Are beliefs or delusions characteristic of obsessive-compulsive disorder?

In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), obsessive-compulsive disorder (OCD) can be diagnosed with a specifier of ‘with poor insight’ whenever the individual does not recognize that the obsessions or compulsions are excessive or unreasonable” (300.3). Yet some insight must have occurred, since by definition, adults with Obsessive-Compulsive Disorder have at some point recognized that the obsessions or compulsions are excessive or unreasonable” (Ibid.). That is, obsessions in OCD are meant to be ego-dystonic; they are seen to be a foreign presence to the patient.

This continues in DSM-5, where it is marked as important that “obsessions are not pleasurable or experienced as voluntary: they are intrusive and unwanted” (300.3, 238). In DSM-5, however, the poor-insight specifier is now accompanied by specifiers for “good or fair insight” and “absent insight/delusional beliefs”. These categories are now defined by how the individual views the beliefs over which they obsess, or to which they react with a compulsion. The good/fair insight specifier is to be applied when the “individual recognizes that obsessive-compulsive disorder beliefs are de finitely or probably not true or that they may or may not be true”. Individuals with poor insight are now said to think their relevant beliefs are “probably true”. Finally, the absent-insight/delusional specifier is for individuals who are “completely convinced that obsessive-compulsive disorder beliefs are true” (Ibid. ,237).

This change in the specifiers, which now classifies insight with respect to attitudes towards beliefs, is curious. In DSM-5, the diagnostic criteria for obsessive-compulsive disorder, outside of the specifiers, does not mention beliefs at all; obsessions are defined as “thoughts, urges or images” that the individual attempts to ignore or suppress (Ibid.). Beliefs are only applicable to the specifiers, where it is pointed out that many “individuals with [OCD] have dysfunctional beliefs” (Ibid., 238)

So, are obsessions beliefs? They seem to clearly be, on occasion, delusional. Are delusions beliefs?

The DSM-IV notes the difficulty in demarcating between delusions and OCD symptoms:

The boundary between Obsessive-Compulsive Disorder (especially With Poor Insight) and Delusional Disorder can sometimes be difficult to establish. The ability of individuals with Obsessive-Compulsive Disorder to recognize that the obsessions or compulsions are excessive or unreasonable occurs on a continuum. In some individuals, reality testing may be lost, and the obsession may reach delusional proportions (e.g., the belief that one has caused the death of another person by having willed it).   (DSM-IV-TR, 297.1)

The literature has some interesting comparisons between delusions and beliefs, namely in the goal of determining whether or not delusions are beliefs. G. E. Berrios, for instance,  argues that delusions are not beliefs. Instead, he says they are “empty speech acts” and calls them “epistemologically manqué”. He goes on:

They are not the symbolic expression of anything. Its ‘content’ is but a random fragment of information ‘trapped’ in the very moment of the delusion becomes crystallised. (Berrios, G. E., “Delusions as `Wrong Beliefs’: A Conceptual History”, British Journal of Psychiatry 159, suppl. 14 (1991)).

This seems incomplete; delusions are sometimes acted on through both verbal and non-linguistic behaviour, often for an extended period of time. A patient who has some delusion P acts as if P were true, just as one with the belief that P would. This seems to contradict Berrios’ implication that delusions lack propositional content. In fact, Berrios’ conclusion seems quite like behaviourism in general; the lack of access to the patient’s subjective thought has led to the conclusion that there is no such thought to speak of. The difference between Berrios’ conclusion and behaviourism generally is that Berrios’ subject has a more scattered, less coherent report of their internal thinking. To deny that such thinking is present might be an overly strong conclusion. We might argue, instead, that even though delusions are not beliefs, they are not devoid of content.

Karl Jaspers presents such a view. Jaspers identi ed four forms of belief: normal beliefs, overvalued ideas, delusion-like ideas and primary delusions. In General Psychopathology, he notes that delusions have three outwardly-visible characteristics:

  1. They are held with unusual conviction.
  2. They resist contradictory experience or argument.
  3. They are obviously absurd or erroneous to others.

Jaspers says that primary delusions are “ununderstanadable” in the context of the patient’s preceding experiences. But understanding is itself a continuum, not a binary notion. Hence, the less understandable an idea is, the more delusional it likely is. For Jaspers, delusions are irreducible to prior thinking; they are not the product of reflection.

