Depersonalization - Self and Sensation.

DEPERSONALIZATION: SELF & SENSATION. Oscar Hedstrom History and Philosophy of Science, Sydney University November 2010 CONTENTS Introduction ………………………….…….…. p. 3 Part One: Past & Present……………..………. p. 6 What is depersonalization and why don’t I know about it? ……..………….……….. p. 6 Historical Attempts…..…………...p. 11 Contemporary Debate………….... p. 21 Part Two: Phenomenal Selfhood………...…. ..p. 30 Humphrey’s Sensation…………… p. 35 Depersonalization & Sensation......p. 40 Metzinger………………………..…p. 46 Stocktake……………………….….. p. 49 Thick-Time Revisited………………p. 50 Conclusions………………………………………p. 54 References………………………….……...……..p. 56 2 Introduction I exist, but outside real life… My individuality has completely disappeared; the way in which I see things makes me incapable of realizing them, of feeling that they exist. Even when I can see it and touch it, the world appears to me like a phantom, a gigantic hallucination…I am perfectly conscious of the absurdity of these ideas, but cannot overcome them. A patient quoted in Ludovic Dugas’ ‘Une cas de depersonnalisation’, (1898). Though symptoms of depersonalization have been documented for well over a hundred years, there continues to be considerable debate over the condition. Is it a ‘condition’, disorder, syndrome, disease, or just a strange experience? Where the DSM-IV classifies Depersonalization Disorder as a dissociative disorder, the ICD-10 lists it as the independent neurotic condition “depersonalizationderealisation syndrome”1. Despite nosological and etiological disagreement, I argue that the core symptoms of depersonalization have shown remarkable homogeneity over time. Whatever the label or source of the disorder, patients feel estranged from both the world and their sense of ‘self’. It appears that beneath depersonalization symptoms lies some alteration so fundamental to phenomenal consciousness that we do not yet have conceptual room for it. This thesis is both an exploration of some of the conceptual problems as well a history and analysis of the search thus far. After a brief outline, the first section will explore the history of depersonalization theory. Early thinkers on the subject, from France and Germany, were often distinct in their approach. The sensory theories belong to the likes of Ribot, Esquirol, Sollier, Seglas and Krishaber; while the work of Löwy, Störring and Jaspers describe depersonalization as an ‘affective’ disorder. But of course, it is not so neat – there are theories of memory and recognition, of body schema, of psychic energy and self-ascription. At first these theories seem remarkable for their variety. But contrary to the opinion of perhaps the foremost expert on depersonalization, Maurico Sierra, I find not divergence but convergence on the 1 Those who take depersonalization seriously might take issue with the fact that depersonalization-derealisation syndrome comes right after ‘neurasthenia’ and other controversial psychosomatic disorders including “writer’s cramp”. 3 historical debates over the condition. I argue that the disagreements are superficial – simply different descriptive approaches to the same fundamental phenomenon. The second section will examine contemporary debate and research into depersonalization. Current diagnostic categories are struggling to adequately accommodate the condition, and these limits will be examined. For instance, there are extremely high levels of comorbidity with other psychiatric conditions – from anxiety and depressive disorders to delusional misidentification syndromes, thought-insertion and cases of multiplicity. While I do not examine psychoanalytical theories of depersonalization, the notable German psychoanalyst Paul Schilder did make the observation that depersonalization was “present in almost every neurosis” (1935). The high levels of comorbidity is a statement to its deeply fundamental nature, and presses the importance of coming to a better conception of the experience for the greater benefit of psychiatry and psychology in general. Even as Sierra (2009) charges “an ‘emotionally colouring’ mechanism” as the source of the dysfunction, it remains with the historical theories in the vague category of ‘whatever it is’ that gives percepts the quality of immediacy, of vividness, of reality. It is not made clear how the vividness of a given percept is related to the experience of selfhood that is so poignantly affected in depersonalization. Of course, an exploration of a fundamental psychological phenomenon is not one restricted to psychiatric cases. It is an exploration into consciousness as a whole. It is an exploration motivated by reverse-engineering, where to understand how something works we must gain insight from cases of disorder. With psychiatry embroiled in diagnostic debates over the condition (and many others), it is of little help (or not even interested in) coming to a deeper phenomenological understanding. The putative advantage of diagnostic psychiatry is that it can steer clear of these murky phenomenological debates. But for the kind of insight I am looking for, to make sense of what the patients are saying as they divulge their symptoms, we must look to a more theoretical psychology, to consciousness studies and the philosophy of mind. 4 Where many cases of mental disorder have been given direct treatment by philosophers, depersonalization has yet to grab their attention. While it’s not clear exactly what theorists or patients are talking about with depersonalization, they are certainly talking about something. Before depersonalization can be analyzed in any philosophical detail, we need to have covered the underlying philosophical terrain. We need to know where to look. To scope this out, I examine the recent work of two theorists in particular. I explore what their accounts of consciousness might be able to lend depersonalization – and vice versa. I look to the work of theoretical psychologist Nicholas Humphrey and his theory of ‘sensation’. Here, Humphrey makes suggestions as to how our experience of the external world is important for the creation of our internal world – the self. We create sensations as an evaluative response to the environment, and these become things that matter to us as subjects, as selves. I choose Humphrey because his discussion of sensation raises issues that have been central to debates about dissociation for a long time. However, the theory sits strangely. There is no broader framework for his ‘sensation’ and the emergent ‘self’ to slot. For this, I turn to the cross-disciplinary juggernaut that is Thomas Metzinger. His computational-representational account of the self- and world-models might be used to couch Humphrey’s sensation, and as a bridge across certain philosophical chasms. I conclude by reflecting on some of the inherent conceptual difficulties involved in the target problems of depersonalization and phenomenal consciousness at large. 5 Part One: Depersonalization - Past & Present The symptoms of depersonalization have been described since the mid-19th century. Despite this, uncertainty surrounds both the etiology and nosology of the condition. The major diagnostic handbooks - DSM-IV and the ICD-10 – still differ in their categorization of pathological depersonalization. An exploration of past and current debates serves to reveal the important features of depersonalization. It also reveals their variety. However, I argue that many historical theories are, at a fundamental level, compatible. I believe that this ‘fundamental’ level is the relevant level for a phenomenology of depersonalization. Disagreements are superficial, though they reveal how diversely important conceptions of sensation and self are to consciousness. Current disagreements are the inevitable result of the attempt to subsume a complex psychological phenomenon into a rigid diagnostic system. But first, a brief overview of what depersonalization is and why you might not have heard of it What is Depersonalization and Why Don’t I Know About It? Patients suffering from depersonalization disorders describe both their experience of the external world and internal self as strange and distant. The symptoms of depersonalization vary in severity, duration, and nature along a spectrum (Lambert et al., 2002). Below is the ICD-10 entry on depersonalizationderealization syndrome: A rare disorder where the patient complains spontaneously that his or her mental activity, body and surroundings are changed in their quality, so as to be unreal, remote or automatized. Among the varied phenomena of the syndrome, patients complain most frequently of loss of emotions and feelings of estrangement or detachment from their thinking, their body or the real world. In spite of the dramatic nature of the experience, the patient is aware of the unreality of the change. The sensorium is normal and the capacity for emotional expression intact. (ICD-10, F48.1) Despite the official status of depersonalization disorders (as included in the DSM and ICD), most laypersons and many psychiatric professionals have never heard of the term. Simeon & Abugel, who wrote the first ‘contemporary’ monograph on 6 the subject, Feeling Unreal (2006) would take issue with the ICD comment that depersonalization disorders are ‘rare’. They assert that “Depersonalization Disorder (DPD) remains one of the most frequently misdiagnosed or underdiagnosed conditions in modern psychiatry” (p.83). Depersonalization experiences do appear to be prevalent. A recent study suggests that 1-2% of the population experience ‘clinically significant’ symptoms of depersonalization (Michal et al., 2010). Even the more conservative estimate of 1% (Johnson et al, 2006) places clinically significant depersonalization on par with well-recognised psychiatric disorders , like schizophrenia and manic-depression. Indeed, a 1964 panel discussing the clinical relevance of depersonalization concluded it was the third most prevalent psychiatric symptom, after depression and anxiety (Stewart, 1964). This is startling, seeing how familiar we all might be with experiences of depression and anxiety. How is it that such a common psychological experience has been so neglected? Simeon & Abugel (2006) draw attention to this perplexity, but fall short of providing clear reasons.2 Sierra (2009), in the second monograph on the subject, suggests three. The first, implied but not clarified by Simeon & Abugel, is that psychiatrists are ‘taught’ that depersonalization disorder is rare or non-existent. More specifically, they learn that if depersonalization symptoms are observed, they are merely secondary, lesser symptoms of another more significant condition (2009, p.54). Often this cannot be denied. Many other psychiatric conditions exhibit high comorbidity with depersonalization symptoms. Brauer et al. (1970) found 80% of psychiatric in-patients admitting to past and present depersonalization experiences. Findings such as these caused some skepticism as to the validity of depersonalization as an independent psychological condition. The contested status of DPD as an independent condition is not a vital issue for this paper. If 80% of in-patients relate to depersonalization experiences it surely demands interest, whether or not it exists as a discrete category of experience. 2 Post-epilogue, the FAQ section (p.217) asks, “Why have so many doctors never heard of depersonalization before?”. They reply that professionals are ‘not well informed’ about depersonalization, so dismiss or misdiagnose it as something else. Which seems circular – why, then, are most psychiatrists and psychologists not well informed of this hardlynew, fairly common disorder? 7 Despite such clinical figures, there is not even a mild familiarity with the phenomenon. While we might not suffer from an anxiety or depressive disorder, we are certainly familiar with the symptoms. You know what it is like to feel anxious or depressed, so can to some degree imagine what it is like to be pathologically so. So while depersonalization disorder might be prevalent, perhaps there is a gap in psychological empathy as to what the experience might be like. Contrary to this intuition, there is growing evidence that many of us do know what depersonalization is like. We just don’t know how to describe it, or what on earth it might be called. There exists a form of ‘transient’ depersonalization, which is benign and especially common to youth. A number of studies have suggested a prevalence of transient depersonalization ranging from 30% to 70% in such normal populations (Sedman, 1966; Myers & Grant, 1972; Trueman, 1984; Elliot et al., 1984). It does not appear that a lack of normal psychological familiarity can be blamed for the neglect of depersonalization in both clinical and lay contexts. A possible explanation comes from what is known as a ‘clinicians illusion’ (Cohen & Cohen, 1984). Here, those patients that seek psychiatric care differ in important aspects to the normal population who have depersonalization experiences. The difference here would be in levels of distress. In a non-clinical study, only 3 out of 20 persons who experienced depersonalization found their experiences distressing enough to justify the diagnosis of a DPD disorder – the same number of those who claimed to find depersonalization enjoyable (Charbonneau and O’Connor, 1999)3. While many might experience depersonalization, as non-clinical studies suggest, they are not always felt to be distressing by the subject, or perhaps not viewed as pathological outside a psychiatric context. A second reason resides in the problematic reluctance of depersonalized patients to seek help, for fear of being thought ‘crazy’. This is especially prominent, given the ineffable nature of the condition. Even if patients do seek help, they have a 3 Michal et al. (2009) found their sample that 4 of their 25 subjects with clinically significant depersonalization symptoms still did not feel distressed by their symptoms at all. 8 very hard time describing their symptoms. Complaints are couched in “as if” qualifiers and vague metaphors of opacity. They describe a veil, mist, fog, glass, plastic wrap, a wall or something similar – between themselves and the world. These can easily be misinterpreted, contributing to the first reason (misdiagnosis). For instance, the statement “I have no emotions” might easily be understood as a ‘depressive’ symptom. The ineffable quality of depersonalization experiences gives some hint as to the fundamental level of whatever it is that is the cause of the disorder. Whatever the reasons, depersonalization has proved an elusive topic. Despite almost a century of exploration and elucidation of these symptoms, there is still allegedly a lack of consensus. Depersonalization Symptoms For purposes of familiarisation, it is necessary to include a brief run down of depersonalization symptoms. It will hopefully provide some idea of what kind of an experience the following theoretical discussions are attempting to frame. A huge variety of depersonalization symptoms have been reported, with various nuances and manifestations. Schilder (1928) describes four main symptoms domains, Sierra and Berrios (2001) use five, Sierra et al. (2005) reduce it to four again, Simeon et al. (2008) find five, and so on. I will try and describe what I think are the four most important experiential components, by a brief grouping of patient statements.4 1) Distorted perception These symptoms are most typically classed as ‘derealization’ symptoms. Examples include: • I’m seeing things differently from how I used to. It feels like I’m looking through someone else’s eyes. 4 The following patient testimonies are taken from both Sierra (2009), p.24-39, and Simeon & Abugel (2006), p.80-82. 