Young s paper (2007) identifies fundamental. If You Did Not Care, You Would Not Notice: Recognition and Estrangement in Psychopathology

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2 If You Did Not Care, You Would Not Notice: Recognition and Estrangement in Psychopathology Lisa Bortolotti and Matthew R. Broome Keywords: psychopathology, emotions, neuropsychology, delusions, cognitive neuropsychiatry, psychosis Young s paper (2007) identifies fundamental differences in the use of the concept of familiarity in the description of the experience of patients affected by the Capgras delusion and by prosopagnosia. Moreover, he suggests a way of disambiguating familiarity and proposes that the experience of Capgras patients is accounted for in terms of estrangement. Although we share the concern that the concept of familiarity might be used too broadly, we find his proposed solution problematic with respect to the Capgras delusion. In this brief commentary, we address two interrelated issues. (1) Can estrangement from an object of experience be coherently distinguished from the failure of re-identification of that object? (2) Given that the delusional belief is what essentially characterizes the Capgras syndrome, can the experience of Capgras patients be accounted for independently of a reference to their delusional beliefs? Recognition and Estrangement There are at least three cases in which an object of experience can turn out to be unfamiliar to the subject of experience. (a) One can fail to re-identify the object and sees it as novel as if one had not experienced it before. A typical reaction to this failure, when acknowledged, would be to say: I ve never seen this before. (b) One can fail to reidentify the object because one sees it as if it were different from how one experienced it before or from how one would have expected it to be. A typical reaction to this failure, when acknowledged, would be to say: It is not x, because it looks different from x. The element of comparison is important in this case. It signals that a similarity or continuity with a previously known object of experience is detected but that the similarity or continuity is not sufficient for the re-identification 2008 by The Johns Hopkins University Press

3 40 PPP / Vol. 14, No. 1 / March 2007 to succeed. (c) One can re-identify the object but fail to have the emotional response toward it that usually accompanied one s previous experiences of it. In this case, one would say something like: I feel differently toward this object. (This is what Young calls estrangement ). Young claims that we cannot describe the experience of Capgras patients in terms of (a) or (b), because The Capgras patient recognizes the familiar face as a familiar face; he experiences, then, the what-it-is-likeness of recognition (31). Although we can see the reasons why he is making this claim, namely that the Capgras patient would not be accusing someone to be an imposter if she found that person entirely new and unfamiliar, there are difficulties in asserting that the patient recognizes the person. The Capgras patient does not recognize that person as the person dear to her, so the recognition that is taking place is just a partial one and its cognitive and affective components cannot be entirely made independent of one another. Moreover, the experience of Capgras patients cannot be characterized purely as (c). Their reaction to the abnormal experience is not consistent with their feeling estranged from the object of experience. If they had an awareness that their emotional reactions or feelings toward the object of experience had changed, but no problem in recognizing the person as the dear one, they would not fail to re-identify the person as their loved one, but would attempt to find an explanation for the radical change in their emotional response. But Capgras patients do offer explanations such as those mentioned in (b), where they claim that the person (as they currently experience her) does not entirely correspond to the person they know. Some reports by Capgras patients (e.g., the imposter s eyes are too small or that she is too tall) indicate that they do make a comparison between two objects of experience (Campbell 2001). One could argue that these reports by Capgras patients should not be taken as evidence for the quality of their experiences, because they might be the effect of post hoc justification (Bortolotti 2005). The claim would be that the reports that seem to indicate a failure of re-identification are caused by the patients attempt to rationalize their lack of emotional response toward the person. Even assuming that the subject has conscious access to the content and character of her experience, and can classify it as lack of emotional response (which is controversial), the evidence mentioned by Young in support of the claim that familiarity qua recognition is present in Capgras patients and that it must be distinguished from lack of familiarity qua estrangement is not entirely convincing. Given that Capgras patients take themselves as not recognizing the person they see as their dear one, on what basis do we claim that the patient s capacity for recognition is intact? Young needs to build a more solid basis for the description of the experience of Capgras patients because his account (i) does not fit the patients reports; (ii) does not seem to explain the formation of the delusional belief that follows such abnormal experiences; and (iii) makes controversial assumptions about the level of conscious engagement of Capgras patients with the quality and content of their experience. The emphasis in the paper is given to the nature of the abnormal experience in Capgras patients, and no account is given of the relation between the experience and the formation of the delusional belief. If more attention were paid to that, the difficulty in distinguishing sharply between lack of recognition and estrangement would be more evident. We turn to the discussion of this point in the next section. The Importance of the Delusional Belief One could argue that lack of recognition, estrangement, or altered affective response is inessential to what is usually referred to as the Capgras syndrome. The core feature, and one that is not examined explicitly in the paper, is the belief that a person close to the sufferer has been replaced by an imposter, and further, the reasons given for this belief are not recognized as adequate by others (David 1997; Enoch and Ball 2001). The neuropsychological findings discussed may go toward giving some account of the possible mechanisms by which an anomalous experience may be generated in a subset of Capgras patients, but do not account for the formation of the delusional belief per se.

