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 psychiatry.org/dsm5.) 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.

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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 (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.

Psychiatric Neuroscience, Stigma and the Aging Brain: Dispatch from the Annual Meeting of One Mind for Research

A few weeks ago I attended the first annual meeting of the One Mind for Research Campaign: Curing Brain Disease. (The group’s new CEO is Ret. General Peter Chiarelli, the commanding officer of the 1st Cavalry Division during the Iraq War, and you could practically taste the battle dust in your mouth at the end of the 3-day offensive to eliminate brain disease and its stigma within 10 years.) The meeting, which included NIMH director Thomas Insel, former NIMH director Steven Hyman, and American Psychiatric Association newly elected president John Oldham, featured sessions on the latest psychiatric neuroscience, stigma, and the aging brain. Here are some highlights:

Heterogeneity

One non-surprising take-home message is that psychiatric disorders are not only heterogeneous but many (most?) may eventually be best characterized at the level of circuits/systems. Regarding heterogeneity, the consensus among several speakers was that patients classified as having one illness or another should be further “stratified” as much as possible in order to treat with different neurodeficit-specific compounds  (which is interestingly contrary to some of the proposed changes to DSM-5, such as lumping Asperger’s and Autism, or eliminating subtypes of schizophrenia). UPDATE (8/24/12) This statement requires clarification. The elimination of subtypes in schizophrenia (paranoid, disorganized, catatonic, undifferentiated, etc.) is due to the belief that the disorder’s clinical heterogeneity may be best understood by using a single diagnosis with distinct symptom “dimensions” of psychopathology – hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, negative symptoms (restricted emotional expression or avolition), impaired cognition, depression, mania – each of which, it is proposed, would be measured on a 4-point severity scale. But it’s important to note that these dimensions, or “domains,”  will “cross diagnostic boundaries” introducing a new set of challenges, especially for drug development (Carpenter, 2012).

Here’s an example of why categories can be confounding. Rene Hen gave a fascinating talk on a hippocampus-related process – pattern separation, the way in which our brains are able to reduce “the average overlap between two representations, thus making similar representations more distinct or orthogonalized in order to afford rapid learning without inducing interference and retrieval errors,” which is balanced by pattern completion. Pattern separation is impaired in PTSD as well as schizophrenia.

Connectivity

But I noticed that interest in the intermediate phenotype concept prevalent in psychiatric neuroscience literature during the last decade is now accompanied by an interest in big science, e.g., fresh efforts (reminiscent of Galen’s rete mirabile) to understand structural and functional connections within and across regions of the brain that are, also, exquisitely sensitive to environmental interactions. And this has significant treatment implications. As Emory fear scientist Kerry Ressler remarked, “we have to change how we think about therapy, the brain is not a bag of molecules that can be treated by a drug.”

MIT computational neuroscientist and TED pundit Sebastian Seung (“I am my connectome”) has received a lot of attention in the popular press recently for his work on the connectivity of individual neurons. (According to Seung, the dynamic or functional connectivity of neurons and the white-matter structural “connectome” interact in much the same way water rushing down a mountainside and the terrain over which it flows do.) But one of the most exciting sessions at the conference featured the work of Olaf Sporns and colleagues, who are focusing on structural and functional connectivity at the macro-scale, based on the concept of brain networks. These investigations rely on diffusion imaging (for structural connectivity) and resting state fMRI (for functional connectivity). In his talk, Sporns likened these anatomical connections to complex social or other kinds of networks that exist in the world. (“A common language is emerging,” said Sporns, one that is able to link network interactions within and across multiple levels of organization, which he referred to as “network science.”) Focusing on these interactions seems a little more doable than trying to link objective biomarkers to subjective experience (which Vaughan Bell of Mind Hacks likened to counting commas in a poem).

In the same session, William Seeley gave a fascinating talk on the connectional architecture of neurodegeneration in brain disorders, including Alzheimer’s, each of which has a distinct pattern. His group found, for example, that resting-state connectivity patterns of healthy brains related to episodic memory using fMRI mirrored the atrophy patterns in Alzheimer’s as the disease progressed from the medial temporal lobe to the neocortex. (The more radical idea (that may be reappearing in the science), another speaker said, is that these disorders are connectopathic and initially triggered by rogue proteins.) Here’s a link to the relevant Neuron 2012 paper.

