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Psychosis and Emotions -- edited by Gumley, Gillham, Taylor and Schwannauer (2013) -- provides a thorough account of the state of the art in psychiatric practice, with a focus on the role played by emotions in the development and manifestation of psychosis. The volume consists of thirteen short essays exploring the issue from different angles, with key themes emphasized by various authors. Chapters 2 & 3 discuss the legacy of early psychiatry on contemporary research that tends to characterize schizophrenia as a disorder of affect (see Moskowitz and Heim; Garfield, Simon & Ramachandran). Chapters 4 & 5 focus on the therapeutic relationship, stressing the importance of the way in which patients frame their experiences (narratives) as well as the way in which they interpret their own mental states (appraisal) -- see Dilks; Harder & Lysaker. Chapters 6 & 10 adopt a developmental perspective and appeal to Bowlby's attachment theory (1969/1980) to draw a connection between the expression of emotions in early infancy and the development of more or less healthy attachment styles in adult life. Both essays then characterize psychotic patients as especially vulnerable in terms of attachment and emotional processing (see Schwannauer; Patterson). Chapter 9 focuses more specifically on the impact that family emotional atmosphere has on patients in the pre-morbid and relapse phase, stressing the importance of factors such as hostility, criticism, emotional over-involvement, warmth and positive comments (Burbach). Chapters 7 & 8 analyze the impact of psychosis from the caregiver's perspective, offering important insights on the ways in which schizophrenic patients can be stigmatized and stereotyped by the clinical staff (see Hinshelwood; Campbell, Byrne & Morrison). Finally, chapters 12 & 13 provide a novel perspective on negative symptoms of schizophrenia -- e.g. flat affect, anhedonia -- by showing a strong connection between these states and social factors such as stigma, discrimination and stress (see Gumley & Birchwood; White, Laithwaite & Gilbert).
Two aspects of this volume are particularly relevant for psychiatrists, psychologists and philosophers interested in the connection between psychosis and emotions. First, most of the essays shed light on the crucial role played by environmental factors -- e.g. social defeat, family atmosphere -- in the aetiology and development of psychotic symptoms. For example, Burbach investigates the strong correlation between relapse and family environments exhibiting high levels of criticism, hostility or emotional over-involvement (p. 117). Again, White, Laithwaite and Gilbert connect the experiences of social subordination or defeat to phenomena such as paranoia and malevolent auditory hallucinations (p. 182). This enhanced attention to environmental factors is significant because it represents a countertendency to the general direction in which psychiatric practice has been moving in the past decades (especially in the United States). Indeed, the approach put forward by the recent editions of the DSM (Diagnostic and Statistical Manual of Mental Disorders, 2013) promotes a view of patients as "objects of scientific study and record" that can be analyzed as "a set of parts […], symptoms and pathologies" (Hinshelwood, p. 87). Within this view, mental disorders are often perceived as neurobiological impairments that can be treated by adopting a strong pharmacological approach. Unsurprisingly, a recent study on the trends of psychiatric treatment in the US between 1998 and 2007 reports an increase in the number of patients receiving solely medication, and an overall decline in the ones receiving psychotherapy (see Olfson & Marcus 2010). Yet -- as stressed by several authors in this volume -- it becomes increasingly important to offer accounts of psychiatry able to integrate neural and psycho-socio-cultural elements. Indeed, schizophrenic patients often exhibit abnormalities at the limbic or cortical level (Robbins, p. 159) as well as dysfunctions in dopamine release (White, Laithwaite & Gilbert, p. 182). At the same time, these neurological changes may result from non-biological factors such as adverse life experiences -- e.g. discrimination -- or detrimental social environments -- e.g. hostile or critical family atmosphere (see chapters 9 and 13). In this sense, an integrated approach has the advantage of acknowledging the complexity of psychosis without having to commit to a privileged level of explanation (biological or psycho-socio-cultural). Further benefits of such an approach also become apparent in clinical practice: in the diagnosticphase, patients are not merely seen as "a set of parts" that need to be targeted in a piecemeal fashion (Hinshelwood, p. 87), but rather as intentional agents with a life history that can prove meaningful in the formation of symptoms. In the therapeutic phase, a successful treatment would address biological and environmental aspects simultaneously. Indeed, whereas some neural aspects of psychosis -- e.g. dopamine imbalance -- can be effectively targeted with medication, others -- e.g. attachment style -- are better tackled through various forms of psychotherapy. Again, this point has been supported by recent studies on depression reporting a higher rate of success for combined therapies over medication alone (see DeRubeis et al. 2008; Pampallona et al. 2004). Given the high degree of co-morbidity between depressed and schizophrenic patients (Gumley & Birchwood, p. 165), a combined approach to therapy is likely to succeed for psychotic subjects as well.
