Clinical delusions are they beliefs The argument from

Clinical delusions: are they beliefs? The argument from Double Bookkeeping Lisa Bortolotti Philosophy, Birmingham Navigating Psychopathology Medical School, Warwick 1

Plan of the session Doxastic and anti-doxastic accounts of delusions The argument from double bookkeeping Motivation and action guidance Conclusions 2

Delusions Irrational belief-like states reported with conviction and often having implausible content. Symptoms of a variety of psychiatric disorders, among which schizophrenia, dementia and delusional disorders. 3

Delusions in the DSM-IV Delusion. A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. ◦ All aspects of this definition have been challenged. 4

The nature of delusions Doxastic account of delusions: delusions are genuine instances of belief. Anti-doxastic account: delusions appear to be beliefs, but are not genuine instances of beliefs. 5

Anti-doxastic accounts Emphasis on the experiential and phenomenological character of delusions over the doxastic one (e. g. , Sass 1994; Gold & Hohwy 2000) 2. Delusions as attitudes towards representations (e. g. , Currie 2000; Currie & Jureidini 2001; Stephens & Graham 2006). 1. 6

Anti-doxastic accounts (cont. ) Delusions as modes of experience encompassing cognition, bodily changes, affect, social and environmental factors (Gallagher 2009). 4. Delusions as defective reasons for action (Fulford 1989). 3. 7

One anti-doxastic argument It is constitutive of beliefs that they guide action in the relevant circumstances. 2. Delusions do not guide action in the relevant circumstances. 3. Thus, delusions are not beliefs. 1. 8

Assessing the argument Premise (2): Is it really true that delusions do not guide action? Empirical premise. Premise (1): Is action guidance a constitutive feature of beliefs? Conceptual premise. When delusions fail to guide action, is it because people do not genuinely believe the content of their delusions? 9

Double bookkeeping Bleuler (1950) first introduces the notion of ‘double awareness’ in schizophrenia: ◦ people with schizophrenic delusions may fail to act in accordance with their delusions. 10

Double bookkeeping (cont. ) “They really do nothing to attain their goal; the emperor and the pope help to manure the fields; the queen of heaven irons the patients’ shirts or besmears herself and the table with saliva” (Bleuler 1924, p. 392) 11

Double bookkeeping (cont. ) Sass (1994, 2001, 2004) and Gallagher (2009) talk about ‘double bookkeeping’: ◦ “A patient describes doctors and nurses as poisoners (in delusional reality) but happily eats the food they give her (in everyday reality)”. (Gallagher 2009, p. 260) 12

Manifestations of delusions �But there are many examples of delusions being manifested in behaviour: ◦ a person with delusions of passivity wears a cap because he wants to prevent his neighbour from inserting thoughts into his head; ◦ people with Cotard delusion stop bathing and eating (Weinstein 1996); 13

Manifestations of delusions ◦ people with persecutory delusions avoid specific situations or certain individuals because they perceive them as threatening (Freeman et al. 2001); ◦ self-inflicted eye injury and self-mutilation are common in people who believe that they deserve punishment due to their delusions of guilt (Buchanan & Wessely 1998); 14

Manifestations of delusions ◦ acts of violence can be motivated by delusions, especially when people react to misperceived threats (Junginger et al. 1998, Förstl et al. 1991, Bourget and Whitehurst 2004, Broome et al. 2010). ◦ These examples suggest that delusions are sometimes acted upon. 15

Revising the argument It is constitutive of beliefs that they guide action in the relevant circumstances. 2. Some delusions do not guide action in the relevant circumstances. 3. Thus, those delusions that do not guide action in the relevant circumstances are not beliefs. 1. 16

Revising the argument (cont. ) Alternative version: 1. It is constitutive of beliefs that they guide action in the relevant circumstances. 2. Delusions do not always guide action in the relevant circumstances. 3. Thus, delusions are not always beliefs. 17

Challenging premise one It is not constitutive of beliefs that they guide action in the relevant circumstances. ◦ Some beliefs guide action: I go to the seminar room at 2 pm, because I believe that the seminar will start at that time. ◦ Other beliefs do not necessarily lead people to act in a way that is explicable by reference to the content of those beliefs. 18

