Publication: Review of posttraumatic cultural concepts of distress

Although not every human culture would recognize psychological terms as we use them in North America and Europe, every culture has ways of talking about how individuals feel, and every culture has terms that describe extreme and abnormal versions of these feelings. Cultural concepts of distress are those culturally-specific ways that people from within a given group express their psychological distress. For example, Cambodians talk about a “khyal attack” as an experience whereby “wind” that flows naturally through the body (akin to chi in Chinese medicine) is blocked from exiting, causing problems that Western psychologists would call symptoms of panic attack (if you’re at all curious, you really should visit the website dedicated to explaining khyal attack).

A couple of colleagues and I recently published a review in Social Science and Medicine of the symptoms that are included in the various ways that different cultures think about the emotional distress following trauma. Our review included 55 studies and identified 116 different cultural concepts of distress. We categorized these concepts based on their symptoms (using hierarchical cluster analysis), and found that the 116 concepts could be described in four basic categories: (1) somatic dysphoria, which largely concerned bodily complaints; (2) behavioral disturbances, “odd” behavior (relative to cultural norms), (3) anxious dysphoria, which as its name implies included lots of anxiety; and (4) depression, which was surprisingly similar to depression as it appears in North American and European medicine. Notably, none of these groups of concepts looked like the psychological disorder that most mental health professionals in North America and Europe think of when they think about trauma — posttraumatic stress disorder, or PTSD.

Of course there are all sorts of limitations to our review, and some would argue that the way we categorized cultural concepts of distress using symptoms alone misses the point of the diversity of these concepts globally (which is broader concerning explanations for distress than it is concerning symptoms). Others would argue that PTSD is actually somewhere in the mix of concepts we reviewed. I’d like to think our review is a starting point for discussion of these issues, rather than a definitive answer to any of these questions.

You can find a link to the publication in Social Science and Medicine here.

“Canine PTSD” or “Army dogs suffer from Pavlovian conditioning”

McGill University’s Summer Program in Social and Cultural Psychiatry presents wonderful opportunities to share ideas with those who think a lot about culture and mental health, culture in mental health, and, perhaps most interesting, the culture of mental health. Allan Young, whose historical ethnography of posttraumatic stress disorder, The Harmony of Illusions, is a must-read for anyone interested in trauma studies, passed along the following example of PTSD’s exaggerated role in current US culture, from the Army Times:

Dogs bring home war’s stress, too

By Michelle Tan – Staff writer
Posted : Thursday Dec 30, 2010 9:41:04 EST

SAN ANTONIO — Dogs suffer from post-traumatic stress, too.

Years of war and frequent deployments have affected military working dogs just as they have humans, and Dr. Walter Burghardt is trying to do something about it.

Dr. Burghardt explains:

“The dogs that go overseas … we’re starting to see some distress-related issues,” he said. “It results in difficulty doing work. They’re distracted by loud noises. We’re not saying it’s the same as in people, but there are common things.”

That includes hypervigilance or showing interest in escaping or avoiding places in which they used to be comfortable. For example, a dog that used to work at a security checkpoint or gate may try to pull away on his leash when he sees he’s being led to that checkpoint or gate, Burghardt said.

Some of the dogs also become very clingy or more irritable or aggressive, the doctor said.

“Canine PTSD” is either the most extreme example of what Richard McNally calls PTSD’s “bracket creep” or some perhaps nonintentional Pavloivan insight into the nature of stress response. Or perhaps both. If we take the “symptoms” reported in the article as accurate, and I have no reason to doubt the staff writers at the Army Times, then yes, dogs get stressed and want to avoid the sources of their stressors — classical conditioning, a la Ivan Pavlov (1849-1936; Pavlov even demonstrated conditioning using dogs, until they drowned in their cages when the River Neva flooded the basement of his laboratory). But canine posttraumatic stress disorder?