This, too, makes delusions quite unlike other beliefs, and it leads Jaspers to conclude that delusions are not really beliefs at all, but rather experiences. They consist of immediate “intrusive knowledge of meaning”. Now, whether or not the idea that “knowledge” here implies some kind of belief is a topic for a whole industry of philosophical thought, but the idea here mirrors a take on beliefs that David Hume held: that beliefs themselves were feelings towards ideas. If we want to retain the idea that beliefs are ideas themselves (a belief can be true or false), we get the idea that delusions are not really beliefs, but a much more primitive feeling that a certain propositional idea is true.

This seems to suggest that, in OCD, any obsession, more broadly, is a feeling towards some propositional content. This gives us the spectrum of possible obsession as the intensity of feeling towards some “thought, urge or image” — not as the thought, urge or image itselfThis is where DSM-5 goes astray; the identification of an obsession with its focus gives the obsession itself propositional content, at least in the case of thoughts.

In the case of a thought, there is propositional content there, but it’s what the obsession is directed at.  A mild obsession is likely a worry that P might be true. A more severe obsession is a stronger feeling that P is true. In both cases, obsessions include some thought, but the obsession itself isn’t a proposition. Urges, on the other hand, are feelings, and so it seems that an obsession probably could be an urge, but an urge is an urge to do something. Just as with obsessions, it is directed at something. Finally, with images, the image would be the focus of the obsession; as with the propositional thought, an image is something that the patient is presented with and has some kind of feeling about, ranging from a mild unease to a more severe repulsion.

Is the DSM-5 wrong to call obsessions “beliefs”, then? If we listen to Hume, no: beliefs and delusions are both feelings, and so the obsession is a feeling about something, like a belief or a delusion is a feeling about some idea. If we listen to Jaspers and Berrios, there’s a more important distinction between beliefs and delusions, and so obsessions, while possibly delusional, are not really beliefs. We can quibble about that all day long, but a sloppy definition of an obsession in the DSM-5 is what leads to this sudden, odd appearance of “beliefs” in the specifiers. Tightening that up is likely to be clinically valuable, as it adds clarity to the issue. Thoughts and images occur to most of us, and there exists a wide spectrum of feelings we can associate with those thoughts or images. Those feelings are obsessional when they are feelings of worry or certainty, when the patient is unreasonably preoccupied with the object the feeling is directed towards, and when the feeling is unreasonably strong. #

Philosophy, Science

Two ugly attitudes towards mental health

Diagnoses of mental disorders are on the way up. The DSM-IV task force, led by Allen Frances, sought to limit this inflation. The DSM-5 is expected by many (including Frances) to make it worse. If it does come to pass that nearly everyone can be diagnosed of a mental disorder of some sort, how should we think about what it means to have such a disorder?

Well, there are two attitudes that we shouldn’t have: we shouldn’t be afraid of apparent epidemics in mental health, nor should we take the other extreme and shrug off mental disorder entirely.

  1. For one, we can see the rise in diagnoses of certain disorders as a sign that all of the chemicals/”toxins”/technologies/radiation/whatever in our food/air/society or that the stresses and immoralities of our lives in the modern era are making us, well, crazy.
  2. We can, alternatively, reduce our thinking about mental health to “everybody’s got something”, meaning that we all fit on a spectrum of mental health somewhere and let’s not make a big deal about it.

The first position is a little big ignorant. I’m not saying that it can’t be that all the dangers of our world aren’t impacting our physical and mental health. They certainly are. But there are other social and psychological issues that are inflating our perception that things are going badly. One of them is the inflation caused by awareness of disorders and the diagnostic criteria of the DSM, in its various incarnations. If you become aware of these facts, you start to see that so-called epidemics are a product of our evolving classifications and not a change in the actual prevalence of certain conditions.

The second position is equally ignorant. Occasionally, people with severe mental health conditions are shrugged off by an individual because that individual knows someone else with a milder form of the same diagnosis. Mental disorders tend to exist on a variety of spectra, to be certain. But the fact that so many people can or are being diagnosed with mental disorders should not trivialize the experience of those who struggle through daily life because of them. To approach these people with a “so, what?” attitude isn’t helpful.

