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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What do clinicians come to know about their patient’s heart sensations?

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What do clinicians come to know about their patient’s heart sensations? This is not a simple question, as it simultaneously looks at patients as people with bodily experiences, but also as humans understood as systems, as a sort of living machine. What is more intimate than our heart-beating, a familiar yet mysterious sensation we know to be at the very basis of our ongoing experience? Feeling a change in the rhythm or intensity of this fundamental aspect of our embodied existence can be very worrisome. Should clinicians believe patients who complain of cardiac rhythm changes? How accurate are people at detecting medically important heart-beat fluctuations? How should clinicians understand the relationship between symptoms as reported by the patient, and underlying physiological processes? These are complex and multifaceted issues, requiring nimble clinicians who integrate scientific knowledge as well as intuition about what the patient is experiencing bodily. Clinicans develop knowledge of their own bodies through life, and then are required to learn complex anatomical, physiological, and etiological concepts they will use to interpret their patient’s symptom reports. What patients have to say about what is happening in their bodies must be taken seriously, but not necessarily believed. The interrelated problems of how clinicians interpret patient verbal reports, reason about the relation between these reports compared to measurements and scientific models, and then make judgments about the patient’s accuracy in knowing about their own bodies are topics well worth honing in on, and to my knowledge, not throughly explored from a neurophenomenological perspective.

These acts of clinician cognition concerning their patient’s symptoms are framed by an evolving social and professional context. Modern medicine, like the Roman god Janus, stands two-faced, towards healing as an art, but also towards scientific models of disease. In the current era, what is known as “evidence-based medicine” requires an important shift in how clinicians operate, from historically rather unfettered individual judgments in some contexts, to increasingly accepting consensus-developed guidelines formulated from reviews of previous findings. Clinicans who have with great effort developed the ability to intuit diagnoses may have to defend their familiar constructs, criteria, heuristics, and practices if these are not bolstered by peer-reviewed studies, randomized clinical trials, systematic reviews, Bayesian statistical approaches to clinical problem solving, meta-analysis of previous data, and effectiveness metrics. Medical organizations can mandate “best practices” of patient care, “gold standards” of cost-effectiveness for ordering certain tests, references to efficacy criteria that must be satisfied before a program of treatment is established, and more. This ongoing process is transforming medicine, requiring that the traditional art of diagnosis based on years of education and experience be integrated with operationalized definitions, committee-approved metrics, and greater formalization, thus constraining individual opinion and practices in favor of organization-mandated standard operating procedures. Can symptoms based on an individual’s embodied experience be given proper attention in this brave new world of medicine?

I hope that more researchers would address the clinical aspects of neurophenomenology. This is a relatively new and undeveloped area. While William James and Erwin Straus were clinicians, as is Antonio Damasio, other pioneers such as Maurice Merleau-Ponty and Francisco Varela backgrounded medical concerns somewhat (however, if you are unaware of Varela’s haunting work at the end of his life “Intimate Distances -Fragments for a Phenomenology of Organ Transplantation“, it is a must-read.) Shawn Gallagher has made an excellent synthesis of philosophy and clinical studies in “How the Body Shapes the Mind“, a work that bears greater attention from the small community of neurophenomenology researchers.

For my part, I shall focus in on a particular area, palpitations, where changes towards operationalizing and standardizing the definition of “clinically significant” symptoms are occurring, with the aim of modeling the relationship between patient symptom reports and “significant” arrhythmias as revealed on ECG measurements. I will especially focus on how the predictive utility and accuracy of the reports can be operationalized, and attempt to represent for one domain how patients’ verbalization of their phenomenological state can be “mapped” onto measurements of cardiac rhythm abnormalities.

Part II of Leder’s The Absent Body

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Spatiotemporal Continuity

The mysterious quality of our visceral space is based not only on such experiences but on all that is not experienced of our inner body, I have hitherto focused on what interoceptions we do have; they are marked by a limited qualitative range and a spatial ambiguity that together restrict our perceptual discriminations. Furthermore, as I will now address, there is a paucity of even such limited experiences.

Exteroception, at least during the waking state, manifests a certain spatiotemporal continuity. My eyes scan a visual world that is without sudden gaps or crevices. If I abandon one sense, perhaps closing my eyes, the other senses help to maintain the continuity of world. Similar­ly, proprioception traces out a completed sense of my surface body, allowing me to adjust every limb, every muscle, in appropriate motoric response to tasks. Though usually this sense is subliminal, I can close my eyes and proprioceptively hone in on the position, the level of tension or relaxation, in any region of the muscular body.

