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The Measure of Madness

1
Life and Mind: Philosophical Issues in Biology and
Psychology

Kim Sterelny and Robert A. Wilson, Series Editors

The Measure of Madness: Philosophy of Mind, Cognitive
Neuroscience, and Delusional Thought, Philip Gerrans, 2014
Evolution in Four Dimensions: Genetic, Epigenetic, Behavioral, and
Symbolic Variation in the History of Life, revised and updated
edition, Eva Jablonka and Marion J. Lamb, 2014
Cooperation and Its Evolution, volume 1: Agents and Environments,
Kim Sterelny, Richard Joyce, Brett Calcott, and Ben Fraser, editors,
2012
Cooperation and Its Evolution, volume 2: Agents and Mechanisms,
Kim Sterelny, Richard Joyce, Brett Calcott, and Ben Fraser, editors,
2012
Ingenious Genes: How Gene Regulation Networks Evolve to Control
Development, Roger Sansom, 2011
Yuck! The Nature and Moral Significance of Disgust, Daniel Kelly,
2011
Laws, Mind, and Free Will, Steven Horst, 2011
Perplexities of Consciousness, Eric Schwitzgebel, 2011
Humanity’s End: Why We Should Reject Radical Enhancement,
Nicholas Agar, 2010
Color Ontology and Color Science, Jonathan Cohen and Mohan
Matthen, editors, 2010
The Extended Mind, Richard Menary, editor, 2010
The Native Mind and the Cultural Construction of Nature, Scott
Atran and Douglas Medin, 2008

2
Describing Inner Experience? Proponent Meets Skeptic, Russell T.
Hurlburt and Eric Schwitzgebel, 2007
Evolutionary Psychology as Maladapted Psychology, Robert C.
Richardson, 2007

3
The Measure of Madness

Philosophy of Mind, Cognitive Neuroscience,

and Delusional Thought

Philip Gerrans

The MIT Press

Cambridge, Massachusetts
London, England

4
© 2014 Massachusetts Institute of Technology

All rights reserved. No part of this book may be reproduced in any form by any electronic or
mechanical means (including photocopying, recording, or information storage and retrieval)
without permission in writing from the publisher.

Library of Congress Cataloging-in-Publication Data is available.

ISBN 978-0-262-02755-7 (hardcover : alk. paper)
ISBN 978-0-262-32098-6 (retail e-book)

d_r1

5
Contents

Acknowledgements
Introduction
1 The Measure of Madness
1.1 Integrative versus Autonomous Theoretical Explanation
1.2 The Basis of Theoretical Autonomy
1.3 Jaspers and the Inscrutability of Delusion
1.4 Meaning Rationalism and Framework Propositions
1.5 Neurobiological Eliminativism
1.6 Cognitive Phenomenology
2 Models, Mechanisms, and Cognitive Theories
2.1 Cognitive Autonomy: Models and Multiple Realizability
2.2 Causal Relevance and the Personal Level
2.3 Cognitive Neuropsychiatry and Neurocognitive Psychiatry
2.4 Autonomy Revisited
2.5 The Cognitive Economy
2.6 Theoretical Definition
3 The Processing Hierarchy and the Salience System
3.1 The Processing Hierarchy
3.2 A Computational Framework
3.3 The Salience System and Reward Prediction
3.4 Salience and the Adaptive Critic
3.5 Dopamine and Delusion
3.6 Applications
4 The Default Mode Network
4.1 Simulations as Narrative Elements
4.2 Mental Time Travel and the Default Network
4.3 Delusions as a “Mixed Mode” of the Default Network

