For those who did not make it to the sold out conference on Cultural and Biological Contexts of Psychiatric Disorder, co-hosted by the Foundation for Psychocultural Research and UCLA, it was a three-day barrage of intellectual stimulation, punctuated by endless streams of conference coffee. Speakers spanned the disciplines of anthropology, psychology, psychiatry, neurosciences, and law.
Sessions organized around interdisciplinary discussions of particular diagnostic categories (autism, bipolar disorder, schizophrenia, and anxiety-related conditions) were framed by others that explored deeper problems troubling the nosological enterprise (integrating biology and culture in the DSM-V; moving beyond categories–dimensions, thresholds, contexts, trajectories). The breadth and depth of presentations and discussions elude summarization; luckily, abstracts are available for inquiring minds. To take just one example, Friday’s session on autism spectrum disorders illustrates the range of disciplinary and epistemological perspectives presented at the conference. During this session, Olga Solomon and Elinor Ochs discussed their ethnographic research examining the narrative social interactions of high-functioning autistic children. As part of the same session, Simon Baron-Cohen surveyed his fetal androgen theory of autism, according to which autism represents an extreme version of those systematizing traits associated with the so-called “male brain.”
One recurring theme throughout the conference was the question of intervention: whether, when, and how. Mary Phillips discussed the implications of her research on identifying biomarkers of abnormal emotion regulation (functional connectivity between amygdala and orbitomedial prefrontal cortex) in adults diagnosed with bipolar disorder for improving early diagnosis and risk identification. Tyrone Cannon spoke of predictors and mechanisms for understanding the conversion to psychosis in at-risk youth through the identification of prodromal symptoms and gray matter reduction.
Yet, experiential and contextual aspects of illness complicate attempts at intervention. As Kay Jamison put it, in describing the addictive qualities of mild mania (both to an individual and those around them), “How do you tell an 18-year-old who feels better than he’s ever felt in his life that he’s sick?” Also commenting on the pragmatics of intervention, Byron Good argued for increased research linked to efforts to provide effective care, and suggested that scholars learn different things by trying to solve problems or intervene than they do when carrying out “basic research.” A source of the tension between biological research and clinical practice was highlighted by Laurence Kirmayer, who noted that researchers are caught in a problem in that grant-writing often forces them to make claims about prevention, distorting the real purpose of such science–to investigate mechanisms. Preventing particular disorders, on the other hand, is a much different and longer-term question. Emily Martin noted that where we imagine we can “intervene”–whether in the genome or in the social domain, for instance–determines where resources will be funneled and where more knowledge will be produced.
Robert Lemelson’s film, “Shadows and Illuminations,” pointed to problems that reach far beyond psychiatric intervention within the clinic. The film explored a Balinese man’s experiences of distressing intrusions of spirits into his mind and body. In contexts of personal and political histories of trauma, alongside questions of cultural interpretation and traditional healing, what does one make of such experiences, and what is the meaning of appropriate intervention?
Another issue at hand was that of categorization. Robert Bilder advocated for a dimensional model (quantitative difference on a continuum) of psychiatric disorders in place of the current categorical (qualitative difference) approach, as there lacks demonstrable evidence of discrete categories in most current DSM diagnoses (with some exceptions noted). Bilder argued that “names don’t create illness forms; they only comfort doctors and relatives,” that the current taxonomy is based on a consensus process caught between academia, the FDA, and pharmaceutical industries, not to mention clinicians, patients, and insurers. Two points Bilder made were that consensus does not constitute science, and that evidence of “positive schizotypy” in healthy people suggests that a severity continuum is more valuable for understanding psychotic phenomena than categorical conceptualizations. In a sign of the recognition of such dimensional models on an institutional-funding level, Bruce Cuthbert described a new NIMH framework for research which is focused not on a specific diagnosis, but on clusters of traits that a investigator identifies as important.
Other participants discussed the meaning and significance of categorical diagnoses in the clinical context. During a panel discussion, David Kinzie argued that psychiatrists don’t necessarily all “believe” in the DSM, but use it as a structure for treatment and to manage their own emotional responses to their difficult work. Similarly emphasizing the pragmatic roles of clinical diagnoses, Peter Kramer suggested that clinicians aren’t much bothered by the slipperiness of diagnostic categories. However, Kramer added that medications do not in fact treat diagnoses, but symptoms.
Tanya Luhrmann also addressed categorization in presenting her work on hallucinations in Christian spiritual practices that invoke “not me” experiences within the self. She also presented a case study of a young man who fulfilled criteria for schizophrenia, in whom the distressing voices vanished after they were treated as real and meaningful. Luhrmann raised the question of the relationship between psychotic hallucinations and dissociative phenomena, and hypothesized that hallucinations may have multiple pathways that respond to contextual invitation.
Returning to the pragmatics of clinical diagnostic tools, Roberto Lewis-Fernández discussed the inclusion of cultural variation and context in the DSM V. Places of inclusion might include criteria, dimensions, text, and appendix; yet, configurations of illness categories outside of the DSM (such as ataque) often involves a network of symptoms that cannot be subsumed under DSM categorical boundaries. Lewis-Fernández emphasized the importance of at least “a minimal attention to what the patient thinks is going on and what he or she wants to do about it,” which can dramatically decrease drop-out rates.
Others suggested a more radical rethinking of psychiatric concepts and diagnostic tools. Agreeing with others at the conference on the importance of developing dimensional—rather than categorical—models of mental disorder, Laurence Kirmayer also emphasized the significance of studying trajectories – examining how people move through various dimensions over time. For example, as Eric Courchesne explained in the session on autism spectrum disorders, recent research on early brain development suggests that a particular developmental trajectory may lead to autism: 1) excessive growth of the frontal, temporal lobes and amygdala; followed by 2) arrested growth; and 3) in some cases degeneration. Tanya Luhrmann noted that shifting categorical conceptions can save people from intense medications, as there is a good prognosis for dissociation, versus a bad one for psychosis.