9 • It is as if I was looking through a pane of glass. (Other metaphors include seeing through a mist, veil, camera, cellophane, goggles, cloud or being ‘on another planet’). • Sounds appear to come from a distance. Music usually moves me, but now it might as well be mincing potatoes…there is no response in me. • The tactile characteristics of objects seem strangely altered. 2) Body Experience This includes perceived deficits in agency, a sense of body ownership, or disembodiment. • I can’t feel myself touching my own body. I exercise but don’t feel I am doing anything, just my muscles but not my body moving. • It’s like auto-pilot has been switched on. I notice my hands and feet moving, but it’s as if they did not belong to me, and were moving automatically. How do I control them? What makes them move? • As I walk, I have the distinct feeling of floating or bouncing up and down on a rubber floor…as if I’m walking on a cloud. 3) Emotional numbing • My husband and I have always been happy together but now he sits here and might be a complete stranger. I know he is my husband only by his appearance – he might be anybody for all I feel towards him. • I just cannot feel anything when somebody else is suffering or in pain. I smile, or give consolations, but it is all an act. • I have no moods. I am dead. I feel nothing. 4) Anomalies in subjective functioning This category includes subjective deficits in recall, imagery and time experience. Schilder (1935) observed that “Patients characterise their imagery as pale, colourless and some complain they have altogether lost the power of imagination”. More recent testimonies include: 10 • My memories feel like they did not happen to me. Remembering my past is like looking at photographs of someone else’s life. My most treasured memories are now dulled. I cannot tell if it has happened or I dreamed it. • Thinking itself feels strange and unnatural: it has lost all spontaneity. • It seems as if things that I have done recently had taken place a long time ago. Historical Attempts The most recurring theme in the history of depersonalization has been a lack of agreement as to how best to conceptualise and classify the condition. (Sierra, 2009, p.19). This section will explore some of the different positions early theorists have taken on depersonalization, for the purpose of gauging how much these theories really disagree about as well as introducing some classic complaints and descriptions of depersonalization experiences. I argue against Sierra’s statement, that there is pervasive conceptual agreement about the condition, that most discrepancies are descriptive in nature. Early Descriptions & Melancholia An abyss, they say, separates them from the external world, I hear, I see, I touch, say many lypemaniacs, but I am not as I formerly was. Objects do not come to me, they do not identify themselves with my being; a thick cloud, a veil, changes the hue and aspect of objects. (Esquirol, 1838, p.414) One of the earliest to professionally describe depersonalization symptoms was the French psychiatrist Jean-Etienne Esquirol. In the quote above, he is summarizing the complaints of five patients of his, which he thought to be suffering from ‘lypemanie’ or melancholia (an early term for depression). As is still the case, depersonalization symptoms are often described (and allegedly ‘cloaked’) by the context and language of depressive illness. At this time, a number of theorists from both France and Germany described depersonalization symptoms in such 11 ‘melancholic’ contexts - including Griesinger (1845), Zeller (1838) and Krishaber (1873). Even at this early stage, there was some awareness that these symptoms of detachment were unlike those of normal depression, and indicative of “a very remarkable state” (Griesinger, 1845). Griesinger speaks of how his patients have “much difficulty in describing [the ‘unreality’], and which we also have ourselves observed in several cases as the predominant and most lasting symptom” (p.157), making him the first to start unraveling depersonalization from its melancholic scroll. Below is a patient testimony from Griesinger that provides a particularly poignant complaint of a depersonalized individual, I continue to suffer constantly…Even though I am surrounded by all that can render life happy and agreeable, in me the faculty of enjoyment and sensation is wanting or have become physical impossibilities. In everything, even in the most tender caresses of my children, I find only bitterness. I cover them in kisses, but there is something in between their lips and mine…The functions and acts of ordinary life, it is true, still remain to me; but in every one of them there is something lacking. That is, the sensation that is proper to them...Each of my senses, each part of my proper self is as if it were separated from me and can no longer afford me any sensation...it seems to me that I never actually reach the objects that I touch. My eyes see and my spirit perceives but the sensation of what I see is completely absent. (Griesinger, 1845, p.157) For Esquirol, Griesinger, and Zeller, the most pressing need was clear description of these baffling symptoms, rather than theories as to their cause. Most got no further than lumping them together as an inexplicable aspect of melancholia. Of these early descriptions, the most comprehensive study was made by the Hungarian ear, eye, nose, and throat specialist Maurice Krishaber (1873). Krishaber described a group of 38 patients suffering from a mix of anxious, depressed, and fatigued moods, classifying them as suffering from what he called “Nevropathie Cerebro-Cardiaque”. Around a third of these patients complained of a baffling loss of reality. It was not until Ludovic Dugas (1898), exploring déjà vu phenomena, that the term ‘depersonalization’ was coined in reference to those particular symptoms describing the ‘unreality’ and self-strangeness of these experiences. 12 Sensory Theories According to Berrios & Sierra (1997), the ‘sensory’ theories of depersonalization are a product of 18th century intuitions associating sensation with selfhood. Krishaber was the first to explicitly suggest a theory of depersonalization, though it was not yet so coined. In 1873, Krishaber concluded that “multiple sensory distortions” were the cause of the “self-strangeness” typical of depersonalization (p.171). He was not alone in relegating the source of disorder to the senses. Ribot, in Les Maladies de la Personnalite (1895), and Seglas’ Les Maladies mentales et nerveuses (1895), saw depersonalization experiences resulting from a change in ‘coenesthesia’ or ‘cenesthopathie’. These terms referred to a holistic sense of “bodily sensation” or “bodily existence”. Sollier (1910) thought depersonalization feelings arose from an impairment of what he more specifically called ‘cerebral coenesthesia’. In Germany, Foerster (1903) developed a slightly more sophisticated theory. He suggested that all sensations had two components – the sensory component (say, vision), and a ‘concomitant muscular sensation arising from the movement itself’ (say, the eyeballs moving to the stimulus). Normally this action was synchronic, and resulted in a sense of subjective reality; but in depersonalization, the second component was not felt. I suggest this two-component model might be rendered analogous to some of the later ‘affective’ theories. Such sensory theories came under fire, though I will argue that the criticism misconstrued the meaning of the theories. Dugas’ (1898) paper ‘Un cas de depersonnalisation’, explained that “analogies can deceive” and theorists supporting sensory theories are mistaken to take patients’ complaints of perceptive distortion so literally (p.456). He criticizes Krishaber (and the philosopher-critic Hippolypte-Adolphe Taine) specifically: Are these phenomena to be considered, as Taine suggested, as ‘distortions of sensation’ and not of judgment and reason? …The fact is that sensations are not affected and that, on the contrary, they are experienced with unusual vividness and intensity. The sensory problems that Krishaber reported …should be considered as chance accompaniments and not as triggers or causes. …In this context, one has to make allowances for the unavoidable use of metaphors by which the subject tries to convey his strange experiences. (p.456-457). 13 Pierre Janet (1928), too, criticized sensory theories of depersonalization. He noted, though it seems obvious, that patients suffering from the alleged ‘feelings of unreality’ in depersonalization could see, hear, feel, etc. perfectly well. Furthermore, he noticed that patients with established sensory disorders – such as diplopia (double vision), or the loss of joint proprioception in patients with neurosyphilis - did not report depersonalization feelings as a sensory theory might predict. While these might be legitimate criticisms to make of some of Krishaber’s comments, they misunderstand what kind of ‘sense’ was allegedly affected by other ‘sensory theories’ of depersonalization. Dugas and Janet seem to understand sensory theories as referring to specific disorders of perception –the functioning of the sensory ‘organs’ or ‘modalities’ themselves. For example, Dugas comments on Krishaber’s observation that his “patients reported seeing objects as flat, as a detached image…” and insists that “this was just a coincidence” (1898, p.457). It is unclear why Dugas accepts this example of a ‘sensory distortion’ as “just a coincidence” when he could just as easily account for such a report as the patient speaking metaphorically, as he dismissed similar complaints. In defence, I believe that the sensory theories of Sollier, Seglas, and Foester do not suggest specific sensory deficits of, say, sight, or hearing. While they include elements of ‘perception’, they imply something more. They evoke a much broader ‘sensory’ deficit when they talk of ‘coenesthesia’ and ‘cenesthopathie’. While Sierra (2009) translates these terms as “a sense of bodily existence”, it seems more obscure to Berrios (1996). Berrios compares these French terms to the German distinction between ‘skin sensations’ and ‘common feeling’, where cenesthopathie and coenesthesia are analogous to the latter. Cenesthopathie is a term: referring to the sensations that are left after touch, temperature, pressure and location are separated off…it thus includes pain and ‘objectless’ sensations such as well-being, pleasure, fatigue, shudder, hunger, nausea, organic muscular feeling, etc. These sensations were also called the coenesthesia and considered as providing a ‘sense of existence’. (Berrios, p.45) 14 Sollier’s “cerebral coenesthesia” would seem to twist this bodily ‘common feeling’ into a more psychological sense of integration. At any rate, the ‘sense of existence’ allegedly distorted in sensory theories of depersonalization is hardly analogous to Janet’s example of sensory distortion, diplopia. Such criticisms seem to misunderstand the theories, opaque as they might be. Illuminated by Berrios’ conceptual analysis of coenesthesia actually makes the sensory theories somewhat redolent of Janet’s own theory of depersonalization, as we shall see. Memory With so many patients couching their symptoms in terms of ‘unfamiliarity’ – both towards objects in the world and their own actions - it not surprising that it was often considered a disorder of memory or recognition, and not a sensory or melancholic phenomenon. Emil Kraeplin appears to have been personally acquainted with depersonalization, which he believed was the result of memory disturbances very much akin to déjà vu phenomena: All of a sudden the surroundings become hazy, as something quite remote…The impressions from the surroundings do not convey the familiar picture of everyday reality, instead they become dream-like and shadowy…as if seen through a veil. (Kraeplin 1887, p.410) As mentioned, Dugas (1894) was first exposed to depersonalization symptoms in his study of déjà vu phenomena, potentially considering them an extreme form of ‘jamais vu’ (‘never seen’). Of particular prominence was Dutch philosopher Heymans (1904), who explored correlations between déjà vu and depersonalization. Heymans undertook two surveys of the two experiences, and found that while déjà vu experiences were more common, there was a correlation between déjà vu and depersonalization experiences. Sierra (2009, p.13) notes that Sno & Draaisma (1993) have confirmed Heyman’s findings. However, it seems that Sno & Draaisma only ‘partially’ confirmed Heyman’s findings and the conclusions he drew from them - those pertaining to the predisposing factors of both experiences. Furthermore, Sno & Draaisma report that from his findings, Heyman’s inference was not that déjà vu and depersonalization were caused 15 specifically by a putative memory disturbance - but from a momentary reduction of ‘psychological energy’.5 While Dugas was first to suggest it, he came to disagree with theories of misrecognition or memory. He argued that the strangeness of depersonalization encompassed all mental activity, whereas in experiences of ‘disturbed recognition’ the feeling is restricted. In other words, when you have a moment of déjà vu, you quite explicitly feel like the present has been previously experienced. Depersonalization seems global and thoroughly inexplicable. Misidentification Misidentification is different from misrecognition, in that it is primarily somatic in nature. A number of theorists found the similarities between depersonalization and delusions of misidentification particularly suggestive. Ehrenwald (1931) notes patients with left hemiplegia and anosognosia who then developed depersonalization-like symptoms. L’hermitte (1939) and Ey et al. (1947) made comparisons to asomatgnosic patients, who lack awareness of certain body parts. L’hermitte makes the comment. …the depersonalized patient] sees his body, touches it without being able to persuade himself that it is his own flesh that feels and moves. We are then in the presence of an asomatognosia since the subject sees his body and does not recognise it. (in Ey et al, p.66) Interestingly, Ey et al. stressed the role of emotional factors in the integration of one’s body image, and like Heyman’s, speaks of ‘energy’: “the image of our bodies is continuously shaped by our sensations and perceptions, but emotional processes constitute the energy and force for the constructive synthesis” (1947 p.67). Again, we see the theory take step away from straight ‘perceptions’, toward vaguer ‘emotional’ processes, to the psychological physics of ‘energy’ and ‘force’. Whatever these are supposed to refer to, I do not think that they are much different from the ‘common feelings’ of coenaesthesia, or the ‘activity-feelings’ of general and specific mental processes. 