Sunday, July 7, 2013

Cultural Factors and Mental Illness

Modern psychiatry has often been criticized because its approach to diagnosing mental illness is based on identifying a particular malady by comparison with a committee-approved collection of symptoms rather than via some sort of physically measurable manifestation. Ethan Watters provides an interesting perspective on mental illness and its manifestations in an article in Pacific Standard. He begins with this lede:

"Psychiatry is under attack for not being scientific enough, but the real problem is its blindness to culture. When it comes to mental illness, we wear the disorders that come off the rack."

What Watters is implying is that when a person is suffering mental distress, the way the person communicates his/her distress is suggested by cultural clues that help insure that this distress will be recognized and taken seriously. In Watters’s view the symptoms expressed become a mechanism for crying out in pain in a language easily understood.

"Viewed over history, mental health symptoms begin to look less like immutable biological facts and more like a kind of language. Someone in need of communicating his or her inchoate psychological pain has a limited vocabulary of symptoms to choose from."

From this perspective, psychiatry and mental health diagnosis looks like an iterative collaboration between the tormented and those who would help the tormented. The very act of defining a set of symptoms that are representative of a particular mental illness, suggests to those in mental distress how to construct their cry for help in a way that will be easily interpreted.

"Because patients usually seek help when they are in need of guidance about the workings of their minds, they are uniquely susceptible to being influenced by the psychiatric certainties of the moment. There is really no getting around this dynamic....The human unconscious is adept at speaking the language of distress that will be understood."

To illustrate this point, Watters reminds the reader that in the late nineteenth century the diagnosis of "female hysteria" was quite common.

"Women by the tens of thousands, after all, displayed the distinctive signs: convulsive fits, facial tics, spinal irritation, sensitivity to touch, and leg paralysis. Not a doctor in the Western world at the time would have failed to recognize the presentation. ‘The illness of our age is hysteria,’ a French journalist wrote. ‘Everywhere one rubs elbows with it’."

These symptoms were consistent with what women were told about themselves, and consistent with what doctors believed about women:

"....fanciful beliefs about female anatomy, an assumption of feminine weakness, and the Victorian-era weirdness surrounding female sexuality."

This form of mental illness eventually disappeared. It vanished not because of some miracle drug or treatment; it vanished because it became unpopular. The symptoms were no longer satisfactory to women as a demonstration of suffering, and psychiatrists were developing a new set of symptoms that they were more willing to recognize. If one wishes to receive help, one has to communicate in the language the help-givers understand.

"The resounding lesson of the history of mental illness is that psychiatric theories and diagnostic categories shape the symptoms of patients. ‘As doctors’ own ideas about what constitutes ‘real’ disease change from time to time,’ writes the medical historian Edward Shorter, ‘the symptoms that patients present will change as well’."

Watters can’t quite bring himself to recognize a logical conclusion that can be drawn from the history he has provided. If "female hysteria" disappeared for non-medical reasons, then it could not have been a mental illness in the sense of representing a brain malfunction.

If cultural cues induced the symptoms that women suffering from hysteria demonstrated, and then, at a later time, made them disappear, how can one differentiate between medical fads and mental illness?

If cultural cues induce symptoms, and symptoms define the mental illness, then why can’t cultural cues induce the illness itself?

If mental illness is related to a chemical imbalance or a neurological malfunction, then how can its symptoms be induced and eliminated by cultural signals?

If psychiatrists and drug companies claim that mental illness can be "cured" by drug therapy, doesn’t that create an environment where people with difficult problems to address will find it easier to declare themselves mentally ill in search of a simple pill-based solution rather than attempt to resolve their problems by addressing them directly?

Consider depression. Everyone suffers from sadness, grief, anxiety, and apprehensions. This is all perfectly normal—up to the point at which it is no longer normal and becomes mental illness. Is there some physical transition that takes place, or are we mainly dealing with culturally defined (and thus arbitrary) norms that define the transition? Clearly there are some people with symptoms so severe that medication is called for to alleviate the symptoms, but how many would be better served by socializing their mental distress and seeking traditional forms of support from family, friends, and counselors? 10%? 50%? 90%?

