Critical Neuroscience-Neurophenomenology in Psychiatry by Laurence Kirmayer, MD

clinical neurophenomenology, disease classification, history of neurophenomenology, medicine, psychiatry, psychology, symptom reports

Here is a thought provoking lecture on YouTube which investigates psychiatry’s problematic foundations, especially in terms of the influence of culture,  individual differences, and neurodiversity.

http://www.youtube.com/watch?v=PsubfDIKgUw Laurence Kirmayer is an MD at McGill University, and he has a lot to say about using clinical neurophenomenology to explore some very murky but important issues in psychiatry.  There really are problems that make psychiatry different from the rest of medicine, because however necessary the reductionistic-biological medical model nearly ubiquitous everywhere else may be, it is not sufficient. I’m very glad Kirmayer is bringing up Daniel Dennett and his work on heterophenomenological methods in the clinical context as well, not because it’s the end-all be-all, but because it orients what have historically been difficult and controversial debates  in an accessible, easy to read, reasonably pragmatic way. He is also doing good work in looking at how psychiatry gets it’s norms, methods, and foundational orientations, prompting him to call for phenomenological investigations in psychiatry. What a timely effort! I can’t help but feel the DSM-V was panned before it was published in 2013 (and not just by angry people with Asperger’s or Scientologists) because this phase of psychiatry may be running out of steam. The mapping between biological mechanisms to the myriad ways individual people in various cultures live out their emotional pain and existential struggles isn’t good enough.  The ontology or foundational ideas about a psychiatric patient must reference existential reality: the meaning of embodiment and how one’s experience brings forth a lived world, while the ontology of neuroscience is based on genes, proteins, signals, action potentials, circuits, modules, information-processing, and maybe even dynamical systems. Current psychiatry seems to me to be inadequately addressing the foundational problem of how to map these domains. All the genome-wide association studies, connectome diagrams, and brain imaging data in the world aren’t enough to create diagnostic categories that cluster the lived meaning, experiences and embodiment of similar bipolar or schizophrenic patients together, and that of dissimilar patients apart. There really is alot of applied work needing to be done on how to model the cognition of patients whose disorders manifest as disturbances of body cognition or existential crises (here’s my version, dealing with heartbeat perception). Moreover, foundational investigations into the ontology of psychiatry may very well provide a needed stimulus to get psychiatry out of it’s current funk betwixt and between medical humanism as a healing art, and bio-reductionistic techno-medicine. Overall I am convinced clinical neurophenomenology is a vital and largely new area, despite the pioneering efforts of the neuropsychiatrist Erwin Straus and the more recent work of neurologists such as  Oliver Sacks and Antonio Damasio. The lodestar of clinical neurophenomenology seems to me to be Varela’s idea of a mutual constraining and mapping between data from lived, embodied phenomenology and theories based on cognition and neuroscience. There is a more about Kirmayer at http://www.mcgill.ca/trauma-globalhealth/people/canada/kirmayer/

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Is pain where you feel it in the body, or in the brain? Neurophenomenology and the spatial aspect of nociception

body knowledge, clinical neurophenomenology, embodiment, interoception, introspection, introspective accuracy, medicine, pain, physiology, symptom report accuracy, symptom reports, visceral perception

Pain is interesting, salient, mysterious. It may feel like it is in one specific place in or on the body. It may feel diffuse, with gradations, or it may seem referred from one area to another. What is happening in the brain and in the body as these spatial aspects of pain are experienced? How much of the causation of pain occurs where we feel it, and how much occurs in the brain? Below is a series of probes and thinking aloud about where pain is, with speculations to stimulate my thinking and yours.  I’m not a “pain expert”, nor a bodyworker that heals clients, nor a physiologist with a specialization in nociception, but a cognitive scientist, with clinical psychology training, interested in body phenomenology and the brain.  Please do post this essay to Facebook, share it, critique, respond, and comment (and it would be helpful to know if your background is in philosophy, neuroscience, bodywork, psychology, medicine, a student wanting to enter one of these or another field, etc). Pain should be looked at from multiple angles, with theoretical problems emphasized alongside clinical praxis, and with reductionistic accounts from neurophysiology juxtaposed against descriptions of the embodied phenomenology and existential structures.  As I have mentioned elsewhere, it is still early in the history of neurophenomenology…let a thousand flowers bloom when looking at pain. We need data, observations, insights and theories from both the experience side as well as the brain side. Francisco Varela aptly described how phenomenology and cognitive neuroscience should relate:

“The key point here is that by emphasizing a codetermination of both accounts one can explore the bridges, challenges, insights, and contradications between them. Both domains of phenomena have equal status in demanding full attention and respect for their specificity.”

