**Links to**: [[Active inference]], [[Active ignorance]], [[Hegel]], [[Foucault]], [[Pathology]], [[The Normal and the Pathological]], [[Melencolia I]] %% 1994 essay “Phänomenologie des Krankengeistes” ('Phenomenology of the Sick Spirit') by philosopher [[Gary Gutting]]. https://catalogimages.wiley.com/images/db/pdf/9781405189606.excerpt.pdf https://www.parrhesiajournal.org/parrhesia21/parrhesia21_muldoon.pdf https://library.oapen.org/bitstream/handle/20.500.12657/63752/9781350340053.pdf?sequence=1&isAllowed=y --> use for [[Anticontinuous]] and don't forget to include in [[001 Introduction to the Poltergeist]] do work on depression and psychedelics [Psilocybin with psychological support for treatment-resistant depression: an open-label feasibility study](https://scholar.google.com/citations?view_op=view_citation&hl=en&user=7_MD_w0AAAAJ&citation_for_view=7_MD_w0AAAAJ:mB3voiENLucC) RL Carhart-Harris, M Bolstridge, J Rucker, CMJ Day, D Erritzoe, M Kaelen, ... The Lancet Psychiatry 3 (7), 619-627 >“All known cognitive agents are collective intelligences, because we are all made of parts; biological agents in particular are not just structurally modular, but made of parts that are themselves agents in important ways. There is no truly monadic, indivisible yet cognitive being: all known minds reside in physical systems composed of components of various complexity and active behavior. However, as human adults, our primary experience is that of a centralized, coherent Self which controls events in a top-down manner. That is also how we formulate models of learning (“the _rat_ learned X”), moral responsibility, decision-making, and valence: at the center is a subject which has agency, serves as the locus of rewards and punishments, possesses (as a single functional unit) memories, exhibits preferences, and takes actions. And yet, under the hood, we find collections of cells which follow low-level rules _via_ distributed, parallel functionality and give rise to emergent system-level dynamics.” (Levin, M. “Technological Approach to Mind Everywhere: An Experimentally-Grounded Framework for Understanding Diverse Bodies and Minds” p. 2). > [[Ray Brassier]] in [[Concepts and Objects]]: “4. We gain access to the structure of reality via a machinery of conception which extracts intelligible indices from a world that is not designed to be intelligible and is not originarily infused with meaning. [[Meaning]] is a [[Function]] of conception and conception involves representation—though this is _not_ to say that conceptual representation can be construed in terms of word-world mappings. It falls to conceptual rationality to forge the explanatory bridge from thought to being. 5. Thus the metaphysical exploration of the structure of being can only be carried out in tandem with an epistemological investigation into the nature of conception. For we cannot understand _what_ is real unless we understand what ‘what’ _means_, and we cannot understand what ‘what’ means without understanding what ‘means’ _is_, but we cannot hope to understand what ‘means’ is without understanding what ‘is’ _means_. 6. This much [[Heidegger]] knew. ...” (p. 1) %% ### _Phänomenologie des Krankengeistes_: A neuroendocrinologically-informed, philosophical account of allostasis under the influence of corticosteroids <small>Keywords: allostasis, neuroendocrinology, active inference, self-narration, dialogical reasoning</small> The parameters which determine a state of (mental) ‘health’ are debatable, if not altogether objectively impossible (Fava et al. 2019, Sterling 2020). In psychosocial allostasis, these parameters are especially difficult to delineate because they pertain to the sociocommunicative frameworks in which a person is embedded: predictive bidirectional dynamics between an agent and their ecological embedding result in the preservation of preferred states in terms of (collective) health; survival (Schulkin & Sterling 2019). Although psychiatric typologies are continually redefined, generally, the hallmark of psychosis has been the perception-production of delusions (López-Silva & McClelland 2023), which, by and large, seem to lead to what from an outside perspective appear as (communicatively) dysfunctional. From a PP perspective, ‘delusions’ can be framed as errors of precision estimation, and dysfunction can thus be understood as a result of allostatic overload: predictive models become overwhelmed by stimulus and/or seek actualization through active inference in order to relieve said overload (Parr et al. 2022, Clark 2023). The biochemical etiology of allostatic overload is the result of perceived interoceptive and/or environmental stress and an ensuing neuroendocrine response, primarily as the release of cortisol (McEwen 2005). Cortisol, the end-product of the hypothalamic-pituitary-adrenal (HPA) axis, is produced in anticipation as well as in response to stress, and its vital dynamics emerge from feedforward and back-regulation between the pituitary gland and the adrenal cortex (Russell et al 2023). Despite decades of research on the psychiatric symptoms associated with corticosteroids (Sirois 2003), showing how corticosteroid-excess and deficiency induces neuropsychological changes, even in short-duration therapy (Russell et al 2023), an account of how they affect the prediction of an allostatic sense of self remains elusive. This has mostly been due to the fact that dysfunction of HPA-axis can result in rather severe diseases (e.g., Cushing’s; Addison’s), however, given advances in pharmacology: efforts to investigate the more subtle neuropsychological aspects of HPA-axis dynamics, such as behavioral regulation, are emerging (ibid., Lightman 2008, Russell & Lightman 2019).  