In case you were concerned that the Army veterinarians were not being careful about differential diagnosis, or perhaps even that some dogs might be faking in order to cash in on the generous disability benefits for veterans with PTSD:

[Dr. Burghardt] cautioned, “canine [post-traumatic stress disorder] is only diagnosed if the dog has combat exposure or repeated, prolonged deployments.”

The article continues with a description of the treatment given the dogs to get them right back “in the service”… which is, of course, the goal of treating human PTSD in the military as well.

More from McGill’s Summer Program: The Affliction Film Series

McGill University’s Summer Program in Social and Cultural Psychiatry is not just about the differences between Swedes and Irish. As part of the summer program’s keynote course, Cultural Psychiatry, McGill luminary Laurence Kirmayer includes a number of film clips in the syllabus to give students a chance to observe some of the phenomena that gets diagnosed by psychiatrists using Western psychiatric categories, but may perhaps make more sense by examining the patient’s cultural and historical context.

One of the most striking films shown (so far) comes from Robert Lemelson’s psychiatric anthropology series, Afflictions: Culture and Mental Illness in Indonesia. In “Shadows and Illuminations,” a man presents with visual and auditory hallucinations of Balinese spirits, disorganized behavior and inappropriate dress. His family and neighbors regard him as odd, so it’s not the case that he is just odd to our foreign eyes. Our psychiatric practice tells us to look for schizophrenia. He reports the symptoms began with the death of his daughter, and we think perhaps it is a posttraumatic stress reaction of some sort. He is examined by two traditional healers and a psychiatrist, all of which have their own treatments, but none of which seem to help. Accommodations are made for the man’s behavior in his own home, and he seems to get a little better. Improvement had nothing to do with our diagnosis, or lack thereof.

Each story in the series situates behavior and concepts of illness within the families and societies in which they occur. Not satisfied with biological explanations of these patients’ problems, Lemelson’s films remind us that psychiatric practices have non-psychiatric implications, specifically around family relations, historical meaning-making, and even implications related to the freedom of the individuals with mental health problems.

The Catholic bishops’ exorcism workshop: Distinguishing demonic possession from mental illness

Next week, Catholic bishops from around the US will meet in Baltimore for their general assembly. As happens before many large conferences, this weekend attendees can take a workshop in order to improve their professional skills: the Conference on the Liturgical and Pastoral Practice of Exorcism. Bishop Thomas Paprocki of Springfield, Illinois has organized the workshop in response to a rising number of requests for exorcisms nationally. The Catholic News Service reports that 56 bishops and 66 priests have signed up.

The Catholic News Service report explains that not everyone in the Catholic clergy can do exorcisms:

Under canon law — Canon 1172 specifically — only those priests who get permission from their bishops can perform an exorcism after proper training.

The Catechism of the Catholic Church explains that an exorcism occurs when the church, in the person of an exorcist, asks “publicly and authoritatively” in Christ’s name “that a person or object be protected against the power of the evil one and withdrawn from his dominion.”

Exorcism is rooted in the acts of Jesus Christ:

Scripture contains several examples of Jesus casting out evil spirits from people.

“We don’t think that’s poetic metaphor,” Bishop Paprocki said.

Not surprisingly, there is a fair amount of tongue-in-cheek coverage of the conference in the US press. However, for mental health professionals like myself, the Catholic Church’s response to this increased demand is nothing to laugh at. Reports of spirit possession are commonplace in many parts of the world, and certainly not limited to Catholics — my own experience with people “tormented by demons” comes from work with Muslim refugees from Darfur, Sudan. Although many of us have psychiatric interpretations of these phenomena when we encounter them, we are in minority; there are many more people who are convinced of their supernatural etiology. In other words, for most of humanity, the reasons for odd thoughts and behavior are spiritual, not scientific. The US is one of only a handful of countries in which spiritual explanatory models do not hold sway. In a global perspective, it is the exorcism conference’s media attention and tongue-in-cheek coverage that is notable, and not the topic of exorcism itself.