6
 4.4 The First-Person Perspective and Decontextualization
4.5 The Default Network and the “Essential Indexical”
4.6 Subjectivity, Affective Processing, and the Hub of the Default
Network
4.7 Default and Decontextualized Processes
4.8 A Mundane Example
5 Dreaming, Default Thinking, and Delusion
5.1 Dreaming and the Default Mode Network
5.2 The AIM Model
5.3 Feature Binding and the Fregoli Delusion
5.4 Context Binding in Dreams and Delusions
5.5 Dorsolateral Deactivation in Dreams and Delusions
5.6 Are Delusions Dreams?
6 The Second Factor: Default or Doxastic Incorporation
6.1 Doxastic Theories and the Second Factor
6.2 Performance Accounts: Endorsement, Explanation, and
Incorporation
6.3 Interactionism, Explanationism, and Attributional Style
6.4 Attributional Style and the Cotard Delusion
6.5 Bias and Default Thinking
6.6 Competence Accounts: Deficits of Belief Fixation
7 Imagination Incorporated
7.1 Incorporating Imagination
7.2 Belief and Imagination; Congruence and Incongruence
7.3 Joint Incorporation
7.4 The Metacognitive Account
7.5 Delusions and Default Processing
7.6 The Dual Nature of Default Thoughts
7.7 Imaginative Resistance and the Essential Indexical
7.8 Cognitive Therapy for Doxastic Theorists
7.9 Imagination and Psychological Structure
8 The Sense of Agency, Lost and Found: Experience and Thought
in Schizophrenic Delusion
8.1 The Sense of Agency, Lost and Found

7
 8.2 The Priority of Visual Experience
8.3 Predictive Mechanisms and Cognitive Architecture
8.4 Experimental Evidence
8.5 Awareness of Predictions in Schizophrenia
8.6 Passivity and Externality
8.7 Mirror Neurons and Other Bodies
8.8 Passivity of Thought
8.9 External Attribution of Thoughts
8.10 External Attribution and Psychological Coherence
8.11 Passivity of Experience, Externality of Thought
9 Louis Sass and the Schizophrenic Lifeworld
9.1 Schreber’s Lifeworld
9.2 Cognitive Phenomenology
Conclusion
Notes
References
Index

8
Acknowledgments

A complete list of people who have helped me with the ideas in this
book would be extremely long. But I must make special mention of
the people and places without whom it could not have been written.
First, at the dawn of the millennium, Kim Sterelny, Martin Davies,
and Max Coltheart initiated a research program of empirically
informed philosophy of mind and cognitive science in Australia. I am
just one of the philosophers who has benefited from their intellectual
and personal support as that program flourished. In the early 2000s,
Kathleen Akins showed generosity and foresight to fund a group of
scholars through her McDonnell Centenary Fellowship. All of those
scholars have gone on to do extremely interesting work at the
border of philosophy and neuroscience. I hope this book does
justice to the goals of that ambitious project. Kevin Mulligan and
colleagues at the Centre Interdisciplinaire des Sciences Affective at
the University of Geneva have provided a home away from home. I
have also been generously supported by the Australian Research
Council over the last decade.

9
Introduction

In 1979 three neuropsychologists reported an unusual case of

delusion developed by a man following his admission to the hospital
in a coma after a car accident. Prior to his accident he had exhibited
signs of psychiatric illness such as paranoid delusions and auditory
hallucinations. However, after his car accident, which produced
extensive brain damage (including a necrotic right frontal lobe, a
detail which will become important in ensuing chapters), he
produced a new series of delusions. Released from the hospital
after ten months, he returned home to visit his family for the
weekend. After this visit,

he stated that he now lived with a second, different family,

virtually identical with his “first” family, and that they lived in a
house just like the one he had lived in previously. …

He insisted that he had two families of identical composition. The

wives of both families had the same given name, the same
maiden name, very similar appearance and manner, came from
the same town, and had brothers with the same names. There
were five children in each family, with the same names and the
same sex distribution, although he believed the children of his
original family were about 1 year younger than those in the
second family. … He described positive feelings toward “both
wives,” showed no anger or distress about his first wife’s
desertion, and specifically expressed thankfulness that she had
located a substitute. (Alexander, Stuss, and Benson 1979, 334)

Alexander, Stuss, and Benson described this delusion, slightly

misleadingly, as a delusion of “reduplication” (1979, 334), forming
part of a family of delusions of misidentification that typically arise
following right hemisphere damage. Over the last two decades,
philosophers and cognitive scientists have become increasingly