Failures of action-guidance I may report that I believe that people should donate ten percent of their salary to their preferred charity, but then fail to do so myself. ◦ When I state a general principle but fail to apply it to myself, one is entitled to doubt my sincerity and ask whether I really have the initial belief (literature on hypocrisy and attitude-behaviour inconsistency). 19

Attitude vs. behaviour In cognitive psychology, there is evidence for the causal efficacy of the unconscious mind (Wilson 2002) ◦ It is difficult to predict people’s behaviour on the basis of their self-reported beliefs and intentions. ◦ When inconsistencies are found, selfreported attitudes and explanations are regarded as largely confabulatory. 20

A reply Delusions often concern events of great significance to the person reporting them, and if they were beliefs, they would be beliefs that one would act upon.

A reply (cont. ) The topic of a delusion often involves: ◦ a self-defining event (‘God spoke to me’, ‘I’m disembodied’, ‘I’m a famous musician’); ◦ an event with great emotional implications (‘My wife has been replaced by an impostor’, ‘Richard Gere is in love with me’); ◦ or possible threats to one’s safety and wellbeing (‘The FBI is having me followed and wants me dead’).

Counter-reply There is no disanalogy between attitude-behaviour inconsistencies in the general population and in people with delusions.

Counter-reply (cont. ) Wilson (2002) argues that discrepancies between attitudes and behaviour in normal cognition can extend to: ◦ beliefs about oneself, ◦ beliefs about the success of one’s romantic relationships and ◦ moral attitudes.

Rational agency Attitude-behaviour consistency should be seen as a requirement for rational agency. 1. One of the conditions for rational agency is that beliefs guide action consistently in the relevant circumstances. 2. Some delusions do not guide action consistently in the relevant circumstances. 3. Thus, when delusions do not guide action consistently in the relevant circumstances one of the conditions for rational agency is not met. 25

Rational agency (cont. ) The conclusion of this latter argument is much weaker than the conclusion of the anti-doxastic argument. It doesn’t show that delusions cannot be beliefs, but leaves it open that some delusions are beliefs held by non-rational agents (not that surprising). 26

Challenging the second premise �Behavioural inertness is not a widespread phenomenon, but even when it occurs it may not determine the nature of delusions. �A person may genuinely believe the content of her delusions and yet fail to act on them. ◦ There may be a failure to acquire or to sustain the motivation to act due to cognitive, affective or volitional factors. 27

Explanations for “behavioural inertness” Intentions to act are not generated Intentions are not converted into action Lack of support or opportunity No commitment to the content of the belief No appropriate emotional reactions towards the goal (flattened affect) Stress, anxiety, or depression may interfere with action (emotional disturbances) Conflicting attitudes or fluctuating conviction The goal is desirable but not pursued for deficits in imagination or projection Lack of engagement in pleasurable activities supporting the pursuit of the goal The goal can’t be No sense of accessed for deficits in autonomy, selfmeta-representation efficacy or competence in the agent No opportunity to act given the structure of the physical or social environment 28

Beliefs and motivation In cognitive psychology it is believed that one’s motivation to act is affected by: 1. the perceived desirability of the goal; 2. the perceived likelihood to achieve the goal; 3. the support of the surrounding environmental and social context (Allport 1937, Ford 1992, Austin & Vancouver 1996, Armitage & Christian 2004, and Kuhl & Beckman 1985). 29

Desirable goals The likelihood to achieve the goal is affected by: 1. the agent’s sense of behavioural control, that is, whether the agent represents the goal as something that can be achieved given its intrinsic features; 2. the agent’s sense of self-efficacy, that is, whether the agent represents herself as able to perform successfully the actions leading to the achievement of the goal. 30

Desirable goals (cont. ) Contextual factors and self-conceptions play a crucial role: 1. the surrounding physical and social environment can fail to be responsive to the agent’s newly formed intention. 2. agents may lack a sense of autonomy, intended as the belief that the action is caused by them, and a sense of relatedness, intended as support from personal relationships (Ryan & Deci 2000) 31

Flattened affect Bleuler (1950, p. 70) identifies schizophrenia with a “breakdown of the emotions” ◦ people affected by schizophrenia often appear indifferent (such “indifference” would now be considered as a negative symptom). 32

