Lisa Bortolotti

On one influential view, the problems that should attract medical attention involve a disorder, because the goals of medical practice are to prevent and treat disorders. Based on this view, if there are no mental disorders then the status of psychiatry as a medical field is challenged. In this paper, I observe that it is often difficult to establish whether the problems that attract medical attention involve a disorder, and argue that none of the notions of disorder proposed so far offers a successful demarcation criterion between medical and non-medical problems. As an illustration, I consider why delusions are considered pathological and whether they attract medical attention in virtue of being pathological, where ‘pathological’ stands for ‘being caused by a disorder’. Although there are several promising answers to what makes delusions pathological, available accounts of the pathological nature of delusions fail to distinguish delusions from other irrational beliefs that are not typically thought of as pathological; and cannot explain why delusions typically attract medical attention whereas other irrational beliefs do not.

In the chapter I suggest that epistemic rationality should not be seen as a condition for intentional agency, but rather as an aspiration. Common failures of epistemic rationality in agents, such as conservatism, superstition, and prejudice, do not prevent us from interpreting and predicting those agents’ behaviour on the basis of their intentional states. In some circumstances, including confabulatory explanations and optimistically biased beliefs, instances of epistemic irrationality are instrumental to agents developing an illusion of competence and coherence, and thereby sustain the agents’ motivation it pursue their goals.

It is estimated that up to 7500 people develop schizophrenia each year in the UK. Schizophrenia has significant consequences, with 28% of the excess mortality in schizophrenia being attributed to suicide. Previous research suggests that suicide in schizophrenia may be more related to affective factors such as depression and hopelessness, rather than psychotic symptoms themselves. Considering suicide in schizophrenia within this framework enables us to develop a novel philosophical approach, in which suicide may not be related to loss of self-consciousness, thought processing dysfunctions or perception disturbances. The action of suicide may be due neither to persistent hallucinations nor other psychotic symptoms, such as delusional beliefs, but to other underexamined, perhaps rational reasons, such as extreme social isolation, severe depression or emotional withdrawal. This paper does not examine the moral character of suicide. Instead, it argues that we should conceive the action of suicide in schizophrenia as an act that is not necessarily irrational. People with schizophrenia might end their life based on reasons if suicide is the best means to achieve their ends. However, the paper does not support assisted suicide. It aims to provide a better understanding of the reasons why people take their own lives and suggests that understanding can inform effective interventions to reduce high rates of suicide.

The two-factor theory (Davies, Coltheart, Langdon & Breen 2001; Coltheart 2007; Coltheart, Menzies & Sutton 2010) is an influential account of delusion formation. According to the theory, there are two distinct factors that are causally responsible for delusion formation. The first factor is supposed to explain the content of the delusion, while the second factor is supposed to explain why the delusion is adopted and maintained. Recently, another remarkable account of delusion formation has been proposed, in which the notion of “prediction error” plays the central role (Fletcher & Frith 2009; Corlett, Krystal, Taylor & Fletcher 2009; Corlett, Taylor, Wang, Fletcher & Krystal 2010). According to this account, the prediction-error theory, delusions are formed in response to aberrant prediction-error signals, those signals that indicate a mismatch between expectation and actual experience. In this chapter, we examine the relationship between the two-factor theory and the prediction-error theory in some detail. Our view is that the prediction-error theory does not have to be understood as a rival to the two-factor theory. We do not deny that there are some important differences between them. However, those differences are not as significant as they have been presented in the literature. Moreover, the core ideas of the prediction-error theory may be incorporated into the two- factor framework. For instance, the aberrant prediction-error signal that is posited by prediction-error theorists can be (or underlie) the first factor contributing to the formation of some delusions, and help explain the content of those delusions. Alternatively, the aberrant prediction-error signal can be (or underlie) the second factor, and help explain why the delusion is adopted and maintained.

In their fascinating and timely article, Blumenthal-Barbyand Ubel (2018) argue that it is often unclear whether patients exhibit hope, are unrealistically optimistic, or are in denial or self-deceived, as distinctions made on the basis of belief accuracy are problematic. The authors maintain that, in most cases, we should respect patients' decisions, even when they exhibit some optimistic bias. We agree on all key points and intend to provide additional evidence to support the authors’ arguments, drawing attention to the fact that in the health domain, as in other areas of life, being unrealistically optimistic can be an asset, leading to self-fulfilling prophecies and giving people a higher chance of living the life they desire.

