Principles of Psychopathology: Two Worlds, Two Minds, Two Hemispheres [1 ed.] 0192622404, 9780192622402

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OXFORD MEDICAL PUBLICATIONS Principles of Psychopathology: Two Worlds—Two Minds—Two Hemispheres

^PRINCIPLES OF PSYCHOPATHOLOGY: Two Worlds—Two Minds—Two Hemispheres

J. CUTTING Honorary Senior Lecturer, Institute of Psychiatry and Kings College Hospital

Oxford New York Tokyo OXFORD UNIVERSITY PRESS 1997

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Oxford University Press, Great Clarendon Street, Oxford 0X2 6DP

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and associated companies in Berlin Ibadan Oxford is a trade mark of Oxford University Press Published in the United States by Oxford University Press Inc., New York © J. Cutting, 1997 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press. Within the UK, exceptions are allowed in respect of any fair dealing for the purpose of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms and in other countries should be sent to the Rights Department, Oxford University Press, at the address above. This book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, re-sold, hired out, or otherwise circulated without the publisher’s prior consent in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent purchaser. A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Cutting, John. Principles of psychopathology: two worlds, two minds, two hemispheres/J. Cutting, p. cm. - (Oxford medical publications) Includes bibliographical references and index. ISBN 0-19-262240-4 (hbk) [DNLM:

I. Psychology, Pathological. I. Title. II. Series. 1. Mental Disorders. 2. Mental Processes. J. Brain-physiology. 4. Philosophy. WM 140C991p 1997] RC454.C88 1997 616.89 -dc20 DNLM/DLC for Library of Congress 96-29144 C1P Typeset by Advance Typesetting Limited, Oxfordshire Printed in Great Britain by Biddles Ltd., Guildford, Surrey

Preface This is a long book and, as it is partly meant to be a comprehensive reference book on psychopathology, it does not need a long preface. However, the book has other aims and, as these only emerged while I was writing it, they are best explicitly stated here. It soon became apparent to me that psychopathology needs theoretical under¬ pinning. The definitions of all the phenomena and conditions which it embraces are only valid within a single philosophical framework, and the one generally assumed is what is referred to as naive realism—a state of affairs in which material reality out there is held to determine and conform to our mental experience of the world. Con¬ sider, for example, the most widely used definition of hallucination—a perception without an object. However, I could discover no major philosopher, certainly since Descartes, who ever subscribed to this position. Therefore I was forced to examine what the major philosophers had said about mind and world—hence Chapter 1. What emerged was that Kant’s scheme at the turn of the nineteenth century was a kind of watershed, in that it was greatly admired by philosophers of widely differing orientations and contained some balance between realism and idealism. Therefore I adopted it for the purposes of defining major psychopathological terms, except in cases where Kant gave no guidance (e.g. emotion). In the course of this exercise I encountered the views of two philosophers, Schopenhauer and Bergson, who were even more congenial to my purpose. My original aim had been simply to update Jaspers’ General Psychopathology (first pub¬ lished in 1913 and last comprehensively revised in 1942) by omitting much of his discussion of anthropology and personality and introducing a neuropsychological perspective, as I regard the last as the most significant psychological advance of the last half of this century. However, when I read Schopenhauer and Bergson, I realized that the pervasive sense of duality which they saw in the human condition was exactly the philosophical framework I needed to accommodate my neuropsychological perspec¬ tive, as this largely comprised the differing roles of the two hemispheres. In Chapter 2,1 briefly review historical trends in respect of the classification, nature, and cause of psychiatric conditions. This is something which Jaspers did magnificently and which I merely touch on in comparison. Chapter 3 is a short account of the spectacular increase in neuropsychological knowledge over the last 50 years, with special regard to the localization of functions within each hemisphere. The purpose of this chapter is to set the scene for the neuro¬ psychological component of the chapters which follow in the main body of the book. Chapter 4 is the central chapter, not surprisingly as it is to do with the world. Half¬ way through writing this, I received a copy of Sass’s book Madness and Modernism, an event which affected me profoundly. It encouraged me in my belief that a major reappraisal of psychopathology was needed, and it strengthened my view that only through philosophy was this going to be possible.

VI

Preface

Chapter 4, and all subsequent chapters, is divided into four sections: philosophy (and psychology), psychopathology, neuropsychology, and an attempted integration of all three disciplines. The philosophical theme followed here is the dichotomy between an individual thing in the world and its class—a theme which permeates most philo¬ sophical speculation. I chose this theme because I had already decided that there was something peculiar about the way that schizophrenics dealt with the uniqueness of events in the world, and also because an earlier analysis of delusional misidentification had led me to believe that the right hemisphere was critical in this respect. To my surprise and delight the choice proved very fertile. Not only did the main types of world psychopathology (hallucination, illusion, anomalous experience, agnosia, and delusion) fall naturally into this scheme, but some of them (delusion and agnosia) could be further classified using these principles. Most exciting of all was the un¬ expected finding that when I analysed the types of hallucination associated with rightand left-sided hemisphere lesions respectively (largely relying on Penfield’s work) there were noticeable differences in the extent to which the content was a unique thing (right-sided) or a general sort of thing (left-sided). Chapter 5 deals with the temporal and spatial framework of the world, as opposed to the world of things dealt with in Chapter 4. Here the philosophers are at sixes and sevens, and the range of psychopathology should inform the philosophy rather than the other way round, as in the previous chapter. However, the duality of Schopenhauer and Bergson fares best in trying to make sense of the peculiar psychopathology which is evident. Chapter 6 is about the body. Here the most useful philosophical formulation was that of Sartre and Merleau-Ponty, who considered that there was a duality between the body as conceived of as a world-determining agent and the body as conceived of as a world-existing thing—pour-soi and en-soi as they called them. Chapter 7 concerns the self. Here most philosophy is of little help to the psycho¬ pathologist because the concept is not discussed at all or because it is equated or conflated with mind (as it was by Freud) or because it has been deconstructed away (as by the post-structuralists). In consequence the psychopathology of the self is a muddled topic with little agreement on terminology. The few established categories that there are (e.g. depersonalization) have been eroded by all sorts of accretions to the original concept. For these reasons I have largely relied on the experiences of my own sample of patients and grouped them as best I can. Chapter 8 is entitled ‘Mind’, by which I mean a cognitive faculty which thinks, remembers, attends, and is conscious. Therefore sections on the psychopathology and neuropsychology of thinking, memory, consciousness, attention, and intelligence are found here. My adherence to Schopenhauer’s and Bergson’s duality of mind (par¬ ticularly Schopenhauer’s in this case) required the above topics to be included together here, and emotion, will, and action to be grouped together separately. This should not be controversial. Chapter 9 was the hardest one to write, and I am far from happy with it. There were several seemingly intractable problems. The first was emotion itself. None of the theories of normal emotion with which I was acquainted appeared to me particularly compelling, even before I tried to accommodate the psychopathology. And then, as if by a miracle, I encountered the work of Scheler.

Preface

vii

This was a revelation, not only for its general plausibility, but, by virtue of his claim that there was a realm or order of values independent of logic, because he has offered implicit support to the sort of duality promoted by Schopenhauer and Bergson. I did not have the confidence to consider the ramifications of his theory throughout psycho¬ pathology, but some of his notions illuminate this chapter. Next there was will. Here the problem was different. Whereas emotion in some form or other is one of the few elements of the human condition whose existence no philo¬ sopher has ever denied, the very concept of the will has been rejected by several major philosophers. In contrast, there was Schopenhauer’s exaltation of it to denote the entire reality of the world, along with human and non-human energy. The concept has been anathema to all three major schools of psychology this century and Jaspers treated it cursorily; therefore there was almost no modern literature on its psychopathology. However, it seemed to me that a whole range of miscellaneous types of behaviour, ranging from catatonic movements and postures at one extreme (quite clearly invol¬ untary) to self-destructive and antisocial acts and habits at the other (which could be construed as irrational rather than involuntary), might be helpfully regarded as something to do with a disturbed will. A superb philosophical perspective on the topic by Arendt encouraged me. Then there was the problem of action and its cause. Here, I could make no headway whatsoever. The three major schools of psychology in this century have had much to say on the issue, but to me the whole area is a convoluted mess. Even the only clearcut manifestation of psychopathology arising from a cortical lesion—apraxia—seemed to me to be incorrectly formulated, although a reading of Liepmann’s original articles on it suggested that he was probably more astute about its nature than most of his successors. Chapter 10 tackles the psychopathology of language, which is relatively straight¬ forward, compared with the previous chapter, once the ambiguity of some of the ter¬ minology is unravelled. Here the views of Saussure, the father of modern linguistics, inform the subject. London December, 1996

J.C.

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Contents 1

Philosophy and psychology—worlds and minds Manifold world—multiple souls One world—one mind Two worlds—one mind One world—two minds No world—one mind One world—no mind No world—no mind—something else Two worlds—two minds Summary

2

Psychiatry and psychopathology Four types of madness—a brief history of psychiatric classification The tripartite mind—a survey of opinions on the nature of madness Two sets of causes—the rationalization of the origins of madness One investigative technique—Jaspers’ phenomenological approach to psychopathology Summary

3

Neurology and neuropsychology One brain—one mind One brain—localized mental functions Major and minor hemispheres—dominant and subordinate sets of mental functions Two hemispheres—complementary sets of mental functions Two hemispheres—mind and quasi-mind Summary

4

The world—things, classes and qualities

1 1 1 4 6 10 12 18 18 22 30

30 40 45 50 53 61 61 61 62 63 65 66 70

Introduction Philosophy and psychology Psychopathology Neuropsychology Philosophy, psychopathology, and neuropsychology

70 73 81 152 163

Summary

194

Contents

X

5

Time and space: the framework of the world Time Space Summary

6

Body Philosophy and psychology Psychopathology Neuropsychology Philosophy, psychopathology, and neuropsychology Summary

7

Self Philosophy and psychology Psychopathology Neuropsychology Philosophy, psychopathology, and neuropsychology Summary

8

Mind Philosophy and psychology Psychopathology Neuropsychology Philosophy, psychopathology, and neuropsychology Summary

9

Emotion, will, and action Philosophy and psychology Psychopathology Neuropsychology Philosophy, psychopathology, and neuropsychology Summary

10

Language Philosophy Psychopathology Neuropsychology Philosophy, psychopathology, and neuropsychology Summary

198 198 221 240

242 242 247 277 278 282

284 284 293 314 320 324

326 326 338 366 373 379

381 381 396 438 447 453

457 457 464 481 484 490

Contents Conclusions Philosophy Psychology Neurology and neuropsychology Psychopathology Summary

xi

493 493 496 497 500 505

References

507

Index

581

1 Philosophy and Psychology Worlds and Minds

—

MANIFOLD WORLD—MULTIPLE SOULS In the beginning there was multiplicity. There was no concept of any of the modes of human existence which we now take for granted. Primitive man recognises no clear-cut difference between the familiar and the strange, an inner and an outer world, life and death, soul and body. For him soul and body are neither of them well defined and demarcated areas. What he does recognise, in him and all around him, is a world of strange forces with a quality of ‘otherness’ ... For the most part one would have to speak of several different souls manifesting themselves in man rather than of a soul ... The soul is never simply immaterial, because the world is never simply material ... For primitive people the world has become something more than just what happens in the course of nature. Here the spiritual and the material are as one, are a single datum ... In and by himself a man is not really a ‘finished product’. He cannot be cut loose from the social pattern ... He is enveloped and engrossed functionally in the socio-mythical sphere ... The person is diffuse ... the soul can be located outside a man’s body. It is born simultaneously with the man, in a particular tree, say ... Melanesian man regards his own intestines as identical in structure with the vegetative world: entrails within and plants without constitute a single identical vegetable realm ... The act of breathing ... the blood oozing rich and red from the wounded flesh ... the loneliness of a deserted steppe no less than the grotesque shape of a rock ... all these things, including the dead body itself, can represent the soul in a particular mode. (Van Peursen 1966)

If this world picture is accurate, then what we have is both a multiplicity of things and a series of two-way interpenetrations—animate and inanimate, human and non¬ human, material and spirit. World, body, soul, and myth are not distinguished; nor are the categories of animal, vegetable, and mineral. Relatively recent concepts such as mind, language, and self have no place.

ONE WORLD—ONE MIND The main thrust of philosophy from its origins among the pre-Socratics (c. 600-400 BC) until Kant (1724-1804) has two conflicting strands: (1) to separate from the welter of experience what is essentially human from what is not; (2) to keep the categories of what there is to a minimum, ideally to one, in other words to unify. The first step was taken by the pre-Socratic philosophers whose endeavours, as far as we know them through aphorisms, were chiefly hypotheses about unification. According to Thales everything was water, according to Anaximenes air, and according to Heraclitus fire. Heraclitus further maintained that everything is characterized by change, whereas Parmenides thought that permanence was the unifying principle. They 1

2

Philosophy and Psychology—Worlds and Minds

can be regarded as early scientists rather than philosophers because their hypotheses concerned the world in toto. The human realm was not separated off. But from their time until the nineteenth century, the experiential unity of the world, whatever it was thought to be ultimately composed of, was largely unquestioned. The next major step was taken by Plato (428-348 bc) and Aristotle (384-322 bc), who were the first major thinkers to concern themselves with the uniquely human element in experience. Neither invented the mind, which was gradually pieced together during the Middle Ages until it achieved pride of place in the scheme developed by Descartes (1596-1650). But Plato’s introduction of what came to be called epistemology—how do humans know what they know?—and Aristotle’s introduction of what came to be called psychology—how does a human function?—required a separation of situations and events involving humans from worldly situations and events. The mind was gradually conceived of as the locus and cause of these human affairs. Neither Plato nor Aristotle had a unified concept of what it was to be human. Their views on the structure and function of body, soul, and fledgling mind, and the interactions of these with each other, with the gods, and with the world, are complex and, at times, inconsistent. But Plato, in particular, produced the first version of what became known as dualism1—a single world of experience and a divine set of ideal forms (of which experience of anything was an attenuated copy). Descartes crystallized the one world-one mind thesis, made it his philosophical credo, and moved it on several steps. The world was one sort of thing, the mind another. Each had its own unique set of properties. From its inchoate status in the philosophies of Plato and Aristotle, sharing the human element of existence with a soul, body, and desire, the mind now became the only thing which characterized being human, as opposed to being inanimate or even non-human animate. The mind was now exactly the same thing as the soul, rather than, as before, a subordinate part of it. The mind was something which thought, nothing else. The body was downgraded to the same class as all non-mental substances. The most adventurous step of all was the notion that the individual’s mind had existential primacy over the individual’s body, over all other non-mental substances, and over other people’s minds. According to Descartes, this followed because he could doubt whether anything else existed except the very fact that he was thinking. The major philosophers in the period between Descartes and Kant each produced their own ingenious solution to the peculiar state of affairs which Descartes had bequeathed them. Locke (1632-1704) was a dualist, in that he believed that the mind and the world were entirely different sorts of things, but he was unhappy with the rigidity of Descartes’s scheme and was profoundly puzzled as to what mind and world were. His main contribution to the issue was to appreciate that part of what was previously considered to be in the world (for example the colour or smell of something) was in fact mental, and he separated primary or real qualities of things—‘bulk, number, figure, and motion’—from such secondary qualities as colour and smell, which he thought were ideas derived from these primary qualities. Leibniz (1646-1716) was also a dualist, and his main contribution to the issue was to provide an explanation of how minds and bodies interacted, something that Descartes left very vague. Leibniz proposed a pre-existing harmony of the physical and

One world—one mind

3

psychological spheres, set in train by God, in which neither physical nor psychological affairs affected one another at all, but merely seemed to do so because of what God had engineered. Spinoza (1632-1677) considered the one world-one mind distinction to be artificial. He believed that one substance or sort of thing, and one only, underlay everything that there was. He was what is now categorized as a monist (p. 18). This was taking unification literally. For him, minds and matter were each a different aspect or ‘mode’ (a changeable quality) of the same thing, with the single thing being God. Berkeley (1685-1753) also disputed the one world-one mind thesis. His solution was to deny the existence of the world. He was the first of the idealists (p. 10). Hume (1711-1776), like Spinoza, was a monist (p. 18). He believed that neither matter nor mind existed as separate sorts of things, but that underlying them both was a more primary sort of thing which was akin to sense impressions or perceptions. Kant was aware of all these attempts to explain, or explain away, world and mind. His overall scheme was a reversion to that of Descartes, in that he recognized both mind and world, but conceived their nature differently from Descartes or any of the above-mentioned philosophers. The world: this undoubtedly existed. But a human being had no notion and no possibility even of experiencing what it was really like. The real world was a collection of noumena, or things-in-themselves, the nature of which a human being could not know. What a human being did know and experience were phenomena—the way in which the thing-in-itself was manifest through the constraints of the human mind and sense organs. Kant called his philosophical position on the matter transcendental idealism. This signalled his belief that the human experience of the world was an active creation of that human being’s mental apparatus, and not a passive copy of the same sort of thing that existed outside it. It was transcendental and not absolute idealism, because the creation relied on there being something out there; what was created was not a complete figment of our imagination, a dream—as in absolute idealism. It was idealism and not realism2 because the appearance of the thing constructed conformed to the rules of mental composition and not to the structure of whatever was out there. The mind: this undoubtedly existed too. But it was far from being a single entity, a simple thinking organ as it was for Descartes. It had three separate faculties— cognition, feeling, and desire (will)—a classification that Kant took over from Wolff (1679-1750) and Mendelssohn (1729-1786), who themselves adopted Aristotle’s classification with minor modifications. The cognitive faculty or pure reason then had the ability to supply 12 categories of understanding or rules which partly determined what sorts of experience were available. (These categories comprised unity, plurality, totality, reality, negation, limitation, substance, causality, interaction, possibility, existence, and necessity.) However, they did these in conjunction with what Kant called forms of intuition. These were two in number and provided the spatial and temporal quality of experience. (They were outside the cognitive faculty and allied somehow with perception.) By virtue of all this, the mind imposed a synthesizing or unifying quality on experience, such that it always came with the mark of being ours and nobody else’s. In Kant’s scheme, the one world-one mind thesis just about collapses under the weight of complexity that he introduces. The real world is there, but as it is completely

4

Philosophy and Psychology—Worlds and Minds

unknowable, it could be made up of any number of substances, elements, or categories of things. The phenomenal world, which is, thenceforth, the only ‘world which is meant in most philosophical systems, is unified by the inherent nature of the mind which constructs it. But there are, for Kant, two worlds: one real, unknowable, and possibly manifold, and the other phenomenal, known, and unified. It is doubtful if there can be said to be one mind (Kant is unclear on this as far as I can determine), but the mind’s overriding function is to unite the panorama of life, and in that sense the mind is unifying if not unified.

TWO WORLDS—ONE MIND It was Schopenhauer (1788-1860) who first suggested that there might be a phe¬ nomenal duality1 in the world, hitherto overlooked by previous philosophers. The title of his chief work—The World as Will and Representation—signalled his belief in this. Schopenhauer was led to this conclusion by what he regarded as Kant’s main con¬ tributions to philosophical knowledge. 1.

Space and time are constructs of the mind and nothing intrinsically to do with whatever exists outside of this mind.

2.

The mind has the property of providing other constructs (he reduced all Kant’s 12 categories to one—causality—and put this on the same level as Kant’s forms of intuition of space and time).

3.

The nature of the thing-in-itself in the outside world, the noumenon, as opposed to its appearance, the phenomenon (which an individual did experience but which merely represented all that they could glean about the noumenon’s nature after the distortions introduced by the application of the 12 categories and the space and time constructs), was completely unknown.

Schopenhauer was particularly interested in the nature of the thing-in-itself as Kant had left it. He concluded that its nature was not as ‘unknowable’ as Kant had thought, and believed that we had a clue to its nature through our knowledge of the workings of our own will. The meaning that I am looking for of the world that stands before me simply as my representation ... could never be found if the investigator himself were nothing more than the purely knowing subject, a winged cherub without a body. But he himself is rooted in that world; and ... his knowledge ... is nevertheless given entirely through the medium of a body ... For the purely knowing subject as such, this body is a representation like any other, an object among objects. Its movements and actions are so far known to him in just the same way as the changes of all other objects of perception: and they would be equally strange and incom¬ prehensible to him, if their meaning were not unravelled for hint in an entirely different way ... The answer to the riddle is given to the subject of knowledge appearing as individual, and this answer is given in the word Will. This and this alone gives him the key to his own phenomenon, reveals to him the significance and shows him the inner mechanism of his being, his actions, his movements ... Every true act of his will is also at once and inevitably a movement of his body

Two worlds—one mind

5

... The identity of the body and the will further shows itself, among other things, in the fact that every vehement and excessive movement of the will, in other words, every emotion, agitates the body and its inner workings, directly and immediately. (Schopenhauer 1818)

In this way Schopenhauer proposes that there is at least one thing in the world— our own body—which we know about from two entirely different sources: (1) as a representation of the sensations we receive from it, and (2) as a set of observations which we make about the workings of the will, based on our experience of our actions and emotions in various circumstances.3 The next step in Schopenhauer’s argument concerns the nature of things-inthemselves other than our own bodies. This follows logically from what he has to say about our bodies, but carries less conviction because he uses the word ‘will’ in an idiosyncratic way. The double knowledge which we have of the nature and action of our own body, and which is given in two completely different ways, ... we shall use further as a key to the inner being of every phenomenon in nature. We shall judge all objects which are not our own body, and therefore are given to our consciousness not in the double way, but only as representations, according to the analogy of this body. We shall therefore assume that as, on the one hand, they are representation, just like our body, and are in this respect homogeneous with it, so on the other hand, if we set aside their existence as the subject’s representation, what still remains over must be, according to its inner nature, the same as what in ourselves we call will. (Schopenhauer 1818)

He goes on to argue that every other object that we might encounter in the world—other people, animals, plants, even stones (by virtue of their behaviour under gravity)—has a will, and that this is what constitutes their essence. Magee (1987) remarked that Schopenhauer’s use of the world ‘will’ in all these instances was ‘a disaster which has led to endless misunderstanding’. In fact, at vari¬ ous places in his book he virtually equates ‘will’ with ‘force’ or ‘energy’, which was remarkably perspicacious as he was writing nearly a century before Einstein and nuclear physics. For our purposes, his attribution of the possession of ‘will’ to in¬ animate objects does not undermine his argument about the ‘double knowledge’ available to humans about their bodies, but is mentioned to show his overall philo¬ sophy. Schopenhauer actually believed that double knowledge about itself was com¬ mon to all animals, with a preponderance of will among lower species and a proportionately increased contribution by the intellect at higher levels of the phylo¬ genetic tree. The impact of Schopenhauer’s ideas on subsequent generations is curious. His main work The World as Will and Representation was published in 1818 when he was 30, and was ignored for most of his life. In his last few years, and for the rest of the nineteenth century, it had an enormous influence. It became the artist’s Bible for Wagner, Thomas Hardy, Joseph Conrad, and Thomas Mann. It was a revelation to the 21-year-old Nietzsche. But artists and philosophers born in the twentieth century have scarcely heard of him. Most curious of all is the fact that it has only recently come to light that philosophers and psychologists who were born in the last half of the nineteenth century and who did have an enormous direct influence on all twentieth-century thinkers (Wittgenstein and Freud) were undoubtedly influenced by

6

Philosophy and Psychology—Worlds and Minds

Schopenhauer, but both they and their early biographers or commentators played this down or failed to acknowledge it.4 The title The World as Will and Representation reflects Schopenhauer’s belief that the duality he had uncovered was apparent to us in the world. According to him, duality was not a property of the mind, intellect, or consciousness. The will, which he regarded as ‘primary and fundamental’, in contrast with the ‘intellect [which was] ... secondary, subordinate and conditioned’, did not have its own mental apparatus for representing these activities independently of the intellect which represented the outer world. Although ‘primary’, as Schopenhauer dubbed it, the will was, according to him, entirely dependent on the ‘subordinate intellect’ for representing its condition. As the century wore on, it became apparent that Schopenhauer was virtually alone among philosophers, psychologists, and physicians in his views on this matter.

ONE WORLD—TWO MINDS In the latter half of the nineteenth century there was an explosion of opinion— philosophical, psychological, and medical—on the nature of the mind. There are so many strands to this, that it is difficult to gain a clear perspective of the train of ideas, even 100 years on, and even less easy to evaluate the contribution of the various protagonists in the debate. In the case of philosophy, Magee (1983) has commented: There is general agreement among serious students of philosophy as to who are the great philosophers from Descartes to Kant, but no such agreement on one single figure since Kant. Some may regard the outstanding philosophers in the period of two hundred years since Kant as Hegel and Marx, some as Kierkegaard and Nietzsche, some as Husserl and Heidegger, some as Mill and Russell, some as Frege and Wittgenstein, some as any other selection or combination of these, or of others.

In the case of psychology, a discipline which takes pride in having detached itself from its philosophical roots during the era that we are discussing, there was a more unified pattern. The principle of ‘associationism’, originating with Hartley (1705-1757), was generally accepted by most of those who regarded themselves as psychologists in Britain, Germany, and France throughout the nineteenth century. Hartley believed that a sense organ was set vibrating by an event in the world and that this vibration was then transmitted to the brain. If a second event occurred, this set up another vibration which was transmitted to a different part of the brain. If, on another occasion, the first event occurred without the second event, the nervous system was now primed such that this first event became associated with the circumstances of the second event, despite the latter’s not having occurred. In this way simple ideas were formed, then complex ideas, and then memories. The main concern of nineteenth-century psy¬ chologists was to amplify this principle. Herbart (1776-1841), for example, introduced a dynamic component, whereby stronger ideas could displace weaker ones and, by means of reinforcement, an ‘apper¬ ceptive mass’ could be formed which gave the mind some direction.

One world—two minds

7

Spencer (1820-1903) gave the process a hierarchical structure in which different levels corresponded to different degrees of adaptation to an individual’s environment. Most psychologists—Fechner (1801-1887) and Wundt (1832-1920) in Germany, and Bain (1818-1903) in Britain—were intent on integrating the associationist doctrine with the new sensory physiological findings such as those obtained by Weber (1795-1878). Medicine, and its subspeciality of psychiatry which emerged during this era, will be discussed in detail in the next chapter. The focus of all these disciplines on the particular aspect of the thesis I am considering here can be conveniently summed up by the title of a book by Ellenberger (1970)—The Discovery of the Unconscious. This notion—the existence of an unconscious mind alongside a conscious one—is now accepted by most people, inside and outside professional groups of psychologists, psychiatrists, and philosophers. But the concept, as we know it, was not part of a Western intellectual tradition until the second half of the nineteenth century. The chief philosophical input into the notion is generally credited to Hartmann (1842-1906) in his book The Philosophy of the Unconscious (1868).5 No kind of volitional activity is possible without ideal content of representation ... the whole content of will is idea, no matter whether the will and idea be conscious or unconscious ... In assuming will we assume idea as its determinative and distinguishing content, and whoever refuses to recognise the ideal, unconscious, content of representation as the What and How determination of action must, to be consistent, also refuse to speak of an unconscious will ... This simple consideration exposes the singular defectiveness of the system of Schopenhauer, in which the Idea is by no means recognised as the sole and exclusive content of Will, but a false and subordinate position is assigned it, whilst the maimed and blind Will nevertheless altogether comports itself as if it had a rational ideal content... Unconscious will is a will with unconscious idea as content.

The change from Schopenhauer’s to Hartmann’s formulation of the will is not simply a shift in emphasis. It is a profound alteration in concept of mind, in fact a statement that instead of one mind there are two. Schopenhauer’s ‘will’ was by itself unencumbered by any paraphernalia of mental apparatus, but Hartmann could not accept that this was possible and, as he makes clear in the passage above, made it a condition of his acceptance of the notion of ‘will’ that it be invariably linked with an idea. This gave it the minimal trappings of a second mind, and, in the formulations of subsequent psychologists, it acquired its own emotional repertoire and even its own consciousness, making it structurally, at least, as complex as the concept of the single mind held by Kant.6 Another strand of evidence leading to the notion of a second mind was the clinical observation that sleep-like states could be induced in apparently normal and awake people. Mesmer (1734-1815) had originally achieved this at the end of the eighteenth century by applying magnets to the body of a woman whom he had previously persuaded to swallow an iron preparation—hence the term ‘animal magnetism’ and the attribution of a physical cause to the peculiar mental state. Subsequent practitioners found that they could produce the same mental state purely by psychological means, without magnets or iron, and in 1843 Braid (1795-1880) called the technique and the resulting mental state hypnosis.

