The use of philosophical phenomenology for conceptual debates in psychiatric nosology and psychopathology is beginning to be recognized. In this paper, we extend this trajectory to include Tourette Syndrome, focusing on so-called premonitory urges (PU) preceding Tourettic tics. We clarify some inconsistencies around typology in both phenomenological description and medical classification (i.e., in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision, International Classification of Diseases, 10th edition [World Health Organization, 2004], and the scales that elicit PU). (...) We show how a less typological approach might be usefully deployed in the field, that being the dimensional approach developed by Fernandez (2019a; 2019b). We test both the typological and dimensional approaches in relation to the experience and etiological role of PU in Tourette’s syndrome. Based on our synthesis of existing studies and new information garnered through phenomenological interviews (using an approach associated with “micro-phenomenology”), we argue that the role of PU in nosology challenges both the current “operational” criteria favored by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision, that are focused on behaviorally observed symptoms, as well as essential and prototypical phenomenological descriptions about a given “type” of experience. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Phenomenological Interviews and Tourette'sThe authors report no conflicts of interest.We appreciate the responses from the two clinicians, Efron and Mathieson. We agree with their reminder about the holistic nature of clinician's engagement (mood, sociality, and work life) and with their emphasis on patient-reported outcome measures, although this is not quite what we did in our interviews. As has recently been recognized in section 24 of the Victorian Mental Health (...) and Well-being Act (to provide a local Australian example), patients and caregivers' "lived experience makes them valuable leaders and active partners in the mental health and wellbeing service system."1In this paper, however, our aim was both more modest and immodest: modest, in that we aimed to work with those "leaders and active partners" to generate a more adequate account of lived experience in concert with behavioral symptomatology; immodest, in that we wondered how the lived experience of Tourette syndrome (TS) aligned (or not) with some of the commonly ascribed features of the condition. Although phenomenology as a discipline does not own lived experience, of course, it is more systematically treated in this tradition, starting with elaborations of Erlebnis.Efron and Mathieson note that older patients are more likely to describe urges or premonitory urges (PUs). This raises the priming question: Has greater exposure to and involvement in medical concepts and treatments transformed the nature of their self-report, or has it provided them with more phenomenological skills, enabling them to pick out discrete parts of experience? Or perhaps they have just been exposed more frequently to the experience over time? We address some related issues below, in our reply to Fernandez, where we outline our interview techniques more fully.They end by noting that the aim of comprehensive behavioral intervention for tics is to become attentive to PUs to better block tics. This is complex and understudied. In principle, becoming aware of something cognitively and experientially can foreground or even perhaps induce that experience. Conversely, from the TS scholarship, we know that attending to urges in certain ways (e.g., via acceptance training) can also reduce perceived urge frequency and intensity (see Gev et al., 2016). We would welcome further work on this link between attention and experience in TS. [End Page 49]Response to FernandezBecause our paper was partly framed around Fernandez' own work on phenomenological psychopathology, we welcome his invitation to provide further "inspiration and guidance" for other phenomenological researchers conducting empirical studies, who may also be dealing with the challenge posed by "narrative habits." When an interviewee uses well-worn medicalized terms to describe their experience, it is not clear whether these descriptions genuinely reveal or rather occlude the experience in question. There are sometimes, perhaps often, second-person phenomenological 'tells' regarding interviewees genuinely re-evoking an experience, but for interviewers it still raises the question of how to prompt alternative and potentially more accurate descriptions of experience.Because of this challenge, we purposely did not use the term "urge" or "premonitory urge" (PU) in our interview questions. Instead, we asked about (and used the broader term of) "experiences" that may occur prior, during, or after ticcing, without assuming that there are such experiences in the first place. We guided interviewees to evoke the memory of a specific, singular tic event (a tic token; see Curtis-Wendlandt 2020, 2023). Once a memory of such an event had been identified, we asked interviewees the following three lead questions:1. What, if anything, did you experience during this tic?2. What, if anything, did you experience before this tic?3. What, if anything did you experience after this tic?The temporal framing of these questions counters common trends and assumptions in the scholarship, which has focused heavily on pre-tic experiences, with little attention given to post-tic experiences (reduced to notions of "relief" and barely investigated), and even less to experiential explorations of the tic itself. Our catalogue of supporting questions sought to elicit fine-grained descriptions of evoked/recalled experiences along sensory and cognitive-affective dimensions:•. Did you see anything before, during, or after this tic? If so, what did you see?•. Did you hear anything... (shrink)

