Original Paper Psychopathology 2015;48:145–152 DOI: 10.1159/000369889
Received: April 29, 2014 Accepted after revision: November 10, 2014 Published online: February 25, 2015
Carving versus Stitching: The Concept of Psychic Function and the Continuity/ Discontinuity Debate Carlos Rejón Altable a Álvaro Múzquiz Jiménez b
Hospital de Día, Hospital, Universitario de la Princesa, UAM, Madrid, and b Centro de Salud Mental Egia, Red de Salud Mental de Gipuzkoa, Donostia-San Sebastián, Spain
Key Words Continuity studies · Delusions · Epistemology hallucinations · Psychic function psychopathology · Psychotic symptoms · Subjectivity
Abstract Background: The current debate on the continuity or discontinuity of psychotic symptoms and common psychic experiences has mainly dealt with methodological, epidemiological and clinical issues, but it has neglected epistemological research on the main concepts of the field. Methods: The implicit epistemic structure of continuity models of psychotic symptoms and its effect on research are addressed. Results: We explain how the seemingly commonsense, unproblematic concept of psychic function may explain the contradictions and paradoxes of research. Conclusions: A new model of symptom individuation and symptom eliciting is proposed – based on the concepts of ‘schemas’, ‘embodied affordances’ and ‘thick/thin descriptions’. © 2015 S. Karger AG, Basel
Introduction
The current debate on the continuity or discontinuity of mental symptoms and common ‘psychic functions’ is far from new. In 1926, Eugene Minkowski wrote an essay © 2015 S. Karger AG, Basel 0254–4962/15/0483–0145$39.50/0 E-Mail [email protected] www.karger.com/psp
where he refused to consider psychopathology as ‘the younger sibling of psychology’ and argued for a non-psychological psychopathology rooted in phenomenological anthropology [1]. Some of the examples he discussed were, not surprisingly, hallucinations and delusions. He contended that psychic functions were misleading concepts, as they group together phenomena which differ in their innermost structure [2]. The very same debate has now been shaped into the continuity/discontinuity discussion. Continuity models understand mental symptoms as intensified versions of common experiences [3]. Discontinuity models seem to identify meaningful differences where descriptive continuity models stress similarities [4, 5]. However, they find it hard to identify the specificity of the clinical experience in a way which matches the large sample sizes and methodological rigueur of continuity work. Continuity models either highlight descriptive continuity of symptoms and ‘normal’ experience along a scale of severity (from suspiciousness to mild or episodic delusion-like ideas to full-blown delusional thought) or focus on continuity of risk for psychotic-like experiences along subjects in non-clinical, at risk and clinical samples. This paper focuses on descriptive continuity and its relation to the concept of psychic function. We list four possible, non-exhaustive stances to be taken in this debate. First, there is no such difference, or it is accidental (i.e. intensity, impairment of reality judgeDr. Carlos Rejón Altable H. de Día H., Universitario de la Princesa – Área 2 C/Marqués de Ahumada 7 ES–28023 Madrid (Spain) E-Mail crejon @ hotmail.com
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a
Carving versus Stitching
Introducing Schemas and Psychic Functions We have developed elsewhere how psychopathology is a process which brings intelligibility to some items of uncommon experience or behaviour [6–9]. It does so through cognitive devices which work as ‘templates’ (the technical term is ‘schema’ and we will stick with it from now on) which bridge the gap between common and uncommon experience and bring together heterogeneous material into a meaningful whole. Either common language or technical language terms (‘perception’, ‘sadness’, ‘delusions’, or ‘voices’) are used to schematize new, uncommon experiences. Quite understandably, schemas (‘I hear voices’, ‘I know I’m in danger’) are too often taken as faithful renderings of pathological experiences (perception went wrong, thought went wrong). Once we have defined ‘hallucination’ as ‘perception but without an object to be perceived’, it is only natural to understand hallucinations in terms of the psychology and physiology of perception [10]. Thus, a putative family of phenomena is neatly arranged in a line going from perception to illusion to hallucination or to dissociative/depressive/schizophrenic hallucinations. This procedure belongs to the conceptual framework of classical psychiatry, and the notion of psychic function is essential to it. This is not mere theoretical speculation. Some research groups consider auditory verbal hallucinations (AVHs) a heterogeneous group of phenomena which includes commanding/commenting voices (usually associated with troubles in inner speech), ‘replay’ voices (with memories), ‘own thoughts’ voices (which share commonalities with inner speech and with memories), and nonverbal auditory hallucinations [11]. There have been others who have tried to make clear the relations between 146
Psychopathology 2015;48:145–152 DOI: 10.1159/000369889
first-rank hallucinations and other kinds of ‘voices’ [12], establish the role of culture in modelling hallucinations or study the differences between alcohol/epilepsy/schizophrenia-related voices [10, 12]. In short, they all break a ‘perceptual’ category into related but different experiential pieces. Why Symptom Individuation Matters In a previous paper [13] we explained how some of the material which has to be schematized appears during individual symptom formation and thus may remain out of descriptive definitions but be handled during symptom eliciting. We also pointed out that pragmatic constraints of research on hallucinations and delusions in non-clinical samples involve some loss of this kind of ‘out-of-definition’ descriptive information and how, as an unexpected spin-off, research is grouping together phenomena with only loose ‘family resemblance’ such as common suspiciousness, paranoia and acute delusions. In this paper we use the extensive body of work dealing with continuity models for hallucinations and delusions to show how continuity models are dependent on the concept of psychic function and how this concept cannot clarify the continuity/discontinuity debate [14]. Are we proposing an absolute cleave between the members of the ‘symptomatic family’? – not quite so. We will try to prove how continuity/discontinuity is better understood through the concept of embodied affordances as the domain assuring continuity and the concept of schema as the procedure that can explain both continuity and discontinuity of uncommon and common experiences.
Continuity Studies
Premises: Why Psychic Functions Are Needed Continuity models of psychotic symptoms (CMPS) share one theoretical premise about syndrome-focused psychiatric research. This premise underpins its substitution for single-symptom research (which is the method of choice for CMPS). It may be written down succinctly as follows: ‘syndrome research hides strict categorical approaches to mental disorders’. Two consequences follow: (1)In syndrome-focused empirical research, ‘syndromes’ are handled as discrete entities, with zones of rarity (the joints of nature) between them [15–18]. (2)In syndrome-focused empirical research, mental symptoms are considered just that: symptoms – either the expression of some underlying dysfunction or part Rejón Altable/Múzquiz Jiménez
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ment, symptoms which co-occur). Second, there are differences which can be seen and pointed in clinical situations but which have (so far) eschewed formal description. Third, there is something wrong with the tool called ‘descriptive psychopathology’; it fails to capture some basics of human language, experience and behaviour, and thus it gives rise to seemingly unsolvable issues such as continuity versus discontinuity. The fourth stance is a mix of stances one, two and three. If reason number one is true, we are not carving nature at its joints. If two is true, we are stitching nature along unperceived fissures. If three is true, some deep retooling in psychiatric semiology must be undertaken.