8

Philosophy and Psychology—Worlds and Minds

Charcot (1835-1893), who was already an eminent neurologist when he tried out the technique, gave it respectability, attributed the various manifestations of hysteria to spontaneous varieties of hypnosis (because the same pattern of symptoms, e.g. paralysis, could be produced in a normal person by hypnosis), and gave a theoretical account of how hypnosis could arise in normal subjects. It has become possible to produce a sort of partial waking in the organ of the psychic faculties. Thus, one can call into existence an idea, or a group of ideas, connected together by previous associations. But this group set in action will remain strictly limited ... Consequently the idea or group of ideas suggested are met with in a state of isolation, free from the control of that large collection of personal ideas long accumulated and organized which constitutes the consciousness proper, so-called the self. It is for this reason that the movements which exteriorally represent the acts of unconscious cerebration are distinguished by their automatic and purely mechanical character. Then it is truly that we see before us the human machine in all its simplicity. (Charcot 1887)

This extract resembles Hartmann’s account of the normal state of affairs, except that there is no mention of the will at all. Whereas Hartmann attached an idea to Schopenhauer’s notion of an isolated will, Charcot removes the will completely and leaves an isolated idea. Janet (1859-1947) widened the scope of the concept of unconsciousness even further. In his first major book L’Automatisme Psychologique (1889) he summarized 100 years of observations on hypnotism and carefully tested the most striking ones on a handful of his own subjects. What impressed him forcibly was the remarkable nature and range of these, for example an apparent inability to see out of the left eye when the right eye is open, induced ‘positive’ visual hallucinations (seeing things that are not there), induced ‘negative’ visual hallucinations (not seeing things that are in the visual field), the adoption of personalities different from the usual one, and the enactment of a command given under hypnosis days earlier, with amnesia for the reception of the command. Janet felt forced to conclude, with some reluctance, it seems to me, in view of his comments in the extract below, that not only were these evidence of an unconscious mind at work, but in some way this unconscious mind must have its own con¬ sciousness.7 As the idea or perception appears completely absent from the mind of the subject we are forced to suppose that it exists outside'of their consciousness, but this is itself hard to explain when one considers that a thought may preserve the memory of something said during the hypnotic state despite the subject’s now being awake ... The suggestion made to a subject in such a hypnotic state is therefore not completely suppressed but rather displaced out of normal consciousness, and turns up again as part of another group of phenomena, in a sort of other consciousness ... There is a sort of knowledge and consciousness of the act, which is also unconscious in that its point of departure is outside the personality of the subject. (Janet 1889)

Janet was clearly struggling with the need to explain how such a rich mental life could be denied by the only apparent conscious self. However, he seemed to believe that separate personalities, different sets of memories, and alternative knots of emotions could exist simultaneously—a consequence, he thought, of the disintegration of some overall co-ordinating faculty.

One world—two minds

9

At the turn of the century, Freud (1856-1939) took on the challenge of drawing together what was now an astonishing number of disparate observations and theories about the mind.8 For the purposes of our present thesis it is sufficient to confine ourselves to his formulation of the one world-two minds notion, which, in his hands, became the most sophisticated that it had ever been. In fact he overburdened the second mind so much that he felt it necessary to introduce a third mind—the preconscious, later called the superego—which was the repository of certain derivatives of experience and certain aspects of personality not represented in the unconscious (id) or the conscious (ego). This then introduced further complications: By accepting the existence of these two, or three, psychical systems, psycho-analysis has departed a step further from the descriptive ‘psychology of consciousness’ and has raised new problems. (Freud 1915)

Just what these problems were is made clear in a later article. We can now play about comfortably with our three terms, consciousness, preconsciousness and unconsciousness, so long as we do not forget that in the descriptive sense there are two kinds of unconscious, but in the dynamic sense only one ... In the further course of psycho-analytic work, however, even these distinctions have proved to be inadequate and, for practical purposes, insufficient ... We have come upon something in the ego itself which is also unconscious ... and this unconsciousness belonging to the ego is not latent like the preconscious, for if it were, it could not be activated without becoming conscious and the process of making it conscious would not encounter such great difficulties. When we find ourselves postulating a third uncon¬ sciousness, which is not repressed, we must admit that the characteristic of being unconscious begins to lose significance for us. It becomes a quality which can have many meanings, a quality which we are unable to make, as we should have hoped to do, the basis of far-reaching and inevitable conclusions. Nevertheless we must beware of ignoring this characteristic, for the property of being conscious or not is in the last resort our one beacon-light in the darkness of depth-psychology. (Freud 1923)

If we add to this his views on the interactions between the various minds—the problem of censors and frontiers9—the system becomes so unwieldy as to be untenable. Thus, although criticized for his illogicality, Freud, in the above extract, engages in the traditional reductio ad absurdum argument to demonstrate that if one permits the existence of two minds, then one has to allow the possibility that there are three, then four, and so on, to infinity. It seems to me that, in the passage quoted above, Freud saw where the argument led, but drew back from its logical conclusion because it would have invalidated his whole system. Although the two/multiple mind-one world notion is to be found in some form or other in writings of all subsequent schools of psychoanalysis, the resemblance between the unconscious and the conscious becomes more attenuated in the proposals of the more original thinkers. For example, if one takes the work of Jung (1875-1961) as a whole, the unconscious appears to be conceived of as a reservoir of self-images and symbols which the conscious ego can draw on, with different selection constraints at different stages of life. For Lacan (1901-1981), the unconscious is a structured set of rules—language—which interact with our experiences of the real world to produce our psychological reality. One set of these rules, mysteriously labelled the ‘real order’, is

10

Philosophy and Psychology—Worlds and Minds

actually the one about which we can know nothing: ‘No one has been able to attain (this real order) since humanity began to express itself’ (Lacan 1972). Neither Jung nor Lacan appear to regard the unconscious as another mind, with the same complement of apparatus (ideas, emotions, etc.) as the conscious mind. In effect, they reverted to a concept of mind as opposed to minds) with some similarities to those of Plato, Schopenhauer, or Kant, with categories or forms (by means of which the thing-in-itself is structured into phenomenal reality) of a more mythological or esoteric nature than the everyday ones which the earlier philosophers used.

NO WORLD—ONE MIND The first major philosopher to argue away the world of matter was Berkeley. He was an idealist, believing that minds existed but that matter did not. What we experienced was in our mind and what caused it to be there was God. God also put the same ideas in other people’s minds, creating an illusion that we all shared a material universe. Berkeley preceded Kant and reference to phenomenal worlds. Berkeley’s proposal was known to Kant, who dismissed it as ‘dogmatic idealism ... degrading bodies to mere illusion’. Hence Kant’s salvaging of the material word in the form of the thing-in-itself. Hegel (1770-1831) came after Kant, and resurrected Berkeley’s idealism. Of all the major philosophers he has suffered the greatest misinterpretation. His turgid style of writing and the ambiguity attached to his crucial terms probably encouraged this. Russell regarded him as a ‘metaphysician’ and a ‘bloodless logician’ who completely spirited away the world. Schopenhauer considered him a charlatan, and abused him at every opportunity. He has been hailed as the ‘greatest abstract thinker of Christianity’ (Stirling 1865) and branded as an ‘enemy of the open society’ (Popper 1945). Yet he was the most influential philosopher of the nineteenth century, inspiring such apparently mutually incompatible thinkers as the British idealists Bradley and McTaggart, the American pragmatists Dewey and James, and Karl Marx. According to Solomon (1983), he was a humanist, and neither particularly Christian nor totali¬ tarian, and, far from being an unworldly metaphysician or logician, he was the first major philosopher to appreciate the social nexus of our world-view and its historical basis. Moreover, also according to Solomon, he prepared the ground for contemporary disillusion with traditional scientific methods (e.g. Feyerabend 1975) and epistemology (e.g. Rorty 1980). How can one man have been so variously interpreted? The answer lies in the solu¬ tion that he came up with for the philosophical problem that Kant had teasingly left for his successors—the problem of the ‘thing-in-itself’, the nature of reality. We have seen how Schopenhauer tackled this—ingeniously, but largely by employing Kant’s own methods. Hegel’s solution was to change the rules of the philosophical game, and it was his method as much as the content of his solution which appealed to subsequent philosophers. Hegel was helped by the efforts of two of his contemporaries and colleagues, Fichte (1762-1814) and Schelling (1775-1854). Each had suggested a revision of Kant’s system which did away with the troublesome thing-in-itself, but left nothing sub¬ stantial in its place to correspond with or explain reality.

No world—one mind

11

Fichte is the most deserving of the epithet ‘arch-idealist’ on account of statements such as the following: Our intuitions (Kant’s term for sensations emanating from the thing-in-itself) too, as well as forms of experience, are posited by the self as a product of the productive imagination.

He then explained the phenomenal existence of the world as a ‘postulate of practical reason’—there to serve our needs and desires. Schelling realized that this would not do, as otherwise there would be no agreement between two individuals on relatively uncontroversial items which did not elicit strong feelings in either of them, for example whether the tree in front of them was a birch or a beech. He proposed that the factor which cemented the world in the eyes of different people was the ‘collective participation in the life of the universe which thus made nature real’ (Solomon 1983). Schelling did not systematically examine the implications of this for philosophy, traditional science, and what were to become the humanities (psychology, sociology, and history). Hegel’s genius was to trace the ramifications of Schelling’s insight into all areas of human knowledge. Hegel agreed with Fichte and Schelling that Kant’s ‘thing-in-itself’ was nonsense. He considered the matter from all angles and concluded that, however it was formulated, it was still nonsense. For example, he argued, in the ‘real world’ green things might be red, but we neither knew that this was so, nor were influenced by it, and so there was no point in considering it further. Even if green things were really green ‘out there’, we only knew this through our experience of green things, a case of class allocation, and our ‘perception’ of green grass could not lead us to assume that it existed ‘out there’ solely through its sharing in the property of greenness. Furthermore, he neatly dis¬ counted another philosophical problem, namely Descartes’s sceptical position that we could never know that anything existed outside our thinking about it. Hegel reasoned that if we were troubled by the thought that the things that we experienced might not exist, then this thought might be just as erroneous as assuming that they were there. The sceptical position, according to him, is not a reasonable view to adopt, and cer¬ tainly not more logically defensible than the everyday view that the world is what we experience. So far, Hegel takes on Descartes and Kant, playing by their rules, and undermines crucial elements in their philosophies. He is then left with the proposition that our experience of the real world is all that there is of the real world, and to doubt it or propose an unknowable world is quite absurd. Therefore the real world is simply in our ideas. But then my idea of the real world and your idea of the real world might be poles apart. According to Solomon, this is where Hegel drew back from the bril¬ liance of the next logical step—that ‘there is an utter impossibility of denying an ir¬ reducible plurality of possible human experiences and consequently possible human worlds’ (Solomon 1983). In other words, there must be a multitude of hermetic selves, each existing independently of their own body and actions vis-a-vis other people. And each human being must be constantly vying with all the others to establish a priority world-view. Instead, Hegel retreated to a position in which he ‘appealed to some absolute, ideal conceptual harmony that was in fact so absent in finite human affairs’ (Solomon 1983).

12

Philosophy and Psychology—Worlds and Minds

At the end of the nineteenth century another version of the no world-one mind formulation was being developed by Brentano (1838-1917) and Husserl (1859-1938). Brentano was primarily concerned with correcting certain mistakes, as he saw them, in the fledgling discipline of psychology. Up to his time, psychologists held either that the mind functioned by associating elements of similarity, contiguity, and intensity among new ideas with the same elements in ideas that were already there (Hartley, Herbart), or that it passively represented the physiological limits of what the sense organs could pick up from the myriad variety of the world out there (Weber, Fechner, Wundt). Brentano considered that both these approaches were trivial, and probably wrong. What the mind did, according to him, was to create the appearance or phenomenon of an object by means of its (the mind’s) own intrinsic structure and then convince the owner of this individual mind that the object was real. It did this by virtue of a rule, which Brentano resurrected from medieval philosophy, that, if something existed in consciousness, this something must have ‘intentionality’ i.e. there must be something that it was directed towards. As this rule covered thoughts about abstract concepts (e.g. thinking about the nature of evil) as well as experiences of a world outside (e.g. seeing a red apple), this meant that there were, in this context, four different aspects of mental activity, all of which he confusingly called ‘phenomena’. There was the act of thinking about something, there was the thing thought about, there was the act of experiencing something in the outside world, and there was the actual experience of it as in the world. Only the last was a physical phenomenon; the other three were mental phenomena. But even the physical phenomenon was only an intentional object of the corresponding mental phenomenon—the act of experiencing—and so mental phenomena were totally dominant in the mind-world equation. And Brentano further emphasized, as had Descartes, that the mind could be more certain about what was happening to it than it could be about the world outside. Although Brentano would have probably claimed that he was steering a course short of out-and-out idealism, the net result of all this, as Bell (1990) remarks, is that ‘the external, material world has quietly slipped away’. Husserl, in his early writings, also stops short of denying the external world, but later, in Ideas (1913), advocates a ‘transcendental-phenomenological idealism’, which ‘brackets’, ‘excludes’ and ‘puts out of action’ the world. This ‘phenomenological reduction’, as he also called it, is a logical consequence of his adherence to Brentano’s notions of (1) intentionality (whereby the thought of something necessarily implies the contemporaneous existence of that something) and (2) the supposition that the contents of consciousness, the thought of something or the act of perceiving something, are more valid than the actual experience of the same item. The world was at most a set of relations among the ‘predicate senses’, the purported correlates of what the mind sets its intentionality at.10

ONE WORLD—NO MIND There have been several attempts this century, if not to deny the existence of a mind altogether, certainly to underplay considerably its role in the scheme of things. These

One world—no mind

13

attempts have come from a number of directions within philosophy and psychology. One principle that they hold in common is that Plato and Descartes are to blame for a one-sided view of the nature of things. Plato is held responsible for concentrating on ideas of things, and Descartes for assigning these ideas an owner, the mind, that is different in every respect from the things that the ideas were about.11 Heidegger (1889-1976), Wittgenstein (1889-1951), Ryle (1900-1976), and Watson (1878-1958) all subscribed to the view that there was something about human behaviour which was more important, and, in Heidegger’s case, more essential to the human condition, than anything that could be said about this behaviour, or indeed anything that could be said about anything. Heidegger’s philosophical system is intricate, extremely ambitious, and extra¬ ordinarily difficult to understand. The main reason why it virtually defies compre¬ hension, even in the original German according to Dreyfus (1987, 1991), is that the focus of Heidegger’s philosophy is an aspect of the human condition which, by its very nature, lies outside the realm of what language normally refers to. Moreover, in trying to describe it in normal language, the essence of what Heidegger is referring to is immediately distorted, because the frame of reference of normal language only covers those aspects of the world which Heidegger regards as artificial. Heidegger wants to talk about hammering, for example, or opening doors—not what a hammer is or what a door handle is, but what happens when someone hammers or opens a door, what it is like, and what it is like to do anything. Some of the main issues in his early philo¬ sophy (Sein und Zeit (1927)) can be illustrated by reference to hammering as an antithesis to philosophers’ normal preoccupations. Firstly, hammering, or some other activity, is exactly what human beings tend to do most of the time. Unlike philosophers, who ask questions such as ‘What is the nature of a hammer?’ or ‘How do I know that there is a hammer there?’, the vast majority of the human race just get on with things. What normal people tend to do, Heidegger would argue, should be more interesting to a philosopher than what philosophers tend to do. Secondly, a hammerer is not constantly aware of the presence of the hammer in the hand, and someone opening a door may not even register this activity if the operation runs smoothly. The hammerer or opener of doors generally only becomes aware of the hammer or the door handle if something goes wrong with the operation. The equip¬ ment then becomes, according to Heidegger, ‘conspicuous’, the hammerer or door opener ‘tarries’, and only at this point can it be said that a ‘subject is related to an object’. Even here, however, Heidegger argues, the situation is not what most philoso¬ phers have imagined it to be, because ‘Holding back from the use of equipment is so far from sheer “theory” that the kind of circumspection which “tarries” and “con¬ siders” remains wholly in the grip of the available equipment with which one is concerned’. In other words, most of the time most people function as human beings without any recourse to ‘mind’, and even under unusual circumstances, when forced to confront a problem in their affairs, what they fall back on bears little resemblance to a Cartesian mind. At such junctures, what happens is rather the recruitment of a sophisticated way of examining the world, for which purpose a ‘mental’ representation of part of the problem is useful. Thirdly, hammering and opening doors are merely simple examples of what people tend to do. They also gather in social groups, when they will eat with a knife and fork

14

Philosophy and Psychology—Worlds and Minds

if in Europe but with chopsticks if in China, and will be affected by the mood of one of their company, positively if one of them is a life and soul of the party type and negatively if there is a ‘wet blanket’ amongst them. Such activity is neither trivial nor the creation of individual minds, but a condition of their being in the world. A European human being can choose to use chopsticks at a London dinner party or try to avoid being brought down by the sombre mood of a companion, but such activities require effort, and are, as in the case of a breakdown in hammering, artificial and out of the mainstream of normal life. Fourthly, the habitual preoccupation of philosophers with whether the world exists or not is, according to Heidegger, merely one of the ways of the world, no more and no less important in the general scheme of things than ‘the child’s world’, ‘the world of fashion’, etc. For a philosopher to regard everything other than the ‘philosopher’s world’ as trivial, is to make the most fundamental mistake that a philosopher could make. With respect to the specific issues of ‘world’ and ‘mind’, Heidegger is quite explicit. The world exists and everyone partakes in some activity which belongs to it: The world as already unveiled in advance is such that we do not in fact specifically occupy ourselves with it, or apprehend it, but instead it is so self-evident, so much a matter of course, that we are completely oblivious to it.

As for minds, he says: Even one’s own Dasein [Dasein meaning roughly the sense in which I am a human being] becomes something that it can itself first ‘come across’ only when it looks away from experiences and the centre of its actions.

Dreyfus claims that this, in conjunction with other comments throughout the book, should be taken to mean that Heidegger accepted that humans were occasionally aware of something similar to what most other philosophers have called the con¬ sciousness, perception, or idea of a thing. What Heidegger steadfastly maintained was that this way of encountering the world was neither common, except among certain philosophers, nor essential to our status as a human being, nor determined our be¬ haviour through intentionality or any other means. At the very most, the ‘mental way of encountering the world’ appears to be one of many techniques available to us.12 Wittgenstein ended his Tractatus (1921) with the words ‘whereof one cannot speak, thereof one must be silent’, but then ignored this advice in later years and jotted down hundreds of thoughts which occurred to him on matters about which, in his early years, he would have enjoined silence. Together—apparently trivial, seemingly pro¬ found, and, for the most part, gnomic comments on psychology and philosophy, published posthumously in 10 or so volumes—they comprise his later work. They are, as he wrote in the preface to Philosophical Investigations (1953), the first of these volumes to be published after his death, ‘sketches of landscapes’ for an ‘album’. There¬ fore it is difficult to extract precisely what he thought of ‘mind’ or ‘world’ or their relationship subsequent to the publication of the Tractatus. It is certain (Magee 1983) that Wittgenstein was strongly influenced by Schopen¬ hauer’s ideas at all stages of his life, and it is likely that the Tractatus was underpinned by Schopenhauer’s view of the nature of things (see p. 4), with Wittgenstein’s original

One world—no mind

15

contribution being an emphasis on the role of logic in the mechanism by which the mind formed ideas. (Schopenhauer merely stated that language or thought was a higher-order representation of a perceptual representation.) By the 1930s, however, he was dissatisfied with all the statements that had ever been made about philosophical or psychological issues, particularly those made by philosophers and psychologists, and saw his role as pointing out the ambiguity of all such statements and all extant theories on these matters. What he would have said if he had been asked what remained of his own views on the mind and the world, after he had subjected them to as rigorous a cleansing as he advocated others should do, is not entirely clear. Moore (1954), who attended his lectures in Cambridge in the early 1930s and took notes, found his views puzzling, and at times contradictory or incomprehensible. According to Moore, he clearly believed that the world existed, as he said that the new philosophical method which he was proposing ‘was something like putting in order our notions as to what can be said about the world’. On the existence, or otherwise, of a mind, he appeared to find something attractive and something unsatisfactory in specific examples of most of the formulations that we have considered here: Cartesian (one mind-one world), Schopenhauerian (one mind-two worlds), Freudian (two or more minds-one world), idealist (one mind-no world), and behavioural (no mind-one world). About Freud, he said that his writings were ‘very good for looking for philosophical mistakes’, but also that ‘Freud had really discovered phenomena and connections not previously known’. On idealism or solipsism, he said that he had often been tempted to say ‘All that is real is the experience of the present moment’, but also that the statement ‘The only reality is my present experience’ is absurd. He illustrated the conflicting attractions of Cartesian and behaviourist viewpoints by various statements that one might make about toothache. ‘I have toothache’ and ‘He has toothache’ are used, according to Wittgenstein, in a different sense in the two sentences. The difference, he thought, was due to the fact that in ‘He has toothache’ we are necessarily talking about a physical body, whereas in ‘I have toothache’ we are not. What we call ‘having toothache’ is what he calls a ‘primary experience’, and what characterizes this ‘primary experience’ is that, in its case, T does not denote a possessor. In one sense, he thought, ‘I’ and ‘conscious’ are equivalent, but in another sense they are not. He recommended, for example, that instead of ‘I think’ we ought to say ‘It thinks’. In the case of ‘He has toothache’, he thought that it was incorrect to say that ‘His toothache is only his behaviour’, because this implied that when we pity someone for having toothache we are merely pitying him for ‘putting his hand to his cheek’.13 In Philosophical Investigations Wittgenstein devoted considerable space to the nature of perception, and identified a particular problem in the way in which we perceive ambiguous pictures such as the duck-rabbit figure (Fig. 1.1). According to a recent biographer (Monk 1990), he was quite preoccupied with this problem and what was eventually published in Philosophical Investigations was a rather inadequate reflection of his views. He was impressed with Kohler’s (1929) book Gestalt Psycho¬ logy,14 but realized that there was a problem in accepting one of Kohler’s conclusions

16

Philosophy and Psychology—Worlds and Minds

about perception, which Kohler thought explained how one could see the rabbit at one moment and the duck the next, namely that there were ‘two visual realities’. But although he rejected this conclusion as nonsense, his own solution implied just this very possibility: ‘The expression of a change of aspect is the expression of a new perception and at the same time of the perception’s being unchanged’. Wittgenstein’s astonishing capacity for exposing the ambiguity in statements about psychological matters leaves all general formulations of the mind-world problem considered here inadequate. In rather Procrustean manner I justify his inclusion in the current formulation for three reasons: (1) his insistence that much of what is said on these matters are language games with a social function; (2) one source of major confusion is that whatever I say about myself during any psychological activity is not applicable to what I can say about someone else engaging in what seems to be the same activity; (3) neither descriptions of mental activities (e.g. perceiving) nor the results of those acts (e.g. seeing a dog), nor descriptions of physical actions (e.g. smiling), nor the presumed cause of these (e.g. happiness) are at all like what philosophers such as Descartes or Brentano would have us believe. Ryle (1949), in The Concept of Mind, attacked the Cartesian version of the one mind-one world formulation head on. He argued that it stemmed not just from a generally confused use of words about psychological issues, but from one particular mistake, the ‘category mistake’, which, in other areas of discourse, virtually everyone avoids. Everyone, he argued, from philosopher to the most stupid of lay people, appreciates that a division of an army is its brigades, battalions and men and is not something separate from the things that it includes. They realize that it would be nonsense to ask, after a march past of the elements of the division, when the division itself would appear. However, Ryle argues, virtually every philosopher makes a similar sort of mistake when it comes to the concept of mind and what it might include. According to Ryle, minds are not something separate from the terms which are applied to a human’s interaction with the world; ‘Peter’s mind is made up’ means simply that Peter is disposed to do something, not that there is a place inside Peter’s head, his mind, where some decision to act was taken. Ryle thus repudiates at least three assumptions implicit in Cartesian doctrine: (1) that a mind is something over and above dispositions

One world—no mind

17

to act; (2) that minds occupy a place somewhere inside a human being; (3) that there are two parts to any action—theorizing about doing it and then doing it: In opposition to this entire dogma, I am arguing that in describing the workings of a person’s mind we are not describing a second set of shadowy operations... occult causes of the perform¬ ances so characterized ... (Instead) we are describing certain phases of his one career; namely we are describing the ways in which parts of his conduct are managed.

Consider his account of perceiving a familiar tune: Roughly to know how a tune goes is to have acquired a set of auditory expectation propensities, and to recognise or follow a tune is to be hearing expected note after expected note ... That a person is following a tune is, if you like, a fact both about his ears and about his mind; but it is not a conjunction of one fact about his ear, and another fact about his mind, or a conjoint report of one incident in his sensitive life and another incident in his intellectual life.

Or consider his account of imagination: I want to show that the concept of picturing, visualizing or ‘seeing’ is a proper and useful concept, but that its use does not entail the existence of pictures which we contemplate or the existence of a gallery in which such pictures are ephemerally suspended ... Seeing Helvellyn in one’s mind’s eye does not entail what seeing Helvellyn and seeing snapshots of Helvellyn entail, the having of visual sensations. It does involve the thought of having a view of Helvellyn and it is therefore a more sophisticated operation than that of having a view of Helvellyn. It is one utilisation among others of the knowledge of how Helvellyn should look, or, in one sense of the verb, it is thinking how it should look ... So far from picturing involving the having of faint sensations, or wraiths of sensations, it involves missing just what one would be due to get, if one were seeing the mountain.

And seeing is: A person who espies [a] thimble is recognising what he sees, and this certainly entails not only that he has a visual sensation but also ... that he has learned enough of the recipe for the look of thimbles to recognise thimbles ... When the actual glimpses of it that he gets are got according to the thimble recipe, they satisfy his acquired expectation-propensities: and this is his espying the thimble.

There is something bogus about all this which, in the vernacular, would be referred to as ‘shifting the goal-posts’. The problem is redefined, rather than fairly treated. The same tendency is even more noticeable in the psychological school of be¬ haviourism. Launched by Watson in 1913, with an article entitled ‘Psychology as the behaviourist views it’, it began as an attack on the methods hitherto used in psycho¬ logical experiments, most of which Watson dismissed as ‘introspective’ and concerned with the analysis of consciousness, which he denigrated as a ‘substitute term for the soul’ (Watson 1930). He then incorporated the animal physiological experiments of Pavlov (1849-1936) and Bekhterev (1857-1927), although these are given less weight in his main writings (e.g. Behaviorism (1930)) than dogmatic statements about how best to rear children, Utopian appeals for a better world, and a generally hectoring and dismissive tone towards any idea in philosophy, psychology, or psychiatry that had been put forward before behaviourism was invented. His own method comprised: experimental technique, the accumulation of facts by that technique, occasional tentative con¬ solidation of these facts into a theory or an hypothesis ... Judged upon this basis, behaviourism is a true natural science.

18

Philosophy and Psychology—Worlds and Minds

It seems to me that some genuine problems about the Cartesian concept of mind, identified and partially tackled by Heidegger and Wittgenstein, are distorted and debased in much of what Ryle and Watson said. Some of their comments are tautologous, some ignore whole aspects of the situation that they purport to be describing, and some (for example, when imagery is described in terms of thinking or seeing, or thinking is dismissed as behaviour) make a mockery of the everyday use of psychological terms.