There is an evolving recognition in healthcare that the patient's subjective experience needs to be privileged both in understanding clinical phenomena and also ensuring the salience of outcomes used to evaluate the impact of treatment interventions. This is reflected in the expansion of patient-reported outcome measures to capture a person's perception of their own health, and the increasing requirement of involving people with lived experience in the co-design of research studies (National Health and Medical Research Council, 2016) and care improvement (...) initiatives. In mental health it has been long understood that observable behavioral phenomena can only partially inform clinical understanding of the experience... Read More. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Priming and Narrative Habits in the Phenomenological InterviewReflections on a Study of Tourette SyndromeThe author reports no conflicts of interest.In "Dimensions, Not Types: On the Phenomenology of Premonitory Urges in Tourette Syndrome," Lisa Curtis-Wendlandt and Jack Reynolds provide new insights into some of the experiences characteristic of Tourette syndrome (TS). Their study is an excellent example of applied phenomenology (Burch, 2021), combining philosophy and qualitative research methods to illuminate (...) experiences that have often been mischaracterized in the existing literature. In their study, they focus on what is commonly referred to as a "premonitory urge" (PU): the "anticipatory urge that is often thought to precede the onset of the motor and phonic tics that are part of Tourette Syndrome" (Curtis-Wendlandt & Reynolds, 2024, p. 26). They ask not only whether PU is a necessary feature of TS, but also whether the very concept of PU accurately portrays the experiences and behaviors that it's intended to refer to. They point out that existing scales used to assess PU, for example, seem to implicitly narrow the relevant experiences by assuming that they are a) always negative and b) always internal, or inwardly focused (Curtis-Wendlandt & Reynolds, 2024, 26). Curtis-Wendlandt and Reynolds question these in-built assumptions about PU, suggesting that they may provide an overly narrow depiction that misses the genuine diversity of experiences that precede the onset of a motor or phonic tic.To explore these phenomena in more detail, they conducted a study intended to elicit fresh descriptions of these experiences. They interviewed 12 teenagers with a diagnosis of TS about their experiences of ticcing and tic suppression. Using the micro-phenomenological method (Petitmengin, 2006), they asked participants to reflect on a specific tic or tic suppression event and to recall the event in detail. Throughout the interview, [End Page 43] they asked open-ended questions about sensory, cognitive, or affective experiences surrounding the event. Through these interviews, they were able to generate rich descriptions of these experiences and investigate how these descriptions differed from standard accounts in the existing literature.Curtis-Wendlandt and Reynolds provide a detailed account of how they designed their phenomenological study, both philosophically and empirically. However, there is an important aspect of their method that they discuss only in a cursory or implicit way, which is what I want to focus on here. Throughout their study, they were concerned that participants might simply parrot back well-worn medicalized characterizations of PU. Such characterizations risk simplifying or even occluding key aspects of the participants' experiences that might be difficult to reflect upon or describe. However, despite stressing the importance of eliciting fresh descriptions, Curtis-Wendlandt and Reynolds provide only glimpses of how the interviews actually unfolded and what kinds of techniques they used to elicit these descriptions.In my experience, it is quite common to hear phenomenological psychologists and psychiatrists express concern that people may simply repeat common psychiatric or medicalized characterizations of their condition, rather than genuinely reflect upon and describe their first-person experiences. The philosophical assumption is that we all fall back on culturally sedimented language and terminology when describing our experiences. Someone who has spent extended periods of time interacting with psychiatrists and other healthcare