Latest Roundup: What is Culture; Interdependence/Empathy; OFC & Prediction; More on Salience Processing


What is Culture? Culture is Context-Dependence by Georg Northoff (Culture and Brain, 2013).

What is culture? The concept of culture has been defined in different ways and terms. I here take a different approach and determine the concept of culture as one specific instance the more general feature of context-dependence. The concept of context is here understood in a wider way that includes different kinds of contexts, social, cultural, mental, and bodily. Culture is then one specific instance of context-dependence. What exactly do I mean by the concept of ‘dependence’? Following the philosopher Susan Hurely, there are different forms of context-dependence instrumental and non-instrumental. Instrumental dependence describes the indirect dependence for instance motor functions on the environment via the sensory functions. Non-instrumental context-dependence refers to a more direct dependence of the motor functions themselves on the context independent of the sensory functions. I now postulate that such non-instrumental context-dependence can also be observed in the brain that encodes its neural activity in direct dependence on its respective context. This is illustrated by three examples, reward, interoception, and social self. Such direct or better non-instrumental context-dependence of the brain’s neural activity is possible only if the neural activity is encoded in a particular way in terms of differences between different stimuli rather than single stimuli themselves; this amounts to what I describe as difference-based coding as distinguished from stimulus-based coding. Does this entail cultural context-dependence? This is illustrated by a fourth example from depression as a psychiatric disorder. In conclusion, I here advocate the view that culture can be determined by direct or non-instrumental context-dependence which I postulate to be mediated by a particular encoding strategy of the brain, that is, difference-based coding.


Differential Neural Activation to Friends and Strangers Links Interdependence to Empathy by Meghan L. Meyer, Carrie L. Masten, Yina Ma, Chenbo Wang, Zhenhao Shi, Naomi I. Eisenberger, Matthew D. Lieberman, Shihui Han (Culture and Brain, Dec 2014)

Two competing views implicate interdependence in empathy. One suggests that interdependence may generally enhance empathy (Woltin et al., British Journal of Social Psychology 50:553–562,2011), whereas another suggests that interdependence enhances empathy for targets with whom one is in a relationship, at the cost of decreasing empathy for strangers (Markus and Kitayama, Perspectives on Psychological Science 5(4):420–430, 2010). Here, we show evidence in support of the latter account. We observed that trait-level interdependence positively correlated with trait-level empathic abilities in perspective-taking and empathic concern. However, using an empathy for social exclusion paradigm, we found that neural responses to a friend’s compared to a stranger’s social exclusion (vs. inclusion) differentially related to interdependence, perspective-taking and empathic concern. During the observation of a friend’s social exclusion (vs. inclusion), neural responses in the medial prefrontal cortex (MPFC), and to a lesser extent the dorsal anterior cingulate cortex (dACC) and anterior insula (AI), positively correlated with self-reported trait interdependence, perspective-taking, and empathic concern. In contrast, during the observation of a stranger’s social exclusion (vs. inclusion), neural responses in the MPFC, and to a lesser extent the dACC and AI, negatively correlated with self-reported trait interdependence, perspective-taking and empathic concern. These findings suggest that while trait interdependence may correspond with enhanced ability to empathize, as indicated by self-report measures, interdependent individuals may preferentially recruit this ability for close others relative to strangers.



The Orbitofrontal Oracle: Cortical Mechanisms for the Prediction and Evaluation of Specific Behavioral Outcomes by Peter H. Rudebeck and Elizabeth Murray (Neuron, Dec 2014)

The orbitofrontal cortex (OFC) has long been associated with the flexible control of behavior and concepts such as behavioral inhibition, self-control, and emotional regulation. These ideas emphasize the suppression of behaviors and emotions, but OFC’s affirmative functions have remained enigmatic. Here we review recent work that has advanced our understanding of this prefrontal area and how its functions are shaped through interaction with subcortical structures such as the amygdala. Recent findings have overturned theories emphasizing behavioral inhibition as OFC’s fundamental function. Instead, new findings indicate that OFC provides predictions about specific outcomes associated with stimuli, choices, and actions, especially their moment-to-moment value based on current internal states. OFC function thereby encompasses a broad representation or model of an individual’s sensory milieu and potential actions, along with their relationship to likely behavioral outcomes.

more on dysfunctions in salience processing

Salience Processing and Insular Cortical Function and Dysfunction by Lucina Uddin (Nature Reviews Neuroscience, Jan 2015)

Repeated Social Stress Increases Reward Salience and Impairs Encoding of Prediction by Rat Locus Coeruleus Neurons (Neuropsychpharmacology, Jan 2015)

Discrete Alterations of Brain Structural Covariance in Individuals at Ultra-High Risk for Psychosis by Heinze, Reniers, Nelson, Yung, Lin, Harrison, Pantelis, Velakoulis, McGorry, Wood (Biological Psychiatry, 2014)

Culture, Mind, Brain Roundup – Dec 2014

We have a new volume in the works on culture, mind, and brain based on our 2012 conference, so I’ve decided to start posting short roundups on a weekly basis of some of my favorite new papers/chapters/books:


A Village Possessed by “Witches”: A Mixed-Methods Case–Control Study of Possession and Common Mental Disorders in Rural Nepal Culture, Medicine, Psychiatry