In adrenal insufficiency (cortisol-deficiency), the normal functioning of the HPA axis is bypassed: the autonomic regulation of stress by the HPA-axis is overseen instead by the cognitive regulation of stress, leading to some interesting (paradoxical) results. The regulation of perceived stress (danger; fight-or-flight) and energy (motivation; ability to cope) does not occur as a silent autonomic process in the background but is under permanent scrutiny due to a patient’s capacity to dose corticosteroids according to what is consciously perceived as necessary and/or appropriate. The predictive bidirectional dynamics between the agent and its ecological embedding are now thus subject to sociocommunicative frameworks in a different way than under “normal” conditions. The patient’s concept of stress, not just its presentation, is now a parameter in the body’s allostatic adaptation. The argument explored is that given the sociocultural embedding of concepts, communication with others about the ‘nature’ and definitions of stress now factor into allostatic (self-)regulation, resulting in the preservation of entirely different preferred health-states than the ones neuroendocrinologically given by the body’s own HPA axis. In order to explore explanatory links between the phenomenology of mental allostasis and neuropsychiatric approaches to psychopathology, this article seeks to expose aspects of allostatic regulation through a first-person account of corticosteroid self-administration. The author will narrate aspects of their own self-prediction when living with adrenal insufficiency, and this account will be theoretically informed by an allostatic account of active inference and state-of-the-art neuroendocrinology. Philosophical introspection will ensue, in every sense of the expression, something which is much needed for updating our understanding of the (predictive) self and (allostatic) health (Cavel 2016, Gallagher 2024). %% ### Phenomenology of _sick_ spirit: a personal account of stress-regulation under the influence of corticosteroids The parameters which determine a state of mental ‘health’ are debatable, if not altogether impossible to objectively determine (Fava et al. 2019). In psychiatric typologies, varying degrees of disruption to allostatic processes lead to some of the parameters which have come to define states of e.g., psychosis. In the context of ‘mental’ allostasis, these parameters are especially difficult to delineate because they pertain to the sociocommunicative frameworks in which a person is embedded: predictive bidirectional dynamics between an agent and its ecological embedding result in the preservation of preferred states in terms of (collective) health; survival (Schulkin & Sterling 2019). Generally, the hallmark of psychosis has been framed as the perception-production of _delusions_ (López-Silva & McClelland 2023), which, by and large, seem to lead to what _from an outside perspective_ appear as (communicatively) dysfunctional. From an allostatic PP perspective, these delusions can be framed as errors of precision estimation (Clark 2023): in a state of psychosis, a person may over- or underestimate aspects of their projections, leading those around them to the conclusion that the psychotic person is “out of touch” with reality, that is: _excommunicated_. This type of dysfunction can be understood as a result of allostatic overload: a cognitive agent’s predictive models become overwhelmed by stimulus and/or seek actualization through active inference in order to relieve said overload (ibid.). The biochemical aetiology of allostatic overload (“overstress”) has its foundations in neuroendocrine corticosteroids such as cortisol (McEwen 2005). Cortisol (the “stress” hormone) is the end-product of the hypothalamic-pituitary-adrenal (HPA) axis, it is produced in anticipation _as well as_ in response to stress, and these dynamics emerge from feed-forward and feed-back regulation between the pituitary gland and the adrenal cortex (Russell et al 2023). Despite decades of research on the psychiatric symptoms associated with endogenous and exogenous corticosteroids (Sirois 2003), an account of how they affect the prediction of an allostatic sense of self remains elusive. Medical accounts of