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Neuropsychiatric Practice and Opinion   |    
Commentary: Knowing and Valuing
John Cutting, M.D., F.R.C.P., F.R.C.Psych., M.Phil.
The Journal of Neuropsychiatry and Clinical Neurosciences 2001;13:410-411. doi:10.1176/appi.neuropsych.13.3.410
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Neuropsychiatric Practice and OpinionDelusions

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This is a delightfully well written paper on a cognitive theory of delusions. Quite why the term "neurobiologically" appears in the title and why it was sent to The Journal of Neuropsychiatry and Clinical Neurosciences is a mystery, because there is no mention of the brain whatsoever, and the article concerns matters that are as far away from the brain as one could get.

The thesis put forward is that the stumbling block in most definitions of delusion, including the various DSM versions, is the rider that tries to separate them from cultural and subcultural beliefs outside the assumed mainstream of humanity. Further, it is the authors' view that a particular sort of cognitive structure, unusual in "normals," is responsible for the delusion.

With regard to the impetus for their article—the problem of what to do with people who simply have "funny" beliefs, relative to the mainstream—I am in total sympathy, although I would separate religious beliefs from "funny" beliefs, for reasons that I shall deal with below. I am in sympathy with the authors because, having thought about the matter for nearly 30 years, it is only recently that I have come upon a possible solution of this.

With respect to their proposed solution, or rather reevaluation, I have little sympathy, although I recognize that within a cognitive model of delusions it might be seen as an advance.

What we are dealing with in this article is a proposed alteration in how a human being cognizes—knows—what is going on. This is the preoccupation of all psychologists, by definition, and of psychiatrists who concern themselves with this. Frankly, their proposal does not interest me at all. It is an issue between psychologists as to whether cognition is like this or like that. Time and time again psychiatrists get dragged into such debates, or, rarely in my experience, purposely start them.

What a delusion is cannot be worked out on this level, for the reason that cognition, by its nature, flattens out all matters. What I mean by this is that if there are, by virtue of their essence in the world, a variety of totally dissimilar sorts of entities—God, the number 3, a living bear, a human being by the name of Joe Smith, a stone, a thought of being lonely—then when it comes to cognizing them, they all appear on the same level, regardless of the massive difference between them in how they actually are.

Delusions, in my view, are not the by-product of inefficient cognition, regardless of whether cognition takes place by the mechanism suggested by these authors or by some other mechanism. Delusions stem from some problem prior to cognition, and cognition only rationalizes what is presented. I can support this thesis "neurobiologically," unlike the cognitive thesis put forward here, which, by its nature, is insupportable "neurobiologically"! Cognition is knowledge, and if there is knowledge, there must be something which knowledge knows about.

What does knowledge know about? It knows something as something, and this second (latter) something is always something else from the first something. The second something might be the current use-value of the first something (science) or the species salvation-value (religion) or simply the wonder that there is anything at all (philosophy).

You might say—what is all this nonsense about a first something that is secondarily interpreted in three ways: scientific, religious, or philosophical? All I can say is that if you look carefully at what schizophrenics say about matters you will find that they eschew the use-value of any matter but are quite preoccupied with the religious (salvation) value and philosophical (wonderment) value of what is.

To return to the authors' starting point—the unsatisfactory nature of the cultural/subcultural clause in DSM-IV's definition of delusion—they are quite right to question this. What I have suggested here is that their answer is quite unsatisfactory, too, though I might say no more unsatisfactory than anyone else's answer about delusion over the last two hundred years or so since it became a question-worthy topic.

What is overwhelmingly apparent in life, it seems to me, is that different people interpret the same event (a first something) in different ways. Whether their interpretations fall into these three classes referred to is arguable, and whether humans' interpretations are more standardized now than in earlier eras is also arguable. Regardless of these issues, it is clear that, as the authors say early on in their article, there is a primordial truth for all humans concerning some matters (holes in the road, for example) and it is this truth from which schizophrenics do depart, and which has to be explained. That there are some marginal situations in which a normal person's assigning an event a religious or philosophical value rather than a use-value seems bizarre in the context of our overwhelmingly use-value—oriented society is simply a diagnostic problem. It is not a reason for invoking a different cognitive structure in those who deviate from society's norms. Cognition "realizes" (i.e., knows) values. If the values, relative to a use-value—oriented society, are anomalous, so is the cognition. If a human's brain is such (and here we do invoke a neurobiological variable) that that human being is valuing awry, then cognition merely follows on and its knowledge is only as accurate as cognitive structures allow it to be—i.e., inaccurate given the primordial anomalous situation.

In short, we have here a brave, well-argued attempt to explain delusions by invoking an anomalous cognitive approach to all matters. I say, and I can produce philosophical support for my position, that cognition is merely knowledge of some primordial situation. Delusions arise from a problem in this primordial situation, and do not result primarily from an inefficient strategy within knowing.

Dr. Cutting is a consulting psychiatrist in East Sussex, United Kingdom.

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