Dissociation and the DSM: Why Psychiatry Needs the Cultural Anthropologist

We have been periodically posting about the 4th interdisciplinary conference on brain, mind, and culture (“Cultural and Biological Contexts of Psychiatric Disorder”) sponsored by the Foundation for Psychocultural Research and UCLA, which took place at UCLA on Jan 22-24, 2010. Below is a brief note on a discussion re the possibility of establishing a small number of universally valid categories of mental disorder. References are included at end of post.

The final interdisciplinary panel of the conference focused on the implications of a biocultural approach to mental illness for the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association) which is forthcoming in 2013. The panel included psychiatrist and session chair James Boehnlein, neuroscientist David Jentsch of UCLA, cultural psychiatrist Laurence Kirmayer of McGill University, cultural psychiatrist (and member of the DSM-5 anxiety disorders work group) Roberto Lewis-Fernández of New York State Psychiatric Institute, and psychological anthropologist Tanya Luhrmann of Stanford University.

One of the issues with DSM-IV is the overspecification of category features (e.g., caffeine- vs. cocaine-induced sleep disorder). Lewis-Fernández said that DSM5.0 and beyond should instead “aspire to become a nosology of fairly universal conditions.” He said that at that level of abstraction a proto-category for dissociative-type disorders [1], for example, would ideally encompass all or most culturally specific variants. [A proto-category, or prototype, is a mental model “based on characteristics that are common in members of the group (‘common features’) rather than ‘defining features’ (i.e., necessary prerequisites for category membership) (Rosch & Mervis, 1975, as cited in Ortigo, Bradley, & Westen, 2010, p. 376).]

Dissociation, for the purposes of this post, “refers to gaps or disturbances in ‘normal’ patterns of integration of perception, memory, identity, and self” (Hollan, 2000, p. 545). These lapses can range from very brief, hypnotic reveries (which may occasionally cause you to wonder who’s been driving your car for the last 3 minutes) to culturally normative trance or possession in cultures that may not value as rigidly as we do “a cohesive, autonomous, and unitary self” (Hollan, 2000, p. 553) to the kind of pathological dissociation characterized in western psychiatry by long periods of “dissociative amnesia and alterations in identity” (e.g., Dissociative Identity Disorder, formerly Multiple Personality Disorder) (Kihlstrom, 2005, as cited in Kirmayer & Seligman, 2008, p. 32).

Positing a proto-category for dissociative disorders raised a number of issues for panelist Laurence Kirmayer:

There is an important move that’s going on in what you’re describing, and it hinges on the double meaning of the word dissociation. You’re moving from the use of the word dissociation as a purely descriptive term of a kind of symptom to an imputation that dissociation is a mechanism.

Kirmayer felt that making dissociative disorders a proto-category implies the existence of a common psychophysiological process, as well as a theory about contributing factors and possible interventions.

If you leave it at the level of symptoms – and I think this is a very important point and maybe should have been brought out earlier in the meeting – most of the symptoms that we’re using as natural kinds or sort of indicators of the environment are from the very beginning, and to a significant degree, culturally constructed. There are many ways to parse what’s going on.

Going forward, we need to integrate culturally patterned symptoms and biological illness mechanisms to capture the complex dynamics of dissociative disorders.

The word “hallucination” raises similar issues, Kirmayer continued, referring to Tanya Luhrmann’s talk earlier that morning. It loosely knits together different experiences and processes, ranging from the “normal” everyday mistaken perception of hearing your name being called (e.g.,  while showering)  to evangelicals’ “hearing God” through prayer to the more extended and distressing auditory hallucinations characteristic of schizophrenia.

For me, the underlying point in terms of psychiatric science – and even in terms of clinical intervention – is that the distinctions that we’re making in terms of what’s notable about a person’s condition, and what’s going to be a target for intervention, builds into it – as in any complex human phenomena – social context, developmental trajectory, and so on. The particular nosology that we are going to use, if it is driven by practical concerns, has to take that into account.

For Kirmayer, far too much attention is being focused on one level of analysis, “where you can make certain distinctions and get certain traction,” and not enough on the specific, situational predicaments people find themselves in (“the bread and butter of mental health care” ), which are lumped together in the V-codes (e.g., V62.4 Acculturation Problem; V61.21 Neglect of Child; V62.89 Religious or Spiritual Problem) at the back of the DSM. Yet these contexts are precisely what can make hallucinations or dissociative experiences  (the latter usually related, in the western psychiatric literature, to prior trauma or acute stress [2]) intolerable or unmanageable, or, in other contexts, pleasurable and deeply engaging (Seligman & Kirmayer, 2008, p. 41).