We all know what pain is phenomenologically, what it feels like, but how to define it? The International Association for the Study of Pain offers this definition: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” Of particular interest to neurophenomenology and embodied cognitive science is their claim that “activity induced in the nociceptors and nociceptive pathways by a noxious stimulus is not pain, which is always a psychological state.” Good that they do not try to reduce the experience of pain to the strictly physiological dimension, but I wonder how Merleau-Ponty, with his non-dualistic ontology of the flesh would have responded. Pain seems to transgress the border of mind and body categories, does it not? I am slowly biting off chucks of the work on pain at the Stanford Encyclopedia of Philosophy. Lots of provocative angles, including this one:

“there appear to be reasons both for thinking that pains (along with other similar bodily sensations) are physical objects or conditions that we perceive in body parts, and for thinking that they are not. This paradox is one of the main reasons why philosophers are especially interested in pain.”

Right now I am particularly interested in the spatial aspect of where pain seems to be, what I might label the spatial phenomenology of nociception. When I introspect on aching parts of my feet, it seems as if the pain occupies a volume of space. Using manual pressure I can find places on my feel that are not sore, right next to areas that are slightly sore, which are in turn near focal areas of highest pain. It seems as if the pain is locatable “down there” in my body, and yet what we know about the nociceptive neural networks suggests the phenomenology is produced by complex interactions between flesh, nearby peripheral nerves, the central nervous system, and neurodynamics in the latter especially. A way of probing this this would be to examine the idea that the pain experience is the experiential correlate of bodily harm, a sort of map relating sensations to a corresponding nerve activated by damage to tissue. So, is the place in my body where I feel pain just the same as where the damage or strain is? Or, Is pain caused by pain-receptive nerves registering what is happening around them, via hormonal and electrical signals? Or is pain actually the nerve itself being “trapped” or damaged, yet in a volume of undamaged tissue one can feel hurts? Could the seeming volume of experienced pain-space be a partial illusion, produced by cognizing the tissue damage as some place near or overlapping with yet not spatially identical to where the “actual” damage is, in other words a case of existential-physiological discrepancy? One scenario could be, roughly, that pain “is” or “is made of” nerves getting signals about damage to tissue; another would be that pain “is” the nerves themselves being damaged or sustaining stress or injury. Maybe pain involves both? Maybe some pain is one, or the other? In terms of remembering how my heel pain started, it’s not so easy, but I love to walk an hour or two a day, and have done so for many years. I recall more than ten years ago playing football in the park, wearing what must have been the wrong sort of shoes, and upon waking the next day, having pretty serious pain in my heel. Here are some graphics that, intuitively, seem to map on to the areas where I perceive the pain to be most focal:

from bestfootdoc.com

from bestfootdoc.com

from setup.tristatehand.com

from setup.tristatehand.com

from plantar-fasciitis-elrofeet.com

from plantar-fasciitis-elrofeet.com

If I palpate my heel, I become aware of a phenomenologically complex, rich blend of pleasure and pain. I crave the sensation of pressure there, but it can be an endurance test when it happens. Does the sensation of pressure that I want reflect some body knowledge, some intuitive sense of what intervention will help my body heal? How could this be verified or falsified? It is not easy to describe the raw qualia of pain, actually. I can describe it as achey and moderately distressing when I walk around, and sharp upon palpating. Direct and forceful pressure on the heel area will make me wince, catch my breath, want to gasp or make sounds of pain/pleasure, and in general puts me in a state of heightened activation. But I love it when I can get a therapist to squeeze on it, producing what I call “pain-pleasure”:

from indyheelpaincenter.com

from indyheelpaincenter.com

This diagram below helps me map the sensations to the neuroanatomy. We need to do more of this sort of thing. This kind of representation seems to me a new area for clinical neurophenomenological research (indeed, clinical neurophenomenology in general needs much more work, searching for those terms just leads back to my site, but see the Case History section in Sean Gallagher’s How the Body Shapes the Mind).