It is rather easy to conclude that clinical depression might be a greatly over diagnosed condition based on cultural factors, but what about a more complex illness such as schizophrenia?

Tanya Marie Luhrmann discusses mental illness in general, and schizophrenia in particular, in an article in the Wilson Quarterly: Beyond the Brain. The title is meant to convey the notion that what we refer to as mental illness is more complex than a mere brain malfunction that can be addressed by appropriate drugs.

"It is now clear that the simple biomedical approach to serious psychiatric illnesses has failed....At least, the bold dream that these maladies would be understood as brain disorders with clearly identifiable genetic causes and clear, targeted pharmacological interventions (what some researchers call the bio-bio-bio model, for brain lesion, genetic cause, and pharmacological cure) has faded into the mist."

She provides this introduction to modern thought on schizophrenia:

"To be sure, it would be too strong to say that we should no longer think of schizophrenia as a brain disease. One often has a profound sense, when confronted with a person diagnosed with schizophrenia, that something has gone badly wrong with the brain."

"Yet the outcome of two decades of serious psychiatric science is that schizophrenia now appears to be a complex outcome of many unrelated causes—the genes you inherit, but also whether your mother fell ill during her pregnancy, whether you got beaten up as a child or were stressed as an adolescent, even how much sun your skin has seen. It’s not just about the brain. It’s not just about genes."

The incidence, severity, and probability of relief from symptoms seem to depend on social and cultural factors.

"In recent years, epidemiologists have been able to demonstrate that while schizophrenia is rare everywhere, it is much more common in some settings than in others, and in some societies the disorder seems more severe and unyielding. Moreover, when you look at the differences, it is hard not to draw the conclusion that there is something deeply social at work behind them."

"Schizophrenia has a more benign course and outcome in the developing world. The best data come from India. In the study that established the difference, researchers looking at people two years after they first showed up at a hospital for care found that they scored significantly better on most outcome measures than a comparable group in the West. They had fewer symptoms, took less medication, and were more likely to be employed and married."

The better outcomes in India seem to be derived from a firmer belief that the illness can be overcome and sufferers will be able return to a normal life. If your belief is that your brain is damaged and requires medical treatment, you will tend to wait around for treatment to come and help—something that rarely happens. Cultural cues are extremely important.

"As a result, none of the patients thought of themselves as having a career-ending illness, and every one of them expected to get better. And at least compared to patients in the West, they generally did."

Luhrmann suggests that the notion that social factors can be both disease activating and disease curative is becoming more widely accepted. She refers to several patient-driven organizations who are dedicated to self-help approaches to illnesses rather than depending on medications. One such group is called the Recovery Movement. Perhaps the most intriguing approach to dealing with the issues of schizophrenia is provided by the "Hearing Voices" movement.

"In Europe, the Hearing Voices network teaches people who hear distressing voices to negotiate with them. They are taught to treat the voices as if they were people—to talk with them, and make deals with them, as if the voices had the ability to act and decide on their own. This runs completely counter to the simple biomedical model of psychiatric illness, which presumes that voices are meaningless symptoms, ephemeral sequelae of lesions in the brain. Standard psychiatric practice has been to discount the voices, or to ignore them, on the grounds that doing so reminds patients that they are not real and that their commands should not be followed. One might think of the standard approach as calling a spade a spade. When voices are imagined as agents, however, they are imagined as having the ability to choose to stop talking. Members of the Hearing Voices movement report that this is what they do. In 2009, at a gathering in the Dutch city of Maastricht, person after person diagnosed with schizophrenia stood up to tell the story of learning to talk with the voices—and how the voices had then agreed to stop."

Dealing with mental illness in a proper fashion is critical. In the past mental illness was rare and episodic. Somehow our society and our science have managed to make it common and chronic.

Something has gone terribly wrong!

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