Philosophy of Mind and Psychology Reading Group – Jakob Hohwy’s The Predictive Mind (Series of blog posts as the group makes their way through a fascinating book). Author interviewed on New Books in Philosophy podcast


Repeated Social Stress Increases Reward Salience and Impairs Encoding of Prediction by Rat Locus Coeruleus Neurons Neuropsychpharmacology

Call for Papers / Culture & Global Mental Health / Society for the Study of Psychiatry & Culture


Culture and Global Mental Health

2015 Annual Meeting

Call for Papers for Charles Hughes Fellowship and John Spiegel Fellowship

Providence, Rhode Island, April 23–25, 2015

Deadline: September 15, 2014. For submissions and questions, contact Brandon Kohrt,

The theme of the annual meeting is Culture and Global Mental Health. We are particularly interested in submissions based on clinical activities, teaching, and research that address the relationship between cultural psychiatry and global mental health, including issues pertaining to mutual contributions, challenges, and collaborations. The deadline for fellowship paper submission is September 15, 2014. Trainees in clinical and social sciences are invited to submit papers for consideration for the Charles Hughes and John Spiegel Fellowships. Fellowships cover meeting registration costs and a $500 award for travel and other expenses.

The Charles Hughes Fellowship is an annual award presented to a graduate student who has an interest in and commitment to cultural psychiatry and mental health. Graduate students in anthropology, public health, psychology, and related disciplines are encouraged to apply.

The John Spiegel Fellowship is an annual award presented to a medical student, resident, or fellow in clinical training who is dedicated to improving clinical care through culturally-­‐informed practice.

Trainees in these fields who are interested in competing for these fellowships should submit the materials listed below by September 15, 2014.

1. Cover page: A cover page should include the following information:

  • Identifying information (name, affiliation, contact information) of applicant.
  • Title of paper
  • Abstract, composed of three parts
    • 2–3 learning
    • Narrative abstract, up to 200 words
    • 1–3 related references

2. Unpublished scholarly paper: An original unpublished scholarly paper on a topic related to Culture and Global Mental Health. Key conference themes for culture and global mental health are listed below. Papers are limited to 8,000 words inclusive of abstract, references, and tables. The applicant must be the first author on the paper. Additional authors can be included. Affiliation and contact information should be included for any additional authors.

3. Biosketch: A 200-­‐word biographical sketch describing your professional training and activities related to culture and global mental health.

4. Statement of Professional Commitment: A 250–word statement about your interests and potential commitment to the mission of the Society for the Study of Psychiatry and Culture, and your vision for contribution to the organization.

5. CV: Your curriculum vitae.

The recipients of the Charles Hughes and John Spiegel Fellowships will present their papers in a plenary session at the annual meeting in Providence on April 23-­‐25, 2014. Recipients of the fellowships have all registration fees waived. An honorarium of $500 is provided to help defer travel, lodging, and related costs.

Please email all materials to Brandon Kohrt,

Conference Core Areas

The conference will center on five core areas, as well as cross-­‐cutting issues in culture and global mental health. Papers submitted for consideration should address one or more of these areas, based on clinical, teaching, or research work conducted by the applicant.

1. Origins and transformations of knowledge and practice in global mental health This core area incorporates epistemology and ontology in global mental health. How is knowledge generated, how are concepts defined, and which individuals and institutions have the power to define concepts in global mental health? What values influence and are reflected in global mental health priorities and praxis? What roles and power do mental health service users, other persons living with mental illness, families, and communities have in influencing global mental health activities? How do epistemology, ontology, and value systems influence what is measured and counted in global mental health through epidemiology, health economics, and other aspects deemed worthy of counting? Ultimately, how does knowledge move between the local and the global?

2. Human rights, ethics, politics, and policy Building upon issues related to values and powers influencing global mental health, this area explores how ethical, political, and rights-­‐based documents and doctrines influence global mental health. How do international policies, programs, and institutions (e.g., United Nations’ bodies, the World Health Organization, humanitarian organizations) frame human rights, and how is this reflected at local and national levels? How do ethical guidelines for clinical care, training, and research (or lack thereof) influence global mental health practice?

3. Social determinants of mental health and health care This theme traces how social and economic conditions and forces inform both mental health problems and mental health services. How do globalization, poverty, international development, health industry priorities, and political economy inform both problems and solutions in driving mental health problems and mental health practice?

4. Intervention development and cultural adaptation How are interventions selected, developed, and tested in global mental health? What constitutes an evidence base for selecting interventions? What is the process for cultural adaptation, and how are cultural adaptations unique (or not) compared to other types of adaptations? How do indigenous or local interventions, systems of medicine and sources of resilience fit with the aims of global mental health?

5. Scaling-­‐up, implementation, and knowledge dissemination How do interventions and practices go from proof-­‐of-­‐concept to large-­‐scale implementation? What and who are the powers that determine worthiness for scaling-­‐up and what benchmarks do they use? How is care implemented in a collaborative framework with other stakeholders ranging from primary care workers to partnerships with advocacy groups, mental health service users, families, and communities? How do objectives of cultural specificity and scalability impact one another?