corticosteroid-excess leading to psychotic and manic states are vast and well-studied, and even short-duration therapy at relatively low doses is known to cause neuropsychological side-effects (Russell et al 2023). Dysfunction of HPA axis dynamics is associated with a variety of symptoms, some of which are rather severe (such as in the case of Cushing’s or Addison’s diseases). Due to the finding of pharmacological solutions these severe expressions (ibid.), new investigative ground is now opening up for attention to the “minor” abnormalities related to HPA axis dynamics, such as behavioral regulation. In order to advance “conceptual and explanatory links between the phenomenology of psychosis and neuropsychiatric approaches to psychopathology” (open call citation), this article seeks to expose aspects of allostatic (_stress_) regulation through a first-person account of corticosteroid self-administration. In the particular condition of adrenal insufficiency with which the author lives, the normal functioning of the HPA axis is bypassed: the autonomic regulation of stress is overseen instead by the cognitive regulation of stress, leading to some interesting (paradoxical) findings. The regulation of stress and perceived energy (motivation, ability to cope, etc.) does not occur as a silent process in the background but is under permanent scrutiny due to the author’s capacity to dose hydrocortisone according to what is perceived necessary and/or appropriate. “hydrocortisone altered both neural dynamics and behavioural responses related to emotional pro- cessing, visual stimulation and resting conditions, improved physical and mental fatigue, and reduced fatigue identification and consequence. ... Whole-brain fMRI revealed differential neural processing to emotional cues and visual stimulation. ROI analysis confirmed changes in the left amygdala and insula. As these areas are involved in emotional ambiguity, post hoc analysis examining ambiguity of facial expression recognition confirmed this behavioural response. This has not only confirmed the relevance of previously performed animal studies to human patients but also provides an important guide to future therapeutics, suggesting that the pattern of hormone replacement is critical for normal cognition under non-stressful conditions. This has wider-reaching implications for the critically diffi- cult aspect of glucocorticoid therapeutics – that is balancing the desired effects with unwanted side- effects. ” Russell et at 2023 but what is the border between delusion, illusion and functional perception? in my experience: aphasia, mcgurk add notes from: falling into place, control, andy clark, feldman barrett, kent, kusters, meijer, lightman and other neuroendo Designations such as _schizophrenia_, ___ ___ or other psychopathologies (which, again, by calling them _psycho_-pathologies we continue to reinforce a Cartesian divide between body and mind), according to e.g., Wouter Kusters sometimes only serve to explain away or “effectively subdue” (2020, p. 64) the inner logic of “madness”. While Kusters seeks to emancipate madness from medical classifications, we seek to explore the phenomenology of the inner logic of mental-state-regulation through the first-person perspectival use of corticosteroids. “Nowadays, delusions are regarded as one of the most severe symptoms of a number of neuropsychiatric conditions with a higher prevalence in schizophrenia (American Psychiatric Association, 2013; Connors & Halligan, 2020; Harrow et al., 2005; Harrow & Jobe, 2010; Rosen et al., 2016, 2017, 2022).” (Lopez-Silva & McClelland 2023, p. 37). Crip theory human stress response has evolved to maintain homeostasis under conditions of real or perceived stress (Russell & Lightman 2019). “But calling it a stress hormone gives cortisol a bad name. It is really an essential part of the system that prepares us for the kinds of actions our brain predicts are on the near horizon.” (Clark 2023, p. 138). This is indeed the case: the problem is not cortisol, the problem is stress. “Thus, suppose that your bodily internal self-monitoring and energy-budgeting system is somehow malfunctioning. Under such conditions you will under- or overestimate your body’s present and future needs. You would then be budgeting badly, storing up or using energy in highly inefficient ways. Sudden waves of unexpected tiredness might then be punctuated by equally unexpected short-lived bursts of enthusiasm and energy. Our bodies’ energy budgeting can also be impacted by air travel, by exercise, and by bereavement and loss. There is, at the very least, a complex two-way street—often mediated by predictions of energetic need—linking the mental and the more standardly physiological. But really, this is just more evidence that (as we started to see back in Chapter 2) the old distinction between the “psychiatric” and the bodily/physiological/neurological needs to be abandoned. This unifying perspective also makes sense of the finding that chronic