Posts Tagged 'depression'

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.

Article supplement: Posttraumatic idioms of distress among Darfur refugees

The September 2011 issue of Transcultural Psychiatry is out, and it includes an article by myself and some colleagues based on some work we did with Darfur refugees a few years ago. Publication lag times as they are (a colleague this morning compared them to the aging of fine wines), by the time an article is finally comes out in print the author’s ideas about what he/she sees as the “take-home” message may have shifted slightly. So here’s my chance to provide the 2011 take-home to a study written in 2009.

The article, Posttraumatic idioms of distress among Darfur refugees: Hozun and Majnun, details the development of a questionnaire (a structured interview, really) for Darfur refugees that we used to help evaluate a psychosocial intervention in camps in Chad. From the article:

We took an emic-etic integrated approach, identifying local constructs and then measuring both Western and local distress constructs within the same population in order to compare associations between two sets of symptoms of theoretically related concepts.

This means we (1) talked to a lot of refugees to hear how they defined their problems (including symptoms of psychological distress) and then followed-up with traditional healers to hear how they categorized these symptoms into larger psychological problems (“idioms of distress” for you budding transcultural psychiatrists out there); and (2) conducted a survey that included these problems and Western concepts (PTSD, depression) to measure how the Darfur problems and Western concepts were differentially associated with trauma experiences, loss, and impairment in daily living. The two Darfur problem sets were labeled hozun — “deep sadness” — and majnun — “madness.”

I’ll let you read the article to get the details, but suffice it to say that these sets of disorders — hozun and majnun on the one hand and PTSD and depression on the other — shared many symptoms in common. Related to this, they were associated with traumatic events and functional impairment at comparable levels — in other words, one could “predict” functional impairment using hozun and PTSD and get similar effect sizes (with slight favor for the locally-defined problems).

One might think that if a measure of PTSD is as good as measure developed for a local distress idiom in predicting a third variable you are interested in, then there is really no reason to develop the local measure. In the article we emphasized that the response to this argument had to do with respecting local populations and avoiding psychiatric colonialism. Now although I agree with those ideals, I would emphasize another point we made (but did not emphasize): Just because many of the symptoms of two different disorders from the Western psychiatric canon (here PTSD and depression) overlap with two different disorders from a different medical tradition (here hozun and majnun), it is how the symptoms are arranged in their respective traditions that define the disorders. From the article:

although they accounted for similar variance in Study 2 as a set of items, these symptoms were categorized by traditional healers into sets that were different that the sets of symptoms in PTSD and depression. This, then, suggests that it would be incorrect to argue that PTSD and depression are culturally valid constructs in settings in which respondents report variance on PTSD and depression simply because of that variance.

In other words, just because non-Western participants in a study answer that they have problems (or do not have problems) that fit into Western DSM-IV ideas of psychiatric disorder does not mean that Western DSM-IV ideas of psychiatric disorders are valid definitions of their problems. Figuring out what are valid definitions for their problems is not, at its most basic, a statistical task, but rather a theoretical one. You have to talk to the people who know the theory, not just the people who have the problems.


Stressed mice moms, less licking & grooming, DNA methylation, & sad mouse dads: An epigenetic model of intergenerational transmission of psychopathology

The recent special issue of Biological Psychiatry on Stress, Neuroplasticity and Posttraumatic Stress Disorder (September 1, 2010) includes an intriguing piece on the transmission of the impact of stressed child-rearing among mice across generations: “Epigenetic transmission of the impact of early stress across generations.” This article was announced by the publisher’s regular newsletter as having implications for intergenerational trauma, and so I figured I better take a look.

Before going into the article itself, a couple of terms. First, epigenetics. Genetics is the study of how traits are passed on from one generation to the next via genes (in DNA) and epi is a prefix indicating essentially “related to but not of” (from the Greek preposition meaning on, around, above, nearby, outer, etc.), so epigenetics concerns those phenomena that result in traits being passed from one generation to the next that are not directly due to genetic material alone. In other words, those things that affect the phenotype without affecting the genotype (for those of you in High School biology). Epigenetics has been a hot field in mental health research for a few years now, particularly among those who want to explain how childhood adversity might influence the ability to tolerate stress later in life.

Second term, DNA methylation (I’ll admit I had to look this one up). Methylation is the addition of a methyl group — a group of chemical characterized by CH3 (for those of you in High School Chemistry) — to DNA. The addition of a methyl group to DNA is critical to development, and the amount and location influences how a gene will be expressed. Importantly, (1) methylation happens because of phenomena external to the gene — i.e., it is epigenetic — and (2) it can be passed on to later generations.