5 Heymans failed to define exactly what he meant by ‘psychological energy’, despite it being crucial to his hypothesis. Sno & Draaisma understand it along the lines of Janet’s ‘psychological tension’, where the reduction of such ‘tension’ resulted in an erroneous evaluation of the present perception (Sno & Draaisma, p.24). 16 Affect Affective theories developed as a reaction to the criticisms of Dugas and Janet on the sensory theories. They steer away from the perceptive modalities, though not, I think, away from what the sensory theories really implied. They [the depersonalized], it is true, see and hear everything. But without experiencing any representation or feeling of their inner stirrings, of their sensory vividness. (Shafer, 1880, p.242). Shafer, like Esquirol and Griesinger before him, thought depersonalization a subtype of melancholia, which he referred to as ‘Melancholia Anaesthetica’. The lack of ‘affect’ he refers to is not simply one of ‘emotion’. It is a certain quality of experiences. Proponents of ‘affective’ theories pick up from what was implied (and subsequently misconstrued) by many of the sensory theories. In Germany Gustav Störring (1900), like Seglas (1895), believed coenesthesia to be necessary for an experience of ‘self’. Though not sufficient, he claimed, …organic sensations are a condition of consciousness of the self; and the awareness of one’s body, which is due to them, must be regarded as one constituent of it. (Störring p.283) In other words, sensations are a necessary condition for bodily awareness, and bodily awareness is vital to a normal experience of selfhood. This is as precise a formulation the historical theories of depersonalization provide as to the relation of sensation to selfhood. Ignoring Dugas’ (1898) criticisms, Störring developed the ideas of Krishaber by insisting that the disturbance in depersonalization was in the “power of perception”, though with some qualification - “…and accordingly of the awareness that one can have of certain perceptions” (p.289). After studying depersonalization, Störring came up with a general theory of ‘self-awareness’, or what I will later characterise as a theory of ‘self-experience’. The theory was three-fold, made up of coenesthesia, activity-feelings, and the power of perception. Österreich (1907), following Störring’s ‘activity-feelings’, postulated that depersonalisation was the result of an ‘inhibition of feelings’ [affect], and that these feelings are responsible for ‘self-awareness’ and feelings of agency. Löwy, 17 also quite taken by Störring’s component of ‘activity-feelings’, later elaborated. Calling them ‘action feelings’, they referred to …the action-feeling of psychological activity, or thought-feeling; it normally accompanies every psychological act, it provides altogether the awareness of the reality of perceived objects…in its absence colours and tones become distant and strange, things become unreal, as if from another world. (1908, p.460). This ‘action feeling’ is thus a general one, though Löwy did suggest there were specific kinds of such ‘feelings’ that accompanied specific psychological acts, e.g. memory feelings, impulse feelings, bodily feelings and so on. These feelings were emotionally neutral – simply the distinct feeling of carrying out a particular mental activity, say, the feeling of ‘coming up with an idea’, or ‘suddenly remembering something’ – irrespective of whether it was a ‘pleasurable’ idea, or a ‘sad’ memory. I suspect that whether the term is ‘feeling’ or ‘sense’, there is not so much difference in terms of what either sensory or affective theories are referring to at heart. Self-Experience Some theorists are not so easily grouped under a specific theoretical label, but nevertheless made important contributions to depersonalization theory. Janet & and Dugas come to point at diminished psychic energy, Mayer-Gross suggests depersonalization is misplaced functional response, and Jaspers couches it in another general theory of self-experience. Considering psychological facts as actions, Janet considered depersonalization to be a case of ‘psychasthenia’. For Janet (1903), consciousness was constituted by both primary and secondary acts. Primary acts are stimulated by the external world, and secondary acts are just a ‘background echo’ as these primary acts are represented. This ‘echo’ is what gives primary experiences their l’mpression de vie, their vitality; and this is what is lacking in depersonalization. Dugas followed suit, ultimately putting depersonalization down to an arguably ‘affect’-laden ‘apathy’. Here, depersonalization was an attenuation of energy that resulted in the impaired ability to integrate psychological activity and attribute 18 this activity to a ‘self’. This energy gave activity its ‘affective’ quality. It was the dysfunction of what he defined as “Personalization[,] the act of psychical synthesis, of appropriation or attribution of states to the self” (Dugas & Moutier, 1911, p.13). Mayer-Gross (1935), in his review of the theories, histories and speculations about depersonalization preceding him, concluded it was “a pre-formed functional response” of the “central organ”. Concerning the significance of this breakdown, he said, The difficulty of description by means of normal speech, the defiance of comparison, the persistence of the syndrome in the face of complete insight into its paradoxical nature – all these point to something more than purely psychic connections. Such a disturbance cannot be explained by the loss of a little wheel out of the clockwork. (1935, p.118) While he may be right, his ‘theory’ once again relegates the source of the disorder to something so fundamental to a subject’s mental life it is not very illuminating. Many theories of schizophrenia have this problem too – putting it down to some basic ‘disconnection’ of thought. If depersonalization is an organized functional response, how does it respond? Which wheels does it affect? While it is interesting to consider the functional value of depersonalization (perhaps as a response to trauma), the fundamental questions still remain. Thirty years later, Karl Jaspers sponsored a theory of depersonalization that appears strikingly similar to that of Löwy, Österreich and Dugas insofar as the ‘activity of the self’ is what is attenuated in depersonalization. Appearing to implicate Dugas, he wrote: …every psychic manifestation whether perception, bodily sensation, memory, idea, thought or feeling carries this particular aspect of ‘being mine’, of having an ‘I’ quality, of personally belonging, of it being one’s own doing. This has been termed personalization. (Italics in original, 1963, p.121) Fundamental Commonalities A historical overview of depersonalization clearly shows a pervasive lack of agreement as to the nature of this putative ‘missing experience’, with different writers pointing to perceptual, emotional, memory or body image related impairments. (Sierra, 2009, p.25) I argue that most of the differences amongst these various theoretical approaches are fairly superficial, if not just terminological. Disagreement is only at the level 19 of description. Whether a theory suggests the depersonalization is a case of ‘sensory’ or ‘affective’ deficit, a distortion of ‘self-experience’, of ‘recognition’ or a putative ‘mental faculty’ or ‘functional response’, there is a remarkable degree of similarity. The explicitly different deficits cohere around a source of disorder so foundational that it allows such disparate descriptive approaches. In review, the sensory theories of Ribot, Seglas, and Sollier reduce to the ‘sense’ of ‘coenesthesia’, of ‘bodily existence’. It is analogous to what Berrios calls “common feeling”. This includes the perceptual modalities but is not only these. This is not incompatible with the ‘body image’ proposed by Ey et al. which “shaped by sensation and perception”, though he adds that this image is ‘synthesized’ by underlying emotional processes (1947, p.67). The two theories gel well with Janet’s ‘psychasthenia’ and indeed Dugas’ ‘affective apathy’. Though Heyman’s theory described depersonalization as a disorder of memory, he attributed the misrecognition to a similar lack of ‘psychological energy’, extremely redolent of Janet and Dugas. For Störring and Löwy, they do not describe the ‘lack’ as psychological ‘energy', but the ‘feeling’ that normally accompanies psychological activity. The difference could easily amount to the same thing. What is energy if not the feeling of activity? Dugas, Mayer-Gross and Jaspers merely propose that the disorder is in ‘whatever’ mechanism or faculty is responsible for ‘personalizing’ (energizing, integrating, synthesizing) these mental events. There are other more general issues these historical theories have in common. These theorists tend to believe that whatever it is that results in the complex phenomenology of depersonalization, it can be reduced to some single source or mechanism. The accounts also assume that psychological ‘action’ or ‘energy’ are intrinsically related to ‘selfhood’. As Dugas announces - “If the person is what vibrates and moves, and not what thinks, then apathy is in a sense the loss of the person” (1898, p.507). The link between psychic energy, dereality, and selfhood is obscure. It remains to be seen what recent studies of depersonalization have revealed about the phenomenon, or at least, what they continue to disagree about. 20 Contemporary Debate Contemporary literature on depersonalization invariably introduces itself by lamenting how ‘neglected’ depersonalization has been by clinical psychiatry, and bemoaning the desperate lack of empirical research. At present, there are two specific centres of depersonalization research. One is the Depersonalization Research Unit at the Institute of Psychiatry, Kings College, London. The other is based at Mt. Sinai School of Medicine, New York. Research into the condition clinical, neurological, and pharmaceutical – is burgeoning. Despite this, or perhaps as a result of it, the etiology and nosology of depersonalization remain shrouded in uncertainty. There are many issues of contention of which I will give a brief overview. There is the debate concerning whether depersonalization is best classified as a dissociative, anxious, or independent disorder. There are also ‘depersonalization skeptics’ who believe it is not an independent condition – that the symptoms are always secondary to another existing condition. On the other hand, there are suggestions that depersonalization experiences form the primary psychological anomaly out of which other psychiatric conditions emerge. This overview will illustrate how those issues up for debate are those created by the demands of diagnostic criteria, rather than any disagreement about the core phenomenology of depersonalization, which has remained stable. A Dissociative Disorder Depersonalization Disorder (DPD) is the diagnosis made by the American Psychiatric Association’s DSM-IV, under the category of Dissociative Disorders. Currently, for a disorder to be classified as ‘dissociative’, the symptom cluster must involve the disruption of consciousness, memory, identity, or perception. The main diagnostic features of DPD in the DSM-IV are as follows: A) Feeling detached from one’s mental processes or body B) Intact reality testing C) Clinically significant distress and/or functional impairment 21 Simeon & Abugel (2006, p.13), arguing for the independence of depersonalization disorder, include the three criteria above, but explicitly omit Brian Keeley! 20/10/10 1:48 PM Comment: criteria ‘Criterion D’: Because depersonalization is a common associated feature of many other mental disorders, a separate diagnosis of Depersonalization Disorder is not made if the experience occurs exclusively during the course of another mental disorder (e.g. Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder). In addition, the disturbance is not due to the direct physiological effects of a substance or a general medical condition. (APA, DSM-IV) This last criterion gives some hint as to the diagnostic complexity of DPD, and expresses mainstream sentiment that DPD is rarely an independent condition. To defend the classification of DPD as a dissociative disorder is to defend a category that has not been so stable itself. Over the last thirty years, there has been considerable uncertainty over the definition of dissociation. The criteria have not always been a disruption of ‘consciousness, memory, identity, or perception’. The DSM-III (1980) definition of dissociation was instead the disruption of consciousness, identity or ‘motor behaviour’. The following DSMIII-R (1987) included a note that admitted that “some, however, question this inclusion [of depersonalization as a dissociative disorder] because disturbance of memory is absent” (p.296). In order to get around this revealing note, “perception in the environment” was added in the most recent DSM-IV (1994) definition of dissociation. There also exists disagreement about the relationship between the different dissociative disorders, and by extension, the nature of any underlying ‘dissociative’ mechanism. Braun (1984) proposes that depersonalization exists on a ‘continuum of dissociation’ with dissociative identity disorder (DID) and psychogenic amnesia. Dell (2006) would appear to support this, having found that 95% of 220 DID patients had prevalent depersonalization symptoms. Yet others insist there are very distinct dissociative types, and thus no such dissociative spectrum (Bernstein & Putnam, 1986; Putnam et al., 1996; Ross, 1997). As might already be clear, there is good reason to doubt the appropriateness of depersonalization as a ‘dissociative disorder’. DPD is atypical of the DSM-IV 22 dissociative criteria. The most obvious (and recognised) divergence is that there is no amnesia experienced in DPD, unlike fugue states, DID, and of course, dissociative amnesia. This is despite the fact that amnesia is said to be the ‘hallmark’ of the dissociative disorders (Putnam et al., 1996). Secondly, the alleged break in perception of the external world is only ‘felt’ – there is no actual gap in conscious awareness of the external and internal world. In other words, there is a continuum of awareness that allows a patient of DPD to notice how different the world seems in comparison to how they normally experience the world. A continuum of awareness might be phrased as a continuum of association (with the world), rather that then purported ‘dis’ association it is categorized as. A third anomaly between DPD and other dissociative states is that with DPD, there is no clear pattern of alteration between the dissociative state and the normal state. The most common pattern, at least for patients with DPD is of “unremitting symptomology, with little fluctuation in severity” (Baker et al., 2003). I would personally counter such a statement by pointing to experiences of transient depersonalization which by their nature are remitting in their symptomology. Fourthly, the relationship between trauma and DPD is not as significant as with the other dissociative disorders.6 Finally, depersonalized patients do not exhibit any noticeable alteration in their ‘personality’ (where personality refers to character and traits of a given subject, not their base feeling of subject-hood). Anxiety Psychiatrists have had much to say about the high rates of comorbidity between depersonalization symptoms and anxiety disorders – as acknowledged by the DSM-V’s Criterion D. As early as 1959, Roth proposed a syndrome he termed ‘phobic-anxiety-depersonalization syndrome’ as an anxiety disorder with the core manifestations as agoraphobia and depersonalization. He later withdrew his commitment to the latter: “it is plain that depersonalization was given an undeserved prominence in the original description” (Roth & Harper, 1962, p.39). 6 There is a thin temporal relationship between minor traumatic incidents, like traffic accidents, and transient depersonalization experiences (Mayou et al., 2001). 23 There is a large amount of clinical research to support arguments that depersonalization is better framed as an anxiety disorder. Of 204 people with a presumed diagnosis of DPD (most having been clinically referred to the Depersonalization Research Unit at the Institute of Psychiatry, London), 71% had been previously diagnosed with an anxiety disorder, 73% reported having recent ‘panic attacks’, and 59% said that they were ‘afraid to go out alone (Baker et al., 2003). Levels of comorbidity are high, with some of the most commonly correlated being: • Acute Stress Disorder (Mayer-Gross et al., 1969; Noyes & Kletti, 1997) • Post-traumatic stress disorder (PTSD)(Bremner et al., 1998), • Panic Disorder (Cassano et al., 1989; Marshall et al., 2000) • Generalized Anxiety Disorder (Simeon et al., 1997) 7 • Obsessive-Compulsive Disorder (Roth, 1970). • Dissociative Identity Disorder (Dell, 2006). Psychiatrists even use shared diagnostic tools. If you compare the criteria, many diagnostic features of DPD in the DSM-IV overlap with the criteria for anxiety disorders. Psychiatrists looking to make either diagnosis must look for symptoms such as having: ‘racing thoughts’, ‘mind emptiness’, ‘emotional anaesthesia’, ‘being in a daze’, ‘feeling faint/dizzy’, and so on. To diagnose panic disorder, two possible symptoms include experiences of depersonalization and derealization. ‘Peritraumatic dissociation’ sounds more or less identical to transient depersonalization, and has been described as involving “an altered sense of time…profound feelings of unreality…experiences of depersonalization; out-of body experiences; altered pain perception; altered body image or feelings of disconnection from one’s body” (Marmar et al., 2004). In terms of etiology, it is commonly held that depersonalization is a psychological ‘defence mechanism’ for situations of overwhelming stress. Noyes & Kletti (1977) argue that “depersonalization is, like fear, an almost universal response to life 7 This tends to be comorbid with everything. 24 threatening danger. It develops instantly upon the recognition of danger and vanishes just as quickly when the threat to life is past” (p.380). However, this study was solely of accident victims, which significantly biases the context of their specific depersonalization symptoms. Depersonalization states can occur without any explicit trigger – traumatic, narcotic or otherwise. 8 In terms of adaptive benefit, Sierra & Berrios (1998) suggest depersonalization provides a state of emotional detachment whilst maintaining ‘automatic alertness’. A study on victims of traumatic events by Shilony & Grossman (1993) found that those who had experienced depersonalization suffered from significantly lower levels of psychopathology at the time of the study compared to those who had no depersonalization symptoms. To the contrary, other studies have found that the presence of depersonalization symptoms in response to trauma increases the likelihood of developing later psychopathologies – specifically PTSD (Taal & Faber, 1997; Breh & Seidler, 2007; Schönenberg et al., 2005, 2008). Such findings raise questions about how different something like PTSD really is from peritraumatic dissociation, and this from panic, and this from depersonalization symptoms…and so on. Diagnostic requirements really do seem to truncate and reify symptoms into artificially discrete entities, out of what in reality seems to be a complex and dynamic spectrum of experience. Independent Category Unlike the DSM-IV, the ICD-10 does not classify clinically significant depersonalization as a dissociative disorder. Nor does it consider it an anxiety disorder. The ICD-10’s “depersonalization-derealization syndrome” is included under the miscellaneous category of “Other neurotic disorders” (F48). Those familiar with the history of psychiatry will perhaps be amused to find it coming straight after neurasthenia, and before other psychosomatic conditions like writer’s cramp and Dhat syndrome. Proponents and patients trying to raise awareness and increase the legitimacy of the diagnosis of depersonalizationderealization syndrome might not be so amused. Secondary 8 For instance, the case of ‘Alex’ in Simeon & Abugel (2006, p.39-47). 25 The German psychoanalyst Paul Schilder (1935) noted early on that depersonalization symptoms were “present in almost every neurosis”. According to both recent monographs on depersonalization, current opinion in psychiatry is that depersonalization is not legitimately an independent condition. This is not surprising considering the huge degree of comorbidity already examined with various anxiety disorders. On this supposedly dominant view, the symptoms indicative of depersonalization are always secondary to a different, primary and more prevalent diagnosis - like an anxiety or depressive disorder. For instance, study of 1071 depressed in-patients found 31% to endorse depersonalization symptoms (Seemuller et al, 2008). Such a view acknowledges depersonalization symptoms, but finds them so ubiquitous as to be clinically irrelevant. Roth introduces his 1959 paper on ‘phobic anxiety-depersonalization syndrome’ with the exact opposite of those contemporary introductions lamenting its obscurity: It is traditional to begin papers such as this dealing with depersonalization by paying tribute to the ubiquity and versatility of the phenomenon, citing in illustration the experiences of Wordsworth, Amiel and Charles Morgan, and continuing with depersonalization occurring in schizophrenia, affective disorder, obsessive states, temporal lobe epilepsy, head injury, encephalitis, carbon monoxide poisoning, hashish intoxication, and botulism… (p.587) As an example of the currently dominant opinion, Parnas & Handest (2003) comment, “Despite a lack of convincing empirical justification, the DSM-IV and the ICD-10 contain depersonalization as a separate disorder” (2003). They believe that depersonalization is a mild experience belonging to the bottom of what they call the ‘schizophrenia spectrum’. This is despite the ICD-10 equivalent to the DSM-IV’s “Criterion D” concession: Depersonalization-derealization symptoms may occur as part of a diagnosable schizophrenic, depressive, phobic, or obsessive-compulsive disorder. In such cases the diagnosis should be that of the main disorder. (F4.81) Primary Anomaly There is the view that depersonalization presents a pre-psychotic state. Since the mid-20th century clinicians have observed patients making a gradual progression from typical depersonalization experiences to a delusional interpretation of the same experiences (Mayer-Gross, 1935; Ackner, 1954). On this view, depersonalization experiences serve as a strange experiential ‘lens’, which might 26 be interpreted into different delusional phenomena. For instance, Young et al. (2004) suggest a model of delusion where either paranoid or nihilistic reasoning biases result in either Capgras or Cotard delusions respectively. From a more theoretical perspective, Kennett & Mathews (2003) and Bayne (2004) suggest delusions of thought insertion could arise from depersonalization-like experiences. Rather than being a mild component of schizophrenia, it might be suggested that depersonalization is the primary anomaly out of which conditions like schizophrenia and DID develops. What’s With All This Fighting? Contemporary disagreements are the result of seriously high levels of comorbidity and interaction with other psychiatric categories. This reveals certain inherent problems with diagnostic psychiatry. Current systems (as typified by the American Psychiatric Association’s DSM) group symptoms of mental distress into clusters. These clusters are labelled, and it is implied that this label represents a distinct psychopathological entity, rather than a point along a continuum of mental experiences (Horwitz, 2002). Each disorder listed in a diagnostic catalogue is designed to “reflect an underlying psychobiological dysfunction”, or at least the coming DSM-V proposes it does (APA, 2010). It is clear that this is an invalid assumption about depersonalization given the huge degree of interrelation involved with depersonalization and other supposedly discrete psychiatric disorders. Truncating a complex psychological experience such as depersonalization (or any other psychological experience, whether deviant or normal) into discrete categories prevents a more holistic and dynamic approach to symptoms and the individuals suffering from them. If it seems that the discrete demarcations made by diagnostic systems do not exist in nature, then this obviously undermines the validity of such a system. It commits a fallacy of reification, of ‘misplaced concreteness’. This raises questions about the methods of treatment it warrants, and begins to undermine the ultimate goal of a diagnostic system – its clinical utility. It also undermines the perceived validity of the disease entity itself, and this diagnostic instability is arguably a large factor in why experiences of depersonalization remain so unfamiliar, despite the high prevalence. 27 It is worth noting that while these issues with diagnostic psychiatry apply to a range of psychological conditions that do not ‘fit’ neatly into existing diagnostic categories, depersonalization does seem to be a particularly slippery case. The alteration in phenomenology really does seem to be at a level so fundamental that adequate description of the experience seems futile. The hazy nature of the experience opens the door for so many descriptive approaches. Schilder (1935) believed that depersonalization was “one of the nuclear problems of psychology and psychopathology”. There is something ‘missing’, and describing it as a lack of sensation, perception, memory, body image, affect is just that – different ways of trying to describe a certain ‘lack’. Radovic & Radovic (2002), in their conceptual analysis of depersonalization symptoms, draw attention to the problematic use of the core term of depersonalization, ‘unreality’. The term ‘unreal’ alludes to something missing from normal experience without doing anything to clarify its nature. The depersonalized patient’s dependency on ‘as if’ qualifiers and vague metaphors is not just an attempt to communicate a novel experience in a familiar way. It expresses a dogged scepticism toward the adequacy of their own descriptions. If patients are themselves sceptical about the adequacy of their own symptom testimonies, one can only be equally sceptical of a theorist’s descriptions of these ineffable symptoms. Despite all the diagnostic debate, the core symptoms of depersonalization have remained remarkably stable over the last 100 years (Sierra & Berrios, 2001). This is something that cannot be said about a great many other psychological phenomena that have disappeared, emerged, and ‘evolved’ over the same period (say; hysteria, myalgic encephalitis, fugue, multiple personality, and so on). While current research into depersonalization is valuable and proceeding at an unprecedented pace, it is important that the concomitance of depersonalization and other psychiatric symptoms (and the surrounding debate) is not viewed as a threat to the legitimacy of the condition. To insist that depersonalization be classified as an anxious, depressive, dissociative, panic, independent or secondary condition is just to emphasise different valid observations of what is a fundamental alteration of a subject’s experience of the world and the self. 28 To conclude this section, historical attempts to conceptualise the condition did not progress much further than a variety of different descriptive approaches to a fundamentally ineffable disorder. Contemporary literature suffers similarly, as trying to bend this diverse experience around formal diagnostic categories results only in endless debate. From here, a more thorough philosophical exploration of the fundamental phenomenology of depersonalization is needed. The rest of this paper is an attempt to ground depersonalization experiences in wider accounts of mind; of phenomenal consciousness and selfhood. It is a mutually fruitful exercise – depersonalization experiences lack a coherent conceptual framework. And as an obviously fundamental alteration of consciousness, any account of mind should be interested in its alterations. 