professionals, for example, is likely to have picked up common ways of describing their condition—ways that may have helped them receive a diagnosis or obtain treatment. There is nothing inherently wrong with falling into these culturally sedimented characterizations. They facilitate everyday communication through a shared language and terminology. But phenomenologists are often concerned that this kind of culturally sedimented language covers over or obscures the phenomenon or experience they are trying to investigate. For example, if a psychiatrist has often described their patient's depressed mood as "sadness," then that patient may be likely to self-describe their mood as sadness in an interview setting. It might, in fact, be the case that their mood is best described as sadness. But it could also be the case that their mood would be more accurately described as, for instance, a sense of emptiness or feeling deep despair. The challenge is therefore to know whether someone's self-description is... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Postmodern Assumptions of Philosophy of PsychiatryThe author reports no conflicts of interest.This paper makes claims for relevance of philosophy to psychopathology, as inspired in part by the work of Karl Jaspers. Yet there is no such thing as philosophy, in a general sense; there are philosophies, or as Jaspers would prefer, there is philosophizing (Ehrlich & George, 1994; Jaspers, 1951). Jaspers' approach to philosophy was akin to Freud's approach (...) to psychology: the goal was to make unconscious assumptions conscious. The unconscious assumption in the present paper is that there is such a thing as philosophy, which could then be useful for psychopathology. In effect, the author is probably meaning academic philosophy, or mainstream thinking in current philosophy of psychiatry. If that is the meaning, then Jaspers' question would be: What are the unconscious underlying assumptions of modern academic philosophy of psychiatry? The author's paper does not ask that question. But if we do, my answer would be that current mainstream philosophy of psychiatry has a basic worldview, another concept very central to Jaspers' thinking (Rindermann, 2021). Its worldview is postmodernist relativism about truth and skepticism about science, especially biology as applied to psychiatry. This unconscious assumption in modern philosophy of psychiatry is a major impediment in any benefits it might provide to psychiatry and psychopathology, as will be explained in the rest of this commentary.The paper refers to major depressive disorder (MDD) without appreciating that the term itself makes assumptions which the paper wishes to argue should be in the province of philosophy to analyze. The term MDD is not the same as depression, although the paper synonymizes the two. This synonym is an unanalyzed assumption, namely, that the Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic system validly defines psychopathology. It clearly does not, for reasons that modern philosophy of psychiatry has not accurately analyzed (Ghaemi, 2014).About a decade ago, when DSM-5 was being developed, colleagues in the field of philosophy of psychiatry had worked for decades on psychiatric diagnosis, and there was initial hope that the time had come for an impact (Kendler et al., 2008). The leader of the prior edition of DSM was unhappy [End Page 17] with the fifth revision. A set of essays were published where philosophers and psychiatrists engaged the former DSM leader about psychiatric diagnosis (Frances, 2013). His response, with a somewhat derisive reference to "philosophyland," was eye opening to me. He explicitly stated that DSM revisions were not based on science or facts, but on "pragmatism," on the beliefs of DSM leaders about what was best for the profession or society. In short, it was admitted that DSM was a social construction, just as postmodern thinking had said about psychiatric diagnosis since Foucault. Yet this admission was made unconsciously; DSM leadership does not use that phrase, nor does it understand its conceptual foundations. Surprisingly to me, colleagues in the world of philosophy and psychiatry also failed to make the obvious connection, or if they did, they seemed to have little problem with it (Phillips et al., 2012). Social constructionism was their worldview too.In effect, philosophy of psychiatry had nothing to provide; it did not analyze or critique the philosophical worldview of DSM leadership; it shared that worldview and participated in it (Kendler, 2013).The result, in my view, is that mainstream philosophy of psychiatry has failed in the role which it could have played, the role of making the unconscious postmodern assumptions of psychiatry conscious, and criticizing those assumptions. Instead, it applauded them.My broader critique of mainstream philosophy of psychiatry gets played out in papers such as this one in relation to the DSM term MDD, which should be dropped because it is not a scientifically sound term; it has many conceptual and scientific falsehoods within it, which both a philosophical analysis and a scientific analysis would demonstrate.The term MDD was invented in the DSM-III process in the late 1970s to get votes for passage of that third revision by the American Psychiatric Association in 1980 (Decker, 2013). It literally was a social construction. To the extent that it had any scientific basis, it had its roots in the... (shrink)