“Explanatory models” are sets of reasons for why things happen the way they do. Mental health practitioners are often interested in their patients’ explanatory models of their psychological problems in order to treat them more effectively. Reading through media coverage you get the sense that although rooted in a predominantly supernatural explanatory model, the perspective of the US bishops organizing the conference is actually somewhat of a hybrid, combining a concern for spiritual hygiene with a concern for psychological well-being. Although the US may be globally out-of-step in terms the majority’s emphasis on scientific explanations, hybrid spiritual-scientific explanatory models are the norm in our globalized world. In other words, in the US most people tend to emphasize scientific parts of explanations for odd behavior whereas in most other parts of the world most people emphasize spiritual parts, but in reality many people hold both types of explanations for such behavior simultaneously. The New York Times report devotes a fair number of column inches to the difference between “real” possession by the Devil and other possession-like states, and this seems to be the point of the conference:

“Not everyone who thinks they need an exorcism actually does need one,” said Bishop Thomas J. Paprocki of Springfield, Ill., who organized the conference. “It’s only used in those cases where the Devil is involved in an extraordinary sort of way in terms of actually being in possession of the person.

So just what are the symptoms of demonic possession?

Some of the classic signs of possession by a demon, Bishop Paprocki said, include speaking in a language the person has never learned; extraordinary shows of strength; a sudden aversion to spiritual things like holy water or the name of God; and severe sleeplessness, lack of appetite and cutting, scratching and biting the skin.

A person who claims to be possessed must be evaluated by doctors to rule out a mental or physical illness, according to Vatican guidelines issued in 1999, which superseded the previous guidelines, issued in 1614.

(That’s 385 years between guidelines, for those of you who were wondering. The next set of guidelines is presumably due in 2384.)

I think it’s safe to say that most Catholics in the US do not believe that training priests in the proper procedure for exorcisms is a priority in 2010. Some posit that other factors are in play behind the pre-meeting exorcism institute. Notre Dame Professor of Catholic history R. Scott Appleby says that the conference is best explained as a way to bring back those among the flock who have strayed because the church is no longer seen as distinct from other, more secular institutions.

“What they’re trying to do in restoring exorcisms,” said Dr. Appleby, a longtime observer of the bishops, “is to strengthen and enhance what seems to be lost in the church, which is the sense that the church is not like any other institution. It is supernatural, and the key players in that are the hierarchy and the priests who can be given the faculties of exorcism.

“It’s a strategy for saying: ‘We are not the Federal Reserve, and we are not the World Council of Churches. We deal with angels and demons.’ ”

Depression, grief & the DSM5

In the opinion pages of today’s New York Times the former chairman of psychiatry at Duke and DSM-IV architect Allen Frances writes a passionate plea to the architects of DSM5 not to inadvertently medicalize normal grief. Although I’d made a promise to myself not to keep referencing major press outlets in the blog (because everyone has access to them), this one was too good to pass up. The controversy surrounds the loosening of the criteria for what counts as Major Depressive Disorder (MDD) — what we in mental health call depression. Frances points out that in drafts of the DSM5, if normal grieving (e.g., following the death of a loved one) carries on for more than two weeks, the person grieving would be diagnosable with MDD.

What would this mean? Well, for starters, it would be a windfall for pharmaceutical companies. But no, there’s no real conspiracy here. As Frances explains:

It is not that psychiatrists are in bed with the drug companies, as is often alleged. The proposed change actually grows out of the best of intentions. Researchers point out that, during bereavement, some people develop an enduring case of major depression, and clinicians hope that by identifying such cases early they could reduce the burdens of illness with treatment.

Ah, good intentions… This is a good example of a fine line that comes up often in mental health: that  between prevention and over-diagnosis. If the discussion at this year’s American Psychiatric Association meeting is any barometer, this is a major discussion within the various groups designing DSM5. We want to catch mental illness before it becomes full-blown, but we also don’t want to diagnose someone who is sad or troubled for really good reasons and will heal on their own (and maybe even grow out of their grief). Frances:

The bereaved would also lose the benefits that accrue from letting grief take its natural course. What might these be? No one can say exactly. But grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both.

