Gatorade, the popular sports drink, uses its slogan “Is it in you?” to describe the competitive drive in athletes, which is presumably enhanced by drinking their product. Just like the Gatorade slogan suggests about athletes, is pyschopathy a condition simply found in some and not in others? Or are there other factors that go into this serious mental condition? This post will explore the mental condition behind psychopathic behavior, how it differs from the normal human condition, and how it relates to the treatment of crime in society.

Psychopathy: What Is It?

While not always associated with crime, psychopathic behavior often comes up as a reason for and a cause of both small and horrendous crimes. A recent review indicates psychopathy is an accurate indicator of a person’s susceptibility to criminal behavior and violence.

“Although psychopaths make up only 4% of the total population, they represent about 50% of serial rapists, as well as a significant proportion of persistent wife batterers. Overall, psychopaths are twice as likely to reoffend as other criminals, and three times as likely to commit violent acts again after being convicted.” (Copley 2008)

Psychopathic behavior also involves someone who in a sense has no conscience. These individuals do not feel any remorse or take moral considerations into their actions, whether violent or non-violent. Thus the sense of guilt or internal punishment that normal people experience on a daily basis is important to dealing with and understanding psychopathic behavior in society.

Guilty Conscience

Guilt is a feeling that most people will experience as an emotional reaction to committing some action which our conscience or culture has told us is wrong. From pick pocketing a candy bar in a grocery store to murdering another individual, guilt creeps into our conscience after committing such an act. This common human emotion can be termed as internal punishment. In the case of small thefts or major crime, this sense of internal punishment can often be more damaging to an individual than any physical punishment. Internal punishment and its effects can be an important link to understanding the relationship between crime and society.

While the feeling of guilt is normal for most, it may not be the same for everyone. Based on our background, moral upbringing, or political and religious views, some people experience a different or heightened sense of guilt. Take one’s childhood. When you were little you probably didn’t know not to beat up your brother, break things that weren’t yours, or steal things from others or maybe even a small grocery store. Yet whenever you did these actions, someone, usually one of your parents, was there to scold you and tell you not to do it again. As a child grows up, this often is the background for his or her moral conscience. In this way the society or environment one lives in helps shape his or her choices, and hopefully in the long run helps prevent crime.

Likewise with punishment, societal expectations often guilt people into admitting their mistakes or show them how to be remorseful and shameful. Without feeling proper internal punishment or remorse, criminals will often not be accepted back into society. In almost any prison one of the main criteria for prisoners to be released on parole is if they can show they are remorseful for what they did.

One good example is the recent scandal surrounding Tiger Woods. While not criminal, the public discovery of his actions has forced him to be remorseful and apologetic to the public. Whether you believe him or not, societal norms tell us that he will be more easily accepted back into good public opinion if he appears shamed at what he did.

Mind of a Killer?

All of this relates back to the problem of individuals who do not experience any regret for what they did, or take little account of morality when carrying out actions. Normal social practices do not shape their mindsets because of this mental condition of psychopathy. So, why don’t certain people feel this guilt or experience their own internal punishment? And how can society prevent crime from occurring or punish such crimes when dealing with psychopathic behavior?

These questions are not easily answered, but are especially important since a significant part of most societal approaches to deterring crime and dolling out punishment rely on ideas about guilt, confession and public shame. However, not all psychopaths are necessarily violent. Rather, psychopathy appears to be a mental disorder characterized by an unusual lack of moral feeling and usually amoral actions. Studies have shown that psychopathic individuals have a large capacity to act like normal people and fit into society. The same article by Jennifer Copley on personality disorders indicates that “Only 20-25% of those in prison are psychopaths.” This supports the theory that many people who exhibit psychopathic behavior are not hardened criminals, cold-stone killers, or some sort of amoral deviants – despite popular depictions.

Yet the fact that psychopaths can fit in with society contrasts with other mental disorders, which often hinder people from fitting into common society, and makes the psychopathic condition unique. An experiment by Professor Declan Murphy elaborates on one theory about the condition, that psychopaths show different responses in their brains to emotional pictures than normal people. He and his colleagues showed six psychopaths and nine healthy volunteers pictures of faces showing different emotions. When they were showed happy faces, the psychopaths experienced slightly smaller brain activity than the normal people. On the other hand, when showed fearful faces, “the healthy volunteers showed increased activation and the psychopaths decreased activation in these brain regions.” (BBC 2006) This further suggests that psychopaths lack empathy or conscience, and thus can fit in with society yet also use people like objects, manipulate people, commit violent crime, and feel no guilt or remorse.

Ask the Expert

One of the leaders in the field of criminal psychology is Robert Hare, a 71-year old professor at the University of British Columbia. Hare was one of the leaders in suggesting that psychopathy relates to brain activity in a study he published in 1991. In an article from the Canadian Encyclopedia, Hare indicates that the term psychopath is often misused in the media.

The article uses the famous movie Silence of the Lambs as a comparison by saying, “In the film Silence of the Lambs…a prison psychiatrist calls serial killer Hannibal ‘the Cannibal’ Lecter a ‘pure psychopath.’ In fact, experts like Hare say that Lecter does not really qualify as a psychopath at all. ‘He’s just insane,’ deadpans the professor.”

This might be just one example from the media, but many movies or stories about psychopathic behavior aren’t necessarily completely factual. Often psychopaths are portrayed as psychotic serial killers or delusional criminals, when in fact they are more prone to be average people who simply don’t feel empathy and are screwed up emotionally.