Second, several essays draw connections between history of psychiatry and contemporary research on mental disorders, uncovering the important contribution of early psychiatrists such as Bleuler, Freud, Jung and Minkowski. This aspect appears -- again -- particularly meaningful because it runs counter the tendency to view psychiatry as a fully operationalized discipline, where the patient's narratives and life experiences are not playing a central role. In this respect, some researchers talk about "the death of phenomenology" in psychiatry (Andreasen 2007) while others emphasize the progressive marginalization of psychoanalysis within the field (Tekin 2014). Yet, many contributions in this volume highlight the value that psychodynamic and phenomenological approaches bring to the table in the research about emotions and psychosis. Notably, Bleuler was the first to characterize schizophrenia as an affective disturbance rather than a mere disorder of thinking: "There is a disease in which the suppression of the emotions may be said to occupy the foreground of the picture" (1906/1912 -- quoted by Moskowitz & Heim, p. 14). Along similar lines, Jung talks about internal representations that are "emotionally charged" and may become pathological if they are powerful enough to distract the individual from everyday tasks (Ibid., p. 11). The -- Jungian -- idea that emotions can guide perception in some important sense has been recently revived by studies on anxiety and fear detection, where highly-anxious subjects tended to interpret neutral stimuli as threatening (see Fox et al. 2002). More generally, Freud has repeatedly stressed the importance of interpreting psychiatric symptoms by looking at the patient's life experience, with particular attention to traumatic and emotionally charged events. Thus -- in a Freudian spirit -- several authors in this volume are exploring the "roots and significance" of psychosis (Freud 1911/1958, p. 36) by looking at patients' stories of stigma (Hinshelwood; Campbell, Byrne & Morrison), social defeat (White, Laithwaite & Gilbert) and disruptive family environment (Burbach).
For these reasons, Psychosis and Emotions constitutes a valuable resource for theoretical and clinical researchers interested in exploring a non-mainstream perspective on psychiatry, where environmental factors and history of the discipline are -- rightfully -- taken into consideration.
§ Andreasen, N. C. (2007). "DSM and the death of phenomenology in America: an example of unintended consequences." Schizophrenia Bulletin, 33(1), 108-112.
§ Bleuler, E. (1906/1912). Affectivity, Suggestibility, Paranoia (Trans. C. Ricksher), Utica, NY: State Hospitals Press.
§ Bowlby, J. (1969/1980). Attachment and Loss. Vol. I: Attachment. London: Hogarth Press.
§ DeRubeis, R.J. et al. (2008). "Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms." Nature Reviews Neuroscience, 9(10): 788-796.
§ Fox, E., Russo, R. & Dutton, K. (2002) "Attentional bias for threat: Evidence for delayed disengagement from emotional faces." Cognition & Emotion 16(3): 355--79.
§ Freud, S. (1911/1958). "The disposition to obsessional neurosis, a contribution to the problem of the choice of neurosis." In The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XII (1911-1913): The Case of Schreber, Papers on Technique and Other Works (pp. 311-326).
§ Gumley, A., Gillham, A., Taylor, K., Schwannauer, M. (eds.). (2013). Psychosis and Emotions: The Role of Emotions in Understanding Psychosis, Therapy and Recovery. New York: Routledge.
§ Olfson, M., & Marcus, S. C. (2010). "National trends in outpatient psychotherapy." American Journal of Psychiatry, 167 (12), 1456-1463.
§ Pampallona, S. et al. (2004). "Combined Pharmacotherapy and Psychological Treatment for Depression: A Systematic Review." Archives of General Psychiatry 61: 714-719.
§ Tekin, S. (2014). "Operationalizing the Self in Scientific Psychiatry: Perils and Promises." Paper presented at the Early Career Scholars Conference in Philosophy of Psychiatry(Pittsburgh, Center for Philosophy of Science).
© 2014 Valentina Petrolini
Valentina Petrolini, University of Cincinnati (Graduate Student), Philosophy Department