Psychiatry and its objects

Whether natural, social or belletristic, all disciplines are related to objects considered as specifically their own. The fact that the objects of some (e.g. zoology, botany) are more easily recognized than those of others (e.g. Social Anthropology or History of Art) is conventionally explained by the claim that the former are ontologically independent. There is in our time a tendency to place the objects of psychiatry in this category. Indeed, work on the philosophy of psychiatry tends to support the view that mental illnesses are natural kinds.¹ Such a justificatory stance is of little use to the psychiatry.² This editorial explores the question of what kinds of objects mental symptoms and disorders are and suggests that they are neither physical (like flowers or brain tumours) nor abstract (like virtues or symbols) but hybrid in nature.

The question “what kinds of things are psychiatric disorders” seems innocent enough.³ However, a cursory analysis shows it to be dependent upon an operational definition of ‘psychiatric disorders’ which clearly carries a conceptual contraband and allows it plausibly to favour the fourth of the options it examines (‘essentialist’, ‘constructionist’, ‘pragmatic’ and ‘mechanistic property cluster kinds’). Further analysis also shows that the chosen option is not really the characterization of a ‘thing’ (object) but the description of a putative epistemological mechanism to confer validity upon biological psychiatry.

The objects of psychiatry

To deal with the above question fairly the analysis must be made to start at the very source of the epistemological river. History shows that the ‘objects’ of psychiatry cannot be studied independently from the’ systems of description, explanation and management’ (SDEM) used to articulate them in the first place.⁴ SDEM name the sets of organized emotional, cognitive and managerial responses and representations that societies formulate to deal with those of their members who are consensually deemed different, troublesome, mad, deviant, etc. SDEM have been part of the social practice of most human groups. In current textbooks of psychiatry we can find the SDEM that governs our own views of ‘mental disorder’.

If it is the case that the objects of psychiatry cannot be conceived independently from the SDEM that articulates them, then it must be concluded that they are ‘relational’ by definition and will secularly change pari passu with changes of SDEM. This view opens up interesting explanatory possibilities, the most important being that models can be designed to account for the formation of psychiatric objects that do not need to have transhistorical or transcultural aspirations.

Psychiatry as a hybrid discipline

Psychiatry can de defined as a theoretical and practical discipline whose epistemological structure straddles the natural and human sciences. This hybrid status is a relic of the epistemological forces that operated on the construction of Alienism during the 19th century. Alienists were expected both to find the ‘causes’ of madness and also to ‘understand’ it. The former expectation was acceptably met by the adoption by Alienism of the anatomo-clinical model of disease predominant in 19th C medicine. The latter task, however, was much harder to undertake and in the event it became an effort manqué⁵ because jobbing alienists found it difficult to incorporate into their (medical) conceptual frames the historicist and hermeneutic trends developing in Europe at the time. These were the very trends that by focusing on subjectivity and intersubjectivity provided the questions around which the modern human sciences were to become organized.

In general, alienists found it more comfortable to emphasize the anatomo-clinical model and up to the turn of the 20th C the only hermeneutic effort had been that undertaken by Freud. This built into psychiatry a conceptual tension that has not yet been resolved. Occasional talk of a ‘biopsychosocial’ model has led nowhere for it only can offer a verbal solution.⁶ The only solution is to develop a model of mental symptom-formation that blend the biological and semantic components.

Symptom-formation and mental symptoms as hybrid objects

According to the Cambridge model, there are at least four pathways for symptom-formation.⁷ Only pathway (a) will be described here. Most mental symptoms start as brain signals resulting from malfunctioning pathways, sites, etc. that upon penetrating awareness give rise to proto-experiences often experienced for the first time. To emphasize their pre-linguistic and inchoate nature these experiences have been called ‘primordial soup’ (PS). Distressed sufferers may seek to communicate them but since communication is based upon meaning such that proto-experiences need to be configured first. This the afflicted individual does by means of personal, familiar, social, and cultural configurators. In this respect, the cognitive management of the PS is no different from that of any other signal. However, ordinary incoming information is readily configured because subjects posses a variety of emotional and cognitive templates acquired through development and education. Such templates, however, are not available to configure novel proto-experiences. This is the reason why subjects often first respond to them with perplexity and emotionality. In the event the subject manages to configure the PS, often with the help of a clinician, and is able to convey it in an utterance. This constitutes the ‘mental symptom’ as entered in the casenotes.

The semantic/cultural configuration of the brain signal may be so profound that the final content of the mental symptom no longer reflects the neuropsychological specificity of its origin. For example, the fact that a subject utters a complaint with a ‘perceptual’ content (‘hearing’ voices or ‘seeing’ people) does not mean to say that the original brain signal originated in perceptual regions of the brain. This because the ‘same’ brain signal can be configured into different types of mental symptoms and different brain signals can be configured into the ‘same’ symptom. Often enough it might be difficult for an individual to decide if her/his PS consists of an image or an idea (much as it happens during dreaming), and whether his proto-experience is finally reported as a hallucination or a delusion will depend more on the cognitive or emotional configuration than on the brain signal itself. Similarly, unpleasant internal states might be interpreted by some patients as ‘depressed’ mood and by others as ‘anxiety’, ‘fatigue’ or ‘pain’. It is important to remember that current research paradigms conceive of mental symptoms as mapping specific brain sites in a one-to-one fashion and hence cannot deal with these cultural reconfigurations.

It is proposed in this editorial that the particular combination of biological signal and cultural configurators gives rise to a new type of object which should be called hybrid object. Psychiatry is not the only discipline able to construct such objects; for example, the history of art, geography, psychology, etc., do likewise. ‘Hybrid objects’ include components from both the natural and social worlds. The proportional contribution of these two components (in relation to each known mental symptom) and the manner of their interaction require further research. It goes without saying that the classificatory needs of hybrid objects and the manner in which they relate to the brain will also differ from that of physical and abstract objects.