Hare gave an interesting talk in 2002 about psychopathy and who it affects. Yet unlike normally suggesting that this condition was related to typical serious criminals, Hare suggested that major businessmen and CEO’s may be psychopaths. While this seems radical, Hare supports this claim in view of the Enron and WorldCom scandals, and the actual definition of a psychopath.

Compulsion

Another facet of the psychopathic condition that has been studied is its relation to compulsive and obsessive behavior. Studies show that psychopaths often commit crime or manipulate others because they feel they can dominate others or use others for their own personal gain. Often this feeling can be predicated by a sense of compulsion. At times, psychopathic behavior can be part of a game to manipulate others. Psychopaths also seek out crime or violent actions simply to get a thrill, which can be heightened because they do not experience any moral guilt or hesitation toward these actions. In a sense, crime for them can be looked at as continually trying to find new ways to manipulate or deceive others and get away with it.

Obsessive behavior also factors into this idea of compulsion. Although not quite synonymous, obsession can result from compulsive behavior. This also applies to psychopathic behavior. The compulsive nature of psychopaths leads them to obsess over committing certain types of crime. One example of this is found in an article examining the relationship between psychopathy and stalking. This research suggests that psychopathic traits are associated with stalkers and what the article calls “stalking risk factors.” The article says, “people with psychopathic traits tended to show escalation in the frequency, severity and/or diversity of their stalking, [and] they were noticeably unrepentant regarding their actions”

Psychopathic Solution?

In conclusion, psychopathy is a condition that may only affect from 1 or 4% percent of the population depending on the research. The main characteristics of this disorder are lack of empathy or conscience, no feelings of remorse or guilt after committing crime, and a general view of others as objects that can be manipulated or used.

So why has so much research and concern been put into understanding the condition and how to treat it? This is likely due to the assumed connection between serious crime and this disorder, as well as the fear that psychopaths might be living among us even as they excel at fitting in.

A final question remains: can psychopathic behavior be treated? A recent article puts it simply, “According to the psychiatrists, No. Shock treatment doesn’t work; drugs have not proven successful in treatment; and psychotherapy, which involves trust and a relationship with the therapist, is out of the question, because psychopaths are incapable of opening up to others. They don’t want to change.” One thing is certain – more research on the problem and how to deal with it is urgently needed.

In the meantime, both individuals and society are left with that Gatorade question: Is psychopathy in you?

You can access the entire draft here at the American Psychiatric Association DSM-5 Development Website. There the APA writes about the comment policy:

The draft disorders and disorder criteria that have been proposed by the DSM-5 Work Groups can be found on these pages. Use the links below to read about proposed changes to the disorders that interest you. Please note that the proposed criteria listed here are not final. These are initial drafts of the recommendations that have been made to date by the DSM-5 Work Groups. Viewers will be able to submit comments until April 20, 2010. After that time, this site will be available for viewing only.

It is interesting to note that the APA included a press release announcing that the DSM-5 Development Process Includes Emphasis on Gender and Cultural Sensitivity.

Actual proposed changes are set up in an interesting way. The opening tab is the proposed revision, but there is also are rationale, severity, and DSM-IV tabs. So it does provide more information than one might think.

So, as one major example, Major Depressive Disorder, Recurrent, has an extensive draft proposal for the DSM-5. Here the rationale isn’t that great, since it largely focuses on single episodes of depression. On the severity side, it’s clear what the APA group is thinking about in terms of differential ratings. And it’s easy to compare the DSM-5 with the DSM-IV criteria.

Vaughan Bell at Mind Hacks includes some extensive commentary, and a wealth of links, on the DSM-5 Draft in the piece The Draft of the New ‘Psychiatric Bible’ Is Published. He opens by saying:

It’s a masterpiece of compromise – intended to be largely backwardly compatible, so most psychiatrists could just get on diagnosing the few major mental illnesses that all clinicians recognise in the same way they always did, with some extra features if you’re an advanced user.

One of the most striking extra features is the addition of dimensions. These are essentially mini questionnaire-like ratings that allow the extent of a condition to be numerically rated, rather than just relying on a ‘you have it or you do not’ categorical diagnosis.

John Grohol, writing over at Psych Central, also provides an initial overview of the main changes in the DSM-V and then provides a review that features the good, the bad and the ugly.

If you’re looking for just the critical, the Psychiatric Times has a piece Opening Pandora’s Box: The 19 Worst Suggestions For DSM-5. Dr. Allen Frances, who chaired the DSM-IV Task Force, identifies two areas that are quite worrisome (and predictable) for a critical medical anthropologist:

(1) Dramatically higher rates of mental disorder, including “millions of newly misidentified false positive ‘patients’ [and] massive overtreatment with medications that are unnecessary, expensive, and often quite harmful”

(2) Unforeseen consequences, where DSM5 options often have an “insensitivity to possible misuse in forensic settings. Work Group members cannot be expected to anticipate the many ways lawyers will try to twist their good intentions.”

You can explore the legal aspects more over at In the News.

For specific diagnoses, Dr. Petra has particularly good coverage on the proposed changes in sexual disorders. Liz Spikol looks at the diagnosis of childhood bipolar disorder with a critical eye.

For more reading, Furious Seasons has some good initial thoughts on the DSM-5. Additional coverage can be found at the NY Times and New Scientist.

Ronald Wintrob, chair of the World Psychiatric Association–Transcultural Psychiatry Section, writes the Introduction to Cross-Cultural Psychiatry for this special report. He notes how migration has increased over the past 20 years, and that 12.86% of the US population are immigrants. Psychiatrists have put increasing effort into engaging these populations.