from reconstructivefootcaredoc.com

from reconstructivefootcaredoc.com

What is producing the pain-qualia, the particular feeling? Without going too far into varying differential diagnosis, it is commonly attributed to plantar fasciitis.  There the pain would be due to nociceptive nerve fibers activated by damage to the tough, fibrous fascia that attach to the calcaneus (heel bone) being strained, or sustaining small ripped areas, and/or local nerves being compressed or trapped. A 2012 article in Lower Extremity Review states that “evidence suggests plantar fasciitis is a noninflammatory degenerative condition in the plantar fascia caused by repetitive microtears at the medial tubercle of the calcaneus.” There are quite a few opinions out there about the role of bony calcium buildups, strain from leg muscles, specific trapped nerves and so forth, and it would be interesting to find out how different aspects of reported pain qualia map on to these. Below you can see the sheetlike fascia fiber, the posterior tibial nerve, and it’s branches that enable local sensations:

from aafp.org

from aafp.org

Next: fascia and the innervation of the heel, from below:

from mollyjudge.com

from mollyjudge.com

Another view of the heel and innervation:

from mollyjudge.com

from mollyjudge.com

Below is a representation of the fascia under the skin:

from drwolgin.com

from drwolgin.com

There is a very graphic,under the skin, maybe not SFW surgeon’s-eye perspective on these structures available here. Heel pain turns out to be very common, and is evidently one of the most frequently reported medical issues. Searching online for heel pain mapping brings up a representation purportedly of 2666 patients describing where they feel heel pain: heel pain mapping I can’t find where this comes from originally and can’t speak to the methodology, rigor, or quality of the study, but the supposed data are interesting, as is the implicit idea of spatial qualia mapping:  the correspondence of experienced pain to a volume of space in the body. It also quite well represents where the pain is that I feel. The focal area seems to be where the fascia fibers attach to the calcaneus, an area that bears alot of weight, does alot of work, and is prone to overuse. So, where is the pain? Is it in the heel or the brain? Is it in the tissue, the nerve, or both? Is there a volume of flesh that contains the pain? I am going to have to think about these more, and welcome your input. What about the central nervous system that processes nociceptive afferents coming from the body? A good model of pain neurophenomenology should involve a number of cortical and subcortical areas that comprise the nociceptive neural network: -primary somatosensory cortex (S1) and secondary somatosensory cortex (S2): -insula -anterior cingulate cortex (ACC) -prefrontal cortex (PFC) -thalamus Here are some representations of the pain pathways, or the nociceptive neural network:

from Moisset and Bouhassira (2007) "Brain imaging of neuropathic pain"

from Moisset and Bouhassira (2007)

Moisett el (2009)

Moisett el (2009)

 

from Tracey and Mantyh (2012)

from Tracey and Mantyh (2012)

Broadly speaking, pain seems to be generated by tissue damage, inflammation, compromising the integrity of tissue, stress on localized regions, and so forth being processed by peripheral afferent pain pathways in the body, then phylogenetically ancient subcortical structures, and then the aforementioned cortical regions or nociceptive neural network.  As I have mentioned many times, making a robust account of how various regions of the brain communicate such that a person experiences qualia or sensory phenomenology will need to reference neurodynamics, which integrates ideas from the physics of self-organization, complexity, chaos and non-linear dynamics into biology.  It is gradually becoming apparent to many if not most workers in the cognitive neurosciences that there are a host of mechanisms regions of the brain use to send signals, and many of these are as time dependent as space dependent. Michael Cohen puts it thusly: “The way we as cognitive neuroscientists typically link dynamics of the brain to dynamics of behavior is by correlating increases or decreases of some measure of brain activity with the cognitive or emotional state we hope the subject is experiencing at the time. The primary dependent measure in the majority of these studies is whether the average amount of activity – measured through spiking, event-related-potential or -field component amplitude, blood flow response, light scatter, etc. – in a region of the brain goes up or down. In this approach, the aim is to reduce this complex and enigmatic neural information processing system to two dimensions: Space and activation (up/down). The implicit assumption is that cognitive processes can be localized to specific regions of the brain, can be measured by an increase in average activity levels, and in different experimental conditions, either operate or do not. It is naïve to think that these two dimensions are sufficient for characterizing neurocognitive function. The range and flexibility of cognitive, emotional, perceptual, and other mental processes is huge, and the scale of typical functional localization claims – on the order of several cubic centimeters – is large compared to the number of cells with unique physiological, neurochemical, morphological, and connectional properties contained in each MRI voxel. Further, there are no one-to-one mappings between cognitive processes and brain regions: Different cognitive processes can activate the same brain region, and activation of several brain regions can be associated with single cognitive processes. In the analogy of Plato’s cave, our current approach to understanding the biological foundations of cognition is like looking at shadows cast on a region of the wall of the cave without observing how they change dynamically over time.” But what of the original question? Is pain where you feel it in the body, or in the brain? It seems to me the answer must be both.  The experience of pain being localized there or a little on the left is a product of local tissue signals and receptor activation, which produces peripheral afferent nerve firing, which gets processed by spinal afferent neurodynamics, brainstem activation, thalamic gating, and then somatosensory, insular, anterior cingulated, and prefrontal cortical regions. Yet the real model of pain, one that invokes mechanisms and causes, remains elusive. And a good model of pain must account for the possibility of pain without suffering as well! For now, what I can offer are probes to get us speculating, thinking critically, and eventually building a clinical neurophenomenology of pain. If that interests you, by all means get involved.