In general, I find our understanding of mental health lacking. We’re fearful that our children will have certain disorders, and in some cases we over-medicate them at the first sign of what might be perfectly normal distress. Yet, at the same time, we trivialize the plight of those who struggle with severe obstacles to mental health and have different mental abilities. There’s a middle ground between panic and apathy here. #

Philosophy, Philosophy of Language

Scott Soames argues that linguistics and psychology are separate enterprises, since they differ in their domain of study and empirical discoveries in one are unlikely to be realized in the other. He does this primarily by identifying what sorts of things linguists are up to, and comparing that with what is properly psychological.

Conceptually distinct

Soames says that linguistics and psychology are “conceptually distinct” (155) in the sense that they differ in their domain of study. In order to do this, he identifies what he calls the three “Leading Questions” (158) of the linguistic enterprise. They are questions concerned with the differences and similarities between actual natural languages, between natural languages and artificial or animal ones, and between languages and their historical variations. These are, according to Soames, the basic questions that define the domain of linguistics because they are the questions that initiate the actual practice of linguistics. It is these sorts of questions that linguists are out to answer.

Soames also highlights facts about linguistics which are clearly not psychological. For instance, semantics in linguistics requires a non-psychological component in the form of truth conditions. Truth conditions are essentially relations between sentences in a language, which may be thought of as abstract or mentalistic, and the real world. To use the famous example, ‘snow is white’ if and only if snow is white. While one can argue that ‘snow is white’ is a mentalistic object, it would be much more difficult to make the case that the fact that snow is white is psychological in nature. Hence, the case of truth conditions in semantics provides a counterexample for the claim that linguistics is entirely about the minds of language users, and hence the claim that linguistics is psychology falls apart. They must differ, at least somewhat, in their domains; some facts about language are linguistic and not psychological.

Soames also comes at the problem from the opposite side, noting that psychologists are concerned with things like the processing times and error rates between individuals speaking certain languages. These, while interesting facts for Soames, are not a part of linguistics proper. That is, theoretical linguistics is not concerned with mental aspects of human speech, but rather the output of the speakers, the language itself. Because there are things that psychologists are concerned with that linguists need not be, the domain again seems to be different. Some facts about language users are psychological and not linguistic.

In short, for Soames, linguistics is about languages as abstract objects, while psychology is about language users.

Empirically divergent

Soames’ second major claim is that linguistics and psychology are “empirically divergent” (155), that is, empirical investigation of language speakers is unlikely to discover that the grammars posited by linguists “correspond exactly” (168) with the mental structures of competent speakers.

To make this case, Soames notes that while some linguistic facts can correspond to psycholinguistic ones (such as the case of grammatical sentences and competent speakers judging sentences to be grammatical), others will not correspond. Instead, there are facts that only one discipline (between linguistics and psychology) will be interested in. Psycholinguistic data will be of interest to psychologists, but not to theoretical linguists. Meanwhile, semantic facts of truth conditions, logical properties and relations (169) will be of interest only to linguists. In formulating their theories, each discipline has its own epistemological domain as well, the domain of empirical facts that are to be admitted into the theory-forming process.

Despite this diversity, there is a logical possibility that the linguistic theory of grammar and the psychological theory of competence will turn out to be isomorphic after all; the theory of grammar may indeed correspond 1:1 to a psychologically real structure, however unlikely this is to Soames. But to say that linguistic theories are psychological in nature is to assume in advance that such theories do correspond. It would be an empirical discovery that an isomorphism exists between a grammar and a competence model.

Soames again appeals also to the actual practices of linguists, noting that linguists aim to produce a theory of grammar that is as simple and general. Again, it may be that the psychologically real model of competence is optimally simple and general, but this cannot be assumed. There is no reason to suppose that things will turn out this way. Hence, to suppose that building a minimalistic and general theory of grammar is the proper means of building a theory of competence is ill-conceived.

Because counting linguistic models as psychological ones rests on epistemologically dubious assumptions, which he thinks are unlikely to be the case, Soames argues that linguistics cannot properly be thought of as a psychological enterprise.

Does Soames beg?

Soames’ criterion of demarcation between the linguistic and the non-linguistic rests on the Leading Questions of linguistics. Soames takes these definitionally as what linguistics is about, which seems to beg the question.