 Stigma

In the session on stigma, Elyn Saks (USC), author of The Center Cannot Hold, discussed the “positive, negative, and cognitive” dimensions of schizophrenia, in regard to the latter dimensions specifically referring to short-term memory, visuo-spatial abilities, etc. She discussed how she was able to balance borderline impairment in some areas of cognition, e.g., short-term memory, by leveraging her strengths and “passed” for many years in academia as “normal.” During the talk I was struck by Dr. Saks’s certainty that psychotherapy is the reason for her lack of negative symptoms, which made me wonder, just how correlated are these symptoms with a person’s level of social disconnection? (The social neuroscience in this area by Naomi Eisenberger – who just published a review in Nature – and others relating social disconnection to some of the same pathways as physical pain is really interesting in this regard.)

Unfortunately, stigma is “alive and well,” according to sociologist Bernice Pescosolido, who spoke eloquently around the depressing fact that despite huge leaps in scientists’ neurobiological understanding of mental illness, despite the disappearance by the rest of us into what Mary-Jo DelVecchio Good calls the “biotechnical embrace” re matters of the mind, there has been virtually no change in Americans’ level of prejudice regarding persons whom NYU anthropologist Emily  Martin refers to as living under the description of a mental disorder. We just don’t believe it’s a disease like any other, and if you or your family have the rotten luck to be on the receiving end, this adds astronomically to the confusion, anxiety, and fear about which neuroanthropologist Greg Downey has so eloquently written ( “Slipping into Psychosis”).

Alzheimer’s and the Fountain of Youth

But I don’t want to end this post on such a depressing note. Stanford researcherTony WyssCoray discussed the importance of not seeing the brain as an isolated organ. His group is studying the effects of stress, inflammation, and other environmental insults on brain function. In one experiment, the investigators infused the blood of young mice into old mice, and there were many positive effects in terms of neurogenesis, increased synaptic activity, increased spine density, reduced neuroinflammation, and improved spatial memory. (This announcement initiated a small wave of mouse jokes.) A brilliant neuroscientist sittling behind me said in a vaguely accented English (seriously) that it would be a difficult and expensive process to determine which substances within the blood to focus on; in the meantime, why not just transfuse old people with young people’s plasma? This is precisely what John Huston, playing a Joseph Kennedy-esque character, does in the movie Winter Kills (“I get it from the kids up at Amherst”). As the general concluded, “What I’ve learned among other things is that, THIS IS A GOOD TIME TO BE A MOUSE.”

3×5: Culture, Neuroscience, and Psychiatry Weekly Roundup (May 21)

My five favorite reads for week of 14–21 May 2012:

Culture

1. Greg Downey of Neuroanthropology: “Not Allowed to Have a Small Heart: Tourette Syndrome.” May 15 – June 15 is Tourette Syndrome Awareness Month and Greg has written a beautiful post about the neuropsychiatric disorder, which includes a review of Rob Lemelson’s deeply moving ethnographic film, The Bird Dancer.

2. Science historian Eric Michael Johnson’s Behind the TIME Cover: Most Human Societies Don’t Get Our Breastfeeding Hangup.

3. The Miami Herald also weighs in on the Time cover with a well-sourced commentary: “Did Cave Babies Have Attachment Parents” for which they pay thanks to Katherine Dettwyler of the University of Delaware and co-editor of Breast-Feeding: Biocultural Perspectives, Katherine Hinde of Harvard University and author of the blog Mammals Suck, and Meredith Small of Cornell University and author of Our Babies, Ourselves: How Biology and Culture Shape the Way We Parent.

4. The research of psychologist Carol Ryff, a speaker at our next Culture, Mind, and Brain conference, is featured in a piece by science journalist and biopsychologist Alice Walton in The Atlantic: “What We Know About How to Be Happy.”

5. Biocultural anthropologist Kate Clancy has a great post on her SCIAM Context and Variation blog about why we shouldn’t prescribe hormonal contraception to 12-year-olds.

Neuroscience

1. Edward Bullmore and Olaf Sporns’s “The Economy of Brain Network Organization” in the May 2012 issue of Nature Reviews Neurosience. 