One of the most practical applications of cultural psychiatry to clinical practice in all fields of medicine is the open-ended questioning of patients and their families about their personal and family background characteristics. This includes identifying features of race, ethnicity, religion, and socioeconomic class, relevant immigration history, experiences of acculturative stress, and personal and family aspirations. A discussion of these background characteristics can lead naturally to the clinician’s exploration of the presenting clinical symptoms and history. Knowledge of the patient’s background will increase rapport with patients and families and aid the process of collecting a more reliable history. In addition, it will improve the likelihood of treatment adherence. This process has been described as “cultural case formulation.”

Three main articles comprise the special issue:

Religion, Spirituality, and Mental Health by Simon Dein, senior lecturer of anthropology and medicine at University College London. This piece provides an in-depth examination of what is currently known about the relationships between religion and mental health, and also includes a handy set of four check points that summarize the main themes of the article.

Cultural Considerations in Child and Adolescent Psychiatry, by Toby Measham, Jaswant Guzder, Cécile Rousseau, and Lucie Nadeau, all in the department of psychiatry at McGill, which presents a series of guidelines and suggestions for how to handle cross-cultural issues in practice with children and adolescents

Cultural and Ethnic Issues in Psychopharmacology, by Keh-Ming Lin, professor emeritus in psychiatry at UCLA. This piece goes from the placebo effect to genetic variation, and argues that “cultural and ethnic influences… should be regarded as central in determining the success of treatment interventions.”

Under the whole category of cross-cultural psychiatry at Psychiatric Times, you can also find other articles, including this one by J. David Kinzie on A Model for Treating Refugees Traumatized by Violence.

Link to the Introduction to the Special Report on Cross-Cultural Psychiatry.

graphic by Alex Trochut, NYTimes

The ethnographic record is full of conditions that didn’t make it into the most recent edition of the DSM — amok, nervios, koro, zar — you can check out Wikipedia or some other source on ‘culture bound syndromes,’ such as Introduction to Culture-Bound Syndromes in Psychiatric Times, to get a fuller discussion of some of these conditions. The Psychiatric Times piece suggests that there are at least 200 culture-bound syndromes.

One thing I really liked about the New York Times Magazine article, however (and by extension, Watters’ book, I suspect), is that the discussion of ‘culture-bound syndromes’ usually tends to treat other people’s syndromes as ‘culture-bound,’ Western psychological illnesses as not ‘culture-bound.’ Watters’ work points out that Western mental illness is both itself culture-bound and that persuading people to believe in Western-style mental illness can affect the way that psychic disorders manifest.

In fact, even Western history is littered with examples of truly odd and intriguing psychic illnesses that we seem to be vulnerable to for short periods of time. If you’re starved for more examples of culturally induced psychological conditions that include both Western and non-Western versions, you could check out Outbreak: The Encyclopedia of Extraordinary Social Behaviour, also discussed at Mind Hacks. Sounds like a brilliant read, with material like the following cited by Vaughan:

The Fortean Times article has some great excerpts covering an outbreak of feinting in a marching band in 1973 Alabama (a classic case of mass hysteria), an outbreak of cat-like meowing in India in 2004, the 1958 hula-hoop craze, a goblin scare that affect Zimbabwe in 2002, a ‘culture bound syndrome’ with the unusual name of the jumping Frenchmen of Maine from the 18th and 19th centuries, various outbreaks of fears about chemtrails, a giant earthworm hoax that panicked a Texas town in 1993, and a version of Orson Well’s War of the Worlds that caused widespread rioting in Ecuador in 1949.

But I digress simply because the examples themselves are so fascinating…

To return to the New York Times Magazine piece, Watters discusses how a group of psychological anthropologists and cross-cultural psychologists have argued that, just as humans are psychologically and socially diverse, they are diverse, too, when it comes to psychic ailments:

Swimming against the biomedical currents of the time, they have argued that mental illnesses are not discrete entities like the polio virus with their own natural histories. These researchers have amassed an impressive body of evidence suggesting that mental illnesses have never been the same the world over (either in prevalence or in form) but are inevitably sparked and shaped by the ethos of particular times and places.

Between the lines, the article suggests two slightly different, competing explanations for this diversity in psychological illness. On the one hand, the variety might arise because the language of somatization of distress varies from place to place. As one source for Watters’ article argues:

“We might think of the culture as possessing a ‘symptom repertoire’ — a range of physical symptoms available to the unconscious mind for the physical expression of psychological conflict,” Edward Shorter, a medical historian at the University of Toronto, wrote in his book “Paralysis: The Rise and Fall of a ‘Hysterical’ Symptom.” “In some epochs, convulsions, the sudden inability to speak or terrible leg pain may loom prominently in the repertoire. In other epochs patients may draw chiefly upon such symptoms as abdominal pain, false estimates of body weight and enervating weakness as metaphors for conveying psychic stress.”

In Shorter’s explanation, symptoms are a kind of social communication of ‘psychological conflict,’ varying because different eras and areas offer different ‘symptom repertoires,’ different palettes in which to paint one’s distress. In this model, because the community or specialists respond to particular sorts of patient presentation, believing that certai symptoms are especially salient, the disorders quickly conform to the expectations of therapists, whether they wear white coats, tweed coats with arm patches, or ritual body paint.

While this is certainly possible, and maybe even probable in some cases, some psychological disorders seem to be less labile, less liable to renegotiation of the symptoms, although the symptoms do vary slightly across cultures or occur at different rates, have varied rates of recovery, or the like. Some disorders have neurological or neurochemical dynamics that are susceptible, at least in part, to treatment with drugs, so all symptoms may not be so culturally negotiable, although they might still vary in frequency, severity, and trajectory as I’ll discuss. That is, the ‘symptom repertoire’ explanation — which I concede likely explains some of the variation, but not all — demands that psychic illness be a kind of unconscious performance of internal, psychic conflict. The assumption seems to be that universal psychic dilemma — conflict — gets expressed in locally variable argot — symptom.