The Nature of Mental Symptoms: Why Psychic Functions Are Needed There is one implicit epistemic choice in CMPS: psychotic symptoms are but points in a continuum which leads from normal psychic function to full-blown symptoms [14]. These symptoms are characterized by a fixed, internal structure which is essentially the same across different contexts (life events, psychiatric syndromes, neurological diseases). This invariable structure should be grasped by (current or future) descriptive definitions [15, 25] and studied transdiagnostically across clinical contexts. The basis for this structure is furnished by the notion of psychic function. Psychic functions are stable across contexts and are present in healthy, subclinical and clinical samples and, as they are rooted in evolutionary processes, they are partially shared by other animals, thus ensuring putative validity of experimental models. However, for some symptoms such as auditory hallucinations this assumption simply does not hold. The phenomena gathered under the umbrella term ‘auditory hallucinations’ and screened for by usual questionnaires range from single words, music or noises to constantly commanding or commenting voices. Even if we focus on AVHs, commonalities between AVHs in different clinical syndromes [10] such as epilepsy, alcohol abuse, posttraumatic stress disorder, schizophrenia, and bipolar disorder go along with clinically relevant differences, and if we look into the symptom itself, some characteristics so far considered essential in descriptive definitions (volume, intensity, location, control) may be considered accessory, even misleading, as they have blurred the different experiential realms behind AVHs [5]. Carving vs. Stitching
Reading Epidemiological Results: Why Psychic Functions Are Needed Perhaps the strongest argument for the ‘psychic function continuum’ is the high prevalence of phenomena similar to classical psychotic symptoms which CMPS report in non-clinical samples. Incidence and prevalence vary. In a 2011 literature review Beavan et al. [26] found that prevalence for auditory verbal hallucinations ranged from 0.6 to 84%, with an interquartile range of 3.1–19.5%. This high range of prevalence is usually considered as an artefact provoked by the heterogeneity of the methodology and designs [3]. Most CMPS report striking similarities between clinical and non-clinical samples – being male, having lower levels of schooling, urbanicity, alcohol and drug use, unmarried status, and trauma [19, 21, 27]. There are some significant differences between them, however. In ‘Strauss revisited’ Van Os et al. [20] reported a higher incidence of positive psychotic symptoms in women. In a recent study by Wiles et al. [28], the incidence of self-reported psychotic symptoms was higher for inhabitants of rural areas, whereas little evidence was found for the the association of psychotic symptoms and marital status, social class, employment status, or educational qualifications. The statistical distribution of symptoms in non-clinical samples varies. Whereas half-normal distribution is the one most commonly predicted and reported in CMPS [19, 21], an exponential, skewed, non-linear distribution [29–32] is also frequently reported. Some authors have even found a normal distribution [15]. These results are usually taken as proof of the existence of the psychic function continuum, but they may very well be the effect of epidemiological questionnaires, designed to address ‘family resemblances’ rather than ‘family differences’ [33–35]. Family resemblances are then taken for identity between phenomena on the basis of the psychic function continuum. Interestingly, the psychotic-like phenomena found in these studies seem to be weak predictors of clinical psychosis [36, 37]. Thus, the hypothesis of the psychic function continuum would back up syndrome deconstruction (through the assumption that ‘symptoms are mal-functions’), dimensionality and transdiagnosticity (psychic functions are the same in all clinical/non-clinical samples), putative over-inclusiveness or lack of distinctiveness of questionnaires (only a minimum information is needed to identify both the function and the mal-function), and the interpretation of epidemiological data. Some empirical research is beginning to address this issue. A few groups have tried to compare the phenomePsychopathology 2015;48:145–152 DOI: 10.1159/000369889
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of a whole called ‘syndrome’. They are not to be found in healthy/common/non-clinical mental life [15, 18– 23] and, as long as symptoms are considered the expression of some underlying general-syndromic dysfunction, the specific psychic/physiological/pathogenic mechanism of hallucinations/delusions/inhibition cannot be adequately targeted. On the other hand, symptoms are considered valid, stable, specifically linked to underlying processes of psychopathology, and less stigma prone [24]. However, if symptoms are not the expression of some general/syndromic/axial dysfunction underlying the variety of clinical features they can only be conceived as the result of disturbed particular psychic functions. Let us take a closer look at this consequence.
Why Continuity Studies Are One Offspring of Classical Psychiatry CMPS share some epistemic core assumptions about the structure of mental symptoms which may be unfolded as follows: (1)Descriptive definitions of symptoms encode the core features of the symptom. Some other features may be important but they are incidental. The addition of ‘core features + incidental features’ characterizes each member of the category exhaustively. Empirical research should address core features, which are present in clinical and non-clinical samples and remain unchanged transdiagnostically. (2)Core features of mental symptoms should be conceived as ‘psychic function + P factor’ units, where P stands for ‘pathological’. Symptoms should be grouped along functions. As we pointed out in the introduction, this premise is deeply rooted in psychiatry and clinical psychology and has been shaped in different ways. But whatever is considered P varies. Some classical psychiatrists considered P not as ‘dysfunction’ but as ‘incidental features’. Thus, hallucinations were not always pathological. If they actually were pathological, they lasted a long time, impaired reality judgement and implied lack of insight and delusional thinking. Some others understood that the P factor included the ‘quality’ of the experience – melancholic sadness was different from common sadness, manic excite148
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ment was not the same as exhilaration and schizophrenic depersonalization did not correspond to melancholic depersonalization. CMPS think of the P factor as a matter of degree and sometimes as a matter of concurrent symptoms too – intense enough suspiciousness becomes delusional. Too frequent/too pervasive/too long hallucinations are pathological. In spite of the different nature assigned to P, the first and second assumptions about the nature of the symptoms and the descriptive language of semiology (psychic function + P, core features + incidental features) can be easily traced back to classical psychiatry development during the 19th century, which means we are dealing with deep problems likely to be rooted in very longlasting epistemological configurations and which will not be solved by re-editing the continuity/discontinuity discussion in terms that parallel Minkowski’s essay of 1926 [1].