depression involves abnormalities not simply of “mood” but also of sleeping-waking cycles, and of metabolic and immunological response. Tying all these together, Barrett suggests, may be a “central problem with inefficient energy regulation. Mistakes in energy budgeting would normally be corrected by prediction error signaling—if your brain “if your brain expects the body to require extra energy in the near future and the expectations prove wrong, prediction errors would normally arise and signal the difference, allowing the brain to update the long-term model that made the erroneous predictions. But among the most notable and devastating characteristics of chronic depression, anxiety, and many other psychiatric conditions is their surprising resistance to new information. This suggests that where such conditions really take hold, there is also a problem with either generating or learning from the prediction error signal. This inability to learn from prediction error results in the situation that Barrett and colleagues describe as that of a “locked-in” brain. From the perspective of predictive processing, the “double whammy” of poor learning and poor energy regulation makes sense if we suppose that the core underlying issue is aberrant precision-weighting. Overweighted expectations and underweighted new information would result in a kind of permanent or semipermanent lock-in of the existing model, leading us to continue with depressive behaviors that actually serve to reinforce the bad model, and that lend false justification to our prior expectations. For example, we expect not to go out and explore new opportunities (as predicted) keep on failing to “present themselves. Hidden within such a familiar cycle may be various failures of bodily prediction involving imprecise interoceptive signals making it hard to correctly estimate bodily needs and hard to update those estimates as prediction errors begin to emerge. Negative affect and fatigue would follow as the body responds by producing “sickness behaviors” designed to conserve energy. These are just broad brushstrokes of some of the existing proposals linking depression and anxiety to disturbances to our bodily predictions. But there will also be—entirely consistent with this—strong psychosocial processes at work in many cases of depression and anxiety. For example, suppose that you experience a succession of unexpectedly negative social events—your partner leaves you, you argue with your boss, a neighbor complains to you. These all result in “social prediction errors” (errors in the prediction of socially important events). You may start to compensate by mistakenly increasing the weighting on small social cues, including all the many signals (facial, verbal, and those involving body language) that help us navigate stressful or important social situations. Faced with all that extra noise, now masquerading as information, you may start to adopt what has been described as a kind of “better safe than sorry” strategy so as to avoid most social interactions, since their outcomes seem increasingly unpredictable. “This is (of course) a foolproof, though ultimately highly counterproductive, way to reduce uncertainty and prediction error. It is in many ways the closest real-world analog to the classic Dark Room scenario. If you seldom place yourself in challenging situations, you will certainly reduce or eliminate many sources of unexpected prediction error. New higher-level explanations (your neighbors all secretly hate you, the boss probably didn’t want to hire you in the first place) may then kick in. The result is a familiar pattern of anxiety-inflated responses to small perceived slights, and then protective disengagement combined with new and increasingly negative images of ourselves and our relations to others. Such maladaptive patterns are often seeded by early experiences such as abuse or neglect that lead us to believe that social rewards are unlikely and social outcomes unpredictable.” (Clark 2023, pp. 156-9) “Predictive processing here positions itself as a new and promising way of making sense of the complex interactions between brains, bodies, and social environments. If it is on the right track, depression is never simply a disorder of mood. It is a disorder of the whole body-brain-environment system, affecting the way the brain forms and runs bedrock bodily energy budgets, and the way it responds to new positive and negative information.” (Clark 2023, pp. 162-3). We could not agree more: cortisol is describes the capacity to undergo continuous adaptation and change so that its physiological parameters will permit an organism to fit optimally and stably into its new (and constantly changing) environment. The terms 'allostatic load' and 'allostatic charge' refer to the collective stress that an organism experiences due to repetitive cycles and/or continuous activation of stress responses (Lazarus & Folkman, 1984;McEwen, 1998;Sterling et al., 1988). An organism must be able