Psychiatric conditions

Abstract

In reviewing psychiatric syndromes, some themes recur. This does not lead to a general theory of disorder, but to an analysis that has some general features. Set against a developmental background, disorder is viewed in relation to the tasks that must be achieved where multiple sets of mental rules are possible. These include the monitoring of internal and interpersonal rules, the maintenance of the individual's experience of continuity in the presence of multiple states of mind, and the capacity to understand the mental states and actions of others. Many of the overarching, metarepresentational functions could also be characterized as functions of the self, and these appear to be disrupted in conditions that are as widely different as schizophrenia and borderline personality disorder. In schizophrenia the monitoring of the individual's own thoughts or actions may be impaired, whilst in borderline functioning the continuity of states of mind is undermined. If the sense of self is derived from the awareness of being the author of one's own actions or thoughts over time, then in these conditions it is undermined in different ways. Inasmuch as the coherence of the self is in turn central to action, disturbances of action are the result of these different forms of disruption of the self.In both condition, further contrasting factors may undermine action. In schizophrenia inefficient information processing may lead either to action based on incidental aspects of a situation, or to inaction based on information overload. In borderline personality disorder experiences in which action has been impossible may lead to action turned on itself, in self injury. However, in both, there may be elements that represent the attempt to preserve action in the face of such threats. In schizophrenia delusions and hallucinations may in part be compensatory mechanisms that reduce uncertainty, hence providing the basis for action. In borderline personality disorder the splitting of mental representations may similarly, by excluding elements that are incompatible with action, provide (partial) representations that provide the basis for action. Thus in both conditions elements of accurate representation are sacrificed, in order for action to continue.Conditions in which action is preserved may be contrasted with those, such as depression, where it is not. In either case a range of intentional and non-intentional origins may be envisaged. In situations of helplessness depression may be seen to be an appropriate and accurate representation that action is not possible. Depression seen in the absence of such threat may result from the intrusion of cognitive and emotional states that undermine action arising from a physical, non-intentional interruption of perceptions, thoughts, feelings, or actions. Equally depression may arise where mental representations that have been maintained inactive or out of consciousness are activated, and are incompatible with action.We conclude by revisiting our starting point. Mental entities, perceptions, feelings, thoughts, and wishes are genuinely causal and must provide sufficient certainty that the individual can act effectively. Throughout biology, intentional states of organisms, from the simplest cellular creatures to non-human primates, have provided the basis for action, and in general the certainty has been derived from the evolution of those intentional states over long periods of time. In this and the preceding chapters we have seen how, in the activities of the human mind there is an infinite elaboration of the potential inherent in all intentional processes in biology. This has introduced novelty, creativity, and flexibility, that are seen in the achievements of language, custom, technology, and culture. It has also increased the risks of uncertainty, confusion, and the undermining of action. These are reduced through an interplay between the sophisticated integrative capacities of the human brain and the continuities of human relationships, skills, beliefs, and social organizations. Disorder is found in the failure of intentional states to underpin action, where these are undermined by the external world, or where intentional states are distorted, contradictory or unintegrated, and where action is undermined or ineffective.