Revisioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health

The concept of mental illness in the West is largely shaped by the DSM diagnostic model. The DSM categorization of psychiatric disorders has been useful in driving research, and psychiatric neuroscience has made enormous strides in identifying some of the brain-based factors that contribute to mental disorders such as autism, schizophrenia, and bipolar disorder, as well as suggesting possible drug therapies. Continue reading

3×5: Culture, Neuroscience, and Psychiatry Schizophrenia Roundup

Many thanks (seriously) to Nev Jones for sending so many great suggestions my way.

Culture/Environment
1. Variation – among individuals, geographically,  and across cultures – in the incidence, precedence, and course of schizophrenia is more complex than previously suggested by three WHO studies (on a putatively better outcome in “developing” vs. “developed” countries). For example, regional data from the Worldwide-Schizophrenia Outpatient Health Outcomes or W-SOHO study suggest a better clinical outcome but a worse functional outcome in regions other than “North Europe” (See, e.g., Haro et al’s “Cross-national clinical and functional remission rates.”)

Studies also continue to support variation within geographical region, e.g., Kirkbride et al’s PLOS One systematic review, “Incidence of schizophrenia and other psychoses in England, 1950–2009,” which describes, in particular, higher rates among “migrants and their descendants of black Caribbean and black African origin” and among those of “mixed ethnicity,” which the authors suggest may be a possible marker of “third-generation descendants.” Urban birth/upbringing also remains a significant risk factor, “independent of differences in the age, sex and ethnic population structure of different geographical areas, and correlated to a number of socio-environmental factors including ethnic density, social cohesion, social fragmentation, deprivation, and inequality.”

2. Early Adversity: A 3/29/12 meta-analysis published online by Jim van Os et al. supports the link between childhood adversity and risk of psychosis.  “Childhood adversities increase the risk of psychosis: A meta-analysis of patient-control, prospective- and cross-sectional cohort studies.” The addition of cannabis use appears to increase risk even further (Konings et al., 2012). But see also Susser and Widom’s July 2012 critique of such studies, “Still searching for lost truths about the bitter sorrows of childhood.

3. Diagnosis and Social Abandonment: In “Psychosis and the fog of reality,” Vaughan Bell of Mind Hacks has provided pdfs of two articles by journalist Rachel Aviv: “God knows where I am: What should happen when patients reject their diagnosis?” in the 5/30/11 New Yorker and “Which way madness lies: Can psychosis be prevented?” in the 12/10 issue of Harper’s. See also David Dobbs’s post, “What’s it like to be schizophrenic” and Jocelyn Marrow and Tanya Luhrmann’s recent paper for Culture, Medicine, and Psychiatry (CMP) on social abandonment in India and the US. And finally, Schomerus et al’s (2012) bleak conclusion of their meta-analysis that “Increasing public understanding of the biological correlates of mental illness seems not to result in better social acceptance of persons with mental illness.”

4. Cognition/Anthropology of Neuroscience: Elizabeth Bromley, Gail Fox Adams, and John Brekke’s “A video ethnography approach for linking naturalistic behaviors to research constructs of neurocognition in schizophrenia” in The Journal of Neuropsychiatry and Clinical Neuroscience (3/1/12). See also Bromley’s exploration of researchers’ understanding of the concept of “cognition” as it applies to schizophrenia in “The Texture of the Real” (CMP, 2012).

5. First-person Experience: The blog Ruminations on Madness, provides, as always, some much-need insight on philosophy, psychiatry, and first-person experience. In “Excerpts from the journals of E” the author provides us with the fragments of a brilliant philosophy student’s trajectory following his first episode of  psychosis.

The blog itself testifies to the more complex view that “schizophrenia” covers a range of conditions, capacities, and behaviors, that outcomes are as diverse as the people to whom the label is attached, and that living with the disorder offers in itself an important research perspective. The blog is an opportunity for significant advocacy, in regard to which, addressing anthropologists, psychiatrists, psychologists, and others in the mental health field in Berlin last year, Arthur Kleinman said,

We have all failed in a way that our brothers and sisters and cousins in the AIDS community have not failed. If you went back twenty years, you would see that everything I’ve said about the chronically mentally ill you could say about AIDS patients. And in twenty years the situation for AIDS patients has radically changed. There has been enormous efficacy from advocacy in the AIDS field. We have failed in the area of advocacy. And what I want to suggest is that in the future those of who who build your careers here: Advocacy will be part of your careers. Rather than seeing advocacy as a threat to academic life, you’re going to come to see advocacy as central to the new academy in the future.”