NO WORLD—NO MIND—SOMETHING ELSE Some philosophers attempted to solve the problems inherent in the mind-world relationship by denying mind and world independent status as fundamental entities. Instead, such philosophers nominate some other aspect of the human condition as the primary matrix, of which mind and world are subsidiary subordinate elements. Such notions are known as double-aspect theories or neutral monism. Mind and world are different aspects of something else, and only one pervasive thing exists and is neutral, in that it is neither mind nor world. Spinoza, Hume, Russell (1872-1970), and Strawson (1959) are generally regarded as holding such views. Spinoza believed that world and mind were both aspects of God, which itself was Nature. The world was that aspect of God considered from a spatially extended point of view. The mind was that aspect of God considered from the perspective of consciousness, particularly of what is going on in the body. His philosophy is also known as pantheism, because God is everything that is. Hume maintained that mankind ‘was nothing but a bundle or collection of different perceptions’. The primary and all-pervasive matrix of everything that there is was ‘perceptions ... or impressions’. Russell held a similar view to Hume’s, in that he believed the fundamental basis of the universe to be a sense datum or percept. Strawson believed that a person’s acquaintance with other people was a primary influence on his world view, to the extent that, according to Strawson, this acquain¬ tance was the underlying element in a subsequent construction by the developing person of mind and world. These philosophies are somewhat peripheral to the theme of this chapter, but are included to show that minds and worlds are such problematic entities that great philosophers have questioned the very existence of both.

TWO WORLDS—TWO MINDS This philosophical formulation of the mind-world problem is the least common, and, to my knowledge, can only be found in the writings of Bergson (1859-1941).15 His views on the nature of mind and world are mainly set out in two books: Essai sur les Donnees Immediates de la Conscience (1889), known in English by the title

Two worlds—two minds

19

Time and Free Will, and Matiere et Memoire (1896) or Matter and Memory. In both these books the notions of a dual sense of reality and a twofold division in the apparatus available for appreciating this world permeate his writings. For Bergson, the world, in the form of matter, undoubtedly exists. Matter, in our view, is an aggregate of ‘images’. And by ‘image’ we mean a certain existence which is more than that which the idealist calls a representation, but less than that which the realist calls a thing,—an existence placed half-way between the ‘thing’ and the ‘representation’ ... the object exists in itself, and, on the other hand, the object is, in itself, pictorial, as we perceive it: image it is, but a self-existing image.

According to Bergson, the realist and the idealist philosopher are both wrong, and for the same reason: they have both been duped into thinking that the intellect’s view of the world is the ultimate reality. The only difference between the two viewpoints, according to Bergson, is that the realist believes that there is also a world out there exactly as the intellect receives it, whereas the idealist believes that there is nothing additional to the perception. Bergson believes that the intellect distorts the world out there, and so traditional realist and idealist positions on the issue are both irrelevant. So far, his scheme sounds like Kant’s. But he then brings in two new arguments which make his view of the world radically different from anything put forward before or since. First, he believes that he has found convincing evidence for the existence of ‘a material world distinct from sensation’ by virtue of the presence of ‘parallelism’ between the order of visual sensations and the order of tactile sensations. How does ... visual extension ... reunite with tactile extension? All that my vision perceives in space is verified by my touch. Shall we say that objects are constituted by just the co-operation of sight and touch, and that the agreement of the two senses in perception may be explained by the fact that the object perceived is their common product? But how could there be anything in common, in the matter of quality, between an elementary visual sensation and a tactile sensation, since they belong to two different genera? The correspondence between visual and tactile exten¬ sion can only be explained, therefore, by the parallelism of the order of the visual sensations with the order of the tactile sensations. So we are now obliged to suppose, over and above visual sen¬ sations, over and above tactile sensations, a certain order which is common to both, and which consequently must be independent of either. We may go further: this order is independent of our individual perception, since it is the same for all men, and constitutes a material world in which effects are linked with causes, in which phenomena obey laws. We are thus led at last to the hypothesis of an objective order, independent of ourselves; that it is say, of a material world distinct from sensation.

There may be flaws in this argument, but I find it quite compelling. Nevertheless, whether it is sound or not, it has not moved us on very far, as Bergson admits. Though the matter which we have been led to posit is indispensable in order to account for the marvellous accord of sensations among themselves, we still know nothing of it, since we must refuse to it all the qualities perceived, all the sensations of which it has only to explain the correspondence. It is not, then, it cannot be, anything of what we know, anything of what we imagine. It remains a mysterious entity.

The real problem is now whether there is any way in which we can bypass ordinary perception, and learn anything about this ‘mysterious entity’, without the distortions

20

Philosophy and Psychology—Worlds and Minds

imposed on it by ordinary perception. This is exactly the impasse Kant had reached 100 years earlier. Schopenhauer (see p. 5) thought that he had found a way round it. Bergson approaches the problem in the same way,16 but ends up with a more radical and ingenious solution. Bergson’s second chain of reasoning bearing on his world view is as follows. Action not sensation should be the starting point ... We start from action, that is to say from our faculty of effecting changes in things ... So we place ourselves at once in the midst of extended images; and in this material universe we perceive centres of indetermination, characteristic of life. In order that actions may radiate from these centres, the movements or influence of the other images must be on the one hand received and on the other utilised ... As the chain of nervous elements which receives, arrests and transmits movements is the seat of this indetermination and gives its measure, our perception will follow all the detail and will appear to express all the variations of the nervous elements themselves. Perception, in its pure state, is then, in very truth, a part of things ... It is the theory of pure perception ... Our pure perception is our dawning action ... The actuality of our (pure) perception thus lies in its activity, in the movements which prolong it ... The past is only idea, the present is ideomotor ... Recognise in pure perception a system of nascent acts which plunges roots deep into the real and at once (pure) perception is seen to be radically distinct from recollection; the reality of things is no more constructed or reconstructed, but touched, penetrated, lived; and the problem at issue between realism and idealism ... is solved, or rather dissolved by intuition.

Like Schopenhauer before him and Heidegger after him, Bergson realizes that there is something about the action of the body which allows us a window on the real world, unobscured (or relatively unobscured in Schopenhauer’s case) by the distortions imposed by the intellect. Unlike Schopenhauer, though, Bergson appreciates that action in humans (and all animals) must be preceded by some prior condition of the nervous system, and that this condition must itself be preceded by some situation in the environment to which it is a response. Bergson calls the prior condition of the nervous system ‘pure perception’ to distinguish it from the ordinary form of perception which the intellect provides. To avoid confusing the two varieties of perception, he later replaces the term ‘pure perception’ with ‘intuition’. Taking stock of the position Bergson has reached so far, we see that he first attempts to establish that there is some order in the world; then, using the fact that humans act in the world as well as see things in that world, concludes that though actions and seeing things both require prior perception of something in the world, the perception is of a different kind in each case. This is a rather bald statement of his position, but it is a fair one because he does not adduce any other evidence. As it stands, the con¬ clusion is quite shaky, and even counter-intuitive, for there is no reason to suppose that actions and seeing things should rely on different sorts of perceptual processing. In fact, it is counter to the Cartesian analysis of reasons and causes for action, and totally foreign to what is held to be the case on these matters by cognitive psychologists (Gardner 1985). In my view, however, Bergson’s conclusion was a stroke of genius (as will be apparent throughout the rest of this book). He also avoided the pitfalls of Schopenhauer’s attempt to demystify the thing-in-itself. Schopenhauer, by not assign¬ ing a cause to the will to action, not only had to equate this will with the thing-in-itself, which is not quite nonsense (if everything in the world is energy), but also had to place human action in the same category of events as stones hitting the ground under gravity, which definitely is nonsense.

Two worlds—two minds

21

If one accepts his creative leap of inspiration, then the elements of Bergson’s world view follow logically. He believed that there must be ‘two different kinds of reality’, ‘two possible conceptions of time’, two versions of space (‘extensity’ and ‘a conception of space’), ‘two kinds of multiplicity’, ‘unity under a double aspect’, ‘two conceptions of the difference between sameness and other’, ‘two conditions of existence’, and a ‘twofold analysis of causality’. The way in which all these fit together is complicated and, at times, contradictory, but there is no doubt that he believes that a significant proportion of Kant’s 12 categories (see p. 3) for construing the world, in addition to the time and space constraints, are divisible into two qualitatively different varieties. A sense of duality pervades his whole world scheme. Bergson believed that the world as known through ‘pure perception’ or ‘intuition’ was very close to the real outside world, whereas the world which the perception provided by our intellectual apparatus presented to us was very far from this real world. Sometimes, in his writings, he equates the former two: There is no essential difference, no real distinction, between (pure) perception and the thing perceived.

At other places in his work, he seems less sure of this: There is in matter something more than, but not something different from, that which is actually given. Consciousness may not be the synonym of existence but only of real action or of immediate efficacy. These two terms, perception (pure) and matter, approach each other in the measure that we divest ourselves of what may be called the prejudices of action. Practically, we perceive only the past, the pure present being the invisible progress of the past gnawing into the future. Pure perception ... is like a fragment of reality.

Taken as a whole, his writings seem to suggest that the intuitive (pure perceptual) mode approaches as close to reality as is possible. (Compare this with Schopenhauer’s view (p. 5) that the information available to us about the actions of our bodies is less distorted than that available to us about external objects in the world, as the latter are distorted by three factors (space, time, causality) but the former is distorted by the time constraint only.) On mind, Bergson’s views also follow logically from the position that he reached about the dual nature of perception. There are ‘two forms of memory’: The past survives under two distinct forms: first in motor mechanisms; secondly, in independent recollections.

There are: Two distinct selves, one of which is, as it were, the external projection of the other, its spatial and, so to speak, social representation.

He stops short of talking about two separate minds, probably, it seems to me, because he believes that ‘pure perception’ or ‘intuition’ is, as he says, ‘a fragment of reality’, ‘really part of matter’. So the duality is chiefly in the world: ‘Conscious life displays two aspects according as we perceive it directly or by refraction through

22

Philosophy and Psychology—Worlds and Minds

space’. But ‘pure perception’ is also ‘the lowest degree of mind—mind without memory’, and so, in effect, he is saying that there are two aspects to mind, if not two minds. This distinction is elaborated in his later writings, particularly L’Evolution Creatrice (Creative Evolution) (1907). However, by this time he had developed profound religious beliefs, and what had been ‘pure perception’, and then ‘intuition’, was now linked with ‘instinct’, and all were part of an ‘elan vital’— a creative life force identical with God. His writing becomes more abstruse at this stage, and his remarks more gnomic. Therefore it is difficult to disentangle his previous epistemological notions from these new metaphysical speculations. His precise views do not matter too much for our purposes. What is relevant to our general thesis is that his formulation of a second mind is less substantial than Freud’s and more substantial than Schopenhauer’s. As Schopenhauer was at pains to emphasize, his concept of ‘will’ was not really a mind at all, merely an impetus for action. Because this seemed so ludicrous, Hartmann attached an ‘idea’ to the will, creating a second mind proper, and then more and more was added to it by Charcot and Janet, culminating in the cumbersome and illogical scheme devised by Freud. Bergson avoids the problems inherent in Schopenhauer’s system, and those in Freud’s, by making one of the minds a virtual replica of reality.

SUMMARY The purpose of this introductory chapter is to trace the progress of a single philosoph¬ ical theme from Classical times up to the present day. The theme concerns the sense in which either the mind or the world can be said to have a double aspect. This sense of duality is not the same as the Cartesian mind-body ‘dualism’, which is more frequently the topic of philosophical enquiry. But, I would argue, the former is actually a more fundamental problem than the latter. All philosophers and psychologists have participated in the debate to some extent. But the two who contributed the most profound thoughts on the topic were Schopen¬ hauer and Bergson, curiously the most currently neglected of major philosophers. The different views on the matter were considered to fall into eight groups, according to a philosopher’s or psychologist’s position on the existence or duality of mind or world: manifold world-multiplicity of souls; one world-one mind; two worlds-one mind; one world-two minds; no world-one mind; one world-no mind; no world-no mind-something else; two worlds-two minds. These eight categories cover virtually all formulations of the problem, with the exception of those of a handful of late-nineteenth century psychologists, who suggested that there were more than two minds, i.e. ‘polypsychism’. Some of the individuals’ claimed adherence to one of these formulations is less than whole-hearted, but their inclusion is then justified because of their fervent opposition to rival formulations. In brief, it is argued that the primitive world view was a conglomeration and interpenetration of the human with the non-human, the animate with the inanimate, and myth with fact. At most, one can say that the world was manifold and inhabited by a multiplicity of souls.

Summary

23

There was then a long phase in the history of ideas, from Plato until Kant, during which the real world was held by most major philosophers to exist in one form or other and to manifest some semblance of unity. During the same era, a single mind was given more and more importance in the scheme of human affairs. The publication of Kant’s The Critique of Pure Reason in 1781 was a watershed. From then on the real status of the world was generally held to be a mystery by the most optimistic accounts or unknowable by the most pessimistic. Thenceforth the focus was on what was knowable—human experience, the phenomena of the world. Thenceforth, also, the role of the mind in determining these phenomena became the battleground of debate. A few philosophers, chiefly Schopenhauer and Bergson, took on the task of trying to solve the riddle of the ‘unknowable’, the thing-in-itself, as Kant had left it. In effect, they were trying to prove the existence of the real world; Kant had considered the failure of all previous attempts to do so a ‘disgrace’. In the course of their investi¬ gations Schopenhauer and Bergson arrived at the conclusions that the world did exist, that it ‘appeared’ to have two entirely different guises, and that human beings had a sophisticated intellectual apparatus which distilled what seemed important to them out of this world, but in the process distorted what was actually there. In addition to all this, there was a part of themselves (‘will’ in Schopenhauer’s case and not a mind, and ‘intuition’ in Bergson’s case and a primitive mind) which was identical with reality or as close to reality as humans could approach. Another solution to the problem of the real world, as Kant had left it, was to resurrect an argument put forward by Berkeley, prior to Kant, and simply deny that it existed at all. This is what Hegel proposed. Alternatively, one could follow Husserl and pretend that, for all practical purposes, it did not exist, to ‘bracket it’. Yet another solution was to undermine Kant’s ‘critique’ by attacking the views of the philosopher who was renowned for being the arch-doubter on the question of the existence of the real world—Descartes. By various means—recourse to logic (Ryle), analysis of the everyday meaning of psychological expressions (Wittgenstein), con¬ sideration of everyday human activity (Heidegger), and, in the final resort, rather hectoring appeals to common sense (Watson)—a number of philosophers and psycho¬ logists convinced themselves that, if there was to be any doubt about the existence of either of the two entities in the mind-world pairing, it was mind not world which was more problematic. A different formulation from any of these, and one advanced chiefly to explain certain abnormal or peculiar mental states rather than to tackle Kant’s philosophical impasse, admitted the existence of one world, but duplicated the mind. Thus it was held by Freud and others that there was a conscious mind, and one or more unconscious minds. Some philosophers, beginning with Spinoza and Hume before Kant, and more recently Russell and Strawson, found the world-mind dichotomy so artificial that they discounted both as basic entities. They then argued that some alternative stuff—God, percepts, sense-data, awareness of other people—was the most fundamental item in the universe. This author, as signalled by the title of this book, chooses to follow Bergson in respect of the duality he proposed for both world and mind.

Philosophy and Psychology—Worlds and Minds

24

NOTES 1.

The term ‘dualism’ is usually applied to Descartes’s system of a mind completely independent from the body which contains it. According to Ryle (1949), the official doctrine is as follows. With the doubtful exceptions of idiots and infants in arms every human being has both a body and a mind. Some would prefer to say that every human being is both a body and a mind. His body and his mind are ordinarily harnessed together, but after the death of the body his mind may continue to exist and function. Human bodies are in space and are subject to the mechanical laws which govern all other bodies in space. Bodily processes and states can be inspected by external observers. So a man s bodily life is as much a public affair as are the lives of animals and reptiles and even as the careers of trees, crystals and planets. But minds are not in space, nor are their operations subject to mechanical laws. The workings of one mind are not witnessable by other observers; its career is private. Only I can take direct cognisance of the states and processes of my own mind. A person therefore lives through two collateral histories, one consisting of what happens in and to his body, the other consisting of what happens in and to his mind. The first is public, the second private. The events in the first history are events in the physical world, those in the second are events in the mental world. In Ryle’s account this dualism is referred to as two different ‘worlds’, but the use of the term ‘world’ to refer to mind confuses the issue from the outset. For there are at least two additional meanings of ‘dualism’ which are frequently encountered in the neurological, psychological, and philosophical literature, and these are often used interchangeably with the mind-body interpretation. One of these is the pairing between mind and external world (a pairing which Ryle, in the above extract, seems to equate with the mind-body dualism). Another is the pairing between mind and brain. Some commentators equate, or rather blur, all three, but they should be kept distinct, as arguments which may be valid for one pair are not necessarily valid for the other two. Taylor (1970), for example, points out that much of the superficial plausibility of behaviourism relies on muddling up the three interpretations, as was done by Hebb (1949): Modern psychology takes completely for granted that behaviour and neural function are perfectly correlated, that one is completely caused by the other. There is no separate soul or life-force to stick a finger into the brain now and then and make neural cells do what they would not otherwise. The truth of the last sentence (appealing to the mind-external world distinction) does not entail the truth of the first (a statement about mind and brain). Rorty (1980) shows that even the three interpretations I have identified here come nowhere near to covering the complexity of the matter. This discussion of the meaning of dualism is necessary because I am going to introduce yet another interpretation, which I shall stick to as rigidly as I can whenever I use the word. I shall use ‘duality’ rather than ‘dualism’ to help keep the meaning distinct. It is not an invention on my part, as it is used by Lacey (1989) when discussing Bergson’s philosophy. In fact, neither his philosophy, nor Schopenhauer’s, can be understood without this interpretation of dualism, and I do not apologize for it. As Schopenhauer’s and Bergson’s view on the nature of mind and world provide the philosophical underpinning for the entire book, it is important to appreciate my use of the term ‘duality’. When Schopenhauer refers to a ‘double knowledge of the world’ (zwei vollig heterogene Weisen gegebene Erkenntniss) or Bergson to ‘two realities of a different order’ (deux realites d’ordre different), what they mean is that there are two alternative apparent or phenomenal realities or aspects of the world which are potentially available to every human. (i)

The duality is in the phenomenal sphere; it is not a statement about the real world_ the thing-in-itself, in Kant’s scheme. The real world could conceivably be dual in some

Notes

(ii)

25

way, or unitary as Spinoza thought, or infinitely divisible as Leibniz thought, but this is not the realm that Schopenhauer or Bergson were referring to and I will follow them. The statement about duality is not primarily about the mind, although it should be logically apparent now, and will be made explicit as the book unfolds, that if the duality is phenomenal and nothing to do with the real world then it must correspond to something dual about the mind. However, there are ways in which the mind can be dual without the phenomenal world being dual also (as in Freud’s formulation (p. 9)), and so, whereas duality of the phenomenal world entails duality of the mind, duality of the mind does not necessarily entail duality of the phenomenal world.

(iii) Why dual? Why not triple, quadruple, infinite? Why not a finite set of activityorientated worlds as in Heidegger’s formulation (p. 13)—the child’s world, the gardener’s world? I shall argue that a superordinate phenomenal duality overrides all these. 2.

Realism can be defined (Rosenberg 1991) as: the ontological position that the external world is real, that is, exists independently of us, and that the objects, structures and mechanisms of that world stimulate our senses.

Idealism is (Priest 1991): the theory that only minds exist: solipsism is the view that only one’s own mind exists.

Note that the terms materialism and realism are not synonymous. The world may exist as a material entity but be entirely different in form from anything we experience; this is Kant’s view—a materialistic and non-realistic philosophy. 3.

Schopenhauer’s views on the will are considered in more detail later (p. 394), but the crucial points in his general scheme were as follows. 1. There were two contemporaneous sources of information about the body: what it appeared to be and what it appeared to do or feel. 2. Both these sources were ultimately represented by the intellect, and therefore both were potentially subject to that organ’s distortions of the thing-in-itself according to his revision of Kantian rules of space, time, and causality. 3. Although the body as known as a representation built up from somatic and visual sensations, and the body as known through the workings of the will, were both appearances or phenomena, there was a qualitative difference between these two types of knowledge. 4. The source of information about the body as representation was subject to all three distortions (space, time, causality) whereas the body known through the workings of the will was exempt from the constructs of space and causality, as these only applied to the acquisition of ‘outer knowledge’, and was only distorted by the time construct. 5. ‘Accordingly’, wrote Schopenhauer, ‘in this inner knowledge the thing-in-itself has indeed to a great extent cast off its veils, but still does not appear quite naked, and in consequence of the form of time which still adheres to it, everybody knows his will only in its successive individual acts, not as a whole’. 6. Because the two sets of phenomena derived from different sources and had different degrees of ‘appearing as through a mask’, there was scope for conflict. The validity of this last assertion requires that there is no overall integration of the two sources, a point which is central to Schopenhauer’s philosophy and which he illustrates several times.

4.

Magee (1983) makes this abundantly clear in the case of Wittgenstein: ‘Wittgenstein was soaked in Schopenhauer’. He even borrowed many of Schopenhauer’s metaphors. In the case of Freud, there is barely a mention of Schopenhauer, either in Freud’s collected works

26

5.

6.

7.

Philosophy and Psychology—Worlds and Minds or in the biography by Jones (1953—1957). However, Magee and others believe that he must have become acquainted with them secondhand. When Otto Rank, one of Freud s inner circle, pointed out to him the exact passage in The World as Will and Representation where Schopenhauer had predated him by 100 years in suggesting that madness might come about if ... sorrow ... is so harrowing that it becomes positively unbearable ... the individual seizes on madness as the last means of saving life’, Freud expressed amazement and put the similarity down to coincidence, commenting that he owed the ‘chance of making this discovery to not being well-read’. One theory is that he was introduced to these ideas by Meynert, professor of psychiatry in Vienna in the 1870s and 1880s, whose lectures Freud attended, and whose house physician he became. Meynert was a devotee of Schopenhauer. Hartmann is generally regarded as an important influence on Freud (Wyss 1966; Ellenberger 1970; Magee 1983). Moreover, Magee sees him as an important link between Schopen¬ hauer and Freud as, according to Magee, Hartmann was a disciple of Schopenhauer, and whereas Freud did not read Schopenhauer in his formative years, he did read Hartmann. The route whereby Schopenhauer influenced Freud may be as Magee maintains (though see footnote 4), but it is not true that Hartmann was a disciple of Schopenhauer. If he was a disciple, he was certainly a deceitful one, because not only did he completely invert the whole thrust of Schopenhauer’s philosophy, as illustrated in the passage on p. 7, but he also disputed whether the mind was capable of constructing space, time, and causality from the raw material delivered to it through the senses, thus undermining the very foundation of Schopenhauer’s system (and Kant’s at the same time). Unlike Schopenhauer’s masterpiece, which virtually no-one bought for 30 years, Hartmann’s book went through eight editions in 10 years, and was ‘the most widely read philosophical book of its time’ (Magee 1983). This is all the more remarkable because, unlike Schopenhauer whose lucid style is almost unique among philosophers, Hartmann writes extremely turgidly. The only charitable men¬ tion of Schopenhauer that I could find in Hartmann’s book was a remark to the effect that if Schopenhauer had got himself a better publisher he might have sold more copies of his books. It is not my intention to attribute to Hartmann the first inklings of the existence of an unconscious part of the mind. As Ellenberger (1970) makes clear, this notion has a longer pedigree, stretching back at least into the eighteenth century. Even much earlier philoso¬ phers than this have been credited with the notion, for example St Augustine (354-430) (Chadwick 1986). Anyway, it is dear that only the tiniest fraction of knowledge that we hold about the world or ourselves (for example the date of the Battle of Hastings, or the name of our favourite composer) is in our consciousness at any moment. This must also have been clear to any philosopher. The early associationist psychologists/philosophers (Hartley, Herbart) laid considerable emphasis on this fact. This is trivial. What was novel about Hartmann’s formulation was the notion of a compartmentalized and integrated set of faculties lying alongside the ‘primary mind’, mirroring the latter in general structure and only differing from it in either the content of ideas or certain qualitative respects (which differed according to its major advocates—Freud, Jung). Janet was not the only person to believe that the unconsciousness could have its own consciousness. Durand (1826-1900) coined the term polypsychism for the notion that: Our subcerebral nervous centres are thus themselves veritable brains, and although subordinate to a higher centre, in each of these resides, as in the superior brain, a psychic individuality and its own consciousness. (Durand 1868)

The notion of an unconscious mind with its own consciousness is patently absurd, as even Freud appreciated: We have no right to extend the meaning of this word ... to ... include a (second) consciousness of which the owner himself is not aware. If philosophers find difficulty in accepting the existence of unconscious

Notes

27

ideas, the existence of an unconscious consciousness seems to me even more objectionable. The cases described as splitting of consciousness ... might be better denoted as shifting of consciousness ... between two different psychical complexes which become conscious and unconscious in alternation. (Freud 1912)

8.

The diverse strands which he tried to tie together included the prevailing associationist theories within psychology, Charcot’s and Janet’s clinical observations and theories, Schopenhauer’s and Hartmann’s philosophical notions, Brentano’s ideas on what was later to be called phenomenology (he attended Brentano’s lectures), the views of Meynert and other neurologists on the structure and function of the brain (he studied neuroanatomy with Mernert, wrote a book on aphasia, and coined the term agnosia), his friend Breuer’s claims about infantile sexuality (Breuer was a Viennese physician respected by Freud), and his own investigations into the nature of dreams. In addition, he was a keen observer of politics, had a deep interest in religion and art, and practised as a psychiatrist at a crucial stage in that discipline’s development (particularly important was the description of dementia praecox by Kraepelin (1896)). His treatment by subsequent critics has been much harsher than he deserves, given the mammoth task that he set himself. Most critics attack him on the grounds that he contravenes the rules of scientific method. I see a muddle here between a cause and a reason ... What he gives is speculation—something prior even to the formation of any hypothesis. (Wittgenstein quoted by Rhees 1982) The psychoanalytic theories were simply non-testable, irrefutable; there was no conceivable human behaviour which could contradict them ... as for Freud’s epic of the ego, superego and the id, no substantially stronger claim to scientific status can be made for it than for Homer’s collected stories from Olympus. (Popper 1963)

However, he is also vulnerable to criticism from the opposing camp, from semiologists like Lacan, Foucault, and Derrida, who thought that he did not go far enough. For example, according to Foucault: Freud did not succeed in going beyond a solidly established postulate of 19th Century psychology: that a dream is a rhapsody of images ... Freud takes the symbol as merely the tangential point where, for an instant, the limpid meaning joins with the material of the image taken as a transformed and transformable residue of perception. (Foucault 1954)

What happened, it seems to me, was that Freud saw that a new interpretation of meaning was possible, one which was independent of the meaning given to things in the everyday world but persisted in trying to link the everyday with the symbolic. 9.

Consciousness stands in no simple relation either to the different systems or to repression ... On the one hand we find that derivatives of the unconscious become conscious as substitution formations and symptoms ... On the other hand, we find that many preconscious formations remain unconscious, though we should have expected that, from their nature, they might well have become conscious ... We are led to look for the more important distinction as lying, not between the conscious and the preconscious, but between the preconscious and unconscious. The unconscious is turned back on the frontier of the preconscious by the censorship, but derivatives of the unconscious can circumvent this censorship ... When, however, ... they try to force themselves into consciousness, they ... are repressed afresh at the new frontier of censorship between the preconscious and the conscious. (Freud 1915)

Although Freud did not regard these frontier skirmishes as particularly problematical, the introduction of censors implies the existence of two self-contained control units, minds in all but name, additional to consciousness, preconsciousness, and unconsciousness. A frontier guard is an agent of the country employing him or her, but is not identical with that organization, and must be permitted some individual responsibility as to who should and who should not be let in. Thus we have three minds and two quasi-minds to consider.