29 Part 2: Phenomenal Selfhood It is an internal sensation, a very obscure feeling, that provides the individual with his consciousness of being. (Lamarck, 1820, p.191) Unlike a great many other cases in psychiatry, depersonalization experiences have not been subject to direct philosophical attention9. The deficits are not as phenomenologically explicit as, say, experiences of thought insertion or cases of dissociative identity disorder – which have been given philosophical treatments (Campbell, 1999; Dennett & Humphrey, 1998; Flanagan, 1996; Kennett & Matthews, 2003; among others). So we will have to start at a philosophically more general level, focusing on the fundaments of sensation and subject-hood. Only from there will we have a conceptual space in which to slot depersonalization and begin a more specific philosophical analysis. I offer no positive theory, but simply make a preliminary gesture as to where a more mature theory might slot. Even by a brief exploration of the philosophical terrain we can begin to make tentative suggestions (for example, the notion of the ‘subjective present’), or at least see where the trickiest problems lie. For guidance, I look to recent work in sensation by Nicolas Humphrey and the self-world model of Thomas Metzinger. Past and present theory on depersonalization attempts to straddle two main elements - the perceived change in the character of the world, and the attenuation of a sense of self. Where some theorists give primacy to the former, others rely on the latter. It does not look like current diagnostic disagreements have done anything to dissolve this dialectic. Such tensions can only be resolved by an account of consciousness where phenomenal experience of the world and a sense of selfhood are intrinsically tied. Were this the case, then a loss of phenomenal quality would necessarily be a loss of one’s sense of self, or vice versa. Before we 9 Bayne (2004) uses depersonalization as a case to test various constraints on the unity of consciousness – epistemic, ecological, psychological and phenomenal. Metzinger (2003) includes depersonalization in a list of types of phenomenal disintegration, but focuses on delusions of misidentification like the Cotard delusion (p.438). He also considers it as a form of deviant self-modeling akin to both the Cotard delusion, but also non-pathological cases like meditative states (p.326) and out of body experiences (p.498). 30 look at potential accounts of phenomenal consciousness, I wish to briefly characterise the theoretical tensions. The basic split is characterised by two types of hypothesis. The first is internal; the second, external. 1) A person’s experience of the world is mediated, determined, or characterised by something, a ‘self’. Without this, experience of the external world appears ‘raw’, unmediated, unfamiliar, and thus ‘unreal’. 2) There is a shift in the way the external world appears to the self. The shift is in the character of the external world. Without a stable or rich phenomenal access to the external world, a subject feels less like a subject, less connected to reality, and their sense of ‘self’ is thus attenuated. We can trace these two tendencies through historical disagreements over the condition. They are mirrored explicitly in the historical division between sensory and affective theory. They are echoed in the discussion over whether the experience is primarily a disorder of agency or subjectivity. And they are most obviously present in the diagnostic (and phenomenological) division between depersonalization and derealization symptoms themselves. It is uncertain whether the two hypotheses represent a real distinction, or at least, a distinction that is easily observed. Regarding the division between depersonalization symptoms and those of derealization; the distinction between the two ‘clusters’ is not as clear as it is presented in the language of the DSM. As a reminder, depersonalization symptoms are described as: “the experience of the self so that one feels detached from, and as if one is an outside observer of one’s mental processes or body”. Whereas derealization is “an alteration in the perception or experience of the external world so that it seems strange or unreal” (APA, 1994). Described in this way, they really do seem like very different types of experiences. But even as early as 1942 Shorvon criticised the usefulness of the division, saying it “does not lend itself to objective distinctions” (1942). Though he preceded the symptom split, Dugas was aware of the highly ambiguous nature of the 31 experience, expressing the problem with precisely: “the individual feels a stranger amongst things, or if one prefers, things appear strange to him” (1898, p.456). It seems to be an issue of perspective – perhaps of patient and practitioner, or some inherent descriptive or reasoning bias. Even a more recent study has conceded that: …apparent phenomenological differences between depersonalization and derealization might simply reflect different descriptive angles of the same experience. (Sierra et al. 2005) This is significant, with both patients and professionals liable to the ambiguity depersonalization experiences present. The internal/external division reflects inclinations to characterise depersonalization as a disorder of either subjectivity or agency. However, it does not seem clear that this is an easy distinction to make in light of patient statements. They seem to have an attenuated experience of both agency and subjectivity. In terms of agency, they say:10 • It’s like auto-pilot has been switched on. I notice my hands and feet moving, but it’s as if they did not belong to me, and were moving automatically. • Words come out my mouth, but they don’t seem to be directed by me. Their experience as a subject, particularly of bodily sensations, is also impaired, especially as evoked by those persistent metaphors of separation: • There is a veil between the world and me. • I don’t feel a thing except for hot or cold; maybe hunger. It’s as if I’m dead. There is only a void. 10 These patient testimonies are taken from both Sierra (2009), p.24-39, and Simeon & Abugel (2006), p.80-82. 32 • My thoughts are separate from my body, as if my mind exists in one place and my physicality in another. Affective theories of depersonalization posit a certain ‘tinge’ to sensational experience. If they are to satisfactorily explain depersonalization, then this tinge would be a self-tinge. Löwy’s ‘action-feelings’, themselves are derivative of Österreich and Störring, would map easily onto such a theory of self-experience. These ‘feelings’ are those that accompany “every psychological act”, which “provides altogether the awareness of the reality of perceived objects” (1908, p.460). This idea is clearest in Jaspers, if we remember that according to him: …every psychic manifestation whether perception, bodily sensation, memory, idea, thought or feeling carries this particular aspect of ‘being mine’, of having an ‘I’ quality, of personally belonging, of it being one’s own doing. (Jaspers, 1963, p.121, italics in original). The sensory theories, taken superficially, would tend to align with the second ‘external’ distortion hypothesis. That is, a distortion in the way the world appears (perception) situates a subject strangely in that world. Accordingly, Krishaber (1873) attributed the experience of “self-strangeness” to “multiple sensory distortions”. Just as the depersonalization/derealization distinction appears more uncertain than it appears in diagnostic manuals, I have already argued that the early sensory/affective distinctions are themselves quite ambiguous – remembering Berrios’ conceptual analysis of ‘cenesthopathie’ and ‘coenesthesia’ (1996). At a deeper level, this division is manifest in whether the processes at the heart of phenomenal consciousness, at the heart of depersonalization, are of activity or passivity. Is the perception of our world around us something we actively do – are there processes of ‘psychic action’ and energy – that are responsible for the character of phenomenal experience; or is there a problem with how we receive information about the internal and external world? This question is a loaded one, and threatens to raise old debates about realism. 33 The fact that depersonalization experiences can be approached from either side of these conceptual distinctions (depersonality/dereality, affect/sensory, subject/agent, receive/create) makes it unlikely any one-sided approach will be satisfactory. As I continue to argue, the source of disorder is clearly so fundamental as to permit such diverse elaboration. Sierra, in the final ‘pulling the threads together’ chapter of his monograph, essentially comes to propose what would be categorised as an affective theory. He concludes that depersonalization is “a disruption of the process by means of which perception becomes emotionally coloured” (2009, p.150). But even after chapters of neurology, neurobiology and pharmacology, it is far from clear what this ‘emotion’ really is or why it might be important for selfhood. There needs to be a solid account of whatever it is that gives percepts their vivacity, if not ‘affect’, and its role in selfexperience. If there is, it might synthesise the tensions under the one explanatory model. To summarise, here are some of distinctions often made in depersonalization theory: Internal External Depersonalization (self) Derealization (world) Affect (feeling, emotion) Perception (sensory information) Agent Subject Activity Passivity/Receptivity 34 Humphrey’s Sensation In order to formulate the debate in more contemporary terms, I look to a recent account of phenomenal consciousness, of phenomenal selfhood and ‘sensation’. It is an attempt to explain why phenomenal character is linked to selfhood, as depersonalization seems to suggest. This is something that is often assumed but also eschewed. Nicholas Humphrey has been hoping his evolutionary theory of sensation might provide the key to consciousness for a number of years now. He admits that most ‘heavyweight’ philosophers remain unconvinced. Nevertheless, the theory is attractive. It is attractive insofar as it might suggest a way of accounting for the tensions that have characterised the theoretical uncertainty over depersonalization. I will briefly explain the theory, and defend it from some of the major objections. I will tidy it up with some help from Thomas Metzinger, and see how depersonalization might fit. Humphrey (2006) hopes to separate more radically than ever the processes of perception and sensation.11 To illustrate their alleged independence, it is easiest to start with his case-in-point, ‘blindsight’. Humphrey worked with Weiskrantz on both monkeys and humans to establishing blindsight as a real phenomenon (Weiskrantz, 1986). It is now a very well known and often deployed case. A patient with blindsight has had their visual cortex either damaged or removed, and reports being blind. Nevertheless, patients can still guess the position and shape of objects with remarkable accuracy. They are not conscious of any visual experience, of any visual phenomenology , of any visual sensation. They must be coaxed into even making a guess. Humphrey argues that in such cases perception remains intact, and sensation is missing.12 Perception, then, is objective information received unconsciously by a brain about the external environment. In contrast, sensation is a side-show generated adjacent to perception. It is an evaluative response to how the external world is affecting the organism itself. Perception would be - “light ray, frequency: 606–630 THz; 11 Humphrey’s Seeing Red (2006) is a more concise explanation of some of the issues explored in his A History of the Mind: Evolution and the Birth of Consciousness (1998). 12 Note that blindsight most commonly occurs in the scotoma. Blindsight of the entire visual field is much rarer, though it seems like it is these that Humphrey focuses on. 35 wavelength: 476–495 nm”, whereas sensation would be more like “ooh, cyan!”. Though separate pathways or processes, their action is deceivingly synchronic. Perhaps his analogy will help: You are sitting at a cinema organ, watching the movie that is being projected on the screen, and as the scene changes you make music to match the mood and content of what you see going on. Now, the way you represent to yourself what the movie is about is by listening to the very music you are creating. (2009, p.90). The music is the sensational activity consciously experienced, the screen is perceptual information not consciously attended by the subject. Humphrey argues that sensations are akin to a sub-class of bodily actions with which we are all familiar - expressions. The sensations we have today, he speculates, are the evolutionary leftovers of primordial ‘expressions’. These were localised bodily responses to the immediate environment – “mere wriggles of acceptance or rejection” (p.87). This pathway (of early sensation) provided an affect-laden, bodily-specific picture of what the external world is doing to the organism itself, and how the organism feels about it. For example, entering a goop of higher acidity, the organism might wriggle ‘acidily’. A separate channel (perception) developed to provide abody-independent representation of the outside world: When the question is “What is happening locally to me?” the answer that is wanted is qualitative, present-tense, transient, and subjective. When the question is “What is happening out there in the world?” the answer that is wanted is quantitative, analytical, permanent and objective. (p.92). Like bodily expressions, sensations are owned by the subject, indexed to a body location, present, qualitatively distinct, and phenomenally immediate (p.81-83). But as the organism developed and became increasingly independent of its immediate environment, it would have had less and less to gain from responding directly to surface stimuli. Nevertheless, it would still be useful to monitor what is happening to its own body, even if it is not useful to physically respond to it. So rather than making actual local responses to, say, acidity; the organism can just monitor the ‘wiggle acidily’ as a source of information about both the world and its place in it. Thus, the pathway becomes ‘privatised’ as an as-if command; and this sensation is only just recognisable as an as-if ‘expression’ today. 