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Anth 207.12 Pathology and society: dissociation, schizophrenia, Tourette
Transcript of Anth 207.12 Pathology and society: dissociation, schizophrenia, Tourette
Macquarie University Schizophrenia dissociation tourette syndrome http://farm5.staticflickr.com/4024/4469199938_2864f16378_z.jpg?zz=1 Illustration by Ronan Honorato Sene, 2010 'Sonho e tempo' http://farm3.staticflickr.com/2713/4447349610_35d51c44b1_z.jpg?zz=1 Illustration by Ronan Honorato Sene, 2010 'Esquizofrenia' http://neerascience.files.wordpress.com/2012/03/schizo-cats.jpg Paintings by Louis Wain, later institutionalised. http://www.tfaoi.com/cm/2cm/2cm509.jpg Zelda Fitzgerald, Mad Tea Party http://www.tfaoi.com/cm/2cm/2cm510.jpg Zelda Fitzgerald, Times Square http://www.sdcitybeat.com/sandiego/imgs/media.images/4468/Beautiful-Begending.widea.jpg "Beautiful Begending" by Michael Carini https://www.youtube.com/watch?v=kj_F9yRpx_M http://www.fas.harvard.edu/~anthro/social_faculty_pages/images/kleinman_arthur.jpg http://farm4.staticflickr.com/3530/3856354939_bf81593823_z.jpg Koro (genital retraction syndrome) Advances in effective psychiatric treatment of specific disorders and recognition that clusters of symptoms and signs have the same prognosis not surprisingly encourage the view that depression, schizophrenia, and phobias are “things” in the real world. (Kleinman 1991: 11) Arthur Kleinman Is the prognosis for someone with schizophrenia different in the developing world? The existence of concept of 'schizophrenia' (a permanent condition, based on brain defect) may work against recovery. Does demand for autonomy make condition worse? Are there social roles for individuals with psychiatric problems? How do family members treat individuals with psychiatric problems? Do families participate in or support recovery and how? Psychiatric condition characterised by disordered thought & poor emotional responses. Often accompanied by auditory hallucinations, paranoia or bizarre delusions (beliefs), confused thinking & speech and significant social and occupational problems. Combination of 'positive' symptoms (delusions, paranoia) and 'negative' symptoms (blunted affect, lack of motivation & little desire to form social relations). Pathoplasticity Culture has an impact on symptoms. Tanya Luhrmann In the US, individuals heard horrible voices telling them to commit suicide & describing monstrous acts. In Accra, Ghanna, individuals heard good voices telling them to ignore the bad voices; some said voices helped them to 'survive'. In Chennai, India patients heard the voices of close kin telling them to get up & clean up; the voices kept them company & even had playful relationships. Luhrmann argues that the understanding of the mind & the condition affect recovery: In the West, 'mind' as seen as private; hearing voices is a clear sign you are 'crazy,' so people fight to suppress them. In contrast, in Ghanna, hearing voices considered normal & the self is seen more as a moral project (having good thoughts). The condition considered to be a 'spirit attack.' In Chennai, the self is understood to be relational, & symptoms considered to be the effect of stress. http://scs.viceland.com/int/v15n2/htdocs/penis_panic/main_large.jpg Photo by Dr. Wolfgang Jilek from the Malay-Indonesian word for 'tortoise.' anxiety, fear of penile retraction leading to death (Asia) or loss of sexual potency (Africa) & measures taken to prevent retraction. cases in Asia and Africa. 'culture bound syndrome' in some African cases, a belief penis has been 'stolen.' cultural effects on psychopathology pathogenic: causing particular pathologies pathoplastic: influences symptoms pathoselective: affects particular groups of people. pathoelaborating: reinforcing particular symptoms. pathofacilitative: culturally prone to particular disorders. pathodiscriminating: defining deviant conditions. Expressed emotion & relapse families with high expressed emotion often have higher rates of relapse into schizophrenia. Hostility, disappointment, critical comments, judgment, emotional over-invovement... culture bound syndromes wacinko Found in some Sioux groups Mutism, withdrawal, anger & immobility, usually targeted at another individual. Passivity has radically different significance in these groups. pathodiscrimination how a society defines psychopathology & what conditions are considered can affect who is classified & their prognosis. since the 1970s, Western psychology has tended to treat psychopathology as discrete 'conditions' with biological causes. 'idioms of distress' Culture can influence the symptoms experienced by distressed individuals. Sufferers measure themselves against role models for disease. Example: in China, 'depression' appears to lead to physical complaints of chronic bodily pain. 'Somatisation': the transformation of distress into symptoms. Example: 'nervios' in Latin America Symptoms explained as temporary condition from stress. Pathology assumed to be continuous with normal condition. Response is generally supportive & decreases stress. 'Disease model' affects community response. http://www.kraepelin.org/db5/00479/kraepelin.org/_uimages/01_Kraepelin.gif Emil Kraepelin 1856-1926 German psychiatrist often credited with being the originator of psychiatry.
Believed that psychopathologies were biological or genetic malfunctions.
Called for psychiatric conditions to be treated like medical conditions.