This is why (pace Sapir [1938/2001], who said we cannot understand the dynamics of culture, society, and history without taking into account the actual interrelationships of human beings) psychiatry needs the cultural anthropologist. Identifying cultural variants and implications of dissociative experiences (e.g., the possible relationship in Indonesia between their prevalence – in the form of trance dance – and the incidence of brief, dissociative-like psychoses as opposed to more chronic forms in the west) will provide essential clues to underlying mechanisms.  As panelist Tanya Lurhmann summarized:

I think the kind of structure that Roberto is outlining is actually quite helpful in thinking about diagnosis more generally, thinking about schizophrenia or psychosis as a process and then identifying culturally specific manifestations as locally relevant and treating the locally relevant manifestations in the United States as being one among other kinds of representations. And that is one structure to which anthropologists can profoundly contribute.

Notes

[1] In the current version of the manual, the disorders are broken into the following subtypes:

Dissociative Disorders (from DSM-IV-TR)

300.12  Dissociative Amnesia

300.13  Dissociative Fugue

300.14  Dissociative Identity Disorder

300.6    Depersonalization Disorder

300.15  Dissociative Disorder NOS

[2] According to Stanford psychiatrist David Spiegel, DSM5 work group members are discussing the possibility of a stress and trauma spectrum section that would include the adjustment disorders, acute stress disorder, PTSD, and the dissociative disorders (Spiegel, 2010, p. 262).

References

Hollan, D. (2000). Culture and dissociation in Toraja. Transcultural Psychiatry, 37(4), 545–559.

Abstract. This article examines the extent to which some psychoanalytic ideas about dissociation and its correlates are useful in helping us to understand possession behavior and related phenomena in places such as Toraja, Indonesia. Although some of these ideas can be useful to us, data from Toraja challenge us to modify some key psychoanalytic assumptions about dissociation. The article demonstrates how cross-cultural data can be used to broaden our perspectives on the construction and breakdown of human consciousness.

Kilhstrom, J. (2005). Dissociative disorders. Annual Review of Clinical Psychology, 1, 227–253.

Ortigo, K. M., Bradley, B., & Westen, D. (2010). An empirically based prototype diagnostic systems for DSM-V and ICD-11. In T. Millon, R. F. Krueger, & E. Simonsen (Eds.), Contemporary directions in psychopathology: Scientific foundations of the DSM-V and ICD-11 (pp. 374–390). New York: Guilford Press.

Rosch, E., & Mervis, C. B. (1975). Family resemblances: Studies in the internal structure of categories. Cognitive Psychology, 7(4), 573–605.

Sapir, E. (1938/2001). Why cultural anthropology needs the psychiatrist. Psychiatry, 64(10), 2–21.

Seligman, R., & Kirmayer, L. J. (2008). Dissociative experience and cultural neuroscience: Narrative, metaphor and mechanism. Culture, Medicine, & Psychiatry, 32, 31–64.

Abstract. Approaches to trance and possession in anthropology have tended to use outmoded models drawn from psychodynamic theory or treated such dissociative phenomena as purely discursive processes of attributing action and experience to agencies other than the self. Within psychology and psychiatry, understanding of dissociative disorders has been hindered by polemical ‘‘either/or’’ arguments: either dissociative disorders are real, spontaneous alterations in brain states that reflect basic neurobiological phenomena, or they are imaginary, socially constructed role performances dictated by interpersonal expectations, power dynamics and cultural scripts. In this paper, we outline an approach to dissociative phenomena, including trance, possession and spiritual and healing practices, that integrates the neuropsychological notions of underlying mechanism with sociocultural processes of the narrative construction and social presentation of the self. This integrative model, grounded in a cultural neuroscience, can advance ethnographic studies of dissociation and inform clinical approaches to dissociation through careful consideration of the impact of social context.

Spiegel, D. (2010). Dissociation in the DSM5 [Editorial]. Journal of Trauma & Dissociation, 11, 261–265.

This entry was posted in cultural & biological contexts of psychiatric disorder, uncategorized by Constance Cummings. Bookmark the permalink.

About Constance Cummings

Constance A. Cummings, Ph.D., is Project Director of the non-profit The Foundation for Psychocultural Research, which supports and advances interdisciplinary research and scholarship at the intersection of brain, mind, culture, and mental health and illness. She is co-editor (with Carol Worthman, Paul Plotsky, and Dan Schechter) of Formative Experiences: The Interaction of Caregiving, Culture, and Developmental Psychobiology (New York: Cambridge University Press, 2010). She received her doctorate in theoretical linguistics from New York University.

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