– Pete Wilson and Rajan Nathan, 18 August 2020
Our knowledge of the brain and its relationship with the mind and mental illness has been revolutionised over the last 30 years. These advances have been driven by developments in brain imaging, and the philosophical, cognitive and computational neurosciences. However, psychiatric and psychological clinical practice on the wards and in the clinics relating to psychosis has not been updated to reflect this. There needs to be a stronger and more immediate connection between mental health research and clinical practice. Two areas of mental health practice which require updating urgently are our psychopathological and diagnostic systems.
In considering advances in mental health research we could easily focus on those that have taken place in the fields of imaging or genetics as excellent exemplars of huge forward progress. But this is beyond the scope of this short blog, in which I wish to focus on the potential contribution to psychosis psychopathology of the phenomenological approach,and notions around explanatory cognitive models and predictive processing. The predictive processing approach has provided a model of understanding in terms of describing how changes in the brain’s inferential processes might result in psychiatric symptoms (Corlett and Fletcher, 2014; Friston et al, 2014; Adams et al, 2015; Huys et al, 2016). The brain and mind are such complex entities that multiple levels of explanation are required; from the genetic, to the molecular, to the cognitive, to the phenomenological (Griffin and Fletcher ,2017; Humpston, 2017). It is the connection of these levels which is key to improving our understanding (Griffin and Fletcher, 2017) and it might be that it is the alliance of a phenomenological approach with cognitive models which enables this. These approaches may at first not appear to be natural bedfellows; but we suggest it is the connecting of subjective patient experience and cognitive neuroscience which may well have a pivotal role in facilitating the clinical application of recent research advances via an update to psychopathology. It has been suggested that a phenomenological approach may be able to guide biological research (Cuesta and Peralta, 2008; Schultze – Lutter et al, 2016; Upthegrove et al, 2016). We tentatively suggest that it may be the integration of a phenomenological approach with cognitive models (aberrant salience, source monitoring and lower level notions of predictive processing) in clinical settings which is able to make this process even more fruitful. It is also a possibility that this may be a two-way relationship, with insights from cognitive and computational neuroscience being able to guide the phenomenology and help define the psychopathology. (Such a reversal of process has been discussed in relation to the National Institute for Health’s Research Domain Criteria (Cuthbert, 2015)). We wonder whether it may be through a subjective phenomenological approach that we are able to access a more valid understanding of the nature of mental illness than our current system of psychopathology and diagnosis allow. That said, we are certainly not anti-psychiatry or anti-diagnosis, and recognise the utility of diagnosis as a short form index to conditions which are a hypothetical construct (Kendler, 2016). This notwithstanding, we suggest any medical system used in a hospital requires updates and advancement. Indeed, the symptom-based system of psychopathology we use has not been significantly updated since the late 19th century.
Phenomenological psychopathology is not a new field, but is enjoying a renewed prominence in academic thinking. Karl Jaspers (1883-1969), both a philosopher and psychiatrist, is considered to be the father of the phenomenological method in psychopathology (Telles Correia et al, 2018). The recent publication of The Oxford Handbook of Phenomenological Psychopathology is testament to a renewed enthusiasm for the approach – something many of the contributors have helped to drive over the past 20 years (Stanghellini (ed) et al, 2019). We consider that the use of this method in a clinical context is key to ascertaining a valid understanding of our patients’ experience. This will allow us to account for heterogeneity and thus tailor treatment individually. Furthermore, it will allow a more advanced formulation, with our patients feeling better understood. It may also provide those looking for biological correlates of mental illness with an updated focus and framework through more accurately describing what it is our patients are actually experiencing.
At the same time as the rising interest in the phenomenological psychiatric method, in a separate but parallel domain, the fields of computational psychiatry and cognitive neuroscience have developed promising frameworks for conceptualising mental illness in the brain and mind. For the strengths of cognitive science to be maximised we consider it needs a close relationship with phenomenological psychiatry. There does seem to be an increasing recognition that mental health practice needs to move towards an approach based on brain and mind process, rather than relying on the current symptom based model. This is exemplified by the Royal College of Psychiatrist’s ‘Neuroscience in training’ project. The suggestion that we should perhaps be ‘neuropsychiatrologists,’ rather than psychiatrists, is apt (Baillet, 2019). Cognitive models and predictive process frameworks can perhaps be used to update psychopathology as practiced on the shop floor. It could be combined with a phenomenological approach to enhance the subjectivity and validity of diagnosis. It will rely on a narrative of brain and mind mechanism, rather than the symptom-based narrative we use currently. It may enable a better understanding of our patients’ experiences and problems, a clearer explanation of why they have become ill, a reliable prognosis, and a personalised rationale for proposed treatment (Bullmore, Fletcher and Jones, 2009).