It is a mistake to think that any philosophical contribution to the study of psychopathology is otiose. I identify three non-exhaustive roles that philosophy can and does occupy in the study of mental disorder, which I call the agenda-setting role, the synthetic role, and the regulative role. The three roles are illustrated via consideration of the importance of Jaspers' notion of understanding and its application to specific examples of mental disorder, including delusions of reference, Capgras delusion and other monothematic delusions, (...) and clinical depression. Together the three roles assign to philosophy of psychopathology the task of determining how to situate the varieties of mental disorder within the system of interpretive and evaluative concepts that partially make up the dynamic but indispensable manifest image. (shrink)

Is addiction a behavioral pattern, or the underlying cause of a behavioral pattern? Both views are found in prominent accounts of addiction, but theorists generally do not notice that they are taking a controversial position, let alone justify it. A third possibility is that addiction consists in both addictive behavior and its causes, though this view is less obviously present in the literature. I argue that two important considerations favor the "cause view" over the "behavior" and "hybrid" views. The first (...) is that we want to be able to explain addictive behavior with reference to addiction. The second is that addiction seems to persist long after addictive behavior has ceased. Only the cause view can easily accommodate both data points. (shrink)

Rosanna Wannberg (2024) has given us a dense but helpful introduction to certain philosophical questions raised by the fact that many patients recovering from psychotic illnesses describe their recovery in terms of gaining or regaining a 'sense of self' and a 'sense of agency,' which often involves acceptance of the 'fact' of being mentally ill, for example, of 'having schizophrenia.' She raises two important questions: How should we understand what is going on in these accounts? and What are the implications (...) of these reports for our understanding of what it is to have a 'sense of self' or a 'sense of agency'—of 'subjectivity' generally—which might have, both, clinical and nonclinical implications?What does it mean... Read More. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:How Narrative Counts in Phenomenological Models of SchizophreniaThe author reports no conflicts of interest.Rosanna Wannberg (2024) offers an intriguing and novel critique of the predominant phenomenological model of schizophrenia, the ipseity disturbance hypothesis. According to this model, which was initially proposed by Sass and Parnas (2003), schizophrenia is best understood as arising from a disturbance or instability of minimal or basic self-hood, the sense of being present to oneself (...) and one's experiences (Henriksen, 2022). This disturbance appears as various experiential anomalies, sometimes termed "anomalous self (or world) experiences" or "self disorders," which include such phenomena as alienation from subjective processes, doubt in the existence of the world or one's own existence, fluidity of boundaries between self and others or self and world, and many other phenomena. Many of these have been captured in the Examination of Anomalous Self Experience (Parnas et al., 2005) and the Examination of Anomalous World Experience (Sass et al., 2017).At the same time, some research reveals the presence of self disorders in nonpsychotic conditions like panic disorder (Madeira et al., 2017) and depersonalization/derealization disorder (Sass et al., 2013). There are also competing phenomenological models that posit schizophrenia instead as a disturbance of dialogical self (Lysaker & Lysaker, 2002) or as a disruption of automatic perceptual processing (Uhlhaas & Mishara, 2007). Such works contain implicit critiques of the ipseity disturbance hypothesis that focus on the specificity of self disorders, or else on the specific nature of the underlying disturbance in schizophrenia.Wannberg's critique is distinct from these others: by considering the validity and function of recovery narratives, she raises crucial epistemological and ethical questions about the phenomenological approach to psychopathology, asking not only whose narrative counts, but how narrative counts. In particular, Wannberg questions a phenomenology that, she suggests, might find any ongoing symptoms as evidence of continued alterations of subjectivity, and that would then be dismissive of recovery narratives—a phenomenology that would prioritize the authority [End Page 71] of consciousness, as Wannberg puts it, over the authority of the person.It is worth stating here that the standard phenomenological response would not