… Humans have developed complicated and culturally determined grieving rituals that no doubt date from at least as far back as the Neanderthal burial pits that were consecrated tens of thousands of years ago. It is essential, not unhealthy, for us to grieve when confronted by the death of someone we love.

I think here Frances misses something (or at least here he misses something — he’s a pretty smart guy, so he probably doesn’t really miss this): taking medication for sadness and stress has become a “culturally determined grieving ritual” for many people in the US. Does that mean that we should accept the medicalization of normal emotions? Of course not. It only means that we should recognize that for many, it has become part of our culture, and turning the tide will take more than rewriting drafts of DSM5.

Brain-mind or heart-mind; TMS or MST; DSM-5 or DSM-V? The American Psychiatric Association in New Orleans

This weekend and the first part of this week the American Psychiatric Association held its annual meeting in New Orleans, LA. In addition to staying out of the way of drifting gulf oil and seeing a lot of great music, I sat in on a few sessions in the monstrous Morial Convention Center to hear the latest from my psychiatric cousins. Psychiatrists in general fascinate me. On the one hand they rely heavily on the biomedical model to explain psychological phenomena (they are, after all, doctors), on the other they talk even more impressionistically than my psychologist compatriots (one of the presentations this year is on Chopin). As doctors, they know so much stuff (doctors have to memorize an amazing number of facts about the body), yet as researchers they can hardly handle more than two-by-two tables in their analyses (to be honest, most psychologists don’t do a whole lot better — they just don’t get published). I get asked all the time whether I’m a psychologist or a psychiatrist, and then, regardless of the answer, if I can prescribe; for those of you wondering: psychologist, and no.

On Saturday, I attended a session run by Devon Hinton (of Mass General) on cultural assessment of non-Western patients. In addition to Devon, his brother Ladson, Roberto Lewis-Fernandez, and myself, Brandon Kohrt of Emory University presented a paper on culture and symptoms. Brandon’s done a lot of work with child soldiers in Nepal, and presented on “child-led indicators” of distress among this population. Lots of good things in there, but my favorite was a distinction made among Nepalis between problems of the “brain-mind” and problems of the “heart-mind.” Your heart-mind is where your emotions are, your brain-mind where your thinking and cognition happen. Heart-mind problems are normal, brain-mind problems stigmatized. Although heart-mind problems can lead to brain-mind problems, they usually can be addressed successfully with appropriate social support. Critically, Brandon reported that Western psychosocial NGOs working with Nepalis affected by the civil war (which ended in 2006) had translated posttraumatic stress disorder into a term associated with brain-mind problems, and thus found it very hard to get people to participate in their interventions. It was only when they started using a heart-mind term that they got more people to participate.

TMS stands for transcranial magnetic stimulation. MST stands for magnetic seizure therapy. I’ll admit here that I am way out of my league here, but I’ll give you the synopsis. Both are new treatments for depression, and both involve magnets applied to your skull (falling under the somewhat euphemistic category of “brain stimulation”). In TMS you are awake, in MST you are under anesthesia. Okay, why do you want to do either of these things? Well, the treatment with the strongest therapeutic effects on people who have suffered multiple bouts of severe depression is well known to be electroconvulsive therapy, ECT. Yes, that means administering electric shocks to people’s brains. The problem with ECT is that associated with shocking people’s brains is some retrograde amnesia. So, electrotherapists have searched for more focal treatments at lower doses, and have found some success by putting strong magnets on the surface of people’s heads. I’m being a bit glib here, but really, this is pretty exciting stuff — particularly for those suffering from depression that is resistant to medication. For more on TMS, see the work of William McDonald; for MST, see Sarah Lisanby (she’s also done TMS work as well).