Neuroscience

See also Ford & Mathalon’s (2012) review, “Neurobiology of schizophrenia: Search for the elusive correlation with symptoms” in Frontiers.

1. Epigenetics: Steven Hyman, “Target practice: HDAC inhibitors for schizophrenia,” in News and Views / Nature Neuroscience published online 8/28/12 re Kurita et al. on targeting epigenetic changes that occur with the use of antipsychotics.

2. Vulnerability: Jim van Os and Richard Linscott’s introduction to a special issue of Schizophrenia Bulletin,The extended psychosis phenotype – Relationship with schizophrenia and with ultrahigh risk status for psychosis.

3. More Gene x Environment: Book review of The Origins of Schizophrenia, edited by Alan Brown and Paul Patterson. (Reviewed by Michael Owen, MRC Centre for Neuropsychiatric Genetics and Genomics, and Neuroscience and Mental Health Research Institute, Cardiff University.)

4. Schizophrenia and Autism: Kong et al’s 8/23/11 Nature paper, “Rate of de novo mutations and the importance of father’s age to disease risk.

5. Auditory Hallucinations: A series of related papers featured in July 2012 Schizophrenia Bulletin prepared by members of the International Consortium on Hallucination Research [InCoHR] working groups.

Psychiatry/DSM-5

1. DSM-5: Randy Tanon and William Carpenter’s, DSM-5 Status of Psychotic Disorders: 1 Year Prepublication” dd. 4/13/12 in Schizophrenia Bulletin provides a “snapshot of current status of potential changes” in DSM-5 regarding psychotic disorders. The proposed revisions include a “schizophrenia spectrum concept (which would include the attenuated psychosis syndrome listed in Section III – see [4] below). Also, the subtypes of SZ will be dropped in favor of eight or nine possible “dimensional ratings of different psychopathology domains,” including hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, and mana. (NB: “Catatonia, formerly a subtype, will now be listed as a “specifier for psychotic disorders, mood disorders, and general medical disorders.”) The authors note that “the issue of how many dimensions are useful, reliably assessed, necessary, and practical remains an open question.”

2. Diagnostic labels: Ruminations on Madness (“In defense of the schizophrenia construct (?)” ) argues that labels can obscure differences between persons and kinds of experiences, but is

less sure … that the advantages of more dimensional or non-label-based approaches outweigh the potential benefits—benefits, specifically, in the domain of identity. Like most sociopolitical minority group labels (Latino or Autistic, for example), “schizophrenic” cuts an arguably over-wide swathe and yet clearly marks something that, for cultural, historical and individual reasons, is shared between individuals and provides a (potentially vital) sense of collective ‘being’ and cohesion. [To make this a little more personal, and to repeat something that I believe I’ve said many times in earlier posts,  I do not think I would be alive today were it not for the deep and sustaining sense of recognition and belonging I found early on in Louis Sass’ brilliant work on schizophrenia.]

3.  Attenuated Psychosis Syndrome (Proposed for Section III of the DSM-5) (Revised April 27, 2012): Because of reliability issues (according to Tanon and Carpenter validity is “fairly established), “this condition is being recommended for further study in Section III, which is the section of the DSM-5 text in which conditions that require further research will be included.”

4. A good prior discussion/debate by Carpenter and Jim van Os, “Should attenuated psychosis syndrome be a DSM-5 diagnosis?” in  Am J Psychiatry 2011, and also a recent review, “A Rose is a Rose is a Rose,” But At-Risk Criteria Differ” by Schultze-Lutter et al. of University Hospital of Child and Adolescence Psychiatry (Bern) and Department of Psychiatry and Psychotherapy (Cologne).

5. William Carpenter’s “The future of schizophrenia pharmacotherapeutics: Not so bleak” in response to Chattaranjan Andrade, Rajiv Radhakrishnan, and Praveen Fernandes, “Psychopharmacology of schizophrenia: The future looks bleak,” in Mens Sana (2012). One question he raises is how reconceptualization of schizophrenia as a multi-dimensional construct will affect drug development?

See also the following (non-psychosis specific):

3×5: Culture, Neuroscience, and Psychiatry Weekly Roundup: Empathy (August 6)

UPDATE: New links from Lori Hogenkamp via Facebook at end of post.

