Tuesday, May 14, 2013

Cultural Illness and the Curse of Shifting Sands DSM V

In evaluating dysfunction or illness, we have long followed the seemingly straightforward model of diagnose, treat, evaluate, iterate

Studio Gibli
However, diagnosis has long been the secret -- or not so secret -- Achilles heel of the psychiatric establishment. Many philosophic issues arise, issues of cultural relativism, ethical issues of financial interests in pharmaceuticals, to name a few. These are issues that 'by the book' psychiatrists frequently dismiss as 'merely philosophical.' Indeed, it's been a relatively long time since Freud or Jung were taken entirely seriously by the establishment doling out the meds.

"By the book." What is "the book"?
Since DSM-III (American Psychiatric Association 1980), disorders have
been defined in terms of syndromes—that is, clusters of symptoms that covary together (see the section following, titled “Need to Explore the Possibility of Fundamental Changes . . .”). ...
The major focus of field trials for DSM-III was establishing the reliability with which multiple clinicians could come to the same diagnostic conclusions when presented with a patient’s expressed signs and symptoms. In this manner, it was possible to demonstrate that an atheoretical, descriptive approach could result in a reproducible diagnosis in multiple clinical and cultural settings. Following the publication of DSM-III in 1980, data began to emerge by 1983 from some new studies that were not consistent with the syndromal definitions in DSM-III. ... A Research Agenda for DSM V

For those that continue to see the DSM as a gold standard in this regard, we don't need to recall the times when homosexuality was considered a mental illness. There are remain plenty of conceptual holes with the schema of the DSM 5. In fact, the NIH has gone so far as to disavow the DSM V as a successful diagnostic standard. 

This is not to argue that there is no need for a standard, or that the DSM is entirely bogus. I have neither the background nor experience to make those claims. However, it is fairly well established that the diagnose for disorder model is plagued with these "philosophical issues." The issue of culture is one that comes up most frequently, next to quandaries of brain and consciousness, body and mind, which we have already touched on.
Anthropologists have become increasingly interested in embodiment—that is, the ways that socio-cultural factors influence the form, behavior and subjective experience of human bodies. At the same time, social cognitive neuroscience has begun to reveal the mechanisms of embodiment by investigating the neural underpinnings and consequences of social experience. Despite this overlap, the two fields have barely engaged one another. We suggest three interconnected domains of inquiry in which the intersection of neuroscience and anthropology can productively inform our understanding of the relationship between human brains and their socio-cultural contexts. These are: the social construction of emotion, cultural psychiatry, and the embodiment of ritual. (Full article.)
Another example:
There is little consensus on the extent to which psychiatric disorders or syndromes are universal or the extent to which they differ on their core definitions and constellation of symptoms as a result of cultural or contextual factors. This controversy continues due to the lack of biological markers, imprecise measurement and the lack of a gold standard for validating most psychiatric conditions. Article.
These are indeed philosophical problems. But that doesn't mean that they don't need to be considered seriously. Philosophy is, in many ways, at its worst when applied to itself, and at its best when applied to the rest of the world. There are deep rooted philosophical issues inherent in many methodologies that are simply painted over with staid narratives. 

There is so much variance from culture to culture that in some, disorders present themselves that exist nowhere else. It's been loosely classified as "culture-bound syndrome."  
In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture. ... Even though the concept is controversial, the term culture-bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) which also includes a list of the most common culture-bound conditions (DSM-IV: Appendix I).

The fourth edition of Diagnostic and Statistical Manual of Mental Disorders classifies the below syndromes as culture-bound syndromes:[11]
NameGeographical localization/populations
Fan deathSouth KoreaNorth Korea
Running amokMalaysiaIndonesiaPhilippinesBruneiSingapore
ataque de nerviosLatinos
biliscóleraLatinos
bouffée déliranteWest Africa and Haiti
brain fagWest African students
dhat syndromeIndia
falling-outblacking outSouthern United States and Caribbean
ghost sicknessAmerican Indian
HwabyeongKorean
koroChinese and Malaysian populations in southeast AsiaAssam; occasionally in West
latahMalaysia and Indonesia
locuraLatinos in the United States and Latin America
evil eyeMediterraneanHispanic populations
nerviosLatinos in the United States and Latin America
PibloktoArctic and subarctic Eskimo populations
Zou huo ru mo (Qigong psychotic reaction)Chinese
rootworkAfrican American and White populations in southern United States; Caribbean
sangue dormidoPortuguese populations in Cape Verde
shenjing shuairuoChinese
shenkuiChinese
shinbyeongKorean
spellAfrican American and White populations in the southern United States
sustoLatinos in the United StatesMexicoCentral America and South America
taijin kyofushoJapanese
zārEthiopiaSomaliaEgyptSudanIran, and other North African and Middle Eastern societies


This might be a case of the same thing appearing different, within different contexts. Although it is just a conceptual example, consider this image: 
At what point does your brain lose sight of the fact that square A and square B are the same shade of gray?

This illusion is a perfect example of cultural blinders too. Not literally (it's our brain) but this shows a little how our brain creates an illusory pattern of its inputs that are more self congruent than necessarily accurate. (Which is a reason I don't trust my beliefs any more than I trust my eyes.)

The whitepaper Cultures as a Causative for Mental Disorder  provides a decent scheme through which we might better understand this issue,
1. Culture May Be Thought to Determine the Pattern of Certain Specific Mental Disorders.
2. Culture May Be Thought to Produce Basic Personality Types, Some of Which Are Especially Vulnerable to Mental Disorder.
3. Culture May Be Thought to Produce Psychiatric Disorders through Certain Child-Rearing Practices.
4. Culture May Be Thought to Affect Psychiatric Disorders through Types of Sanction.
5. Culture May Be Thought to Perpetuate Psychiatric Malfunctioning by Rewarding It in Certain Prestigeful Roles.
6. Culture May Be Thought to Produce Psychiatric Disorders through Certain Stressful Roles.
7. Culture May Be Thought to Produce Psychiatric Disturbance through Processes of Change.
8. Culture May Be Thought to Affect Psychiatric Disorder through the Indoctrination of Its Members with Particular Kinds of Sentiments.
9. Culture per se May Be Thought to Produce Psychiatric Disorder.
10. Culture May Be Thought to Affect the Distribution of Psychiatric Disorders through Patterns of Breeding.
11. Culture May Be Thought to Affect the Distribution of Psychiatric Disorder through Patterns Which Result in Poor Physical Hygiene.
Though thorough, even this analysis is problematic in its idea of a centrality of disorder. What is categorized as normal or aberrant is clearly subject to social standards and contexts.

This is summed up in the abstract to this article,
Changes incorporated into the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) include a number of features designed to enhance its cross-cultural applicability. However, the overt move toward a culture-sensitive nosology is undermined by an implicit assumption of the universality of its primary syndromes.
It might be facile to point out that war is state mandated murder, but there it is. However, even when the state mandates it, many people recoil. (Are those that recoil, those that develop PTSD, those that accept it and adapt, or those that enjoy it the ones with a disorder?)

How can we come to grips with this issue when evaluating our own mental and/or physical wellbeing? Can we trust our pharmeceutical methodology at all when it seems likely that the placebo effect itself is getting stronger?

These are issues that we will continue to wrestle with for all time, I believe. It is the mythologizing reflex itself which forces us into a conceptual hall of mirrors.

[Where is the fucking counterculture? Mythos Media.]

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