Cognitive Embodiment and Anxiety Disorders
Glas's article is one of several in an interesting special issue focused on applying concepts from enactivism to psychiatry; his focuses on anxiety in particular. Given ongoing developments in work on enactivism, and ongoing debates about how to progress psychiatry, this application is timely. Here, I make three general points about the application of enactivism to psychiatry; I exemplify these with occasional comments on social anxiety disorder.
First, as de Haan notes in her introduction, the term enactivism encompasses a number of authors and ideas. Wilson and Foglia (2017) note that enactivism falls within a broader literature on "embodied cognition." This literature is partly conceptual, but also relies on empirical work in cognitive science (Lakoff & Johnson, 1999). Although much earlier cognitive literature focuses on symbolic processes in the person's brain-mind, work on embodied cognition emphasizes that cognition is situated: it necessarily involves a person interacting with the world (Norman, 1993).
Two key authors in this tradition, Lakoff and Johnson, have made a number of points about emotions, including that cognition and emotion are embodied in such a way that they cannot be separated out as distinct processes, and that metaphors structure our understanding of many concepts including that of emotion (Lakoff & Johnson, 1999). Thus, the metaphor "emotional experiences are physical forces" enables discussion of being overcome by emotion or of why emotional experiences can be painful, and the "thinking is perceiving" metaphor allows a range of related mappings, including "understanding is seeing," "taking seriously is listening," "personal preference is tasting," and "emotional reaction is feeling" (Lakoff & Johnson, 1999).
When social anxiety is discussed, this is therefore done with key metaphors used to conceptualize the mind and emotions. The essential self-metaphor, for example, may be used to describe how the person cannot express their "real self" in public. "The self-control is object possession" metaphor may be used to indicate how they are seized by fear in such situations. And "the emotional experiences are physical forces" metaphor may be used to describe how the person is overcome by embarrassment in these instances.
Second, within the literature on embodied cognition, there is often discussion of several E's; authors refer to cognition as embodied, embedded, extended, and enacted (Gallagher, 2015; Walter, 2013). Glas focuses on two key aspects of anxiety: that anxiety is contextually embedded (so that anxiety is not simply located in the individual but rather emerges in the context of a person interacting with their environment), and that anxiety has self-referential qualities (anxiety says something about the person as well as about the situation). [End Page 53]
These considerations seem consistent with work on embodied cognition as a whole. This literature holds that all cognitive-affective processes are contextually embedded, emerging from the interaction of people with environments. Social anxiety, for example, emerges in the context of individuals involved in social interactions, during which they experience a range of negative emotions. Similarly, the literature on embodied cognition accepts that cognitive-affective processes can be self-referential. Indeed, in social anxiety, the individual is concerned precisely with issues of self-presentation.
Glas argues that anxiety symptoms are therefore more than simply expressions of underlying dysfunction. I would emphasize, however, that the very construct of "dysfunction" itself relies on commonly used cognitive-affective metaphors (e.g., "dysfunction as imbalance" or "dysfunction as obstacle") (Stein, 2008). (Evolutionary theory might be proposed as a non-metaphoric account of dysfunction, but its yardstick of reproductive success is too blunt a measure for nuanced distinctions of functional vs dysfunctional). In her introductory article, de Haan posits that mental disorders are disorders of sense-making: it may be useful to understand to what extent this idea draws on, and contributes to, the extension of metaphors commonly used to conceptualize mental processes, such as the "thinking is perceiving" metaphor (Lakoff & Johnson, 1999).
Third, the argument is made by Glas and other authors in the special issue that enactivism is useful insofar as it provides an integrative framework for psychiatry. Glas, for example, argues that rethinking anxiety from a contextually embedded and self-referential perspective "helps to escape from both objectivistic reductionism (which views anxiety as just an organismic state) and subjectivist introspectionism (which sees anxiety as just an inner state, unconnected with the body and the world)." Similarly, in her introduction, de Haan argues that enactivism allows an integration of different aspects of mental disorders (experiential, physiological, sociocultural, and existential).
I agree with both Glas and de Haan that integrative approaches are key. Glas mentions that work on anxiety disorders has often been done within the framework of an ethological/neurobiological tradition, a behaviorist tradition, or a cognitive tradition, although he notes their ongoing merging. Indeed, I would argue that work based in biology necessarily involves an embodied and embedded approach, using integrative psychobiological constructs, in order to fully account for evolutionary adaptation. de Haan too argues for complexity, asserting that much work in psychiatry is one-dimensional/reductionistic or dualist, and that biopsychosocial approaches have failed to include the existential aspect of mental disorders or to integrate different aspects of these conditions. I would suggest that the framework of embodied cognition is particularly useful insofar as it allows an integration of considerations about mechanisms and about meanings (Stein, 2008).
Nevertheless, the question remains open of how much the sophisticated conceptual frameworks of embodied cognition will drive forwards the science and practice of psychiatry, and conversely, of whether cutting-edge research on mental disorders is really one-dimensional. Consider, for example, recent work by LeDoux and Pine (2016) on the psychobiology of anxiety disorders, or Fox and Kalin (2014) on the psychobiology of social anxiety disorder: despite not employing an enactive approach, such work also aims explicitly at synthesizing a range of findings, and providing an integrative approach. Furthermore, such work might well lead to new insights into key cognitive-affective mechanisms, as well as into their ontogeny and phylogeny. Indeed, given that work on embodied cognition depends in part on empirical findings, it may well be that findings in psychiatric science ultimately influence the way in which we think about enactivism.
Dan J. Stein is Professor and Chair of the Department of Psychiatry at the University of Cape Town, Director of the South African Medical Research Council's Unit on Risk & Resilience in Mental Disorders, and Scientific Director of UCT's Neuroscience Institute. Dan Stein's training includes doctoral degrees in both clinical neuroscience and philosophy, and a post-doctoral fellowship in psychopharmacology. He is a clinician-scientistadvocate whose work has long focused on anxiety and related disorders, including obsessive-compulsive spectrum conditions and posttraumatic stress disorder; his publications include "Philosophy of Psychopharmacology: Happy Pills, Smart Pills, Pep Pills."