Brief note: I’ve come to realize that empathy (and its putative component processes – mirror neuron networks, affect sharing, mentalizing) brings out almost everything that’s problematic in social neuroscience research: problems of a conceptually vague cover term, problems with extrapolating from animal models (e.g., monkeys don’t imitate); problems with fMRI/ROI, problems with science writing for the public (e.g., this publisher blurb for Marco Iacoboni’s Mirroring People: “From imitation to morality, from learning to addiction, from political affiliations to consumer choices, mirror neurons seem to have properties that are relevant to all these aspects of social cognition”), problems with a too-powerful metaphor (err, the mirror) that’s hard to repack in the box after that last quote :( problems with extrapolating in other ways (see Emily Willingham’s post on what she describes as the “no empathy in autism meme” – as Ian Hacking said, “The history of late 20th century medicine will … also [be] a history of advocacy groups”), etc., etc.

On second thought, there are many positive implications that hover over all this work – for theory of mind, radical embodied cognition, network science approaches to the brain’s structural and functional connectivity  . . .

Many thanks to the Neuroanthropology Interest Group on Facebook for suggestions and Center for Building a Culture of Empathy and Compassion for inspiration! 

Culture

1. “Empathy as cultural process: Insights from the cultural neuroscience of empathy” by Bobby Cheon, Vani Mathur, and Joan Chiao (WCPRR, 2010).

2. Via Eugene Raikhel (Neuroanthropology Interest Group): See the just-published special issue of “Science in Context” on “The Varieties of Empathy in Science, Art, and History.” It includes an article by Shaun Gallagher (“Empathy, Simulation, and Narrative“), one by Allan Young (“The Social Brain and the Myth of Empathy“) and a number of others.

3. Roundup on “Anthropology, Teaching, and Empathy” in early 2012 by Jason Antrosio of Anthropology Report and a related post by Rex on Savage Minds, “Empathy, or, seeing from within.”

4. Hollan, D. C., & Throop, C. J. (2011). The anthropology of empathy: Experiencing the lives of others in Pacific societies. New York: Berghahn.

5. Blog post by Emily Willingham (Dec 2011): “Autistic people: Insensitive to social reputation, sure, but what about empathy?” on the website Autism and Empathy.

Neuroscience

1. Bernhardt, B. C., & Singer, T. (2012). The neural basis of empathy. Annual Review of Neuroscience, 35, 1–23.

2. Decety, J. Norman, G. J., Berntson, G. G., & Cacioppo, J. T. (2012). A neurobehavioral evolutionary perspective on the mechanisms underlying empathy. Progress in Neurobiology, 98(1), 38–48. See also, Decety, J. (2011b). The neuroevolution of empathyAnnals of the New York Academy of Sciences, 1231, 35–45.

3. Zaki, J., & Ochsner, K. N. (2012). The neuroscience of empathy: Progress, pitfalls and promiseNature Neuroscience: Focus on Social Neuroscience [Perspective], 15(5), 675–680.

4. Decety, J. (2011a). Dissecting the neural mechanisms mediating empathy. Emotion Review, 3,92–108. See also, Decety, J. (2010). To what extent is the experience of empathy mediated by shared neural circuits? Emotion Review, 2(3), 204–207.

5. “Empathy and pro-social behavior in rats” Inbal Ben-Ami Bartal, Jean Decety, and Peggy Mason. See also 2011 Science paper by same group.

 

Psychiatry

1. Cheng, Y., Hung, A., & Decety, J. (2012). Dissociation between affective sharing and emotion understanding in juvenile psychopathsDevelopment and Psychopathology, 24, 623–636.

[From Abstract]. . . youth with HCU [high callous-unemotional traits] exhibit atypical neural dynamics of pain empathy processing in the early stage of affective arousal, which is coupled with their relative insensitivity to actual pain. Their capacity to understand intentionality, however, was not affected. Such uncoupling between affective arousal and emotion understanding may contribute to instigating aggressive behaviors in juvenile psychopaths.

[From the paper] It is  important that the affective arousal deficit . . . cannot be explained by a lack of sensorimotor resonance [i.e., mirror neurons], as measured by mu wave suppression [this was an ERP study], which was present in a ll participants. This finding indicates that affective arousal is not mediated by the mirror neuron system.