36 Problems Even this far, Humphrey’s theory raises a few problems, which I will briefly deal with. The first objection asks why we think perception and sensation are part of the one process if they are not. It asks why the character of sensations appears to be out there in the world if they are not. They are related. As one critic put it “We don’t feel ‘redly’ about parts of our visual field…we project our visual sensations as something external to us” (Hardcastle, 2000, p.52). McGinn (1992) makes a similar objection. Looking at an apple, it appears that the phenomenal character of the apple is due to the physical properties of the apple itself, rather than a response generated by my brain. One part of the answer is the watertight association of perception and sensation, their ‘deceptive’ synchrony. Though separate, perception and sensation correspond to identical stimuli, so they are never (or rarely) found disjointed. Humphrey points to evidence of the deceptive nature of synchrony, for why correlation so often seems like causation – in experiments performed by Vilayanur Ramachandran. These show that we reliably mislocate tactile sensations to fake hands or even the top of a table (Ramachandran, 2003). In a similar fashion we often mislocate ‘taste’ to our tongue (or more accurately, our mouth) where in reality most of our ‘taste’ is olfactory. Most people cannot tell the difference between a piece of raw potato and an apple if they have had their nose blocked. The same might be said of ‘phantom limbs’: the sensation of having an arm is not only located in the arm itself, but in a neural map that remains long after the limb may not. Daniel Dennett makes a different, deeper, objection. He asks, as philosophers tend to do, about robots. Would a robot that could detect red, that ‘redded’ in the presence of red (that is, generated an evaluative ‘red’ sensation response), that could notice and appreciate its own ‘redding’ action, and that had our evolutionary history programmed in –experience Humphrey’s sensation? At one level, this objection might fail simply because both Dennett and Humphrey remain mutually vague as to exactly what “redding” involves, so it descends into tautology. For Humphrey, if the robot was indeed “redding” just as we “redded”, then it would of course be “redding” in the proper way. Humphrey believes that 37 the very fact that we are tempted to say “no” to thought experiments like these (those that wonder whether minimal functional or physical replicas to ourselves might be conscious) are in fact an adaptive illusion. It was advantageous to think we’ve got something very special going on up in our skulls, something no other species could possibly have (see his Leaps of Faith, 1998).13 Humphrey’s theory of sensation raises a few indomitable ghosts. One is the exact representational character of his ‘sensation’. This could be described as an explanatory gap, which Dennett is sure to pounce on: Humphrey emphasises the personal and authorial aspect of redding, but since he acknowledges that at the sub-personal level, these actions consist, exhaustively, of neuronal events mindlessly plugging away, it is not clear to me how he thinks he can elevate some such phenomena to personal-level dignity. (2007, p.594) The question as to what transforms firing neurons into “stuff that matters” (to use Humphrey’s parlance) is among the ‘hardest’ problems in the philosophy and sciences of the mind. Acknowledging this, it can perhaps be forgiven if Humphrey has not come up with a shining solution, with Dennett’s sparkling ‘Xfactor’. However, it is not for lack of trying. Humphrey goes all-in, pushing his candidate for the “X-factor”. For support, he looks to two places. The first is the notion of the ‘extended present’, historically derivative of Husserl and William James’ “specious present”, and more recently taking a cue from Natika Newton (2001). The notion is that the present we inhabit in consciousness is impossibly thicker than the theoretical instant that is the spatio-temporal ‘present’. This paradoxical experience is vital to the ineffability of phenomenal consciousness. Humphrey argues that the thick moment of the extended present is the “X-factor” which elevates mere ‘sensory’ information into the realm of the phenomenal. He doesn’t leave this hanging, but points to neural ‘re-entrant circuitry’ - to explain this temporal thickening.14 The resulting resonance allows the sensory instant of the 13 Like Dennett’s robot that lacks ‘proper’ sensation, patients of DPD often describe themselves as feeling like an automaton or zombie; creatures common to the philosophical literature on mind and phenomenal character. 14 “…the command signals for sensory responses could well begin to interact with the very input to which they are a response – so as to become partly self-creating and self- 38 present to stretch out into thick time. It seems that the existing sensational circuitry provides the means for thick time to emerge. Without temporal thickening, we would have no space in which to consciously experience sensations, there would be no room in which to appreciate phenomenal character. The evolutionary utility of this space, of thick time, is that it allows the potential for selfhood. According to Humphrey, “It lifts the subject out of zombiedom” (2006, p.123-4). While this is all very good, there is still a gaping hole between resonant circuitry and personal level phenomenal character. I have not been able to give much detail, and even if I had, the theory is far from robust. There are gaps and holes to poke at, and perhaps it will all come crashing down at the close scrutiny of a picky philosopher. A diagram of re-entry circuits will forever be far removed from the rich character of phenomenal consciousness, no matter how useful the notion might be. This is a shame, since Humphrey’s theory promised to resolve many of the inherent and currently irresolvable tensions surrounding experiences like depersonalization. It describes from a new angle what it is that people might mean by ‘affect’ – not a knowable ‘emotion’ or ‘feeling’ but the very activity of subjecthood – of an organism responding to the world and the monitoring of those responses. The response is one where vivacity and character are vitally important to the subject if it is to keep track of its place in the world. The explanatory gap still remains, and a better explanation of the exact nature of sensation is wanting. Nevertheless, I imagine that any attempt to give a scientific account of depersonalization will be haunted by this. I will address this issue a little later, we should not give up on it yet as it promises to be conceptually clarifying. I will now show how Humphrey’s framework supplies some ideas that make sense of depersonalization. sustaining. These signals would still take their cue from input from the body surface, and still get styled by it, but on another level they would indeed have become signals about themselves.” (Humphrey, 2006, p.122) 39 Depersonalization & Sensation Humphrey’s framework supplies some ideas that have some explanatory value to depersonalization, or at least, depersonalization theory. Under this conception of sensation, and of depersonalization as a disorder of sensation, many of the theoretical tensions subside. Under Humphrey, sensations are affect-laden responses to sensory information, an active process yet witnessed by a subject. It is not a question of either affect or sensory, active or passive, agential or subjective – but all of these. Affect/Sensory They [the depersonalized], it is true, see and hear everything. But without experiencing any representation or feeling of their inner stirrings, of their sensory vividness. (Shafer, 1880, p.242). I have already argued that historical debates between the affective and sensory theories are superficial, and they are really talking about something quite similar. Where one spoke of the sensory vividness, the other spoke of the ‘feeling’ attached to sensory experiences. Under Humphrey, it is much the same. Patients of DPD can negotiate the external world without trouble, so ‘perception’ is clearly intact. As Griesinger observed, “My eyes see and my spirit perceives but the sensation of what I see is completely absent” (1845, p.157). Sensation, however, is far from absent. A subject experiencing depersonalization maintains awareness of sight and sound, they still observe colours and smells. It is just the quality of sensation that is altered. That theorists have taken different theoretical approaches is a result of competing intuitions as to whether phenomenal character is out there in the world to be detected, or the result of internal “stirring”, to use Shafer’s term. Humphrey’s sensation sublimates the detection, and elevates the reaction. Störring saw depersonalization as the disturbance “…of the awareness that one can have of certain perceptions” (p.289). We should understand him as meaning ‘sensation’, rather than perception, as we have no awareness of perception. 40 Humphrey’s sensation, though it emphasises affect, accounts for inclinations toward more ‘sensory’ or external hypotheses. Foester’s (1903) two-factor sensory theory was a combination of a) a specific sensory component (visual, auditory, etc) and b) an attendant sensation arising from the movement of the sense itself. For Humphrey, component b) is not an actual movement, but the monitored ‘as if’ movement we experience as sensation. Furthermore, as the evolutionary leftovers of bodily responses, sensation is a highly embodied process. This might be considered a gesture toward the covert sense of ‘bodily existence’ very early sensory theories described as ‘coenaesthesia’ (Sollier, Seglas, Ribot). Humphrey’s theory emboldens earlier suspicions that the affective and sensory theories were more or less the same, as both describe different aspects of an subjectively-laden, embodied process. Sensation, as Humphrey describes it, depends both on external world for the initial stimulation of the senses, but also on the creation of an evaluative (affective) response to that stimuli. Passive/Active As a creature of sensation, the subject takes both an active and passive role. It is active insofar as it is an ‘as-if’ response to stimulus. While the acts of perception could be described as ‘passive’ (in that the senses receive real information about the world), they remain below the level of phenomenology. In a more important sense, the subject that creates the sensation is the subject of its own ‘sensational’ activity. It ‘smiles’ or ‘cyans’ automatically, but is also privy to its work - ‘Ooh look, I’m smiling!’, ‘Ohh, there must be a bit of cyan out there if I’m cyan-ing right now!’. It is a passive witness to its own activity. In the historical record, there is a lot of talk of some vague psychic ‘activity’. Perhaps sensation is the process behind Heyman’s “psychological energy”, Lowy’s Aktionsgefuhle; or the psychic “synthesis” that Janet, Dugas and Ey are so sure of. Dugas’ term ‘Personalization’ simply meant “the act of psychical synthesis, of appropriation or attribution of states to the self” (Dugas & Moutier, 1911, p.13). Where Dugas imagined a specific faculty of ‘personalization’, the action of Humphrey’s sensational synthesis constitutes the basic condition for personhood itself. 41 Agency/Subjectivity The supposed ‘activity’ involved in sensation is not one that involves feelings of agency. While it is obvious that I am the subject of my sensations, it is not obvious that I am also their author. But as Humphrey has tied (or justified) his account of phenomenal subject-hood with selfhood, it becomes clearer how it might affect one’s sense of agency. Sensational activity comes to create the person, reversing an old principle. This principle can be traced to the philosopher/logician Gottlob Frege, although he was arguably tidying up after Descartes’ cogito. Frege pronounced, “An experience is impossible without an experient. The inner world presupposes the person whose inner world it is” (Frege, 1918, p.27). With Humphrey’s sensation, to be an ‘experient’ is to depend on experiences, not vice-versa. It unites the intuition of coenaesthesia with Störring’s conditions of self-awareness: sensations -> bodily awareness -> selfhood. To be a subject, you must first have experiences to be the subject of. This positions phenomenal experience as a necessary condition for selfhood. Clinical results regarding DPD confirm such a principle, as ‘derealization’ symptoms are the most commonly experienced, and accompanies all other symptom domains of DPD. Its isolated occurrence has been questioned as impossible. In other words, you can’t feel de-personalized without having the world appear de-realized. An alteration in the experience of sensation is an alteration in you, an alteration in your place in the world, in your status as a subject. But it is still unclear how a general attenuation of phenomenal selfhood could result in perceived deficits in agency. Humphrey’s account will need some expanding. I wonder if it helps to fold in some other work on agency. Feinberg (2000), as well as Frith (1992) and Campbell (1999) before him, explores analogies between thinking and other motor processes. In the standard picture of motor processing, instructional or ‘efferent’ copies accompany intentional actions, and are allegedly responsible for feelings of agency. With the intention to ‘wriggle big toe’, there is a motor instruction sent to my big toe, to make it wriggle - but also an ‘efferent copy’ of that instruction sent to some central monitor, so that it is aware the first instruction has been sent. You might compare 42 it to having to cc: the boss for every company email. It is proposed that what grounds a ‘sense of agency’ in action is a match between the efferent copy received at the monitor, and the sensory feedback we get about the movement (Campbell, p.612). For motor acts, the efferent copy allows a subject to adjust their action through the relevant feedback. So if you miss the object you’re trying to pick up, you can adjust and reach it, having known where you just told your arm to be. This model of motor activity (accepted since Held (1961)) is attractive as it provides an explanatory model for certain delusions of external control, like ‘alien’ arm. Campbell expanded the model from motor acts to intentional thoughts, in order to account for cases where mental agency is disrupted – cases like ‘thought insertion’. With ‘thinking’ as a motor process, an efferent system is useful for keeping a train of thought on track. It allows us to think in the deliberate and organized manner we (ideally) do. Is the notion of an ‘efferent copy’ relevant to Humphrey’s own perceptionsensation model? Processes of sensation might operate in a similar manner, and ground a global sense of self and agent. There is a ‘feeling’ of executing mental and motor activity, even if we normally don’t pay it much attention. By feeling is simply meant that there is something it is like to come up with an idea, to think deeply about something, or to intend to scratch your nose. This something-it-islike is its sensational character. Of course, there are many aspects of our motor and mental activity that do not have phenomenal character - eye saccades, heartbeats, the workings of our ‘subconscious’, and so on. Experiences of ‘alien arm’ might be analogous to blindsight in this way. In both cases, the subject is not “cc’d” the normal information. While the sub-systems are running as normal, the subject is cut out of the loop. And as the subject does not receive the relevant feedback, he cannot explain the activity to himself – it seems completely unreasonable that they are the agent responsible for the activity – whether the missing information is ‘the intention to move arm’ or an area of visual sensation. 