Studied case histories to establish types of psychiatric disorders (inc. 'dementia praecox'). Kraepelin's influence Defined schizohrenia and manic-depression.
Overlooked for a long time because of Freud & psycho-dynamics.
Arguably, psychiatry has returned to his perspective.
His theories now form the basis for diagnostic categories (DSM-IV).
Partially discredited because views on eugenics & 'self domestication.' 'the number of idiots, epileptics, psychopaths, criminals, prostitutes, and tramps who descend from alcoholic and syphilitic parents, and who transfer their inferiority to their offspring, is incalculable.' 'the well-known example of the Jews, with their strong disposition towards nervous and mental disorders, teaches us that their extraordinarily advanced domestication may eventually imprint clear marks on the race.' Cross-cultural psychiatry Kleinman (1997) has argued that the DSM-IV is itself a 'culture bound' document, generalising psychological conditions that are US into general 'universal' psychiatric conditions. Taskforce on Culture and DSM-IV 'The Cultural Formulation section... was intended by its authors to appear in the Introduction, so that everyone who uses the book would learn a method for taking culture into account in the clinical application of DSM to patients. It does not appear in the Introduction but in the ninth appendix. The not-so-covert message is clear: culture is optional-a remote option, in fact. This is only underlined by placing it side-by-side with the Glossary of Culture-Bound Syndromes, where it was never intended by its authors to appear. The immediate presence of the glossary is troubling, because it conveys a distinct sense of remote exoticism to a method that is intended to be applicable to every patient receiving a DSM-based assessment.' 'the culture of psychiatry and the institutional culture of the clinical setting regularly affect the diagnostic and treatment process in ways invisible to practitioners. These influences include socially learned attitudes and behaviors that patients often find offensive, such as insistence on organic/functional or mind/brain dichotomies, concern for disease processes over illness experience, preference for individual autonomy over social obligation, and stereotyping (which can become a kind of racism).' Two key issues: 'the culture of patient/families is most often relevant because of its intersection with, poverty and near-poverty. In fact, in fin de siecle America ethnicity is routinely a surrogate for social class. The danger of this correlation is that in turning to cultural issues, we may be avoiding more-intractable political and economic problems.' (Diagnostic and Statistical Manual of Mental disorders) The DSM-IV Published by the American Psychiatric Association
First edition in 1950.
Currently a fifth edition in preparation. Much more about this next week! In one review, only 8% of psychiatric research subjects were members of minorities. 'The DSM is not a scientific document. It is a bunch of smart people who studied the literature and then came up with the best way to define diseases – very few of the categories have an empirical base.' Robert Spitzer http://thinkprogress.org/wp-content/uploads/2012/05/Dr.-Robert-Spitzer-292x300.jpg Especially influential in the classification of mental disorders in the 1970s & 1980s. Arguably most influential psychiatrist of the twentieth century. Chaired task force for third version of DSM as it moved away from Freudian understandings. Although some of his research on homosexuality extremely controversial, he spearheaded effort to remove 'homosexuality' from list of disorders by APA in 1973. Broader issue was that the DSM-3 'medicalised' psychiatric conditions, some of which may have been normal or transitory. medicalised perspective tends to attribute psychiatric problems to glitch with brain or genes. can lead to stigmatising, isolation & spiral of social-emotional effects. tends to isolate individual & focus therapeutic interventions on the individual (& biology) tends to disregard the symptoms themselves as irrelevant (e.g., content of delusions) http://farm6.staticflickr.com/5007/5327349694_817d65cd67_z.jpg photo by charamelody, 2010, creative commons Medicalisation &and pharmaceutical industry often cheaper to prescribe drugs for symptoms than deal with more complex causes of underlying of distress. more profitable for manufacturers. diagnoses have a veneer of scientific credibility, but virtually all involve subjective evaluation by psychiatrist & cannot be objectively confirmed. pathogenic communities? Nancy Scheper-hughes, Saints, Scholars and Schizophrenics examined high rates of 'schizophrenia' in rural Ireland, especially among 'bachelor farmers.' suggested distress a result of loneliness, isolation & forced celibacy. family dynamic of brutal socialisation and coercion of family 'runt' to remain with parents (guilt & disinheritance threat) - pathoselective. ethnography was extremely controversial, especially with former subjects. Syndromes found only in Western countries are not called 'culture bound.' but was it really 'schizophrenia'? Are non-Western societies more pathogenic than Western, especially given their poverty? 'culture bound syndrome' pathologising normal behaviour? 