be to distrust or dismiss accounts of recovery. Ideally, phenomenological models, along with their ongoing theoretical developments and empirical work, are based on a deep respect for patients' experience and self-descriptions, striving to attend to experiences as they are lived without imposing pre-defined constructs that would limit or alter the experiences in a fundamental way (Nordgaard et al., 2013).Questions about the nature of recovery might be addressed within phenomenology by considering the difference between minimal (or basic) self and narrative (or extended) self, a more complex self-understanding or self-interpretation that is founded on the more basic, pre-reflective sense of being alive in the world (Gallagher, 2000; Parnas, 2007). According to proponents of the ipseity disturbance hypothesis, disturbances of basic self-hood can contribute to disturbances of narrative self, such as confusion about one's future goals or difficulties making sense of one's life history, though it is unlikely for disruptions that originate in the narrative self to trickle down to the minimal self (Henriksen, 2022). Such a view might similarly suggest that it would be unlikely for work on the level of the narrative self to lead to improvements in minimal self. Recovery, according to this approach, might best be viewed as an understanding of and compensation for alterations in basic self-hood, such that a person can develop a relatively solid narrative self that accounts for and manages disturbances of minimal self—while the minimal self may also grow more solid through various therapeutic interventions (Skodlar & Henriksen, 2019).Wannberg finds a more transformative possibility in Wittgenstein's grammatical approach, which is concerned with the function and rules of discourse. According to her grammar of recovery, recovery narratives are not only the product of a process of meaning-making and self-understanding, but they can create meaning and new realities. Furthermore, this process, according to Wannberg, has an inherently social and normative quality to it: the self-work that occurs in recovery and the recovery narrative involves the development of agency, autonomy, and responsibility in a social world... (shrink)

In "Philosophy's role in theorizing psychopathology," Gibson presents a defense of the continued relevance of philosophy to psychopathology, and a non-exhaustive framework for the role of philosophy in this domain (Gibson, 2024). I find it hard to disagree that psychopathology is soaked in philosophy from its origins, and that to try and dry it out would be both unwise and impossible.In this commentary, I go back to Karl Jaspers' account of the role of philosophy in his General Psychopathology. In doing (...) so, I do not find that Gibson adds anything new, but instead gives us a well-illustrated reminder that philosophy "is operative within every living science" (Jaspers, 1997, p. 770).Gibson addresses a broad 'we' who... Read More. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Social, the Outer and the ReflexiveSome More Dimensions of Subjectivity, Schizophrenia, and Its RecoveryThe author reports no conflicts of interest.First of all, I want to express my gratitude to the Association for the Advancement of Philosophy and Psychiatry, Philosophy, Psychiatry, & Psychology, and the Karl Jaspers Award Committee for their recognition of my paper "Institution or individuality? Some reflections on the lessons to be learned from personal accounts (...) of recovery from schizophrenia" (Wannberg, 2024). I am also very thankful for Dr. Paul B. Lieberman's (2024) and Pr. Elizabeth Pienkos' (2024) stimulating comments on the paper.In the original paper, I used the case of the first person accounts of recovery from schizophrenia as a paradigm to elucidate the components of subjectivity more generally, as well as their logical relations. My main point was that considering the "recovery claim" as potentially endowed with a meaning sufficiently close to the official definition of the "personal" sense of recovery at stake—that is, in brief, having "become oneself" despite recurring or residual symptoms—invites us to question current phenomenological, narrative and constructionist approaches of the self in psychopathology. By contrast to these, I stressed the need of a conception of the self more sensible to its social and interpersonal dimensions, which I attempted to sketch out notably by resorting to Wittgenstein's (1953/1997) idea of "grammar." I am very happy that both Lieberman and Pienkos see the appeal to the social as a welcome move with regard to prevailing approaches to schizophrenia and its recovery. But what does it really mean for the subjective or the individual to be socially and interpersonally constituted, and how are we to account for that? [End Page 75]At a first glance, appealing to the social seems to be in line with current trends in psychopathology, including, as Pienkos points out, in the phenomenological tradition. She elsewhere announces a "shift in emphasis" currently taking place within phenomenological psychopathology, characterized by an increasing