Understanding Madness: Science, Philosophy, and the Experience of Delusions (2015)

Despite multiple trials with antipsychotics, I really struggle to filter out ‘irrelevant’ information (as this blog clearly demonstrates). Ordinary information becomes ‘hypersalient information’ and I’m compelled to explain ‘it’, whatever ‘it’ is… it’s great for compiling long lists of citations of varying (ir)relevance – thankfully, I don’t struggle with too many delusions. I found the following interesting as an insight into psychosis:

Understanding Madness: Science, Philosophy, and the Experience of Delusions (2015)

A Review of The Measure of Madness: Philosophy of Mind, Cognitive Neuroscience, and Delusional Though

At the beginning of my training in psychiatry, I encountered an attitude that psychosis was inherently beyond human understanding, as if schizophrenia were an alien thing, and that the mad were unreachable, at least until medicines restored something of their humanity. I later learned that such abhorrent, even dangerous, views may have originated from a misinterpretation and generalization of what Karl Jaspers had written about the “ununderstandability” of certain delusions— psychic experiences that were not meaningful and precluded empathy. A partial antidote to this perspective, I discovered, came from mid-century psychoanalytic approaches to psychosis through which a method in madness could be discerned, albeit limited and imperfect…

“…[Gerrans] proposes that delusions result from the operations of a “default cognitive processing” mode under twin conditions of reduced “supervision” by higher level decontextualized (prefrontal) processing, and dominance of “hypersalient information” mediated by dopaminergic systems.

Gerrans works through key aspects of the literature concerning the salience system and reward prediction, the role of dopamine neurotransmission in these neural processes that are concerned with novelty and motivation, and culminates with the work of Kapur (2003) and others who have proposed a central role for enhanced dopamine transmission in producing a state of hypersalience (or “aberrant salience”) in which stimuli acquire heightened significance—intense phenomenal events that compel explanation. Decontextualized processing refers to hypothesis-testing-like cognitive processes for verifying interpretations or conclusions about experience of the world and inner life. It relies on several cognitive functions that involve activation of the dorsolateral prefrontal cortex. Gerrans argues that this system is absent, diminished, or compromised in delusional states, or somehow not operative in “supervision” of the dominating effects of hypersalient information.

The most interesting element introduced by Gerrans centers on what has been called the default mode network, a cognitive system involving the ventromedial prefrontal cortex that simulates “fragments of autobiographical/personal narratives.” It is an imaginative process, sometimes with dream-like qualities, a “default state” to which the mind reverts in the absence of a salient problem on which to focus. Gerrans proposes that delusions emerge from the hyperactivation of this cognitive system in which, rather like acts of creative imagination, highly salient thoughts, untrammeled by top-down decontextualized processing, are incorporated into autobiographical narrative fragments and achieve “subjective adequacy.” By this is meant a kind of story that “fits” with the person’s psychology, rather than publicly shared beliefs, and that seems to emerge spontaneously and with a compelling intensity.

Using this model, the author offers a critique of a leading doxastic theory of delusion formation, particularly the two-factor theory that proposes an initial anomalous perceptual experience, which generates a quasi-rational but delusional explanation for the experience, followed by a failure to reject that explanation due to a faulty reasoning or “belief evaluation” system, related in turn to damage or dysfunction in the right frontal hemisphere (e.g. Coltheart, 2005). The problem with this theory, Gerrans proposes, is that it treats delusions as hypotheses, to be tested and confirmed or disconfirmed, when they are no such thing, but rather “narrative elements [that] go on to play a role in structuring the agent’s psychology”…

An interesting implication of Gerrans’ view that the default thinking involved in delusion formation is “essentially an imaginative process” with a result that achieves “subjective adequacy” is that it introduces the notion that a creative process is involved, perhaps leading to an aesthetic effect in the subject (Carr, 2010). As such, the processes of delusion formation not only bear similarities to dreams, daydreaming, and reverie, but to creative processes generally, including artistic expression and scientific insight.”

“…madness is a human experience. Delusion is not alien and unfathomable if we have the tools required, make the effort to understand it, overcome the barriers to empathy, and engage with the person gripped by delusion…”

“My hope, however, is that psychiatrists will read it, think about its subject matter deeply, and how it might better inform their view of the person and the mind/brain behind madness, thereby perhaps helping to counter the enormous contemporary pressures towards biomedical reductionism in our profession. Delusions are more than antipsychotic deficiency states; there is more to understanding madness than dopamine receptors, and there is more to delusions than madness itself.”
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