Time for a Different Model: Embodied Affordances and Schemas
Let us consider now another model, which we believe is able to account for both the similarities and the differences found between the various kinds of phenomena gathered under any given symptomatic category. We shall first introduce three premises concerning what symptom, categories and descriptions are not. Then we shall propose some alternative approaches. Symptoms, Categories, Descriptions: What They Are Not First Premise: Mental Symptoms Are Not ‘Natural Events’ CMPS handle mental symptoms as stable natural kinds. Only for such objects do the methodological and ontological assumptions described above make real sense. Social and cultural contexts are considered risk factors which belong to the wide array of risk factors for psychotic symptoms known today (genetic, obstetric, physical/ sexual abuse). Although this is a widespread model, it has been criticized from different perspectives [6, 40–43]. Human beings talk, behave and experience. Language, experience and behaviour may be abnormal, but the form and meaning of human experiences and behaviour are shaped within a particular semantic space, without which they would be completely different or even disappear [40, 41]. This space is grounded in cultural strata partially Rejón Altable/Múzquiz Jiménez
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nology of AVHs in clinical and non-clinical samples. Daalman et al. [38] assessed the characteristics of AVHs in a clinical and non-clinical sample using PSYRATS. The following items showed significant differences: negative content, lower control and higher frequency in the patient group. Clear, unexpected differences on attribution were also found – an internal attribution (‘their own mind’) was more frequent in the patient group. In the non-clinical group, an ‘external-paranormal’ source was more frequently reported. Similar results were found in earlier studies [39]. Qualitative research would find further differences. A recent study [4] designed to assess the phenomenal quality of hallucinatory experiences through open, narrative descriptions of AVHs found a very different quality in the experience of voices between the clinical and non-clinical group – only the former reported long-lasting changes in their personal identity and relationships associated to voices. For the non-clinical group, voices were isolated experiences associated with particular events – not enmeshed in their own personal identity.
Second Premise: Symptom Categories Are Not Structured Through ‘Necessary and Sufficient Features’ CMPs group together phenomena which share family resemblances rather than identity. Such categories are structured through partial similarities between particular items in a sort of horizontal chain. These items do not share ‘necessary and sufficient conditions’ [44–46]. Categories structured through family resemblance show a prototype effect called ‘graded centrality’, where every item is considered a good or bad example of the category depending on its closeness to some specific items considered typical [46]. Common practice arranges the ‘hallucination’ category (whose members could be pseudo-hallucinations, visual hallucinations in Bálint’s syndrome, oneiroid hallucinations, non-psychotic hallucinations, music hallucinations, simple auditory hallucinations, such as names, related to fatigue, auditory hallucinations with spared insight in chronic alcoholism, and AVHs) around a central position occupied by those items which better fit the ‘function + P’ formula, where P means ‘no object’ + ‘no insight’. In CMPS this central position is considered both descriptive and psychologically and physiologically core. Third Premise: Descriptive Definitions Are Not Thick Enough Descriptions From an epistemic point of view, descriptive definitions (function + P) are quite ‘thin’ – they encode very little information about the items described [47, 48]. Berrios [49] has convincingly argued that descriptive definitions of mental symptoms meet the discrimination power needed to fulfil diagnostic/therapeutic/prognostic needs of the 19th century. Quite astonishingly, conventional wisdom in psychiatric research tends to equate thin with core – descriptive definitions are considered to enclose the features shared by all members or the category. However, descriptive definitions cannot isolate core, structural features of mental symptoms in the ‘function + P’ formula introduced above because, to the best of our knowledge, there is no such thing as ‘core, structural features’. Marková and Berrios [41] have shown how similar sympCarving vs. Stitching
toms do not necessarily share the same internal structure. Unfortunately, this still remains a sort of unquestioned epistemic premise in many research programmes. Schemas: What Do They Mean? What Do They Do? Fourth Premise: Descriptive Definitions Are Schemas Descriptive definitions are usually conceived as ‘function + P’ units which are backed up by ‘normal’ psychic functions – only this is not true. These ‘thin descriptions’ (hallucination as perception without object and delusion as an irrational, impossible, non-culturally shared idea held with excessive conviction and impervious to disconfirmation by experience) work as schemas. The term ‘schema’ with this meaning was introduced by Immanuel Kant in the second book, first chapter of his ‘Critique of Pure Reason’ [50]. Schemas perform a double task there. Firstly, they must bridge aesthetic and conceptual realms. Secondly, they must do it by a sort of preconceptual unity which enables the transition from perceptual representations to concepts. Contemporary debates on Kantian schemas may be found in analytic philosophy [51] and cognitive science [48]. In psychopathology, this schematic activity is 2-fold too – it must bring together different features into meaningful wholes and bridge the gap between shared and non-shared experience. The features brought together may or may not be present in usual descriptive definitions. Bridging is achieved by mapping uncommon experiences on common domains of experience, which are not functions but embodied affordances (see below). From a cognitive point of view, descriptive definitions/ schemas work as ‘basic concepts’ [46]. These basic concepts are usually embodied interactional concepts that are contextually neutral, easy to handle and deeply entrenched in culture. Similarly, descriptive definitions/ schemas are practical devices which have been selected through two hundred years of medical practice because of their practical advantages. They are easily learned and communicated, easily spotted in clinical situations and seem to work with the minimum amount of contextual information. When departing from basic concepts/schemas, any further explorations of mental symptoms need ad hoc information which varies with individual items and thus cannot be included in descriptive definitions. In our previous paper [13] we showed the reasons why this material could not be included in descriptive definitions and how clinical judgement should balance ‘in-the-definition’ and ‘out-of-the-definition’ material. We outlined Psychopathology 2015;48:145–152 DOI: 10.1159/000369889
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shared by patients and clinicians alike. Clinical practice adds specific nuances to this space where behaviour and experiences become symptoms [43]. Therefore, mental symptoms should be conceptualized as unstable hybrid objects both natural and social in origin [41, 42], arising from pathological entrenchment between biological and symbolic structures [6–8].