questions about information-processing theories of body-knowledge

cognitive science, embodiment, introspection, symptom reports

Cognitive science explains mind and brain in terms of computation, information-processing, and representationalism: the ability of a cognitive system to change internal microstructure so as to correspond with important features of the internal or external world. One could do worse than to sum up the cognitivist model of the mind as “computations over representations”, in which features of the world or body are coded by the brain as symbols.

Whatever merits this “cognitivist” research program may have for models of syntactical production, the consolidation of short-term memories into long-term, the recognition of familiar faces, logical problem-solving, and other phenomena, I suspect that critical aspects of how people have knowledge of their bodies are not adequately accounted for by cognitivist approaches. I maintain that a careful analysis of the evidence reveals cognitive science has a flawed approach to modeling how well people know what is happening inside their bodies, and what mental and biological processes underlay this knowledge.

There are many aspects of psychological life that have never been the focus of cognitive science, and this absence is at it’s foundation the Cartesian rift at the heart of objective models that depict mind as machine. People experience a world of meaning framed by temporality and grounded in the lived body, but cognitive science focuses on a subpersonal realm of symbols, algorithms, information processing, representation, where mind is reduced to computation. To the extent that this approach yields results, it should be pursued, but cognition outstrips what cognitivism can model. There are aspects of cognition that are characterized by the existential questions, embodied experience, consciousness, meaning, and other phenomena, but it is precisely these that objectivistic, Cartesian cognitive science has not, for the most part, tried to explain. The difference is that of between worlds, like the gap between music grasped as experienced and meaningful, compared to music understood as a system that can be analyzed through abstract system-centered objectivistic modeling. It is true that science is typically understood in the latter terms, but neurophenomenology aims at a dialog between psychological life as experienced and cognition understood as a mechanism produced by te brain. There is not an immediate move toward reduction nor a premature assumption that embodied experience can be automatically modeled as a byproduct of systems.

In everyday life, and especially in conditions of sickness or disease, people notice aspects, qualities, and states of their bodies, and seek to get information about and from their bodies. Getting information about body-state can involve perception of a symptom, focused attention or introspection toward specific body regions or parts, remembering the way one’s body felt previously and comparing this to a current assessment, attempting to verbally express feelings about the way one’s body seems, paying close attention to a body part that is usually indistinct or in the background but suddenly is painful, and many other similar activities. Consider the following examples:

• a subject in a clinical trial of a medical device is asked whether or not they notice anything unusual or different about the way their body feels, and if so, to rate how much on a numeric scale;

• a person taking psychiatric medication for depression tells their psychiatrist about adverse side effects, such as a decline in libido, and an inability to grieve the loss of a loved one while at a funeral;

• someone who is drinking alcohol may calibrate their intake based on the memory of nausea from previous episodes of over-consumption;

• an obese woman is reported by American media to have been shocked upon finding she was in labor and on the verge of giving birth, having no previous knowledge of her pregnancy.

• a person who is being massaged, when asked to describe the sensation, reports a mixture of significant pleasure and mild pain when pressure is applied to very specific regions of their upper-back

In these and in similar cases, individuals involved are sensing, perceiving, remembering, and judging about their symptoms, body states, feelings, and sensations, and in some examples, reporting their experience to others. These are cognitive phenomena, but can ideas derived from symbolic logic and representationalist epistemology suffice to explain them? I would argue that there are a number of open questions about the utility of information-processing theories of body-knowledge.

Are the introspective reports, assessments, and statements generated by people about their body-state generally accurate, or not? What mechanisms account for the accuracy, or lack thereof?

To what extent do legacy concepts from cognitive science or information-processing models help or hinder the development of an understanding of how people access information and gain knowledge about their bodies?

How are we to understand the meaning(s) of the term “information” used to explain how and how well people know their own mental and physiological states? What is the relationship of “information” in the sense of physiological or biological systems to consciously reportable sensation, such that a person is getting information about their body state?