Okay, the article. A group of researchers in Switzerland set up an animal model of transgenerational transmission of the impact of early life stress using mice. (Animal models are useful to mental health research because they allow researchers to manipulate aspects of research design.) How did the Swiss operationalize early life stress in this model?

Dams and litters were subjected to unpredictable maternal separation combined with unpredictable maternal stress (MSUS). (p. 408)

Essentially, they stressed out the new mice mothers (“dams”) and took them away from their mice children (“litters”) at irregular intervals (“MSUS”) throughout the first two weeks following birth. They also left a separate group of dams and litters alone. They observed these two groups of mice, and found what others have found, that among the “treated group” (i.e., the ones with unpredictably separated and stressed mothers) there were fewer of the behaviors associated with healthy mouse development — arched-back nursing, regular licking and grooming, and time hanging out on the nest — when the moms were in contact with their litters. In addition, when the little mice grew up, males in the treated group spent more time floating passively in a “forced swim” test (dropping mice in water and seeing how fast they swim, essentially), spent more time immobile in a “tail suspension” test (holding mice by their tails), and ate less sugar (a “sucrose consumption test”) than mice in the nontreated group. These traits were seen as “depressive-like” behavior. Notably, females were not different from all the mice who were raised without the unpredictable and stressed mothering.

Once the two groups of litters were old enough to breed, the researchers bred the males of the stressed group with a new set of female mice (who grew up normally) quickly separated them from their litters and female partners so as not to influence the behavior of their children once born, did not stress the mothers, and then observed the behaviors of their offspring — i.e., the second generation. Then they did the same thing with the next — the third — generation as well. With some slight variability, results from the first generation were replicated in both second and third generations, suggesting that not only is there an effect of early life maternal child-rearing practices that persists across (mice) generations, but also that this effect is independent of how subsequent mothers rear their litters, and thus it must be carried by the father.

So how is this done? What is the mechanism of transmission? Combining their findings and the knowledge about epigenetics, our Swiss friends thought that maternal separation combined with unpredictable maternal stress might be altering gene expression through DNA methylation in sperm cells. So:

To determine whether DNA methylation was altered by early stress in the male germline, we examined its level in the promoter of the several candidate genes in sperm from F1 MSUS males. (p. 412)

The “several candidate genes” here were genes that are associated with the regulation of depressive-like behavior. What did they find?

Methylation of the CpG island surrounding the transcription initiation site of MeCP2 and CB1 genes was increased in F1 MSUS sperm. In contrast, for the CRFR2 gene, methylation in a stretch of the CpG island located 5′ of the transcription initiation site was decreased. Methylation was not changed in target regions of the 5-HT1A or MAOA gene. (p. 413)

What did they find? Essentially, DNA methylation was different for some of the genes in the group that had been subjected to maternal separation combined with unpredictable maternal stress than in the group that had been allowed to lead a normal mouse childhood.

So early maternal separation and distress can have effects at the epigenetic level that are carried through paternal lines to subsequent offspring. This is important news for developmental psychologists studying depression and other disorders, and should not be underestimated. That someone has figured out how care-taking behavior affects gene expression and can be carried across generations to me is simply phenomenal. But what does it all mean for trauma studies? I mentioned above this article was advertised as important for trauma studies, but the term trauma never comes up once in the manuscript — rather, the authors focus on “depression-like” behavior. This may be relevant to trauma studies — most people who develop PTSD also develop depressive disorders as well — but the research doesn’t show that somehow PTSD is passed along intergenerationally.

There is another, more subtle critique to be made here as well. The title of the article mentions “early stress” and the authors consistently refer to “chronic and unpredictable stress in early postnatal life” (p. 413) and the like. But I think it’s a mistake to apply these findings to childhood adversity in general, or even neonatal adversity in general. Their model of early stress was particular to one key developmentally crucial relationship: that of an offspring to it’s mother. Although there is good reason to believe that several types of early life adversity can affect one’s proclivity towards depression and other disorders, it does not follow that among these several types that there is one pathway for all, and certainly not that all are best seen as versions of being unpredictably separated from a stressed mother.

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.

Stressors, more stressors, and blaming the victim in wartime

Those people who dedicate their lives to addressing stressors among displaced populations are frequently faced with an uncomfortable truth: people under a lot of stress sometimes create more problems for themselves. This is a well-observed phenomenon across populations, and is generally known as “stress generation.” As regards trauma work, there is good research to show that the best predictor of future trauma is past trauma. For those of you not well-versed in stress generation, see Constance Hammen’s reflection on her career researching stress generation among depressed individuals in the Journal of Clinical Psychology.