Embodied Affordances: What Do They Mean? What Do They Do? Perception, thinking, emotions, are not psychic functions in any empirical sense. They name embodied affordances – things that social/cultural living beings do or suffer through their bodies. As such, they constitute basic domains of experience and do not necessarily map onto psychic or brain functions. The term ‘embodied affordances’ is a tentative one. It tries to pinpoint a middle ground between ontological inquiries such as those of Heidegger [52], and the ‘ecological psychology’ concept of affordance coined by J.J. Gibson in 1966 and 1979 [53]. This middle ground has a structure of its own and is impervious to splitting into psychic functions or faculties. Embodied affordances retain the radical relational nature of human subjectivity highlighted by Husserl’s or Heidegger’s work and refurnish it with an eye on the needs of psychopathological research. This term builds on the concept coined by Gibson introducing the qualifier ‘embodied’. Gibson’s ‘affordance’ is a relational concept (it points to features or properties of the environment relative to a particular animal, including emergent properties of the animal-environment system [54]), but it is usually interpreted as belonging to the environment. Thus, the qualifier ‘embodied’ stresses the body pole of the relation – the sort of living cut-out that human embodiment maps on the environment [55]. This is especially necessary for psychopathology as it covers the role of the acculturation process which makes social practices, demands and standards second nature to human subjects and their meaning as directly perceived as Gibson’s functional meanings. Finally, it keeps the fruitful ambiguity of embodiment – the irreducible role of the lived body and 150
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the constraints imposed by physiology on the subjectworld-others relation. Embodied affordances ground the folk/cultural concepts which are used to make sense of human behaviour or experience and, through these folk concepts, they ground scientific theories too [45] – only this grounding may be faint or become heavily loaded with epistemic assumptions. Let us see an example. Perception as an embodied affordance implies ‘perceiving as’ and ‘understanding with no room for doubt’. English expressions such as ‘don’t you see it?’ or ‘just listen you’ll know!’ are linguistic renderings of these common experiences. Folk psychology, however, distinguishes ‘seeing’ from ‘thinking’, which has some experiential, embodied grounding too. Early empirist theories of perception drew on this conceptualization, added further constraints and, finally, emptied perception of its categorizing features. Phenomenology of perception and post-sixties theories of perception had to turn to the embodied affordance to offer fresh conceptual approaches. As this example implies, there are connections between affordances and psychic functions; but affordances are not functions. They may be served by a wide array of functions, or some functions serve different affordances. Recent meta-analysis [56] on the intrinsic architecture of brain networks shows parallel conclusions. There is no such thing as a domain-specific behaviour-psychic function-brain network but general networks which serve different affordances in a one-tomany many-to-one basis. This may seem counterintuitive, but historical research shows both long-lasting awareness of embodied affordances and slow but deep change in technical knowledge on psychic functions [49, 57, 58]. Schemas and Embodied Affordances: How Do They Work Together? In our model, ‘function + P’ definitions are schemas grounded in embodied affordances employed to make sense of uncommon experiences. They may do so by ‘cognitive metaphors’ (this phenomenon ‘seems’ to be perception or imagination but gone awry) or ‘cognitive metonymy’ (this phenomenon shares some perception/ imagination characteristics) [44–46, 59]. Bringing schematic features to the fore may explain both contradictions (AVHs are not related to perceptive faculty but show a perceptive quality which, in turn, resembles but does not equal usual perception; delusional perception is both perception and thinking) and successes of psychiatric semiology. However, which embodied affordance or experiential domain may be modelled as a Rejón Altable/Múzquiz Jiménez
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different types of not-in-the-definition information which change between individual symptoms but which are nonetheless essential for symptom eliciting. Finally, we concluded that descriptive definitions had to be ‘completed’ some way or another during symptom eliciting and that clinicians were trained to do so through repeated exposure to paradigmatic examples of the symptom. At least some of these individuation conditions are contextual, which is why they cannot be translated into a collection of features pertaining to the item. Both item and context are needed. Thus, these relational features cannot be employed to thicken the descriptive definition/schema, although they do thicken descriptions of particular items (for a thorough discussion, see [9] and [13]). That is why we must add a fifth premise: ‘thick’ descriptions pertain only to individual symptoms.
psychic function, and how closely a particular mental symptom is mapped onto it, remains an empirical issue. AVHs have been modelled as disturbances in perception, inner speech or self-consciousness.
Conclusions
Family resemblances, prototypes, thin descriptions working as schemas and thick description of particular items which employ not-in-the-definition, item-pertaining information are the basic premises of this alternative model. How does it deal with the continuity/discontinuity issue? Continuity and discontinuity are explained by the duo embodied affordances/schemas. Embodied affordances provide the wide but finite space of possibilities of human action or passion. Psychiatric disorders affect emotion, language, self, action, knowledge, or imagination. Continuity must be found there. But affordances remain in a different level than that of psychic/brain functions and the disorders which disturb these affordances eschew ‘functionalization’. They may involve unexpected changes in the experiential realm organized through affordances. These experiences will be conceptualized through schemas. Since schemas are grounded in embodied experience it is highly expected to find some anomalies in their ‘neural reference space’. As there is no need for every member of the family to share the same structure, mapping symptoms to psychic functions to brain
functions is highly expected to be, as has been the case so far, only partially successful. Due to the fact that schemas are grounded in embodied experience and in western folk psychology they are readily understood by online interviewees or lay interviewers. Because not-in-the-definition information is still needed, we have no way to control and assess the kind of information used in these non-clinical scenarios. As the ‘function + P ’ formula rests on a functionalization of affordances which withholds only a minimum of information, it is likely to stitch nature along lines it cannot fully track. As clinical psychopathology still relies heavily on this formula, the continuity/discontinuity issue cannot be unravelled without a change in its epistemic focus. This schema/individuation model of psychopathology takes into account a wide array of cognitive, linguistic, logical, and philosophical insights. It also brings together both classical functions of schematism (meaningful wholes, bridging domains of experience), does not tie psychopathology to any basic language and, we believe, provides a sound approach to the ever-present contradictions in research data. The lack of consistency which mars theoretical, research and clinical practice, defying a huge amount of high-tech, high-quality science, may be due to the sort of conceptual dead end this paper tries to describe. However, models are models. This one may be empirically disproven or show theoretical inconsistencies. A definitive answer to the continuity/discontinuity nature of psychotic experiences is a collective achievement yet to come.
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44 Lakoff G, Johnson M: Metaphors We Live By. Chicago, University of Chicago Press, 1980. 45 Johnson M: The Body in the Mind. The Bodily Basis of Meaning, Imagination, and Reason. Chicago, University of Chicago Press, 1987. 46 Lakoff G: Women, Fire and Dangerous Things. What Categories Reveal about the Mind. Chicago, University of Chicago Press, 1987. 47 Geertz C: Thick description toward an interpretive theory of culture; in Lincoln YS, Denzin NK (eds): Turning Points in Qualitative Research. Walnut Creek, Altamira Press, 2003, pp 143–168. 48 Ryle G: The thinking of thoughts. What is ‘Le penseur’ doing? In Collected Essays 1929– 1968: Collected Papers, vol 2. London, Routledge, 2003. 49 Berrios GE: Descriptive psychopathology. Conceptual and historical aspects. Psychol Med 1984;14:303–313. 50 Kant I: Crítica de la razón pura. Madrid, Alfaguara, 1998. 51 Thornton T: An aesthetic grounding for the role of concepts in experience in Kant, Wittgenstein a McDowell. Forum Philos 2007;12: 227–245. 52 Heidegger M: Zollikoner Seminare. Frankfurt, Vittorio Klostermann, 1987, pp 92–98. 53 Gibson JJ: The Ecological Approach to Visual Perception. Boston, Houghton Mifflin, 1979. 54 Stoffregen T: Affordances as properties of the animal-environment system. Ecol Psychol 2003;15:115–134. 55 Heft H: Affordances and the body an intentional analysis of Gibson’s ecological approach to visual perception. J Theor Soc Behav 1989;19:21–30. 56 Barrett LF, Satpute AB: Large-scale brain networks in affective and social neuroscience: towards an integrative functional architecture of the brain. Curr Opin Neurobiol 2013; 23: 361–372. 57 Pigeaud J: La maladie de l’âme. Étude sur la relation de l’âme et du corps dans la tradition médico-philosophique Antique. Paris, Les Belles Lettres, 2006. 58 Starobinski J: Les sciences psychogiques à la Renaissance; in L’encre de la mélancolie. Paris, Seuil, 2012, pp 231–244. 59 Ramos Gorostiza P, Vírseda Antoranz A: Delusion as psychopathological metaphor. Act Esp Psiquiatr 2005;33:221–230.
