Wednesday, April 08, 2020

Deep questions about mental illness

Patricia Churchland discussed the question 'Do we have free will?' as part of the attempt by New Scientist to tackle what it called the deepest challenges faced by science. Biology and social sciences, at least, haven’t escaped philosophy.

Churchland began her article with a case report. This 40 year old male patient displayed impulsive sexual behaviour with paedophilia, including sexually molesting his 8 year old step-daughter, and was found to have a right frontotemporal tumour. Churchland asked how different are normal humans from this patient where free will is concerned? I'm not convinced she gave the best of answers to this question.

Although the patient was orientated, there were neurological signs, such as marked constructional apraxia and agraphia. Poor impulse regulation and an acquired sociopathy do occur with adult-onset damage to the orbitofrontal cortex, although this case may be the first description of paedophilia as a specific manifestation of orbitofrontal syndrome. Signs of orbitofrontal lobe dysfunction may be quite subtle but do reflect an organic illness like dementia and delirium.

As I said in a previous post, organic problems are cerebral disease, which can be primary, or secondary to a systemic illness, or resulting from an exogenous toxic agent, or due to physical withdrawal of an addictive substance. In this case, the problem was clearly due to brain disease. 'Normal humans', as Churchland refers to them, do not have brain disease. Certainly issues of mental capacity apply to people with and without brain disease, but it may well matter whether it is brain disease that is affecting mental capacity.

Churchland says "brains make decisions" but it's actually people that do. Decision making capacity may well be affected if people have brain disease. Capacity may also be affected by whether people are psychotic for example, but actually delusional thinking may not be that much different from our ordinary thinking (see previous post). Of course there is a neurobiology of self-control, and as Churchland says, "the self is a construction of the brain". But it’s us that make sense of our world, not our brains. Neuronal processes are not meaning making and lack intentionality (see previous post). The sense-making activity of people also needs to be set into a context (see another previous post).

Jo Moncrieff in her recent PPP paper also starts from Churchland’s clinical case. She uses the example of a brain tumour causing behaviour to discuss the views of Thomas Szasz about the myth of mental illness. I’ve criticised before the view, like that of Szasz, that illness is only physical in nature (see eg. previous post). It’s only really since about the middle of the nineteenth century that we’ve had this perspective on illness, with the development of the anatomoclinical method, relating clinical symptoms and signs at the bedside to underlying physical pathology. Of course I’m not saying illness was not seen as bodily disorders, but how they were explained was very different from our modern pathological, including histological, understanding (see eg. previous post). We’ve always needed myths to explain illness (see eg. another previous post). For example, the theory of the four humours - blood, phlegm, black bile and yellow bile - remained a major influence in understanding the working of the body until well into the 1800s. Our modern biomedical understanding of disease helps us to make sense of symptoms in the same way as the humoral theory of disease did for centuries before. That doesn’t mean it’s necessarily true. And, here, I agree with Jo, Szasz was on to something by realising that what was called mental illness cannot be reduced to brain disease, in the same way as physical illnesses.

Of course, psychiatry, and medicine in general, had realised this situation well before Szasz. Its solution was to separate functional mental illness from organic mental illness (see eg. previous post). Trouble is that particularly over recent years, psychiatry too has adopted Szasz’s definition of illness and no longer makes a distinction between organic and functional mental illness, when it should (see eg. another previous post).

Jo’s right that psychiatry does need to look to philosophers, like Wittgenstein, for a critique of reductionism and positivism. For example, Pat Bracken & Phil Thomas in their version of critical psychiatry, which they called postpsychiatry, have already said this (see eg. previous post). As Laing (1979) pointed out in the New Statesman, there is little attempt to provide an in-depth analysis of the structures of power and knowledge in Szasz's perspective (see eg. Szsaz’s (2004) perspective on Laing in return). But it may explain why Jo needs to turn to a weighty philosopher like Wittgenstein to support her argument for Szasz. Szasz himself didn’t really do that.

As I keep saying (eg. see previous post) though, although Szasz contributed to critical psychiatry in the sense that he argued that the biological basis of mental illness is a myth, I don't think he's a good place to start to explain critical psychiatry. His trenchant views could actually be said to have detracted from the cultural critique of psychiatry and medicine in general (eg. see my book review).  Jo's right that we should make more of whether a brain tumour has caused a behavioural disturbance or whether that disturbance is functional. And we should give up trying to explain mental illness in physico-chemical terms, which modern psychiatry has always wished to be able to do but can't (see previous post). 

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