To what extent do self-deception and delusion overlap? In this paper we argue that both self-deception and delusions can be understood in folk-psychological terms. “Motivated” delusions, just like self-deception, can be described as beliefs driven by personal interests. If self-deception can be understood folk-psychologically because of its motivational component, so can motivated delusions. Non-motivated delusions also fit the folk-psychological notion of belief, since they can be described as hypotheses one endorses when attempting to make sense of unusual and powerful experiences. We suggest that there is continuity between the epistemic irrationality manifested in self-deception and in delusion.

b is collection focuses on conceptual issues that arise within the theoretical dimension of psychiatry. In particular, the invited contributions centre on the nature of psychiatric classification and explanation by addressing important methodological issues. Two strategies are exemplified here. Either the authors directly contribute to foundational issues in psychiatry concerning the nature of psychiatric classification and explanation; or they provide a conceptual analysis that can play a role in developing adequate theories of specific psychiatric disorders.

After briefly reviewing some of the empirical and philosophical literature suggesting that there may be an adaptive role for delusion formation, we discuss the results of a recent study consisting of in-depth interviews with people experiencing delusions. We analyse three such cases in terms of the circumstances preceding the development of the delusion; the effects of the development of the delusion on the person’s situation; and the potential protective nature of the delusional belief as seen from the first-person perspective. We argue that the development of the delusional belief can play a short-term protective function and we reflect on the implications that this might have for our understanding of psychotic symptoms, for the stigma associated with mental health issues, and for treatment options.

Findings from the cognitive sciences suggest that the cognitive mechanisms responsible for some memory errors are adaptive, bringing benefits to the organism. In this paper we argue that the same cognitive mechanisms also bring a suite of significant epistemic benefits, increasing the chance of an agent obtaining epistemic goods like true belief and knowledge. This result provides a significant challenge to the folk conception of memory beliefs that are false, according to which they are a sign of cognitive frailty, indicating that a person is less reliable than others or their former self. Evidence of memory errors can undermine a person’s view of themselves as a competent epistemic agent, but we show that false memory beliefs can be the result of the ordinary operation of cognitive mechanisms found across the species, which bring substantial epistemic benefits. This challenge to the folk conception is not adequately captured by existing epistemological theories. However, it can be captured by the notion of epistemic innocence, which has previously been deployed to highlight how beliefs which have epistemic costs can also bring significant epistemic benefits. We therefore argue that the notion of epistemic innocence should be expanded so that it applies not just to beliefs but also to cognitive mechanisms.

In this paper I discuss the costs and benefits of confabulation, focusing on the type of confabulation people engage in when they offer explanations for their attitudes and choices. What makes confabulation costly? In the philosophical literature confabulation is thought to undermine claims to self-knowledge. I argue that when people confabulate they do not necessarily fail at mental-state self-attributions, but offer ill-grounded explanations which often lead to the adoption of other ill-grounded beliefs. What, if anything, makes confabulation beneficial? As people are unaware of the information that would make their explanations accurate, they are not typically in a position to acknowledge their ignorance or provide better-grounded explanations for their attitudes and choices. In such cases, confabulating can have some advantages over offering no explanation because it makes a distinctive contribution to people’s sense of themselves as competent and largely coherent agents. This role of ill-grounded explanations could not be as easily played by better-grounded explanations should these be available. In the end, I speculate about the implications of this conclusion for attempting to eliminate or reduce confabulation.

Neuroscience has long had an impact on the field of psychiatry, and over the last two decades, with the advent of cognitive neuroscience and functional neuroimaging, that influence has been most pronounced. However, many question whether psychopathology can be understood by relying on neuroscience alone, and highlight some of the perceived limits to the way in which neuroscience informs psychiatry. Psychiatry as Cognitive Neuroscience is a philosophical analysis of the role of neuroscience in the study of psychopathology. The book examines numerous cognitive neuroscientific methods, such as neuroimaging and the use of neuropsychological models, in the context of a variety of psychiatric disorders, including depression, schizophrenia, dependence syndrome, and personality disorders. Psychiatry as Cognitive Neuroscience includes chapters on the nature of psychiatry as a science; the compatibility of the accounts of mental illness derived from neuroscience, information-processing, and folk psychology; the nature of mental illness; the impact of methods such as fMRI, neuropsychology, and neurochemistry, on psychiatry; the relationship between phenomenological accounts of mental illness and those provided by naturalistic explanations; the status of delusions and the continuity between delusions and ordinary beliefs; the interplay between clinical and empirical findings in psychopathology and issues in moral psychology and ethics. With contributions from world class experts in philosophy and cognitive science, this book will be essential reading for those who have an interest in the importance and the limitations of cognitive neuroscience as an aid to understanding mental illness.