Hybrid objects should not be considered as a mere ‘combination’ of physical and abstract objects for they result from the configurative action of moral agents and hence are imbued with the emotional, volitional and cognitive force that persons generate when confronted with a complex and (often) perplexing experience (primordial soup). As dynamic responses, hybrid objects are fully consonant with personality and mental state. They are the expression of the manner in which beliefs, cultural codes and views of the world get knitted together in response to a strange experience.

The brain inscription of hybrid objects (mental symptoms)

The sui generis nature of hybrid objects raises the question of how do they relate to the brain for many to consider psychiatric disorders in general as the expression of pathology affecting this organ. Surprisingly, there is not a great deal of work on theoretical models accounting for the specific brain inscription of mental-symptoms. This may simply result from the fact that the 19th C assumption that all mental acts are primarily inscribed in the brain is considered as proven; and because it is believed that the issue is empirical rather than conceptual.⁸

In this editorial ‘Localization’ will mean the “The process of fixing, or fact of being fixed, in some particular part or organ of the body” (OED); ‘Representation’: “An image, likeness, or reproduction in some manner of a thing” (OED); and ‘Inscription’: “A marking upon some organ or part produced by another in contact with it; esp. a marking on the fleshy part of a muscle where a tendon crosses it” (OED). The phrases ‘brain representation’ and ‘brain inscription’ (in preference to brain localization) will be used to refer to any of the ways in which mental acts may relate to the brain and are meant to be neutral in regards to: (1) fixedness of localization (as in hard-wired brain functions like motor sensory function, language, etc.) and, (2) primariness (as in being the ‘originator of the said mental activity’). In this regard, the Cambridge model of mental-symptom formation respects the postulate that ALL mental activity must be related to brain activity. However, it also endeavours to show that brain inscriptions of mental symptoms are complex relational states, different in many ways from the naive claim that they express some sort of fixed one-to-one correlation.

Hence, it is suggested in this editorial that there are (at least) two forms of brain representation / inscription: primary and secondary. Examples of primary forms of inscription can be found in perception, memory and other hard-wired mental functions where the nature of the relationship between mental function and anatomical substratum is such that: (a) a lesion of the latter will affect the former generating and (b) therapeutic manipulation of brain inscription may alleviate the disturbance in the mental function concerned (as it may happen in neurological disorders, e.g. a brain tumour causing hallucinations, some manifestations of epilepsy, etc.).⁹

Secondary brain inscription is used here to refer to the manner in which a complex symbolic mental state relates to or is represented in the brain. Symbolic mental states are defined as mental states whose definition, essence and causal force have become more dependent upon a temporary singular meaning acquired in relation to a specific relational situation than upon their original neurobiological substratum as a standard thought. What matters in symbolic mental states is not that they are thoughts or emotions as such but that in relation to specific social interaction they have gained a supervenient level of significance which drives the subject to behave, feel, etc. in a particular way.

This supervenient meaning originates in the semantic space¹⁰ that temporarily forms between interacting human beings as a result of localized language and emotional exchanges. This meaning may last (if recorded or remembered) but often enough it fades away once the dialogical relationship and its semantic space break up. Nonetheless, whilst present it has a driving force of its own to induce specific feelings and behaviours in the participants. An interesting feature of these supervenient meanings is that they are not ‘inside the head’ of the participants but in the temporary semantic space created by them. The issue is how do these supervenient meanings relate to the brain of each of the participants.

An example of a supervenient meaning is Austin's perlocutionary function of speech acts.¹¹ If one were to ask how are the latter localized in the brain the answer is likely to be different for each of its components. Given that language is considered as a hard-wired function it might be claimed that the locutionary and illocutionary components should primary be inscribed. However, when it comes to the perlocutionary function things get complicated for it has only meaning in an interpersonal space. When a priest tells a couple ‘I declare you husband and wife’ the fact that it is possible to localize in the brain the pronunciation of his words is irrelevant to the performative act. The performative act is a symbolic action which gains meaning only if the context is right, if the participants are free to marry, if the place has been accredited for the purpose, etc. To say that the performative act is also localized in the brain (because the uttering of the words is) of the priest seems nonsensical. It is suggested here that at least some mental symptoms contain cultural configurators and symbolic overlays that make them to be functionally closer to the performative component of the speech act.

It is likely that both primary and secondary brain representations of mental symptoms will be captured by neuroimaging. However, only the identification (and manipulation) of the former will have therapeutic import. Therapeutic interventions on secondary brain inscriptions are likely to be counterproductive. The primary/secondary distinction thus gains a very practical importance because it is likely that many mental symptoms (and the ‘disorders’ they are members of) are only secondarily represented. On account of this, it is of the essence that psychiatrists develop criteria to differentiate between mental symptoms with primary and with secondary brain representation.

In summary, mental symptoms are special kinds of objects different from both physical and abstract objects. They are the outcome of a complex process whereby brain signals are configured by cultural codes. This completely changes their meaning and content and makes them irreducible to neurobiological explanation. The hybrid nature of mental symptoms generates new theoretical and research needs in regards to their hermeneutic understanding, classification and brain inscription. These should be met as a matter of urgency not for theoretical reasons but because there are people out there suffering from mental symptoms. Any model that may generate therapeutic responses to their affliction that are personalized, useful and predictive should be preferred. In this sense, the philosophy of psychiatry has a crucial role to play in the analysis of the nature and management of psychiatry and her objects.

Conflict of interest

The author declares no conflict of interest.