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17 Craddock N. Owen MJ: Rethinking psychosis: the disadvantages of a dichotomous classification not outweigh the advantages. World Psychiatry 2007;6:84–91. 18 Bentall RP, Fernyhough C: Social predictors of psychotic experiences: specificity and psychological mechanisms. Schizophr Bull 2008; 34:1012–1020. 19 Van Os J, Linscott RJ, Myin-Germeys I, Delespaul P, Krabbendam I: A systematic review and meta-analysis of the psychosis-continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychol Med 2009;39:179–195. 20 Van Os J, Hanssen M, Bijl RV, Ravelli A: Strauss (1969) revisited: a psychosis continuum in the general population? Schizophr Res 2000;45:11–20. 21 Johns LC, Van Os J: The continuity of psychotic experiences in the general population. Clin Psychol Rev 2001;21:1125–1141. 22 Verdoux H, Van Os J: Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophr Res 2002;54:59–65. 23 Johns LC, Cannon M, Singleton N, Murray RM, Farrell M, Brugha T, Bebbington P, Jenkins R, Meltzer H: Prevalence and correlates of self-reported psychotic symptoms in the British population. Br J Psychiatry 2004; 185: 298–305. 24 Mojtabai R. Rieder RO: Limitations of the symptom-oriented approach to psychiatric research. Br J Psychiatry 1998;173:198–202. 25 Garety P. Hemsley D: Delusions. Investigations into the Psychology of Delusional Reasoning. Hove, London, New York, Psychology Press, 1997. 26 Beavan V. Read J. Cartwright C: The prevalence of voice-hearers in the general population: a literature review. J Ment Health 2011; 20:281–292. 27 Van Os J, Hanssen M, Bijl RV, Vollebergh W: Prevalence of psychotic disorder and community level of psychotic symptoms. An urbanrural comparison. Arch Gen Psychiatry 2001; 58:663–668. 28 Wiles NJ, Zammit S, Bebbington P, Singleton N, Meltzer H, Lewis G: Self-reported psychotic symptoms in the general population. Br J Psychiatry 2006;188:519–526. 29 Freeman D, Pugh K, Antley A, Slater M, Bebbington P, Gittins M, Dunn G, Kuipers E, Fowler D, Garety P: Virtual reality study of paranoid thinking in the general population. Br J Psychiatry 2008;192:258–263.
Received: April 29, 2014 Accepted after revision: November 10, 2014 Published online: February 25, 2015
Carving versus Stitching: The Concept of Psychic Function and the Continuity/ Discontinuity Debate Carlos Rejón Altable a Álvaro Múzquiz Jiménez b
Hospital de Día, Hospital, Universitario de la Princesa, UAM, Madrid, and b Centro de Salud Mental Egia, Red de Salud Mental de Gipuzkoa, Donostia-San Sebastián, Spain
Key Words Continuity studies · Delusions · Epistemology hallucinations · Psychic function psychopathology · Psychotic symptoms · Subjectivity
Abstract Background: The current debate on the continuity or discontinuity of psychotic symptoms and common psychic experiences has mainly dealt with methodological, epidemiological and clinical issues, but it has neglected epistemological research on the main concepts of the field. Methods: The implicit epistemic structure of continuity models of psychotic symptoms and its effect on research are addressed. Results: We explain how the seemingly commonsense, unproblematic concept of psychic function may explain the contradictions and paradoxes of research. Conclusions: A new model of symptom individuation and symptom eliciting is proposed – based on the concepts of ‘schemas’, ‘embodied affordances’ and ‘thick/thin descriptions’. © 2015 S. Karger AG, Basel
Introduction
The current debate on the continuity or discontinuity of mental symptoms and common ‘psychic functions’ is far from new. In 1926, Eugene Minkowski wrote an essay © 2015 S. Karger AG, Basel 0254–4962/15/0483–0145$39.50/0 E-Mail [email protected] www.karger.com/psp
where he refused to consider psychopathology as ‘the younger sibling of psychology’ and argued for a non-psychological psychopathology rooted in phenomenological anthropology [1]. Some of the examples he discussed were, not surprisingly, hallucinations and delusions. He contended that psychic functions were misleading concepts, as they group together phenomena which differ in their innermost structure [2]. The very same debate has now been shaped into the continuity/discontinuity discussion. Continuity models understand mental symptoms as intensified versions of common experiences [3]. Discontinuity models seem to identify meaningful differences where descriptive continuity models stress similarities [4, 5]. However, they find it hard to identify the specificity of the clinical experience in a way which matches the large sample sizes and methodological rigueur of continuity work. Continuity models either highlight descriptive continuity of symptoms and ‘normal’ experience along a scale of severity (from suspiciousness to mild or episodic delusion-like ideas to full-blown delusional thought) or focus on continuity of risk for psychotic-like experiences along subjects in non-clinical, at risk and clinical samples. This paper focuses on descriptive continuity and its relation to the concept of psychic function. We list four possible, non-exhaustive stances to be taken in this debate. First, there is no such difference, or it is accidental (i.e. intensity, impairment of reality judgeDr. Carlos Rejón Altable H. de Día H., Universitario de la Princesa – Área 2 C/Marqués de Ahumada 7 ES–28023 Madrid (Spain) E-Mail crejon @ hotmail.com
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a
Carving versus Stitching
Introducing Schemas and Psychic Functions We have developed elsewhere how psychopathology is a process which brings intelligibility to some items of uncommon experience or behaviour [6–9]. It does so through cognitive devices which work as ‘templates’ (the technical term is ‘schema’ and we will stick with it from now on) which bridge the gap between common and uncommon experience and bring together heterogeneous material into a meaningful whole. Either common language or technical language terms (‘perception’, ‘sadness’, ‘delusions’, or ‘voices’) are used to schematize new, uncommon experiences. Quite understandably, schemas (‘I hear voices’, ‘I know I’m in danger’) are too often taken as faithful renderings of pathological experiences (perception went wrong, thought went wrong). Once we have defined ‘hallucination’ as ‘perception but without an object to be perceived’, it is only natural to understand hallucinations in terms of the psychology and physiology of perception [10]. Thus, a putative family of phenomena is neatly arranged in a line going from perception to illusion to hallucination or to dissociative/depressive/schizophrenic hallucinations. This procedure belongs to the conceptual framework of classical psychiatry, and the notion of psychic function is essential to it. This is not mere theoretical speculation. Some research groups consider auditory verbal hallucinations (AVHs) a heterogeneous group of phenomena which includes commanding/commenting voices (usually associated with troubles in inner speech), ‘replay’ voices (with memories), ‘own thoughts’ voices (which share commonalities with inner speech and with memories), and nonverbal auditory hallucinations [11]. There have been others who have tried to make clear the relations between 146
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first-rank hallucinations and other kinds of ‘voices’ [12], establish the role of culture in modelling hallucinations or study the differences between alcohol/epilepsy/schizophrenia-related voices [10, 12]. In short, they all break a ‘perceptual’ category into related but different experiential pieces. Why Symptom Individuation Matters In a previous paper [13] we explained how some of the material which has to be schematized appears during individual symptom formation and thus may remain out of descriptive definitions but be handled during symptom eliciting. We also pointed out that pragmatic constraints of research on hallucinations and delusions in non-clinical samples involve some loss of this kind of ‘out-of-definition’ descriptive information and how, as an unexpected spin-off, research is grouping together phenomena with only loose ‘family resemblance’ such as common suspiciousness, paranoia and acute delusions. In this paper we use the extensive body of work dealing with continuity models for hallucinations and delusions to show how continuity models are dependent on the concept of psychic function and how this concept cannot clarify the continuity/discontinuity debate [14]. Are we proposing an absolute cleave between the members of the ‘symptomatic family’? – not quite so. We will try to prove how continuity/discontinuity is better understood through the concept of embodied affordances as the domain assuring continuity and the concept of schema as the procedure that can explain both continuity and discontinuity of uncommon and common experiences.