Further, Soames also says that “nothing [linguistic] logically follows” (159) from certain facts about processing times and grammatical mistakes between speakers of different expression types. This is based on the assumption that languages are abstract entities and that linguistics is about them. If, on the other hand, one takes the position that languages are mentalistic in nature, Soames’ reasoning doesn’t seem to work.

A bit of ontology

Soames frequently refers to the facts that linguists and psychologists rely on. One might wonder whether these facts are all mentalistic in nature if they are meant to be separate from states of affairs. He also says that truth conditions are at least partly about non-psychological facts. How a theory of truth is to work, however, is no simple matter. A coherence theory of truth, however implausible, would not rely on a correspondence with an external reality but rather with how they logically cohere with other beliefs the speaker has—both elements thus being mental states. Pragmatic theories of truth might suffer from similar struggles.

Soames, Scott. ‘Linguistics and Psychology’. Linguistics and Philosophy 7 (1984). 155–179. #

Epistemology, Metaphysics, Philosophy

In his Mind and World, McDowell contrasts three positions in his concerns with spontaneity and intentional states in general. These are what he calls bald naturalism, rampant platonism and naturalized platonism, the last of which he defends. What McDowell calls ‘bald naturalism’ I will argue for, but I will refer to it more favourably, as ‘naturalism proper’.

The proper naturalist position counts the mind as part of the world, as McDowell wants to do. What a naturalist proper cannot coherently talk about is the Kantian subject. Instead, there are only objects. For those who would say that things are only objects in the sense that they are the object of some subject, then we may use the word ‘substance’, in the earlier Greek sense, to talk about physical things. Thus, the naturalist position is that everything is a substance; in Heidegger’s terminology, everything is essentially present-at-hand[1] and though further supposed properties or features of substances (readiness-to-hand, the existence of Dasein, the mind, intentionality, subjectivity) are reducible to that raw substance. In contemporary physics, that substance is identified with particles, though the details may be somewhat more complex than that[2]. The manifest image of the world[3], the normative space in which intentionality and morality are thought to lie, is composed of that same physical substance that makes up the brains of those who experience and project outwards.

So, for the naturalist proper, the space of reasons is not a realm outside of the natural or physical world, as it is in rampant platonism, nor is it an autonomous space within the world as it is in McDowell’s naturalized platonism. Rather, all rationality, normativity and intentionality is identical with brain states. There is no one space of reasons with which human beings have a connection; rather, each human being can be thought to have their own space of reasons. This space is not especially private, though. It can be seen physically by examination of the neurological states of the brain, and with the proper technology, those states may even be translatable into intelligible images. In another sense, it is not fully private, since glimpses into its content can be seen through behaviour.

‘Content’ needs qualification in that last remark. Intentional mental states are mental states that are about something else in the world. But they are neither a metaphysical link through some imaginary (or real) space to other substances which they are about, nor are they really representations of the substances they seem to be about. They are not the former because such space doesn’t exist in any important way. They are not the latter because, of course, the neurological features of our brain do not form a structure that mimics the outside world. Rather, they form a structure that allows us to have a mental state (which is identical with that brain state) such that we think we have a representation of the substance we are thinking about. So, when I close my eyes and picture the CN Tower, I do not obtain or summon some representation of that object. That object may be gone, moved, or different than I remember. Instead, my brain generates a certain arrangement such that it looks like the CN Tower to itself.[4] All of the qualia, ‘what it’s like to be’[5] and private world phenomena that philosophers expect to find in a separate mental world are  merely what the brain’s activity looks like from the point of view of that very brain.

Against the rampant platonist, the naturalist’s response is brief. Whatever attitudes one has towards the empirical observations with which one is presented, one does not survive without indulging in them. With a proper account of naturalism, any reason to favour a platonic account dissolves. Naturalism proper offers an explanation of intentionality, removes the “spookiness” (McDowell 92) of a separate space of reasons that McDowell complains of. We don’t need to add anything ontologically, and we have a hope to answer the how questions about mental states and intentionality through study of the brain. Spontaneity doesn’t need any explanation here, either, because it is not sui generis, if it’s counted as existing at all. We’re better off with the naturalist account.