Advances in cognitive neuroscientific accounts have reached a stage which now means we can ask our patients about process rather than symptoms alone. For example, we could move to towards diagnosing a source monitoring defect rather than auditory hallucinations. This is the first step towards basing our diagnoses on brain and mind mechanism rather than symptoms alone. It will bring us to parity with other medical specialties. A new phenomenological psychopathology will need to have mechanism at its core.
Future mental health care service provision needs to be arranged in close partnership with patient centred phenomenological, genetic, neuroscientific, cognitive and computational approaches. A new psychopathology and diagnostic system must have the identification of mind and brain process at its centre. Our vision is that this will involve a greater subjective understanding of the patient rather than being reductionist. It will be a phenomenological, cognitive and computational psychopathology. A move to a mind and brain process system rather than a symptom-based system will be just as relevant to clinical psychology as it will to psychiatry (Bullmore, Fletcher and Jones, 2009). The different levels of explanation required to develop a new model based on process and subjective patient experience will need input from researchers and clinicians from a wide range of disciplines. Multi-disciplinary teams such as those at Hearing Voice in Durham and the Institute of Mental Health at the University of Birmingham are models of inclusivity to aspire to. Philosopher, geneticist, molecular biologist, psychiatrist and psychologist will rub shoulders to put mental health care back on parity with other branches of medicine.
References
Adams RA, Huys QJM, Roisier JP, 2015. Computational Psychiatry: towards a mathematically informed understanding of mental illness. Journal of Neurology, Neurosurgery and Psychiatry. 87:53–63.
Baillet, S, 2019. A predictive machinery: network dynamics of brain perceptual inferences. McGill University, Canada. Lecture delivered at the launch of the Institute for Mental Health, University of Birmingham.
Bullmore E, Fletcher P, Jones P, 2009. Why psychiatry can’t afford to be neurophobic. The British Journal of Psychiatry. 194, 293–295. doi: 10.1192/bjp.bp.108.058479
Corlett PR, Fletcher PC, 2014. Computational psychiatry: A Rosetta stone linking the brain to mental illness. Lancet Psychiatry. 2014; 1(5):399–402.
Cuesta M and Peralta V, 2008. Current Psychopathological Issues in Psychosis: Towards a Phenome-wide ScanningApproach. Schizophrenia Bulletin. vol. 34 no. 4 pp. 587–590.
Cuthbert B, 2015. Research Domain Criteria: toward future psychiatric nosologies. Dialogues in Clinical Neuroscience. Vol 17. No. 1.
Friston KJ, Stephan KE, Montague R, Dolan RJ, 2014. Computational psychiatry: the brain as a phantastic organ. Lancet Psychiatry. 1(2):148–58.
Griffin J. and Fletcher P, 2017. Predictive Processing, Source Monitoring, and Psychosis. Annual Review of Clinical Psychology. 08;13:265-289.
Humpston C, 2017. Predictive Processing and Source Monitoring in the Psychosis Continuum. (PhD) Cardiff University.
Huys QJM, Maia TV, Frank MJ, 2016. Computational psychiatry as a bridge from neuroscience to clinical applications. Nature Neuroscience. 19:404–13.
Kendler K, 2017. DSM disorders and their criteria: how should they inter-relate? Psychological Medicine 47, 2054–2060. doi:10.1017/S0033291717000678
Schultze-Lutter, Debbané, Theodoridou, Wood, Raballo, Michel, Schmidt, Kindler, Ruhrmann and Uhlhaas, 2016. Revisiting the basic symptom concept: toward translating risk symptoms for psychosis into neurobiological targets. Frontiers in psychiatry. doi: 10.3389/fpsyt.2016.00009
Stanghellini G, Broome M, Fernandez A, Fusar-Poli P, Raballo A, Rosfort R.(eds.) 2019. The Oxford textbook of phenomenological psychopathology. Oxford: Oxford University Press.
Telles-Correia, Saraiva, Gama Marques, 2018. Jaspers’ Phenomenology. Folia Medica. DOI: 10.2478/folmed-2018-0009
Upthegrove R, Broome MR, Caldwell K, Ives J, Oyebode F, Wood SJ, 2016. Understanding auditory verbal hallucinations: a systematic review of current evidence. Acta Psychiatrica Scandinavica. 133: 352–367 DOI: 10.1111/acps.12531
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