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Book Reviews   |    
Books by John Cutting
Reviewed by Fred Ovsiew, M.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2013;25:244-246. doi:10.1176/appi.neuropsych.250301
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Fred Ovsiew, M.D., is Professor of Clinical Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, and Diplomate, Behavioral Neurology and Neuropsychiatry, United Council for Neurological Subspecialties, Fellow and Past President, American Neuropsychiatric Association.

Cutting J: Principles of Psychopathology: Two Worlds, Two Minds, Two Hemispheres. New York, Oxford University Press, 1997 (cited below as PP)

Cutting J: Psychopathology and Modern Philosophy. East Sussex, U.K., Forest Publishing Company, 1999 (PMP)

Cutting J: The Living, The Dead, and the Never-Alive: Schizophrenia and Depression as Variants of These. East Sussex, U.K., Forest Publishing Company, 2002 (LDNA)

Cutting J: A Critique of Psychopathology. East Sussex, U.K., Forest Publishing Company, 2011 (CP)

A widely-read textbook of psychopathology illustrates the dilemma of the psychopathologist with a diptych.1 In one panel, a physician is examining the abdomen of a patient by palpation. In the other, the hapless psychopathologist, blindfolded, and with hands bound, is listening as the patient reports the results of palpating his own abdomen. This is amusing, but fails to capture the nature of the problems facing psychopathology. Listening to the patient’s account of his or her subjective experience is only one means of investigating exploration of subjective psychological phenomena, the phenomenological approach for which Jaspers’s work is foundational. He then devoted the next 143 pages to “those perceivable objective facts which … give us access to the other person’s psyche.”

But, more important, to portray accurately the situation in which we find ourselves as psychopathologists, the illustration would somehow need to show us palpating the abdomen without knowing what organs are located within it. The clinician who finds comprehensive and compelling a “mental status examination” divided into categories such as “thought content,” “mood,” “affect,” and their bullet-pointed like, has failed to reflect on the nature of the object under study. Yet contemporary psychiatry has moved away from a grasp of fundamentals and toward a stereotyped, ostensibly operationalized, but shallow inventory of symptoms. This has led to a paradoxical loss of phenomenological richness as a supposedly phenomenological program was implemented.2

Two approaches have recently tried to discern the contents of mental space in regard to psychopathology. One is cognitive neuropsychiatry, which tries to explain psychopathological symptoms as malfunctions of a small number of well-understood cognitive mechanisms.3 Despite some initial apparent successes—and some triumphalist rhetoric4—at best, cognitive neuropsychiatry has, for the foreseeable future, a limited reach.

The second approach is that of John Cutting. His work is, so far as I know, not only unequalled, but unparalleled, in contemporary psychopathology. Cutting, a psychiatrist, wrote on neuropsychiatric issues, such as anosognosia, and on schizophrenia, including an important book containing translations of key European papers on the subject. He wrote a number of empirical research papers, often as sole author, devoted to clarifying psychopathological phenomena. One notable effort was his personal evaluation of 100 patients with delirium, using the Present State Examination, in which he identified patterns of abnormal thinking not previously recognized.5 In 1990, he produced a major monograph, The Right Cerebral Hemisphere and Psychiatric Disorders, on the intersection of his neuropsychiatric work and his work on schizophrenia.6 In that volume, he proposed the heterodox thesis that schizophrenia was a disorder underlaid by impaired functioning of the right cerebral hemisphere. (Later, as discussed at length in the volumes under review, he concluded that, in schizophrenia, deficits occur both in the intuitive grasp of the world by the right hemisphere and its representation and the judgment made upon this by the left.)

He then turned his attention to writing a comprehensive survey of psychopathology. He aimed, as he explained in the preface to PP, to update Jaspers, especially by including the perspective of neuropsychology. But, in the course of this ambitious, if still relatively conventional, undertaking, he encountered the work of Bergson, Schoperhauer, Scheler, Heidegger, and other 19th- and 20th-century philosophers, and he recognized that they tended to a view of metaphysics that paralleled and enriched his own thinking about psychopathology. Each hemisphere could be understood as creating an experiential world, as had been described, such as were measured by neuropsychologists. Hence, the subtitle of PP: Two Minds—Two Worlds—Two Hemispheres. By now, we are well outside the conventional ambit of general psychopathology. Having made this realization, Cutting was forced (by his own substantial sense of intellectual rigor) to pursue the foundations of psychopathological understanding as these could be illuminated by contemporary philosophy. As he puts it, “my approaches to psychopathology … reveal a path whereby a committed scientist becomes a disillusioned scientist, and then, perforce, philosopher because of the facts facing him” (LDNA p. 165, emphasis in original). This path led from PP to the subsequent volumes under review.

