Dimensional approach in psychiatry and process philosophy: preliminary notes Abordagem dimensional em psiquiatria e filosofia do processo: notas preliminares

Dimensional psychopathology and process philosophy form together a potentially fruitful research field in psychiatry and philosophy. The continuum of mental disorders and the tradition of unitary psychosis might profit from process metaphysics, which emphasizes flowing processes in a creative nature that comprises consciousness. Seeing dimensions through the lens of process philosophy means that there are internal relations among psychopathological manifestations, that is, they are not detachable, isolated things and do not simply present themselves randomly side by side. Electromagnetism and quantum physics show a dematerialized nature in which vibrations, forces or energies act flowingly at the basis of reality: matter would be derivative or moments in a process. Psychiatric syndromes can be considered moments in a process as well. Nature is more vivid, loaded with a panexperientialism or pansubjectivism, making it less problematic, or rather a misplaced question, the riddle of how the mind arises from objects.


Introduction
One of the fiercest disputes in psychiatry refers to the categorical versus dimensional approach of mental disorders. Concerning functional or endogenous psychosis, Jaspers sustained that the categorical approach directed to separate disease units is a fruitful landmark in the special psychiatric research. On the other hand, mental disorders as stages and variations of the unitary psychosis, that is, in a dimensional continuum, imply that real disease units do not exist for psychiatric science. In other words, according to Jaspers, disease units in psychiatry are only ideas and should not be taken as real things or as natural kinds. In this regard, it´s better to think of ideal types (Jaspers, 1946, pp. 469-70, 477).
Process philosophy could contribute to this debate, considering an emphasis on the side of the dimensional continuum. However, difficulties in understanding representative authors of process philosophy, which is not itself a developed doctrine but a promising project (Rescher, 2000, p. 21), have been notorious. In this paper we intend to present only an initial framing of the process philosophy, with the purpose of further elaboration.
Not that psychiatry itself is any simpler. Therefore, dealing in both fields is a prerequisite for exposing oneself to unreliable notions or to misunderstandings. On the other hand, the hope is that the knowledge and difficulties of one side, philosophy, can illuminate those on the other side, psychiatry, and vice versa.
In this work, "dimensional" refers not only to measuring concrete objects or natural kinds in space and time, but also encompasses "grading" abstract objects. In other words, "dimensional" comprehends here hybrid psychopathological manifestations, which, according to Berrios and Marková (2013), are proportions of concrete and abstract objects.

Materialism and positivism versus process philosophy
Prevailing scientific mechanist, materialist and reductionist-positivistic orientations are very much based on isolated categories of delimited and self-sufficient substances or things (Seibt, 2018). So, why shouldn't there be delimited disease units? For Kraepelin this was a clear principle: disease units along with corresponding causes, anatomic pathological findings and clinical manifestations (Kraepelin, 1910;Hoff, 2015).
The conception of disease units is in tune with this prevailing ontological premise founded in permanent substances. We stay here with Parmenides: "whatever is is, and what is not cannot be," meaning that all reality is one, changeless, timeless, uniform, and necessary.
It is a static view of the world prone to definitive forms or to an atomism. Our mainstream scientific orientation is impregnated with this notion of immutable or stable elements, whereby changes are derivative and would take place thanks to the combinations of the elements in a mosaic form. So, in psychiatry, brain structures or rather atoms and molecules would take charge of explaining mental disorders and the mind, under respective physical laws or chemical formulas (physicalist reductionism). Or, if one prefers, the mind, the consciousness, or the self are only abstractions that do not exist in nature (eliminativism or eliminative materialism). Correspondingly, subjectivity is excluded from the natural sciences.