Against McDowell’s naturalized platonism, the proper naturalist has to say that McDowell is wrong about naturalism. He argues against his ‘bald naturalist’, saying that “knowing one’s way around the space of reasons, the idea of responsiveness to rational relationships, cannot be reconstructed out of materials that are naturalistic” (McDowell 77). But the naturalist proper doesn’t want to reconstruct a space of reasons, really. The naturalist proper holds that all reasoning, all intentionality, all communication—the entire manifest image—takes place between physical substances across physical substances. The naturalist isn’t committed to reconstructing any intentional state beyond this because she doesn’t hold it to exist. What counts as intentionality for a naturalist proper is evidenced through behaviour, and it consists of a brain processing incoming information. The space of reasons, the finer points of language, art, morality, knowledge and so forth can be talked about as abstractions. They are useful in the processing that the brain must do; they result in digestible inputs. But the naturalist proper is ever-mindful that these are not things in themselves, but that they are always identical with and reducible to the states of the brain. The same holds of spontaneity. The naturalist counts human judgments to be determined (in a deterministic or indeterministic sense[6]) by the physical processes that cause them. Thus, spontaneity can be said either to not really exist, or at least to be denied status as sui generis, as is the case with the other ideas McDowell wants to preserve. Where McDowell wants to say that human beings are free to choose their beliefs, to take their experiences and spontaneously form judgments about them, the proper naturalist denies this. For the naturalist proper, sometimes brain states will have the disposition to respond to the stimulus of a red bench and form the belief that there is a red bench. Sometimes, because of other beliefs, brain states will not have such a disposition and will not form such a belief. Whether or not this happens is not an act of spontaneity, but a function of the states of the brain, including the stimulus received and the beliefs already held.

By positing an autonomous space of reasons, and a second nature with which humans can access it, the naturalized platonist gains little in the way of explanation and much in the way of recalcitrant philosophical questions. McDowell thinks that he gets out of the “threat of supernaturalism” (78) by saying that scientific advancements don’t clarify nature as a whole, but only the realm of law. This step does not work; it only redefines “nature” to include what the naturalist counts as supernatural. McDowell renames nature as the realm of law, says that the platonic heaven, the space of reasons, also exist, and says that there’s this new thing, now called nature, previously called existence, which encompasses all of them. The connection between the realms of laws and reasons is as sketchy as ever, and it is only through proper naturalism of intentionality and spontaneity that the confusion is finally dissolved.


[1] See: Heidegger, Martin. Being and Time. Trans. John MacQuarrie and Edward Robinson. New York: Harper & Row, 1962. p. 98; p. 69 in the original German.

[2] String theories and wave-particle duality in physics play a role here, but they are beside the point. Scientific skepticism about what substances are physically is important. Equally important is the fact that extra-physical phenomena haven’t turned up at all. That is, the naturalist account is the best lead we have.

[3] From Sellars.

[4] …because we are always our physical selves and are never apart from our brains.

[5] From Nagel.

[6] Indeterminism as is afforded by quantum mechanics offers a sort of natural spontaneity, but it is not immediately clear how, or even if, this would impact judgments. #

Logic, Philosophy

Here’s a tautology in propositional logic:

⊨(P → Q) ∨ (Q → R)

Try throwing that into English. Here’s a reading using some propositions I just came up with:

“I’ll die if I’m immortal, or I’ll live if I die.”

Obviously, neither of those are the case. But this formula, (P → Q) ∨ (Q → R), is both provable and self-implied in classical propositional logic.

Here’s a syntactic proof by means of natural deduction using some basic rules of inference:

Continue Reading #

Philosophy, Science

One of the major objections to the idea that time travel is possible is the apparent fact that we haven’t been visited by tourists from the future.  If travel to the past is possible, it’s likely that future historians may be tempted to take advantage of it, that terrorists or criminals may travel back in time to alter history, that someone would go back to visit their ancestor… and that, with those and so many other possible motives, it’s unlikely that the technology would never be used.

The most obvious answer to why we haven’t seen travellers from the future is that backwards time travel is either impossible or never gets invented.  Maybe humanity dies out before inventing it, for example.  But obviously we don’t want humanity to die out, and time travel is too cool to go uninvented, so what are we left with?

Fear not… all of your twisted sci-fi dreams may yet come to pass.  Here are some possible explanations for why we haven’t met any time tourists yet…
Continue Reading #