Are there many kinds of “information” involved in these models of internal state perception or “body cognition” found in clinical neurology, medicine, experimental psychology, and theoretical cognitive neuroscience? Or is there but one type of “information”, with different qualities or aspects that are described or measured in different ways?

How accurate are people at knowing what is happening inside their bodies?

cognitive science, embodiment, interoception, introspection, neurophenomenology, symptom reports, visceral perception

Were people utterly inaccurate at judging their body state and reporting on it, clinical medicine would be deprived of a critical tool.  Evidence has accumulated that in certain circumstances, some people are evidently able to access information about the physiological processes inside of their bodies, and to report on it.  Experiments seem to demonstrate that some people are relatively accurate perceivers of symptoms or physiological state (Jones and Hollandsworth, 1981), (Adam, 1998), and that subjects can be ranked into good or poor estimators of internal state; for instance, with perceivers of heart rate (Schandry, 1981).

When we are actually aware of specific processes inside our bodies and can state this verbally, it would seem that in some fashion unconscious information (or unconscious “information”) has generated or has been transformed into knowledge. However, there is contradictory evidence about accuracy of symptom perception: how good people really are at perceiving various physiological states, and how accurate symptom-reports or other verbal-reports actually are. Many studies have yielded data consistent with the idea that people are not particularly good at accurately reporting on their symptoms or physiological states (Pennebaker, 1982). It is worth pointing out the assertion that people are generally inaccurate about knowing about physiological processes in their bodies reformulates the principle that humans lack epistemological privilege concerning introspective or verbally reported data. In considering the question: are we are likely to be in error when we report on the contents of what is in our minds, or not, it is critical to appreciate the persuasive interpretation of experiments written up in papers such as “Telling More than We Can Know” by the psychologists Robert Nisbett and Timothy Wilson (1977), which seems to show how introspection-based retroactive judgments can are in error.  This category of research typically features subjects placed in circumstances where their choices are influenced by variables controlled by experimenters, and who give explanations for their choosing that display incorrect “folk psychological” constructions. Nisbett and Wilson’s analysis can properly interpreted as to cast doubt on the ability of people to know the causes of our behavior and “higher order” information-processing, and can be summed up with their statement that people may possess “little ability to report accurately on their cognitive processes” (p. 246).

However, I assert that this valuable critique of retrospective judgments has been improperly extrapolated to support a broad skepticism about introspection, what I shall call the “received view” or the “overly skeptical view”, which I might sum-up as the belief that introspective data should generally be regarded with skepticism. As has been noted by careful researchers on introspection, (Schwitzgebel, 2006), this more general rejection of introspection certainly goes beyond what Nisbett and Wilson argued: while they do indeed assert that the evidence of numerous studies shows people are poor at using verbal report-based introspection to the cognitive process behind our judging and deciding, they do not support a general disdain for introspective data. Rather, they state that instead of arguing that introspective reports should simply be discredited, while people do not have introspective access to the cognitive processes, they do have such access to the contents of their cognitions. For instance, Nisbett and Wilson (pg. 255) state that introspection can yield forms of knowledge: knowledge about cognitive content, as an everyday person:

“…knows what his current sensations are and what almost all psychologists and philosophers would assert to be “knowledge” at least quantitatively superior to that of observers concerning his emotions, evaluations, and plans”

Furthermore, the “received view” that introspective reports are to be generally regarded with suspicion is in tension with the clinical use of patient introspection, as well as the high accuracy ratings sometimes displayed in experiments where subjects are asked to evaluate their own physiology. Therefore, while showing appropriate regard for data suggesting limits on introspective access to cognitive information (indeed I will suggest that models of body-knowledge should account for this data), I will nonetheless highlight certain clinical and experimental data that support the following assertion, which  contradicts the view that introspective data should be generally regarded with skepticism:

There exist cognitive processes that allow people to access internal body-state or physiological information in a way that enables fairly, or even highly, accurate verbal reports.  Insofar as this is true, people evidently have some degree of epistemologically privileged access to internal body state or interoceptive information. This relative privilege allows for knowledge of the body, as distinct from mere beliefs.

However, if this is true, some accounting of to what degree or how true it is, with which mitigating conditions, and with what reference to underlying cognitive and neurophysiological mechanisms would be necessary.  For that matter, even if true, demarcating the explanatory power of this principle relative to data adequately explained by the “received view” or “overly skeptical view” is of critical importance. It may be that only special or rare abilities are at issue here, and that the people who have privileged access to their internal physiological information are outliers.