Does optimism lead to success? Friends of optimism argue that positive beliefs about ourselves and our future contribute to fitness and mental health, and are correlated with good functioning, productivity, resilience, and pro-social behaviour. Sceptics, instead, claim that when we are optimistic we fail to react constructively to negative feedback, and put ourselves at risk because we underestimate threats. Thus, it is controversial whether optimistic beliefs are conducive to success, intended as the fulfilment of our goals in a given domain. According to the traditional view, optimistic beliefs lead to success when they do not involve any distortion of reality, and according to the trade-off view, they lead to success when they involve a distortion of reality, but a small one. Based on the literature about positive illusions in the perception of romantic partners and in the assessment of future health prospects, I suggest that optimistic beliefs lead to goal attainment when they support agency by contributing to the sense that we are competent and efficacious agents and that our goals are both desirable and attainable.

In this chapter we argue that some beliefs present a problem for the truth-aim teleological account of belief, according to which it is constitutive of belief that it is aimed at truth. We draw on empirical literature which shows that subjects form beliefs about the real world when they read fictional narratives, even when those narratives are presented as fiction, and subjects are warned that the narratives may contain falsehoods. We consider Nishi Shah’s teleologist’s dilemma and a response to it from Asbjørn Steglich-Petersen which appeals to weak truth regulation as a feature common to all belief. We argue that beliefs from fiction indicate that there is not a basic level of truth regulation common to all beliefs, and thus the teleologist’s dilemma remains. We consider two objections to our argument. First, that the attitudes gained through reading fiction are not beliefs, and thus teleologists are not required to account for them in their theory. We respond to this concern by defending a doxastic account of the attitudes gained from fiction. Second, that these beliefs are in fact appropriately truth-aimed, insofar as readers form beliefs upon what they take to be author testimony. We respond to this concern by suggesting that the conditions under which one can form justified beliefs upon testimony are not met in the cases we discuss. Lastly, we gesture towards a teleological account grounded in biological function, which is not vulnerable to our argument. We conclude that beliefs from fiction present a problem for the truth-aim teleological account of belief.

In some neuropsychological disorders memory distortions seemingly fill gaps in people’s knowledge about their past, where people’s self-image, history, and prospects are often enhanced. False beliefs about the past compromise both people’s capacity to construct a reliable autobiography and their trustworthiness as communicators. However, such beliefs contribute to people’s sense of competence and self-confidence, increasing psychological wellbeing. Here we consider both psychological benefits and epistemic costs, and argue that distorting the past is likely to also have epistemic benefits that cannot be obtained otherwise, such as enabling people to exchange information, receive feedback, and retain key beliefs about themselves.

It has been argued that schizophrenic delusions are “behaviourally inert.” This is evidence for the phenomenon of “double bookkeeping,” according to which people are not consistent in their commitment to the content of their delusions. The traditional explanation for the phenomenon is that people do not genuinely believe the content of their delusions. In the article, we resist the traditional explanation and offer an alternative hypothesis: people with delusions often fail to acquire or to maintain the motivation to act on their delusional beliefs. This may be due to avolition, to emotional disturbances, or to the fact that, given the peculiar content of some delusions, the surrounding environment does not support the agent’s motivation to act.

The right not to know is often defended on the basis of the principle of respect for personal autonomy. If I choose not to acquire personal information that impacts on my future prospects, such a choice should be respected, because I should be able to decide whether to access information about myself and how to use it. But, according to the incoherence objection to the right not to know in the context of genetic testing, the choice not to acquire genetic information undermines the capacity for autonomous decision making. The claim is that it is incoherent to defend a choice that is inimical to autonomy by appealing to autonomy. In this paper, I suggest that the choice not to know in the context of genetic testing does not undermine self-authorship, which is a key aspect of autonomous decision making. In the light of this, the incoherence objection to the right not to know seems less compelling.

In this paper we address Bernard Williams' argument for the undesirability of immortality. Williams argues that unavoidable and pervasive boredom would characterise the immortal life of an individual with unchanging categorical desires. We resist this conclusion on the basis of the distinction between habitual and situational boredom and a psychologically realistic account of significant factors in the formation of boredom. We conclude that Williams has offered no persuasive argument for the necessity of boredom in the immortal life. 1.