The second explanation which I find more compelling is implicit in the article, and not fully developed. A more holistic model of variation in psychological illness would concede that, in some cases, symptoms are very malleable, and some symptoms of a disorder may be susceptible to this type of modification-by-expectation, but there might be more intransigent organic dimensions of disorders that still might vary culturally, but not due only to therapists’ expectation. The domain of the ‘cultural’ might be broader and less inherently conscious than just ‘beliefs.’

The case of anorexia nervosa in Hong Kong

Let’s take the case of anorexia nervosa in Hong Kong that Watters discusses. According to Watters, Dr. Sing Lee documented occurrences of a rare form of anorexia in Hong Kong throughout the 1980s and 1990s. Lee’s patients ‘did not intentionally diet nor did they express a fear of becoming fat,’ instead complaining that they felt ‘bloated.’ Then in 1994, a very public case of a girl who had starved herself hit the press, and Dr. Lee noticed a shift in anorexia: the number of cases climbed, and the sufferers began to diet and express fear of becoming fat, just like the American version of the disorder: ‘As the general public and the region’s mental-health professionals came to understand the American diagnosis of anorexia, the presentation of the illness in Lee’s patient population appeared to transform into the more virulent American standard.’

Lee explains how generalized psychological disorder leads to a specific eating disorder: ‘When there is a cultural atmosphere in which professionals, the media, schools, doctors, psychologists all recognize and endorse and talk about and publicize eating disorders, then people can be triggered to consciously or unconsciously pick eating-disorder pathology as a way to express that conflict.’

But is that really all that happened, people talking about anorexia? Was it simply a matter of mental-health professionals inadvertently causing the more benign strain of anorexia in Hong Kong to mutate into the American version? The increase in fat phobia among anorexic sufferers did not occur in a vacuum, I would argue, affected only by mental health specialists. I suspect other Western influences likely also contributed to the shift, including ‘diet’ discourse, maybe even changes in actual diet, media imagery of idealized bodies, and the fitness industry. And what about shifts within this population in anxiety levels, sexuality-related expectations, fashion, socializing, male-female relations, and other more indigenous, though certainly not isolated dynamics? And was there an incursion of the material culture of Western dieting, such as diet drinks, calorie counting techniques or food labelling, or even high-fat foods to both affect body type and to provide a medium in which to express control over oneself. Just as the changing prevalence of anorexia nervosa in the West can’t simply be chalked up to a single cause such as patients’ suggestibility, I doubt we could do the same in Hong Kong. Sure, the anorexia outbreak may be ignited by ‘psychic conflict,’ but why does it take this specific form, and why does the form change in prevalence?

That is, the simple story that therapists gave their patients anorexia is possible, but there are other potential candidate explanations, and we’re quite likely to have an accumulation of cultural shifts that helps to explain the change in Hong Kong. After all, not every Western disorder grows at the same rate simply because therapists talk about them; they intersect with local anxieties, changing lifestyles, even physiological traits.

Western ‘culture’ is not just a set of ideas but a whole constellation of ideas, concepts, images, practices, customs, material culture, technology, and other everyday factors that feed into these disorders, even when they are ‘expressions of of psychological conflict.’ Certainly in terms of global diet and bodily culture, Western ideas are not the only factors affecting global change: technological, commercial, economic, agronomical, demographic, educational, and even mechanical (in terms of access to transport) changes are also influencing how bodies are changing internationally. We shouldn’t be too surprised that disorder, hypervigilant eating becomes more prevalent when food ways are in such a state of upheaval, body images are raining down on these populations, activity patterns are shifting, and so many of the new choices are unhealthy, fattening, and alien.

Without doubt, Western ideas about mental illness are directly affecting expectations of psychic distress around the world; see, for example, Vaughan at Mind Hacks discussing Did Antidepressants Depress Japan?. Here Vaughan highlights another force, one touched on by Watters but not explored; pure mercenary impulses, as drug companies try to persuade new markets that the individuals ‘need’ their products, suffering as they do from disorders of which they were previously unaware. Here, the idea that it’s just the ‘beliefs’ about illness held by therapists and authorities obscures the naked greed that goes into public relations campaigns designed to produced disorder.

My argument is not so much that Watters is wrong, as that culture is not just in the ideas people have about disease; these changes in mental illness are also provoked by the social, technological, and material world, for example, how the export of Western-style education affects childhood elsewhere (and thus illuminates ‘disorders’). When Watters writes the following, I whole-heartedly agree:

In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness. This does not mean that these illnesses and the pain associated with them are not real, or that sufferers deliberately shape their symptoms to fit a certain cultural niche. It means that a mental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions — the idiosyncratic cultural trappings — of the mind that is its host.

Although I’m a little uncomfortable with the word ‘mind’ in the last sentence, I especially like the end of the passage. Yes, it’s true, you can’t understand a mental illness without understanding a bit about the… well, okay, ‘mind’ of the person suffering. It’s just that it’s not that narrow: you have to understand a bit about the developmental influences on their brain, about the social network that supports or stigmatizes them, the behavioural reserves for unusual behaviour or thoughts… It’s not just about the conscious stories and understandings, but also about the harder-to-pin-down social, behavioural, and developmental factors that affect disease expression.

Watters actually provides a great example of these non-belief cultural factors when he discusses one of the more interesting dilemmas in cross-cultural psychiatry:

The research showed that patients outside the United States and Europe had significantly lower relapse rates — as much as two-thirds lower in one follow-up study. These findings have been widely discussed and debated in part because of their obvious incongruity: the regions of the world with the most resources to devote to the illness — the best technology, the cutting-edge medicines and the best-financed academic and private-research institutions — had the most troubled and socially marginalized patients.