10
interested in these delusions because their explanation interweaves
philosophical questions about the nature of belief and rationality with
the explanation of clinical symptoms by cognitive science and
neurobiology (Stein 1996).
In this book I provide an account of what is going on in this type of
case that extends to other cases of delusion and irrational belief. I
argue that we can explain delusion without necessarily invoking a
failure or malfunction in a process dedicated to the rational
evaluation of beliefs for truth or empirical adequacy. There is a
sense in which delusions, and, I will argue, many thoughts, bypass
processes of rational belief fixation. If this is correct then the
explanation of delusions, and many other species of irrational
“belief,” does not require us to treat delusions as beliefs produced by
reasoning deficits or biases. Rather, we need to explain how it is that
delusions can arise in response to experience, be maintained, and
interact with other mental states to control behavior, all without
necessarily being believed (Dennett 1991).1
Of course, for many philosophers and psychologists, the fact that
delusions are psychologically embedded in this way automatically
qualifies them as beliefs. For these theorists, someone with a
delusion of misidentification who murders his father while deluded
that he is attacking an impostor surely believes his delusion.
I am not so sure. Delusions certainly resemble straightforward
empirical beliefs; they are formed in response to perceptual
information and often regulate behavior. Equally, however, they
have some properties that make them difficult to assimilate to
straightforward cases of empirical belief. They are often extremely
subjective, in the sense not only of being produced as a response to
personal experience, but of being somehow insulated from public
standards of justification, openness to dialogue, and disconfirmation
by obvious counterevidence. Similarly, when pressed, delusional
patients often show a lack of commitment to their delusion that they
do not show to other empirical beliefs. There is also something
about the phenomenology of delusion, the first-person experience of

11
delusional life, that seems to distinguish it from other modes of
experience that lead straightforwardly to empirical belief.
Of course, the fact that a mental state is based on strange and
intractable forms of experience, is subjective, maintained with
ambivalence, and insulated from disconfirmation according to
intersubjective standards does not show that it is not a belief.
Delusions might be beliefs that arise and are maintained in unusual
ways. Much of the research on delusion takes place from within this
doxastic framework, trying to explain how it is that the neural and
cognitive correlates of delusion can introduce things like
confirmation biases, dysfunctional gaps, deficits, or shortcuts into a
belief-fixation system. As with the heuristics and biases tradition in
psychology, the idealizations of logic and probability theory provide
a standard of competence against which irrational human
performance is initially measured and explained. For example, the
differing performance of delusional and nondelusional people on an
inductive reasoning task has been used to explain the difference
between delusional and nondelusional belief fixation (Garety and
Freeman 1999; Garety, Hemsley, and Wessely 1991; Hemsley and
Garety 1986; Huq, Garety, and Hemsley 1988; Startup, Freeman,
and Garety 2008; Broome et al. 2007).
My argument in this book is that we can set aside questions about
the nature of rationality and still satisfactorily explain the puzzling
belief-like properties of delusion, as well as its puzzling non-belief-
like properties. The methodology I recommend is to pay close
attention to and describe the cognitive properties of the neural
mechanisms that produce delusion. Thus, the approach I take is
consistent with that proposed by Dominic Murphy in his plea for a
(cognitive neuro-) scientific psychiatry: “we arrive at a
comprehensive set of positive facts about how the mind works, and
then ask which of its products and breakdowns matter for our
various projects” (2006, 105).
If our project is to explain why someone says that her family has
been replaced by doubles, it is not clear that the concept of belief,

12
anchored as it is in conceptual debates about the nature of
rationality, needs to play a large role in that explanation. Rather, to
explain delusion we describe the components of the information
processing system active in delusion and trace the flow of
information through the system. We do so making use of the
evidence available from different disciplines, ranging from molecular
neurobiology to clinical psychiatry and cognitive neuroscience.
A clue to the cognitive nature of delusion is provided by
Alexander’s patient in an interview with his doctors:

E. Isn’t that [two families] unusual?

S. It was unbelievable!

E. How do you account for it?

S. I don’t know. I try to understand it myself, and it was virtually

impossible.

E. What if I told you I don’t believe it?

S. That’s perfectly understandable. In fact, when I tell the story, I

feel that I’m concocting a story … It’s not quite right. Something is
wrong.

E. If someone told you the story, what would you think?

S. I would find it extremely hard to believe. I should be defending

myself.

(Alexander, Stuss, and Benson 1979, 335; my italics)

I believe that the patient is right. He is telling a story. The story is

consistent with his experience (though not with his knowledge about
the nature of reality), but from the point of view of a third person it is
unbelievable. Nonetheless, he cannot abandon that story or revise it
to fit with his wider empirical knowledge and so continues to act

13
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