28

Philosophy and Psychology—Worlds and Minds

10. Ryle (1932) and Bell (1990) trace Husserl’s path in detail. Phenomenology, as the method became known, is still indirectly influential. Through Jaspers (1883-1968), whose philosophical system combines the less idealist aspects of that of Husserl with the more comprehensible of that of Heidegger, it became the standard technique for establishing categories of psychopathological experiences (p. 51). His application of phenomenology to psychiatry, General Psychopathology (Jaspers 1913), is still regarded by psychiatrists as a paradigm of what psychopathology should be about. The ideas of Brentano and Husserl are also to be found in one of the newest schools of psychology cognitive psychology—of which Neisser’s Cognitive Psychology (1967) provides the guiding prin¬ ciples. Modern cognitive psychologists may deny the provenance, but their preoccupa¬ tion with consciousness, perception, intentionality, and meaning, as in books such as Mandler’s (1975) Mind and Emotion, leaves little doubt as to the link. Moreover, as Dreyfus (1991) points out, the theoretical underpinning of the latest psychological venture of all—the construction of artificial intelligence computer programs—is almost pure ‘Brentano-Husserl’. 11. Iam not concerned here with the issue of materialism (Sprigge 1985; Priest 1991). This is a philosophical doctrine arguing that the nature of mind and the world is inorganic matter. It is true that materialists would subsume minds under matter, but they might still believe that a mind and non-mind worldly things were entirely different species. Sometimes, the mind-world dichotomy is coterminous with the mind-matter dichotomy, as in Descartes’ scheme for example. But Hobbes (1588-1679) was a materialist and believed in God and held that minds existed (although they were matter in motion). And Kant, according to Priest (1991), was a materialist, believing that there was a material world, a phenomenal world, and a complex phenomenal-world-inducing mind. The general issue covered in this chapter is the mind-world equation, which cuts across other dichotomies. 12. This is an extreme precis of some of the deepest speculations ever made by a philosopher, but will suit our purpose on the issues of minds and worlds. In his later work, referred to by some commentators as post-Kehre (after the turn around), Heidegger appears to disown some of the views set out in Being and Time. There is much more reference to thinking and language, but in neither case does he mean what we mean by these terms. For example, he refers to language itself doing the talking, not to someone talking. The emphasis on the nature of what it is to be something (their Dasein)—whether the something is thinking, talking, or hammering—is his central message. There is no mind, conceived of as a collection of activities belonging to someone, set apart from a world, conceived of as a collection of things that this someone encounters. 13. Wittgenstein’s unravelling of the complexities inherent in such statements leaves one dizzy. Of course, it is easier to criticize philosophical arguments than to formulate a water-tight system de novo on a major topic, as is apparent in the behaviourist proposals of Ryle and Watson. However, Wittgenstein’s intention is never to be destructive for its own sake, but to seek what is worthwhile about all such arguments, to ‘relieve mental cramp’ as he put it. I suspect that, on balance, he considered Cartesian arguments to be more ‘cramp-inducing’ than behaviourist ones. Consider his statement about the ambiguous duck—rabbit drawing (Fig. 1.1): And above all do not say After all my visual impression isn’t the drawing; it is this—which I can’t show to anyone . Of course it is not the drawing, but neither is it anything of the same category, which I carry within myself. (Wittgenstein 1953, p. 196)

Consider also Moore s comment, above, that he thought it would be helpful if someone said it thinks rather than I think in certain situations. This last remark is not as bizarre as it sounds, when considered in the light of what schizophrenics sometimes say (p. 342).

Notes

29

14. The Gestalt school of psychology managed to distil most that was worthwhile from the relatively new discipline of psychology. Its founders Wertheimer (1886-1943), Koffka (1886-1941), and Kohler (1887-1967) followed Wundt’s lead in regarding psychology as a separate discipline from philosophy or physiology. It also relied exclusively on experi¬ mental data, including animal research. (Watson’s claim that only behaviourism (p. 17) is ‘a true natural science’ or takes account of animal behaviour is false.) Von Ehrenfels (1859-1932), a member of what is known as the Wurzburg school of psychology, realized that Wundt’s general scheme of psychology was wrong. Like most associationists, Wundt believed that the mind built up an idea of something by synthesizing sensations into con¬ scious perceptions and then into ‘apperceptions’, with the last of these constituting the identification and integration of experience. Von Ehrenfels considered this view to be false, because a tune, for example, must consist of something other than a sequence of notes, since one can recognize the same tune played in a different key. Furthermore, the same note, say middle C, can occur in different tunes in different keys and thus contribute to an entirely different experience each time. If different elements can produce the same experience, and different experiences contain the same element, Wundt’s theory must be wrong. Von Ehrenfels coined the term Gestaltqualitat (form quality) to denote the extra dimension which something possesses which cannot be reduced to its component parts. It was this that formed the cornerstone of Gestalt psychology. Even apes, when given sticks and boxes with a banana well over their head, do not try every combination of their material, but experiment with a few and then suddenly arrive at a seemingly ‘thoughtful’ solution. Humans also structure their environment to take account of regular patterns; they search for order in the world. 15. Bergson’s ideas were extremely popular during his lifetime, so much so that his weekly lectures before the First World War were social occasions for the Parisian intellectual elite. His fame plummeted after the Second World War, and his name and ideas are now virtually unknown. Unusually for someone writing in French, his prose style is at times turgid and impenetrable. I believe that this is a consequence of the same problem which Heidegger was to face later—that of trying to communicate ideas which, by their very nature, are almost inexpressible in normal language. Subsequent English commentators have generally dis¬ agreed with virtually everything that he said (Russell 1946; Lacey 1989), and, in the case of Lacey, failed to grasp his major contribution to philosophy. Kolakowski (1985) provides a sympathetic but brief account. In addition to his profound insights into the nature of mind and world, he was the first philosopher to appreciate the philosophical significance of the advances in neurology and neuropsychology of the last half of the nineteenth century (see Chapter 3). 16. Bergson was definitely acquainted with Schopenhauer’s philosophy. In an interview (Chevalier 1959), he said of Schopenhauer: He is the only German philosopher who has influenced me, no doubt because he was nourished by French and English psychologists.

A biographer (Baillot 1927) recorded that Bergson greatly admired Schopenhauer because, alone among German metaphysicians, he was a psychologist.

2 Psychiatry and Psychopathology FOUR TYPES OF MADNESS—A BRIEF HISTORY OF PSYCHIATRIC CLASSIFICATION Pre-nineteenth century There have been documented instances of madness for as long as there have been records of human activity. During Roman times, some consensus was reached as to how it should be classified, and this classification persisted largely unchanged until the beginning of the nineteenth century. The extent of the agreement is illustrated in Table 2.1, where the opinions of three of the most eminent Roman physicians and those of four subsequent writers on the topic are shown. There was one type associated with febrile illness—variously called phrenitis, frenisie, or delirium. There was dementia, also variously named. Then there was mel¬ ancholia. So far, there was considerable agreement. But madness not accounted for by the above categories was the subject of much dispute. (What are now regarded as neurological, developmental, and neurotic conditions were placed in the same category as madness.) This left-over group was generally referred to as mania, but this is simply the Greek word for madness and it did not have the restricted meaning that mania has now. The fact that most of these writers felt obliged to subdivide it suggests that they were unhappy with it as an entity.

Kraepelin (1855-1926) During the nineteenth century, this scheme was subjected to intense scrutiny, primarily by French psychiatrists, joined, towards the end of the century, by German psychia¬ trists. All this activity culminated in a classification proposed by Kraepelin in 1899 (Table 2.2), which, with only minor modifications, is accepted by almost all psy¬ chiatrists to this day. What is remarkable about Kraepelin’s proposal is how closely it resembles the pre¬ nineteenth century system, if one takes into account the reassignment of epilepsy and the like to the newly formed speciality of neurology, and the creation of a new category of psychiatric disorder—neurosis—to cover those which are not true instances of madness. There are now several types of psychosis consequent on bodily ill-health, rather than the single ‘phrenitis’, but the form that the madness takes, as Bonhoeffer (1909) was soon to point out, is identical in all four instances. There are several varieties of demen¬ tia, but, according to Kraepelin, one of these—dementia praecox—is quite different in form from the other three and is soon (Bleuler 1911) to be renamed schizophrenia to

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Four types of madness—a brief history of psychiatric classification

35

Thus GPI became a model with which to compare other types of madness, as in Falret’s remarks: What should be sought is the progression and the various stages of the true species of mental disorders which are still unknown to this day but which the close study of the successive phases of these diseases will enable us to discover. For the notion of a natural form implies that of a well-defined course, and vice versa the notion of a natural course that can be predicted pre¬ supposes the existence of a natural species of disease with a pattern of development. It is here, in our view, that the most important advance is to be made in our special field. (Falret 1864)

Thus Bayle’s discovery provided three seemingly incontrovertible facts about the nature of madness, which all future psychiatrists venturing on classifications of madness were advised to heed. 1.

Brain disease could definitely give rise to madness.

2.

If there were varieties of madness, then these, like physical illnesses, would have their own unique ‘life cycles’, with phases (development, progression, decay) which might well throw up different symptoms and obscure any essential quality of an individual variety.

3.

The very existence of discrete varieties of madness, based on some enduring quality through these phases, was not at all ensured, because the enshrined var¬ ieties (melancholia, mania, dementia) appeared to be but phases of the same brain disease observed at different times.

These considerations influenced Falret in 1854, and Baillarger (1809-1890) in the same year, to propose an amalgamation of part of the old concept of melancholia with part of the old concept of mania to produce new varieties of madness—folie circulaire (Falret) and folie a double forme (Baillarger). They so impressed Griesinger (1817— 1868), who was professor of psychiatry in Berlin, that he proposed that madness (or psychosis as it was generally called after an article by Feuchtersleben (1845)) was a single species—an opinion which is now referred to as the ‘Einheitspsychose’ (unitary psychosis) theory and attributed to Guislain (1833). The third major influence on nineteenth-century psychiatric classification, again a French innovation, was the concept of degeneration. In 1857, Morel published a Treatise on the Physical, Intellectual and Moral Degeneracy of the Human Race. In 1859, Moreau (1804-1884) published Morbid Psychology and its Relationship to the Philosophy of History. Both these works contained a number of interrelated ideas which were to affect psychiatric classification. The main idea was the notion of degeneracy. This itself had several strands, and, as Berrios (1985) has pointed out, had a very shaky basis in fact. Morel, who was the more influential of the two, believed that human beings had degenerated over the cen¬ turies from ‘the primitive human type’ as a result of adverse social conditions. He fol¬ lowed Lamarck in believing that physical conditions acquired during an individual’s life could be passed on to the next generation. He thought that both physical and psy¬ chiatric disorders would accumulate from generation to generation in certain families until the line became extinct through sterility. Therefore the concept of degeneracy denoted a complex interplay of environmental and genetic factors which could influ¬ ence brain function and cause psychiatric disorders. The religious (fall from grace) and

36

Psychiatry and Psychopathology

Lamarckian elements, which formed the core of Morel s ideas, were later abandoned by his followers (of whom the chief was Magnan). But the comprehensive and inter¬ locking nature of the scheme had considerable appeal for all subsequent psychiatrists, who then extracted from it elements which were to provide the framework for psy¬ chiatric classification and notions of cause still in place to this day. Firstly, there was the emphasis on genetic predisposition to madness. As Dowbiggin (1985) has pointed out, although Esquirol and others in the first half of the nineteenth century admitted the possibility of hereditary transmission of madness, they gave it very little weight compared with a host of other possible causes. Esquirol, for example, regarded it as only a ‘remote cause’. But by 1886 Magnan was referring to it as: the almost unique efficient cause of mental alienation... The habit is to invoke a variety of causes that are only commonplace... If, however, these do come into play they can do so only by virtue of another cause, more essential and inherent in the constitution of the subject himself that which is called predisposition. (Magnan 1886) The change of emphasis paved the way for the endogenous-exogenous dichotomy of madness.3 Secondly, it provided some rationale for the concept of functional psychosis, which was gathering momentum. Following Bayle’s discovery of ‘arachnitis’, a palpable and visible brain lesion, in a minority of cases of madness, there was hope that some other sort of lesion would be found in the remaining majority. However, it soon became apparent that in most cases of madness other sorts of lesions were simply not to be found at post mortem. To solve the problem of the similarity in the madness between cases where visible brain damage did occur and those where it did not, the notion of a functional lesion was put forward. Morel, for example, proposed: It is in another order of functional cerebral lesions that it will be necessary to search for the pathological element in the great number of circumstances. This element is nothing else than the degeneracy with which hereditarily tainted individuals are invariable stricken in the normal development of their nervous systems. (Morel 1857) Moreau (1859) was more forthcoming about the form that the functional lesion might take, although, because it had never been identified, his descriptions were neces¬ sarily vague. At various times he refers to it as a ‘diffuse pathological state’, a ‘disequil¬ ibrium’, a ‘neuropathic diathesis’, a ‘morbid modification’, and a ‘nervous dynamism’. Despite the crude nature of the concept—formulated with the help of hypothetical notions drawn from pathology, physiology, and psychology—the dichotomy between an organic and a functional psychosis soon became an established principle.4 The third factor to be abstracted from Morel’s shaky edifice was the concept of a neurosis.5 Fourthly, Morel’s belief that diverse physical and psychiatric conditions could occur in different members of the same family across several generations contributed further to the demise of the nosological independence of delirium, dementia, melancholia, and mania. Over four generations, according to Morel, nervous temperament and moral inferiority might occur in the first, neuroses and alcoholism in the second, psychoses and suicide in the third, and idiocy, physical malformations, and sterility in the fourth. This appeared to provide independent confirmation of Bayle’s thesis that

Four types of madness—a brief history of psychiatric classification

37

the traditional forms of madness were no more than manifestations of some underlying predisposition to become mad, whether genetic (in Morel’s scheme) or the result of brain damage (in Bayle’s cases of GPI). Finally, Morel bequeathed the concept and name of a form of madness which was eventually to fill completely the contentious fourth category of earlier psychiatrists, and even spill over into other previously self-contained categories—demence precoce (a concept and a term which Kraepelin took over in its virtual entirety). According to Morel (1860), this was the sort of condition which could occur in the fourth generation of a family tainted with hereditary degeneracy ‘as the sad termination of hereditary insanity... demence precoce indicating that the patient has reached the end of his intellectual life that he can control’. Faced with all this richness supplied by French psychiatrists, all that was left to the Germans in the last quarter or so of the century was, as Jaspers (1913) noted, ‘to take their ideas over, clear them of the trimmings, deepen the concepts and make invest¬ igations that could contribute in an objective way’. They had a medical definition of disease provided by one of their own physicians and pathologists which complemented that of Bayle and Falret: ‘Diseases represent the course and appearance of life under changed conditions’ (Virchow 1847). They also had Griesinger’s (1845) rationalization of the nature of madness (p. 43) as a model. But they generally opted for the same approach as Magnan—multiplying categories of madness, until the whole exer¬ cise looked futile. Two of these categories, hebephrenia (Hecker 1871) and catatonia (Kahlbaum 1874), achieved temporary renown as independent entities, but Kraepelin rejected their claim to independent status and incorporated them, along with most in¬ stances of paranoia (p. 54), in his category of dementia praecox. Thus, at the end of a century of intense speculation and upheaval in psychiatric classification, what remained to be passed on to twentieth-century psychiatrists was distinctly meagre. Dementia praecox or schizophrenia increasingly dominates the whole scheme, with manic-depressive illness, dementia, and delirium being the only generally agreed alternative forms of madness. What was generally accepted from nineteenth-century notions was the correctness of separating neurosis and personality disorder6 from psychosis, and discrete neurological or neuropsychological entities (e.g. aphasia, agnosia, amnesia, etc.) from madness proper.

Twentieth century The chief events in this area in the twentieth century have concerned dementia praecox, although there have been various proposals on how to dismantle the concept of manicdepressive insanity (see Kendell 1976). The most notable revisions of the dementia praecox concept have been as follows: (1)

its renaming as schizophrenia, together with recommendations that the diagnosis should not be contingent on either a poor outcome or the presence of delusions and hallucinations, but rather should involve a search for a particular set of defi¬ cient mental functions in the spheres of thinking, emotion, action, and involve¬ ment in the real world (the pathological features corresponding to these being

38

Psychiatry and Psychopathology loosening of associations, altered affectivity, ambivalence and autism) (Bleuler 1911);

(2)

the designation of certain types of delusions and auditory hallucinations as firstrank symptoms of the condition (Schneider 1946);

(3)

a plethora of diagnostic schedules or operational criteria from all over the world, but particularly the United States, incorporating some of the recommendations of Bleuler and Kraepelin, but mostly those of Schneider (e.g. DSM-IV (APA 1994)).

In the first half of the century, there was less overall agreement about the details of the scheme than there is now. In France, for example, Magnan’s category of chronic delusional states remained viable, and several subcategories were devised: delires d’interpretation (misinterpretative delusional states) (Serieux and Capgras 1909); delires d’imagination (confabulatory delusional states) (Dupre and Logre 1911); psychose hallucinatoire chronique (chronic hallucinatory psychosis) (Ballet 1911); psychoses passionelles (psychoses of passion) (de Clerambault 1921). These varieties, which to¬ gether replaced the paranoid subgroup of schizophrenia in use elsewhere, were throw¬ backs to Esquirol’s attempt to devise categories based on impairment of part of the mind. The impaired portions in the above four categories are reasoning, imagination, perception, and feeling respectively. In Germany, an anti-Kraepelin trend among a minority of psychiatrists took a different direction, with Wernicke (1900) and Kleist (1928) promoting a classification based on similarities between certain aspects of mad¬ ness and the neurological (or neuropsychological) syndromes which had been delineated in the last half of the nineteenth century (e.g. aphasia, agnosia, apraxia, etc.) (p. 61). Another minority approach advocated by some Scandinavian (e.g. Wimmer 1916) and German (e.g. Kretschmer 1918) psychiatrists was to separate psychoses which were understandable, in terms of an event in the sufferer’s world or by virtue of their personality, from those which were not (see p. 142). In this way, psychoses were designated as psychogenic (if preceded by a world event sufficiently devastating, in the view of the psychiatrist, to ‘cause’ anyone to become mad). Alternatively, they were considered examples of what Kretschmer called sensitiver Beziehungswahn (delusional states in those of sensitive personality) if the personality of the individual who sub¬ sequently became psychotic was, in the view of the psychiatrist, so fragile anyway that the slightest world event would turn them from sane to mad. This particular approach undercut a whole series of twentieth-century assumptions about the nature of madness (e.g. validity of the distinction between psychosis and neurosis, psychosis as a break with reality, psychosis as ‘ununderstandable’, and psychosis as caused by a brain event or endogenous predisposition). Finally, there was yet another trend in psychiatric classification, prominent in the Soviet Union and the United States in the first half of the century. This was to extend the boundary of what schizophrenia encompassed into areas which no previous physician or psychiatrist would have considered appropriate. In the Soviet Union, a category of ‘sluggish schizophrenia’ was held to exist, by virtue of which an individual could be deemed mad for holding beliefs contrary to the official state doctrine. In the United States, subgroups of schizophrenia were proposed—ambulatory (Zilboorg 1941), pseudoneurotic (Hoch and Polatin 1949), abortive (Mayer 1950), and

Four types of madness—a brief history of psychiatric classification

39

Table 2.4 List of names for a proposed alternative psychosis to either schizophrenia or manic-depressive psychosis (1950-1990) Oneirophrenia Angst-Gluck psychose Motilitatspsy chose Verwirrtheitspsy chose Atypische Psychose Atypische phasenhafte Familienpsy chose Bouffee delirante Schizophrenic ahnliche Emotionspsy chose Legierungspsy chose

(anxiety-ecstacy psychosis) (motility psychosis) (confusion psychosis) (atypical psychosis) (atypical phasic familial psychosis) (schizophrenia-like emotional psychosis) (alloy psychosis)

Atypical psychosis Borderline psychosis Hysterical psychosis Oneiroiden Emotions¬ psy chose

Cycloid psychosis Psychogenic psychosis Reactive psychosis Delusional depression Acute confabulatory psychosis Pseudopsychosis Schizomania Schizodepression Acute delirious mania

(oneiroid emotional psychosis)

Meduna (1950) Leonhard (1957)

Pauleikhoff (1957) Elsasser and Colmont (1958) Ey et al. (1960) Labhardt (1963) Arnold et al. (1965) Mitsuda (1965) Grinker et al. (1968) Hirsch and Hollender (1969) Boeters (1971) Perris (1974) Stromgren (1974) McCabe (1975) Kantor and Glassman (1977) Koehler and Jacoby (1978) Bishop and Holt (1980) Brockington et al. (1980#) Brockington et al. (1980h) Bond (1980)

pseudopsychopathic (Bender 1959)—the very names of which testify to an incursion of the concept of schizophrenia into areas of mental disease, and even normal realms of experience, hitherto regarded as nothing to do with insanity. In both countries, the social consequences of an individual’s madness were given undue diagnostic weight, with the result that any individual behaving in a similar way (although for non-insane reasons) was deemed mad. During the second half of this century, most of the national idiosyncrasies in psych¬ iatric classification have withered away, although a list of alternative diagnoses pro¬ posed for madness between 1950 and 1990 (Table 2.4) is by no means meagre. This reductionist tendency has come about more through American hegemony in cultural and scientific matters, itself a consequence of general European passivity, than through any increased conviction that Kraepelin was right in his broad perspective. The insid¬ ious acceptance of the recommendations of the American Psychiatric Association’s Diagnostic and Statistical Manual for psychiatric diagnosis in all countries in recent years testifies to a dearth of creativity, and possibly a weariness with the issue, on the part of European psychiatrists rather than to any active consensus. There is a certain

40

Psychiatry and Psychopathology

amount of sniping and chipping away at some of the assumptions, but Kraepelin s edifice, and by extension the pre-nineteenth-century system, is stronger today than it has ever been.s

THE TRIPARTITE MIND—A SURVEY OF OPINIONS ON THE NATURE OF MADNESS The nature of madness should be clearly distinguished from its causes (see next section). The nature of madness can be discussed within whatever version of the mind-world formulation (Chapter 1) one holds to be true, independently of a considera¬ tion of its causes. In essence, in all formulations which admit the existence of a mind, a discussion of the nature of madness boils down to an analysis of the alteration in the mind to which it corresponds. Even if one holds an extreme behaviourist version of the mind-world formulation, madness can still be conceived of as a particular set of behaviours. The causes of madness are then any antecedent conditions—whether con¬ sidered in terms of the state of the brain, body, world, or mind itself (the last condition being invalid in behaviourist formulations)—which satisfy criteria for a cause and effect relationship with the state of mind (or set of behaviours) corresponding to madness.9

Pre-nineteenth century Discussions concerning the nature of madness prior to the nineteenth century are not easy to relate to contemporary ideas because they presuppose views of the world, mind, brain, and body, and their interrelationships, which are entirely foreign to our current way of thinking (and this is true whatever formulation of the mind-world problem we may now hold). Some of this foreignness is accounted for simply by in¬ accurate notions of the anatomy and physiology of the brain and other bodily organs. Some of it stems from the contamination of all systems of knowledge—in this context psychology, anatomy, and physiology—by metaphysical and false cosmological specu¬ lations. However, a certain amount is due to a genuinely different Weltanschauung, which would still remain even if one could somehow go back in time and give the medi¬ eval physician a crash course in twentieth-century anatomy, physiology, and astron¬ omy, and convert him to atheism at the same time. This, it seems to me, is what the hermeneutic school of philosophy, and Foucault (1961) in particular as he applied their principles to the concept of madness throughout the ages, are driving at. According to this school of thought, all knowledge is locked in a time warp which no other culture can fully penetrate. Despite such constraints, it is still instructive to examine the rough framework within which early thinkers did conceive the nature of madness because, by analogy with the legacy passed on by pre-nineteenth-century classifications of madness, some of our modern ideas on its nature may also be illuminated.

The tripartite mind—a survey of opinions on the nature of madness

41

Hippocrates (460-377 BC) considered madness to be a consequence of an unhealthy condition of the brain. In particular, he believed that it would be agitated if it became too moist, and the agitation would render sight and hearing unsteady. Plato had a preoccupation with the number three. Although this probably owed more to its mystical significance than to any rational account of the nature of soul, mind, or body, this figure crops up time and again in later psychological theories. For Plato, there were three souls: a rational one created by God and situated in the head, and an irrational one which was split into two, with the superior part in the heart and the inferior part below the diaphragm. The first was responsible for reason, the second for energy, and the third for desire and nutrition. There were three modes of existence: that of the body, that of the soul and body, and that of the soul alone. The soul was capable of three states: knowledge, opinion, and ignorance. In this scheme, madness was either a result of the severing of the irrational souls from the rational, or was a divine revelation in which the rational soul became infected by one of the Gods. Aristotle mostly dispensed with the rule of threes and rigid subdivisions in general. He believed that the soul could be said to have a number of functions or faculties, which could be roughly divided into nutrition, sensation, thought, and motion. In his scheme, the soul was the sum of the activities of the body, and not a thing apart. He considered that there was a ‘common sense’—a physiological rather than psychological process—which somehow extracted sensations from the form of objects in the outside world and passed them on to the imagination to turn them into images. Madness could come about, he believed, through a fault in this ‘common sense’. Galen devised a scheme combining Aristotle’s physiological and Plato’s psycholog¬ ical notions which was to serve physicians concerned with madness for more than 1000 years. In his view, madness was a disturbance in the balance between three sys¬ tems: (1) the four humours (blood, phlegm, yellow bile, and black bile); (2) the three chief organs of the body (brain, heart, and liver) which provided intellect, vitality, and desire respectively; (3) the three faculties of the soul’s provision of intellect (reason, imagination, and memory).10 During the seventeenth and eighteenth centuries, anatomical and physiological knowledge of the brain and heart advanced to such an extent that contemporary notions about the nature of madness begin to resemble our own, although a meta¬ physical component persisted in some proposals right up to the beginning of the nineteenth century. Schelling (1810) and Heinroth (1818), for example, held views sim¬ ilar to those of Plato, in which madness represented an imbalance between a divinely given soul and the banal human mind. British physicians clearly subscribed to the less radical and pre-Mendelssohnian version of the tripartite mind theory. For example, Battie (1704-1776) characterized the essential quality of madness as ‘deluded imagina¬ tion’, Monro (1715-1791) characterized it as ‘vitiated reason’, and Arnold (1742-1816) recognized two varieties, one consequent on ‘disturbed imagination’ and the other follow¬ ing ‘disturbed reason’. Locke regarded madness as an illustration of what happened when the mind went wrong, according to his own theory of it, although he was also attracted by the opposing theories of disturbed imagination or disturbed reason. (Madmen) do not appear to me to have lost the faculty of reasoning, but having joined together some ideas very wrongly, they mistake them for truths; and they err as men do that argue right

Psychiatry and Psychopathology

42

from wrong principles. For by the violence of their imagination, having taken their fancies for realities, they make right deductions from them. Kant made a remarkably pragmatic and modern suggestion, which bears little resemblance to anything that had been said before. The only general characteristic of insanity is the loss of sense for ideas that are common to all and its replacement with a sense for ideas peculiar to ourselves. In

summary,

ideas

about the

nature

of madness,

like

those

on

psychiatric

classification, changed little between Greek and Roman times and the beginning of the nineteenth century. Latterly, they threw off the hydrodynamic and metaphysical components, and gave the brain its proper place in the scheme, but otherwise the philosophical and psychological input was relatively static.

Nineteenth century One theme characterizes virtually all the major nineteenth-century opinions on the nature of madness—the notion of a lack of harmony between disparate parts of the mind. This entirely new theme can be found in almost all the contributions to the topic, and its emergence at this point in the history of ideas is directly attributable to the development of the notion of a radical tripartite mind during the latter half of the eighteenth century. The elements of the concept of mind prior to this—imagination, reasoning, memory— were all intellectual faculties. The elements of the new version of the tripartite mind (as developed by Wolff and Mendelssohn, and adopted by Kant) were given various names: intellect, emotion, and will; knowledge, feeling, and desire; pure reason, judgement, and practical reason. But, however named, the elements were more disparate than those in any division hitherto envisaged. Indeed, in Kant’s scheme they were inde¬ pendent, and in Schopenhauer’s revision of Kant’s scheme (see pp. 4 and 25) the intellect had no direct knowledge of what the will was up to at all, but had to glean what it could about this as a mere passive observer. Such philosophical and psycho¬ logical doctrines as this gave psychiatrists much more scope for discussing madness than previously, when they were allowed only one relatively homogeneous mind with which to explain everything. Now, they had three major faculties with which to speculate, not to mention numerous permutations of disharmony and loss of control between these. Reil (1759-1813), a German anatomist and physician, was one of the first to take advantage of this psychological versatility in his book Rhapsodien (Reil 1803). He pro¬ posed three mechanisms whereby madness might arise: (1) through a loss of an integrative function of the brain on the mind; (2) through the derangement of a sense organ, leading to false perceptions; (3) through excess bodily stimuli, giving rise to false ideas about the world. Pinel (1801) actually drew an analogy between the loss of control over the emotions by the masses, which he had witnessed during the French Revolution, and madness. He believed that in the latter case an individual’s will weakened, and this unleashed un¬ controllable emotions.