4 Bortolotti and Broome / Recognition and Estrangement in Psychopathology 41 With the emphasis on a certain neuropsychological account of facial recognition, the strangeness of Capgras syndrome is somewhat tamed. The crucial thing about Capgras is that, for the sufferers, someone emotionally close to them has been replaced by an imposter who looks identical, for a usually malign reason, and they know this with incorrigible certainty. This is not a simple mistake or misrecognition. Young s paper focuses on a mechanism that may account for some of the anomalous experiences generated that in turn may feed into the pathogenesis of the Capgras syndrome, but this does not address the formation of the delusional belief (e.g., my wife is an imposter ) as such at all (Freeman et al. 2002; Garety et al. 2001). Further, only a subpopulation of Capgras patients are likely to have the neuropsychological dysfunction described, and the commonest form of delusional misidentification in psychopathology is not that for people but for places. Thus, the account offered may offer a useful analysis of a certain step in the pathology of the Capgras syndrome in a subgroup of more neurological patients, but is unlikely to inform us about delusions more generally, or those with Capgras in the context of a functional psychosis such as schizophrenia or bipolar disorder. A deeper issue is the dualism of recognition and affective response. It seems, analogously to Davidson s assault on scheme-content dualism (Davidson 1974/2001), rather incoherent to think that we are presented with some neutral given that we then conceptualize in a certain emotional manner. We could, learning from McDowell (1994), reject dualism between recognition and emotional response, without rejecting the duality. Mood and emotion are given a central epistemological role in the work of Heidegger (1962, 1995, 1999), especially in his analysis of anxiety, boredom, and wonder as world-revealing and disclosing stances. The message we can draw from these philosophical analyses of the nature of experience is that, for us to notice anything, for something to enter phenomenal consciousness, it has to have a meaning for us, be of value, and thus we take up a stance toward it, whether negative or positive. Recognition implies an affective response: If we did not care, we would not notice. In recognizing another, this becomes more pronounced. We see people not as Cartesian automata but as autonomous moral agents whom we feel responsibility toward. Thus, in the Capgras case, it is not a two-step process (I recognize her as my wife minus the affective response and I feel estranged from her), but a unitary radically novel and disorientating experience. The experience, given the typical delusional content and elaboration, must be something like: This woman is an imposter who looks exactly like my wife but she bears malice toward me and is part of some wider plot against me. When one thinks of the affective response, one must thus think not of an absence of love, affection, and security, but rather one full of dread, fear, and anxiety. Such an approach is similar to our current understanding of the neuroscience of psychotic symptoms (Broome et al. 2005). In this account, a crucial step is the role dopamine plays in the generation of salience, and thus, which representations enter awareness, and the valence of one s affective response to such stimuli. In psychosis, the idea is that there is an inappropriate, contextless attribution of salience to stimuli that otherwise may not have reached consciousness; this leads to the puzzling and frightening experience of things in the world being of seeming relevance and importance to the individual, that otherwise would not be (Broome et al. 2005; Hemsley 1993, 1994, 2005; Kapur, 2003; Kapur, Mizrahi, and Li 2005). Further, commonly this would be associated with a negative emotional valence such that the world became threatening and malevolent. The world becomes a place where neutrality is no longer possible: Even the most benign, banal item is part of a malign purpose toward the patient, and gradually, over time, the plot becomes clear. The Capgras patient with an isolated and circumscribed delusional belief regarding the identity of one person is the exception, rather than the rule, in psychosis. Most Capgras sufferers will have elaborated delusional beliefs regarding why their wife has been abducted, how the imposter was found/created, and the purpose of the switch, plus beliefs regarding the surveillance and control they may themselves be experiencing. The imposter is thus typically one part of a wider conspiracy.

5 42 PPP / Vol. 14, No. 1 / March 2007 Conclusion A rigorous analysis of the many senses of familiarity is a welcome and important contribution to the literature on delusional experience. But we resist the suggestion that lack of recognition and estrangement in the experience of Capgras patients should be sharply distinguished. References Bortolotti, L Delusions and the background of rationality. Mind and Language 20: Broome, M. R., J. B. Woolley, P. Tabraham, L. C. Johns, E. Bramon, Murray, G.K., C. Pariante, P. K. McGuire, and R. M. Murray What causes the onset of psychosis? Schizophrenia Research 79: Campbell, J Rationality, meaning, and the analysis of delusions. Philosophy, Psychiatry, & Psychology 8, no. 2/3: David, A. S Atypical psychosis. In The essentials of postgraduate psychiatry, ed. R. Murray, P. Hill, and P. McGuffin, Cambridge: Cambridge University Press. Davidson, D. 1974/2001. On the very idea of a conceptual scheme. Inquiries into truth and interpretation, Oxford: Oxford University Press. Enoch, D., and H. Ball Uncommon psychiatric syndromes. London: Hodder Arnold. Freeman, D., P. A. Garety, E. Kuipers, D. Fowler, and P. E. Bebbington A cognitive model of persecutory delusions. British Journal of Clinical Psychology 41: Garety, P., E. Kuipers, D. Fowler, D. Freeman, and P. Bebbington A cognitive model of the positive symptoms of psychosis. Psychological Medicine 31: Heidegger, M Being and time. Oxford: Blackwell The fundamental concepts of metaphysics: World, finitude, solitude. Bloomington/Indianapolis: Indiana University Press Contributions to Philosophy (from Enowning). Bloomington/Indianapolis: Indiana University Press. Hemsley, D. R A simple (or simplistic?) cognitive model for schizophrenia. Behaviour Research and Therapy 31: A cognitive model for schizophrenia and its possible neural basis. Acta Psychiatrica Scandinavica Supplementum 90: The development of a cognitive model of schizophrenia: Placing it in context. Neuroscience & Biobehavioral Reviews 29: Kapur, S Psychosis as a state of aberrant salience: A framework linking biology, phenomenology, and pharmacology in schizophrenia. American Journal of Psychiatry 160: Kapur, S., R. Mizrahi, and M. Li From dopamine to salience to psychosis linking biology, pharmacology and phenomenology of psychosis. Schizophrenia Research 79: McDowell. J Mind and world. Cambridge, MA: Harvard University Press. Young, G. Clarifying familiarity: Phenomenal experiences in prosopagnosia and the Capgras delusion. Philosophy, Psychiatry, & Psychology 14, no. 1:29 37.