The concept of continuum denotes, however, difficulties concerning the above orientation of delimited substances. If we take a continuous line from A to B, this means that we can divide it endlessly, since there are no limits between point A and B. But what if we reach the smallest particle in the universe? It means that there is no continuum because those smallest particles are delimited parts or substances, let's say atoms. How to go then from one to another? This is related to Zeno's paradoxes. In this regard, according to Leibniz, the notion of continuum is a maze for the human mind (Daker, 1994, pp. 9-22;. Returning to our point, what prevails: units of static diseases or a dynamic continuity of them? Other alternative philosophical approaches tend to consider nature more dynamically changeable or as reputed by Heraclitus, for whom "No man ever steps into the same river twice." This means that the world is not constituted by stable things, but by fundamental forces and the variety and fluctuating activities they manifest, denoting the fallacy of materializing nature (Rescher, 2000, pp. 3-5). According to these dynamical approaches, the continuous view in psychiatry should transcend the condition of a mere denial of stable disease categories, as in Jaspers. That is, it should prevail over the static world of immutable substances: everything is movement in time.
Such dynamic approach points to a new ontology or paradigm that give us better resources to overcome some paradoxes and the Cartesian view of the world, the mind-body dichotomy and the corresponding human and natural sciences. This alternative metaphysical ground facilitates, as we will see, the inclusion of consciousness in the bosom of nature. This is what the process philosophy seems to tell us. In psychiatry, the weight would then fall on the dimensional dynamic approach.
It is not that the things we see and identify as static categories or units do not exist.
They exist, just as there are certain characteristic syndromes in psychiatry, but now are considered moments or "occasions" or "concrescences" in a flowing process, they are momentary actualities. Even a stone is considered a moment or occasion in process philosophy, because it transforms itself over time. Clearly, a stone is less dynamic than the mental symptoms or the mind, making a dynamic approach more suitable to the latter, whereas a static approach might be satisfactory, according to the desired investigation, to the former.
What is considered to exist or to be truly concrete or actual depends upon our metaphysical fundaments: it would be material and mental substances for Descartes, ideas or forms are the truly actual entities for Plato, patches of color and patterns of sound for Hume, probably Geist for Kant and Hegel, atoms for the Greek atomists, monads for Leibniz. Deciding what sorts of entities are truly concrete or actual is a fundamental task for philosophy and for physics as well. What makes up the world according to process philosophy has been called "actual occasions". They are happenings, occurrences, or events, rather than substantial entities that endure unchanged through time (Cobb, 2008).
Actual occasions encompass action and being acted and, strikingly, they are experiences with a subjective connotation, loaded with purpose, decision, feeling, value, satisfaction, meaning, reason. For instance, decision or self-determination gives rise to the probabilistic laws of science and to creativity in nature, as well as to human freedom.
Actual occasions are not matter and they act to constitute themselves as what they become. The act of taking other past actual occasions (from all potentialities) into account and constituting itself (decision) with a view to the future is the actual occasion. There is no actor distinguished from the act. Similarly, a human experience does not exist in function of an actor or a person, but it is the experience itself. The person is constituted as a long series of such unified occasions growing out of one another and out of the body.
The self is seen as an integrated process rather than a thing. Things are not the ultimate actors but rather the outcome of many individual actions of actual occasions, therefore, processes are basic and things derivative. Categorical properties of things are simply stable clusters or patterns of process-engendering dispositions. Evolution requires fundamental continuities underlying the discontinuities (Rescher, 2000;Cobb, 2008).
In this sense, all nature is immersed in panexperientialism or pansubjectivism. Of course, only in the living organisms this can reach the mode of "presentation immediacy," which refers to psychism. Taking these notions from process metaphysics, the enigma of how subjectivity can evolve from a world consisting only of objects now seems to be based in a misleading metaphysics: animal experience could not emerge out of a complex of neurons understood materialistically or mechanically. In the eyes of process metaphysics, consciousness ceases to be a thing-like object, a delimited substance (what implies solipsism). It is not about external relationships between different substances or elements but rather about actual occasions or actual entities relating internally or organically among themselves. Therefore, process philosophy is sometimes designated as philosophy of the organism. Within internal relations the effect is not fully constituted by the cause, and in experience causality is a meaningful concept (Rescher, 2000;Cobb, 2008). For sure, nature shows itself now feelingly more vivid and creative than one supposedly governed by things.
