me is profoundly altered in illness versus health, to
the extent that I might even stop believing I could
exist without the illness.
[T]o me, ‘Emily’ became nothing more or less
than anorexic Emily. My blank or distraught
or irritable or fragile moods, my need for
routine and privacy, my slight figure, my
lack of friends and my worship of academic
achievement, all seemed like innate parts of
me, and there seemed no reason to believe
that eating breakfast or lunch would make a
difference to any of them. The extent to which
‘I’ was the product of years of malnutrition
and the rigid, ritualised mental life and
physical limitations that malnutrition itself
created was not something I was capable of
comprehending, since to do so I would have
had to imagine my life as otherwise than it
was – and I had neither the ability nor the
desire to do that. It was a perfect vicious circle:
the anorexia had become so completely what
I was that I couldn’t see how completely it had
taken over ‘Emily’, nor could I therefore have
any motivation to try to find her again.
(Troscianko, 2012, p. 242)But does this mean that we should think of the ill-
ness as itself an ASC, or as something which brings
about an ASC (or multiple ASCs)? For Antti Revonsuo
and colleagues (2009),
the definition of an ASC refers to the
temporary (as opposed to permanent)
nature of alterations in the representational
mechanisms of consciousness. The altered
state commences at some specifiable
time-window, and the normal state of
consciousness and brain returns at some
later time.
(p. 196)This means that if psychosis such as schizophrenia
were a permanent pathological state, it could not be
an ASC, but temporary episodes within it could be.
Any neat distinction between permanent and
temporary, illness and episode, is easy to ques-
tion: does it really make sense to separate the
ongoing distortions brought about by chronic
semi-starvation in anorexia, for example, from the
‘it is not the state itself that
is producing heightened
suggestibility but rather
the person’s perception of
being in an altered state’(Kirsch, 2011, p. 359)shorter-term effects of acute fasting? There are differences, to be sure, but
why does one count as an ‘altered state’ and the other not? In other kinds of
illness, like bipolar disorder, discrete episodes of psychosis may come and
go, but for illnesses in which transitions between moods and other cognitive
states are more continuous (like some forms of depression, say), would there
be no ‘altered’ consciousness because all the boundaries are blurred and the
timescales protracted?
As their definition shows, Revonsuo and colleagues’ answer is that the alteration
in an ASC is an alteration not to consciousness per se, but to the representational
relationships between consciousness and the world, with the ‘neurocognitive
background mechanisms of consciousness’ producing ‘misrepresentations such
as hallucinations, delusions, and memory distortions’ (2009, p. 187). This argu-
ment is intended to make ‘normal’ and ‘altered’ objectively definable in terms of
the accuracy of information being transferred from ‘world’ to ‘consciousness’. But
given all the arguments about mental and neural representation we explored in
Chapter 3, it is unclear whether accuracy of our information about the world can
reliably help separate ‘unaltered states’ from ASCs – or whether it even makes
sense to say that there is a representational relationship between consciousness
and the world.
As well as relying on such concepts as ‘conscious representation in the brain’ and
‘content in phenomenal consciousness’, this line of thinking ultimately reduces an
ASC to its neural correlates:
to objectively determine the presence of an ASC, one must show
that the background mechanisms of conscious representation in the
brain are altered in a way likely to lead to (globally and temporarily)
misrepresentational content in phenomenal consciousness.
(2009, p. 196)
Clearly Revonsuo and colleagues are urging an objective definition of ASCs, with
all the problems that entails. Changes in neural activity are easily identified in
both illness and recovery, with one study on psychosis, for instance, finding that
changes in connectivity in brain different areas predicted improvement in psy-
chotic or emotional symptoms following cognitive behavioural therapy (Mason
et al., 2017). But this does not necessarily mean we can or should define psychosis
in terms of those connective patterns.The case of mental illness also raises again that nagging question about the
baseline from which ‘alteration’ is made. If any illness can be accompanied by
or induce an ASC, health is presumably the baseline. But how do we define
that? For the person concerned, the differences between mental illness and
health are tangible and life-defining. And for any mental illness there are con-
crete ways of operationalising the kinds of suffering it involves, for the unwell
person and sometimes also for other people. The difficulties come when we try
to pin down precise points of transition, in time or in quality of life: where does
dieting stop and an eating disorder begin, for instance, or exhaustion shift into
chronic fatigue?
In general terms, we could define health simply as the absence of illness, but if
we try to do better than that, we may find ourselves gravitating towards ideas‘psychiatric diagnostic
labels [. . .] should not
be classified as ASCs or
not. Only the psychotic
episodes, had by any
kind of patients, can be
ASCs.’(Revonsuo et al., 2009, p. 201)‘an ASC should not be
defined as an altered
phenomenal state of
consciousness, but an
altered representational
state’(Revonsuo et al., 2009, p. 196)