interest in the situated and dated aspects of subjectivity (Pienkos et al., 2023). This is a valuable turn. However, I am quite dubious that the well-known distinction between an "experiential" and a "narrative" self to which Pienkos appeals is apt to do all the conceptual work required to attain a satisfactory conception of the self and its social dimensions. In my original paper, I took the "recovery account" to challenge both these notions. As concerns the experiential dimension, I held that this type of account questions the phenomenologist's assumption that subjectivity is ultimately grounded in lived (self-)experience. Provided that typical symptoms of schizophrenia (e.g., thought insertion) are expressions of a disorder situated at this most "fundamental" level of the self and provided that they are stemming, at least according to one of the most widespread phenomenological models, from a trait-like disposition present before the onset of psychosis (e.g., Henriksen et al., 2019), it is quite natural to think that these symptoms persist in some form in the context of recovery (e.g., as intrusive thoughts or as "thoughts spoken out loud"). This is indeed the case for several of the authors "in recovery" in the Schizophrenia Bulletin's archives (e.g., Greenblat, 2000), which provided the main source of my analysis. But if this is so, we cannot see their recovery claim as an expression of a "whole" self, so to speak. So we must either say that "personal" recovery from schizophrenia is an illusion or a contradiction, or else we must revise the foundational status of the experiential dimension (other possible options are left aside for the purposes of this brief comment). I argue for the revisionist option. For the equation between the subjective and the experiential does not only lead to an unwelcomed skepticism about the recovery account. There are also more straightforward philosophical reasons for refusing it. Wittgenstein (1980) made a first important step by inviting us to better take into account the variability of the psychological concepts. He notably made a crucial categorical distinction between "lived experiences" (like sensations and mental images) and "attitudes" (like beliefs and intentions) such that all concepts which, when used in the first person... (shrink)

Abstract:In this paper, I argue for a social conception of subjectivity, via a philosophical reading of first-person accounts of recovery from schizophrenia, published in the Schizophrenia Bulletin. Following the hypothesis that these accounts exemplify a more general tension between, on the one hand, normative and social dimensions of the self, and on the other, experiential and psychological dimensions, the first section of the paper formulates the problem from a philosophical perspective inspired by Ludwig Wittgenstein's grammatical approach. The second section explores (...) and rejects different possible readings (sociologistic, phenomenological, or narrativist readings), as conceiving the subject in too passive a relationship with him or herself, and as leading to overly skeptical conclusions about the claims in the first-person accounts insisting on the notion of recovery as a restoration of a sense of self and as empowerment. The third section suggests that a more positive answer can be given via the idea of a certain grammar of recovery governing these narratives, and sketches out how this relates to the more general philosophical question on subjectivity. (shrink)

Research in the philosophy of addiction commonly explores how agency is impacted in addiction by focusing on moments of apparent loss of control over addictive behavior and seeking to explain how such moments result from the effects of psychoactive substance use on cognition and volition. Recently, Glackin et al. (2021) have suggested that agency in addiction can be helpfully analyzed using the concept of affordances. They argue that addicted agents experience addiction-related affordances, such as action possibilities relating to drugs, drug (...) paraphernalia, and drug-related activities, as aberrantly salient motivations for action. Building on this approach, we present a novel two-tiered affordance model of addiction. In doing so, we suggest that what is significant about the addicted person’s world is not simply what affordances are experienced as salient, but also the way in which the addicted person’s world is shaped by a dominant concern. It is not only that addiction-related affordances become more prominent as addiction progresses but that one’s plurality of concerns become monopolized by and funneled through addiction. Our model endorses Glackin et al.’s idea that addiction-related affordances become aberrantly salient, while proposing why they become and remain so. This way of viewing agency in addiction also brings to light important implications for recovery and treatment. For, if an addicted person adopts a new, even “socially approved”, dominant concern, there is a risk that the shape of addiction is preserved, even though the content changes, leaving an individual at the risk of addiction substitution or relapse. (shrink)