The tripartite mind—a survey of opinions on the nature of madness

43

Gall (1818), the Viennese phrenologist, believed that loss of control over a particular ‘organ’ of the brain (each was the site of a faculty, and there were many more than three in his scheme (p. 61)) resulted in madness. He thought that this loss of control was itself a consequence of that ‘organ’s heightened activity and irritability’. Schelling (1810) held that there was an imbalance between three levels in an individual: soul (the highest), then spirit (containing will and intellect), and then mind (along with emotion) at the lowest level. The imbalance allowed mind with its emotions to contaminate the other levels. Later in the century, Jackson (1894) put forward a sophisticated version of the notion of loss of control. He believed that all forms of insanity, and also the symptoms of all diseases of the nervous system, were a composite result of two simultaneous processes: (1) what the mind could no longer do as a result of ‘loss of function’ or ‘a negative lesion’ in the highest cerebral centres, and (2) what the intact lower centres then did as a result of this new state of affairs. In his paper ‘The factors of insanities’’ (Jackson 1894), he wrote about the dissolution of these higher centres resulting in ‘removal of control over the lower layers of those centres’, with compensatory ‘activity of healthy nervous arrangements’ coming in to fill the gap. Rather than a perpetual

imbalance being the root of the problem, Jackson reasoned that it was a fundamental characteristic of biological systems that a new balance would always be set up follow¬ ing damage to one part of the nervous system, with the remaining undamaged com¬ ponents ‘evolving’ to accommodate to the new situation. Griesinger (1845), undoubtedly the most modern of the nineteenth-century psych¬ iatrists, put forward a theory which was more in keeping with some of the best twentieth-century views, and almost existentialist in its themes. Instead of a simple disharmony between impersonal components, he introduced the notion of a change within the personality. There is an essential change in a man, an alienation from the former self ... (manifest) as discomfort, oppression and anxiety, owing to the fact that the new groups of ideas and instincts are usually at first exceedingly obscure ... The diminished power and energy of the (old) self, the contraction of its sphere of ideas, produces an indefinite state of mental pain ... The new morbid perceptions and instincts produce divisions of the mind, a feeling of division of the personality, and of imminent annihilation of the [old] self ... Everything feels strange to him ... and he feels a strong inclination to ascribe his condition to the direct influence of the outer world—to believe that he is pursued, influenced, governed. (Griesinger 1845) In summary, the theme of disharmony, division, or lack of control within a more complex mind was the new note struck on the nature of madness by nineteenth-century psychiatrists.

Twentieth century During the second half of the nineteenth century, the general consensus that had obtained among philosophers since Classical times concerning the unity of the mind and the unity of the world broke down completely (see Chapter 1). There had even been a reasonable consensus up till then about the internal nature of the mind, but that broke down also. Therefore by the early part of the twentieth century, when these

Psychiatry and Psychopathology

44 Table 2.5

Psychological theories of the nature of schizophrenia (1900—1940)

Stransky (1904) Gross (1904) Weygandt (1907) Jung(1907) Meyer (1910) Bleuler (1911) Chaslin (1912) Kraepelin (1909-1913)

Intrapsychic ataxia—imbalance between intellect and will Lowering of consciousness Disorder of apperception Pathological transformation of emotional complexes Conflict of instincts Loosening of associations and blocking or splitting of ideas Discordance between mental functions Loss of inner unity of intellect, emotion, and will, in themselves

Jaspers (1913) Freud (1915)

and among one another Ununderstandable Primary psychological process manufacturing dream images out of

Kretschmer (1922) Wetzel (1922) Schilder (1924) Minkowski (1927) Zutt (1929) Pavlov (1932) Vygotsky (1934) Goldstein (1939)

latent dream thoughts Phylogenetic regression Complex emotional change without insight Maldevelopment in progression of imageless to formed thought Loss of vital contact with reality Complex personality change without insight Chronic hypnosis Regression to adolescent thinking Loss of abstract attitude

disagreements had filtered through to psychiatrists, there was not just one notion of a mind, however versatile, with which to explore the nature of madness, but several models, all versatile and all incompatible with one another. Added to this was the growth of behaviourism during the century, which, even though it did not admit a disturbed mind corresponding to madness, did permit discussion of mad behaviour, and this allowed plenty of scope for theorizing. It is not surprising that psychological accounts of madness flourished in this climate. I have discussed those accounts pertaining to schizophrenia in detail elsewhere (Cutting 1985). The main ones are summarized in Tables 2.5 and 2.6. There are also accounts of the nature of delirium (Lipowski 1980) and dementia (Berrios 1994). Concerning manic-depressive psychosis, the manic pole has only rarely been con¬ sidered from this point of view (Hare 1981) but there are several analyses of the essential nature of depression (Table 2.7). Because neuroses are generally regarded as psychogenic in origin, their nature, according to this view, is entirely explained by their cause and there are relatively few theories of their nature divorced from cause. The numerous theories about the nature of each psychotic phenomenon, and about what happens to various mental functions (e.g. attention, memory, intellect, thinking) in each condition, are considered in the main body of the book. Latterly, purely psychological theories about the nature of all these conditions have gone out of fashion, and have largely been replaced by neuropsychological notions incorporating cause (p. 48). The theories listed in Tables 2.5, 2.6, and 2.7 say more about the chaotic state of psychology in the twentieth century than about the nature of schizophrenia or depression.

The tripartite mind—a survey of opinions on the nature of madness Table 2.6

Psychological theories of the nature of schizophrenia (1940-1980)

Binswanger (1944) Cameron (1944) Hunt and Cofer (1944) Shakow (1950) Rodnick and Garmezy (1957) Weckowicz (1957) Mednick (1958) Cavanaugh (1958) Conrad (1958) McReynolds (1960) Broen and Storms (1966) Hemsley (1977) Frith (1979) Magaro (1980)

Table 2.7

45

Progressive narrowing, loss of power, and emptying of personality Disorganization of biosocial reaction systems defining personality Extinction of standards for socially rewarded performance Inability to maintain major set Vulnerability to social censure Breakdown in perceptual constancy High anxiety without insight Motivation defect Breakdown of Gestalt perception Undue anxiety impairing assimilation of percepts Collapse of response hierarchies Inappropriate pigeon-holing of information Defective mechanism controlling contents of consciousness Inability to integrate perceptual and cognitive processes

Psychological theories of the nature of depression

Freud (1917) von Gebsattel (1928) Skinner (1953) Beck (1967) Seligman (1975)

Mourning for loss of person Vital inhibition: standstill in the flow of life Extinction of normal behaviour through lack of positive reinforcement Faulty and unduly negative cognitive appraisal of world events Learned hopelessness—passivity rather than flight in face of adversity

NB There is an implication of cause in most of these which is not present in the theories of the nature of schizophrenia listed in Tables 2.5 and 2.6.

TWO SETS OF CAUSES—THE RATIONALIZATION OF THE ORIGINS OF MADNESS Pre-nineteenth century Before 1800, and well into the nineteenth century, one finds long lists of suggested causes of madness compiled with little regard as to their plausibility and their relative importance, or whether they might be a consequence rather than a cause. The items selected in different epochs say more about contemporary preoccupations than about madness itself. In Roman times, for example, Aretaeus includes ‘superstition, too much love of philosophy, search for glory and avarice’. In the Middle Ages, Bartholomaeus (thir¬ teenth century) mentions ‘drinking strong wine, passions of the soul, great thoughts, excessive studying, exposure to pestilential air’. At the end of the eighteenth century,

Psychiatry and Psychopathology

46

Arnold (1742-1816) blames ‘an empire of passions ... all inordinate desires and affec¬ tions which manifest themselves ... in fondness for scheming and traffic of the most romantic, extravagant, childish or absurd kind’. There were two individuals in the last half of the eighteenth century who rose above this. One was the British physician Battie (1704-1776), and the other was Kant. Battie distinguished between ‘original madness’, arising from a congenital disorder of the nervous system, and ‘consequential madness’, which could be produced by mechanical or moral causes. Kant, however, regarded all forms of madness, except febrile delirium, as inherent in the individual’s make-up and thus devoid of ascertainable cause.

Nineteenth century The sequence of ideas during the nineteenth century is considered on pp. 33 and 35, as it had marked repercussions on the classification of psychiatric disorders. Apart from Bayle’s (1822) contribution, which provided definitive proof that brain disease could cause insanity, the rest was speculation. From our vantage point, the discussions appear to have revolved round the relative contributions of dichotomous sets of causes which were differently formulated as the century progressed. The first polarization was between two groups of German psychiatrists known as the Psychiker and the Somatiker. Kraepelin (1917), in his book One Hundred Years

of Psychiatry, gives the best account of the orientations of these two groups. It was essentially a standpoint on the role of moral versus bodily causes. The first group, represented by Heinroth and Ideler (1795-1860), believed that insanity was a consequence of man’s evil and selfishness. The second group, represented by Jacobi (1775-1858), believed that it was caused by a bodily disorder, not necessarily within the brain. It was not to a patient’s advantage to fall into the clutches of either group, because the treatments devised to remedy the supposed cause were equally barbaric. In the middle of the century, the preferred dichotomy among French psychiatrists was organic versus functional, where organic now meant observable brain disease at autopsy, and functional meant assumed, but unobservable, brain dysfunction (p. 36). At the end of the century, the main dichotomy was exogenous versus endogenous (p. 55), with exogenous generally referring to identifiable causes situated outside the mind (untoward body or brain events), and endogenous covering both unknown causes (assumed to be inherent in a person’s genetic make-up or personality) and world events impinging on them. However, it was clear that untoward world events con¬ stituted a different class of possible cause from those attributable to inheritance or personality, and deserved their own name—hence the term psychogenic11 which was introduced by Sommer (1894).

Twentieth century The legacy passed on from the nineteenth century on the matter of cause was already complex, and when new issues were raised quite early in the twentieth century, the whole problem of the cause of psychiatric disorders soon became quite bewildering. First, Kraepelin s system, although superficially resembling the pre-nineteenthcentury classifications, had three extra components. There was the new category of

Two sets of causes—the rationalization of the origins of madness

47

neurosis (which itself was soon to comprise five separate conditions—anxiety, phobias, hysteria, depression, and obsessional states). Each neurosis required a different ex¬ planation. It also recognized a number of disorders of higher mental functions (later to be called neuropsychological disorders)—aphasia, agnosia, apraxia, and amnesia. All the disorders named above had been described in a relatively short space of time, between 1861 and 1900 (p. 61), and, although they were generally regarded as noth¬ ing to do with madness itself, their identification complicated the previously single category of dementia (category 2 in Table 2.1). In addition, there was the category of psychopathic personality disorder. Furthermore, although prior to the nineteenth cen¬ tury different causes had generally been sought for melancholia, as opposed to true madness, this practice was largely suspended during the nineteenth century while the unitary psychosis theory held sway. With Kraepelin’s reassertion of the distinction between dementia praecox and manic-depressive psychosis, psychiatrists were again forced to consider different causes for each. Secondly, psychiatrists were bequeathed the various causal dichotomies (endo¬ genous-exogenous,

organic-functional,

and

psychogenic-non-psychogenic)

which

they continued to use, only half aware that they had been devised to solve certain nineteenth-century problems. Their continued use as the twentieth century progressed produced more problems than it solved. Thirdly, the twentieth-century psychiatrist was the beneficiary of several mutually incompatible

psychological

and

philosophical

formulations

of the

world-mind

problem, as set out in Chapter 1. Unlike the position of his or her colleague in the early nineteenth century, there was a veritable feast to choose from, should he or she wish to assign a purely psychogenic cause to any of the types of psychosis and neurosis. Fourthly, should he or she wish to adopt a purely organic view on causation, there was an equally rich choice. It was no longer sufficient to say merely that schizophrenia was a disease of the brain. There was the site of the proposed damage to consider (following Broca’s (1861) demonstration that a particular mental state (aphasia) was linked with a particularly sited brain lesion (left third frontal convolution) (p. 61). There was also what might be called the level of brain events to take into account— anatomical, physiological, or biochemical. Finally, a relatively new dimension, the consideration of social factors, was added to psychiatry during this period. Certain historians of psychiatry (Foucault 1961; Doerner 1969) claim that doctors and others involved with the mad through the ages have al¬ ways been more influenced in their views on madness by the norms of their culture than by any philosophical theory of the mind or scientific advance in the basic sciences. I believe that this view of psychiatry has been overemphasized. Nevertheless, it is un¬ doubtedly true that, in the twentieth century, psychiatrists have recognized that not only does madness have social consequences (e.g. legal implications, something that they have long recognized), but it might itself be socially conditioned. Certain nineteenthcentury British psychiatrists (e.g. Burrows 1828) gave weight to social causes of mad¬ ness (economic and political crises affecting an individual’s constitution). However, extreme theories incriminating social factors independently of psychogenic or organic, as in Faing’s, Szasz’s, and Scheff’s dismissal of madness as a sociological artefact, were twentieth-century creations.

48

Psychiatry and Psychopathology

Table 2.8

Schematic list of proposed causes of schizophrenia during the twentieth century

Psychogenic Psychoanalytic

Freud (1932)

‘Turning away from reality brought about by unconscious repression being excessively strong’

Existential

Binswanger (1945)

‘Inability to come to terms with inconsistency and disorder in own experience’

Social

Bateson et al. (1956) Murphy (1968) Laing (1959) Szasz(1961) Scheff (1966)

Organic Physiological

Double bind—ambiguous parental communication in childhood Role conflict—ambivalent social status in adulthood Artefact due to misinterpretation of social rules

Bliss et al. (1959) Rosenzweig (1959) Hemsley (1977)

Sleep deprivation Sensory deprivation Sensory overload

Biochemical

Carlsson and Lindquist (1963) Osmond and Smythies (1952)

Dopamine overactivity Serotonin overactivity

Anatomical

Stevens (1982) Murray and Harvey (1989)

Brain-stem disease Generalized immaturity of nervous system

Neuropsychological

Torrey and Peterson (1974) Davison and Bagley (1969) Flor-Henry (1969) Dimond (1979b) Weinberger (1987) Cutting (1985)

Limbic system dysfunction Temporal lobe dysfunction Left hemisphere dysfunction Corpus callosum dysfunction Frontal lobe dysfunction Right hemisphere dysfunction

NB Not all these theories carry the implication of a final cause of the condition, but they go further than merely recording the nature of schizophrenia.

In view of all these, often conflicting, influences, it is not surprising that twentiethcentury psychiatrists have felt baffled about the whole issue. The main causal notions about schizophrenia are summarized in Table 2.8. The chief proposals concerning the causes of manic-depressive illness are listed in Table 2.9, and those for neurosis are given in Table 2.10. Like earlier tables in this chapter concerning the classification and nature of madness, Tables 2.8-2.10 on cause again serve to emphasize the profoundly unsatis¬ factory state of psychiatry. They merely underline the fact that, without an agreed psychological framework for the normal state of affairs, any discussion of madness is

Two sets of causes—the rationalization of the origins of madness

49

Table 2.9 Causes of manic-depressive insanity (mostly pertaining to melancholia) proposed during the twentieth century Psychogenic Untoward childhood experience

Brown et al. (1977) Loss of parent

World event as adult

Brown et al. (1973) Recent world event

Organic Biochemical

Schildkraut (1965)

Neuropsychological

Deficiency of monoamines Flor-Henry (1969) Right hemisphere dysfunction Cutting (1990) Left hemisphere dysfunction

Table 2.10 Causes of neurosis (hysterical, obsessional, anxiety, phobic) proposed during the twentieth century and late nineteenth century Hysterical neurosis Psychogenic

Freud (1894)

Unacceptable idea rendered innocuous by being transformed (converted) into

Behavioural

Kendell (1982)

something somatic Abnormal illness behaviour—advantages of being sick as a child continue into

Social

Szasz(1961)

adulthood Artefact of false ‘medical model’

Freud (1909) Beech and Perigault (1974)

Equivalent to avoidance responses

Bowlby (1969)

Separation resulting in reliving separation

Eysenck (1976)

Failure to extinguish conditioned fear

Obsessional neurosis Psychogenic Behavioural

Regression to anal eroticism

Anxiety neurosis Psychogenic

from mother Behavioural

response

Phobic neurosis Psychogenic

Freud (1895)

Anxiety associated with real problem transferred to symbolic representation

Behavioural

Marks (1969)

of it Inappropriate persistence of fear based on trivial incident

50

Psychiatry and Psychopathology

futile. It inevitably degenerates into a dispute about the relative merits of alternative psychological theories of normal minds or behaviour, and leaves madness relatively untouched. As we shall see in the next section, the only technique available for evaluating each theory actually condones and consolidates the chaos, for it gives scientific respect¬ ability to any theory on the extremely dubious grounds that any theory is another piece of the jigsaw of life and should be taken seriously.

ONE INVESTIGATIVE TECHNIQUE—JASPERS’ PHENOMENOLOGICAL APPROACH TO PSYCHOPATHOLOGY The term ‘psychopathology’ was introduced by Emminghaus, a German professor of psychiatry, in 1878. He meant it to refer to the scientific basis of psychiatry. From 1913,

however,

with

the

appearance

of the

first

edition

of Jaspers’

General

Psychopathology, its meaning has been virtually synonymous with that given to it by Jaspers. For Jaspers, psychopathology was ‘the scientific (appraisal of) every psychic reality which we can render intelligible by a concept of constant significance’. This is an extremely wide brief, and yet it still did not include the whole of psychiatry. That part of psychiatry which was not psychopathology, according to Jaspers, was all that was not yet or which never would be scientific—aspects which he referred to as the ‘expertise’, the ‘art’, or the ‘aesthetics’ of the discipline. Moreover, there is no mention in his definition of a primary concern with abnormal states of mind or of the fact that there might be other equally valid avenues for approaching the problem of madness. For example, observation of an individual’s behaviour was only relevant in so far as it might throw light on that individual’s reality of himself and the world. Psychological tests and neurobiological investigations were also allowed, but, again, only in so far as they might provide a clue to the cause of the changed state of reality as experienced by the individual. On the positive side, Jaspers provides a brilliant account of the state of psychiatry up to 1942 (the date of the fourth edition of his book, which was the last one which he revised to any extent). His encyclopaedic knowledge and his uncanny ability to distil the essence of a psychiatric concept have the same mental-cramp-relieving effect as reading Wittgenstein on psychological and philosophical issues. On the negative side, however, there was a partly concealed agenda, which was Jaspers’ own profoundly enigmatic approach to madness. On the surface, he aimed to outline a method whereby any fact or theory pertaining to any aspect of psychiatry could be evaluated. The method was as follows. Every object should be examined by a number of different methods ... The object becomes in this sense something ill-defined and inexhaustible, a crude fact, indefinable in its totality. What it really is as an object reveals itself only through the methods we use.

One investigative technique—jaspers’ phenomenological approach

51

So, the method was itself the application of methodsl Whose methods? What methods? It was certainly not any single person’s idea or any single theory. If on the other hand we have some theory of reality to go by, the classification of our knowledge appears much easier. A few principles and basic factors will then afford us a comprehensive whole—‘we grasp reality itself’. Hence the often transitory success of attractive theoretical systems in which the thing in itself seems to be completely comprehended, and every newcomer gets a grasp of the whole very quickly, feeling that he has reached the heart of reality straightaway. So, there are no easy solutions. Now his own method again: A more difficult process, but a truer one, is this process of classifying by method ... We can see clearly how far we have got, and what certain methods will tell us, but the total human being is left as an open question. ‘Puzzle’, ‘enigma’, ‘unknowable’: these words occur time and time again in Jaspers’ work. We can make some sense of all this by tracing the steps in Jaspers’ own philosophy. The English translation of General Psychopathology was published in 1963 and was based on the seventh edition of Allgemeine Psychopathologie (1958) which was largely unchanged since the fourth edition of 1942. At the time of the first edition in 1913, Jaspers was a psychiatrist, working as an unpaid research assistant in the Psychiatric Department of Heidelberg University. It was his first book. In 1915, he took up an academic post as a psychologist and, in 1921, he was appointed professor of philos¬ ophy. His main philosophical works were Psychologie der Weltanschauungen (The Psychology of World Views) (1919), Philosophie (1932), and Vernunft und Existenz (Reason and Existence) (1935). The philosophical notions contained in these were incorporated into the fourth and subsequent editions of Allgemeine Psychopathologie. In the first edition of Allgemeine Psychopathologie, Jaspers was concerned with two main issues: (1) the possibility of applying the principles of phenomenology (p. 12) to classifying the experiences of psychiatric patients; (2) the value of applying another notion, recently introduced by Dilthey (1833-1911) and Weber (1864-1920) for study¬ ing what had been newly designated the social sciences (history, sociology, and economics) as opposed to the natural sciences (physics and chemistry), to examine the cause of psychiatric disorders. The first project was immensely successful. He carried this out by the enumeration of a number of outward characteristics of the mental state, of the conditions under which it occurs, through vivid, illustrative comparisons and symbolisations, through a kind of suggestive representation ... based on empathy and which is supposed to enable the reader of a phenomenological description empathically to perceive the phenomenon described. (Lefebre 1957) In this way, delusions, hallucinations, anomalous experiences, and many other pre¬ viously loosely defined psychopathological terms were delineated, and are generally still used in the way Jaspers recommended to this day. The second project was less successful, as judged by its subsequent appeal to psychiatrists and psychologists. However, it was no less brilliant in conception than the first.

Psychiatry and Psychopathology

52

Weber was Jaspers’ mentor (Manasse 1957). He regarded him as one of the four people who had influenced him most; the others were Kant, Kierkegaard (1813—1855), and Nietzsche (1844-1900). Weber, following Dilthey, was trying at that time to formu¬ late the principles of social sciences, to understand how one historical event caused another. Weber realized that cause and effect in the social sciences functioned in a different way from cause and effect in the natural sciences. In the former case, the investigator could only surmise a link between one thing and another by means of his or her intuition. However, in the latter case cause and effect could be rigorously tested by experiment. Jaspers appreciated that psychology and psychiatry were anomalous subjects, in that they were part social sciences and part natural sciences. This meant that both types of cause-and-effect rules applied. Therefore he proposed two complementary methods for analysing all psychological issues, which he referred to as Verstehen and Erklaren. The most appropriate translation of each term has been much debated, as the usual meaning of Verstehen is understanding and that of Erklaren is explanation. This does not help much. However, what he was getting at is fairly clear, and in my view is best conveyed by treating Verstehen as intuitive or empathic reason and Erklaren as causal explanation. To illustrate the difference, we can follow one of Jaspers’ examples—the link between season of the year and suicide rate. One might assume that, in Europe, suicide rates would be higher during the autumn and winter because the miserable weather or gloomy atmosphere at these times would depress someone’s mood. In fact, suicide rates, as Durkheim (1897) showed, vary in direct proportion to the length of days. Therefore the rates are highest during the seemingly joyous days of summer. Thus, intuitively, we are wrong, and the causal explanation of the link must be outside the list of empathic reasons we might come up with. (The exact cause or causes is not yet given, but we have moved on to a position where we can test various other hypotheses, or whatever.) But note that if the average person believes that suicide rates are highest in winter, this will govern his behaviour, although he is wrong. For example, he might telephone an unhappy child away at college more during the winter. To summarize, the empathic or intuitive reasoning approach comprises everything that one might infer about the reasons for someone else’s state of mind or behaviour without having to resort to ‘extra-conscious’ explanations. Therefore the psychopatho¬ logist has to try to empathize with the person in front of him, put himself in that person’s shoes, taking account of cultural, subcultural, and individual differences in world-views, and decide if statements about the other person’s subjective experience of his world or his behaviour are reasonable or not. If the decision is that they are not, then the interviewee’s mental state or behaviour is deemed ‘ununderstandable’, and ‘extraconscious’/explanatory/causal connections are invoked. Jaspers’ genius was to appreciate that both intuitive reasoning and causal explanations were relevant in all human situations.12

Psychology der Weltanschauungen (1919) was Jaspers’ first sketch of what he thought that philosophy was about. (It has never been translated into English, but a good summary has been given by Lefebre (1957).) The title is usually translated as

The Psychology of World-Views, but this gives a one-sided impression of its content. Jaspers was now preoccupied with the dichotomous nature of human existence and the search for categories along a number of parameters. Whereas in Allgemeine

One investigative technique—Jaspers’ phenomenological approach

53

Psychopathologie he had set out to categorize the sorts of reality which humans could experience and the reasons and explanations for them, now he was to tackle the problem from the experiencer’s viewpoint and why he lived the life that he did.

Psychologie der Weltanschauungen has more to do with the attitude and personality of the viewer of the world (Einstellung) than with the world-view (Weltbild) itself. Superficially it resembles a book of biographical sketches, rather than a treatise on either psychology or philosophy, as these are usually conceived. Nietzsche, Kierkegaard, and his hero Weber feature prominently, as do stereotyped descriptions of ways of living (e.g. ascetic, sensation-seeking, etc.), each linked with its corresponding world-view (e.g. philosophical, romantic, etc.).13 His Philosophic was published in 1932 and his Vernunft und Existenz in 1935. These were systematized accounts of his earlier work. The dichotomies which he had previously identified are marshalled, elaborated, and added to. Experiencer and exper¬ ience, world and mind, what is known and what cannot be known, all enter the equa¬ tion. The result is a set of seven ‘modes of being’, all under an ultimate superordinate covering everything that is or could be—called ‘the encompassing’.14 To conclude, Jaspers eventually constructed a framework for considering all aspects of what it is to be human. Layer upon layer, each with its dichotomous elements, are mirrored in the onion-like structure of the final editions of General Psychopathology: each section builds on an earlier one, each considers the same topic from opposite viewpoints, and gradually the various ‘modes of being’ (whether it is ‘being a schizo¬ phrenic’ or ‘being an obsessional neurotic’ etc.) are pieced together.

SUMMARY A brief history of psychiatry, focusing on four crucial aspects, has been attempted in this chapter. First, we consider the issue of classification. Despite new words replacing old, and old terms taking on new meanings, a four-part division of madness has usually been the norm since Roman times. Delirium, dementia, and melancholia have been recog¬ nized for two millenia, and are still recognized. However, the fourth category is as con¬ tentious now as it always has been. Currently, it is called schizophrenia and has a relatively large domain. For most of the period under consideration, it was simply regarded as the chief form of insanity or mania (the Greek for madness). Only during the nineteenth century, and the early part of this century in some quarters, was it subdivided to any extent, but the views of Kraepelin at the end of that century, that it is a relatively uniform condition, prevailed then, and still largely prevail today. Opinion as to the nature of madness has always closely followed contemporary notions of the nature of the soul or mind. Physicians, and then psychiatrists, have often denied that they were influenced by philosophers or psychologists in this matter. How¬ ever, the formulations which they produced leave little doubt as to their origins. Some version of a tripartite soul (or, in later centuries, a tripartite mind) was a commonly agreed starting point for discussion. Physicians or psychologists then generally dis¬ puted the relative roles of impairment of one of the three faculties (reason, imagina¬ tion, or memory in early centuries; intellect, will, or emotion more recently) in the

54

Psychiatry and Psychopathology

genesis of insanity. This century there has been a plethora of opinions on the matter, with the increase being attributable to the availability for the first time of several radically different competing models (at least eight major ones) of the mind (or non¬ mind, in the case of behaviourism). With respect to our knowledge of the cause or causes of madness, there has undoubtedly been steady, albeit slow, progress over the centuries. False cosmological notions were first discarded, and then inaccurate anatomical and physiological ideas were redressed. In the last century, definite brain disease was identified in some instances of madness. In the last century, too, inheritance of some forms of madness was generally agreed upon and is now beyond question. The issue of psychogenesis was much debated over the centuries, and although its role in causing madness de novo is still in dispute, at least the rules for investigating the matter are clearer. Despite all this, the essential cause of the elusive fourth category of madness is unknown. Finally, Jaspers, one of the greatest of twentieth-century philosophers, bequeathed a technique for studying all these issues, known as phenomenology. This does not have the same meaning as was given to it by the phenomenological school of philosophy. Jaspers’ meaning is roughly a recommendation to the psychopathologist to classify the subjective experience of a person and to separate out by empathic means the intuitive meanings of what is discovered from causal explanations in terms of neurobiological or social factors.