2. “Empathy and alterity in cultural psychiatry” by Laurence Kirmayer (Ethos, 2008).

3. “Empathy and otherness: Humanistic and phenomenological approaches to psychotherapy of severe mental illness” by Elizabeth Pienkos and Louis Sass (Pragmatic Case Studies in Psychotherapy, 2012).

4. Empathy in mental illness edited by Tom Farrow and Peter Woodruff (CUP, 2007).

5. “Zero degrees of empathy” by Simon Baron-Cohen, covering disorders of empathy (borderline personality disorder, psychopathy, narcissism) and genetic, endocrine, and social influences.

UPDATE:

3×5: Culture, Neuroscience, and Psychiatry Weekly Roundup (July 30)

Culture

1. Ginger Campbell (Brain Science Podcast) interviews UC Berkeley biological anthropologist Terrence Deacon about his book Incomplete Nature: How Mind Emerged from Matterwhich was reviewed by Raymond Tallis is WSJ last November. But see also “Stolen Ideas? Or Great Minds Thinking Alike?” by Tom Bartlett in the Chronicle of Higher Education, which discusses the book’s overlap with works by Alicia Juarrero (Dynamics in Action) and (our favorite) Evan Thompson (Mind in Life). (The FPR interviewed Evan Thompson last year.)

2. Neuroanthropology’s Daniel Lende’s post “Inside the Minds of Mass Killers” is a must-read.

3. Another terrific post on Aurora, which Daniel’s links to, is philosopher Evan Selinger’s “The Philosophy of the Technology of the Gun,” which appeared in the Atlantic.

I think Daniel and Evan throw some much-need light on the social, political, and material environment (including cultural scripts and how technology, to use a thread-bare metaphor, “gets under the skin”) from which acts of violence emerge and, in addition,  the importance of not “lightly equat[ing] mental illness and violence.”

But a commentator (“N” – and I’m assuming “N” is the same author whose brilliant work is featured in a post by David Dobbs) questioned “the divide” Daniel seemed to be drawing “between the cultural & sociopolitical and ‘mental illness,'” as well as that between violence and certain forms of psychosis. A thoughtful back-and-forth with “N” and other commentators followed. I highly recommend reading the whole thing!

4. Speaking of Daniel, Neuroanthropology’s Facebook page is a lot of fun!

5. Somatosphere has a great summary by Dörte Bemme and Nicole D’Souza of a recent global mental health workshop and conference hosted by Laurence Kirmayer and McGill’s Division of Transcultural Psychiatry.

There seems to be a shift among this new generation of researchers (including the post’s authors) to move beyond “static dichotomies (north, south, west, HIC, LMIC, global, local)” and top-down or bottom-up approaches but I’m not sure to what, precisely, apart from recognizing “interesting frictions”?

One advance that has gotten less press is DSM-5’s recognition that mental health, like physical health, is a developmental process and exquisitely sensitive to the timing as well as the intensity of experiences and events. Another comes from recognition of the need for a developmentally oriented network of primary care at the community level that address biological, social, and environmental risk factors for mental as well as medical illnesses – infectious diseases, poverty, stress, migration. (See, e.g., Sunday’s NYT magazine article, “What Can Mississippi Learn from Iran?” re primary health care reform.)

[Dr. Aaron] Shirley [creator of HealthConnect, a model inspired by Iran's primary health care systems] says he believes that the problems of the American poor — living conditions, deficient education, harmful behaviors and the lack of family support and access to healthful lifestyles — demand house calls. This approach was used by groups in Atlantic City and Camden, N.J., profiled by Atul Gawande in The New Yorker last year, which identified the worst offenders of emergency-room readmission and deployed social workers and nurses to figure out the myriad sources of ill health. What was clear above all else from Gawande’s account is that what these people needed was constant attention. Because one stumble — an unpaid electricity bill, for example — can lead to cascading health setbacks.

Neuroscience

1. Great Book, Great Interview: Ginger Campbell interviews Olaf Sporns about Networks of the Brain (MIT, 2011).

2. John Hawks linked to a fascinating paper on his blog, “Evolutionary History and Adaptation from High-Coverge Whole-Genome Sequences of Diverse African Hunter Gatherers” by Lachance et al. in Cell., which points out high levels of genetic diversity within African hunter-gatherer populations.