43 An objection to this sort of model of sensation is that the most robust efference systems are for the most part unconscious (e.g. the VOC and other ocular control systems)15. There are two ways around this. One is to maintain that while we might not have conscious access to a clear ‘efferent copy’ at the neurological level, there is some phenomenological upshot of our unconscious processes. Such models assume this - as they explain the absence of a feeling of ownership in terms of a breakdown in the system. This assumes that normally the system does have some phenomenal register, some ‘feeling’. This is true of Frith’s picture. We have a case where there is no access to a copy that is needed by control systems, with the result that you do not feel like the agent of the relevant experience. So we might say we have conscious access to some output of the system – which starts to conflate efferent systems of either intention or sensation with epiphenomenalism. The other option is to accept that the analogy between perception/sensation and efferent copies is imperfect – that sensation is like efferent systems only the copies are consciously accessible. If the relevant fact with efferent system is that they are unconscious systems, then the whole purpose of the analogy is undermined. In which case, it is perhaps better to turn to Frith et al.’s ‘forward’ and ‘inverse’ models of motor action (2000a, 2000b). Here, the ‘forward’ model predicts the outcome of a given motor command (‘wriggle big toe’) and compares it to the sensory feedback of the actual outcome (‘soft carpet’). It is the ‘inverse’ model that actually provides the motor commands for the action – the fine-tuned instructions for a specific toe-wiggling activity. Frith et al. argue that the workings of the inverse model are unconscious, but we have some conscious access to the forward model. In cases of form agnosia, patients who are unconscious of the shape and position of a given object are still able to effectively grasp the object. Their inverse model is intact, while their forward model is impaired. If sensation operates like Frith’s forward model in this way, then depersonalization would be analogous to the deficits of form agnosia – subjects can still get around the external world without a problem, but there is a strange mismatch between their 15 Thanks to Brian Keeley for pointing this out. 44 forward and inverse models; their sensations of the world and the activity of the self is askew and hard to attribute to either external or internal reality. If depersonalization is a global attenuation of our sensational activities, from the traditionally phenomenal experiences of sight and sound; to the more expansive – of mental and motor activity – that there is reason to believe that a person’s sense of agency would be diminished, and account for statements like: I talk and the words are just coming out. I don’t feel I have control as to what I’m saying. It’s like auto-pilot has been switched on. (Sierra, 2009, p.27) I see myself doing things, like I’m in a movie. I go through the motions as if I’m in a play. My arms and legs don’t feel like they’re mine. How do I control them? What makes them move? (Simeon & Abugel, 2006, p.80). Cases of ‘alien’ arm and ‘phantom’ limb might be the converse of each other; where the former has lost sensation (the sensation of agency, specifically – the arm is moving but is experienced as out of the control of the subject) despite having an arm; and in the latter, bodily sensations remain, despite missing the limb. Studies by Gazzaniga et al (1996) divide agency into two parts – an experiential component, and a cognitive attributional one. In depersonalization, the experiential component is affected, but cognitive abilities remain unaffected. Patients of depersonalization can still [cognitively] attribute their activities to themselves, despite the experience of agency being affected, where patients of ‘alien arm’ and ‘thought insertion’ cannot.16 If it is an efferent copy that is responsible for attributional components of agency, that depersonalization might well be the inverse of Frith’s examples. Instead of having the experience and a total lack of agency (as in delusions of external control), depersonalized patients lack or have distorted experience of an action while still being able to attribute the action to themselves. This would suggest that there is some sort of central monitoring system in place, with the usual (experiential) phenomenology missing or affected. Humphrey’s account of sensation is attractive insofar as it intimately connects the experience of the external world with the creation of an ‘internal’ space of selfhood. It can account for how a change in his process of sensation might be 16 This might be due to certain reasoning styles or biases (Davies & Coltheart 2000). 45 simultaneously be described and experienced as ‘derealization’ or ‘depersonalization’, affective or sensory, subjective or agential. Just because a theory is convenient does not mean it is correct. I will now try and address some of the philosophical concerns we found facing Humphrey by turning to recent work by German neurophilosopher Thomas Metzinger. Metzinger Something like Humphrey’s sensation would seem to resolve a lot of competing intuitions about selfhood and phenomenal experience. I argue that Metzinger’s representational approach to the world and self provides a more robust conceptual architecture into which we can slot the problem of sensation. I hope it better satisfies the concerns of McGinn and Dennett regarding how sub-personal sensory information might come to achieve the phenomenal character we experience as sensation. Metzinger, though helpful, reveals why phenomenal experience of sensation and self is such a problematic area of study. Metzinger’s self-world model provides a cognitive/computationally grounded account of what might be at stake or affected in experiences of depersonalization and derealization. It parallels Humphrey’s perception/sensation distinction, and provides consciousness as an internal self-world interface that accounts for the aforementioned internal/external tensions. Of particular importance are notions of transparency and the extended present. As with Humphrey, I will briefly sketch the theory, and then try and apply our concerns to it. Even more drastically than with Humphrey, the brevity with which I must treat Metzinger’s intricate account will inevitably not do justice to it.17 17 See Metzinger’s overwhelmingly comprehensive Being No-one: The Self-Model Theory of Subjectivity (2003); or the more accessible Ego Tunnel (2009). 46 The World-Model Under Metzinger’s brand of representationalism, the world as it appears to us is simply the content of our world-model. We are not in ‘direct’ contact with the external world. The world that appears to us is just a particular model of what is an inconceivably richer physical reality. To say that the world as it appears to us is constructed is not to deny the existence of an external world. And it is not to belittle our phenomenological ‘reality’. It is a ‘virtual’ reality, where ‘virtual’ is the only experience we can ever have. The world appears in such high resolution that we are unable to recognise the world as a model. We are able to recognise images only insofar as they are poorer in quality than those of our world model. The sensations our senses deliver are those that proved relevant to getting about in the world. We have no phenomenological experience of UV-rays, or magnetic fields, though these things surely exist in the physical world. On the other hand, there is no such ‘thing’ as colour out there in the world. The azure of a clear sky is not a real property of the sky itself. It is an internal property of our world-model of a clear sky. As the existence of ‘metamers’ attests, there are no clear one-to-one mappings of colour sensations to physical properties, as a variety of different wavelengths produce the same colour sensations. What’s more, colour sensations remain constant despite fluctuating light conditions (‘colour constancy’). In support of Humphrey’s sensation, Metzinger makes the claim that “All evidence now points to the conclusion that phenomenal content is determined locally, not by the environment at all” (2009, p.10). The minimal requirement for any item of phenomenal content – say, the smell of lavender – is not the actual presence of the lavender, nor the stimulation of certain olfactory receptor cells (say, t-14, k222 and BB-04), or even a number of activated glomeruli – but a particular ‘sensational’ location or process in the brain. Self-Model While the generation of a world is an incredible feat, the real achievement is that within this world-model appears a self-model. As with the external world, we are not in direct contact with an internal, metaphysical ‘self’. The content of the selfmodel includes a vast array of things – memories, emotions, psychological states, and so on. The self-model is framed by a variety of phenomenological constraints, 47 the two most important of which are a window of ‘presence’ (thick time) and the unity of the world-model. By placing the self-model in the world-model, a centre is created. That centre is experienced as ‘ourselves’ – the origin of the first-person perspective, of being in the world. In between these two models is the virtual reality ‘tunnel’ we phenomenally inhabit. There is a lot more to the basic cognitive architecture hinted at here, but this will have to suffice for now. Transparency Crucial to Metzinger’s self-model theory of subjectivity is the notion of transparency. We are not aware that the world and our selves are representations. We see straight through the processes of modelling onto the ‘content’ they represent. This is functionally fundamental, as …fully transparent phenomenal representations force a conscious system to functionally become a naïve realist with regard to their contents: whatever is transparently represented is experienced as real and as undoubtedly existing by this system. (2003, p.167). The notion of transparency provides one way of bridging the explanatory gap threatening Humphrey’s sensation. Metzinger understands transparency in terms of the attentional availability of cognitive processes. With vision, for instance, we cannot direct personal-level attention to the activity of the relevant processes in the visual cortex. It is not so much the speed of information processing that matters, but the relative speed of different types of informational processing – e.g. visual perception versus attentional systems: If you attend to your perception of a visual object (such as this book), then there is at least one second-order process (i.e. attentional processing) taking a first-order process –in the case, visual perception – as its object. If the firstorder processes – the process creating the seen object, the book in your hands – integrates its information in a smaller time-window than the secondorder process (namely, the attention you’re directing at this new inner mode), then the integration process on the first-order level will itself become transparent, in the sense that you cannot consciously experience it. By necessity, you are now blind to the fundamental construction process. (2009, p.42). Here, Metzinger could be seen to split Humphrey’s perception/sensation into earlier/later (or faster/slower) processes. ‘Perception’ would describe those processes modelling the external world that are attentionally unavailable, and 48 sensation would describe the resulting representational content. Under this notion of transparency, a patient of blindsight would have intact first-order processing capacities, but the later (or slower) stage – whatever represents the final phenomenal content or attends to it – is impaired. Blindsight, then, shows how other sub-personal systems can have access to first-order information that secondorder systems do not – as something ‘knows’ what is being detected by the retinas as the blindsight patient is forced to guess, even if the patient doesn’t have conscious access to that information. Thus Metzinger’s representational account of the mind goes into considerably more detail than Humphrey. While it doesn’t fill the explanatory gap, it at least explains why it’s there. When Dennett wonders how ‘mere’ neuronal events could ever lead to Humphrey’s personal-level sensations; an adequate response is that the sub-personal events are