Central to the conference were questions of cultural and historical context in psychiatric diagnosis. Devon Hinton described Kyol Goeu or “wind overload”–a Cambodian nosological concept with some parallels to Western psychiatric notions of panic, yet involve a very different network of meanings that generate particular feedback loops between arousal-reactive sensations, metaphoric associations, catastrophic cognitions, interoceptive conditioning of sensation, and psychological and somatic fear. Anxiety and panic are woven into a history of political violence and traumatic associations among refugees. Ann Becker discussed the relationship between rapid economic development and eating disorders in Fiji, where none out of over 500 girls in a study met criteria for anorexia nervosa or bulimia nervosa, yet many had clinically significant symptoms of food refusal and purging. Becker noted the link between traditionalism and diminished distress over binge eating, suggesting the model of “cultural moderation” of pathology, rather than “culture-bound syndromes.” Richard Grinker discussed the controversies surrounding the claims of an “autism epidemic,” suggesting that changes in context (including a decline of the stigma-perpetuating mid-20th century theories which attributed autism to the parenting of “refrigerators mothers” and the rise of patient advocacy and disability rights movements) have led to increased attention to autism (not to a sudden epidemic of cases). The apparent increase in prevalence, Grinker explained, is an achievement because it indicates more treatment and diagnosis.
The problem of separating the cultural and the biological was also highlighted in Nobel laureate Eric Kandel‘s keynote address. For Kandel, the distinction between the social and genetic is a false one, as any long term change in the human animal involves a change in gene expression, and short term changes impact brain function; neural anatomy is altered through long-term training through synaptic changes. Beginning his speech with a slide entitled, “From Psychoanalysis to Psychoanalysis” (his intellectual interests began with psychoanalysis, moved toward biology, and back toward questions of psychoanalysis) Kandel noted that long-term change in the form of psychotherapy might constitute persistent functional and anatomical changes in the brain. The praise for psychotherapy was echoed in Elyn Saks and Kay Jamison, who both emphasized the absolute importance of psychotherapy in their own attempts to cope with schizophrenia and manic-depression, respectively. For Saks, psychotherapy provided a reduction of stress, a safe space to talk about private thoughts, interpretation, and most crucially, “someone accepting you–good, bad, and ugly.”
Moshe Szyf described relatively recent research into the epigenome—the set of molecular mechanisms which may mediate the effect of social environments and experiences (particularly at certain developmental stages) on adult mental health. Epigenomics examines how the expression of the genome is influenced by the environment through mechanisms such as DNA methylation. Research in this area has shown that the DNA of rats displays different methylation patterns depending on the degrees of maternal care they receive. Szyf emphasized that such distinct methylation patterns cannot be interpreted as inherently not good or bad; rather they represent adaptive variation: maternal care programs the animal to respond to an anticipated environment—either harsh or safe. Szyf also described the analysis of a British 1958 birth cohort study which showed that socioeconomic position in early life has a strong effect on methylation patterns, and emphasized that the epigenome may be more responsive to signals at certain critical life periods, such as early childhood and puberty.
While talks such as these involved an attempt at overcoming the Cartesian mind-body dualism, traces of tension still haunted moments of conversation. During a panel Q&A, one neuroscientist problematized the common “assumption” among presenters that psychiatric disorders are socially or culturally determined, when in fact there is no distinction between culture and biology. All phenomena, said the neuroscientist, including social and cultural ones, work through the brain; culture is not the antithesis of biology. Anthropologists at the scene refuted through agreement–indeed, there is no antithesis–the social scientists had not been claiming mental illness as socially determined, but rather as social facts–a concept that needn’t, and doesn’t, preclude the role of biology. To this, the neuroscientist retorted: “well everything is a social fact!” to which an anthropologist countered: “I agree!” There ended the session; they agreed to… agree.
The moment marked a ghost that lingers despite the profusion of works that have gone far beyond the mind-body divide. Five years prior to this, at the FPR’s 2005 conference on childhood, neuroscientist Darlene Francis opened her presentation with the premise: “The debate over nature versus nurture…is long over… Neurobiologists now asking how they interact, not whether they do.” Yet, the debate lingers in disciplinary concepts, practices, and imaginaries. Periodically, through quiet slippage or apparent discord, through missed communicative attempts or straw men constructed from all fronts, disciplinary boundaries are re-reified despite concurrent struggles to wade past the constraints congealed in discursive, practical, and institutional histories. Of course, the mutual suspicion is not wholly unwarranted; those focused on working toward dismantling epistemological barriers and hierarchies between mind, body, and collectivity remain a limited bunch. And importantly, as noted by Emily Martin, current conditions for knowledge production are such that forms of knowledge regarding the “social”–artificial binary or not–remain devalued both in terms of authority and resources as compared to knowledge regarding the “biological.” Thus, questions of resources, interest, and power maintain a sense of distance and apprehension between the departments of knowledge–a problem that will not be resolved within the confines of any three-day conference.
Formerly a research assistant at the FPR, Emily Ng is a first year graduate student at the University of California, Berkeley, in the UCB-UCSF joint doctoral program in Medical Anthropology. Her interests have revolved around the question of bipolar disorder in urban China, particularly experiences of ‘mania’ and ‘depression’ in across changes in the sociocultural context and role of psychiatry.
Additional notes for this post where contributed by Keziah Conrad, a graduate student in anthropology at UCLA.