2. Also, in Frontiers in Psychiatry, Alex Fornito and Edward Bullmore recently discussed the possibility of “connectomic intermediate phenotypes for psychiatric disorders.”

3. Fascinating PNAS paper on maternal stress and affective problems (“Maternal cortisol over the course of pregnancy and subsequent child amygdala and hippocampus volumes and affective problems“) by Buss et al.

4. Also in PNAS, emotion related circuitry in young children (I recently heard one of the co-authors,  Lucina Uddin of Stanford, give an interesting talk about functional connectivity with implications for autism at UCLA): http://www.pnas.org/content/109/20/7941.short?rss=1.

5. Finally, there is a great review on shared neurosubstrates by Naomi Eisenberger in the June 2012 issue of Nature Reviews Neuroscience:  “The pain of social disconnection.”

Psychiatry

1. China Daily discusses the country’s shortage of mental health services.

2. New England Journal of Medicine has a commentary by Paul McHugh and Phillip Slavney on the DSM (“Mental Illness – Comprehensive Evaluation or Checklist?”).

3. Jones, Rahman, and Everitt’s fascinating paper on psychiatric diagnosis at Maudsley Hospital 1924-1935  in latest History of Psychiatry  is about an era “before classification systems were tested for reliability” and “diagnosis was fluid, reflecting changing hypotheses about causation, pathology and treatment.”

4. In case you’re thinking of buying, here’s a pdf of Catharine Coleborne’s review of Waltraud Ernst and Thomas Mueller’s Transnational Psychiatries: Social and Cultural Histories of Psychiatry in Comparative Perspective c. 1800-2000.

5. Finally, in response to my post on the DSM-5, George Dawson suggested I read Justin Marley’s passionate rebuttal of Edward Shorter’s blog post in SCIAM. I did before and have done so again! I’d recommend both (but I’m totally Team Shorter on this)  – as well as the McHugh & Slavney commentary in NEJM mentioned above.

Bonus

Beneficial neural effects of bilingualism http://www.pnas.org/content/109/20/7877.short?rss=1

DSM-5: Plus ça change …

UPDATE 5/17/12: Psychiatrists Paul McHugh and Phillip Slavney’s “Mental Illness – Comprehensive Evaluation or Checklist?” [perspective] in New England Journal of Medicine.

John Gever of MedPage Today, has done a terrific summary of the proposed changes to the DSM (“DSM-5: What’s In, What’s Out“).

The umpteenth person just described the DSM-5 process to me as a major rehaul. Is it? Aside from the changes in how we want to sort the world of persons living with psychiatric disorder (and everyone would agree it’s still a flawed taxonomy as long as we don’t understanding cause), there are two interesting developments that presage better things to come for the next next edition.

The first is the inclusion of cross-cutting dimensional assessments ranging from normal to pathological (consider Tanya Luhrmann’s work on the experience of “hearing voices” in her new book, When God Talks Back). As Gever explains:

These are indicators of severity for certain symptoms. They may be common “cross-cutting” features that appear in conjunction with many disorders, such as suicide risk and anxiety. Or they may be specific to a particular disorder, such as the frequency of flashbacks in PTSD.

The second is the use of biomarkers for sleep-related disorders like narcolepsy.

Many sleep-wake disorders in DSM-5 will require polysomnography for a diagnosis. Also, narcolepsy is set to become narcolepsy/hypocretin deficiency, with the latter condition diagnosed on the basis of hypocretin measurements in cerebrospinal fluid.

Otherwise, as historian Edward Shorter argues in a 5/9 sciam blog post. nothing has essentially changed.

According to Shorter, the main difficulty is that the principal diagnoses of psychiatry are “artifacts.” He goes on to discuss major depression, schizophrenia, and bipolar disorder, specifically. All of these disorders are loosely grouped clusters of symptoms for which we currently lack causal explanations. (The interesting exception is melancholia, which doesn’t appear in the current DSM but which may well be an actual category of illness rather than composed of something that can be ranged along a continuum.)

This matters because, Shorter writes, “[y]ou can’t develop drugs for diseases that don’t exist.”

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.”