Watters seeks to explain this unexpected gap in treatment by discussing the work of anthropologist Juli McGruder (University of Puget Sound) on families of schizophrenics in Zanzibar. In Zanzibar, schizophrenics are believed to be suffering from intermittent bouts of spirit possession. To cut to the chase, this belief affects those around them, especially family members, which affects how they treat the individual with the condition: ‘With schizophrenia… symptoms are inevitably entangled in a person’s complex interactions with those around him or her. In fact, researchers have long documented how certain emotional reactions from family members correlate with higher relapse rates for people who have a diagnosis of schizophrenia.’ It turns out that interaction patterns with a person possessed by spirits are actually healthier than those of family members in the West who believe the individual has a ‘mental illness.’ In fact, with US families, the more they try to ‘care’ for the schizophrenic family member, the more they fall into an unproductive interaction pattern with the individual with the illness. The issue is not just the belief, but the emotional quality of family interaction with a suffering individual; treat them one way, and it’s not just that you believe they’re different — the individual actually becomes different.

The discussion of trauma and trauma recovery is quite short, but Watters does highlight nicely some of the problems of exporting Western-style treatment to deal with trauma that we expect others to feel.

Behind the promotion of Western ideas of mental health and healing lie a variety of cultural assumptions about human nature. Westerners share, for instance, evolving beliefs about what type of life event is likely to make one psychologically traumatized, and we agree that venting emotions by talking is more healthy than stoic silence. We’ve come to agree that the human mind is rather fragile and that it is best to consider many emotional experiences and mental states as illnesses that require professional intervention. (The National Institute of Mental Health reports that a quarter of Americans have diagnosable mental illnesses each year.) The ideas we export often have at their heart a particularly American brand of hyperintrospection — a penchant for “psychologizing” daily existence.

Even dealing with Australians, I find that this is a huge difference, that the need for hyperintrospection, for obsessive re-tracing of distressing events or conflict, the need for a ‘talking out’ to resolution of issues is simply not shared. And Australian are widely considered to be some of the most culturally similar people to Americans. Certainly, the gap I felt in Brazil was even greater.

I found the conclusion to the article even more surprising, a kind of reverse-diagosis of Americans to suggest that the exportation of American psychiatric health may not be in the interest of the globe:

If our rising need for mental-health services does indeed spring from a breakdown of meaning, our insistence that the rest of the world think like us may be all the more problematic. Offering the latest Western mental-health theories, treatments and categories in an attempt to ameliorate the psychological stress sparked by modernization and globalization is not a solution; it may be part of the problem. When we undermine local conceptions of the self and modes of healing, we may be speeding along the disorienting changes that are at the very heart of much of the world’s mental distress.

I’ll just leave it at this, as I don’t have anything else to add to the conclusion. I heartily recommend the original article, and was genuinely surprised to read something I felt was both engaging (well written) and yet still very thorough (well thought).

by Drew Matott and Drew Cameron

Jake was fond of saying that even though he had become dumber, he wasn’t quite dumb enough. He knew that the improvised explosive device (IED) in Iraq had mangled his body, brain and self.

Jake (a pseudonym) lost 30 IQ points due to Traumatic Brain Injury (TBI) from that IED blast. According to the military, he was still smart enough to function and hold down a job, so they didn’t plan to include TBI in his disability rating.

He fought them on this, just as he fought them on the decision not to amputate his leg. After countless surgeries and rehabilitation techniques, his leg was almost useless, allowing him maybe 30 minutes of use before it started rebelling against its reconstructed form. The pain that caused was excruciating; he simply couldn’t use it more.

Eventually Jake won his battle to lose his leg. It was the best thing that happened to him during the year I got to know him while doing my dissertation fieldwork at Walter Reed Army Medical Center in Washington, D.C. (yes, that Walter Reed).

Dealing with, or writing about, TBI is rarely as clear as an amputation. The same is true of TBI’s nearly constant companion, Post Traumatic Stress Disorder (PTSD). TBI and PTSD are not injuries that you can see, unlike a lost leg. Despite the high numbers of TBI and PTSD cases from Iraq and Afghanistan, the relationship of these conditions to more obvious forms of combat trauma remains a fraught one: Witness the debate about PTSD and the Purple Heart.

Most people think that the Purple Heart, that most iconic of military honors, is awarded to American military members injured in combat. As with most issues military, it is not quite that simple.

In 2008, after months of consultation, the decision was made not to award the Purple Heart to those suffering from PTSD because, in part, the medal “recognizes those individuals wounded to a degree that requires treatment by a medical officer, in action with the enemy or as the result of enemy action where the intended effect of a specific enemy action is to kill or injure the service member.” PTSD doesn’t count.

Though the decision was officially framed in rather bureaucratic terms, the debate which surrounded it raises much deeper issues about the nature of trauma. Thinking through these issues has led me to think about the Cartesian split between the (internal) mind and the (external) body and the nature of trauma inside and out.

From one perspective, TBI is trauma itself. It is the physical result of the brain being banged around inside the skull or otherwise damaged. But its symptoms – being ‘dumb’, acting out, short term memory loss – are the kinds of things we normally associate with an interior self.

To complicate matters further, in the soldiers I worked with, TBI was accompanied by visible injuries, sometimes to the head, sustained during the same event. Jake, for example, had nearly his whole scalp peeled from his skull along with his helmet. But this actually had nothing to do with his TBI, which was caused by the force of the IED blast itself.