In addition, there are cross-­‐cutting issues that may play a part in each of the above:

  • Knowledge transfer between and among low-­‐ and middle-­‐income countries (LMIC) and high-­‐ income countries (HIC) How are knowledge and lessons learned transferred from high to low-­‐resource settings and vice-­‐versa? How is knowledge transferred among low-­‐resource settings, e.g. South-­‐South collaborations?
  • Technologies This includes the use of guidelines (e.g., mhGAP, DSM, IASC guidelines), digital technologies (e.g., mobile phones, internet-­‐based communication platforms), and biotechnologies?
  • Stigma Stigma influences activities and programs from the level of clinician-­‐patient interactions to policy-­‐making and implementation.
  • Populations and predicaments For each of the areas, the specific populations should be defined. For example, are program beneficiaries defined by specific disorders, risk factors, or other context or health-­‐related factors?

Recommendations for Paper Submissions Papers submitted for consideration will be peer reviewed. Papers are judged on the following criteria:

1. Original contribution of the trainee – The paper should represent activities conducted by the applicant. First-­‐hand research, training, or clinical activities are required. This may include conducting interviews, ethnographic research, intervention implementation, clinical work, or other related activities. Papers with only secondary data analysis (either quantitative or qualitative) are not eligible for the fellowships.

2. Research or clinical question and contribution to the field – The research or clinical question should be grounded in the literature on global mental health and culture. The question should be novel and have implications for future research, training, and/or practice. The results of this study should be interpreted in light of the history of culture and mental health research, training, and clinical work. Other areas that will have a contribution to the field such as capacity building for beneficiary communities, providers in cross-­‐cultural settings, and advocacy groups could also be reflected in this score.

3. Ethical conduct – All research projects should include details on IRB approval from the applicant’s home institution as well as IRB approval from the country where research was conducted if the research was carried out outside the United States. Papers that do not have information on appropriate IRB approval will not be considered for review. For clinical cases, IRB approval is not required, but appropriate anonymization practices should be observed in documentation.

4. Methods/analysis – Projects demonstrating high levels of participation in design, implementation, and interpretation with the beneficiary community will be prioritized. Rigorous methods and analysis using best practices in qualitative or quantitative research in culture and mental health are recommended.

For qualitative methods – what type of theory was used for coding and theory building (e.g., grounded theory, interpretative phenomenological analysis, content analysis, etc.); was the selection of participants appropriate for a qualitative study; for ethnographic studies, how was participant observation incorporated into the design, etc.?

For quantitative studies – were culturally validated instruments used or was there a cultural validation as part of the study; was the sample representative with regard to recruitment and target population; were statistical analyses appropriate for this study design, etc.?

Instructions for Preparing Learning Objectives

Please make sure you use learning objectives, not teaching objectives. Teaching objectives state what you are trying to teach. Learning objectives are what you expect the attendee to know or be able to do after attending your presentation.

The objectives must use action verbs, which allow for the measurement of quantifiable outcomes. For example, At the conclusion of this presentation learners will be able to: (1) define what an action verb is and list three characteristics of it; (2) describe two reasons why educational objectives are important; (3) discuss the importance of action verbs in preparing measurable educational objectives.

An excellent reference for this task is Robert Major’s, Preparing Instructional Objectives, 3rd edition, available from if not at your local library. All individual papers must contain two or three learning objectives.

Instructions for Preparing Narrative Abstract Abstracts should be structured, and they should NOT exceed 200 words, excluding the objectives. Guidelines for preparing structured abstracts, though slightly more detailed than we require, can be found in the Archives of General Psychiatry’s Instructions to Authors section on preparing structured abstracts.

Abstracts for submissions classified as Research will include the following subsections: (1) Background, (2) Aims/Objectives, (3) Methods, (4) Results, and (5) Conclusion.

Abstracts for submissions classified as Education and Training, Clinical, Theoretical/Conceptual, or Policy will include the following subsections: (1) Background, (2) Aims/Objectives, (3) Proposition and Discussion, and (5) Implications.

For submissions and questions, please contact Brandon Kohrt, at For additional conference or SSPC information, please contact Roberto Lewis-­‐Fernández, Chairman of the Program Committee, at, or Liz Kramer, Executive Director, at or call her at (717) 848-­‐2978.

2015 FPR-UCLA Conference Announcement!

Save the Date!

FPR-UCLA Interdisciplinary Conference

A Critical Moment

Sex/Gender at the Intersection of Culture, Brain, Behavior

FPR-UCLA Interdisciplinary Conference

23–24 (Fri–Sat) October 2015

This conference occurs at a critical moment in sex/gender research in neuroscience, anthropology, psychology, and related disciplines. New theories are utilizing a conception of the brain as dynamic, plastic, and adaptable and of sex and gender differences in brain and behavior as subject to the influence of a broad range of biological, cultural, and social or environmental factors. In organizing this conference, our aim is to bring the neuro- and social sciences together to consider three cross-cutting questions on sex and gender: why now? what’s fixed/changing/changeable? what’s at stake?

DAY 1: Friday, October 23, 2015

PART 1: Why Now? Chair: Art Arnold, PhD, Director, Laboratory of Neuroendocrinology, Brain Research Institute, UCLA Session 1: Toward a More Integrated Approach to Sex/Gender: Biological, Cultural, and Historical Perspectives

PART II:  What’s Fixed, Changeable, CHANGING? Chair: Gilbert Herdt, PhD, Professor and Founder, Graduate Program in Human Sexuality, California Institute for Integral Studies Session 2: Evolutionary and Cultural Contexts of Sex/Gender Differences in Brain and Behavior

DAY 2: Saturday, October 24, 2015

PART II (Continued): What’s Fixed, Changeable, Changing?