By way of contrast, the stream of interoceptive experience is marked by ineluctable discontinuities. In the above example, after eating the ap­ple it largely disappeared from perception only to resurface in an exper­ience of heartburn. This then faded away to silence, broken some time later by insistent cramps. This too passed. Finally, hours later I become aware of sensations from a new region signaling the need to defecate. But these are intermittent punctuations in a shroud of absence. Most of the intricate digestive process—its enzymatic secretions and peristaltic waves, its diffusions and active transports—proceeds without the pos­sibility of conscious apprehension. This is equally true of circulation, respiration, thermal or fluid regulation. By far the greatest part of my vegetative processes lies submerged in impenetrable silence.

Causal relations are rendered uncertain by these spatiotemporal lac­unae. I cannot be sure if my cramps are caused by an apple I previously ate, for this apple has, in the interim, disappeared from experience. Mo­ments of discomfort are noted while the baseline of ordinary functioning is largely invisible, it is as if my eyes only reacted to flashes of blind­ing light, the rest of the time residing in darkness.

This darkness is never absolute. When I focus inward at even the qui­eter times I still find some vestigial sense of my midsection enveloped in a sort of sensory neutrality, neither full nor empty, pleasured nor in pain. And this vague aura is not devoid of meaning. It shows that any hunger or illness has subsided. The very absence of discomfort is tinged by a positivity.

Moreover, through a heightened focusing of attention, I can increase my awareness of visceral processes. Certain dim sensations that I had never noticed—the feeling of my pulsing blood, the depths of respira­tion, the subtler reactions of my stomach to different foods—can be brought into experience by conscious effort. As cultural variations show, a certain degree of visceral disappearance can be attributed to Western insensitivities and overcome by a systematic development of powers. The awareness of and control over the inner body exhibited by trained yogis has far surpassed what used to be thought possible in the West.

Yet even such achievements take place only within an overall context of experiential disappearance. The very need for highly specialized training is evidence of the perceptual reticence of our viscera as com­pared to the body surface. And just as it is possible to speak of null points in relation to the surface body, the corporeal depths have their own phenomenological null points. That is, there are visceral regions that are almost entirely insensitive. In focusing upon stomach and gut I have ac­tually chosen two of the more loquacious organs. The kidney, gallblad­der. bone marrow, spleen, yield far less interoceptively. The par­enchyma of the liver, the alveolar tissue of the lung, are virtually with­out sensation. Unlike the completed perception of the proprioceptive body, our inner body is marked by regional gaps, organs that although crucial for sustaining life, cannot he somesthetically perceived.

We rarely thematize this sort of disappearance. Upon introspecting, I do not feel an emptiness in my body where my liver should be. This would make the absence into a presence-as-concealed hovering before my awareness. Rather, the absence of the liver parenchyma is so total that few would ever come to realize or remark upon it. Yet a medical mishap can suddenly awaken us to the significance of such bodily lac­unae. The vast gaps in our inner perception may conceal potentially damaging processes until they are far advanced. For example, while I may feel pain once damage to the liver has progressed to the point of affecting its membranous capsule, the initial process can go unper­ceived. Similarly, hypertension is experientially hidden through much of its career. As with my surface body, I can bring to bear upon these depth organs certain strategies of reflective observation. A blood sample can tell me a good deal about my liver function. Through a sphygmomanometer I can read off my blood pressure. I can look at an X ray of my lungs. I can even gaze through a colonoscope at the lumen and folds of my own colon. Such techniques enable me to gain knowledge concerning my viscera. Yet, as with my surface body, the absences that haunt my bodily depths are not effaced by these reflective maneuvers. Though I can visu­ally observe my colon, its processes still elude experience from within, The magical power my body has to absorb water and electrolytes is not perceived as I gaze through the endoscope upon this furrowed, tubular space. The mystery of my body is only heightened by the very strange­ness of the organ before me, its phenomenological noncoincidence with my body-as-lived.

Moreover, unlike the body surface, my inner organs tend to resist even these partial reflections. My viscera are ordinarily hidden away from the gaze by their location in the bodily depths, there is aspect of withdrawal may seem contingent, resulting from a sheerly physical harrier rather than an existential principle. Ye t this is to draw a false distinction; in the lived body, the physical and existential always intertwine.

