Many psychiatric disorders may be better explained by non-reductive, network models, as exemplified by Borsboom et al. in the target article, than by reductionist models that condense or dismiss distinct but interrelated cognitive processes. The influences of culture and individual social flexibility on mental disorders and outcomes are among the processes that network models can robustly account for. We agree with the authors’ descriptions of the interplay between mental state contents and culture in symptom networks. To further enrich the discussion, we examine (1) the relevant details of the relationships between mental state contents and culture; (2) how these relationships might arise and feed back into themselves; and (3) the implications these relationships have for further defining appropriate network models.
Culture influences the causal relationship between symptoms in a network model. Culture also largely shapes the contents of mental states and intentionality of many mental states (e.g., Ambady & Bharucha Reference Ambadyp and Bharucha2009; Ramos-Sánchez & Atkinson Reference Ramos-Sánchez and Atkinson2009; Varela & Shear Reference Varela and Shear1999). The network relationships between symptoms appear causally related once their contents and intentionality are understood (Borsboom et al. in the target article, and see also Borsboom Reference Borsboom2008). In the example by Borsboom et al. in the section on “the content of mental states” (sect. 5), someone who believes the Central Intelligence Agency (CIA) is watching will close the curtains. According to their line of argument, the CIA watching would be part of the cultural influence of being a patient in a country where the CIA is a relevant entity, such as the United States; however, the intentional act of closing the curtains and withdrawing from social life is also part of the cultural effects. These actions may be considered comprehensible in the United States, for example, because of the cultural interpretation of how to obtain safety from governmental agencies. Alternative actions, such as becoming hypersocial to find safety by remaining in a large group of people, may be equally understandable in a cultural context where groups are perceived as safer than isolation. This interpretation harmonizes recent findings in cultural psychiatry, such as variations in hallucination experiences of psychotic patients (Luhrmann et al. Reference Luhrmann, Padmavati, Tharoor and Osei2014), with findings in neuropsychiatry and on real-world patient behaviors (Bowie et al. Reference Bowie, Leung, Reichenberg, McClure, Patterson, Heaton and Harvey2008; Menon & Uddin Reference Menon and Uddin2010).
Culture, of course, is characterized by numerous continua of common beliefs and behaviors (Kemmelmeier & Kühnen Reference Kemmelmeier and Kühnen2012), and one must also ask how an individual decides which culturally informed behaviors to adhere to. Cognitive mediation of cultural information is arguably a key process that gives rise to the contents and intentionality of mental contents as well as many of the false beliefs that contribute to pathology (Crafa & Nagel Reference Crafa and Nagel2013; in Reference Crafa and Nagelpress; Kitayama & Uskul Reference Kitayama and Uskul2011). Cognitive mediation in this context refers to the process of identity and belief construction based on consciously or unconsciously subscribing to or rejecting information in the sociocultural environment. Because social information is continuously encountered throughout the lifespan, this process is a feedback loop that constantly feeds into itself, but that also shapes the biological, neurological, and psychological constitution of the individual (Crafa & Nagel Reference Crafa and Nagel2013; Reference Crafa and Nagelin press). New social experiences may reinforce or alter existing biological, neural, and psychological processes by providing both information and impetus. For example, the reification or undermining on the levels of existing beliefs, neural networks, or behavioral outputs changes what information in the social environment is experienced (e.g., other people respond differently to you depending on how you think and behave) and perceived (e.g., if you believe the CIA is after you, you will attend to different environmental information and interpret that information differently than you might otherwise) (Archpru Akaka & Chandler Reference Archpru Akaka and Chandler2011). The information in the social environment that is experienced and perceived then feeds back, either reinforcing or undermining existing processes, and the cycle continues ad mortem. This feedback loop shapes neural networks, behavioral outputs, and other biopsychological processes.
When examining the relationship between mental disorders and cognitively mediated feedback loops, individuals vary substantially in their abilities to adapt to novel or dynamically changing social situations (Folke et al. Reference Folke, Carpenter, Walker, Scheffer, Chapin and Rockström2010). Social rigidity and hyperflexibility are symptoms of many disorders, such as obsessive-compulsive disorder, autism, and schizophrenia (Bliksted et al. Reference Bliksted, Fagerlund, Weed, Frith and Videbech2014; Chamberlain et al. Reference Chamberlain and Menzies2009; Geurts et al. Reference Geurts, Corbett and Solomon2009). From the perspective of a network model, it is useful to consider rigidity and hyperflexibility as parts of a single continuous trait of social flexibility. Where an individual falls on this continuum of social flexibility is informative for understanding whether exposure to new social information will reinforce or undermine existing processes to larger or smaller extents. Thus, in turn, an individual's degree of social flexibility may indicate how mental contents or intentionality might continue to develop across the lifespan and the magnitude of those changes. In other words, not all feedback loops are created equal. Considering the role of social flexibility as a key feature of any feedback loop can help further characterize the development, strength, and possible trajectories of network connections, and further specify how we can understand the complex reasoning of individual patients as well as the relationship between their reasoning and their underlying neurobiology.
The impact of culture on the contents of mental states and how a person cognitively mediates those experiences may vary depending on how flexible a person is. Understanding variations in human flexibility can be informative for characterizing and potentially predicting the impact network relations may have on the trajectory of individual mental states. Network models of psychiatric disorders will benefit from the inclusion of these interrelated processes in order to ultimately better understand the patient.