Part III: WHAT’S AT STAKE? (“What makes a difference and why?”)

Chair: Carol Worthman, PhD, Samuel Candler Dobbs Professor of Anthropology; Director, Laboratory for Comparative Human Biology, Emory University

An Interview with Anthropologist Karen Nakamura

[This interview is cross-posted at and]

Science writer Karen A. Frenkel interviews anthropologist Karen Nakamura for the FPR.

Nakamura-informal Karen Nakamura is Associate Professor of Anthropology and East Asian Studies at Yale University. A cultural and visual anthropologist, her research focuses on disability and minority social movements in contemporary Japan. Her ethnography about sign language, identity, and deaf social movements, Deaf in Japan, was published by Cornell University Press in 2006. More recently, Nakamura has been engaged in a new project on the comparative politics of severe physical and psychiatric disabilities in the United States and Japan. While her main focus is disabilities and minorities, she also works on issues surrounding gender and sexuality.

Below, Nakamura discusses her new book, A Disability of the Soul, also published by Cornell University Press just this month. It is a fascinating portrait of Bethel, a community of schizophrenics living in Northern Japan. Chapters of the book alternate between profiles of Bethel members, and such topics as the history of psychiatry in Japan, Bethel’s founding, the role of religion, and the attending psychiatrist and his philosophy of treatment. Nakamura also produced two documentary films that accompany the book, one of daily life at Bethel, and the other of the funeral of one member. She describes her experience living at Bethel while researching her book and films – including how she prepared to live in the environment; her methods of observation; how doctors, staff, and patients themselves manage schizophrenia; how that compares with treatment in the West; concepts of “giving up hope” and “a life in decline,” and how her work at Bethel changed her.

KAF/FPR: How did you prepare to immerse yourself in the Bethel environment?

KN: The position of an ethnographer can be ambiguous, especially in clinical settings. We’re not patients/members/clients/family members and we aren’t staff/clinicians/nurses, although we mix with people in all of those categories. Because of our own educational backgrounds, it’s often easiest for anthropologists to focus mostly on interactions with professional staff. From the beginning, I wanted my project to approach Bethel from the ground up, from the perspective of the members rather than the staff.

One of the things that I didn’t do before going to Bethel was read a lot of clinical manuals. While I knew about the basic contours of schizophrenia (hallucinations, delusions, flattened affect, etc.) and the other mental illnesses that the Bethel members have, I didn’t want to consciously or unconsciously try to diagnose them.

While I went over to the doctor’s house from time to time, and spent a good amount of time with Mr. Ikuyoshi Mukaiyachi, a social worker at Bethel, my main interaction on a daily basis was with the Bethel members. I tried to adjust my own daily rhythm to theirs.

KAF/FPR: How does your book differ from other ethnographies about people living with mental illness?

KN: With a very few exceptions, such as Susan Estroff’s Making it Crazy, most ethnographies of mental illness have fallen into one of two categories: (1) clinical ethnographies of psychiatry and psychiatrists that look at the social construction of a particular mental illness; or, (2) person-centered ethnographies of an isolated individual with mental illness. A Disability of the Soul was designed as a community study, the type of village-level study that anthropologists used to do. I wanted to understand what made Bethel work. There are very few functional communities of independent people with mental illness, so I can understand why the ethnographic literature in this field is relatively limited.

KAF/FPR: Was there any resistance to your being a “participant observer” at first? If so, how did you overcome it?

KN: No, although I also avoided some of the people who had long been the focus of attention and were most probably quite tired of outsiders. For example, Kiyoshi Hayasaka, a Bethel member (OK to identify him that way? yes) wasn’t interested in yet another retelling of his life story, and didn’t necessarily want an anthropologist always hanging around waiting for the next sound bite. We’re good friends, but I think that was because I backed off of the participant/observation role and just related to him as a person.

KAF/FPR: Let’s talk about your interviewing and observation methods – if and how you modified them. Did you alter your usual way of working for this community?

KN: My first book, Deaf in Japan, looked at a social-movement organization and the social history of the deaf civil rights movement in Japan. I spent most of the time in the headquarters of the Japanese Federation for the Deaf in Tokyo or at their regular meetings.

A Disability of the Soul is really more of a community study. The town of Urakawa is quite small, so I would wander around (much like Bethel members), going to events or workshops, stopping by people’s homes.

KAF/FPR: In your book you explain that the goal for people with schizophrenia at Bethel is to accept their condition and to learn to live with it. How does this differ from current treatment elsewhere in Japan today and in the past?

NK: For most people with schizophrenia in Japan, the diagnosis of schizophrenia means a life sentence in the psychiatric ward of a hospital or secluded at home. Life is permanently interrupted for them as they occupy what sociologists call the ‘sick role’ — passively accepting their diagnosis and treatment, remaining optimistic about their prognosis, willing to give up other social roles, etc. The Bethel philosophy is to try to recover their social lives by working again, recreating social bonds, creating families, etc. There is no cure for schizophrenia, only medications that can dampen the symptoms (while causing side-effects of their own). It’s really the shift from seeing schizophrenia as a chronic mental illness to seeing it as a psychiatric disability.