NOTES 1.

2.

Lewis (1970) traces the twists and turns in the history of the term paranoia. Hardly used at all prior to the nineteenth century, it grew in importance, particularly among German psy¬ chiatrists, as the century progressed. By Kraepelin’s time, some German psychiatrists were applying the label to 50 per cent of their mad patients; others hardly used it. Kraepelin became increasingly unhappy with it from edition to edition of his textbook. In an article in 1912, he recommended abandoning it altogether, although he kept it on under the new name of paraphrenia in the last edition of his textbook published before he died (1909— 1913). Lewis believed that if Kraepelin had lived longer he would have dispensed with it altogether. Kolle (1931), who followed Kraepelin as professor of psychiatry in Munich, and who re-examined patients who had been diagnosed as having paranoia during Kraepelin’s time there, found only a handful who fulfilled the prescribed criteria. Kolle came to believe that so-called cases of paranoia were rare forms of schizophrenia. WFiat the term did cover during the last half of the nineteenth century varied enormously from psychiatrist to psychiatrist: a delusional state without other psychotic phenomena; a delusional state based on hallucinations; a delusional state secondary to any other mental disorder and not a distinct condition in itself; any case with persecutory delusions or delu¬ sions of grandeur. During the twentieth century, the term has cropped up in some national and individual classifications as a description for a psychosis which shows signs of being understandable in terms of the pre-psychotic personality of the individual (p. 142). Esquirol was not the first person to claim that his classification of madness was not based on philosophical or psychological ideas. Most physicians and psychiatrists, from Greek times up to the present day, have tended to claim that their classification of psychiatric disorders is built solely on clinical observations—a psychiatry without psychology. This is a naive assumption on their part. For one thing, the very labels that they use—monomania (mania

Notes

55

focused on one object), schizophrenia (a split mind), and depression (a lowering of spirits)— presuppose a theory of mind. Moreover, a psychiatrist cannot seriously maintain that he or she can study mental disorder without entertaining some notion of what the mind does. Furthermore, classifications of diseases of bodily organs outside the head—pancreas, liver, etc.—do take note of the function of that organ, yet psychiatrists, despite claiming adher¬ ence to the medical model of disease, refuse to believe that they should take heed of func¬ tions of the mind in their classifications.

3.

As Berrios (1985) shows, the opposition which Esquirol’s notion of monomania encoun¬ tered is further testimony to the naivete of psychiatrists. The chief criticisms were (1) whether it was appropriate to apply faculty psychology to the study of madness, and (2) whether it was correct to split up the mind anyway and create a class of ‘partial insanity’. It cannot be coincidence, either, that the only other nineteenth-century schemes along similar lines to Esquirol’s—those of Heinroth (1818) in Germany and Prichard (1835) in England—encountered similar opposition and never achieved popularity. Prichard’s notion of ‘moral insanity’ was eventually incorporated into the concept of psychopathic personality disorder (p. 57), further evidence of the spurious belief that madness itself was not amenable to psychological analysis. The introduction of these terms into psychiatry is the responsibility of Mobius (1893). The best elucidation of their meaning is provided by Jaspers (1913) and Lewis (1971). Jaspers commented: In so far as we divide the whole unity of life into outer and inner world and both are broken down into factors, we attribute the phenomena of life either to causal factors of the outer world, which we call exogenous, or to those of the inner world, which we call endogenous.

However, the distinction is only valid within a Cartesian framework. Therefore any un¬ toward bodily event (e.g. thyrotoxicosis) or brain event (e.g. cerebral tumour) is a potential exogenous cause of psychosis, even though the body or brain event, as in these examples, is itself largely independent of the environment. But events occurring in the outside world may be potential exogenous or endogenous causes, according to whether they are deemed to affect the mind through the body and then the brain (e.g. contracting typhoid fever from contaminated water—exogenous) or the mind directly (e.g. the aftermath of experiencing an earthquake—psychogenic, which is a subclass of endogenous in Jaspers’ scheme). However, the distinction is profoundly unsatisfactory, even to a Cartesian, because the large majority of people who become psychotic have neither identifiable endogenous nor exogenous causes of the above type. The term degenerative in Magnan’s time, and the term endogenous now, are simply applied to those instances of psychosis where the cause is unknown. It is assumed to be endogenous, and this itself is assumed to be a blend of inherited predisposition (to what?) and acquired personality traits. But it is not at all clear, within a Cartesian framework, whether the predisposition acts via the brain on the mind (in which case it should be an exogenous effect) or whether it sets up a fragile mental attitude (in which case it is genuinely endogenous). Birnbaum’s (1923) analysis of the issue introduces even more complications, because he separates classes of true causes (‘pathogenic’ factors) from classes of events which modify the form of psychosis in someone who already has sufficient cause (‘pathoplastic’ factors). In his scheme, the same untoward event (in the realm of body, brain, world, or mind) in one individual may be potentially pathogenic, while in another individual it may be merely pathoplastic. Moreover, while retaining an overall endogenous-exogenous classification, he proposes five types of psychosis based on relative admixtures of the two classes of causal factors. It is no surprise that schizophrenia attracts the most complicated formulation of all—part exogenous and part endogenous.

56

Psychiatry and Psychopathology

4.

In this scheme an organic psychosis was one in which an abnormality of the brain was discernible at autopsy with the naked eye, or else there was good reason to suppose that some chemical toxin (heavy alcohol consumption, illicit drug ingestion) had produced temporary brain damage. A functional psychosis was one in which, although anatomical or biochemical evidence of brain damage was lacking, it was assumed that there must be something amiss with the functioning of the brain. It was further assumed that this must be of a similar nature to that produced by an observable autopsy lesion, or why else should organic and functional psychoses, defined as above, be so similar in form? ‘Functional’ and ‘endogenous’ are not synonymous terms. They share the property of applying to psychoses of uncertain cause, but whereas ‘functional’ refers to the hypothetical state of the brain in such cases, ‘endogenous’ refers to hypothetical causes in these cases. The history of twentieth-century psychiatry can be summarized as a continual attempt to do away with the notion of a functional psychosis, as defined above. On the one hand, there have been claims to have found an organic substrate in the majority of instances of psy¬ chosis, a quest that eluded nineteenth-century psychiatrists from Bayle onwards. Modern versions of Moreau’s autopsy-negative hypothetical brain dysfunction abound. Examples are as follows: ‘impaired neuronal proliferation and migration ... leading to immature pat¬ terns of cells and anomalous connections in the maturing nervous system’ (Murray and Harvey 1989); delayed maturation of the frontal lobe, thereby assuming that the frontal lobe is the leading co-ordinating centre in the brain, disrupting other brain zones at adolescence (Weinberger 1987); disorganized arborization of and interconnections between neurones, leading to disruptive information transfer (Randall 1983). However, there have been deter¬ mined attempts to reinterpret ‘functional’, not as referring to an organic brain dysfunction that is yet to be found—an untoward brain event—but as referring to a psychogenic cause (p. 59)—an untoward world event affecting the mind. This conceptual metamorphosis, ‘organic’ brain damage —> ‘functional’ brain dysfunction —» ‘psychogenic’ cause, was com¬ pleted in the case of the neuroses (p. 57). The same process took place in the case of schizophrenia in the first and middle thirds of this century (p. 44), although recently this trend has generally been reversed.

5.

The term ‘neurosis’ was coined by Cullen at the end of the eighteenth century as a generic name for all diseases of the nervous system, neurological and psychiatric, with or without structural damage. Its scope enlarged even more during the early part of the nineteenth century, when physicians used it for any bodily symptoms without obvious cause in an organ outside the nervous system—indigestion, headache, general malaise (Lopez Pinero 1983). In the latter half of the nineteenth century, as individual neurological and general medical diseases became delineated, its applicability outside psychiatry became restricted to those conditions where there was no structural damage in either the nervous system or the bodily organs. Thus a large number of people who consulted their doctors with symptoms and signs of apparent bodily origin (pain, palpitations, tiredness), but where the doctor could find no evidence of any of the real diseases known at the time, were deemed to be neurasthenic or hysterical in the nineteenth century, and now are described as anxious, hypochondriacal, obsessional, panicky, or neurotic. In this way, the term neurosis, as Bynum (1985) shows, completely changed in the course of the century from referring to any disease of the nervous system to referring to bodily symptoms in the absence of disease of the nervous system or any other bodily organ. Because by the twentieth century psychiatrists had acquired the reputation of dealing with people whose symptoms appeared unrelated to actual organic damage of the brain or body, ‘neurotic’ patients became their province. Among psychiatrists, the concept of a neurosis was developing in parallel and in a similarly negative way. Berrios (1985) gives a good account of this process as it applies to our modern concept of obsessional neurosis. Morel plays a crucial role in this. He adopted

Notes

57

one of EsquiroPs varieties of monomania—‘affective monomania’—as the basis for obses¬ sional states and neuroses in general, commenting that these were types of ‘delire emotif (a delusional state involving the emotions) ... that is not an insanity but a neurosis, a disease of the emotions ... not entailing an involvement of intellectual functions’ (Morel 1860). Morel believed, in accordance with his views on hereditary insanity in general, that there was ‘a functional lesion’ in the brain underlying this. It was a ‘neurosis of the ganglionic system’, and, true to Cullen’s original notion, he believed that it was a genuine disease of the nervous system, affecting, he thought, the ‘autonomic system’. However, by the end of the century the ‘functional’ element had been discarded and, through the influence of Charcot, Janet, and Freud, all neuroses were considered psycho¬ genic (p. 59) in origin.

6.

The modern concept of a neurosis is well set out by Roth (1963). He makes it clear that it is generally defined in terms of its contrast with psychosis: preserved contact with reality; retained insight; understandable behaviour; unaffected aspects of personality; initially, at least, the condition is a relevant response to stress; the behaviour during the course of the illness bears a close relationship to characteristics of the premorbid personality. The concept of a personality disorder as a category of non-insane psychiatric disorder only emerged at the very end of the nineteenth century (Berrios 1993). Pinel’s (1801) variety of mania without delusional state (Table 2.1) and Prichard’s (1835) notion of moral insanity are sometimes regarded as the forerunners of one form of personality disorder—the psychopathic variety. But it was Koch’s (1891) monograph Psychopathic Inferiorities which delineated the last group of psychiatric disorders to emerge from the nineteenth-century classificatory upheavals. Koch defined three groups: (1) psychopathic disposition (a predis¬ posing personality trait of weakness which, by itself, was benign); (2) psychic inferiority (covering all manifest varieties known to the lay person by such terms as ‘misguided geniuses’, ‘bad lots’, and ‘talented wasters’); (3) psychopathic degeneration (a more severe version of (2) with additional intellectual problems). Schneider’s (1923) revision of the con¬ cept is the one accepted today. He defined an ‘abnormal personality’ as A variation upon an accepted yet broadly conceived range of average personality. The variation may be expressed as an excess or deficiency of certain personal qualities and whether this is judged good or bad is immaterial to the issue. The saint and the poet are equally abnormal as the criminal. All three of them fall outside the range of average personality as we conceive it so that all persons of note may be classed as abnormal personalities.

A ‘psychopathic personality’ was that subgroup of these statistically abnormal people who ‘either suffer personally because of their own abnormality or make the community suffer 7.

because of it’. Four anti-Kraepelin trends have waxed and waned in the last half-century. The first is a proliferation of proposed subtypes of the fourth category of madness. Mere inspection of the list of names (Table 2.4) should be sufficient to convince the reader of the futility of the exercise, as most of the labels are borrowed from other diagnostic categories or chosen according to the prominence of a single aspect of the mental state. This tendency has now abated. A second trend was to resurrect Kraepelin’s category of paranoia, restricting it to psychoses with a single delusional theme and nothing else. Winokur (1977) renamed it delusional disorder, and others have described subgroups, for example Munro’s (1988) monosymptomatic hypochondriacal psychosis. This diagnostic practice persists, with the official blessing of DSM-III, although in most studies which have examined the relative frequency of such a pure delusional state compared with schizophrenia, it has been very rare (e.g. only 29 instances in one hospital over 50 years (Winokur 1977)).

58

Psychiatry and Psychopathology A third trend, prominent in the 1960s (Laing 1959; Szasz 1961; Scheff 1966), and possibly resurfacing (Boyle 1990), has been to deny the existence, not just of schizophrenia, but of madness altogether. The arguments put forward can be loosely construed as behav¬ iourist, in that madness is reduced to eccentric behaviour and this is then interpreted mean¬

8.

ingfully within the subject’s social milieu. A final trend has been to revive the mid-nineteenth-century notion of a unitary psychosis, and amalgamate the third and fourth traditional categories of madness (Crow 1990a). There has been a definite trend towards viewing the diversity of psychotic presentations as a consequence of what Birnbaum (1923) (see note 3) called the interplay of pathoplastic factors. These are factors which supposedly alter the clinical picture of one of the major psychoses, making it atypical. The main factors recognized in this respect are (1) sex, (2) age, (3) intelligence, and (4) race. (i) There are undoubted sex differences in schizophrenia: its age of onset (5-10 years earlier in men than in women (Zigler and Levine 1981; Loranger 1984)), its social consequences (men have a poorer prognosis than women, judged by hospitalization requirements (Seeman 1982)), and its psychopathological pattern (women are more elated or depressed (Franzek and Beckmann 1992), and men are more thought disordered (Katschmg and Lenz 1988) and prone to involuntary movement or posture (Franzek and Beckmann 1992)). There are also sex differences in depressive illness, albeit of a different pattern: age of onset is the same in both sexes but the overall prevalence in women is twice as high (Bardenstein and McGlashan 1990), and the social consequences are comparable but there are differing frequencies in the core symptoms (Angst and Dobler-Mikola 1984). Anxiety, phobic neuroses, and hysterical neuroses are more common in women. (ii) I am not concerned with the specific psychopathology of children in this book. My own belief is that the most obviously psychotic disorder of children, infantile autism (Kanner 1943) or Asperger’s syndrome (Asperger 1944), is a pathoplastic variety of schizophrenia (Cutting 1990). The effect of ageing on the clinical picture of schizophrenia has been the subject of considerable attention. Earlier views (Fish 1960; Kay and Roth 1961) were to the effect that elderly women could develop a related psychosis, paraphrenia, which was sufficiently different on a number of counts to be worth distinguishing nosologically. More recent views (Grahame 1984; Jeste et al. 1995) have tended to favour the pathoplastic argument, with the difference from younger schizophrenics being attributed to (a) the pathoplastic effect of sex (there is a marked preponderance of women in the group of schizophrenics with onset after the age of 45) and (b) the pathoplastic effect of age on the sort of delusions which develop (persecutory is more common as age increases (Albee 1950; Lucas et al. 1962)). (hi) Low intelligence distorts the typical pattern of both schizophrenia and manicdepressive psychosis (Reid 1972). (iv) Racial differences also affect the clinical picture and outcome of a psychosis. There is a large and controversial literature on these matters (Sartorius et al. 1986; Fernando 1991). The controversies stem from claims that schizophrenia is more common in some races than in others and counterclaims that this excess is partially due to racial stereotyping by psychiatrists (diagnosing psychosis where some less serious label is warranted) and partially due to the fact that racial minorities tend to be underprivileged and more liable, for socio-economic and not racial reasons, to possess whatever causes schizophrenia.

9.

This definition may seem excessively pedantic, but considering that Jaspers devoted dozens of pages of his General Psychopathology to this single issue, it is clearly of central im¬ portance. Failure to observe some of the basic tenets of the principle can lead to fruitless arguments, such as Boyle’s (1990) denial that madness exists.

Notes

59

Some of the controversy surrounding the use of the term psychogenic, which Lewis (1972) considered so misleading that he recommended that it be ‘buried’, can be put down to a failure to distinguish between a state of mind as corresponding to the nature of mad¬ ness and a state of mind as an antecedent condition. The possibility that the latter might cause the former is logically feasible (e.g. my inner sense of loneliness drove me mad), although whether it is empirically correct is a different matter. Jaspers referred to questions such as these as the difference between understandable and causal explanations, and they are considered on pp. 51-2. 10. The humours were both ingredients of temperament, and real channels of different fluids which could alter the temperature of organs, including the brain. The brain’s role in psy¬ chological and psychiatric matters was given more weight than these other organs as the Middle Ages progressed, but was not universally regarded as the sole contributor until the sixteenth or seventeenth centuries. A concept of mind, which achieved its full flowering in Descartes’s formulation, was arrived at only gradually during the millenium following Galen. The various bits and pieces of soul, spirit, desire, and common sense, scattered throughout the head and body, were gradually gathered up to form a mind and given a site within the brain. The origin of the concept of a tripartite mind is particularly hard to pinpoint. Brett (1921), in his influential A History of Psychology, attributes the notion to Aristotle, but Aristotle neither said much about minds nor approved much of dividing up the activities of the soul. If anyone can be credited with this, it should be Plato, who was prone to divide things into threes and who certainly identified and separated the forerunners of the eventual components of the tripartite mind—reason (—» intellect), vitality (—» will), desire (—> emo¬ tion). According to Hilgard (1980), a definitive version of the tripartite mind was first suggested by the philosopher Mendelssohn (1729-1789) in 1755. He increased the two faculties of the mind (knowledge and appetite) identified by Wolff, the founder of faculty psychology, to three by subdividing appetite into desire and feeling. Kant systematized this by regarding these as ‘three absolutely irreducible faculties of the mind’. However, the situa¬ tion is complicated by the existence of an earlier tripartite division of the intellect itself into reason, imagination, and memory. This is present in Galen’s scheme, and crops up through¬ out the Middle Ages and even in the eighteenth century (see below). For example, Du Laurens (1560-1609) placed imagination anteriorally in the brain, reason in the middle, and memory at the back. This in turn affected psychiatric notions. Bartholomaeus con¬ sidered madness (category 4 in Table 2.1) as an ‘infection of the foremost region of the head, with privation of imagination’, melancholy ‘as infection of the middle portion of the head with privation of reason’, and ‘forgetfulness’ (probably equivalent to our dementia) as a problem of memory in the ‘hind region’, while ‘frenesie’ (delirium) appears to have involved the entire brain and all these three faculties. 11. The term psychogenic, as defined by Sommer, referred to ‘disease states evoked by per¬ ceptual representations [Vorstellungen]’. Lewis (1972), in his review of the topic, trans¬ lated Vorstellungen as ideas, repeating the mistake made by the first English translator of Schopenhauer’s Die Welt als Wille und Vorstellung (The World as Will and Idea, rather than the more correct The World as Will and Representation). Although Lewis considered that ‘Sommer rendered psychiatry a disservice when he coined the word psychogenic’, I do not agree with this judgement. Among Scandinavians (Wimmer 1916; Stromgren 1974) the concept of a psychogenic psychosis was probably rather overused, and the twentiethcentury assumption that all neuroses are psychogenic is totally unwarranted. Nevertheless, there is definitely a need for some word to stand for what Sommer was referring to. The word ‘reactive’ is sometimes used synonymously with psychogenic, but reactive, at least as Jaspers (1913) defined it, is too restrictive. To qualify as a reactive illness in his scheme, not only did the abnormal mental state have to exhibit a plausible causal relationship with the

60

Psychiatry and Psychopathology world event, in that the latter should have directly preceded the former, but the delusional and hallucinatory themes in the abnormal state had to reflect the nature of the world event and the abnormal mental state had to remit when the world event dissipated. The problems raised by Jaspers’ distinction between meaningful and causal connections in assessing the

significance of a world event are dealt with on p. 52. 12. Jaspers’ criticism of Freud, for example, was that psychoanalysis was a ‘quasi Verstehen’ approach, misconstruing the material uncovered by Verstehen by thinking of it in terms of causal relations. The lukewarm reception accorded to Jaspers’ dichotomous method is easily explained. Most subsequent psychiatrists and psychologists simply did not heed his advice, and had only one or the other perspective. They have been successors of one or other of the camps established during the nineteenth century which Jaspers was trying to integrate (p. 46), with organic psychiatrists versus psychoanalysts being a typical mid-twentieth century confrontation. 13. Psychologie der Weltanschauungen is generally considered to have generated the philo¬ sophical school known as existentialism. It was the emphasis on doing, being, and living— creating a life—as opposed to simply discovering what was alledgedly there already which was the refreshing and innovative aspect. 14. This encompassing comprised existence, Existenz, consciousness-as-such, spirit, world, reason, and transcendence. Existence (with a lower case e) was the sense in which we are everyday, living, and doing human beings (the Dasein of Heidegger (p. 14)). Existenz (with a capital E, and left in the German) was the sense in which we are creatures of possibility and the extent to which, as existentialist philosophers were later to emphasize, we are actualizing our potential. Consciousness-as-such is that aspect of our mind which creates the very division in our experience of there being objects out there and our experiencing them. Spirit was the sense in which we are part of history and can partake in the ideas which it has thrown up. The world was the sense in which there is something really out there, akin to Kant’s thing-in-itself. Reason was the faculty of thinking. Transcendence was the sense in which we experience our origin as coming from something else—our belief in God or other speculations about our being dependent on some creative process.

3 Neurology and Neuropsychology ONE BRAIN—ONE MIND The origins of neurology as a medical speciality can be traced to Willis (1621-1675) and Cullen. Willis, as well as coining the term ‘neurology’, established that the sub¬ stance of the brain, as opposed to its ventricles or other parts of the body, was the organ of the mind. Cullen (1800) proposed a classification of neurological conditions, which he called neuroses (p. 56). These included the various forms of insanity which, for the first time, were placed in a different subclass from the neurological conditions. During the seventeenth and eighteenth centuries, the various parts of the soul, pre¬ viously considered to be scattered throughout the body, were amalgamated into a mind, and this mind was then linked with the brain and no other organ. The precise relation¬ ship between brain and mind perplexed most commentators, but by the start of the nineteenth century some link was accepted by all students of the matter, and this set the scene for a scientific evaluation of the effect of brain disease on mental functioning.

ONE BRAIN—LOCALIZED MENTAL FUNCTIONS Some localization of mental faculties within the brain itself was acknowledged by some physicians from the late Middle Ages onwards (p. 59). However, it was not until Gall (1758-1828) introduced his system of phrenology that the issue was critically dis¬ cussed by physicians. Gall himself, by his own extravagant claims, virtually destroyed credibility in the whole idea of localization of mental faculties (or functions as they were later called). A committee of enquiry was even set up in Paris, and this committee, which included Pinel, dismissed his ideas as worthless. However, within half a century, Gall was to be proved right, not about his claims of a link between personality types and shapes of skull, but on the general issue of localization of certain mental functions within the brain. The first published proof was the report by Broca (1861) of an association in one man between observable brain damage at autopsy in a circumscribed area within the frontal lobe of the left hemisphere and loss of speech 20 years earlier. Further proof came in 1870, when Fritsch and Hitzig stimulated the exposed frontal cortex of a dog and caused movements in the opposite side of the body. In the last quarter of the nineteenth century a series of separate links between damage to a particular part of the brain and the loss of a specific mental function were reported. Wernicke (1874) identified an area in the posterior portion of the first tem¬ poral gyrus on the left in which damage resulted in a loss of memory for ‘auditory images’. Both the area, now called Wernicke’s area, and the resulting condition, now called Wernicke’s aphasia, differed respectively from the critical area for speech dis¬ covered by Broca (Broca’s area) and the ensuing condition if it were damaged (Broca’s

61

62

Neurology and Neuropsychology

aphasia). Exner (1881) found a link between a lesion in the left second frontal gyrus (near Broca’s area) and an isolated disorder of writing—agraphia. Lissauer (1890) described a failure to recognize familiar objects, now called agnosia, in conjunction with a left posterior lesion. Dejerine (1891) reported a patient with acquired reading problems, alexia, and a left parieto-occipital lesion. Liepmann (1900) suggested the term apraxia for a disturbance in the execution of actions in the absence of paralysis, sen¬ sory loss, or incoordination. His patient had a left frontoparietal lesion. Korsakoff (1887) described a condition which he called ‘cerebropathia toxaemia psychica’, and which later was to be called Korsakoff’s syndrome and regarded as a pure form of amnesia resulting from damage to a circumscribed area of the midbrain. Despite this apparently overwhelming evidence in favour of the separate localization of at least half a dozen discrete mental functions, a substantial body of neurological opinion throughout the first quarter of the century disputed all or some of the above claims. Thus, like Gall a century earlier, advocates of the principle of localization encountered strong opposition, being dubbed by Head (1926), for example, as overzealous ‘diagram makers’. The antilocalizationists’ case gradually withered away, however, as yet more discrete clinicoanatomical links were uncovered. The most notable of these, prior to the Second World War, were between left parietal damage and constructional apraxia (impaired execution of actions within a spatial framework) (Kleist 1922), and between left ang¬ ular gyrus damage and finger agnosia (inability to distinguish one finger from another) (Gerstmann 1924).

MAJOR AND MINOR HEMISPHERES—DOMINANT AND SUBORDINATE SETS OF MENTAL FUNCTIONS The fact that all the discrete mental functions to have been localized were lefthemisphere-based understandably led to the notion that the left hemisphere was much more important than the right in governing the mind. In fact, prior to the 1940s, noone except a handful of writers regarded the right hemisphere as contributing anything of real significance. Wigan (1844) was the first physician to propose that the two hemispheres of the brain might ‘pursue independent courses’ under certain circumstances, but Jackson (1868, 1876, 1880) was the first to appreciate that, even under normal circumstances, the two hemispheres made different contributions to mental life. However, he believed that the nervous system was arranged hierarchically, that mental functions could be ranked in order of importance, and that propositional speech, served by the left hemisphere, was the zenith of human achievement. Therefore, although he was the first neurologist to attribute any specific functions to the right hemisphere, he relegated these to a subordinate position. Jackson was far ahead of his time and a genius. Even his own contemporaries regarded him as such, despite their living in a time of dramatic neurological advances, with German and French neurologists discovering new conditions every few years. In a series of articles published over half a century he documented evidence of the type of mental disorder experienced by patients with right-hemisphere damage. He believed

Major/minor hemispheres—dominant /subordinate sets of mental functions

63

that such patients encountered problems in ‘expressing emotional speech—swear words, exclamations’, in ‘recognising objects, persons and places’, in ‘summating sen¬ sory information from all parts of the body’, and in becoming ‘objectively conscious of visual objects in the outside world’. Jackson’s views on these matters went unheeded for several generations until Potzl (1928) and Lange (1936) again began to speculate on the role of the right hemisphere in perception. For example, Potzl considered that the right hemisphere might play some part in the appreciation of the spatial component in our world, and Lange won¬ dered whether it might not provide ‘the background framework for our world-view’. The right hemisphere was at last given a specific and unique role, vis-a-vis the left hemisphere, during the 1940s and 1950s. Brain (1941), Paterson and Zangwill (1944), and Hecaen et al. (1956) established that patients with a right-hemisphere lesion had a collection of morbid subjective experiences and anomalies in behaviour which set them apart from normal individuals and from anything that had been described in patients with left-hemisphere damage. Brain (1941) reported three patients, all with right parieto-occipital damage, who appeared oblivious to that part of the external world which lay on their left side, including the left half of their own body. Paterson and Zangwill (1944) confirmed this finding in a further patient with right parieto-occipital damage, and noted that another patient with a lesion at the same site had great difficulty in drawing and constructing simple models, but showed no neglect. Hecaen et al. (1956) widened the range of the problems that such patients encountered. They divided these into six classes of problems: (1) ‘disorders of spatial thought’ (loss of topographical memory, inability to draw designs; (2) ‘body-schema disturbances’ (denial of a left-sided paralysis, lack of awareness of the left side of the body); (3) ‘dressing apraxia’ (impaired ability to dress); (4) ‘visuo-constructive disabilities’ (inaccurate execution of drawings involving a threedimensional element); (5) disturbed calculation; (6) ‘optico-vestibular disturbance’ (subjectively reported visual distortions of aspects of the environment). These reports provided the first convincing evidence that the right hemisphere was at least responsible, and uniquely so, for representing some aspects of the external world—aspects which can loosely be designated as the spatial matrix of the body and the outside world.1 Despite this discovery of unique functions of the right hemisphere, the left hemi¬ sphere continued to be regarded as major or dominant and the right as minor or non¬ dominant. This practice can be found to this day in some textbooks.