Verbal report data: psychologists may be skeptical, but clinicians are more practical

clinical neurophenomenology, cognitive science, introspection, medicine, symptom reports

Cognitive neuroscience and psychology needs to account for  verbal report data from people about their body states. In perceptual psychology and psychophysics experiments, in cognitive studies of human problem-solving, in clinical trials of drug efficacy and safety, in phenomenological-psychological investigations into the thematics of body experience, researchers routinely ask subjects or patients to answer questions. This is so common that its significance is perhaps under-appreciated. Science, at least in a narrow sense,  is conventionally understood to be based on objectively observable facts, not subjective opinions. But certain phenomena can not only be observed from the outside, as part of a system, but can also be reported on by people from the inside, as perceived or experiential events.

This regular use of the human self-reporting capacity is more remarkable in the light of intellectual history.  “Orthodox” cognitive science developed in the era of behaviorist dominance, and inherited certain skepticism about the trustworthiness of verbal reports, which are viewed as being sources of data, but not “privileged.” This stance indicates a rejection of older philosophical and psychological traditions that emphasized the use of introspection. Nonetheless, even in the time of behaviorist hegemony, psychologists still asked subjects questions in perception experiments, and clinicians have always used patient assessments to gain insight (Nahmias, 2002). While certain path-breaking cognitive scientists and psychologists explored the nature of introspection, and worked out the circumstances in which verbal reports could be authoritative and true accounts of aspects of cognitive processes (Erickson and Simon, 1991), (Ericsson, Chase, and Simon, 1979), the results of other widely cited experiments have been interpreted to denigrate introspective data, especially that of Nisbett and Wilson’s (1977) “Telling More than we can know” paper. Their research has been interpreted to indicate, for instance, that subjects made demonstrably inaccurate judgments about their underlying mental states because human beings apparently have little or no direct introspective access to the underlying cognitive processes of the mind (pg. 233):

The accuracy of subjective reports is so poor as to suggest that any introspective access that may exist is not sufficient to produce generally correct or reliable reports.”

The interpretation of their data featured assertions that are now influential:  subjects lack  introspective access to the causal relationship between stimuli controlled by the experimenter and the verbal reports they produce. They are unable to accurately report which stimuli affected their responses. Rather, these verbal reports of effects of stimuli are based on unvalidated belief (such as naïve “folk psychological” theories about the causal connections between the stimuli and their response). Furthermore, if the reports on stimulus-response relationships are correct, it is because their naïve theories happen to be correct, and not because introspection gave them any privileged access to information. The upshot can be summarized as: subjects in situations with variables controlled by scientists make introspective judgments about why they behave in a particular manner or think a certain way, they state this explanation verbally to an experimenter, who can show the explanation to be false: (pg. 243)

“In order to test subject ability to report influences on their associative behavior, we had 81 male introductory psychology students memorize a list of word pairs. Some of these word pairs were intended to generate associative processes that would elicit certain target words in a word association task to be performed at a later point in the experiment. For example, subjects memorized the word pair “ocean-moon” with the expectation that when they were later asked to name a detergent, they would be more likely to give the target “Tide” than would subjects who had not previously been exposed to the word pairs….Immediately following the word association task, subjects were asked in open-ended form why they thought they had given each of their responses in the word association task. Despite the fact that nearly all subjects could recall nearly all of the words pairs, subjects almost never mentioned a word pair cue as a reason for giving a particular target response. Instead subjects focused on some distinctive feature of the target (“Tide is the best-known detergent”), some personal meaning of it (“My mother uses tide”), or an affective reaction to it (“I like the Tide box”).

The influence of this research has had the practical effect of renewing suspicions among psychologists and other researchers about introspective data, even if such methods continue to be used (Jack and Roepstorff, 2003) and despite the balanced view of Nisbett and Wilson where introspection has some utility regarding “sensations and/or private facts”, which takes into consideration the longtime use of introspective data as a method in psychology. Cognitive scientists, psychologists, physicians, and others can adopt their pragmatic distinction between the contents of cognition, such as sensations and emotions which can indeed be known and verbally reported, and the underlying causes, the information-processing or cognitive processes, which remain epistemologically inscrutable to introspection.

Yet while clinical medicine often regards introspective data with caution, it nonetheless uses it pragmatically. For instance, the standard neuropsychology text Clinical Neuropsychology (Heilman and Valenstein, 2003) states (pg.5)

at times, patients’ observations of their own mental state may not only be helpful but necessary.”