To reconstruct modern human evolutionary history and identify loci that have shaped hunter-gatherer adaptation, we sequenced the whole genomes of five individuals in each of three different hunter-gatherer populations at >60× coverage: Pygmies from Cameroon and Khoesan-speaking Hadza and Sandawe from Tanzania. We identify 13.4 million variants, substantially increasing the set of known human variation. We found evidence of archaic introgression in all three populations, and the distribution of time to most recent common ancestors from these regions is similar to that observed for introgressed regions in Europeans. Additionally, we identify numerous loci that harbor signatures of local adaptation, including genes involved in immunity, metabolism, olfactory and taste perception, reproduction, and wound healing. Within the Pygmy population, we identify multiple highly differentiated loci that play a role in growth and anterior pituitary function and are associated with height.

3. Russell Fernald’s “Social Control of the Brain,” in latest Ann Rev of Neurosci using a fish model.

4. Latest SCAN: “The Association Between Financial Hardship and Amygdala and Hippocampal Volumes: Results from the PATH Through Life Project.

5. Finally, here is a link to the pdfof the 2012 Human Brain Project report because I’m obsessed with this image:

And, in my simple minded way, if we can do this, our collective experts can come up with a solution for Mississippi.

Psychiatry

1. Rutgers press release dd. 7/19/12: Anxiety Disorders in Poor Mothers More Likely to be the Result of Poverty, not Mental Illness.

2. In the July 2012 issue of BJPsych, Psychotic symptoms in young people without psychotic illness: mechanisms and meaning by Graham Murray and Peter Jones.

Psychotic symptoms are common in the general population. There is evidence for common mechanisms underlying such symptoms in health and illness (such as the functional role of mesocorticostriatal circuitry in error-dependent learning) and differentiating factors (relating to non-psychotic features of psychotic illness and to social and emotional aspects of psychotic symptoms). Clinicians should be aware that psychotic symptoms in young people are more often associated with common mental disorders such as depression and anxiety than with severe psychotic illness.

3. Also in the same issue,, psychiatric neuroscientist Mary Phillips has an editorial on “Neuroimaging in Psychiatry: Bringing Neuroscience into Clinical Practice.”

4. Freedman et al’s “Treating a physician patient with psychosis,” Asian Journal of Psychiatry, June 2012 via @JonesNev

5. Also via Nev Jones (@JonesNev): “Voice Hearing and Pseudoseizures in a Maori Teenager: An Example of Mate Maori and Maori Traditional Healing” in Australas Psychiatry, 19 July 2012. See also “Maori Healers’ Views on Wellbeing: The Importance of Mind, Body, Spirit, Family and Land” in Social Science & Medicine (June 2010).

Abstract

Objective: The aim of this paper is to describe a Māori traditional healing approach to assessment and treatment of distressing psychiatric symptoms in a young man.Method:We describe the case of a 17 year old Māori male with voice hearing and pseudoseizures and the assessment and intervention by one of the authors (WN). We report on the young man’s and his family’s experience of this treatment. We outline concepts from a Māori world view that illuminate an indigenous rationale for this approach. Results: A single session traditional Māori healing intervention was associated with immediate resolution of this young man’s psychiatric symptoms and restoration of his sense of wellbeing, despite cessation of antipsychotic treatment. He and his family felt satisfied with the cultural explanation about the origin of his distress, which was congruent with their world view. He remained well at follow-up one year later. Conclusions: Collaboration between psychiatrists and traditional Māori healing practitioners can enhance the mental health care of Māori whaiora (service users) and their families. Indigenous research is required to further evaluate the acceptability and effectiveness of such joint approaches.

Deadline Extension to 8/3: Ethnographic Perspectives on Global Mental Health

Just received this notice via McGill’s listserv. See also Somatosphere’s excellent summary of McGill’s Global Mental Health workshop and conference (Global Mental Health and Its Discontents) by Dörte Bemme and Nicole D’Souza.

We invite paper submissions for a panel titled: Ethnographic perspectives on
‘global mental health’ at The 17th World Congress of the International Union
of Anthropological and Ethnological Sciences (IUAES), University of
Manchester, UK, 5-10 August 2013.