TWO HEMISPHERES—COMPLEMENTARY SETS OF MENTAL FUNCTIONS In the late 1950s and early 1960s reports of the consequences of two new neuro¬ surgical procedures radically altered the way that psychologists viewed the working of the two hemispheres. It was about this time also that psychologists rather than neurologists became the chief researchers into the localization of brain functions, and the term neuropsychology became widely used.

64

Neurology and Neuropsychology

One neurosurgical procedure was the operation of temporal lobectomy—resection of part of the temporal lobe with the aim of removing an epileptogenic focus. Milner (1958) found that the pattern of scores on a preoperative battery of psychological tests had some value in predicting which temporal lobe contained the pathogenic lesion. This pattern was found to be exaggerated if the same tests were administered postoperatively. Milner claimed that the most obvious differences between the results of these tests on subjects with left and right temporal lesions (or lobectomies) were (1) the impairment of verbal memory in the former and its sparing in the latter group, and (2) the impairment of pictorial memory in the latter and its sparing in the former group. She generalized these findings into a formulation of the essential difference between what each hemisphere represented under normal circumstances. The left temporal lobe contributes to the rapid understanding and subsequent retention of verbally expressed ideas ... the right minor temporal lobe on the other hand appears to be more critically involved in perceptual than in verbal skills ... the right temporal lobe facilitates rapid visual identification and in this way it enters into the comprehension of pictorially expressed ideas ... these differences relate to the functional asymmetry of the two hemispheres, the left being primarily concerned with verbal, the right with non-verbal skills. (Milner 1958)

Milner’s formulation turned out to be wrong,2 but heuristically useful nevertheless. As more evidence on the effect of unilateral hemisphere lesions accumulated during the 1960s and 1970s, it became clear that the left hemisphere did not have a monopoly on language and the right hemisphere did not play a major part in all non-verbal matters. This then stimulated other researchers to propose alternative formulations of the characteristic modes of processing information employed by the two hemispheres. The chief suggestions are shown in Table 3.1. The latest of these (Kosslyn 1987) fits the facts best of all. A second neurosurgical procedure—severing the corpus callosum and other major commissures between the two hemispheres—was even more important for the light it

Table 3.1

Dichotomies purporting to reflect the essential hemisphere difference

Reference

Purported hemisphere characteristic Left

Right

Verbal Analysis Propositional Abstraction

Non-verbal Gestalt Appositional Imagery Judgement of sameness Parallel processing Global processing Novel information

Milner (1958) Levy-Agresti and Sperry (1968) Bogen (1969) Paivio (1971) Egeth and Epstein (1972)

Judgement of difference

Cohen(1973)

Serial processing

Martin (1979) Goldberg and Costa (1981) Kosslyn (1987)

Local processing Well-rehearsed information Categories of things

Spatial co-ordinate of things

Two hemispheres—complementary sets of mental functions

65

shed on the relationship between the hemispheres. The operation is variously referred to as the split-brain procedure, callosectomy, or commissurotomy. It was first carried out in 1940 by van Wagenen and Herren, two American surgeons, with the aim of reducing the severity of a fit by preventing an epileptic discharge orig¬ inating in one hemisphere spreading to the other. These surgeons abandoned the pro¬ cedure because it did not appear to produce the desired effect. Akelaitis (1941), who administered psychological tests to the operated subjects, noticed no striking psychological consequences. However, when Bogen and Vogel (1962) reintroduced the operation, they deemed it a success, and their psychologist colleagues (in particular, Sperry, Gazzaniga, and Zaidel) then uncovered a whole host of facts about the indi¬ vidual functions of each isolated hemisphere, and about their co-operation, which comprise the most significant body of knowledge about psychology ever reported. The importance of the split-brain procedure was that it opened a window on the mental apparatus of each hemisphere which no other method before or since allowed.3 Two major discoveries were made. The first was the remarkable richness of the isolated right hemisphere. Bereft of speech, it is normally entirely reliant on the left hemisphere, which does have speech, for communication with the outside world. However, as an isolated entity, it could communicate via the left hand. In this way, it was found to be nearly as good as the left hemisphere on a variety of perceptual and language tasks, to be better than the left hemisphere on some tasks, and to approach all tasks in a qualitatively different manner. It soon became clear that the right hemisphere represented the world along entirely different lines from the way that the left hemisphere did. The second discovery concerned the quality of co-operation which existed between the two hemispheres. In brief, the results obtained from experiments on this co-opera¬ tion revealed an astonishing degree of ignorance on the part of the left (supposed major) hemisphere about what its partner, the right (supposed minor) hemisphere, was up to.4

TWO HEMISPHERES—MIND AND QUASI-MIND During the late 1970s and 1980s it became clear that, although some observations about hemisphere differences could be formulated in terms of complementary aspects within the same broad class of traditional mental function (e.g. two modes of perception, two approaches to thinking), this could not explain all the data. It became necessary to assume that each hemisphere has, in addition, unique functions. Ever since Broca’s report in 1861, the left hemisphere has been linked with the capacity for speech, but this had been overgeneralized in Milner’s equation of hemi¬ spheric differences to include all aspects of language. It is now apparent that the left hemisphere has unique responsibility for control of the execution of speech, among other functions. There is no complementary function corresponding to this in the right hemisphere. However, the right hemisphere also has its own unique domains. These will be revealed in the main body of the book, but here it can be mentioned that one such is emotion. By whatever technique this is examined, and whatever aspect of emotion is

66

Neurology and Neuropsychology

under consideration, the right hemisphere is generally found (notwithstanding some dissenting investigators) to be linked in every way (p. 439). The current state of the literature on hemisphere differences5 points to the fact that each hemisphere contains sufficient mental functions to allow it to interact in¬ dependently with the outside world (including its own body). Whether or not each collection of functions deserves the epithet ‘mental’ will be considered later. At this point in the argument, there is reason to leave the equation in the form of two hemispheres—mind and quasi-mind on the following grounds. First, the left hemisphere has the advantage of speech, which the right hemisphere does not. Second, it houses categorical and conceptual thinking, whereas the right hemisphere lacks this. Third, and more speculatively, the left hemisphere has a multipart image-generating capacity (Farah 1984) and link with ‘consciousness’ (p. 372), which is not in the repertoire of the right hemisphere. Therefore a set of functions which include speech, thinking, and consciousness must clearly be deemed a mind, according to the usual definitions of this. However, the set of functions uniquely linked with the right hemisphere include emotional responding, body representation, and willed movement generation (p. 444), by no means an unsophisticated amalgam, and at the very least must be considered a quasi-mind.

SUMMARY In this chapter, the progress of neurology (or that aspect of it concerned with the effect of brain disease on the mind) has been traced from its origins as a philosophical/ anatomical statement linking brain with mind to its current status as a vast body of puzzling ‘neuropsychological’ observations concerning the localization and interaction of certain mental functions. The progress of knowledge has not been smooth, for there seems to be an inherent distrust among neurologists and then psychologists of the principle of localization of mental functions. Admittedly, Gall’s original proposals were extravagant, but the observations of Broca and Wernicke, which were soundly based on fact, met the same degree of scepticism. It remains to be seen how the currently burgeoning evidence on the richness of the right hemisphere’s mental repertoire will be treated by subsequent generations of researchers.

NOTES 1.

There are several notable points about this discovery. The most striking of these is that it had not been made before. Nearly a century had elapsed since Broca’s identification of a speech centre within the left hemisphere. At least a dozen other functions had been localized in the meantime to the same hemisphere. How¬ ever, comparably severe problems in manipulating and appreciating the spatial aspect of the world when the right hemisphere was damaged had been overlooked. Secondly, the fact that only the left side of the body and the left part of the external world tended to be ignored, in patients with right hemisphere damage, was not properly appre¬ ciated even at this time. This is also curious, because one of the six classes of problems that

Notes

67

Hecaen and colleagues brought together—denial of a hemiplegia, termed anosognosia by Babinski (1914)—had already been well described in the literature (upwards of 200 case reports between 1914 and the 1950s). There is an overwhelming excess of left hemiplegias and right-sided brain lesions in these reports. No-one realized, until Ratcliff (1982) pointed it out, that this lateralized pattern could only occur if the left side of the body, and the left half of the subject’s perspective of the external world, were uniquely represented within the right hemisphere and if the right side of the body, and the right half of the subject’s perspec¬ tive of the external world, were represented in both hemispheres. Looked at another way, from the point of view of each hemisphere, the right hemisphere has jurisdiction over both visual fields and the entire body, but the left hemisphere has jurisidiction only over the right field and the right half of the body. 2.

3.

Even at the time there was contradictory evidence. For example, Meyer (1959) was also studying patients before and after temporal lobe surgery, and found that those with a left¬ sided lesion not only had difficulty in learning word pairs which they were given by ear, but also had difficulty in learning to pair designs shown visually. Other investigators found that memory for familiar objects presented visually was affected more by a left-sided than a right-sided lesion (Kimura 1963a), and that memory for colours which could not easily be described by a name (e.g. bluey-orange as opposed to pure blue) were affected more by a left-sided than a right-sided lesion (Boiler and Spinnler 1967). Later, overwhelming evidence was uncovered to the effect that the right hemisphere was heavily involved in language itself: metaphor (Winner and Gardner 1977), pragmatics (Foldi 1987), lexical representation (Drews 1987), and even syntax (Chernigovskaya and Deglin 1986). Therefore Milner’s formulation was wrong in virtually every aspect. The only drawback to the split-bram method is the fact that the subjects who underwent the operation were abnormal by virtue of their intractable epilepsy. In most subjects the epilepsy was a consequence of a focal area of bram damage or abnormality incurred before birth or in early childhood, and therefore one cannot be sure that their distribution of hemi¬ sphere functions was normal. However, the other methods for obtaining a glimpse of a hemisphere’s working in isolation have generally provided supportive evidence. Several alternative techniques are now available for examining a hemisphere in isolation. One is the tachistoscope. A stimulus is flashed up rapidly in the lateral part of one or other visual field. The anatomy of the visual system is such that stimuli in the left lateral visual field go first to the right visual cortex, and those in the right lateral visual field go first to the left visual cortex. However, a subject must be instructed to look straight ahead for this to be valid, and, even if one can rely on this, a subject’s eyes will tend to move laterally towards the stimulus. This puts the constraint on an experimenter that the stimulus can only be displayed for less than 150 milliseconds, i.e. the time that it takes for the eyes to move from the midline to the periphery. Therefore experiments involving anything more than a yesno identification or a same-different judgement on a relatively simple stimulus are excluded. A second technique is known as the dichotic listening procedure. Pairs of sounds are presented simultaneously, one to each ear, and subjects are asked to report which one they heard. The rationale for this is that sounds arriving at one ear are mostly conveyed to the contralateral hemisphere (although there is some ipsilateral transfer). However, only a limited amount can be tested using this procedure, and there are problems in the interpre¬ tation of results. Thirdly, there are various systems of mirrors fixed on glasses, or contact lenses, which maintain the position of a stimulus in the desired place in the visual field, independently of eye movements (Zaidel 1975; Dimond et al. 1976). However, there is some doubt, particu¬ larly with Dimond’s procedure, as to whether the apparatus does what is claimed for it.

68

Neurology and Neuropsychology In fact, split-brain patients will tend to move their eyes also, even if instructed to look ahead, and stimuli must be presented via tachistoscope, dichotic listening, or mirror arrangement. However, in their case the situation is less contaminated by inter-hemispheric transfer than in normal subjects, and this allows a clearer window on the isolated hemi¬ sphere than in the case of normal subjects. A word should also be said about various invasive and inactivating procedures. One is known as the carotid amytal test (or Wada’s procedure, or carotid inactivation). It would not be ethical to carry this out on normal subjects because a slight morbidity is attached to it. Therefore it is restricted to subjects with known cerebral pathology, in which it is a useful pre-operative assessment of the lateralization of various functions. The bar¬ biturate amytal is injected first into one carotid, and later the other, and each results in temporary inactivation of the entire cortex of one hemisphere. By this means one can ob¬ serve or test for whatever issue one is interested in—emotional behaviour, state of con¬

4.

sciousness, etc. Another procedure, used in the former Soviet Union but rarely elsewhere, is to study the same matters at the time of inactivation with unilateral electroconvulsive therapy, presum¬ ably given as treatment for some major psychiatric illness. Finally, there is the problem of how to interpret the morbid phenomena or behaviour which result from a unilateral brain lesion in an adult who was normal up to that point. Throughout the book, I shall be making more use of such cases than any of the above procedures in trying to establish the pattern of hemispheric allegiance of some function or phenomenon. This is because the relevant instances of this method are much greater than those of all the other procedures put together. However, interpretation is not always straightforward. For example, if someone with a right frontal lesion displays unaccustomed anger, is that because the right hemisphere subserves that particular basic emotion and is releasing the sort of emotional state it normally deals in? Or, is it that the left hemisphere subserves anger normally and a lesion in a comparable area of the right hemisphere (which subserves some cancelling-out emotion) allows free rein to the left hemisphere’s hegemony over anger? These hypothetically contrasting models appear to apply in reality in the case of an epileptic discharge and an electrically silent lesion respectively, although one cannot rely on this rule. In view of all this, conclusions as to the neuropsychological basis of some matter are better drawn from studies using any of the other methods. Unfortunately, this is not always possible, in which case the conclusions have to be treated with caution. Consider this interaction. A split-brain subject was presented simultaneously, via a tachis¬ toscope, with two pictures—one of a chicken claw in his right visual field projecting to his left hemisphere, and another of a snow scene in his left visual field projecting to his right hemisphere. The subject was then shown four pictures—a chicken, a shovel, a hammer, and an apple—and asked to choose, with either hand, a picture relating to what he had seen. His right hand picked the picture of a chicken, and his left hand picked the picture of a shovel. When asked what he had seen, he (through the speaking left hemisphere) replied, without hesitation or embarrassment, ‘I saw a claw and I picked a chicken, and you have to clean out the chicken shed with a shovel’. The investigators in this experiment concluded: The left hemisphere ... without batting an eye would incorporate the right hemisphere’s response into the framework. While we know exactly why the right hemisphere had made its choice, the left hemisphere could merely guess. Yet, the left did not offer its suggestion in a guessing vein but rather a statement of fact as to why that card had been picked. (Gazzaniga and Le Doux 1978) Dominant the left hemisphere may be, in the sense that it abrogates decision-making to itself in the absence of any rational evidence as to what is going on. Subordinate the right hemisphere may be, in the sense that it allows the left hemisphere to fabricate, when it, the

Notes

69

right hemisphere, knows the truth. However, as will unfold in the course of the book, this way of looking at dominance and subordination is quite specious. Each hemisphere has its own mode of surveying, representing, and communicating with the world and with its partner hemisphere. 5.

Throughout the book, the terms ‘hemispheric differences’, ‘left hemisphere functions’, or ‘right hemisphere functions’ will refer to the typical pattern in a right-hander. I shall be disregarding the anomalous effects of sex and age. Therefore I should mention here that handedness, sex, and age do distort whatever typical pattern exists. Some neuropsycho¬ logists have gone as far as saying that individual differences are so influential that to talk of typical hemisphere differences is nonsense. I do not accept this. The thrust of neuro¬ psychological research, from Gall onwards, has been punctuated by pessimistic outbursts, such as this, concerning the unfeasibility or theoretical unlikelihood of mapping the brain in any general way. Progress in this respect has been relentless nevertheless. However, there is no doubt that handedness and sex, and to a lesser extent age, complicate the issue, although the exact position is far from clear. A minority of left-handers (15 per cent according to Milner (1975); 10 per cent according to Warrington and Pratt (1973)) have speech functions supplied by the right hemisphere. A further minority (10 per cent according to Warrington and Pratt (1973)) have bilateral representation of speech. Even a family history of left-handedness in a right-hander in¬ creases the chance of anomolous distribution of functions (Hecaen et al. 1981). The effect of sex on the distribution of typically hemisphere-linked functions is uncertain. Kimura and Harshman (1984) concluded that women were more likely than men to have their speech-generating mental apparatus concentrated within the left hemisphere in the anterior region, and to have other language functions more bilateral or right-hemisphere based. Others (McGlone 1980; Inglis et al. 1982) have disputed this. However, males have been said to have better spatial abilities because they possess a more lateralized righthemisphere spatial-generating apparatus (Kimura and Harshman 1984). With respect to age, Kimura (1963b) claimed that the left hemisphere’s speech controller developed earlier in girls than it did in boys. There is also evidence that characterist¬ ically right-hemisphere functions deteriorate faster in old age than characteristically lefthemisphere functions (Kocel 1980; Meudell and Greenhalgh 1987).

4 The World Things, Classes and Qualities —

INTRODUCTION Philosophy and psychology One of the major preoccupations of philosophers, probably the major, from Plato onwards, has been the nature of the distinction between individual things encountered in the world and our knowledge of the sort of thing that they are. The dichotomous terms used in the debate have varied in different epochs—particular/universal, nominalism/ realism, percept/concept, reference/sense. However, as Rorty (1980) has argued,1 the change in terminology largely reflects a different approach to the same problem. Rorty identifies three phases in the history of the debate. From Plato until the end of the Middle Ages, the concern was with the nature of things (forms, substances, particulars, universals, species). From the time of Descartes and Locke until the end of the nineteenth century, the main issue became one of how the mind came to represent these things—how, in Rorty’s words, the ‘outer becomes inner’. This century, the emphasis has shifted towards language and logic: how do words and sentences allow us to refer to these things? The contribution of psychologists to the issue is meagre compared with that of philosophers. According to Rorty, this is because psychology is largely confined to epistemology, the second of the above approaches, and thus is bound to view the matter in a narrow way. In fact, in one school of psychological thought, behaviourism, the issue is hardly considered at all because not only is it held that there is no mind, but even the world is rather shadowy, reduced to an interaction between the body and a set of stimuli emanating from ‘outside’. In psychoanalysis also, the outside world of an adult person has only limited importance in itself, being merely a set of triggers calling up memories from childhood. However, there are a handful of outstanding cross-cultural studies which will be mentioned.

Psychopathology The relevance of the issue to the study of psychopathology is enormous. Of the two main classes of psychopathological phenomena, hallucination and delusion, which between them are virtually pathognomonic of madness, the former is almost entirely accounted for, and the latter partly so, within the framework of this chapter. In Esquirol s widely accepted ‘realist’ definition of a hallucination—‘a perception without an object an individual ‘thing’ is perceived, and accordingly its phenomeno¬ logical appearance is taken to correspond to a thing out there, when in fact no corresponding thing exists. In Kantian terms, appearances of things (phenomena) are

70

Introduction Table 4.1

71

Psychopathology of appearance of thing in the world

Category

Definition

Hallucination

Appearance of an individual thing in the world without any corresponding material event Deviation from customary appearance of an individual thing in the world which does correspond to a material event, and which is correctly identified and classified Appearance of an individual thing in the world corresponding to some material event but wrongly classified Appearance of an unsortable thing in the world corresponding nevertheless to some material event An anomalous belief about a particular state of affairs in the world, removed from immediate consciousness, and at odds with past personal evidence and prevailing consensus on the matter

Anomalous experience

Illusion Agnosia Delusion

experienced in an awake state without there being a corresponding thing-in-itself (noumenon). The essence of a hallucination is that a phenomenon of an individual thing is experienced as residing in the world, when in fact it does not. The criterion for establishing the hallucinatory status of the phenomenon lies outside the experiencer; other people do not experience it. Before dealing with delusions, which are notoriously problematical, we should con¬ sider three other categories of morbid experience which also involve a disturbance in the customary correspondence between the appearance of a thing and a material thing in the world. The first of these is what Jaspers referred to as ‘anomalous perceptions’, and which I will refer to as anomalous experiences (which I believe is more correct within the Kantian framework that I am adopting). These are experiences of some thing in which the customary quality of the thing is deviant. The affected quality can be colour, shape, size, familiarity, temporal or spatial verisimilitude, and even reality value, among others. The phenomenological experience does correspond to something material, a fact which can be checked against the experience of other people, and it is taken to reside in the world (albeit, in the case of derealization, with an odd quality in this respect); therefore it is not a hallucination. Moreover, the experience is correctly classified into the sort of thing that it really is (e.g. apple, dog, face) and is correctly designated as a particular individual thing (e.g. the apple I bought at the supermarket last Thursday, my dog Rover, my spouse’s face); therefore it is not an illusion or agnosia (see below). The essence of an anomalous experience is that a correctly sorted, correctly identified, and correctly world-allocated phenomenal experience is neverthe¬ less experienced as deviant from its customary appearance. The criterion available to the experiencer for checking this is his or her memory of what such things looked like in the past; recourse to peer opinion is generally unhelpful. Next, there is illusion. Here, the problem is faulty class allocation. A phenomenal experience within the world is attributed to the wrong sort of thing. For example,

72

The World

Things,Classes and Qualities

—

waking up in the middle of the night and ‘seeing’ what is in fact a shadow of a curtain in the moonlight, we take it for a burglar. It is not a hallucination because there is genuinely a material event in front of us. It is not an anomalous experience because the thing experienced is not just qualitatively different, but is completely misconstrued as another sort of thing entirely. The essence of an illusion is that a correctly worldallocated phenomenal experience is considered to belong to a different class of object from what it is in fact. The experiencer can check this with any other person. Thirdly, there is agnosia. The simplest definition, provided by Teuber (1968), is a ‘perception stripped of its meaning’. It was called ‘mind blindness’ by Lissauer (1890), and agnosia was the term suggested by Freud (1891). Hecaen and Albert (1978) defined it as ‘a disorder of recognition that cannot be explained by a general disturb¬ ance of mental functioning or by a defect of elementary sensory function’. None of this is very helpful in distinguishing it from other faulty correspondences between the phenomenon experienced and a material event. Consider a typical account (Gelb and Goldstein 1918) of Schneider, a man who sustained brain damage in the First World War. The patient’s visual data lack any specific and characteristic structure. His impressions, unlike those of a normal person’s, have no firm configuration; they have not, for instance, the typical look of a ‘square’, a ‘triangle’, a ‘straight line’ or a curve. Before him he sees only patches in which his sight allows him to pick out only salient characteristics, such as height and breadth and their relation to each other ... A gardener sweeping a path fifty yards away is ‘a long streak with something moving backwards and forwards towards the top of it’ ... In the street the patient distinguishes men from vehicles by the fact that ‘men are all the same—long and thin; vehicles are wide, unmistakably so, and much thicker’.

There is clearly the perception of something, and some meaning is derived from it, albeit with the help of other experiences. But the main problem that Schneider had was in distinguishing the sort of thing each appearance on its own was. The appearance of the gardener deviates from its customary one, the hallmark of an anomalous experi¬ ence, but this is trivial compared with the complete lack of ability to allocate the experience to being something in general. In agnosia the appearance is both anomalous and unsortable, whereas, in the generality of instances of anomalous experiences discussed earlier, the anomaly does not prejudice sorting. Therefore, the phenomenon before Schneider coincides in space and time with some material thing, but does not conform to any sort of thing which he would readily have recognized prior to his injury. The essence of agnosia is that some correctly world-allocated experience is unclassifiable. It is not a hallucination because it is correctly linked with some material event. It is not primarily an anomalous experience because it does not merely carry a deviant quality. It is not an illusion because it is not simply misclassified but is unclassifiable. There is no way that the experiencer can check his or her experience—memories of the conventional classification of things are obliterated as pervasively as are ongoing attempts to make sense of immediate experience. Finally, there is delusion. Whereas all four morbid categories considered so far affect the correspondence of a phenomenon immediately presented to consciousness with its material counterpart in the real world, delusion refers to a mismatch between a belief

Introduction

73

about some state of affairs in the world and an actual state of affairs in the world not immediately given to consciousness. The belief may concern any of the issues which form the basis of hallucination, anomalous experience, illusion, or agnosia—namely the existence or non-existence of a thing in the world (positive and negative hallucina¬ tions occur (p. 84)), or the quality of a thing or the class a thing belongs to. A delusion differs from these other morbid categories in respect of its being once removed from the ongoing tableau of experience. The extant definitions of delusion, of which the best are those of Jaspers, DSM-IIIR (APA 1987) and Spitzer (1990) (see pp. 116-22), emphasize different aspects of a delu¬ sion: its falsity, the alleged overwhelming conviction attached to the belief, and the alienation from prevailing social consensus. The problematical nature of delusion requires an extended discussion (pp. 122-5). For the moment it can be defined as a conviction that a particular state of affairs involving the existence, identity, quality or class of a thing obtains, contrary to invalidating evidence from the subject’s own past experience and from contemporary sources outside the subject on the matter.

Neuropsychology Our understanding of the localization within the brain of the mental faculties con¬ cerned with creating identity, quality, and class membership from the otherwise amorphous panoply of sensory information has advanced hugely in the last 100 years. The knowledge so gained, particularly about hemisphere differences, has revolu¬ tionized the classification of mental functions. It has led to the delineation of numerous neuropsychological categories (aphasia, apraxia, agnosia, etc.) but, so far, has had little impact on the psychopathological categories abstracted by Jaspers from the hetero¬ geneous concept of madness. The integration of these neuropsychological advances with traditional psychopathological categories is attempted in this chapter.

PHILOSOPHY AND PSYCHOLOGY Plato and Aristotle The pre-Socratic philosophers were mainly concerned with the general structure and origin of the world—what it was made of, how it worked. It was not until Plato and Aristotle that philosophy began as a series of questions about a human’s acquisition of knowledge of this world. Plato identified the essential problem straight away: Surely some science is needed—perhaps the most important of all ... (for) ... dividing according to kinds, not taking the same form for a different one or a different one for the same ... knowing how to distinguish kind by kind, in what ways the several kinds can or can not combine. (Sophist, Plato)

Plato’s theory of ‘forms’ or ‘ideas’ was a recognition that if we only dealt with indi¬ vidual things in the world, whatever they were made up of, then any meaningful inter¬ pretation of the world would be impossible because no thing would link up with any

74

The World—Things,Classes and Qualities

other thing. Therefore there must be some means of classification of entities in the world which could explain our ability to relate the individual things meaningfully. As Wedberg (1982) pointed out, the theory of forms has logical, semantic, psychological, and metaphysical components. The most relevant aspect of all these to our theme is that Plato thought that what we regard as a general thing (e.g. a dog) was the basic element in the world as we knew it, and the individual thing (e.g. my dog Rover) owed its existence to partaking of the nature of the general thing (e.g. dogginess). (He also believed that qualities, marked by adjectives (e.g. red or good), followed the same pattern, that our knowledge of forms was innate, whereas perception of individual things involved the body, that forms were hierarchically arranged, stretching from goodness down to more banal qualities, and that although ideas were themselves per¬ fect, human beings in the course of their life could only dimly know them.) Aristotle modified Plato’s notions in several ways. Most importantly, he abolished the shadowy status that Plato had given to individual things as opposed to forms. He did this by first introducing the notions of ‘substance’ and ‘universal’. Substances were now the basic and real things in the world, and included individual examples of things such as my dog Rover. Universal were any class of thing or quality or quantity which was not a substance. Reversing the relative status that Plato had accorded the two sets of things, substances were real and universals were not. However, Aristotle’s notion of substance did not merely comprise individual things. Commentators differ on what he did mean, and, according to Frede (1987), he changed his views in later years. Russell (1946) dismissed Aristotle’s opinions on this matter as ‘muddle-headed’, but this is grossly unfair. There was a logical component and an ontological component (what things do exist in the world?) to Aristotle’s notion of substance, and the two did not blend very well and were often contradictory. But the second component was the more interesting and innovative, and, to my mind, the crux of the problem. The logical component just about covered the issue of individuality. Aristotle maintained that if something could replace ‘so-and-so’ in the phrase ‘this is so-and-so’, then that something was a substance (e.g. this is John Smith or this is my dog Rover, but not this is elephant or this is dream). However, he also maintained that substance involved the extent to which something was separable in the world. According to Barnes (1982), this was a complex notion, something akin to the extent to which a thing could stand alone, independently of anything else, with the result, according to Barnes, that ‘middle-sized material objects are the primary furniture of Aristotle’s world’. But Frede (1987) maintains that Aristotle’s final thoughts on the matter were that varieties of anything, living or in¬ animate, were basic substance, and subordinates as well as particular individuals were substances. Moreover, Aristotle’s division of substances into primary and secondary, with the latter being the lowest level of his categories of universals (genus? species?), further complicates the issue. It seems to me that Aristotle was searching for the best cut-off between what he saw as some essential division between what did in fact popu¬ late the world and what humans thought populated it, and chose a point just above the individual varieties of any thing. His notions of forms, beings, and essences were all part of this search.

