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Thoughts and Delusions of Thought Insertion On the Architecture of Psychosis: Thoughts and Delusions of Thought Insertion A thesis submitted to the University of Manchester for the degree of Doctor of Philosophy in the Faculty of Humanities 2015 Pablo López Silva School of Social Sciences Contents ABSTRACT 5 DECLARATION 6 COPYRIGHT STATEMENT 7 ACKNOWLEDGMENTS 8 INTRODUCTION: MAPPING THE TERRAIN 10 1. WHAT ARE DELUSIONS? 11 1.1. THE TYPOLOGY PROBLEM 12 1.2. THE AETIOLOGICAL PROBLEM 17 1.2.1. BOTTOM-UP VS. TOP-DOWN APPROACHES 17 1.2.2. ENDORSEMENT VS. EXPLANATIONIST APPROACHES 19 2. ON THE HETEROGENEITY OF DELUSIONS: KEY DISTINCTIONS 20 2.1. FUNCTIONAL-ORGANIC / MOTIVATION-DEFICIT DELUSIONS 21 2.2. MONOTHEMATIC VS. POLYTHEMATIC DELUSIONS 22 2.3. CIRCUMSCRIBED VS. ELABORATED DELUSIONS 22 2.4. PRIMARY VS. SECONDARY DELUSIONS 23 2.5. BIZARRE VS. MUNDANE DELUSIONS 23 3. WHAT IS THOUGHT INSERTION? 24 3.1. THOUGHT INSERTION: MAIN SUBJECTIVE FEATURES 25 3.2. DISAGREEMENTS SURROUNDING THE SUBJECTIVE FEATURES OF THOUGHT INSERTION 29 3.3. THE DIAGNOSTIC ROLE OF THOUGHT INSERTION IN PSYCHIATRY 32 4. THE PHILOSOPHICAL RELEVANCE OF THOUGHT INSERTION: MAKING SENSE OF THE COLLECTION 35 5. REFERENCES 39 CONSCIOUS THOUGHTS AND ATTRIBUTIONS OF MENTAL AGENCY: 45 AN AFFORDANCE MODEL 45 1. FROM SELF-ATTRIBUTIONS OF BODILY MOVEMENTS TO SELF-ATTRIBUTIONS OF THOUGHTS 46 2. EXPERIENCING AND SELF-ATTRIBUTING THOUGHTS: A LAND OF DISAGREEMENTS 49 2.1. THE PHENOMENAL CHARACTER OF THOUGHTS: A LIBERAL STANCE 49 2.2. MODALITIES OF MENTAL-SELF ATTRIBUTION: SUBJECTIVITY, OWNERSHIP, AND AGENCY 50 2.3. THE PHENOMENOLOGICAL PASSIVITY OF THOUGHTS 54 3. EXPLAINING SELF-ATTRIBUTIONS OF MENTAL AGENCY 60 3.1. THE TOP-DOWN FORMULATION 60 3.2. THE BOTTOM-UP FORMULATION 63 4. ATTRIBUTIONS OF MENTAL AGENCY, PSYCHOSIS, AND THINKING AS A MOTOR PROCESS 66 5. AFFORDING MENTAL AGENCY: A PROPOSAL 69 6. IMPLICATIONS OF THE AFFORDANCE MODEL OF MENTAL AGENCY: EXPLAINING EXTERNAL ATTRIBUTION 73 7. CONCLUDING REMARKS 76 REFERENCES 77 2 THOUGHT INSERTION AS HYBRID DELUSIONAL BELIEFS 82 1. INTRODUCTION 83 2. UNDERSTANDING MADNESS: DOXASTICISM ABOUT DELUSIONS 85 3. BOTTOM-UP EXPERIENTIAL LOADING AND THE CONSCIOUS EXPERIENCE OF THOUGHT INSERTION 88 3.1. REPORTS ON THOUGHT INSERTION 89 3.2. TWO DOXASTIC ROUTES TO DELUSIONAL BELIEFS OF THOUGHT INSERTION 90 3.2.1 THE EXPLANATIONIST ALTERNATIVE 91 3.2.2. THE ENDORSEMENT ALTERNATIVE 92 4. ENDORSEMENT OR EXPLANATION? 95 4.1. THE NON-SENSORY PHENOMENAL NATURE OF THINKING 95 4.2. SUBJECTIVE CERTAINTY 97 4.3. THE AMBIVALENCE PROBLEM: TO BE, OR NOT TO BE? 99 4.4. THE EXPERIENTIAL ENCODING PROBLEM 104 4.4.1. THE INCREDIBILITY OBJECTION 104 4.4.2 THE NON-AGENCY OBJECTION 106 4.5. THE DOXASTIC ENCODING PROBLEM 107 5. TOWARDS A POTENTIAL SOLUTION: THOUGHT INSERTION AS HYBRID DELUSIONAL BELIEFS 110 6. CONCLUDING REMARKS 114 REFERENCES 115 PSYCHOSIS AND THE ROLE OF AFFECTIVE IMPAIRMENTS IN THE AETIOLOGY OF THOUGHT INSERTION 119 1. AFFECTIVE STATES AND TWO STORIES ABOUT THE FORMATION OF DELUSIONS 120 2. THOUGHT INSERTION: MAIN SUBJECTIVE FEATURES 124 3. IMPAIRMENTS IN AFFECTIVITY AND THE FORMATION OF DELUSIONS 125 4. AFFECTIVE ROUTES TO DELUSIONS: THOUGHT INSERTION AS THOUGHT AVERSION 128 5. THE THOUGHT AVERSION HYPOTHESIS UNDER EXAMINATION 131 6. THE PLACE OF EGODYSTONIC STATES IN THE AETIOLOGY