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

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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.

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

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

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

Deadline: August 3rd, 2012

Panel LD36: Ethnographic perspectives on ‘global mental health’

Conveners

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

Short Abstract

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

Long Abstract

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

How are GMH policies deployed in diverse locales?

What are the effects of these policies on local populations?

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

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

How does this approach mould health-seeking behaviours?

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

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

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

Best wishes,

Sumeet Jain & David Orr