The depth location of the viscera is no more contingent than the sur­face placement of the sensorimotor organs. Eye and hand could not perform their perceptual role unless they opened onto the external world- Thus, in order to perceive they must take their place among the perceptibles. They must be located at the body surface available to the gaze of myself and others, By way of contrast, my visceral organs, not constructed for ecstatic perception, disappear from the ranks of the per­ceived, I do not perceive from these organs; hence, they can hide beneath the body surface such that I do not perceive to them either. In fact, they require this seclusion just as the sensorimotor body requires exposure. My stomach, neither an organ of exteroception nor voluntary move­ment, could not screen the environment, secure appropriate foods, repel threats. It depends on a mediating surface, active and intelligent, to stand between it and the world, selecting what is needed for metabolic maintenance and protecting the vise us from hostile impacts. The hiddenness of vital organs, though frustrating at limes of disease, is essen­tial to healthy functioning.

Thus it is quite rare for the viscera to be exposed in life. This can happen, as in surgery, wartime injury, or violent accidents, yet these are pathological and dangerous occasions, Most commonly, the direct ex­posure of the inner organs implies or threatens the death of the person, Hence, as Foucault notes in The Birth of the Clinic, when nineteenth-century medicine made the direct perception of diseased organs an epistemological goal, the corpse, not the live patient, became the paradigmatic figure of truth. For the “anatomo-clinical” gaze, “that which hides and envelops, the curtain of night over truth, is, paradox­ically, life; and death, on the contrary, opens up to the light of day the black coffer of the body.”” While Foucault addresses this as a historical devel­opment, it manifests my phenomenological point; life itself is allied to a certain concealment, a withdrawal and protection of its vital center.

more on the status of introspection in psychology and in neuroscience

cognitive science, introspection

An index of the status of introspection within psychology comes from Medin, Markman, and Ross (2004) in the textbook Cognitive Psychology, which notes (pg.20) that:

Although introspection is not an infallible window to the mind, psychological research is leading to principles that suggest when verbal reports are likely to accurately reflect thinking

These perspectives all can be said to implicitly or explicitly challenge what I shall call the “received view” or the “overly skeptical view”, which is an interpretation of the Nisbett and Wilson work that goes beyond what those authors’ famous paper actually said. While it is the case that the “Telling More than we can Know” Nisbett and Wilson paper argued persuasively that introspection-based reports of subjects asked to retrospect on the causes of their behavior are generally not accurate, these authors made a point of not dismissing the value of introspection and verbal reporting on the contents of cognition one is aware of , such as sensation or perception and “private facts”. But the “received view” of their research all too often neglects or ignores the more nuanced and balanced view about introspection of the authors, as well as that of other cognitive scientists who carefully investigated the issues involved, such as Anders Ericsson and Herbert Simon (1993).   This is an important concept: see Eric Schwitzgebel’s excellent take on the “Nisbett-Wilson myth“.

What is the most important concept to take away from the controversies about introspection? Probably it is that insofar as researchers want to be able to take advantage of all possible tools and data sources to make sense of the complex, enigmatic processes characterizing body knowledge, they should follow the example set by many physicians and some experimentalists, and be willing to get data by asking subjects or patients for their observations on body state. But here I will go one step further, and assert that the accuracy, or lack of accuracy, of verbal report data relative to other data, can serve as that which must be explained by a comprehensive and robust model of personal or self-reportable knowledge of the body. Doing so would require experiments where verbally reported data might be compared to, and possibly integrated with, data from external sources, such as from brain measurement: “neurophenomenology” in operationalized form.

One such effort came from a trio of researchers interested in assessing whether introspective data on pain had measurable neural correlates (Coghill, McHaffie, Yen, 2003, pg. 8538):

Using psychophysical ratings to define pain sensitivity and functional magnetic resonance imaging to assess brain activity, we found that highly sensitive individuals exhibited more frequent and more robust pain-induced activation of the primary somatosensory cortex, anterior cingulate cortex, and prefrontal cortex than did insensitive individuals. By identifying objective neural correlates of subjective differences, these findings validate the utility of introspection and subjective reporting as a means of communicating a first-person experience

This forward-looking research in effect turns behaviorism on its head: instead of verbal reports being rejected or at best tolerated within the overall context of strict objectivity, the very phenomenon the model seeks to explain is “subjective”!

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.