which people take responsibility for crimes that they have not committed. Although the idea of innocent people willing to face legal charges appears counterintuitive, studies in forensic psychology show that false confessions are relatively frequent. A famous case is portrayed in DuVernay’s series When They See Us and involves the men who came to be known as the “Exonerated Five”.

How should we think about different cases of disrupted agency? One important distinction concerns self-attribution versus feeling of agency. While self-attribution may be correct or incorrect, the feeling of agency comes in degrees. Extreme cases of hypoagency – such as AVH – exemplify situations in which self-attribution is incorrect and the subject lacks a robust feeling of agency. By contrast, in mind-wandering the perceived lack of agency usually fails to be accompanied by misattribution: even if I can’t stop thinking about the Scorpions song, I do not perceive it as externally generated. 

Things are more complex with hyperagency. Both pathological guilt and false confessions exemplify situations in which self-attribution is incorrect and the subject reports a strong feeling of agency. The difference between these cases is thus likely to be one of degree, where quantitative factors such as duration or intensity may be taken as reliable indicators.

Tuesday, 12 January 2021

Reflections about electroconvulsive therapy

Today's post is by Emiliano Loria (Universit√† La Sapienza, Roma). Here he summarises a recent paper he wrote, "A desirable convulsive threshold: Some reflections about electroconvulsive therapy", published open access in a special issue of the European Journal of Analytic Philosophy on Bounds of Rationality.

Emiliano Loria

Long-standing psychiatric practice confirms the pervasive use of pharmacological therapies for treating severe mental disorders. Nevertheless, we are far from triumphal therapeutic success. Despite the advances made by neuropsychiatry, this medical discipline remains lacking in terms of diagnostic and prognostic capabilities when compared to other branches of medicine. 

An ethical principle remains as the guidance of therapeutic interventions: improving the quality of life for patients. Unfortunately, psychotropic drugs and psychotherapies do not always result in an efficient remission of symptoms. I corroborate the idea that therapists should provide drug resistant patients with every effective and available treatment, even if some of such interventions could be invasive, like Electroconvulsive Therapy (ECT).

ECT has an almost centennial history that began in Rome (Italy) in 1938, at the Clinic of Nervous and Mental Diseases, run at the time by (psychiatrist) Ugo Cerletti. ECT still represents one of the most important and controversial therapeutic discoveries in the field of psychiatry. ECT carries upon its shoulders a long and dramatic history that should be better investigated to provide new insights. 

From the examination of the Archives of Pediatric Neuropsychiatry in Rome - a section of the Roman Clinic specifically dedicated to minors - I discovered t the first child ever administered with ECT (September 18, 1940), a 7-year-old boy diagnosed with “dementia praecocissima”, a diagnostic category introduced by Sante De Sanctis, who was Ugo Cerletti’s predecessor to the direction of the Roman Clinic, as well as the one who established the first department of Neuropsychiatry.

ECT has attracted renewed interest in recent years. This is due to the fact that antidepressant drugs in younger patients show often scarce effectiveness and unpleasant side-effects. Moreover, thanks to modern advances, ECT may work as a successful form of treatment for specific and rare cases, such as severe depression (with suicide attempts) and catatonia. 

When pharmacotherapy fails to improve depressive symptoms, then, response rates of about 50–60% can be achieved by ECT. For this reason, particularly in depressed patients at high risk of suicide, ECT should be recommended earlier than its conventional “last resort” position. In fact, the risks of suicide have been shown to relieve quickly through ECT, when administered in continuity with previous treatments, that are essential to sustain its benefits.

The ethical puzzle that I raise is the following. Is it possible to administer a therapy to help severely suffering patients (be them adults or minors)? If the answer is yes, at least for some types of severe diseases, why should we prolong the severity of the symptoms by making the life of patients and their family members unbearable? One therapy for the improvement of some severe psychotic symptoms exists and is practicable. ECT is such a therapy. In this sense, ECT does not constitute an alternative model of treatment, but an additional therapeutic tool that does not replace, but rather integrates pharmacotherapy and psychotherapy.

Tuesday, 5 January 2021

Delusions in the two-factor theory: pathological or adaptive?

Today's post is by Eugenia Lancellotta (University of Birmingham). Here she talks about a recent paper she wrote, "Delusions in the two-factor theory: pathological or adaptive?", published open access in a special issue of the European Journal of Analytic Philosophy on Bounds of Rationality.

Eugenia Lancellotta

Are delusions pathological, adaptive, or both? I investigated this issue with Lisa Bortolotti. We framed the question in the context of one of the most popular theories of delusion formation and maintenance: the two-factor theory.

Two-factor theories hold that the formation and maintenance of delusions involve two factors. Factor 1 is usually a neuropsychological impairment, while Factor 2 is a cognitive deficit or bias. While two-factor theorists agree on the broad two-factor architecture involved in the formation and maintenance of delusions, they disagree on some aspects of it. Coltheart and McKay are among the most prominent two factor theorists. 

While for Coltheart, Menzies and Sutton (2010) Factor 2 is a cognitive deficit that only gets activated in the maintenance stage of delusions, for McKay (2012) it is a bias that is already present when delusions are adopted. In other words, for Coltheart delusions are initially a rational explanation of the anomalous feelings or experiences engendered by Factor 1, but they then become problematic when maintained in the face of counterevidence. For McKay instead, adopting the delusion in the first place is already problematic. Therefore, according to McKay, a bias in reasoning – though not a deficit - must already be present in the adoption stage of delusions.

How do these theories relate to the notion of pathology? We argue that in the Coltheart model, delusions are pathological both on a normativist and naturalist view. On a normativist view, delusions are pathological because they disrupt psychological functioning, while on a naturalist view, delusions are pathological because they are due to a cognitive dysfunction (Factor 2 in the Coltheart model). For McKay, delusions are not pathological on a naturalist view, because their formation and maintenance are due to a bias rather than to a dysfunction, while they can be pathological on a normativist view, because they can disrupt psychological functioning.

What about the relationship that such theories entertain with adaptiveness? Delusions are adaptive if they are designed to act as an emergency mechanism, providing psychological or biological benefits in the face of adversities, traumas or cognitive impairments. On Coltheart’s reading, maintaining delusions in the face of counterevidence could be a response to a crisis that prevents the cognitive system from collapsing, so delusions might be adaptive. On McKay’s model, adopting some delusions could be a response to a crisis that prevents the cognitive system from collapsing, so delusions could be adaptive when adopted. This is compatible with those delusions being the outcome of a cognitive bias.

The conclusion of our investigation is somewhat surprising. In the McKay model, some delusions can be pathological and adaptive, though not at the same time. Adaptive, because they prevent the person’s cognitive system from breaking down when adopted; pathological, on a normativist account, because they disrupt the person’s psychological functioning in the long-term. However, in the Coltheart model, delusions cannot be adaptive and pathological, because the fact that they are the outcome of a dysfunction (pathological in a naturalist sense) is incompatible with the possibility that they are the outcome of an emergency mechanism which breaks by design.