Deadline: August 3rd, 2012

Panel LD36: Ethnographic perspectives on ‘global mental health’

Conveners

Sumeet Jain (University of Edinburgh), Email: sumeet.jain@ed.ac.uk
David Orr (University of Sussex), Email: d.orr@sussex.ac.uk

Short Abstract

The ‘global mental health’ (GMH) agenda has attained considerable policy
influence. However, debates continue about its universal validity. This
panel takes an ethnographic approach to how GMH-informed interventions
respond in practice to disparate manifestations of mental distress.

Long Abstract

This panel takes an ethnographic approach to investigating how interventions
informed by the ‘global mental health’ (GMH) movement respond in practice to
disparate manifestations of mental distress. The GMH agenda now dominates
academic and policy discussions of mental health in low and middle income
countries. Its rise can be traced to specific developments in the 1990s that
shaped how the ‘disability burden’ of mental health disorders came to be
measured, and a series of policy and research reports on mental health which
afforded direction and impetus to efforts to push mental health up the list
of governmental priorities. Today the GMH agenda is backed by the World
Health Organisation and has played its part in the continuing worldwide
spread of psychiatry’s reach. Yet social scientists and psychiatrists have
questioned how ‘globally’ valid some of its concepts and assumptions prove
in framing and acting on experiences of mental distress in diverse contexts
and social configurations. This panel invites papers that draw on
anthropological theory and ethnographic data to comment on, add to, or
critique the evidence base for claims on both sides, and consider how these
discourses are formed and re-formed on the ground. High on the list of
questions we seek to address are:

How are GMH policies deployed in diverse locales?

What are the effects of these policies on local populations?

How is this agenda re-shaping clinical and non-clinical settings?

How do GMH discourses transform the interaction between patient and health
professional?

How does this approach mould health-seeking behaviours?

Please note that the deadline for paper proposals is August 3rd, 2012.
Proposals should be submitted by August 3rd, 2012 through the ‘Propose a
paper’ link on the following page :

http://www.nomadit.co.uk/iuaes/iuaes2013/panels.php5?PanelID=1705

If you require further information, do not hesitate to contact either of us.

Best wishes,

Sumeet Jain & David Orr

Beyond DSM-5: Levels of explanation in psychiatry (the “fuzzy set” approach)

Daniel Lende of Neuroanthropology has listed a lot of interesting reading re the DSM-5 process that basically boils down to whether this discussion and debate should be open to the public.

I think it should, and not only because psychiatry intersects with powerful market forces (i.e., the global psychopharmaceutical industry – UPDATE: See Kalman Applbaum’s terrific coverage of the Texas vs. Johnson & Johnson Risperdal trial at Somatosphere.net) and the use of the DSM extends well beyond psychiatry (neuroscience researchers, schools, the legal system, how we define disability) but also because the DSM “suffuses the ways in which patients (and the broader public) make sense of their distress and dysfunction” (Gone & Kirmayer, 2010). Greg Downey in a January 2011 post, makes a great point about the consequences of diagnosis:

What Desjarlais’ account [from Shelter Blues: Sanity and Selfhood Among the Homeless] suggests is that being diagnosed as insane or schizophrenic or some other medical condition can, through a process that is as much sociological and economic as it is medical, lead a person to become homeless.  In the process, the day-to-day reality of the individual becomes increasingly slippery, increasingly challenging — for a mentally ill individual, this transition might make recovery virtually impossible as they are shorn of all the material supports of normal personhood and pushed into an alternative reality that would severely test the healthiest among us.

But I also think a tremendous amount of care and thought has gone into the DSM-5 process on the part of individual work groups. For example, William Carpenter and Jim van Os (both members of the psychosis work group) provide a thoughtful commentary on the pros and cons of recognizing an attenuated psychosis syndrome in adolescents and young adults at high risk for schizophrenia and other psychotic disorders in the American Journal of Psychiatry, which opens with the following excerpts:

The best hope for secondary prevention of the often devastating course of psychotic disorders resides in early detection and intervention when individuals first develop symptoms. There is sufficient evidence for attenuated psychosis syndrome as a clinical syndrome with predictive validity to establish this diagnostic class. There is much that clinicians can and should do for care-seeking individuals with distress and dysfunction who manifest early psychotic-like psychopathology. A new DSM-5 diagnosis can focus attention on this syndrome and stimulate the creative acquisition of new knowledge that may be life altering for afflicted persons. There is little reason to rely on less specific diagnostic categories, such as anxiety and depression, if we can reli- ably give patients and their families a more informative picture of their situation.—William T. Carpenter