to accommodate a significant allostatic load to maintain its autonomy and selforganization as well as its survival within a dynamic equilibrium. ... Fregna, Locatelli, Colombo 2020: “[In depression] {s}imple acts become difficult; the body is perceived as extremely heavy, stuck and incapable of projection.” Gravitational metaphors frame the entire semantic space of mental well-being (de Jager 2020, Kent 2023). Illness has been defined as ‘a feeling, an experience of unhealth which is entirely personal, interior to the person of the patient’ (Marinker, 1975;1(2):81–84.) Cortisol and Mental Wellbeing Cortisol, often dubbed the “stress hormone,” plays a multifaceted role in our bodies. Beyond its immediate response to threats (think of the antelope facing hungry lions), cortisol influences various physiological processes. When cortisol levels are out of balance, mental health issues may arise. Striking the right equilibrium is crucial1. 2. The Significance of First-Person Perspectives Advancements in medical science hinge not only on objective data but also on subjective experiences. First-person perspectives—those intimate narratives of lived experiences—provide invaluable insights. By listening to patients, researchers gain a deeper understanding of illness, recovery, and the human condition. These narratives enrich medical knowledge and guide compassionate care2. 3. Wouter Kusters and the Philosophy of Madness Wouter Kusters, a Dutch philosopher, delves into the enigmatic realm of madness. His work transcends conventional boundaries, exploring the intricacies of altered states of consciousness. Kusters challenges prevailing paradigms, inviting us to question what we consider “normal.” His philosophy opens new horizons, bridging the gap between reason and the ineffable3. 4. A Phenomenology of Sick Spirit In the context of mental health, a phenomenology of the “sick spirit” delves into subjective experiences. It examines how mental distress shapes perception, emotion, and cognition. By immersing ourselves in the inner world of those who suffer, we gain insights that inform therapeutic approaches and foster empathy. The sick spirit, as explored by phenomenologists, invites us to see beyond symptoms and embrace the whole person4. 5. Meta-Reflection from a First-Person Perspective Meta-reflection—the act of reflecting on our reflections—holds immense value. When individuals share their introspective journeys, they contribute to collective wisdom. Meta-reflection bridges the gap between personal insight and universal truths. It reminds us that healing extends beyond the clinical to the profound interplay of mind, body, and soul. In summary, cortisol’s impact on mental wellbeing, the power of first-person narratives, Wouter Kusters’ philosophical explorations, the sick spirit’s phenomenology, and meta-reflection converge to shape a holistic understanding of human health and suffering. The key to closely approaching a patient’s illness is empathy. Edith Stein, a German philosopher, describes that empathy ‘allows me to see or understand the inner life of another and the body of the other as both other and similar to my body’.3 To understand illness with empathy, there is a helpful reflective mode, phenomenology. Phenomenology itself has been developed by various philosophers such as Husserl, Heidegger, Sartre, and Merleau-Ponty.4 Among recent phenomenologists, Toombs and Carel have elaborated particularly on the phenomenology of illness. Havi Carel, a professor of philosophy at the University of Bristol, explores what patients experience when ill using phenomenological analysis in her book, Phenomenology of Illness. She introduces phenomenology as ‘a method for examining pre-reflective, subjective human experience as it is lived prior to its theorisation by science’, and it ‘enables us to direct our attention towards others in thoughtful empathy’.5 open call topics Phenomenology of psychosis The role of the self within the PP architecture Self and psychosis Conceptual and explanatory links between the phenomenology of psychosis and neuropsychiatric approaches to psychopathology Self-modeling and psychosis: clinical implications The narrative and minimal self within hierarchical architectures The nature of the descriptive and pathogenic role of the self in psychopathology Predictive processing and clinical approaches to psychosis “These mediators {cortisol and adrenaline} of the stress response promote adaptation in the aftermath of acute stress, but they also contribute to allostatic overload, the wear and tear on the body and brain that result from being “stressed out.” This conceptual framework has created a need to know how to improve the efficiency of the adaptive response to stressors while minimizing overactivity of the same systems, since such overactivity results in many of the common diseases of modern life. This framework has also helped to demystify the biology of stress by emphasizing the protective as well as the damaging