This gives TBI a slightly strange status on the physical-mental continuum that you can see in things like the RAND study on Invisible Wounds which consistently pairs mental health issues and TBI, thus linking them together while still setting TBI apart. So does all of this make TBI any more or less bodily? Any more or less interior?

PTSD, on the other hand, is the reaction to trauma. It is linked to the memory of, and psychological response to, a physical event or threatened physical event. This would seem to put it squarely on the mental end of the continuum. Yet most recent innovations in the treatment of PTSD have focused on the bio-chemistry and physicality of the brain.

Such a ‘physical’ approach has its benefits. For example, most of the soldiers I worked with were highly resistant to talk and other ‘interior’ kinds of therapy while they relished the idea of treatments which work on the mind through the body. Medication does that, but so do things like Virtual Reality Exposure therapy. (For more background on the causes and treatments for PTSD in soldiers, see Erin Finley’s terrific posts here and here).

And while we tend to think of PTSD as a psychological reaction to a particular traumatic event, in my fieldwork it was more often the result of a whole slew of experiences which had very much to do with the body, sights, sounds, smells, and corporeal feelings of discomfort, pain, heat, exhaustion, sleeplessness. These same bodily sensations constitute in part the experience of PTSD, meaning that while diagnoses or theorizations of PTSD may focus on the mind, the subjective experience of it is very much in the body.

Even when we recognize that the mind and the body are connected, as we do in the realms of psychopharmacology, most people generally subordinate one to the other and deny their unity. We do that by relying on Cartesian dualism, by splitting the self into body and mind and then mapping the two parts onto the outside and inside. By marking the bodily self as the province of medicine and the mind as the province of psychiatry, we deny a more complete understanding of the subjective experience of trauma.

Jake’s amputated leg, his short term memory loss, his insomnia, his problems with linear thought, his 30 missing IQ points, his headaches, these are all part of his transformed self and way of being in the world. Though it may be required, in certain clinical settings, to typologize these pieces of him, to call them symptoms and assign them to various qualitative and quantitative categories, as anthropologists we are relatively free of these paradigmatic constraints. Our discipline is essentially an empathetic one and when working with people who have endured certain kinds of trauma, we ought to do our best to maintain the integrity of their experience. After all, haven’t they been ripped apart enough?

Zoë H. Wool is a doctoral candidate in anthropology at the University of Toronto. You can reach her at zoe.wool@utoronto.ca

It is a sparkling day in mid-June, the sun out in full force, the sky a limpid blue. I am lying on my back on the grass, listening to the intermittent chirping of nearby birds; my eyes are closed, the better to savor the warmth on my face. As I soak up the rays I think about summers past, the squawking of seagulls on the beach and walking along the water with my daughter, picking out enticing seashells, arguing over their various merits. My mind floats away into a space where chronology doesn’t count…

So opens Daphne Merkin’s recounting of her life with severe depression. A Journey through Darkness is the feature article in this week’s New York Times Magazine. On that sparkling day in mid-June, Daphne was on a “fresh air” break in The Patients’ Park & Garden, the all-concrete highlight of her latest clinic.

Merkin recounts her life, an intractable life, in this moving essay. She mixes in recounting her latest stay in a clinic with reflections on depression and how this illness has shaped her life in such fundamental ways. Here are two pieces that spoke to me.

This is the worst part of being at the mercy of your own mind, especially when that mind lists toward the despondent at the first sign of gray: the fact that there is no way out of the reality of being you, a person who is forever noticing the grime on the bricks, the flaws in the friends — the sadness that runs under the skin of things, like blood, beginning as a trickle and ending up as a hemorrhage, staining everything. It is a sadness that no one seems to want to talk about in public, at cocktail-party sorts of places, not even in this Age of Indiscretion.

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This was enraging in and of itself — the fact that severe depression, much as it might be treated as an illness, didn’t send out clear signals for others to pick up on; it did its deadly dismantling work under cover of normalcy. The psychological pain was agonizing, but there was no way of proving it, no bleeding wounds to point to. How much simpler it would be all around if you could put your mind in a cast, like a broken ankle, and elicit murmurings of sympathy from other people instead of skepticism.

Link to A Journey through Darkness

The Foundation “promotes the use of ethnographic research and mixed-methods approaches to improve understandings and treatments of mental illness, broadly defined. FAPA facilitates collaboration among scholars and practitioners who wish to integrate clinical work with ethnographic research and advocacy initiatives related to culture and mental health.”

FAPA also offers reduced-fee psychotherapy services to residents in the Saint Louis, Missouri area. To find out more, check out FAPA’s description of its clinical services and approach.

Rebecca Lester is a professor of anthropology at Washington University in Saint Louis. You can read about her treatment philosophy. For researchers, Rebecca has put together a great list of books in psychiatric anthropology.

And here’s Davinder Hayreh’s LinkedIn profile. He is presently nearing the finish of his residency in psychiatry at Barnes-Jewish Hosptial in Saint Louis.

For more information, you can contact them at office @ psychanthro.org [remove spaces].

Hundreds of thousands of US veterans are not able to leave the horrors of war on the battlefield. They bring the combat home and re-experience it in their minds each and every day, no matter how much time has passed.

“I don’t like people. I just live my life.”

Many PTSD veterans live a life riddled with divorce, unemployment, and loneliness because they are unable to form lasting social networks within civilian life. It is not uncommon for a war veteran plagued with PTSD to desire a solitary life in the mountains. One informant described Montana as the ideal locale – far away and quiet.

“I should have buried him.”

