1. PSYCHIATRY AND REALITY –
PERCEPTION OF MATTER OR
MATTER OF PERCEPTION
Ursula Werneke MD, MSc, FRCPsych
Department of Psychiatry, Umeå University and
Sunderby Hospital, Luleå, Sweden
With special thanks to Kiran Bagadiya for the illustration of this presentation

2. GOALS
• To review the consequences of the concepts of subatomic
reality for macroscopic reality
• To explore the meaning of an uncertain reality for the
diagnosis of psychosis
• To consider the implication in an increasingly computerized
world.
• To derive implications for psychiatric practice here and
now.

3. The argument
Current concepts of delusions (beliefs held with conviction
which are impossible or false or irrcorrigible) rely on the
assumption that one single objective reality exists.
But this assumption is out of keeping with modern physics.

4.  Within the atom, there is no reality beyond
what is revealed by the act of measurement
or observation.
 The state of a particle depends on whether
it is being observed or not.

5. MATTER OF PERCEPTION
This suggest that
reality is probabilistic and … uncertain.
the universe is a cloud rather than a clock.*
* Popper, 1977

6. BUT
If there is no single objective reality as a benchmark for our
internal experience, then
• …the current definition of delusion may not hold.
• ... we have to rethink the definition.

7. IS THE MOON REALLY NOT THERE WHEN NOBODY IS
LOOKING?*
• A chair is a chair and an apple is an apple.
• Do medium-sized objects obey different physical
rules?
• Where is the boundary between the microscopic
and the macroscopic world?
(*Einstein as quoted by Pais)

8. PERCEPTION OF MATTER
• Either reality is not real but only subjective…
• …Or there is a missing link which makes reality
real.
• …Or reality is real but there is more than one
version.

9. PLURALITY OF WORLDS AND THE
MULTIVERSE
There is an infinite number of parallel universes and actions
in one universe can be complemented by actions in
another.
(Everett III, 1957; Lewis, 1986)

10. FOR PARTICLES THIS MEANS…
They assume one state in one universe and another state in
a parallel universe.
(David Deutsch, 1997)

11. NOT CONVINCED?
 “Common sense has neither absolute authority in
philosophy nor is it infallible” (David Lewis, 1986).
 We are not adapted to feel the Earth moving, yet it moves
(David Deutsch, 1997).
 “Our a conscious minds tend to think in serial steps”(Steve
Scott, as quoted by The Economist, 2011).

12. WHAT ARE THE IMPLICATIONS OF AN
UNCERTAIN REALITY FOR PSYCHIATRY?
 “If somebody were claiming that the world is
round, we would never suspect this claim to
be a delusion (Spitzer, 1990)”.
 Eppur si muove… (Galileo Galilei 1633, if he said this)
 Evolution vs. creationism

13. EASY?
 “The fact that a delusion is false makes
it easy to recognize but this is not its
essential quality” (Fish’s Clinical Psychopathology, 2007).
 Martha Mitchell effect: “Mrs. Mitchell was the wife of John
Mitchell, Attorney General in the Nixon administration. When
she alleged that White House officials were engaged in illegal
activities, her claims were attributed to mental illness”.
.

14. ”TRUE / FALSE” = ”HEALTHY / ILL”?
Since the publication of DSM-III in 1980, there has been a
steady decline in the teaching of careful clinical evaluation
that is targeted to the individual person’s problems and
social context and that is enriched by a good general
knowledge of psychopathology.
Students are taught to memorize DSM rather than to learn
complexities from the great psychopathologists of the
past.”
(Andreasen, 2007)

15. VIRTUAL REALITY
• “Systematically alters the usual relationship between
external reality and the user’s experience of it”.
• ”May one day manipulate our senses overriding their
normal functioning so that we can experience the
specified environment instead of our actual one”.
• Individulizes human experience.
(Deutsch, 1997)

16. PARALLEL REALITY AND VIRTUAL REALITY ARE NOT
THE SAME - BUT THEY ARE RELATED
• …as two strands in the fabric of reality.
• …as converging to some kind of “cross reality” between the
real and the digital worlds (Siegele, 2010).
• …since through quantum computing parallel realities could
deliver virtual realities (but not vice versa).
(Deutsch, 1997)

17. WHAT WE DON’T KNOW
• ...how people react to this “virtualization of the real
world”.
• ...how people diagnosed with psychosis experience and
interpret virtual reality.

18. I saw it on YouTube…
• Difficult to refute.
• Using YouTube may per se be in keeping with one’s
cultural context.
• However, the actual virtual experience may not.

19. “In Second Life,
WHERE WILL IT STOP? there's always
someone to talk to,
dance with, learn
from or perhaps even
love. You can meet
people all over the
world without ever
“In Second Life, you can reside in leaving your home.
a place that is as unique and And here, there's no
special as you are. Live in a jet lag and the clubs
friendly neighborhood or buy that are always open.”
private virtual island you've always
dreamed of. Perhaps you'll
become a landlord, or just host a
party for your friends. Here, the
weather never puts a damper on
your plans.”

20. VIRTUAL REALITY AND THE BRAIN
The brain is a virtual reality generator since it defines the
relationship between external reality and our
experience of it.
This implies that even if we believed in a single external
reality we could never experience this reality as it is.

21. THIS EXPLAINS….
• why individual experiences of reality are
extremely difficult to extinguish.
• why CBT for psychosis fails to prevent
relapse (cf. Garety et al, 2008).

22. THUS…
“We have no choice but to accept the world as it seems, but
should be aware
that the world as it seems is not the world as it is.
We cannot know anything about the world as it is, other
than that there is a world as it is. “
(Immanuel Kant, 1787).

23. SCENARIO: PERSON A THINKS S/HE IS PERSON B
(BUT NOBODY ELSE BELIEVES IT)
Three interpretations:
Current: The person is A no doubt, his/her virtual reality
generator (brain) has gone haywire.
Virtual reality: Both A and B are renderable states, but A is
much more likely than B.
Parallel reality: In some universes the person is A, in others B.
The copies which are A outnumber the copies which are B.

24. DIAGNOSING PYSCHOSIS: IS MY EXPLANATION REALLY
BETTER THAN THE PATIENT’S?
DO
 Take a meticulous history
 Embrace probabilty when eliciting and interpreting symptoms
 Cultivate professional empathy
 Practice social psychiatry
 Allow CBT to acknowledge multiple realities?
DON’T
 Diagnose schizophrenia based on positive symptoms alone
 Fragmantize care: it decreases understanding!
 Scrap teaching the long case in specialist examinations.

25. ULTIMATELY THOUGH…
It will become neccessary to rethink our currently accepted
concept of psychosis.
This may become inevitable by the time we master
technologies to create sophisticated virtual reality
environments individualizing human experience.

26. MILLE GRAZIE / THANK YOU
Bob was in the right place
at the wrong time in the but Susan was at the right
right universe place at the right time in
the wrong universe…
Max was at the wrong Fred again was…..
place at the right time in
the right universe