The development of DSM-5 was a big topic at APA 2010. The publication of the DSM-5 in May of 2013 (at APA San Francisco) is already a much-heralded event, and those on the various subcommittees have been doing due diligence throughout the various mental health conference circuits. I heard a lot about DSM-5 at APA 2010, but perhaps the most interesting proposed conceptual change I heard was the decoupling of disability from the notion of mental disorder. Since DSM-III (1980), criteria for diagnosing most disorders has included a functional criterion; i.e., you can’t just have some symptoms, the symptoms have to keep you from doing the things you want or need to do. So, someone with depression who is really sad but gets everything done cannot really have clinical depression. Decoupling symptom criteria from functional disability would put DSM-5 in line with the World Health Organization’s ICD-10/ICF system (ICD-10 is the WHO’s classification disorders manual; ICF is their functional disability manual). It would also clearly expand the number of people with disorders, as the functional criterion limits the application of a given disorder. Over-diagnosis will likely result. However, leaving things as they are means that the functional criteria limits prevention efforts: if you have to wait to diagnose a disorder before it becomes disabling, how can you administer (or more to the point, how can you pay for the administration of) prevention efforts? Stay tuned… or just check out the DSM-5 website. (By the way, it’s settled: DSM-5, not DSM-V.)

Book review of Crazy Like Us on STATS.org

STATS is an organization that examines the reliability and validity of quantitative findings in social science and medicine for laypeople, specifically journalists. Today they feature a book review of Ethan Watters’ Crazy Like Us: The Globalization of the American Psyche, by none other than yours truly. Here’s a teaser:

those of us who work in the small corner of mental health research that examines the differences in diagnoses and symptoms between cultures are somewhat surprised by Crazy Like Us; our field, generally, remains well hidden in the crease between psychology and anthropology. That our first popular treatment should be a highly critical survey of this field of mental health is doubly shocking.

Keep reading, here .

Flying monks, talking turtles, brain tumors: A cautionary tale in cross-cultural medicine from Laos

A few weeks ago, a young woman named Chloe Thomas contacted me in response to the placebo series. She has a fascinating real-life cautionary tale in global health: what the clash between Lao traditional medicine and globalized Western medicine means for a man with a potentially operable brain tumor. No easy answers, stories like these are important in illustrating the sticky points and pitfalls of cross-cultural health care.

Last year when traveling through Southeast Asia I was deeply inspired by the beauty of the people of Laos yet frustrated by their lack of access to basic health services. Small and landlocked, Laos routinely places among the lowest in many health and development indicators. I returned, college idealism in hand, dedicated to help in anyway I could. I found a volunteer opportunity with a NGO in the capital, Vientiane. The NGO’s work attempted to preserve Lao traditional medicine for both its cultural heritage and importance as the sole access to healthcare of any kind for most rural and impoverished populations.

I know many of you reading this may share my initial skepticism, traditional medicine as hokum, an almost ignorant naiveté. But approximately 60- 80% of the global population is dependent on medicinal plants to fulfill primary healthcare needs, and in Africa and Asia, this figure may be upward of 80%. This widespread use is most often attributed to confidence in efficacy, accessibility, and affordability. (For those needing further persuasion, information and/or definitions see the WHO’s Traditional Medicine Strategy.) Furthermore, the use of medicinal plants employed by these various cultures is often the first step in the discovery of bioactive compounds that lead to novel drugs[1] — think artemisinin.

As a medical school aspirant I was eager to explore the evidence-based efficacy of traditional medicinal plants and their potential health benefits, as well as understand different cultural perspectives in medicine. Armed with only a BA and having no experience in either the aid world or ethnomedicine, I was aware I needed to reach out to those more capable of undertaking research and inducing change. Promoting the safety and standardization of plants currently being used was, and should be, a priority. I hungrily began reading, researching, and contacting those in the field.

The first few months proved a crash course in aid politics, grant writing and how to tactfully navigate through the Lao bureaucracy. It was also during this time my Director (whom I will henceforth call Mr. Smith) slowly revealed himself as a self-proclaimed master in Lao traditional medicine (though seemingly without formal, or even informal training). I was not too concerned with this, as over 70% of Laotians routinely use traditional medicine. However, when he continued to talk about his ability in the same sentence with flying monks and talking turtles, and then spoke of his life goal of being able cure the sick by simply walking past them, it became clear that this religious conviction and personal ambition would pose a great challenge to any objective approach I made.