Philosophy and psychology

75

Medieval philosophers Aristotle’s choice of the cut-off point between substance and universal somewhere just above the level of individual things led to endless controversy during the Middle Ages. The medieval philosopher was already under dire theological constraints, whereby any formulation of a philosophical problem had to accommodate the existence of God. Thus Aristotle’s legacy, most of which was unavailable or only available second-hand, became a focus for conflicting opinions about the role of God in man’s knowledge of things. Despite these uncertainties and constraints, a series of sophisticated notions on the issue of individuality emerged. Five philosophers—William of Auvergne (1180-1249), St Thomas Aquinas (12251274), Henry of Ghent (1217-1293), Duns Scotus (1266-1308), and William of Ockham (1285-1349)—contributed most to the particular problem at issue here. William of Auvergne introduced two new notions into the debate. Firstly, he suggested that what the intellect knew were signs (intrinsic to the mind) rather than forms of things (distilled from the world). It did not receive impressions of form, but rather generated signs of the likeness of things. These signs were God-given, with the intellect being ‘inscribed’ with signs. Secondly, he believed that individual things as well as universals were known to the intellect, and in a similar manner—the former were the result of detailed focusing on things, and the latter were acquired through a more distant viewpoint (‘abstraction’). Thomas Aquinas proposed a multistage process whereby the intellect could know everything there was to know about something: the sort of thing it was (what he called its quidditas—quiddity or whatness), the individual varieties, and the species to which it belonged. It did this by first grasping the quiddity of something, then considering its act of grasping this which revealed the species, and finally alighting on the ‘phantasmata’ (or images) which emerged during the process, which rendered up the individual variations. Henry of Ghent dispensed with the three-stage process and maintained that the intellect could gain knowledge of the individual thing directly, and that the universal was achieved by the intellect’s stripping the ‘phantasm of its individuating features’ (Marenbon 1987). Duns Scotus proposed yet another method whereby universals and individuals might be known—the parallel action of two intellectual activities. One picked up individuals, the other universals. William of Ockham commended the most radical solution of all—one which became known as nominalism, and which was an early version of the epistemological solutions of philosophers from Descartes to Kant. Previous philosophers, from Plato to Duns Scotus, had assumed that if something were real in the world (whether universal or individual), then it could not exist anywhere else (hence the epithet realism applied to their notions). William of Ockham maintained, for the first time, that in addition to individual things which were real in the world, there were thoughts about individual things which were not real in the world (though they were real in the soul). Moreover, he believed that no universals were real in the world (though, as with thoughts of individuals, they were real in the soul). This change in emphasis was not an idealistic philosophy (i.e. mind exists, world does not), but a recognition that for everything that

76

The World

Things,Classes and Qualities

—

did exist in the world (individual things only), there was a complementary thought (proposition or word).

Descartes to Kant This period saw an eclipse of interest in individual things in themselves. Instead, there was a preoccupation with universals. Both the trio of rationalist philosophers (Descartes, Spinoza, Leibniz) and the trio of empiricists (Locke, Berkeley, Hume) were united in believing that ‘whatever is directly perceived and whatever is thought, including universals, are ideal and in the mind’ (Aaron 1967). The two groups of philosophers are contrasted chiefly by their views on how the mind arrived at its universals. For each, during the process whereby the ‘outer became inner’, the distinction between an individual and its class was lost, or at least blurred. Of the latter group, Hume, and to some extent Berkeley, believed that a general idea was an exact copy of an individual thing. Locke believed that the mind fabricated the sort of thing that something was ‘through the workmanship of the understanding’, and, by virtue of the fallibility of humans, concepts tended to be arbitrary in the actual minds of humans, though ‘real essences of species’ were there to be found. The rationalists were primarily concerned with establishing the primacy of mind in these matters, and, as it worked with universals, individual things (except for a single subject’s own mind) could only be treated as a topic of scepticism or as some form of replica of elements of an individual mind. Kant realized that all these proposals missed the point. His distinction between the ‘thing-in-itself’, in the real world, and the ‘phenomenon’, constructed according to ‘rules’ of the mind, solved, in his view, the chief inconsistencies. As he put it: Leibniz intellectualized appearance, just as Locke ... sensualised all concepts of the under¬ standing ... Instead of seeking in understanding and sense two sources of ideas, which while quite different can supply objectively valid judgments of things only in conjunction with each other, each of these great men holds to one only of the two. For Kant, the concept was a ‘rule’, emanating entirely from the mind, and a univer¬ sal. With regard to particular instances—individual varieties—Kant believed that the mind possessed the ability to recognize them, but by what faculty he did not know. It was ‘an art concealed in the depths of the human soul, whose real modes of activity nature is hardly likely ever to allow us to discover’.

Nineteenth and twentieth centuries The chief development in this era, as far as our theme is concerned, is the shift in em¬ phasis in philosophy towards an analysis of language and meaning. The main figure in this new climate of opinion is Frege. Frege’s contribution was to enlarge the framework within which the topic had to be discussed. The Greek and medieval philosophers had dealt with the issue on one level—did either universals or particulars exist or not? The post-Descartians up to this era had added a further level—what was the relationship between particulars and/or

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universal in the world and particulars and/or universal in the mind? (To some extent this was all rolled up into a debate about the relationship between perception—largely considered to be the way we were acquainted with particulars—and concepts or thinking—largely regarded as to do with our knowledge of universal.) Frege was now to introduce a third ‘realm’—that of ‘sense’ {Sinn). Frege held that three ‘realms’ had to be taken into account in any consideration of the meaning of things. Firstly, there were objects, classes of objects, relationships between objects, and values (including truth-values); all these existed in the outside world, and all could act as a ‘referent’ (Bedeutung) to particular aspects of language. Secondly, there was the realm of the purely mental. The third realm, that of sense, was neither mental nor was it any part of the real world. It was ‘the route from the name to the referent: names with different senses but the same referent correspond to different routes leading to the same destination’ (Dummett 1973). Frege gave examples of proper names differing in sense but not in reference, which clarifies this. One was the difference between the ‘Morning Star’ and the ‘Evening Star’, both referring to the same entity, the planet Venus, but clearly differing in sense. Another was a hypothetical case of an explorer discovering a mountain and naming it ‘Afla’, and years later another explorer approaching the same mountain from another direction and naming it ‘Ateb’. Until the region is properly mapped and the error corrected, the same referent is considered to be different, to have different ‘senses’. According to Frege, this realm of sense pervades the whole domain of language. It is not only proper names that have a sense as well as a reference. The distinction becomes even more important in the case of non-proper names, what Frege called ‘incomplete expressions’ (equivalent to predicates in a sentence). The result of this three-realm formulation of the links between language, meaning, mind, and world was to complicate greatly the way in which the debate about particulars and universal could be conducted. Frege himself was not especially inter¬ ested in the problem of particulars, as he considered that his new system undermined all previous analyses of it. There were objects in the world and names for these in language, but neither abstract nor concrete (wirklich) objects nor possible major distinctions between their corresponding proper names were given special treatment. What Frege did emphasize was that the ‘sense of a proper name fixed the criterion of identity for the object named’ (Dummett 1973). During the same period, Russell was tackling similar philosophical problems. His solution to one of these—the logical status of expressions such as ‘the author of Waverley was Scotch’ or ‘The present King of France is bald’—is known as the Theory of Descriptions. At the time (Ramsay 1931) it was regarded as a ‘paradigm of philosophy’, and it is relevant to our theme because it was essentially an attempt to do away with the problem of individuals, in so far as reference to human individuals was concerned. Russell thought that he could translate statements about individual facts, true or fictional, into a cluster of statements about the generality of the issue in question. Therefore ‘The author of Waverley was Scotch’ was broken down into a syllogism: ‘At least one person wrote Waverley; at most one person wrote Waverley; whoever wrote Waverley was Scotch’. Russell’s efforts in this exercise are now gener¬ ally regarded as misguided (Strawson 1959), and so a ‘paradigm’ it may be, but a wrong paradigm. The mistake can be put down to Russell’s belief that he could solve

78

The World

Things,Classes and Qualities

—

the problem of universal versus particular within the one realm of language. Frege has survived as the more astute philosopher of the two because he remained aware of the need to make whatever he said about this realm tie up with the other realms. Therefore, for example, grasping a thought was a mental process, but the thought itself was in the third realm of sense. Later on in the century, there were several contributions within this framework on the specific problem of individuality (Strawson 1959; Kripke 1972; Gracia 1988) or class (Quine 1960; Putnam 1970). Strawson tried to identify common principles in the way that individual and non¬ individual things could be discussed in two of Frege’s realms—the outside world and language. In the world, ‘the basic particulars’ were ‘material bodies’ plus ‘persons’. (The addition of persons to Aristotle’s scheme is Strawson’s attempt to explain away the possibility of a solipsist world-view. The fact that other persons are around us gives us a standard for our own views.) These individual ‘primitives’ or ‘primary particulars’ are laid out in a ‘spatio-temporal world’. According to Strawson, the same set of ‘particulars’ also provided the ‘subject’ in a sentence of subject and predicate, and in this way what existed in the world, and what could be talked about as existing within language, can be approximated. Kripke was also concerned with finding a sophisticated way in which a name of an individual thing and some real thing in the world to which it purportedly referred might tally. It was a sophisticated proposal because it acknowledged the fact that earlier proposals which had equated the name of a thing with some actual thing in the world (the correspondence theory of truth, associated with John Stuart Mill (1843)) or Wittgenstein’s attenuated version of this in the Tractatus that ‘logic mirrors the world’ were both wrong. Kripke believed that when the name of an individual person (e.g. Shakespeare) first became relatively common knowledge, it was ‘baptized’ with certain referential attributes (e.g. the person who wrote Hamlet). The subsequent meaning of Shakespeare then evolved over generations, even being able to accommodate the suspicion that Shakespeare may not have written the plays that he is attributed with having written. The word Shakespeare is, for Kripke, a rigid designator, which retains a direct reference (i.e. bypasses Frege’s third realm of sense) to something in the real world, even though that something is different from what it used to be in some pre¬ vious era, and may not even now exist. The relevance of this proposal to our theme is that Kripke claims that the same principle applies to words designating ‘natural kinds’ (universals, in previous philosophical formulations) such as tiger; therefore the distinc¬ tion between universals and particulars, in so far as they enter language, is abolished. Gracia teases apart the notion of individuality, and finds that some of the controversy in the past can be attributed to a failure to notice that individuality is a heterogeneous concept. First there is the intension of the concept—the set of attributes which could not be removed without destroying it. Gracia says that there is only one attribute, that of ‘noninstantability’ (incapable of having instances of it). Then there is its extension—the set of things to which it is applicable. On this point he says that it is applicable to everything which is not universal, i.e. that individuality and universality are mutually exclusive and exhaustive. Then, on the third issue, that of ontology the nature of something in the world—he says that individuality is a ‘mode’, by which he means a quality of the mind which treats everything which exists in a

Philosophy and psychology

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particular way. Then there is the principle of individuation—what underlies the fact that individual specimens of some general sort do occur. Gracia simply notes that this entails the notion of the existence of anything, and rejects the common assumption that occupation of spatio-temporal co-ordinates provides a sufficient explanation. Fifthly, he sets discernibility apart from other aspects, and here he accepts that spatio-temporal co-ordinates are useful to someone concerned with this, but are not the only means at their disposal. Finally, individuality as a reference point for language is, according to Gracia, accounted for by Kripke’s baptism theory. Quine proposed a solution to the universal-particular problem by giving primacy to universals, which he calls classes, within sentences. For Quine the dispute about where the cut-off between classes and individuals should lie is artificial, and largely a philo¬ sopher’s artefact. A normal person learns the sentence ‘Milk is white’, in which, according to Quine, both ‘milk’ and ‘white’ are classes, and then individuates both classes according to the circumstances of their life, and in particular the way that they translate these classes into their own terms. Therefore individual objects are then functions of the general class, in so far as they make up space and time in a person’s life. An individual dog ‘is the lifelong filament of space-time taken up by a dog’. Putnam also gives primacy to ‘natural kind terms’ rather than individuals. A term such as water refers directly to all samples of water, and does so by means of a stereo¬ type. Like Quine, Putnam admits no clear division between class and individual— the former is built up over the years from examples of the latter, and the latter is con¬ tinually moulded by the state of the stereotype (which bits of it are accruing or fading at any given time).

Psychology The most outstanding psychological contribution to the debate is the work of Rosch (1977). In a series of experiments involving a New Guinea tribe with only two colour terms (dark and light, but no words for hues such as red or blue) she established that, despite the lack of linguistic terms for red and blue, members of this tribe, the Dani, could remember typical reds or blues (judged to be such by Americans) better than they could atypical instances such as reddy-oranges and bluey-greens, just as Americans with these colour terms did. She also showed that the members of the tribe could remember sets of three coloured chips best when they were arranged around a typical instance of a hue rather than an atypical instance, a pattern also seen in Americans. Therefore she concluded that there were colour ‘universals’ independent of words for these. Rosch found the same pattern among the Dani for geometrical forms (triangles, squares, circles) despite the tribe’s lack of acquaintance with these, as, according to her, their ‘world’ was a Stone Age culture. She then moved to ‘real-world objects’ such as fruit, tools, or trees, and studied the structure of these ‘semantic categories’ in Americans. She devised four measures by means of which she claimed she could delineate ‘basic objects, i.e. categories at basic levels of abstraction’ from ‘superordinates’ and ‘subordinates’. Such ‘basic objects’ in ‘non-biological taxonomies’ were things like car, bus and truck, whose common super¬ ordinate was vehicle, and whose subordinates include sports car, city bus, and pick-up truck. Among biological taxonomies, tree would be a superordinate, maple, birch, and

80

The World—Things,Classes and Qualities

oak would be basic-level objects, and silver maple, river birch, and white oak would be subordinates. Her four methods for establishing the ‘basic object’ were as follows. 1.

Basic objects were ‘the most inclusive level of classification at which objects have numbers of attributes in common’. Raters were asked to list as many attributes as they could think of which were common to sets of superordinates (e.g. fish, bird, tree), basic objects (e.g. bass, trout, salmon), and subordinates (e.g. sea bass, rain¬ bow trout, Scotch salmon). Superordinates were judged to have very few attributes in common, basic objects had more, and subordinates had no more than basic objects.

2.

Basic objects were ‘the most inclusive classes at which consistent motor pro¬ grammes were employed (if they could be)’. Subjects were asked to describe how they would use or interact with superordinates, basic objects, or subordinates, and their movements were observed. Virtually no movements occurred in association with the description of superordinates, but some were observed in the case of basic objects, with no increase on this in the case of subordinates.

3.

Basic objects were those which were ‘the most inclusive categories in which the shapes of objects showed a great gain in objective similarity over the next higher level of abstraction’. Pictures of things from the three levels were prepared and similarity of shape measured by ‘the amount of overlap of the two outlines when the normalised outlines (standardized for size and orientation) were juxtaposed’. Again, the same principle as in attributes and movement was found—basic objects were more similar in shape, one to another, than superordinates were one to another, and there was no great change in this for subordinates.

4.

Basic objects were ‘the most inclusive level at which it was possible to form a men¬ tal image which is isomorphic to an average member of the class’. Subjects were invited to try and identify superordinate, basic object, and subordinate from aver¬ age outlines of the normalized overlaps of shapes as produced in the third measure above. Basic objects were better identified than superordinates and no better iden¬ tified than subordinates.

From further experiments on real objects Rosch came to a remarkably similar conclusion to that of Putnam, that classes of things are made up of a ‘prototype’ (e.g. robin for bird) and that the boundaries of a class are fluid, not fixed. (Consider, for example, whether a tomato is a fruit or a vegetable?) The most relevant part of all this to our general theme is Rosch’s comment: ‘Basic level objects for the biological taxonomies studied were consistently at one level of abstraction higher than that predicted by anthropological and linguistic data’. In other words, if we replace her notion of ‘basic-level objects’ by Aristotle’s ‘substance’, then she has found a conglomerate of measures which provides a cut-off between substance and universal, and, as in Aristotle’s formulation, the cut-off is set well above the level of the individual thing. In fact, Rosch did not examine individual members of any subordinate class (e.g. the sea bass I caught last Wednesday, or the silver birch that blew down in my garden in last year’s gales). But her search for the way ‘organisms cut up the environment into classifications by which non identical stimuli can be treated as equivalent’ is of considerable relevance to the philosophical debate outlined earlier.

Psychopathology

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PSYCHOPATHOLOGY Hallucination Definition A hallucination is a perception without an object (within a realistic philosophical framework) or the appearance of an individual thing in the world without any corre¬ sponding material event (within a Kantian framework).2

Classification Hallucinations can be classified phenomenologically (Table 4.2) according to (1) the sensory modality in which they appear, (2) the presence or absence of any precipitating circumstances, (3) broad classes of content, and (4) (unsatisfactorily) according to

Table 4.2

Phenomenological classification of hallucinations

Sensory modality Visual Auditory Olfactory Gustatory Bodily (kinaesthetic, tactile, visceral) * Multimodal Content Visual Elementary Formed Panoramic Auditory Non-verbal Voices Precipitating circumstance Functional Reflex (synaesthetic) Hypnagogic Hypnopompic Degree of attenuation of reality True hallucination Pseudo-hallucination Extracampine hallucination Heightened imagery

*NB See Chapter 6.

Precipitating stimulus and hallucination in same modality, both experienced simultaneously Precipitating stimulus in different modality from that of hallucination When just about to fall asleep When just waking up

82 Table 4.3

The World—Things,Classes and Qualities Classification of hallucinations according to cause

Mental state Purported mechanism

Autonomous representation, module, engram Release mechanisms Reality misattribution Misrecognition of ownership of thoughts Waking dreams

Diagnostic link

Dementia Delirium and alcoholic hallucinosis Schizophrenia Depressive psychosis Mania Hysteria

Sensory organ loss or malfunction Peripheral blindness Peripheral deafness Brain abnormality Site of lesion

Specific condition Hallucinogenic substance

Cortical, subcortical, or visual pathways Occipital, parietal, or temporal lobes Right or left hemisphere damage Migraine Narcolepsy LSD, mescaline

Outside world alteration Sensory deprivation Sensory overload Bereavement

what can best be termed the degree of attenuation of reality (e.g. true hallucination, pseudo-hallucination). Hallucinations can also be classified by virtue of their cause, according to the abnormal state of affairs which is assumed to underlie their appearance (Table 4.3). This aetiological scheme groups them according to whether the abnormal state of affairs is considered to lie within the realm of (1) the mind (purported psychological mechanisms, diagnostic links), (2) the body (loss or dysfunction of a sensory organ), (3) the brain (site of lesion, certain conditions which affect the brain in a characteristic way, hallucinogenic drugs), or (4) the outside world (sensory deprivation, sensory overload, bereavement).* * 3 Phenomenology Sensory modality and content Visual hallucinations What is ‘seen’ depends on the particular mechanism respons¬ ible (see below). In general, though, what is ‘seen’ can be considered to lie along a

Psychopathology

83

spectrum stretching from the ‘real’ at one end to the ‘unreal/surreal’ at the other end. At one end the hallucination is a virtual replica of what would be seen under normal circumstances (i.e. the situation of a normal person seeing the same phenomenon when the corresponding thing was there); in the middle, the hallucination is of a denatured wraith of an object; at the other end, there occur geometrical patterns or flashes of colour (unlike any phenomenon that relates to anything in the real world). Taking the literature as a whole, it is certain that visual hallucinations can be things that are not normally seen, but it is not entirely certain that visual hallucinations can be things that are normally seen. For example, Mize (1980), recalling her own experience of encephalitis, categorized her hallucinations as ‘form constants’ (stars, mosaics), ‘intermediate’ entities (blends of form constants and body parts), and ‘complex scenes’ (cartoon characters, visualiza¬ tions of herself, symbolic scenes). The teichopsia (fortification hallucinations) of migraine (Panayiotopoulos 1994) and Lilliputian hallucinations (e.g. little green men), largely confined to delirium and temporal lobe epilepsy (Le Roy 1922; Goldin 1955; Lewis 1961), are also ‘unrealistic’. So are the visual hallucinations of schizophrenia (p. 93); hardly any of the instances in my series was a plausible everyday occurrence. Therefore Sims’ (1988) remark that ‘an hallucination is indistinguishable from a normal percept’ is false, unless he meant by this that what is ‘seen’ is taken for reality, in which case he should have said so. Dreams are considered real at the time that they occur, and, as Schopenhauer appreciated in his law of causality (p. 4), it is a funda¬ mental rule of the mind that the phenomena which it constructs are taken for real, a rule which applies equally to conscious percepts, dreams, and hallucinations. This does not mean that there is not something peculiar about the reality of the hallucinator. But the peculiarity emerges only when it is contrasted with ‘normal’ reality. In other words, the ‘world’ of the hallucinator is no less real to the participant during a hallucinatory phase than is the ‘world’ of the sane person when awake. To understand the nature of hallucinations it is not sufficient simply to determine the conditions under which non-real mental events (e.g. images, thoughts) somehow become invested with reality. This mistake is made by virtually all investigators of hallucinations in the recent past (see p. 89). The mistake arises from two false assumptions: one, which is excusable, concerns the nature of experience; the other is sheer ignorance about the heterogeneity of hallucinations. It makes no sense to regard a hallucination as a unique and generally pathological instance of subjective-turnedobjective phenomenon, and to enquire into the reasons for this, if, according to Kant and Schopenhauer, normal perception is achieved in exactly the same way, albeit with some configuration in the material world to guide the precise spatial and temporal appearance of the phenomenon. Even an investigator who holds a realist view of per¬ ception should wonder whether it makes sense to concentrate the enquiry on why a person is tricked into assuming that a phenomenon is real when it is not, when the large majority of visual hallucinations are things which that person would never have encountered as real before, for example chimeric blends of form constants and body parts (Mize 1980) or women delivering babies in handbags (Flynn 1962). Reality is not something added on to normal perception or hallucination. Reality is integral to them. Therefore the most relevant question to ask about hallucinations is why the mind constructs phenomena which are impossible or extremely implausible within the

84

The World—Things,Classes and Qualities

subject’s own previous experience of the real world and sometimes within the total experience of the human race. These phenomenological issues were fully recognized by several psychiatrists earlier this century (Straus 1935) and by the philosopher Merleau-Ponty (1945). Consider the following. The patient lives within the horizon of his landscape, under the sway of universal impressions which, lacking any motif or basis, are no longer made to fit into the universal order of the world of things, or into the universal sense-relationships of language. The things to which patients refer by familiar names have ceased to be the same things for them that they are for us. What they have retained and made into parts of their landscape are mere broken remnants of our world, and even these do not remain what they were or parts of the whole. (Straus 1935) The hallucination is not a perception, but it has the value of reality, and it alone counts for the victim. The world has lost its expressive force ... when it is a question of real things, a rat for example, these are represented only by their general style and physiognomy ... Although hallucination is not a perception, there is a hallucinatory deception, and this is what we shall never understand if we take hallucination to be an intellectual operation. (Merleau-Ponty 1945).

A number of different types of visual hallucinations have been described, some with epithets, some with eponymous names, and some with causal links. There are positive and negative hallucinations. A negative hallucination may seem a contradiction in terms, but it is difficult to know what else to call the following example. A man with a left occipital infarct experienced his wife disappearing from her chair (when in fact she was still there), while the chair she was sitting in remained in front of him (Keefover et al. 1988). Negative hallucinations of this sort have been reported in hypnotized subjects (Janet 1889; Prince 1905). There may be hallucinations of words (Rousseaux et al. 1994), as in a boy with a left temporoparietal lesion. By far the large majority of visual hallucinations, however, are positive and of non¬ verbal things. There is no recognized classification by content, but the terms elemen¬ tary, formed, and panoramic are sometimes used. Elementary visual hallucinations are those where the phenomenon bears no resemblance to any sort of thing encountered in the natural world—the ‘fortification spectra, teichopsia, scintillating scotoma, phosphenes’ of migraine, for example (Panayiotopoulos 1994). Formed hallucinations are recognizable sorts of things—a familiar face (in a patient with right temporal damage (Cohen et al. 1992)) or ‘fish swimming in the air’ (in a patient with impaired vision (Holroyd et al. 1994)). Panoramic hallucinations are complex scenarios of events, processions, or natural history scenes. Differences in content may have causal implications (see below) but there are large degrees of overlap. Even ‘normal visions’ are not readily distinguishable in content, individually or even statistically, from hallucinations which are their morbid counterpart. In a survey of 862 normal Icelanders, Lindal et al. (1994) found that 22 per cent experienced a ‘vision’ at some stage of their life; just over half of these depicted an unknown person, a third a known person, and the remainder elementary or formed animals or inanimate things. Twelve of 19 schizophrenics in the same study reported visual hallucinations, with a similar distribution of content. Auditory hallucinations The same phenomenological principles apply here as they do to visual hallucinations. There may be hallucinations indistinguishable from a normal

Psychopathology

85

percept, but there are definitely hallucinations which are different. Examples of the latter are as follows: ‘a voice of a person pretending to be uncouth’, ‘a voice as if a German were trying to talk Yiddish’, and ‘a young man imitating an old man’s voice’ (Minkowski 1932); ‘it is as if I heard with my mouth’ (Schroder 1926); ‘much of what she says and thinks is repeated by a “voice” behind the top of her breast-bone’ (McCowan 1939). There are fewer variables than in the case of visual hallucinations to allow contrast with a normal perception, but it is clear from these accounts that there may be something peculiar about the tone or accent of the voice and there may be an impossible location for it. Merleau-Ponty’s comments on auditory hallucinations are as apt as his comments on visual hallucinations. Hallucinations are played out on a stage different from that of the perceived world, and are in a way superimposed. The fact that the hallucination does not take its place in the stable and intersubjective world means that it lacks the fullness, the inner articulation which makes the real thing reside in itself, and act and exist by itself. (Merleau-Ponty 1945)

Nayani and David (1996) have carried out the most comprehensive phenomenologi¬ cal study of 100 instances of ‘hearing voices’ among psychiatric patients, most of whom had a diagnosis of schizophrenia. Romme and Escher (1993) provide an alternative account, treating the issue as a normal anomalous experience. In the study by Nayani and David, the main conclusions were as follows: (1) the emotion of sadness encouraged the voice in more than half the sample; (2) 49 heard the voice through their ears as externally in the world, and 38 heard it in internal space, usually their head; (3) the voice was male in nearly three-quarters of instances, regardless of whether the patient was male or female; (4) 71 experienced the voice as having a different regional accent from their own, with the most common being an upper-class ‘BBC voice’; (5) 39 could not identify the owner of the voice; (6) 62 heard non-voice sounds in addition to voices, most commonly music; (7) in those who located the origin of the voice outside them, 22 experienced it as coming from the right and nine from the left; (8) the presence of a third-person grammatical statement in the voice did not distinguish schizophrenics from those with manic or depressive psychoses, nor did the presence of an accusatory voice; (9) a vulgar expletive was the most common sort of voice; (10) there was a persistent theme to the voice, often recurring from one episode of psychosis to another (an observation also made by Hoffman et al. (1994)). Auditory hallucinations are conventionally classified into non-verbal and ‘voices’. The non-verbal hallucinations reported appear to be ‘realistic’, in that they are plaus¬ ible events in the experience of the subject (babies crying or bagpipes playing (delirium) (Cutting 1987*3 e d 5 jj o

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