Continuity Studies
Premises: Why Psychic Functions Are Needed Continuity models of psychotic symptoms (CMPS) share one theoretical premise about syndrome-focused psychiatric research. This premise underpins its substitution for single-symptom research (which is the method of choice for CMPS). It may be written down succinctly as follows: ‘syndrome research hides strict categorical approaches to mental disorders’. Two consequences follow: (1)In syndrome-focused empirical research, ‘syndromes’ are handled as discrete entities, with zones of rarity (the joints of nature) between them [15–18]. (2)In syndrome-focused empirical research, mental symptoms are considered just that: symptoms – either the expression of some underlying dysfunction or part Rejón Altable/Múzquiz Jiménez
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ment, symptoms which co-occur). Second, there are differences which can be seen and pointed in clinical situations but which have (so far) eschewed formal description. Third, there is something wrong with the tool called ‘descriptive psychopathology’; it fails to capture some basics of human language, experience and behaviour, and thus it gives rise to seemingly unsolvable issues such as continuity versus discontinuity. The fourth stance is a mix of stances one, two and three. If reason number one is true, we are not carving nature at its joints. If two is true, we are stitching nature along unperceived fissures. If three is true, some deep retooling in psychiatric semiology must be undertaken.
The Nature of Mental Symptoms: Why Psychic Functions Are Needed There is one implicit epistemic choice in CMPS: psychotic symptoms are but points in a continuum which leads from normal psychic function to full-blown symptoms [14]. These symptoms are characterized by a fixed, internal structure which is essentially the same across different contexts (life events, psychiatric syndromes, neurological diseases). This invariable structure should be grasped by (current or future) descriptive definitions [15, 25] and studied transdiagnostically across clinical contexts. The basis for this structure is furnished by the notion of psychic function. Psychic functions are stable across contexts and are present in healthy, subclinical and clinical samples and, as they are rooted in evolutionary processes, they are partially shared by other animals, thus ensuring putative validity of experimental models. However, for some symptoms such as auditory hallucinations this assumption simply does not hold. The phenomena gathered under the umbrella term ‘auditory hallucinations’ and screened for by usual questionnaires range from single words, music or noises to constantly commanding or commenting voices. Even if we focus on AVHs, commonalities between AVHs in different clinical syndromes [10] such as epilepsy, alcohol abuse, posttraumatic stress disorder, schizophrenia, and bipolar disorder go along with clinically relevant differences, and if we look into the symptom itself, some characteristics so far considered essential in descriptive definitions (volume, intensity, location, control) may be considered accessory, even misleading, as they have blurred the different experiential realms behind AVHs [5]. Carving vs. Stitching
Reading Epidemiological Results: Why Psychic Functions Are Needed Perhaps the strongest argument for the ‘psychic function continuum’ is the high prevalence of phenomena similar to classical psychotic symptoms which CMPS report in non-clinical samples. Incidence and prevalence vary. In a 2011 literature review Beavan et al. [26] found that prevalence for auditory verbal hallucinations ranged from 0.6 to 84%, with an interquartile range of 3.1–19.5%. This high range of prevalence is usually considered as an artefact provoked by the heterogeneity of the methodology and designs [3]. Most CMPS report striking similarities between clinical and non-clinical samples – being male, having lower levels of schooling, urbanicity, alcohol and drug use, unmarried status, and trauma [19, 21, 27]. There are some significant differences between them, however. In ‘Strauss revisited’ Van Os et al. [20] reported a higher incidence of positive psychotic symptoms in women. In a recent study by Wiles et al. [28], the incidence of self-reported psychotic symptoms was higher for inhabitants of rural areas, whereas little evidence was found for the the association of psychotic symptoms and marital status, social class, employment status, or educational qualifications. The statistical distribution of symptoms in non-clinical samples varies. Whereas half-normal distribution is the one most commonly predicted and reported in CMPS [19, 21], an exponential, skewed, non-linear distribution [29–32] is also frequently reported. Some authors have even found a normal distribution [15]. These results are usually taken as proof of the existence of the psychic function continuum, but they may very well be the effect of epidemiological questionnaires, designed to address ‘family resemblances’ rather than ‘family differences’ [33–35]. Family resemblances are then taken for identity between phenomena on the basis of the psychic function continuum. Interestingly, the psychotic-like phenomena found in these studies seem to be weak predictors of clinical psychosis [36, 37]. Thus, the hypothesis of the psychic function continuum would back up syndrome deconstruction (through the assumption that ‘symptoms are mal-functions’), dimensionality and transdiagnosticity (psychic functions are the same in all clinical/non-clinical samples), putative over-inclusiveness or lack of distinctiveness of questionnaires (only a minimum information is needed to identify both the function and the mal-function), and the interpretation of epidemiological data. Some empirical research is beginning to address this issue. A few groups have tried to compare the phenomePsychopathology 2015;48:145–152 DOI: 10.1159/000369889
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of a whole called ‘syndrome’. They are not to be found in healthy/common/non-clinical mental life [15, 18– 23] and, as long as symptoms are considered the expression of some underlying general-syndromic dysfunction, the specific psychic/physiological/pathogenic mechanism of hallucinations/delusions/inhibition cannot be adequately targeted. On the other hand, symptoms are considered valid, stable, specifically linked to underlying processes of psychopathology, and less stigma prone [24]. However, if symptoms are not the expression of some general/syndromic/axial dysfunction underlying the variety of clinical features they can only be conceived as the result of disturbed particular psychic functions. Let us take a closer look at this consequence.