Several weeks later, I checked my email to find an attachment from my Director of the medical record of a mid-twenty year-old, complete with a CT scan noting a mass in the right posterior fossa. The clinical impression relayed to me by Mr. Smith (obtained from the patient) was that this was a brain tumor, which without surgery would give the patient only months to live. Although Mr. Smith admitted that he was told the patient would have a good prognosis with an operation, he insisted that he another local traditional medicine practitioner, they could cure him using solely traditional medicine, and that he wanted me to document the progress.

Most likely the patient sought my boss’s care because they could not afford the operation. If this was the case, I was uncomfortable sitting by idly and watching this vulnerable person be used as a human subject to substantiate an experimental treatment. Human lives should be more precious than tools to validate one person’s conviction or to further their ambitions.

What’s worse still is that if the patient had opted for surgery (assuming he could find the means) and it was unsuccessful, Mr. Smith would no longer accept the patient, citing that the traditional medicine treatment would no longer be effective, almost as if it was out of personal vengeance. Choosing to respect one form of treatment should not mean having to reject the other.

Echoing the South African controversy surrounding traditional treatment for AIDS (involving the now deceased Health Minister Manto Tshabalala-Msimang), a myriad of emotions ran through me, bafflement, hostility, frustration. After a heavily emotional argument in which I pressed that we should at least advocate for funds for the operation if money was the sole determinant in the patient’s choice, my Director accused me of not believing in traditional medicine or his ability to cure.

I am not a doctor and still remain unsure about the accuracy of the diagnosis or the validity of the medical team’s consultation. But, I do realize what I was presented with was irresponsible and potentially fatal. While some plants have shown promise in cancer treatments, too many unknowns still remain for me to allow myself to participate in such a high stakes gamble.

No doubt there has been and will continue to be cases such as this. The ethical implications remain thorny, and literature scant (see here for one of the few articles I have found). With the growing use and recognition of the benefits of traditional medicine systems, there is also a growing need for safety, efficacy, quality and rational use. In fact, nationalization of Lao Traditional Medicine is a goal of the Government, and this would undoubtedly necessitate regulation, standardize treatments and hopefully create a governing body to whom malfeasance can be reported. Professionalization among traditional medicine practitioners would also enable a body of educated primary health care providers in the most rural and remote regions. Unfortunately, discerning the tangible from the intangible in these often religiously contextualized treatments will prove harder still.

It’s a sad reality not every person can afford the care they may desperately need. While I will respect this particular patient’s decision, I will only do so if presented with clear and accurate information on his choice, I will not be involved in a situation in which a patient is mislead by the desire of one person’s goal of attaining supernatural ability. My dilemma left me wondering–when do we admit the most realistic options for medical treatment? What’s the middle ground between Western medicine and traditional systems? Can the two ever co-exist in harmony while still respecting the benefits and fundamental beliefs in both systems? Or are there too many differences, areas of profound misunderstanding that make them perpetually destined for conflict. Perhaps my dilemma was just an example of this.

Apart from this instance, most of my experiences working with traditional medicine were positive, forcing me to revaluate my own perception and views of healthcare and medicine. It was challenging finding the delicate balance between science and religion, and acknowledging that my Western train of thought is just one among many world-views. Though I remain without clear resolve on many of the ethical issues that have arisen with the growing use of traditional medicine and alternative treatments, I hope that with more education will come more clarity. However, what I will take into my medical education is the importance of mutual understanding and respect when treating patients humanely and effectively across cultural chasms, for no matter where I work, there is no doubt that I will continue to work with patients whose healing beliefs greatly differ from my own.

Ms Thomas is originally from California, and a graduate from UC Berkeley (2008) in Molecular and Cell Biology. She is currently in the process of applying for medical school in the United States.

————————————–

[1] R. Alves et al., “Biodiversity, traditional medicine and public health: where do they meet?” Journal of Ethnobiology and Ethnomedicine (2007), 3:14