OF THOUGHT INSERTION: A PROPOSAL 134 7. EXPLORING A THEORETICAL INTEGRATION 141 8. CONCLUDING REMARKS 142 REFERENCES 144 PSYCHOSIS AND THE SUBJECTIVITY OF PHENOMENAL CONSCIOUSNESS 148 1. INTRODUCTION 149 2. MINENESS AND SELF-CONSCIOUSNESS: MAPPING THE DEBATE 149 2. THE SELF-PRESENTATIONAL VIEW OF CONSCIOUSNESS 152 2.1. FROM CONSCIOUSNESS OF EXPERIENCES TO SELF-CONSCIOUSNESS 152 2.2. FROM A SENSE OF MINENESS TO SELF-CONSCIOUSNESS 153 2.2.1. PHENOMENAL CHARACTER 154 2.2.2. DOUBLE STRUCTURE OF CONSCIOUS EXPERIENCES 155 2.2.3. SUBJECTIVE CHARACTER 156 3. THE SPV AND THE CHALLENGE FROM PSYCHOPATHOLOGY 157 3.1. THOUGHT INSERTION AS A DISRUPTION IN THE SENSE OF MENTAL AGENCY 159 3.2. STREAM OF CONSCIOUSNESS AND SENSE OF MINENESS VIA LOCATION 163 4. CONCLUDING REMARKS 167 REFERENCES 169 MAKING SENSE OF THE ADAPTIVE ROLE OF PSYCHOTIC DELUSIONS 173 3 1. DELUSIONS AS MALADAPTIVE MISBELIEFS 174 2. MAPPING THE DEBATE: MODES OF ADAPTIVENESS AND THE TYPES TO DELUSIONS 176 2.1. MODES OF ADAPTIVENESS OF BELIEFS 177 2.1.1. PSYCHOLOGICAL ADAPTIVENESS 177 2.1.1. BIOLOGICAL ADAPTIVENESS 177 2.2. TWO TYPES OF DELUSIONS 178 2.2.1. MOTIVATED DELUSIONS 178 2.2.2. DEFICIT-BASED DELUSIONS 179 2.2.3. MOTIVATED OR DEFICIT-BASED DELUSIONS? 180 3. DOXASTIC DEFICITS AND THE ADAPTIVENESS OF DELUSIONS 182 4. MAKING SENSE OF THE ADAPTIVE ROLE OF DELUSIONS: A PROPOSAL 184 4.1. THE CONTEXT OF DELUSIONS 184 4.1.1. PRE-DELUSIONAL AFFECTIVITY AND THE FORMATION OF DELUSIONAL BELIEFS 185 4.1.2. DELUSIONAL MOODS AND DELUSIONAL BELIEFS 187 4.2. DELUSIONS AS BIOLOGICALLY ADAPTIVE MISBELIEFS 188 5. CONCLUDING REMARKS 195 REFERENCES 197 CONCLUDING REMARKS 202 4 Abstract The University of Manchester Pablo Andrés López Silva Doctor of Philosophy On the Architecture of Psychosis: Thoughts and Delusions of Thought Insertion In its many manifestations, psychosis leads to a number of clinical and philosophical debates. Despite their practical and conceptual importance, a number of these debates remain unresolved. Appealing to the connection between phenomenological descriptions, empirical evidence, and philosophical analysis, this dissertation is devoted to the careful examination of five of the main debates surrounding the occurrence of delusions of thought insertion, one of the most complex and severe symptoms of psychotic disorders. Roughly speaking, patients suffering from thought insertion report that external agents of different nature have placed certain thoughts into the patients’ minds. The introduction to this compilation clarifies the main distinctions underlying the general discussions about delusions and the specific debates surrounding thought insertion. The introduction is followed by a collection of five papers. The first paper tries to explain the way in which subjects self-attribute their own conscious thoughts in terms of agency. The second paper, assuming that delusions are a type of belief, engages with the discussion about the role that experiential abnormalities have in the process of formation of the delusional belief of thought insertion. The third paper examines the role that affective impairments might have in the process of production of thought insertion, an issue that is often overlooked by current dominant approaches to thought insertion. Taken altogether, the first three papers of this collection offer a novel understanding of the