Why Continuity Studies Are One Offspring of Classical Psychiatry CMPS share some epistemic core assumptions about the structure of mental symptoms which may be unfolded as follows: (1)Descriptive definitions of symptoms encode the core features of the symptom. Some other features may be important but they are incidental. The addition of ‘core features + incidental features’ characterizes each member of the category exhaustively. Empirical research should address core features, which are present in clinical and non-clinical samples and remain unchanged transdiagnostically. (2)Core features of mental symptoms should be conceived as ‘psychic function + P factor’ units, where P stands for ‘pathological’. Symptoms should be grouped along functions. As we pointed out in the introduction, this premise is deeply rooted in psychiatry and clinical psychology and has been shaped in different ways. But whatever is considered P varies. Some classical psychiatrists considered P not as ‘dysfunction’ but as ‘incidental features’. Thus, hallucinations were not always pathological. If they actually were pathological, they lasted a long time, impaired reality judgement and implied lack of insight and delusional thinking. Some others understood that the P factor included the ‘quality’ of the experience – melancholic sadness was different from common sadness, manic excite148
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ment was not the same as exhilaration and schizophrenic depersonalization did not correspond to melancholic depersonalization. CMPS think of the P factor as a matter of degree and sometimes as a matter of concurrent symptoms too – intense enough suspiciousness becomes delusional. Too frequent/too pervasive/too long hallucinations are pathological. In spite of the different nature assigned to P, the first and second assumptions about the nature of the symptoms and the descriptive language of semiology (psychic function + P, core features + incidental features) can be easily traced back to classical psychiatry development during the 19th century, which means we are dealing with deep problems likely to be rooted in very longlasting epistemological configurations and which will not be solved by re-editing the continuity/discontinuity discussion in terms that parallel Minkowski’s essay of 1926 [1].
Time for a Different Model: Embodied Affordances and Schemas
Let us consider now another model, which we believe is able to account for both the similarities and the differences found between the various kinds of phenomena gathered under any given symptomatic category. We shall first introduce three premises concerning what symptom, categories and descriptions are not. Then we shall propose some alternative approaches. Symptoms, Categories, Descriptions: What They Are Not First Premise: Mental Symptoms Are Not ‘Natural Events’ CMPS handle mental symptoms as stable natural kinds. Only for such objects do the methodological and ontological assumptions described above make real sense. Social and cultural contexts are considered risk factors which belong to the wide array of risk factors for psychotic symptoms known today (genetic, obstetric, physical/ sexual abuse). Although this is a widespread model, it has been criticized from different perspectives [6, 40–43]. Human beings talk, behave and experience. Language, experience and behaviour may be abnormal, but the form and meaning of human experiences and behaviour are shaped within a particular semantic space, without which they would be completely different or even disappear [40, 41]. This space is grounded in cultural strata partially Rejón Altable/Múzquiz Jiménez
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nology of AVHs in clinical and non-clinical samples. Daalman et al. [38] assessed the characteristics of AVHs in a clinical and non-clinical sample using PSYRATS. The following items showed significant differences: negative content, lower control and higher frequency in the patient group. Clear, unexpected differences on attribution were also found – an internal attribution (‘their own mind’) was more frequent in the patient group. In the non-clinical group, an ‘external-paranormal’ source was more frequently reported. Similar results were found in earlier studies [39]. Qualitative research would find further differences. A recent study [4] designed to assess the phenomenal quality of hallucinatory experiences through open, narrative descriptions of AVHs found a very different quality in the experience of voices between the clinical and non-clinical group – only the former reported long-lasting changes in their personal identity and relationships associated to voices. For the non-clinical group, voices were isolated experiences associated with particular events – not enmeshed in their own personal identity.
Second Premise: Symptom Categories Are Not Structured Through ‘Necessary and Sufficient Features’ CMPs group together phenomena which share family resemblances rather than identity. Such categories are structured through partial similarities between particular items in a sort of horizontal chain. These items do not share ‘necessary and sufficient conditions’ [44–46]. Categories structured through family resemblance show a prototype effect called ‘graded centrality’, where every item is considered a good or bad example of the category depending on its closeness to some specific items considered typical [46]. Common practice arranges the ‘hallucination’ category (whose members could be pseudo-hallucinations, visual hallucinations in Bálint’s syndrome, oneiroid hallucinations, non-psychotic hallucinations, music hallucinations, simple auditory hallucinations, such as names, related to fatigue, auditory hallucinations with spared insight in chronic alcoholism, and AVHs) around a central position occupied by those items which better fit the ‘function + P’ formula, where P means ‘no object’ + ‘no insight’. In CMPS this central position is considered both descriptive and psychologically and physiologically core. Third Premise: Descriptive Definitions Are Not Thick Enough Descriptions From an epistemic point of view, descriptive definitions (function + P) are quite ‘thin’ – they encode very little information about the items described [47, 48]. Berrios [49] has convincingly argued that descriptive definitions of mental symptoms meet the discrimination power needed to fulfil diagnostic/therapeutic/prognostic needs of the 19th century. Quite astonishingly, conventional wisdom in psychiatric research tends to equate thin with core – descriptive definitions are considered to enclose the features shared by all members or the category. However, descriptive definitions cannot isolate core, structural features of mental symptoms in the ‘function + P’ formula introduced above because, to the best of our knowledge, there is no such thing as ‘core, structural features’. Marková and Berrios [41] have shown how similar sympCarving vs. Stitching
toms do not necessarily share the same internal structure. Unfortunately, this still remains a sort of unquestioned epistemic premise in many research programmes. Schemas: What Do They Mean? What Do They Do? Fourth Premise: Descriptive Definitions Are Schemas Descriptive definitions are usually conceived as ‘function + P’ units which are backed up by ‘normal’ psychic functions – only this is not true. These ‘thin descriptions’ (hallucination as perception without object and delusion as an irrational, impossible, non-culturally shared idea held with excessive conviction and impervious to disconfirmation by experience) work as schemas. The term ‘schema’ with this meaning was introduced by Immanuel Kant in the second book, first chapter of his ‘Critique of Pure Reason’ [50]. Schemas perform a double task there. Firstly, they must bridge aesthetic and conceptual realms. Secondly, they must do it by a sort of preconceptual unity which enables the transition from perceptual representations to concepts. Contemporary debates on Kantian schemas may be found in analytic philosophy [51] and cognitive science [48]. In psychopathology, this schematic activity is 2-fold too – it must bring together different features into meaningful wholes and bridge the gap between shared and non-shared experience. The features brought together may or may not be present in usual descriptive definitions. Bridging is achieved by mapping uncommon experiences on common domains of experience, which are not functions but embodied affordances (see below). From a cognitive point of view, descriptive definitions/ schemas work as ‘basic concepts’ [46]. These basic concepts are usually embodied interactional concepts that are contextually neutral, easy to handle and deeply entrenched in culture. Similarly, descriptive definitions/ schemas are practical devices which have been selected through two hundred years of medical practice because of their practical advantages. They are easily learned and communicated, easily spotted in clinical situations and seem to work with the minimum amount of contextual information. When departing from basic concepts/schemas, any further explorations of mental symptoms need ad hoc information which varies with individual items and thus cannot be included in descriptive definitions. In our previous paper [13] we showed the reasons why this material could not be included in descriptive definitions and how clinical judgement should balance ‘in-the-definition’ and ‘out-of-the-definition’ material. We outlined Psychopathology 2015;48:145–152 DOI: 10.1159/000369889
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shared by patients and clinicians alike. Clinical practice adds specific nuances to this space where behaviour and experiences become symptoms [43]. Therefore, mental symptoms should be conceptualized as unstable hybrid objects both natural and social in origin [41, 42], arising from pathological entrenchment between biological and symbolic structures [6–8].