transparent. They will always be impossibly removed from phenomenology. The informational processes responsible for representing the personal-level content are inaccessible to conscious attention. Stocktake It is time to take stock. Some people experience a bizarre alteration in the way their world and self appears to them. This experience has been framed by a variety of different theoretical guises, but I think they are all talking about the same thing. I wonder if that ‘thing’ might be understood as sensation. We went to Humphrey for an account of exactly what ‘sensation’ could be, and why it is advantageous to use this notion rather than the others. It is useful because it subsumes the other theoretical approaches and establishes a needed link between ‘sensation’ and selfhood. Sensation is an ‘affect’ laden process created in response to the world, as it appears to a subject. This flow of sensation is the flow of phenomenal character that floods conscious life; the appearance of the world as well as the phenomenal character of many aspects of our internal world. I have looked to Metzinger to provide a greater self-world model for this ‘sensation’ to slot into. The alteration occurring in depersonalization is fundamental. While it affects sensation, it is ‘below’ sensation. It is phenomenally and introspectively 49 inaccessible, which explains the many problems plaguing attempts to conceptualise it from a study of symptomatology. The nature of the alleged impairment might be something we know about but haven’t thought of, or more probably, something altogether unfamiliar. As a start, I thought I’d look at just one of the things we know a little bit about, at least philosophically. Once again, I don’t offer it as a concrete candidate, but as gesture towards which kind of philosophy of psychology we might consider. Thick Time Revisited While Humphrey’s account is distinct for his sensation/perception separation, a large part of it depends on the existence and experience of ‘thick time’. The thickening of the physical present is what allows sensations to be subjectively attended to in the way that we do. It allows for the space in which information can resonate, to accrue phenomenal character, to linger long enough for the creation of an appreciative subject. Our conscious experience of time is a simulated space, one that proved useful for a particular organism with particular needs. Our experience of time is “approximate to the temporal structure of an organism’s domain of casual interaction” (2003, p.127). Other organisms plausibly experience time in a way selectively thickened or thinned by factors specific to their temporal environment. Metzinger and Humphrey are mutually emphatic about the significance of time in subjective life. The ‘workspace’ provided by the extended present is characterised by a number of features. The most obvious is that of unidirectional flow (from the past to the future). Events appear in series, one after another. Individual events are integrated into temporal figures. Each event provides the context for the next; we gain a notion of duration. Just as in visual experience, the isolated properties of colour, shape and texture are bound into a figure subjectively experienced as one object (Metzinger 2003, p.127). Metzinger suggests that as in visual object formation or hearing a musical phrase, the ‘Now’ is a segment of temporal background that is reified to vivacity. The ‘Now’ is an artificial atoll lumped by the brain out of an ocean of geophysical time. Of course, such metaphors seem a 50 little obscure. The literature tends to speak in supposedly more concrete terms - of pathways, loops, connections and circuits. As Humphrey looked to Pollen’s work on ‘re-entrant circuits’ (Pollen; 1999, 2003), Metzinger points to the likes of Lamme (2006) and Dejaene (2006). The latter two have converged on the central importance of ‘recurrent connections’ as a, if not the, functional basis for consciousness. On both the particular level (say, of visual percepts) and the more general, continuous feedback loops create a circular flow of information so that whatever happened a few milliseconds ago is continually mapped back to what is happening ‘now’, resounding as vivid and embedded in ‘thick’ subjective time. It is illuminating to return to Janet’s model, which now appears very familiar. For Janet, all psychological activity was either primary or secondary. Primary acts are stimulated by the external world, and secondary acts are just a ‘background echo’ as these primary acts are represented. This ‘echo’ is what gives primary experiences their l’mpression de vie. Note especially the metaphors of looping and resonance: Thousands of resonances, constituted by secondary actions, fill the spirit during the intervals between external stimulations, and give the impression that it is never empty…This complex activity links up the [primary] actions brutally determined by the external world, and causes an impression of vitality, of spontaneity, and – at the same time – of certitude”. (Janet, 1928, p.126). Metzinger stresses the construction of the ‘subjective present’ as the essential precondition for subjective experience: “subtract the global characteristic of presence from the phenomenal world-model…we subtract consciousness tout court” (2003, p.126). If this were true, it is definitely not missing in depersonalization. Consciousness is not subtracted tout court. But might it be altered? If ‘emotion’ and ‘affect’ are just labels for a certain ‘vivacity’ or quality to a percept, the quality theorists are looking for might just be one of ‘presence’. The hypothesis I am poking around with here is whether an impairment in subjective time construction (say, a failure of those putative ‘feedback-loops’) could explain the entirety of depersonalization symptoms. While patient reports do not seem to have been a good guide to theoretical insights in depersonalization, it certainly can’t hurt to wonder whether their phenomenology of time is affected. 51 As it so happens, symptoms concerning time-experience are easily found. There are even a number of mid-20th century theorists who observe that complaints in time-experience were always present among depersonalization symptoms (Lewis, 1931; Winnik, 1948; Oberdorf, 1941). Here is a patient of Lewis’, …I want to get something back to my mind that seems to have gone, to let me see the present and the future…everything seems ages ago. And yet time seems to go faster. Everything comes new to me and fresh…the future to me is remote...Time just doesn’t appeal to me…I couldn’t tell you how long I’ve been sitting here; an hour seems like a minute. Time doesn’t seem to go at all… (Lewis, 1931 p.614). Another patient reveals, “I think about them all three at once, past, present and future” (p.614). It is very clear, from these and others, that these patients are not experiencing time in the ‘thick’ sense that we normally do. Talking about depersonalization in the context of time experience, Lewis says that, I would regard the syndrome as indicative of the disturbed state of consciousness in which the immediate data of perception- an active, not a passive process – are so changed as to have lost their primary attribute of reality” (p.614). Both Humphrey and Lewis, then, can agree that perception (if we take Lewis to be using it in a broad sense) is an active, not a passive process. The implication I am hunting for is that the ‘primary attribute of reality’ – conscious reality – is intrinsically related to the subjective experience of time. Freeman & Melges (1978) suggest that ‘time perspective’ functions as a frame of self-reference without which the experience of self becomes distorted and unfamiliar. Or, again in Lewis’ words, Time-consciousness is a matter of immediate experience: it is an aspect of all conscious activity: it is essential to all reality…we live in time… The perceived world…is but the embodiment of our personal interest which reaches back over the past and forward to the future, so that past and future are represented in the present. (p.612, italics added) Contrary to these reports of (subjectively) impaired time experience, a study found that patients of depersonalization perform no worse at verbal estimates of real time intervals (Cappon, 1969). In line with their capacity for empathy (see Lawrence et al, 2007; Sierra et al., 2002) and attributional components of agency (Gazziniga, 1996), there appears to be a distinction between cognitive experience of a given capacity and subjective or phenomenal experience. Patients can 52 recognise someone else is sad, but not feel it; they can cognitively attribute an action to themselves but not feel like it was them; they can guess periods of time with accuracy even if it feels distorted. But just because patients report experiences of time distortion does not prove the thick-time hypothesis correct. If everything we consciously experience is experienced in the temporal immediacy of the present it cannot be bracketed off as an individual problem. If the processes responsible for the subjective present were to be affected, it would not be enough to ask the subject if their experience of ‘time’ was any different. It goes far deeper than that – it is the necessary workspace for all phenomenology. A patient would be unable to recognise that their impairment was one of time-consciousness. At the same time, it would be wrong to say that testimonies of time distortion repudiate the hypothesis. The distortion of the processes underlying the extended present would have bizarre and ineffable ramifications. It is suggestive to remember the intuitive comparisons early theorists (Dugas, Heymans, Kraeplin) made between depersonalization and déjà vu experiences. As above, Dugas dismissed the déjà vu link because it was too restricted compared to the allencompassing experience of depersonalization. If there is a global distortion of the putative ‘feedback loops’ responsible for thick time, the result might well be the bewildering unfamiliarity of the world and the person ‘present’ in it. Perhaps their thick moment of the present is not sufficiently reified from the temporal gestalt surrounding itThe sensations of the present, though experienced, might sit strangely. The phenomenal content of the infinite ‘now’ might seem constantly ‘out of context’, and thus un-‘real’. Their symptoms would be wide ranging. They would include the experience of the self and world, of time and affect, somatosensory distortion and disembodiment; in short, the diverse range of symptoms present in depersonalization-derealization phenomenon. 53 Conclusions These are plausible things to wonder. But at this stage they remain very speculative. It is illuminating to accompany any concluding thoughts with some of the conclusions contemporary work on depersonalization has come to. Below is Sierra ‘pulling the threads together’ from his monograph: The view that ‘emotional feelings may be a core experiential component of perception rather than just a reaction to it, has been a neglected idea in neuropsychology… Such an ‘emotional colouring’ mechanism is likely to be a major contributor to feelings usually described in terms of ‘immediacy’, ‘atmosphere’, and ‘vividness’ (Gloor, 1990). There is evidence suggesting that … when perception becomes conscious, it is already ‘emotionally coloured’ (Halgren, 1992; Halgren & Marinkovic, 1994). (Sierra, 2009, p.143) Pointing to either ‘thick-time’ or ‘affect’ comes of as a somewhat ad hoc bridge over the explanatory gap faced by any account phenomenal consciousness. Whether affect or the subjective present, they fulfil the same supposed function – giving percepts a certain qualitative character, their phenomenal immediacy. Pointing to something general enough to account for the wide range of the symptoms found in the depersonalization spectrum is pointing to something out of reach. Whatever the process, it will be transparent. Whether the construction of an extended present via looping sensations, Dugas’ ‘Personnalisation’, or the work of Sierra’s pre-conscious ‘emotional colouring mechanism’ – the activity remains at a sub-personal level. The debates over the condition, then, cannot be settled by an examination of symptoms. Phenomenology will provide an ill-informed guide to the source. You can describe something invisible however you want. The central term of depersonalization experiences – unreality - is of poor explanatory value. While we know why there is an explanatory gap, it doesn’t help us describe it. It can only be defined functionally, as a dysfunction of whatever it is that imbues our world and self models with their essential ‘reality’. Diagnostic psychiatry, which relies on such descriptive symptoms, will struggle to adequately frame the experience. It will spill out into a whole range of other categories of mental experience, as exemplified by current nosological debates over the condition. But the fact that a given experience is descriptively and thus 54 diagnostically problematic cannot undermine its experiential validity. Debates both theoretical and diagnostic need to recognise the fundamental nature of the experience, and not let uncertainty lead to illegitimacy in the eyes of professionals and popular opinion alike. Depersonalization provides a fascinating insight into phenomenal consciousness; of the alleged relationship between perception and sensation, of agency and subjectivity, embodiment and self - the basics of consciousness and perceptual realism. The objects of our first-person perspective are more fragile and complicated than we take for granted; the stable presence of the external world and the inner ‘self’ we so readily assume is not as fixed nor independent as it appears. The world, or at least the world as it appears to a conscious subject, is one of sensation. It is sensation that links what we so often separate – the world and the self. It is sensation that we both create and depend on, that makes us subjects at all, that allows a world to appear to a self – a self that feels, a self witness to it’s own feeling. If the normal character of our sensation is altered, both the world and our place in it will seem out of kilter. Acknowledgements Thanks must go to Dr. Dominic Murphy for his encouragement and advice, for supporting my speculations. And thanks also to Prof. Brian Keeley for many helpful comments and clarifications. 55 References American Psychiatric Association. (1980). 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