aetiology and architecture of thought insertion. The fourth paper examines a much larger discussion that overlaps with the debate about the subjective features of thought insertion. It is argued that cases of thought insertion – in conjunction with other psychotic phenomena – undermine the current self-presenting theory of consciousness, a theory meant to explain the most fundamental subjective character of conscious experiences. Finally, the fifth paper of the compilation engages with a more general discussion about the nature and role that delusions might play in a subject’s life. It is argued against the dominant view that there are good reasons to characterize a certain type of monothematic delusions (including some cases of thought insertion) as biologically adaptive. 5 Declaration No portion of the work referred to in the thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning. 6 Copyright Statement i. The author of this thesis (including any appendices and/or schedules to this thesis) owns certain copyright or related rights in it (the “Copyright”) and s/he has given The University of Manchester certain rights to use such Copyright, including for administrative purposes. ii. Copies of this thesis, either in full or in extracts and whether in hard or electronic copy, may be made only in accordance with the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has from time to time. This page must form part of any such copies made. iii. The ownership of certain Copyright, patents, designs, trade marks and other intellectual property (the “Intellectual Property”) and any reproductions of copyright works in the thesis, for example graphs and tables (“Reproductions”), which may be described in this thesis, may not be owned by the author and may be owned by third parties. Such Intellectual Property and Reproductions cannot and must not be made available for use without the prior written permission of the owner(s) of the relevant Intellectual Property and/or Reproductions. iv. Further information on the conditions under which disclosure, publication and commercialisation of this thesis, the Copyright and any Intellectual Property and/or Reproductions described in it may take place is available in the University IP Policy (see http://documents.manchester.ac.uk/DocuInfo.aspx?DocID=487), in any relevant Thesis restriction declarations deposited in the University Library, The University Library’s regulations (see http://www.manchester.ac.uk/library/aboutus/regulations) and in The University’s policy on Presentation of Theses. 7 Acknowledgments There are certain things in life that cannot be done without the support of others; this dissertation is a clear example of that. Although it has been the most intense period of my life, the indelible support of many people made of this journey a pleasant and unforgettable experience. I thank God for not giving up on me, and for giving me the strength to keep going during all these years. I shall also express my deepest gratitude to the persons to whom I own everything, my parents. There are no words to express how much I love and admire you. This dissertation is not only the result of my individual work, but also an extension of everything they have done for me over all these years; it is also the product of all their sacrifices.
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