This implies that it is a standard clinical methodology to use introspective data, and that patients have some useful access to their own minds.

This data-collection method of asking subjects and patients for self-reports is routinely used, according to psychologist Arthur Stone (Stone, 2000) (pg. 297):

“In both clinical practice and in research, the primary method of obtaining information about physical symptomology is through self-reports. Every day, thousands upon thousands of health care providers ask their patients to describe how they are generally feeling and too discuss specific symptoms. Patients present their doctors with panoply of global states (“I feel lousy,” “I am fatigued,” “I don’t feel right”) to very concrete descriptions (“I have a sharp pain in my right knee that is worse on awakening”). Information from these interviews, along with various medical tests, provides the basis for treatment and for the evaluation of its efficacy. In medical research, information of the same sort is obtained with questionnaires and structured interviews. These data-collection methods may provide a more systematic way of gathering physical symptom information, but regardless of the mode of data collection, the information is self-reported. Thus, reports of physical symptoms may be considered the mainstay of medical practice and research”

the legacy of Cartesian “objectivity” makes it hard to understand patient verbal reports

clinical neurophenomenology, embodiment, introspection, medicine, symptom reports

Psychiatrist Allan Beveridge (2002) hones in on a facet of the patient-physician relationship relevant to neurophenomenology: the over-adoption in medicine of the scientific attitude of objectivity towards phenomena. While entirely appropriate in the many research contexts, this may make understanding the personal body-knowledge of the patient more difficult (pg. 101):

In the mental state examination, a standard method of describing the clinical encounter is to contrast the patient’s supposedly ‘subjective’ account with the doctor’s ‘objective’ description. In this model, the doctor is granted a privileged position: the clinician’s perspective is taken to be superior to that of the patient. The doctor’s objective approach is considered neutral, scientific and representing the truth of the matter. In contrast, the patient’s subjective report is regarded as unreliable, distorted and potentially false. The lowly status of the subjective perspective is further emphasized by the frequent use of the accompanying prefix, merely. On reflection, this dichotomy is an extraordinary one. It is held that the doctor is an authority on the patient’s inner experiences. The doctor knows more about how the patient is thinking and feeling than the patient him-/herself

This “scientific” medical stance towards patient subjective reporting is consistent with the Cartesian heritage of the sciences of the mind. The implications, hidden or unexamined commitments should be critically examined if the verbal reports about patient body-states are to be better grasped by science and medicine. To the extent cognitive science, psychology, neuroscience, and medical fields uncritically base their methodologies on unexamined premises, certain problems may appear just due to the very choices of what is considered “data”. The relegation of patient verbal reports to the category of “merely subjective” allows for Cartesian assumptions about cognition to create difficulties at the outset of any research project attempting to model personal knowledge of the body. It may be that the very categories of subject and object, or scientific knowledge vs. subjective or “folk psychological” naïve theories of the body, present foundational problems for understanding how neurophysiological processes relate to verbally reportable knowledge of the body. But as a practical matter, health care professionals must simply cope with patient statements as one more data source (Ersser and Atkins, 2000, pg. 68):

Clinical decisions involve information of a necessary type and quality. Professionals take account of both objective and subjective data during the clinical assessment process to decide on a patient’s health care need and care plan. The difficulty lies in professionals understanding how best to reconcile their objective perspective with that of the patient, when formulating clinical judgments

Before a doctor revives technical training, he or she is a person with experiences of health and sickness. The verbal reports of patients are interpreted by professionals with their own history of embodiment. To what extent does their personal body knowledge consciously or unconsciously affect their clinical intuition about the accuracy of patient verbal reports? Does expert knowledge of the body gained from studying anatomy and physiology allow for better knowledge of one’s own body? Such questions point to our current rather murky understanding of embodied cognition, underscoring the need for models capturing richer, more subtle aspects of experience, cognition, and brain.

symptom verbal reports and existential-physiological discrepancy

clinical neurophenomenology, interoception, introspection, medicine, symptom reports, visceral perception

While the anatomical basis of how nerve projections enable perception of the body is rather well known, physicians confront situations where patient verbal reporting about symptoms does not match models based on neurophysiological mechanisms. For instance, the Merck Manual Medical Library (2009) states:

“Painful stimuli from thoracic organs can produce discomfort      described as pressure, gas, burning, aching, and sometimes sharp pain. Because the sensation is visceral in origin, many patients deny they are having pain and insist it is merely discomfort”