Contemporary psychiatrists (to modify Keynes’s remark) who believe themselves to be quite exempt from any philosophical influence are usually the slaves of some defunct philosopher. For example, Cutting points out, the current conceptualization of schizophrenia derives from “Kraepelin, for whom dementia praecox was a disorder of will (“will” being a preoccupation of early 19th century German philosophy); Bleuler, for whom schizophrenia was a disorder of associative thinking (association psychology being a joint German and British preoccupation in the 19th century); and Schneider, “who…overall followed Jaspers’ route” (LDNA p. 136). Admiring Minkowski and Louis Sass, in particular, and thoroughly informed by his own clinical experience, Cutting does not hesitate to condemn “the inadequate, over-inclusive, and sometimes platitudinous and tautological interpretations which the extant psychological models of the human being encourage” (LDNA p. 138).

Many practitioners seemed to have dispensed with it without a second or even a first glance. It is out-of-print and sure to remain so. The neuropsychiatrist will be attracted to its careful attention to abnormal mental phenomena, irrespective of their traditional assignment to neurology or psychiatry. It and its successor volumes contain extensive discussions of psychopathological phenomena that elude the attention of most clinicians, such as anomalous experiences of time and space, as well as masterly expositions of topics central to the psychiatric enterprise. The reader encounters brief discussions—based on clinical research (the data typically being presented in tabular form) and on Cutting’s own clinical experience—of topics such as the Ganser state, the differences between hallucinations due to left hemisphere and right hemisphere damage, and the phenomenology of anomalous bodily experience. These are of great neuropsychiatric utility in themselves but are always placed in the context of the metaphysical questions that animate Cutting’s work: what sorts of mental phenomena are there, and how can they be systematically considered?

Among these fundamental topics, I will focus briefly on delusion, which is considered in all the volumes. The discussion of delusions in PP begins with attention to the DSM definition (“a false belief,” and so on) and to the influential views of Jaspers. After a nuanced discussion addressing, in particular, the important contribution of Manfred Spitzer, Cutting offers his own definition of delusion: “a delusion is an imagined anomalous version of some realm of human affairs” (PP p. 124). He argues that, for the clinician faced with a delusional patient, this is the “overriding fragment” (PP p. 123). Clinically, this means that a delusion is like a volcanic island, impressive when considered as an island, but understandable only if considered as part of a submerged and invisible mountain range. The significance of each element of Cutting’s definition is fully spelled out and elucidated with reference to clinical research, some of it, his own. As he puts it later, “a delusion is the judgment of reason on the anomalous state of affairs thrown up by intuition” (PMP p. 259), and, still later, “a deluded person is he or she who claims to know some matter in a certain way; a way of knowing, however, which is inappropriate to the matter in question” (CP p. 59). Cutting is blunt about the failure of the DSM-IV view of delusion, which “can only be described as an institutionalized form of intellectual dishonesty” (PMP p. 336). I cannot in this review do justice to the subtlety of Cutting’s dissection of the problematic notions that are ignored in ordinary psychiatric practice; for example, whether a delusion is a belief at all, or whether delusions in schizophrenia are the same kind of thing as delusions in depression or mania. Reading Cutting on delusion is bracing intellectual exercise.

The first third of PMP, the successor to PP, offers a précis of modern philosophy in its relevance to psychopathology. This section—which will be rough going for most psychiatrists—is followed by a lengthy review of evidence as to the experiential worlds of the left and right hemispheres, as shown, for example, by the phenomenology of hallucinations in the right- and left-hemisphere–damaged states. The remaining half of the book explores a remarkably broad range of psychopathological conditions from the perspective imparted by the philosophical, psychopathological, and proto-nosological entities whose very names should bring dismay to the psychopathologist, as they signify a murky, 19th-century past of medical terminology and outworn notions: hysterical pseudodementia, Ganser’s syndrome, clouding of consciousness, Korsakoff’s syndrome, depressive pseudodementia, subcortical dementia, stupor, torpor” (PMP p. 282). Yet the history of the concepts is not irrelevant: “without knowing what was a live concern at some earlier time, … [we] will miss out on potentially significant findings” (PMP p. 349).