Flattened affect (cont. ) Positive correlation between affect and motivation: ◦ when there are strong emotional reactions relevant to a person’s delusions, such as anger or anxiety, the person is more likely to act on her delusions. ◦ if these emotions associated with the content of the delusions are not manifested, then the motivation to act may also be undermined. 33

Avolition People with schizophrenia are not necessarily unable to represent their goals as desirable. They find it harder than controls to act in such a way as to enjoy the pleasant emotions associated with the pursuit and achievement of their goals and channel them into action. ◦ Foussias & Remington (2008) 34

Avolition (cont. ) People with psychopathologies report that they experience fewer positive emotions than controls. ◦ They cannot imagine future outcomes of their action or anticipate the pleasure they may derive from the action. ◦ They are able to enjoy pleasurable actions, but they actually engage in them less frequently, because they have fewer opportunities for social interaction. 35

Explanations for “behavioural inertness” Intentions to act are not generated Intentions are not converted into action Lack of support or opportunity No commitment to the content of the belief No appropriate emotional reactions towards the goal (flattened affect) Stress, anxiety, or depression may interfere with action (emotional disturbances) Conflicting attitudes or fluctuating conviction The goal is desirable but not pursued for deficits in imagination or projection Lack of engagement in pleasurable activities supporting the pursuit of the goal The goal can’t be No sense of accessed for deficits in autonomy, selfmeta-representation efficacy or competence in the agent No opportunity to act given the structure of the physical or social environment 36

The receptivity of the world Given the content of delusions, the world and others just do not offer a way of acting. ◦ Jaspers – true/primary delusions are ‘impossible’. People with delusions may find themselves in a physically or socially structured environment in which there are no available actions relevant to their beliefs. 37

Lack of affordances Thus, a person fails to act on her delusion because, given the contents of the delusion and the constraints imposed by the world … … eithere just is no action that she can take; … or the only appropriate action would have unpleasant or dangerous consequences. 38

Examples A woman believes that the world is ending and she is the only one who can save the world by deciphering signs that God sends her in her dreams. ◦ The woman is well aware that other people are unlikely to believe her, so she may not warn others about the end of the world. 39

Examples A man with Capgras delusion says that he can’t go to the police to report the disappearance of his wife because the police wouldn’t believe that aliens have abducted her and replaced her with an impostor. ◦ The social environment would not be supportive of the person’s actions, and this is precisely what inhibits action. 40

Examples The strangeness of the belief seems to inhibit action. Impossible beliefs contradict laws of biology and physics. 1. a man who felt that his body was occupied by a superhero team devoted to battling for the good of Crystal Palace Football Club; 2. a woman who believed that she was endlessly pregnant and giving birth to a series of Messiahs. 41

Examples People in the examples above felt privileged about their conditions but, other than talking about their beliefs, they felt no need to act on them. ◦ They, as individuals, were ‘containers’ of other entities and they thought that they were themselves not under any threat. ◦ What action could people with those delusions have taken? 42

Effects of “impossible” delusions Frustration and impotence in the sufferer, and bafflement and perplexity in the people around them. As a result of unsuccessful attempts at communication, people with delusions just stop trying to engage others in their beliefs. This may lead to depression, isolation, and the entrenchment of delusions. 43

Unresponsive environment The world is such that some bizarre delusions cannot give rise to desirable goals, or give rise to any goals whatsoever, because the environment surrounding the agent is unresponsive. 44

Conclusions The following explanation for double bookkeeping in delusions is very popular: ◦ people fail to act on their delusions because they do not genuinely believe the content of their delusions. 45

Conclusions (cont. ) Instead, people may fail to act on their delusions for the same reason people ordinarily fail to act on their nondelusional beliefs, because they are unable to to acquire or sustain the motivation to act. 46

THANK YOU! 47

Some questions for discussion Recently it has been suggested that delusions are hybrid states, inbetween beliefs and imaginings or beliefs and desires. Do you find this view plausible? 2. Do you think the phenomenon of double bookkeeping is widespread in the non-clinical population? Can you come up with some examples? 1. 48

Some questions for discussion Does it matter whether delusions are defined as beliefs or as something else? Is it just a terminological dispute? 4. Can you imagine situations in which it would be difficult to distinguish a delusion from another irrational beliefs? 3. 49