This veteran is still tormented by the fact he did not give an honorable burial to a fellow soldier. He knows he would have met a similar fate if he tried to leave his foxhole; yet his inability to act haunts his memory. He asks himself everyday why he didn’t even try to honor his fallen comrade. He also has never been able to justify why he wasn’t the soldier left unburied on that remote Pacific island.

“I didn’t even have the motivation to kill myself.”

Many of these men and women believe their situation will never improve. Some contemplate suicide as their only relief from the symptoms of PTSD. A number of the veterans we spoke with had thought about or even tried to end their own lives. They also participate in risky activities, threatening their life in a deliberate yet indirect way.

“I always feel like there is someone behind me – following me.”

Being on edge is the only way to survive in combat. Unfortunately, many PTSD veterans are unable to readjust within the civilian world. Everyday life becomes a battlefield.

Something as mundane as walking through a crowded grocery store aisle can be a source of intense anxiety for a veteran suffering from PTSD. Overwhelmed by a feeling that the shoppers behind them are enemies, PTSD veterans always feel as if they are under attack. A trigger as simple as the clashing of shopping carts can make them jump in fear of an imminent explosion. They are forever at war.

OUTREACH

Over the course of 4 months, South Bend veterans with Posttraumatic Stress Disorder (PTSD) have revealed their daily realities to us, five undergraduates at the University of Notre Dame. In conjunction with a course taught by Dr. Daniel Lende entitled Researching Disease: Methods in Medical Anthropology, we have engaged in community-based research with members and supporters of PTSD, Vets, Inc. Here, with the approval and encouragement of these vets, we seek to give their experiences a well-deserved voice.

We’ve come to understand that PTSD is a debilitating condition. However, there tends to be a general lack of understanding of the condition itself as well as its symptoms, diagnoses, and treatments. Here are some things these PTSD veterans want every person to know:

Many older veterans have suffered from PTSD for decades without ever knowing they had the disease. These men and women insist that their quality of life would have been significantly improved with early intervention. This has been supported by numerous studies, which suggest that diagnosis soon after the traumatic event is critical for positive, long-term outcomes. Traumatic memories tend to become resistant to treatment over time. The quicker the symptoms can be addressed, the better the outlook for a PTSD veteran.

A clinical diagnosis serves as a profound moment for a veteran with PTSD. It confirms and validates the symptoms experienced by the individual. One informant describes his diagnosis: “It was like a nail on the head. Finally someone knew.”

Veterans with PTSD often believe that they are “crazy” before a formal diagnosis by a healthcare professional. Previous to having a diagnosis, these men and women have the symptoms but no explanation for their cause. They begin to question their sanity. They ask, as one veteran phrased it, whether or not “it’s all just in [our] heads.”

A formal diagnosis is an empowering facet of PTSD treatment because it lets veterans know that there is a physiological and psychological basis for their behavior. War has changed their brains and there are ways of learning to cope with those changes.

More than anything else, a diagnosis lets them know that they are not alone.

Many of the vets expressed that feeling alone in handling their condition and the isolation that often results are the most painful aspects of PTSD, often making it difficult for many PTSD vets to ask for help and seek treatment. Group therapy among PTSD veterans is a vital component of treatment because very few civilians have seen and experienced the same events that these men and women have. Nor can civilians understand the trials and tribulations of living with PTSD caused by war trauma. In this way, it can be seen that many PTSD veterans will only talk about their experiences with other veterans.

We have received direct feedback that group therapy benefits many of the veterans, as it provides an avenue for them to speak openly about their suffering. While many veterans destructively turn to alcohol and drugs as a means of coping, group therapy provides a healthy alternative and is an outlet for them to express their anger, fear, guilt and countless other emotions attributed to PTSD. In confidence they can tell each other things that they haven’t even told their husbands or wives. In the group they are getting these things out in a sensible manner. Telling their stories matters.

An important question in regards to group therapy is how it can be improved in order to provide the most benefits for the veterans that are returning home from war. The VA and several other organizations are examining what aspects of group therapy may be altered to make it as effective as possible for providing PTSD treatment to veterans.

One approach that veterans in South Bend are attempting is peer counseling. Those with PTSD consider a commitment to helping other veterans to be a central facet of managing the disease. Older members of the group want to reach out to soldiers returning from Afghanistan and Iraq with PTSD. They know better than anyone what it is like to live with PTSD and want to stress the importance of receiving early treatment. By counseling young veterans, these members hope to prevent a lifetime of suffering which they themselves had to live through. This then helps to validate their own suffering.

The peer counseling doesn’t just benefit one side of the relationship, however. By instilling them with some agency over the disorder, the counseling provides a method of coping in addition to more standardized treatment for the older group members. More generally, this emphasis on helping other veterans simply by making them as aware of PTSD as possible underscores the importance of awareness in the effort to improve its diagnosis and treatment among all veterans.

AWARENESS

The substantial impact of PTSD on the lives of veterans afflicted by it makes greater understanding of this disorder of utmost necessity. With knowledge about PTSD, returning veterans can seek the early diagnosis and treatment they need, giving them a chance to reclaim their quality of life. Although many veterans we spoke with stressed that PTSD never goes away, with treatment, including group therapy, counseling, or medication, veterans can avoid a life ravaged by isolation, drug and alcohol use, depression, and the countless other daily struggles of PTSD.

Awareness and understanding can also foster the support of families that is often necessary to motivate vets to seek the treatment they need. Increasing the visibility of the prevalence of the disorder among veterans and working to remove the stigma associated with it can help veterans get the support they need and deserve. Finally, awareness among the general public will give veterans an additional level of acceptance and advocacy that may work to reduce the impact of PTSD on their lives.