The uncomfortable part of all this is that it can move quickly into “blaming the victim” (particularly as it pertains to trauma). If a combat veteran presents with PTSD and marital conflict due to the irritability and anger that is a part of the PTSD diagnosis, it can be very difficult not to get really frustrated with that vet’s anger and sink into “it’s your own damn fault” despite our initial sympathy. An automobile accident survivor has a higher likelihood of getting into another automobile accident than someone who hasn’t been in an automobile accident because the survivors tend to be extra cautious following their first accident, drive more slowly at the wrong times, get distracted by other drivers, etc.; if these things cause an accident, who is responsible?

When it comes to refugees, blaming the victim may result in less critical aid from the international community and stigma upon resettlement. And yet it’s clear to anyone who’s worked in refugee camps that a stressed population is a difficult population is difficult to work with. Indeed, one of the impetuses behind bringing psychosocial interventions into humanitarian aid is the danger that stressed refugees can pose to aid workers. There are numerous reports of refugees striking out against aid workers for small irregularities in aid distribution or changes in policies. (I should add that their are also striking reports of other refugees coming to the aid of aid workers.)

So how do we reconcile stress generation with our discomfort? Well, first by reminding ourselves that the first order of health provision is not morality. (I’ve harped on that before, and you probably don’t need to read it again here.)

Second, by looking further into stress generation research so we know what we’re talking about. In this literature, folks like Hammen make the distinction between “dependent, interpersonal” stressors and “independent, fateful” stressors. It turns out that research with people with mental health diagnoses have (on average) more stress-dependent events than people without mental health diagnoses, but have the same number of independent events. Dependent events are almost uniformly interpersonal in nature — and therefore plausibly related to how one would act towards others if really stressed. Independent events may be interpersonal, but their core feature is their fateful nature — they are not affected by how someone is acting.

How does the dependent-independent dichotomy map on to the typology of conflict-related stressors proposed in the last entry in this blog? Well, it’s pretty clear that mental health problems aren’t to blame for people being attacked or cause them to end up in unstable resettlement contexts — this is the “direct war exposure potentially traumatic events (PTEs)” category. For “collateral” and “other PTEs” (which, as I think through them may not be as distinguishable as they first seemed), the picture is less clear, and that some of these stressors are related to “being stressed” means that education campaigns surrounding the affects of stress (at the very least) are important. “Social ecological stressors” are clearly set off by displacement, but the breakdown of community institutions may be exacerbated by interpersonal problems. This is why the “social” in “psychosocial intervention” has always struck me as the more important of the two traditions. “Daily hassles” are likewise split between those problems that are outside of the control of the individual (e.g., a military checkpoint) and those that are exacerbated (unemotional reactions to hearing of abuse of loved ones). So perhaps the dependent-independent dichotomy is a second axis that runs through the typology proposed a few days ago. (Again, comments encouraged here.)

Important to remember through all of this is that all of these stressors are precipitated by an initial event — the event that was the cause of displacement. It would be difficult to argue that displacement events were dependent stressors. And yet many subsequent stressors, be they mild or traumatic, are dependent to some degree. In order to address these, humanitarian aid workers must remember the latter, and the former; they are equally important.

Article addendum: Stressors during wartime

The April 2010 issue of the American Journal of Orthopsychiatry includes an article comparing the effects of war-related trauma on mental health to effects of the “current stressors” one finds in refugee camps. I’m the first author on this article, and so I’m going to take the privileges afforded by that role and be somewhat critical of the work here.

The article is based around the idea that there are lots of things that happen during wartime that cause emotional and cognitive distress in addition to armed conflict. In order to decide what to do about distress in displacement camps, one should consider these non-conflict stressors. In the paper, we measured war-related traumas (or “potentially traumatic events” to be more precise) separate from other “camp stressors” and examined which was more highly associated with the psychological problems of posttraumatic stress disorder, depression, and two local idioms of distress (local ways of discussing emotional problems). We found that war trauma and camp stressors among Darfur refugees were both related to all four psychological problems, and in several cases the number of camp stressors was actually more strongly associated with these than the number of war traumas. We went on to find that camp stressors partially mediated the effects of war trauma on most psychological problems. We concluded that humanitarian aid agencies interested in addressing general distress in camps thus had empirical support for interventions that target everyday camp stressors, in addition to popular war-related and trauma-focused interventions (which are already empirically-supported for displaced persons with posttraumatic distress).