'Drapetomania' 'Mania' for slaves to run away. A result of masters who 'made themselves too familiar with [slaves], treating them as equals.' http://upload.wikimedia.org/wikipedia/commons/e/e9/Samuelcartwright.jpg Samuel Cartwright If a slave was 'sulky and dissatisfied without cause,' an early symptom of condition, Cartwright prescribed, 'whipping the devil out of them.' an example of pathodiscrimination? In The Culture-Bound Syndromes, Charles C. Hughes estimates that there are 200 documented 'folk' psychiatric illnesses. Latah 'culture bound syndrome' In Malaysia & Indonesia, people prone to startling are called 'latah' (hyperstartling). Clear roles & expectations for those who have 'latah', including saying inappropriate things & being suggestible. Cycle of behaviour & provocation, trained over time. Are psychological conditions discreet entities? Evidence suggests overlap of symptoms, cultural variation in presentation & variable prognosis. How do we determine 'truth' if our ideas themselves are efficacious and shape these conditions? What if Western diagnosis leads to worse prognosis? What makes a dissociative state cause for clinical alarm? Seligman and Kirmayer How can dissociation be adaptive? In what circumstances? How is dissociation related to healing in the US? In Brazil? Dissociation may be a disruption of higher order processes (such as emotional tagging of memories) by intense attentional demands. 'Bio-looping' may create patterns of attention that are interpreted with local scripts. Some societies provide socio-cultural niches where this dissociative strategy is not maladaptive, but favoured. Even Kraepelin thought serious pathologies were the result of Western civilisation (trip to southeast Asia in 1919). Pattern also appears in the intensely demanding, small nuclear families of Western middle class. Michael Goddard “While censorious of those who default on social obligations, the Kaugel people [of Papua New Guinea] are relatively accepting of crazy behaviour, both chronic and temporary, so long as no significant person or material damage is caused.” Do Western patients become 'trapped in chronicity' even if they might recover? Robert Desjarlais Studied homeless shelter for the mentally ill in Boston. Found that the conditions in the shelter were so disorienting that difficult to regain a sense of normality. Already fragile, life on the street made it hard for individuals to recover. Pathoelaborative Inherited neuropsychiatric tic disorder. Once thought very rare, now that we recognise a range of tics (& not just the most dramatic) prevalence estimates as high as 4% of children. 'Tic': sudden, repetitive, non-rhythmic gestures or utterances. Most dramatic symptom is coprolalia: sudden uttering of obscenities. Approx. 10% have this symptom. Our understanding of the condition shaped by the way it is portrayed. Often portrayed as social misfits, inevitably with coprolalia. Delusions 'evolve with the times' (e.g., decreased delusions of guilt & religion) A “delusion,” one of the five key symptoms listed for schizophrenia, is a “false belief… firmly sustained despite what almost everyone else believes.” A “bizarre delusion,” a more severe symptom, has gone through numerous revisions.
In one edition of the manual, it had to have “patently absurd” content with “no possible basis in fact”; in the next, it involved “a phenomenon that the person’s culture would regard as totally implausible.” However, when is a delusion a symptom? After the revision, 10 percent of patients who were previously deemed schizophrenic were given a new diagnosis, the majority of them because their delusions were no longer bizarre. (Aviv 2010: 36-37) This belief system supports the perception that there is no protection against adversity and that anything that happens to others can also happen to oneself. It would seem that this external locus of control perspective might impress Latinos with the need to be more compassionate, understanding, and tolerant of other people’s failures, such as mental illness. This orientation may be one of the factors accounting for the low levels of anger and hostility elicited by Mexican American families when presented with schizophrenic relatives… (Weisman 1997: 27) Schizophrenia in a Latino family (US) Desjarlais: “For many the sensorium of the street involved a corporeal existence in which a person’s senses and ability to make sense soon became dulled in response to excessive and brutal demands on those senses” (127) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1140960/ Psychiatric Research by Ted Watson Listening to the voices? Therapeutic movement to encourage people to listen to & negotiate with their voices (not just schizophrenics). Some inspiration from Julian Jaynes and his theory of the 'bicameral mind.' Can the relationship to one's voices be changed over time? Luhrmann: ‘the world as imagined can change the world as it is’. Diagram from Westermann, Gert, Denis Mareschal, Mark H. Johnson, Sylvain Sirois, Michael W. Spratling and Michael S.C. Thomas. 2007. Neuroconstructivism. Developmental Science 10(1): 75–83. 'Truth' is not necessarily the most powerful therapeutic knowledge. Neither purely psycho-dynamic nor purely biological models of psychopathology have been fully successful. Therapy may require a shift in social worlds, just as disorder may also originate or be reinforced by social dynamics. Conclusions Cross-cultural evidence is not easy to interpret, but it does suggest that causes are likely mixed. This mixture should add to our therapeutic creativity & recognition of multiple tools to help those in distress. Thank you!
Questions? effects of stigma condition can be so stigmatised that potential patients avoid contact with health care professionals.
Puts off diagnosis, treatment & decreases compliance. Diagram from Westermann, Gert, Denis Mareschal, Mark H. Johnson, Sylvain Sirois, Michael W. Spratling and Michael S.C. Thomas. 2007. Neuroconstructivism. Developmental Science 10(1): 75–83. immigrants also disproportionately suffer from schizophrenia. stress from immigration & dislocation? unusual symptoms more likely to be labeled 'schizophrenia' by psychiatric professionals?
(e.g., bus driver who sat with Devil) cultural incongruity with sense of reality? Is recovery understood to be possible? health-care system may encourage patients to become 'full-time crazy' so as to deserve benefits & support. Rob Lemelson