Embodied Affordances: What Do They Mean? What Do They Do? Perception, thinking, emotions, are not psychic functions in any empirical sense. They name embodied affordances – things that social/cultural living beings do or suffer through their bodies. As such, they constitute basic domains of experience and do not necessarily map onto psychic or brain functions. The term ‘embodied affordances’ is a tentative one. It tries to pinpoint a middle ground between ontological inquiries such as those of Heidegger [52], and the ‘ecological psychology’ concept of affordance coined by J.J. Gibson in 1966 and 1979 [53]. This middle ground has a structure of its own and is impervious to splitting into psychic functions or faculties. Embodied affordances retain the radical relational nature of human subjectivity highlighted by Husserl’s or Heidegger’s work and refurnish it with an eye on the needs of psychopathological research. This term builds on the concept coined by Gibson introducing the qualifier ‘embodied’. Gibson’s ‘affordance’ is a relational concept (it points to features or properties of the environment relative to a particular animal, including emergent properties of the animal-environment system [54]), but it is usually interpreted as belonging to the environment. Thus, the qualifier ‘embodied’ stresses the body pole of the relation – the sort of living cut-out that human embodiment maps on the environment [55]. This is especially necessary for psychopathology as it covers the role of the acculturation process which makes social practices, demands and standards second nature to human subjects and their meaning as directly perceived as Gibson’s functional meanings. Finally, it keeps the fruitful ambiguity of embodiment – the irreducible role of the lived body and 150
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the constraints imposed by physiology on the subjectworld-others relation. Embodied affordances ground the folk/cultural concepts which are used to make sense of human behaviour or experience and, through these folk concepts, they ground scientific theories too [45] – only this grounding may be faint or become heavily loaded with epistemic assumptions. Let us see an example. Perception as an embodied affordance implies ‘perceiving as’ and ‘understanding with no room for doubt’. English expressions such as ‘don’t you see it?’ or ‘just listen you’ll know!’ are linguistic renderings of these common experiences. Folk psychology, however, distinguishes ‘seeing’ from ‘thinking’, which has some experiential, embodied grounding too. Early empirist theories of perception drew on this conceptualization, added further constraints and, finally, emptied perception of its categorizing features. Phenomenology of perception and post-sixties theories of perception had to turn to the embodied affordance to offer fresh conceptual approaches. As this example implies, there are connections between affordances and psychic functions; but affordances are not functions. They may be served by a wide array of functions, or some functions serve different affordances. Recent meta-analysis [56] on the intrinsic architecture of brain networks shows parallel conclusions. There is no such thing as a domain-specific behaviour-psychic function-brain network but general networks which serve different affordances in a one-tomany many-to-one basis. This may seem counterintuitive, but historical research shows both long-lasting awareness of embodied affordances and slow but deep change in technical knowledge on psychic functions [49, 57, 58]. Schemas and Embodied Affordances: How Do They Work Together? In our model, ‘function + P’ definitions are schemas grounded in embodied affordances employed to make sense of uncommon experiences. They may do so by ‘cognitive metaphors’ (this phenomenon ‘seems’ to be perception or imagination but gone awry) or ‘cognitive metonymy’ (this phenomenon shares some perception/ imagination characteristics) [44–46, 59]. Bringing schematic features to the fore may explain both contradictions (AVHs are not related to perceptive faculty but show a perceptive quality which, in turn, resembles but does not equal usual perception; delusional perception is both perception and thinking) and successes of psychiatric semiology. However, which embodied affordance or experiential domain may be modelled as a Rejón Altable/Múzquiz Jiménez
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different types of not-in-the-definition information which change between individual symptoms but which are nonetheless essential for symptom eliciting. Finally, we concluded that descriptive definitions had to be ‘completed’ some way or another during symptom eliciting and that clinicians were trained to do so through repeated exposure to paradigmatic examples of the symptom. At least some of these individuation conditions are contextual, which is why they cannot be translated into a collection of features pertaining to the item. Both item and context are needed. Thus, these relational features cannot be employed to thicken the descriptive definition/schema, although they do thicken descriptions of particular items (for a thorough discussion, see [9] and [13]). That is why we must add a fifth premise: ‘thick’ descriptions pertain only to individual symptoms.
psychic function, and how closely a particular mental symptom is mapped onto it, remains an empirical issue. AVHs have been modelled as disturbances in perception, inner speech or self-consciousness.
Conclusions
Family resemblances, prototypes, thin descriptions working as schemas and thick description of particular items which employ not-in-the-definition, item-pertaining information are the basic premises of this alternative model. How does it deal with the continuity/discontinuity issue? Continuity and discontinuity are explained by the duo embodied affordances/schemas. Embodied affordances provide the wide but finite space of possibilities of human action or passion. Psychiatric disorders affect emotion, language, self, action, knowledge, or imagination. Continuity must be found there. But affordances remain in a different level than that of psychic/brain functions and the disorders which disturb these affordances eschew ‘functionalization’. They may involve unexpected changes in the experiential realm organized through affordances. These experiences will be conceptualized through schemas. Since schemas are grounded in embodied experience it is highly expected to find some anomalies in their ‘neural reference space’. As there is no need for every member of the family to share the same structure, mapping symptoms to psychic functions to brain
functions is highly expected to be, as has been the case so far, only partially successful. Due to the fact that schemas are grounded in embodied experience and in western folk psychology they are readily understood by online interviewees or lay interviewers. Because not-in-the-definition information is still needed, we have no way to control and assess the kind of information used in these non-clinical scenarios. As the ‘function + P ’ formula rests on a functionalization of affordances which withholds only a minimum of information, it is likely to stitch nature along lines it cannot fully track. As clinical psychopathology still relies heavily on this formula, the continuity/discontinuity issue cannot be unravelled without a change in its epistemic focus. This schema/individuation model of psychopathology takes into account a wide array of cognitive, linguistic, logical, and philosophical insights. It also brings together both classical functions of schematism (meaningful wholes, bridging domains of experience), does not tie psychopathology to any basic language and, we believe, provides a sound approach to the ever-present contradictions in research data. The lack of consistency which mars theoretical, research and clinical practice, defying a huge amount of high-tech, high-quality science, may be due to the sort of conceptual dead end this paper tries to describe. However, models are models. This one may be empirically disproven or show theoretical inconsistencies. A definitive answer to the continuity/discontinuity nature of psychotic experiences is a collective achievement yet to come.
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