LDNA takes up many of the same issues that had been addressed in the earlier books, but a subtle shift has occurred. Cutting has come to the view that “the only way to conceive of psychopathology is as an anomalous philosophy of the normal. A scientific approach merely shrouds the matter in question.… One has to commit oneself, and that means be a philosopher, regardless of whether professional philosophers look down their noses at you” (LDNA p. 166; emphases in original). As he puts it in CP, “what some phenomenological psychiatrists were driving at, and what some contemporary philosophical psychopathologists are also attempting, is a metaphysical analysis of the nature of psychopathological entities. If this term sounds highfaluting, then so be it. I wish to raise the stakes of what we are considering as high as possible” (CP p. 259).

Does this shift provide a perspective that leads to new ideas? For example, about schizophrenia—and one gets the feeling that an understanding of schizophrenia, or at least finding a place to stand from which one could gain such an understanding—is that most schizophrenic delusions, in terms of the content or nature of knowing, are hereby exposed as futile, because the schizophrenic person is not just someone who knows something in a different way from the way the sane person does, but, rather, for the schizophrenic person, knowing and being are identical” (LDNA p. 175, emphasis in original). This is a metaphysical way of formulating his longstanding idea that schizophrenia is essentially a disorder of common sense, in which an intuitive relation to the world, derived from right-hemisphere activity, is lost, and a hypergnosic left-hemisphere produces an anomalous version of reality.

These brief allusions to Cutting’s series of books do no more than hint at the changes in his own views on controversial matters. He is candid about the development of his views. For example, in the latest of the books under review, after summarizing the thesis of the first of the series, he states, “I now see this whole approach as false” (CP p. 182). To the reader of the series of volumes, this evolution is one of the most appealing features of the work. The evident seriousness of and commitment to his intellectual venture, which he himself recognizes as a “quest” (PMP p. 335), should inspire us all.

Sims  ACP:  Symptoms in the Mind: An Introduction to Descriptive Psychopathology , 3rd Edition.  Edinburgh, Scotland,  W. B. Saunders, 2003
 
Tucker  GJ:  Putting DSM-IV in perspective.  Am J Psychiatry 1998; 155:159–161
[PubMed]
 
David  AS;  Halligan  PW:  Cognitive neuropsychiatry: potential for progress.  J Neuropsychiatry Clin Neurosci 2000; 12:506–510
[CrossRef] | [PubMed]
 
Ellis  HD:  Cognitive neuropsychiatry and delusional misidentification syndromes: an exemplary vindication of the new discipline.  Cogn Neuropsychiatry 1998; 3:81–89
[CrossRef] | [PubMed]
 
Cutting  J:  The phenomenology of acute organic psychosis: comparison with acute schizophrenia.  Br J Psychiatry 1987; 151:324–332
[CrossRef] | [PubMed]
 
Cutting  J:  The Right Cerebral Hemisphere and Psychiatric Disorders .  Oxford, New York,  Oxford University Press, 1990
 
References Container
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References

Sims  ACP:  Symptoms in the Mind: An Introduction to Descriptive Psychopathology , 3rd Edition.  Edinburgh, Scotland,  W. B. Saunders, 2003
 
Tucker  GJ:  Putting DSM-IV in perspective.  Am J Psychiatry 1998; 155:159–161
[PubMed]
 
David  AS;  Halligan  PW:  Cognitive neuropsychiatry: potential for progress.  J Neuropsychiatry Clin Neurosci 2000; 12:506–510
[CrossRef] | [PubMed]
 
Ellis  HD:  Cognitive neuropsychiatry and delusional misidentification syndromes: an exemplary vindication of the new discipline.  Cogn Neuropsychiatry 1998; 3:81–89
[CrossRef] | [PubMed]
 
Cutting  J:  The phenomenology of acute organic psychosis: comparison with acute schizophrenia.  Br J Psychiatry 1987; 151:324–332
[CrossRef] | [PubMed]
 
Cutting  J:  The Right Cerebral Hemisphere and Psychiatric Disorders .  Oxford, New York,  Oxford University Press, 1990
 
References Container
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