Since the manuscript was accepted (fall of 2009) I have had a number of opportunities to think about the variability within this category of “current stressors.” Critical to this was the opportunity to co-author an editorial on trauma-focused versus psychosocial perspectives in humanitarian aid with my friend and sometimes collaborator Ken Miller, who is really the pioneer in this work (look up his stuff on Afghanistan and Sri Lanka for examples). Something has always bothered me about the category “current stressors” and a common criticism is that we are throwing a lot of different types of stressors — with different effects — into the same conceptual bag. So, I’d like to propose — really by way of proposing a starting point, not answering the problem outright — a typology of stressors that are critical to consider in studying the psychological consequences of armed conflict and displacement.

1. Direct war exposure potentially traumatic events (PTEs): Direct (both personally experienced and witnessed) exposure to the violence and destruction of war. Examples include (but are in no way limited to) direct attacks by military (or paramilitary) personnel, being pursued by these forces, bombing, and exposure to mines.

2. Collateral PTEs: Direct exposure to trauma collateral to war (i.e., coming about because of war) but not comprising an act of war itself. This may include abuse by non-military persons during flight (e.g., criminals or fellow refugees), attacks by locals in the displacement context, abuse by peacekeeping forces, and motor vehicle accidents occurring during flight.

3. Other PTEs: Non-war-related traumatic events that increase during wartime. It has been noted that all forms of violence increase during wartime (e.g., see the work of James Garbarino for particularly articulate illustrations), whether because of stress on the perpetrators of these events or degraded safety of settings which allow these events to occur more frequently. Examples include domestic violence, child abuse, and attacks by dangerous animals (e.g., poisonous snakes are evidently a big problem in some refugee camps in Sri Lanka).

4. Social ecological stressors: War-related degradation of social institutions (both formal and informal). Examples are destruction of schools and subsequent lack of educational opportunity, diminished health care, loss of social support networks, religious institutions, war-induced poverty, and famine. It may be difficult to distinguish some of these from preexisting conditions (e.g., the difference between war-induced and preexisting poverty may be minimal in some cases).

5. Daily hassles: Daily hassles are those seemingly minor problems of daily life that either come to exist or increase in intensity in wartime. These have shown to be strongly related to mental health problems in non-war contexts, even moreso than stressful major life events. These may include checkpoints along a commute, regular questioning by military or police, mild forms of humiliation (e.g., degradation by authorities, bribes), needing multiple forms of documentation in order to complete simple tasks, long wait times in order to get basic resources (e.g., food distribution at refugee camps), and hearing complaints about such daily hassles from loved ones. All involve some persistent inconvenience or stressor that is not physically abusive or threatening. Some daily hassles may at times come close to collateral trauma (e.g., regular questioning that involves strip searches).

It is important to note that for individuals exposed to the different types of stressors delineated above, differences may seem phenomenologically trivial. Stressors related to direct attacks, harassment and abuse during flight, and loss of social networks may be part and parcel of a single, undelineated narrative of war. Moreover, for many these categories may not be readily distinguishable from non-war-related stressors. War-induced poverty may be seen as an extension of preexisting poverty, increases in domestic abuse may be experienced as an extension of pre-war abusive relationships, and bribes paid to police during wartime may have the same effect as bribes during peacetime. In order to study the effect of conflict, researchers should conduct work that estimates the change in prevalence, incidence, and effect on outcomes of these phenomena over time (i.e., pre-conflict to conflict).

Let me reiterate that these are only a first pass at types of stressors, and I welcome all comments. Next: The sticky problem of stress generation among displaced populations.

Louis Menand in the New Yorker on depression and therapy: Mental health as science? Science as science?

In this week’s New Yorker, Louis Menand writes eloquently about depression, psychotherapy, psychopharmacology, and our American culture. Although as a journalist he glosses over a few complex issues, for the most part he presents them with impressive clarity and even a history lesson (re valium in the 1970s and ’80s). Here’s a teaser:

The position behind much of the skepticism about the state of psychiatry is that it’s not really science. “Cultural, political, and economic factors, not scientific progress, underlie the triumph of diagnostic psychiatry and the current ‘scientific’ classification of mental illness entities,” Horwitz complained in an earlier book, “Creating Mental Illness” (2002), and many people echo his charge. But is this in fact the problem? The critics who say that psychiatry is not really science are not anti-science themselves. On the contrary: they hold an exaggerated view of what science, certainly medical science, and especially the science of mental health, can be.

Mental health has come under fire recently, and Menand shows us why — but the conclusion is not as simple as it might seem.

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