A true knowledge about all aspects of PTSD needs to rise amongst veterans, their families, the public, and our policy-makers, so veterans currently suffering with PTSD and the soldiers returning from Iraq and Afghanistan may acquire the help needed to fight back in the war that rages within their subconscious.

For more information on PTSD and how to seek treatment please visit the helpguide. To learn more about the veterans of PTSD, Vets, Inc., who so graciously shared their stories, visit www.ptsdvets.com.

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Written by: Christina Del Guzzo, Megan Ericson, Daniel Graciaa, Casey McNeill & Mark Quaresima

Acknowledgements: Many thanks to Dr. Michael Sheehan, PTSD Vets, Inc., and the many veterans who opened their hearts and shared their stories with us.

The article “If I Were You: Perceptual Illusion of Body Swapping” by the Swedish researchers Henrik Ehrsson and Valeria Petkova appears this week in PLoS ONE, and is ably summarized over at Neurophilosophy. You can also read Ehrsson’s previous article on the virtual arm illusion and his Science piece on the experimental induction of out-of-body experiences.

The approach in all of this research is rather simple. You can see the out-of-body experiment design pictured to the right. Body swapping adds another person with goggles.

A subject stands or sits opposite the scientist, as if engaged in an interview.. Both are wearing headsets, with special goggles, the scientist’s containing small film cameras. The goggles are rigged so the subject sees what the scientist sees: to the right and left are the scientist’s arms, and below is the scientist’s body. To add a physical element, the researchers have each person squeeze the other’s hand, as if in a handshake. Now the subject can see and “feel” the new body. In a matter of seconds, the illusion is complete.

This “switching” happens because the brain is literally embodied – after growing up with this particular body, it’s a fair assumption to assume that one’s eyes and one’s hand are getting feedback about the same interactive phenomenon. For a first-person view of this, see Karl Ritter’s AP article today on the body-swap illusion, which includes this photo of the two-goggle set-up.

Ehrsson is excited about being able to trick the brain in this way: “You can see the possibilities, putting a male in a female body, young in old, white in black and vice versa.” The NY Times article pushes the uses body swapping can have in therapy.

Couples who fight, self-centered adolescents, people who prey on others like rapists, all could take on the perspective of another body. Seeing “the encounters in their daily life from others’ point of view” can help prompt change. Kristene Doyle, head of clinical services at Albert Ellis Institute, says, “This is especially true for adolescents, who are so self-involved, and also for people who come in with anger problems and are more interested in changing everyone else in their life than themselves.”

But will this really work? As Ehrsson notes at the end of the report, the sensations are strange. Strange sensations are not quite therapeutic change. Part of the work to be done will be through virtual reality. Jeremy Bailenson and Nick Yee at Stanford’s Virtual Human Interaction Lab have studied the Proteus Effect (pdf) or “transformed digital self representation.” People can get morphed in physical attractivess, weight, age and gender, and the effects of the experimental linger into the real world. Suddenly old people start contributing more to retirement (see pdf). Those with a fit image exercise more.

Still, producing identification with others is a difficult task. It’s not just about perception. So even virtual reality and body swapping will have its limits. But over time it might even be able to help with problems like autism. Jessica and Robert Hobson have proposed identification as a crucial component to intersubjective engagement, arguing in this 2007 paper that “the propensity to adopt the bodily anchored psychological stance of another person is essential to certain forms of joint attention and imitation, and that a weak tendency to identify with others is pivotal for the developmental psychopathology of autism.”

Rachel Brezis, who presented at our Encultured Brain panel, takes this sort of research a step further, linking it back to what Ehrsson does – the identification is also about the self and not just others. This move brings us to disorders like anorexia where body image also plays a role. And that brings us to gender, relationships and culture, explored so well in Caroline Knapp’s book Appetites.

The NYT piece Sharing Their Demons on the Web begins:

For years they lived in solitary terror of the light beams that caused searing headaches, the technology that took control of their minds and bodies. They feared the stalkers, people whose voices shouted from the walls or screamed in their heads, “We found you” and “We want you dead.”

When people who believe such things reported them to the police, doctors or family, they said they were often told they were crazy. Sometimes they were medicated or locked in hospital wards, or fired from jobs and isolated from the outside world.

But when they found one another on the Internet, everything changed. So many others were having the same experiences.

The article goes on to discuss this “extreme” online community that gives peer support a whole new meaning! Mind control, stalking and paranoia become the delusions of the net. “The views of these belief systems are like a shark that has to be constantly fed,” Dr. Hoffman said. “If you don’t feed the delusion, sooner or later it will die out or diminish on its own accord. The key thing is that it needs to be repetitively reinforced.”

On the other hand, Derrick Robinson, a janitor in Cincinnati, says “It was a big relief to find the community. I felt that maybe there were others, but I wasn’t real sure until I did find this community.” Mr Robinson has gone on to become the president of Freedom from Covert Harassment and Surveillance.

Vaughan estimates that there are a small number of these intense sites that are frequented around the Internet. I ran across a similar phenemenon exploring pro Ana websites that support anorexia a couple years back. But Vaughan has published everything! The article ‘Mind Control’ Experiences on the Internet: Implications for the Psychiatric Diagnosis of Delusions (pdf) appeared in Psychopathology (also available here through Scribd).

As expected, Vaughan documents the NY Times article over at Mind Hacks. He described the outcomes of this research in an earlier post on Internet mind control and the diagnosis of delusions. As Vaughan concludes about this research:

This is interesting because the diagnostic criteria for a delusion excludes any belief that is “not one ordinarily accepted by other members of the person’s culture or subculture”, whereas these individuals have formed an online community based around their delusional belief, creating a paradox.