Various debates in bioethics have been focused on whether non-persons, such as marginal humans or non-human animals, deserve respectful treatment. It has been argued that, where we cannot agree on whether these individuals have moral status, we might agree that they have symbolic value and ascribe to them moral value in virtue of their symbolic significance. In the paper I resist the suggestion that symbolic value is relevant to ethical disputes in which the respect for individuals with no intrinsic moral value is in conflict with the interests of individuals with intrinsic moral value. I then turn to moral status and discuss the suitability of personhood as a criterion. There some desiderata for a criterion for moral status: it should be applicable on the basis of our current scientific knowledge; it should have a solid ethical justification; and it should be in line with some of our moral intuitions and social practices. Although it highlights an important connection between the possession of some psychological properties and eligibility for moral status, the criterion of personhood does not meet the desiderata above. I suggest that all intentional systems should be credited with moral status in virtue of having preferences and interests that are relevant to their well-being.

This open access book offers an exploration of delusions--unusual beliefs that can significantly disrupt people's lives. Experts from a range of disciplinary backgrounds, including lived experience, clinical psychiatry, philosophy, clinical psychology, and cognitive neuroscience, discuss how delusions emerge, why it is so difficult to give them up, what their effects are, how they are managed, and what we can do to reduce the stigma associated with them. Taken as a whole, the book proposes that there is continuity between delusions and everyday beliefs. It is essential reading for researchers working on delusions and mental health more generally, and will also appeal to anybody who wants to gain a better understanding of what happens when the way we experience and interpret the world is different from that of the people around us.

Here we consider the nature of unrealistic optimism and other related positive illusions. We are interested in whether cognitive states that are unrealistically optimistic are belief states, whether they are false, and whether they are epistemically irrational. We also ask to what extent unrealistically optimistic cognitive states are fixed. Based on the classic and recent empirical literature on unrealistic optimism, we offer some preliminary answers to these questions, thereby laying the foundations for answering further questions about unrealistic optimism, such as whether it has biological, psychological, or epistemic benefits.

The right not to know is often defended on the basis of the principle of respect for personal autonomy. If I choose not to acquire personal information that impacts on my future prospects, such a choice should be respected, because I should be able to decide whether to access information about myself and how to use it. But, according to the incoherence objection to the right not to know in the context of genetic testing, the choice not to acquire genetic information undermines the capacity for autonomous decision making. The claim is that it is incoherent to defend a choice that is inimical to autonomy by appealing to autonomy. In this paper, I suggest that the choice not to know in the context of genetic testing does not undermine self-authorship, which is a key aspect of autonomous decision making. In the light of this, the incoherence objection to the right not to know seems less compelling.

In this paper we have two main aims. First, we present an account of mood-congruent delusions in depression (hereafter, depressive delusions). We propose that depressive delusions constitute acknowledgements of self-related beliefs acquired as a result of a negatively biased learning process. Second, we argue that depressive delusions have the potential for psychological and epistemic benefits despite their obvious epistemic and psychological costs. We suggest that depressive delusions play an important role in preserving a person’s overall coherence and narrative identity at a critical time, and thus can be regarded as epistemically innocent.

In this paper we review two debates in the current literature on clinical delusions. One debate is about what delusions are. If delusions are beliefs, why are they described as failing to play the causal roles that characterise beliefs, such as being responsive to evidence and guiding action? The other debate is about how delusions develop. What processes lead people to form delusions and maintain them in the face of challenges and counter-evidence? Do the formation and maintenance of delusions require abnormal experience alone, or also reasoning biases or deficits? We hope to show that the focus on delusions has made a substantial contribution to the philosophy of the mind and continues to raise issues that are central to defining the concept of belief and gaining a better understanding of how people process information and learn about the world.

There is no satisfactory account for the general phenomenon of confabulation, for the following reasons: (1) confabulation occurs in a number of pathological and non-pathological conditions; (2) impairments giving rise to confabulation are likely to have different neural bases; and (3) there is no unique theory explaining the aetiology of confabulations. An epistemic approach to defining confabulation could solve all of these issues, by focusing on the surface features of the phenomenon. However, existing epistemic accounts are unable to offer sufficient conditions for confabulation and tend to emphasise only its epistemic disadvantages. In this paper, we argue that a satisfactory epistemic account of confabulation should also acknowledge those features which are (potentially) epistemically advantageous. For example, confabulation may allow subjects to exercise some control over their own cognitive life which is instrumental to the construction or preservation of their sense of self.