The best hope for early intervention in psychotic disorders resides in public health measures for the population as a whole rather than in attempts to diagnose risk in individuals for what will be a low incidence of future psychosis. Making services more accessible, providing general diagnostic training to primary care workers, and creating community awareness will make the filters on the pathway to mental health treatment more permeable for people with early psychotic symptoms in need of care. Individual treatment should be initiated early but when it is indicated, as when cri- teria are first met for psychotic disorder not otherwise specified. Creating a diagnostic class that does not unambiguously define a specific group, treatment, or outcome does not add value for patients and their families.—Jim van Os

DSM-6.0 and Beyond

The DSM-5 system of classifying mental disorders may be the last of its kind. (Is there anything else particularly ground-breaking about the DSM-5, apart from the possibility of including a “person-centered” dimensional approach in the case of personality disorders, which would involve “a reduction in the number of specified types” as well as an interesting DSM-II-ish description of specified types (or prototypes) “in narrative format that combines typical deficits in self and interpersonal functioning and particular trait configurations”?)

On the other hand, Kenneth Kendler has a review in the latest issue of Molecular Psychiatry (“Levels of explanation in psychiatric and substance use disorders: Implications for the development of an etiologically based nosology”) that argues for an understanding of disorder “in terms of “fuzzy sets of cross-level mechanisms varyingly instantiated in individual patients.”

Such a viewpoint has been developed to explain what kinds of things biological species are – fuzzy sets defined by mechanisms at multiple levels that act and interact to produce the key features of the kind [Boyd, 1999].

(Actually, Boyd uses a phrase, “‘homeostatically’ sustained clustering of properties or relations,” that has a nice, systems-oriented ring to it.) This seems like a good direction for DSM-6.0 and beyond.  The next ten years may reveal an even more radical rethinking of all sorts of boundaries that will create deeper understandings of brain and mind in social, cultural, and physical contexts in terms of complex systems that have the potential of underwriting more collective and powerful responses to our “problems of living.”

Grad Students! Society for Study of Psychiatry & Culture Call for Papers

                   Charles Hughes Fellowship in Cultural Psychiatry

The Society for the Study of Psychiatry and Culture announces its 11th annual call for papers for the Charles Hughes Fellowship in Cultural Psychiatry, an annual award presented to a graduate student who has an interest in and commitment to cultural psychiatry and mental health.  Graduate students in the social sciences who are interested in competing for this award should submit an original scholarly paper on a topic in cultural psychiatry, along with a CV and a letter of recommendation from his/her department or committee chair, to Joan D. Koss-Chioino, Ph.D.

Email all 3 documents to: joan.koss@asu.edu

The deadline is December 1, 2011.  The Society will pay partial travel costs for the awardee to present his or her paper at its annual meeting to be held May 9-11, 2012 in New York City.

For more information, contact Dr. Joan Koss-Chioino at  joan.koss@asu.edu

Defining Mental Illness in Children: The SSI “Safety Net”

Quote

Excerpt from forthcoming New York Review of Books (“The Illusions of Psychiatry” by Marcia Angell dd. 7/14/11 ):

One would be hard pressed to find a two-year-old who is not sometimes irritable, a boy in fifth grade who is not sometimes inattentive, or a girl in middle school who is not anxious. (Imagine what taking a drug that causes obesity would do to such a girl.) Whether such children are labeled as having a mental disorder and treated with prescription drugs depends a lot on who they are and the pressures their parents face.[1]  As low-income families experience growing economic hardship, many are finding that applying for Supplemental Security Income (SSI) payments on the basis of mental disability is the only way to survive. It is more generous than welfare, and it virtually ensures that the family will also qualify for Medicaid. According to MIT economics professor David Autor, “This has become the new welfare.” Hospitals and state welfare agencies also have incentives to encourage uninsured families to apply for SSI payments, since hospitals will get paid and states will save money by shifting welfare costs to the federal government.

Growing numbers of for-profit firms specialize in helping poor families apply for SSI benefits. But to qualify nearly always requires that applicants, including children, be taking psychoactive drugs. According to a New York Times story, a Rutgers University study found that children from low-income families are four times as likely as privately insured children to receive antipsychotic medicines.

[1] Duff Wilson, “Child’s Ordeal Reveals Risks of Psychiatric Drugs in Young,” The New York Times , September 2, 2010.