KAF/FPR: How does it compare with current treatments in the West?

KN: The same recovery-based movement is visible in the United States as well, but it’s made considerably more difficult because of our lack of a good social welfare network and universal health coverage. In Japan, people with mental illness can access a living income, housing, and free health care. This makes the Bethel system possible in a way that’s still unimaginable for most in the United States.

KAF/FPR: Is the manifestation of schizophrenia and paranoia filtered by Japanese culture? In other words, do Japanese people with schizophrenia have different symptoms from their American counterparts?

KN: From my experience, not really. But I wasn’t interested in looking at the symptoms or diagnostic category as I was in how the community functioned.

KAF/FPR: What are the three most interesting or unexpected things you learned from Bethel about learning to live with schizophrenia?

KN: The related concepts of “giving up hope” and “a life in decline” were the most difficult for me to grasp. I still struggle to view them positively. Hope is such a powerful motivator and upward mobility such a core element of contemporary society. Given that there is no cure for schizophrenia and many Bethel members die quite young from the side-effects of the illness, comorbid conditions, or the side-effects of medications (prescribed or self-administered), I can see why the philosophy of “a life in decline” is a more realistic prognosis than saying that one could regain one’s position in the rat race of Japanese society. It relieves a great deal of pressure from Bethel members, but still…. I have trouble with the concept that this isn’t just about giving up.

KAF/FPR: I am fascinated by two ideas that you discuss in your book: (1) Community members share what their voices say so that they know they are not alone and can benefit from others’ interpretations. (2) The doctor does not believe in eradicating their illness, but rather facilitates learning to live with the disease. There is no notion of cure.

Are there analogous ideas in other cultures with regard to diseases or syndromes?

KN: (1) Hallucinations and delusions follow regular patterns. UFOs land regularly in Urakawa. Invisible people are quite frequent. But, symptoms of schizophrenia are often episodic, so members can learn to recognize when the symptoms are flaring up in other members, and then apply that self-understanding to themselves. The Doctor likes to say that Bethel members are the main experts in (“on,” or is this on purpose? Note sure about the right grammar: They are experts in themselves (their own background and history) and their own particular symptoms) themselves. This is quite contrary to most clinicians who believe that people with schizophrenia have low self-awareness. Insight is possible if the appropriate social conditions are created. (2) One parallel is between the shift from understanding deafness as an auditory condition to deafness as a culture.

KAF/FPR: The head psychiatrist seems very charismatic and the community itself is quite insular. What ideas about mental illness or methods of treatment might carry over to the United States?

KN: The close working relationship between the hospital, the town social workers, and the Bethel organization is quite unique, even in Japan. Still, even though the social welfare system is fraying in Japan because of the prolonged recession, there are enough services to make something like Bethel still function.

I’m quite pessimistic about the future of mental health care in the United States. Most proposals for mental health reform have followed mass shooting incidents, and have thus focused on greater surveillance and institutionalization, not for improved treatment in community-based programs. There are, and have been, experimental programs in community-based care in the United States, but they have been under attack by fiscal conservatives.

KAF/FPR: What is your greatest hope for the influence of your book and films?

KN: That it will make people stop and think. Given that schizophrenia and other severe mental illnesses manifest in people’s late teens or early twenties, I hope that my book is read by college students, who will push their schools for better accommodation for students with mental illness.

KN: That it will make people stop and think. Given that schizophrenia and other severe mental illnesses manifest in people’s late teens or early twenties, I hope that my book is read by college students, who will push their schools for better accommodation for students with mental illness.

KAF/FPR: How have you changed as a result of your study of Bethel?

KN: I’m half a decade older and my body and mind are definitely in decline (smile). I’ve learned to accept more of myself as I am and not to punish myself for my self-perceived failings. In that regard, I really appreciate the Bethel philosophy. But I am also much sadder. I’ve made many lifelong friendships at Bethel, but some of those people have also died much before their time.

Karen A. Frenkel is a journalist, editor, and author who covers science and technology and their impacts on society.

Further resources:

A trailer for Bethel: Community and Schizophrenia in Northern Japan

DSM-5 on Culture: A Significant Advance

[A]ll forms of distress are locally shaped, including the DSM disorders.

– DSM-5 (APA, 2013, p. 758) 

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders  (DSM-5; APA, 2013) was finally presented on May 18th at the American Psychiatric Association’s annual meeting in San Francisco. Much ink has been spilled in the media about the ten-year process leading up to last month’s unveiling. But there has been virtually no mention of the fact the DSM-5 is a vast improvement in its treatment of culture. It reflects a much more inclusive description of the range of psychopathology across the globe, not just the particular constructs or exemplars most commonly encountered in the US, Western Europe, and Canada. I think the cultural component of DSM-5 has the makings of a model on which subsequent versions of the manual should be based.

What follows is a summary of a few talks that were given at the annual meeting of the Society for the Study of Psychiatry and Culture on May 3–5 in Toronto outlining the changes.