At the level of particles, quantum physics has shown that there are no ongoing things at all, but only spatiotemporal patterns of process or moments of stabilities. There are waves, energy or forces, but no clear cut, definite atom that supposedly couldn't be broken into smaller parts. Indeed, there has been a dematerialization of physical matter (Rescher, 2000;Desmet & Irvine, 2018, Seibt, 2018. Quantum physics appears to corroborate those philosophers who advocated a more dynamic view of nature. Talking about forces instead of isolated substances favors thinking in internal relations and a more holistic view of nature, an inner togetherness of things, to the point of conceiving that everything is everywhere at all times (let's say, since the Big Bang).
Indeed, there is the abandonment of the notion of simple location or of independent existence (we can think here about electromagnetic fields or quantum physics) and past experiences are alive in present experiences, as a chord of a music is related to the previous chords: the former "prehends" the latter. Every occasion has some effect in the current experience, wherein the majority past occasions' effects is negligible, but not zero.
The idea is that everything that happens affects everything that will happen in the future (Desmet & Irvine, 2018;Cobb, 2008).

Philosophers such as William James, Henri Bergson, Martin Heidegger and Alfred
North Whitehead can be considered process philosophers. Whitehead's work Process and Reality brings a more defined connotation of this philosophical approach. Many of these thinkers would have been influenced or preceded by the post-Kantian natural philosopher Friedrich Wilhelm J. von Schelling. Schelling's natural philosophy embedded valuable concepts as autopoiesis and complex systems, and productive imagination and dialectical thinking were considered relevant to capture a creative nature, which comprises consciousness. Until then, Baconian, Galilean, Cartesian and Newtonian assumptions had been -indeed still are-overwhelming and responsible for seeing science according to materialistic premises, without much regard for life and sentient beings. Kant had also defended the priority of mathematical physics for sciences of nature, albeit in a problematic dualism with his categories of consciousness and with his concept of noumenon. Schelling tried to overcome Kant's difficulties. Some authors sustain that process philosophy can succeed Kantians or neo-Kantians, Positivists and Logical Empiricists, being currently the most defensible tradition of philosophy, also comprising an ecological connotation (Gare, 2002;Beaulieu, 2012).
The emphasis of phenomenology on temporality reveals confluences with process philosophy. Its emphasis on the first-person approach or on subjectivity seems also to reveal connections with the internal relations in process philosophy. The first-person approach can contribute to the third-person approach that is usually applied in psychiatry both for categorical and dimensional perspectives, the latter offering a more complex and refined view of the patient's psychopathological conditions than the former (Fuchs & Pallagrosi, 2018). A dynamic view in psychopathology is also demanded in the tradition of the phenomenological-anthropological psychiatry (Kraus, 2007). Considerations of the influence of Heraclitus in the late Husserl and in Merleau-Ponty (Whitmoyer, 2016) would show how phenomenology and process philosophy might be further connected.
Merleau-Ponty came to examine the work of Schelling, Bergson and Whitehead, but died before developing these ideas (there were posthumous editions of his lectures) and his work inspired efforts by Varela and others (Gare, 2018).

Mental symptom complexes as identifiable patterns of a continuum
"All colors have all colors," once told me a painter teacher of mine, Frederico Bracher Jr. At first, that sounded puzzling. Later, I realized that when we see an object it reflects all colors of the environment. Ultimately, all infinite color shades are everywhere.
At that time, I was initiating in psychiatry and had almost the same impression concerning mental disorders: they were everywhere always, even if potentially in different stages of a continuum or as contrary poles. Certainly, this was a more dynamic dimensional way of seeing mental disorders than looking for delimited categorical disease units, as I was trained for in the medical school. In William Jame's words, it is about "conjunctive" relations rather than "disjunctive" relations (Bird, 2008).
