Philosophy, Psychiatry, & Psychology

A team of professionals considers whether a patient in her early 50s is developing Alzheimer’s. The patient is not experiencing the memory symptoms typical of that disease, with so far a few years of sporadic (albeit marked) attentional lapses as the predominant cognitive complaint. Her most dramatic symptom is her impression that two versions of her husband live with her. One is her real husband, the other a “fake.” There is no elaborated story about who the fake is or why he is there, and there is little in the way of behavior (other than verbal attestations to the difference) consistent with the idea. To the patient, there is a vague sense that her husband doesn’t belong in the house, but no clearly articulated notion that he is an imposter or replacement.

In a certain kind of diagnostic mode one is supposed to take evidential items and place them on the scales of a differential. Insidious onset of a new cognitive disorder, with attentional features: the probability of Alzheimer’s goes up. Absence of a clear amnestic impairment: the probability goes down. Presence of a neuropsychiatric symptom: probability goes up. Absence of atrophy on the MRI: probability goes down... For the sake of this example, we will say that the neurologists conclude the patient has Alzheimer’s. There is a question about whether her husband-related symptom rises to the intensity of a delusion, and a further question about whether it is an instance of the Capgras delusion. But diagnostically those questions take a back seat. The presence of a neuropsychiatric symptom in the vicinity of a Capgras delusion (the ideas about her «fake» husband may not be a delusion proper, but they are more than a little Capgrassy) is enough to put weight on the «organic disease» side of the scale.

In this example then, the phenomenologically inclined psychologist has scope to become what we might call distracted from the diagnostic issue at hand. Does it really matter that the symptom does not have all the hallmarks of a “delusion proper”? Are the phenomenological questions we can ask about the symptom, (the precise nature and strength of an idea, or whether it is in fact a belief), however valuable in the service of empathy building, really diagnostically relevant?

I start with this example to highlight a bald sociological fact: to a certain species of clinician (not me I hasten to add), details of cognition and phenomenology are little more than a sort of self-indulgent hair splitting when taken beyond the information that yields a diagnosis. Especially in the realm of neurocognitive disorders, where brain scans and other biomarkers are also likely to be weighed on the evidential scale. In other areas of psychiatry, less can be wrought from scans, and more has to be garnered from (the more charitable [End Page 21] reading) or read into (the less charitable reading) fine distinctions of subjective experiences.

Humpston’s article elucidating an over-arching category of ontologically impossible experiences turns this notion on its head. Here it is the quantitative weighing up of supposedly countable symptoms that could be viewed as a distraction.

Ontologically impossible experiences are those particular psychotic symptoms having to do with breaches in our self experience. Thought insertion and somatic passivity are named, but clearly other of Schneider’s first rank symptoms (thought broadcasting; though withdrawal) also fit the bill. It is not just the fully fledged versions of these experiences (their “endpoints”) that concern Humptson, but also the subtle early shifts in consciousness that mark their earliest manifestations.

Such experiences are those that—given our ordinary western conceptions about the boundedness of the self—stand at odds with beliefs most people hold about what could possibly pertain. They contradict how most (Western) people imagine themselves. It is in this particular contradiction (even paradox) that their diagnostic value lies. The radical doubt about the Cartesian certainty (the taking for granted of which is pathognomonic for one understanding of sanity) makes these experiences more dramatic, more sinister than the more commonly identified symptoms of delusions and auditory hallucinations. Humpston is concerned to explain what it means...