According to cultural psychiatrist Roberto Lewis-Fernández (Columbia University), “including information on cultural concepts of distress in DSM-5 will enhance the validity and clinical usefulness of diagnostic practice” across the board. Lewis-Fernández began his talk by briefly describing the limitations of DSM-IV-TR, which listed twenty-five “culture-bound syndromes” in an appendix. The use of the term “culture-bound” made these conditions appear highly localized and confined, a cabinet of curiosities. The list was also heterogeneous, Lewis-Fernández continued, some “syndromes,” including nervios, seemed to represent specific situational predicaments, or variations in the way people express their distress, rather than coherent collections of symptoms. Other expressions, such as ataque de nervios, are syndromic, but do not always represent psychopathology. Still others (like shenjing shuairuo or ‘neurasthenia’) appeared to be a cover term for several common, but seemingly unrelated, human ailments (e.g., fatigue, dizziness, headache, GI problems, sexual dysfunction, excitability); another group of conditions simply defied DSM categorization, such as mal de ojo (‘evil eye’).

Under the direction of Kimberly Yonkers and Lewis-Fernández, chair and co-chair respectively of the Gender and Cross-Cultural Issues Study Group, DSM-5 is a vast improvement. The new volume is divided into three sections – Section 1: Introduction (“DSM-5 Basics”); Section II: “Diagnostic Criteria and Codes”; Section III: “Emerging Measures and Models” – and an Appendix, which includes a “Glossary of Cultural Concepts of Distress.” Section III includes a chapter on cultural formulation, featuring an updated version of the outline introduced in DSM-IV as well as an approach to assessment, using the Cultural Formulation Interview (CFI). The chapter also includes a section discussing “Cultural Concepts of Distress” (pp. 758–759).

As Lewis-Fernández explained, the notion of “culture-bound syndromes” has been replaced by three concepts: (1) cultural syndromes: “clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts . . . that are recognized locally as coherent patterns of experience” (p. 758); (2) cultural idioms of distress: “ways of expressing distress that may not involve specific symptoms or syndromes, but that provide collective, shared ways of experiencing and talking about personal or social concerns” (p. 758); and (3) cultural explanations of distress or perceived causes: “labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress” (p. 758).

Lewis-Fernández used depression as an example of a cultural concept. For western clinicians, major depressive disorder (MDD) can be considered a “syndrome,” or cluster of symptoms that appear to “hang together.” But depression can also be considered an “idiom of distress,” in the sense that westerners commonly talk of feeling depressed in everyday life. Finally, the label depression can imbue a set of behaviors with a particular meaning. No single concept maps onto a specific psychiatric disorder, and, conversely, no single psychiatric disorder (e.g., MDD) maps onto a cultural concept (e.g., nervios). In all, the glossary lists nine of  “the best-studied concepts of distress around the world” – ataque de nervios (‘attack of nerves’), dhat syndrome (‘semen loss’), khyâl cap (‘wind attack’), kufingisisa (‘thinking too much’), maladi moun (lit. ‘human caused illness’), nervios (‘nerves’), shenjing shuairuo (re-glossed as ‘weakness of the nervous system’), susto (‘fright’), and taijin kyofusho (‘interpersonal fear disorder’).

In practice, according to Lewis-Fernández, “each illness has to be assessed in its own right” and both the practitioner’s expertise and epistemological assumptions and the individual’s understanding of the illness should apply. That is, the clinician must not only draw from diagnostic experience, available categories of illness, and the various dimensions along which aspects of the illness may range, but also recognize and try to understand each individual’s anomalous experience. Furthermore, he said that nosology “has to be constantly evolving” due to “cultural variation over time in the way that psychopathological experiences are constructed.” But the information provided throughout DSM-5, and particularly in the cultural formulation chapter should help practitioners avoid misdiagnosis, obtain clinically useful information, improve clinical rapport and therapeutic efficacy, guide research, and clarify cultural epidemiology.

Lewis-Fernández sketched the structure of the Cultural Formulation Interview (CFI), which is also included in Section III. The CFI is a semi-structured interview composed of 16 questions that focuses on individual experience and social context (the objective is to assess cultural factors using a person-centered approach). The text is divided into two columns, with questions on the right and instructions on the left. Two versions are available, one for the individual and one for an informant, such as a family member or caregiver. (The interviews are available online at There are also 12 Supplementary Modules to the CFI, which provide additional questions to flesh out domains assessed briefly in the 16-item CFI (e.g., cultural identity) as well as questions that can be used during the cultural assessment of particular groups, such as children and adolescents, older adults, immigrants and refugees, and caregivers.

Lewis-Fernández also described how the glossary works using ataque de nervios as an example. Briefly, ataque is a syndrome characterized by “intense emotional upset, including acute anxiety, anger, or grief; screaming and shouting uncontrollably; attacks of crying; trembling; heat in the chest rising into the head; and becoming verbally and physically aggressive,” or otherwise feeling out of control (p. 833). (Ataque, like depression, also qualifies as an idiom of distress and an explanation.) The entry in the glossary cross-references related conditions in other cultural contexts and in the main text of DSM-5 (e.g., panic disorder). Conversely, a section in the entry under “panic disorder” in Section II of the volume (“Culture-Related Diagnostic Issues,” pp. 211–212) describes ataque and refers the reader to the glossary. In this way, clinicians are alerted to culture-related features of DSM prototypes in the main text and in more detail in the glossary. The cross-referencing, absent in DSM-IV, should enhance the ability of the clinician to diagnose syndromes in an appropriate cultural context.