The result was a PhD on unitary psychosis, a traditional concept in German psychopathology (Einheitspsychose). Many psychiatrists can be considered to advocate this conception along the history of psychiatry: Guislain, Griesinger, Ey, Llopis, Rennert, Conrad, Menninger, Janzarik, Kendell, Crow and many others (Kumbier & Herpertz, 2010). The continuous spectrum of the unitary psychosis varies according to the authors' conception, ranging from all mental disorders, including those due to other medical conditions (Llopis), also personality disorders (Hoche, Rennert), to a core centered in the schizoaffective psychosis (Janzarik). The initial conception of unitary psychoses comprised a hierarchical downgrading from affective disorders to dementia (Guislain, Griesinger), but there are variations of this, to the point of considering non-linear complex systems (e.g. Ciompi's affect-logic conception, 1997), which are themselves often related to process metaphysics (Gare, 2000;Ferrari, 2013).
Considering internal relations and a holistic view indeed allows us to think in terms of a unitary psychosis. An interesting question concerns whether the border of the holistic view also comprises the normal psychism. To many psychopathologists the answer is yes. There seems to be no clear divide between personality disorders and normal psychism, as well as no clear divide between personality disorders and more severe functional mental disorder. That implies a continuum between normal psychism and mental disorders. How could that be? Certainly, if we think in terms of isolated diseases units that would be unthinkable. But a dynamic view in time (especially considering the whole population instead of single individuals) turns such continuum not only possible but more in agreement with most available data.
That is why many renowned psychopathologists, including Bleuler and Kretschmer, concluded that functional mental disorders are reactions of personalities (Bumke, 1993). Hoche (1912) was one of the authors who made clear the relation between personality and the psychiatric syndromes. Carl Schneider (1942) emphasized the relation between symptom associations and normal mental functions. According to Schneider -what seems in agreement with process philosophy-, it is important not to regard the identified associations as static constructions in the sense of a rigid categorization, but as expressions of an ever-fluid process of life with dynamic effects and changeable responsiveness, also keeping the totality of the picture in mind when investigating the more elementary facts of the clinical picture (Schneider, 1942, pp. 194, 227-8).
In other opportunity, we investigated that historical period when syndromes or symptom associations/complexes were the focus in psychiatry and were related to aspects of personality (Daker, 2018(Daker, , 2019. Including the late Kraepelin, who conceded the possibility that "the affective and the schizophrenic manifestation forms of insanity do not represent, in themselves, the expression of certain disease processes, but merely reveal those areas of our personality in which they take place" (Kraepelin, 1920). If this is the case, psychopathological syndromes are not simple detachable pathological things to be removed, unless humankind itself is removed.
Probably we need another view of nature to be able to better understand such puzzles. The bet here is that a dimensional dynamic view of mental disorders within the frame of process philosophy might help. Symptom complexes would be interrelated (internally related) moments or patterns of a process also interrelated with normal mind, with the world and with nature in general. In this scenario, symptom complexes could possibly be manifestations of a dynamic anthropological structure or matrix concerned with human mind (Daker, 2019). Maybe, in an analogy to the senses of touching, hearing and vision, a structure composing a sense of meaning, in terms of an endogenous disposition (Daker, 2018).

Conclusion
Psychiatry has always relied on knowledge that could help in its field: neuropathology, psychoanalysis, phenomenology, existentialism, neurosciences and so on. Process philosophy seems to be another source of knowledge of interest with potentiality for fruitful results. It seems we are dealing here with an auto-creative and vivid nature more suitable to life and mind than the nature of positivistic contours. The link between the dimensional approach in psychiatry and process philosophy might be a fecund fieldwork. Not as much as in a world of ideas, as Jaspers thought of in respect to Kant, which seems to dissociate us from the actual world: neither categories nor dimensions are real. Through process philosophy we shall be dealing with reality itself.