The Mayo Clinic Heart Book (Gersh, 2000) describes the concept of uncomfortable feeling of thumping inside the chest known as palpitations, but does so from the point of view of patients (pg. 38):

“Although the apparent cause of the thumping in the chest would seem to be the heartbeat, this is not always the case. Some people have a normal heart rate during their palpitations. Presumably, they are either anxious or experiencing chest wall twitching that is mistaken for heartbeats”

Situations where the “folk physiological” (see Churchland, 1989, for a description of expert knowledge vs. folk beliefs) understanding of the body is apparently falsified by science can be labeled examples of existential-physiological discrepancy (Laughlin, McManus, D’Aquili, 1990). Mismatches between body-as-experienced compared to the “objective body” of scientific medicine and physiology (including the feeling of “phantom limbs” by amputees) are based on the idea that people may often have very limited “true” access to physiological processes. A more commonly presented variant or subset of this principle is the idea of “referred pain”, where the region causing understood to be causing the pain is spatially removed from the area where the patient senses it.

The Merck Manual (2009) gives an example: sometimes pain felt in one area of the body does not accurately represent where the problem is, because the pain is referred there from another area. Pain can be referred because signals from several areas of the body often travel through the same nerve pathways in the spinal cord and brain. For example, pain from a heart attack may be felt in the neck, jaws, arms, or abdomen. Pain from a gallbladder attack may be felt in the back of the shoulder.

Jack and Roepstorff on introspection

cognitive science, introspection, symptom reports

From Trusting the Subject (2003), Anthony Jack and Andreas Roepstorff write:

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“The unique challenge facing a science of consciousness is that that the best instrument available for measuring experience depends on cognitive processes internal to the subject. So just how much faith can we place in the capacity of the mind to understand itself? In principle, the construction of a maximally robust methodology for introspective evidence would require a detailed understanding of the operation of introspective processes — the processes that mediate the acquisition of introspective knowledge and underlie the production of introspective reports”

And:

“It is important to realize that no principled problem stands in the way of the scientific assessment of various types of introspective evidence. The testing of the reliability, consistency and validity of various types of introspective report measures lies well within the orbit of currently available methods. A measure may be called ‘reliable’ if it yields the same results when tested in multiple sessions over time (‘test–retest reliability’) and across individuals (a cousin of ‘inter-rater’ and ‘inter-observer’ reliability). Of course, subjects’ reports may differ, and so appear to be unreliable, simply because their internal mental processes and states vary. Thus it is critical to establish well controlled experimental conditions for eliciting reports. The considerable advances in behavioural science since the time of the Introspectionists offers experimenters considerable advantages in this regard (see Ericsson, this volume). Not only do these advances make it much more probable that experimenters can establish conditions under which introspective measures can be shown to be reliable, they also provide much greater insight into the behavioural and neural correlates of experiential phenomena.

A measure may be called ‘consistent’ when it can be shown that the results are not due to specific features of the measurement technique. Tests of consistency provide a means of checking that the observed effect is not due to a methodological artefact. Thus we might test the consistency of introspective  evidence by comparing immediate forced-choice button-press reports with retrospective and open-ended verbal reports. In this way we might establish, for instance: that the results of forced-choice button-press reports have not been influenced by variations in the criterion for response or by automatisation of response such that they no longer constitute true introspective reports; and that retrospective reports have not been distorted by forgetting or memory interference effects.

‘Validity’ is the most important factor to establish, yet it is also the most theoretically complex, and a particularly vexed issue in cognitive science. A measure is validated when it can be shown to accurately reflect the phenomenon it purports to measure. Validity is complex because scientific measures are often simultaneously interpreted as providing evidence for phenomena at a number of
different levels. A rough characterisation of three major sources of evidence in cognitive science might read as follows:

-Data from functional Magnetic Resonance Imaging (fMRI) serves most directly as evidence of cerebral blood flow (which has been validated), less directly as evidence for neural activity (which is in the process of being properly validated), and least directly as a means of identifying and localising specific cognitive functions (far from well validated).

– Behavioural measures (e.g. the averaging of reaction time measures over multiple trials) serve most directly as evidence for stable patterns of behaviour, less directly as a means of assessing information processing, and least directly as means of establishing the existence and operation of specific cognitive functions.

-Introspective reports serve most directly as evidence about the beliefs that subjects have about their own experience, less directly as evidence concerning the existence of experiential phenomena, and least directly as evidence concerning the operation of specific cognitive functions.