In closing, Lewis-Fernández said that further research must continue to improve the international applicability of DSM by exploring the range of cultural variation (such as the nine examples provided in the glossary) and making revisions. The objective is that DSM-5 and subsequent versions reflect a more inclusive description of the range of psychopathology across the globe, not just the particular constructs or exemplars most commonly encountered in the US, Western Europe, and Canada.

In the next talk, psychiatrist-anthropologist Devon Hinton (Harvard Medical School) discussed the glossary in more detail, using khyâl cup (‘wind attack’) as an example. He began by saying that the purpose of the “thick, more detailed” descriptions in the glossary is to increase the effectiveness of assessment by encouraging greater consideration of cultural concepts of distress and their role in understanding how something akin to, e.g., “panic disorder” might be expressed, understood, and treated in particular settings. For instance, he continued, work on khyâl indicates that an episode can generate catastrophic cognitions about panic attack symptoms that create pernicious feedback loops, which have to be addressed. (Similarly, the dissociation frequently experienced during an initial ataque may lead to more dissociative episodes in response to stress.) The entries in the glossary “are not just distractions but key parts of local ontologies that need to be evaluated.” In other words, thinking through the three concepts or dimensions (cultural syndrome, cultural idiom of distress, and cultural explanation) is clinically useful for a “rich” diagnosis (Parnas & Gallagher, forthcoming).

A khyâl attack is a syndrome found among Cambodians. Symptoms include palpitations, dizziness, shortness of breath, and neck soreness, the triggers for which might be worry, fright, standing up, riding in a car, or going into a crowded area. The attack also includes catastrophic cognitions related to the symptoms that create pernicious loops (fear of the symptoms amplifies the symptoms and consequently the fear). The point, according to Hinton, is that khyâl attacks are not just labels; more generally, cultural syndromes are “key ways in which realities (the body, social worlds) are experienced, and they profoundly shape how anxiety and other disorders play out in particular contexts.”

It is important to note that these attacks include other co-occurring symptoms that “you don’t usually see in Americans with panic attacks, or we don’t ask about at least, such as soreness of the joints, neck soreness, tinnitus, and also headache and a feeling of being out of energy.” In part this is because, according to the Cambodian understanding of the physiology underlying an attack, khyâl (a windlike substance that flows along with blood throughout the body) is suddenly flowing up toward the heart, lungs, and neck. The lack of downward flow of khyâl and blood causes hands and feet to grow cold, and possibly stroke; and as the khyâl and blood flow upward, they may potentially stop the heart or burst the neck vessels before the khyâl exits from ears or eyes (which causes the related tinnitus or blurry vision). A khyâl attack can be mild, moderate, or severe. Degree of severity is determined during the course of treatment, typically coining (the streaks can range from light red to a more serious dark purple). The coining is also a way to remove blockages and restore the flow of khyâl and blood; it can create a warming effect, which is considered curative because it means khyâl is travelling out through the streaks left by the edge of the coin on the skin.

Hinton’s final point was that every symptom that clinicians might associate with an anxiety attack is “read according to the local ethnophysiology of khyâl.” As one example, fear of khyâl overload makes Cambodians hyper-vigilant to any sensation they may feel on standing, especially if they haven’t slept at night or haven’t been eating well, he added, “so you can see how these panic cycles can happen.”


One comment at the close of the session by cultural psychiatrist Laurence Kirmayer particularly resonates: The DSM-5’s cultural revisions challenge “the fundamental logic of psychiatric nosology”– i.e., “describing problems located inside peoples’ heads” – which is at odds not only with the fact that “when we start talking about languages and suffering . . . we are embedded in social networks and interpersonal relations and local worlds,” but with new work in social and cultural neuroscience and social genomics that illuminates how social factors, like childhood adversity, social isolation, migration, and stigma, affect mental health and illness.

The cultural aspect of DSM-5 signifies a richer diagnosis for people “living under the description of” a psychiatric disorder, in the words of Emily Martin. And, as Roberto Lewis-Fernández and Devon Hinton’s work on ataque de nervios and khyâl has shown, identifying the right cluster has major implications in terms of helping to elucidate the complex interactions of mechanisms  – physiological, psychological, and social – and their various feedback loops.

3×5: Culture, Neurosci, Psychiatry Roundup – fMRI, Ian Hacking, A Historic Exchange (Bateson, Wiener, von Neumann)


Russell Poldrack (UT Austin) discusses the use of fMRI in cognitive neuroscience and the more recent focus on brain connectivity on UT San Antonio’s Neuroscientists Talk ShopRegarding fMRI, one of the issues he mentions is that the brains of, say, Chinese speakers and English speakers, look far more alike than expected due to the method’s high threshold for significance (see Lieberman & Cunningham, 2009 on Type I and Type II error concerns in fMRI research).

The opposite problem seems to occur in resting-state fMRI. Micah Allen has an insightful post on some possible confounds (“Is the resting BOLD signal physiological noise? What about resting EEG?”).