effects of the body's attempts to cope with the challenges known as stressors.” (McEwen 2005) ### Introduction The parameters which determine a state of mental ‘health’ are debatable, if not altogether impossible to objectively determine. Dynamic feedback cycles of self-regulation ground the vital and functional conditions of organisms, and it is precisely because organisms display repeating tendencies towards specific sates, that we can speak of _homeostasis_. However, as famously proposed by Sterling and Eyer (1988), internal homeostatic function alone cannot account for the adaptive responses to cycles of stress to which an organism becomes exposed. In order to explore stress beyond internal organism dynamics, they introduced the concept of _allostasis_. Allostasis, is defined by them as the capacity to “maintain stability through change”, which in the context of predictive processing we can certainly frame as how persistent organisms alter their models of expected stability “so as to adapt to changing needs and environments” (Clark 2023, p. 137). The conjecture could be made that homeostasis is expanded by allostasis revealing the scientific understanding of states of optimality/equilibrium beyond the single agent. Stress, a very popular term nowadays, has come to signal something similar as well: it is not necessarily the person who has a problem, but the person is exposed to an unhealthy/adverse environment. Barrett has considered depression an allostatic disorder, that is pertaining to “mistaken forms of bodily prediction involving energy regulation.” (Clark 2023, p. 156). We propose to look at the “mistakes” in energy regulation resulting in varying degrees of prediction-projection through the lens of cortisol: taking from personal experiences with the use of corticosteroids to regulate adrenal insufficiency, the argument will be made that sensing interoceptive energy-availability, which is primarily regulated through cortisol, leads to variations in ability to predict. One’s light-cone (Levin) is expanded in optimal cortisol conditions, and greatly reduced when in need of cortisol. This is an unavoidably biased first person account, but entirely based on current neuroendocrinological research on the relationship between cortisol and mental states. From an allostatic PP perspective, these delusions can be framed as errors of precision estimation (Clark 2023): in a state of psychosis, a person may over- or underestimate aspects of their projections, leading those around them to the conclusion that the psychotic person is “out of touch” with reality, that is: _excommunicated_. This type of dysfunction can be understood as a result of allostatic overload: a cognitive agent’s predictive models become overwhelmed by stimulus and/or seek actualization through active inference in order to relieve said overload (ibid.). ### Bibliography Barrett, Lisa Feldman. _How emotions are made: The secret life of the brain_. Pan Macmillan, 2017. Carel, Havi. _Phenomenology of illness_. Oxford University Press, 2016. Clark, Andy. _The experience machine: How our minds predict and shape reality_. Pantheon, 2023. Fava, Giovanni A., et al. “Clinical characterization of allostatic overload." _Psychoneuroendocrinology_ 108 (2019): 94-101. Gutting, Gary. “Michel Foucault’s Phänomenologie des Krankengeistes.” _Discovering the history of psychiatry_ (1994): 331-347. Lightman, Stafford L. “The neuroendocrinology of stress: a never ending story.” _Journal of neuroendocrinology_ 20.6 (2008): 880-884. Lopez-Silva, Pablo, and Tom McClelland. _Intruders in the Mind: Interdisciplinary Perspectives on Thought Insertion_. Oxford University Press, 2024. McEwen, Bruce S. “Stressed or stressed out: what is the difference?” _Journal of Psychiatry and Neuroscience_ 30.5 (2005): 315-318. Parr, Thomas, Giovanni Pezzulo, and Karl J. Friston. _Active inference: the free energy principle in mind, brain, and behavior_. MIT Press, 2022. Russell, Georgina, and Stafford Lightman. “The human stress response.” _Nature reviews endocrinology_ 15.9 (2019): 525-534. Russell, Georgina, et al. “Ultradian hydrocortisone replacement alters neuronal processing, emotional ambiguity, affect and fatigue in adrenal insufficiency: The PULSES trial.” _Journal of Internal Medicine_ 295.1 (2024): 51-67. Schulkin, Jay, and Peter Sterling. “Allostasis: a brain-centered, predictive mode of physiological regulation.” _Trends in neurosciences_ 42.10 (2019): 740-752. Sirois, François. "Steroid psychosis: a review." _General hospital psychiatry_ 25.1 (2003): 27-33. Sterling, Peter. _What is health?: Allostasis and the evolution of human design_. MIT Press, 2020. these were not added in abstract: Kusters, Wouter, Philosophy of Madness Marinker M. Why make people patients? J Med Ethics. 1975;1(2):81–84. https://eltalondeaquiles.pucp.edu.pe/wp-content/uploads/2016/05/Modern-European-philosophy-Siep-Ludwig_-Hegel-Georg-Wilhelm-Friedrich-Hegels-Phenomenology-of-spirit-Cambridge-University-Press-2014.pdf