Many psychiatric disorders may be better explained by non-reductive, network models, as exemplified by Borsboom et al. in the target article, than by reductionist models that condense or dismiss distinct but interrelated cognitive processes. The influences of culture and individual social flexibility on mental disorders and outcomes are among the processes that network models can robustly account for. We agree with the authors’ descriptions of the interplay between mental state contents and culture in symptom networks. To further enrich the discussion, we examine (1) the relevant details of the relationships between mental state contents and culture; (2) how these relationships might arise and feed back into themselves; and (3) the implications these relationships have for further defining appropriate network models.
Culture influences the causal relationship between symptoms in a network model. Culture also largely shapes the contents of mental states and intentionality of many mental states (e.g., Ambady & Bharucha Reference Ambadyp and Bharucha2009; Ramos-Sánchez & Atkinson Reference Ramos-Sánchez and Atkinson2009; Varela & Shear Reference Varela and Shear1999). The network relationships between symptoms appear causally related once their contents and intentionality are understood (Borsboom et al. in the target article, and see also Borsboom Reference Borsboom2008). In the example by Borsboom et al. in the section on “the content of mental states” (sect. 5), someone who believes the Central Intelligence Agency (CIA) is watching will close the curtains. According to their line of argument, the CIA watching would be part of the cultural influence of being a patient in a country where the CIA is a relevant entity, such as the United States; however, the intentional act of closing the curtains and withdrawing from social life is also part of the cultural effects. These actions may be considered comprehensible in the United States, for example, because of the cultural interpretation of how to obtain safety from governmental agencies. Alternative actions, such as becoming hypersocial to find safety by remaining in a large group of people, may be equally understandable in a cultural context where groups are perceived as safer than isolation. This interpretation harmonizes recent findings in cultural psychiatry, such as variations in hallucination experiences of psychotic patients (Luhrmann et al. Reference Luhrmann, Padmavati, Tharoor and Osei2014), with findings in neuropsychiatry and on real-world patient behaviors (Bowie et al. Reference Bowie, Leung, Reichenberg, McClure, Patterson, Heaton and Harvey2008; Menon & Uddin Reference Menon and Uddin2010).
Culture, of course, is characterized by numerous continua of common beliefs and behaviors (Kemmelmeier & Kühnen Reference Kemmelmeier and Kühnen2012), and one must also ask how an individual decides which culturally informed behaviors to adhere to. Cognitive mediation of cultural information is arguably a key process that gives rise to the contents and intentionality of mental contents as well as many of the false beliefs that contribute to pathology (Crafa & Nagel Reference Crafa and Nagel2013; in Reference Crafa and Nagelpress; Kitayama & Uskul Reference Kitayama and Uskul2011). Cognitive mediation in this context refers to the process of identity and belief construction based on consciously or unconsciously subscribing to or rejecting information in the sociocultural environment. Because social information is continuously encountered throughout the lifespan, this process is a feedback loop that constantly feeds into itself, but that also shapes the biological, neurological, and psychological constitution of the individual (Crafa & Nagel Reference Crafa and Nagel2013; Reference Crafa and Nagelin press). New social experiences may reinforce or alter existing biological, neural, and psychological processes by providing both information and impetus. For example, the reification or undermining on the levels of existing beliefs, neural networks, or behavioral outputs changes what information in the social environment is experienced (e.g., other people respond differently to you depending on how you think and behave) and perceived (e.g., if you believe the CIA is after you, you will attend to different environmental information and interpret that information differently than you might otherwise) (Archpru Akaka & Chandler Reference Archpru Akaka and Chandler2011). The information in the social environment that is experienced and perceived then feeds back, either reinforcing or undermining existing processes, and the cycle continues ad mortem. This feedback loop shapes neural networks, behavioral outputs, and other biopsychological processes.
When examining the relationship between mental disorders and cognitively mediated feedback loops, individuals vary substantially in their abilities to adapt to novel or dynamically changing social situations (Folke et al. Reference Folke, Carpenter, Walker, Scheffer, Chapin and Rockström2010). Social rigidity and hyperflexibility are symptoms of many disorders, such as obsessive-compulsive disorder, autism, and schizophrenia (Bliksted et al. Reference Bliksted, Fagerlund, Weed, Frith and Videbech2014; Chamberlain et al. Reference Chamberlain and Menzies2009; Geurts et al. Reference Geurts, Corbett and Solomon2009). From the perspective of a network model, it is useful to consider rigidity and hyperflexibility as parts of a single continuous trait of social flexibility. Where an individual falls on this continuum of social flexibility is informative for understanding whether exposure to new social information will reinforce or undermine existing processes to larger or smaller extents. Thus, in turn, an individual's degree of social flexibility may indicate how mental contents or intentionality might continue to develop across the lifespan and the magnitude of those changes. In other words, not all feedback loops are created equal. Considering the role of social flexibility as a key feature of any feedback loop can help further characterize the development, strength, and possible trajectories of network connections, and further specify how we can understand the complex reasoning of individual patients as well as the relationship between their reasoning and their underlying neurobiology.
The impact of culture on the contents of mental states and how a person cognitively mediates those experiences may vary depending on how flexible a person is. Understanding variations in human flexibility can be informative for characterizing and potentially predicting the impact network relations may have on the trajectory of individual mental states. Network models of psychiatric disorders will benefit from the inclusion of these interrelated processes in order to ultimately better understand the patient.