What’s the best tool for studying psychopathology? Is HCP the answer? Here’s a useful roundup of studies focusing on structural and functional connectivity which appeared in Barch et al. (2013): autism (Vissers et al., 2012), schizophrenia (Fitzsimmons et al., 2013Fornito et al., 2012Repovs et al., 2011 and Whitfield-Gabrieli and Ford, 2012), ADHD (Fair et al., 2012) mood disorders (Hulvershorn et al., 2011 and Strakowski et al., 2012), addiction (Sutherland et al., 2012),

Ian Hacking on Autism

Many thanks to The Center for Medical Humanities for posting a link to a podcast available on the British Society for the History of Science website featuring Ian Hacking: “Making Up Autism,” Inaugural C. L. Oakley Lecture in Medicine and the Arts, University of Leeds (May 13, 2013).

Ian Hacking’s website includes a list of related publications (see “The Making Up People Project“).

The First Macy Conference

Anthropologist Emily Martin (@hanmuli) via Somatosphere has unearthed a fascinating paper by Steve Heims that gives us a sense of the synergy at the first Macy conference (“Teleological Mechanisms”). The interdisciplinary Macy conferences (1946–1953) allowed scientists and scholars time and space to discuss mechanisms underlying biological and social systems and develop a common language (they were also the inspiration behind the FPR).  The first conference in 1946 brought together Gregory Bateson (cultural anthropology) and mathematicians John von Neumann (game theory) and Norbert Wiener (cybernetics). The Heims paper ends with a really lovely paragraph about Norbert Wiener. We need more peripatetic interdisciplinary geniuses like NW and Ian Hacking!

Wiener’s humane reflections and moral decision was one part of his public role. Another was his heralding, recognition, and interpretation of a new era: the era dominated by the concerns and the technology of communication, control, information, and organization. This recognition and interpretation of the present era was imbedded in and supported by a rich texture of historic and philosophical insight and a wide-ranging familiarity with contemporary science and high technology; morever, it was presented with literary fluency, style, and passion. His public function had become not that of a “mere” scientist, but that of an intellectual, an original thinker about the state of our society and civilization, one who also had a first-hand acquaintance with science and technology. Without that first-hand knowledge, he would not have been nearly so convincing. At MIT he came to play the role of peripatetic interdisciplinary genius, wandering from department to department, bending any willing listener’s ear with ideas, concerns, and suggestions, which might deal with topics in mathematics, physics, biology, engineering, psychology, or philosophy. Often, however, they dealt with humane and human concerns.


Allen, M. (2013, May 16).  Is the resting BOLD signal physiological noise? What about resting EEG? [Blog post]. Retrieved from

Barch et al. (in press). Function in the human connectome: Task-fMRI and individual differences in behavior. NeuroImage. Available online 16 May 2013.

Burklund, L., & Lieberman, M. (2011). Advances in functional neuroimaging of psychopathology. Philosophy, Psychiatry, & Psychology, 18(4), 333–337.

Heims, S. P. (1977). Gregory Bateson and the mathematicians: From interdisciplinary interaction to societal functions. Journal fo the History of the Behavioral Sciences, 13, 141–159. Heims_1977.pdf

Lieberman, M. D., & Cunningham, W. A.  (2009). Type I and Type II error concerns in fMRI research: Re-balancing the scale. Social Cognitive and Affective Neuroscience, 4(4), 423–428.

Poldrack, R. (Guest). (2013, March 7). Episode 96 [Audio podcast]. In Neuroscientists talk shop. Retrieved from


From Vera Keller, “The ‘new world of sciences’: The temporality of the research agenda and the unending ambitions of science”

The notion of intellectual voyaging has persisted, although desiderata have fundamentally changed. They now include lists of already extant mundane objects (such as specimens and books), which Bacon would never have considered desiderata. Philosophers still also compose ambitious epistemic desiderata, which for some play a central role as goals toward which scientific inquiry continually advances.22 Perhaps most novel, and most at odds with Bacon’s intentions, has been the recent evolutionary concept of “biological desiderata.” Biological organisms, parasites, and even parents and children have sometimes coinciding and sometimes conflicting desiderata lists. Such lists are dictated by the inexorable if nonteleological demands of reproduction, not by conscious human authorship, and they are fulfilled not by collaborative human effort but by genetic code. Rather than a means to unite humankind against nature, the concept of desiderata now divides individual organisms, both from each other and from human-authored cultural and moral goals.23


The “New World of Sciences, or Desiderata” envisioned by Bacon has changed beyond recognition. However, its former shape contributed to the idea of interlocking research specialties moving forward in concert. Researchers continue to conceptualize the advancement of knowledge as a process of filling in the gaps of scholarly literature. But advancement toward what? For Bacon, a new world lay at the end of the journey. Failure to reach that world has bequeathed to us the idea of unending advance. The edge of the horizon always retreats before us, and knowledge remains continually at sea.


Understanding Pain: Cultural, Neuro, Philosophical Perspectives (Roundup)

I’ve come across a lot of interesting material about pain –how we process our own pain experiences as all as those of others – and now the topic is so sadly present in the news. Here’s a quick roundup to keep track of some of the issues being considered/discussed/investigated, e.g., our “deep,” or embodied, ability to simulate others’ pain; the neural overlap between physical and social pain experiences; the frequent (clinical) cultural de-medicalization of patients’ descriptions of pain; and the tensions or paradox of pain experiences (from a philosophical perspective). Overall, we have an extraordinary capacity to feel others pain and to lighten it; it’s likely that our best selves emerge in this process. Continue reading