The role of race in human genetics and biomedical research is among the most contested issues in science. Much debate centers on the relative importance of genetic versus sociocultural factors in explaining racial inequalities in health. However, few studies integrate genetic and sociocultural data to test competing explanations directly.

Note how that fits so well into the points just made in Nature/Nurture: Slash to the Rescue. But Gravlee, Non and Mulligan don’t just say we need to overcome the nature vs. nurture dichotomy, they do research that bridges it and even better, test ideas on both sides: “We draw on ethnographic, epidemiologic, and genetic data collected in southeastern Puerto Rico to isolate two distinct variables for which race is often used as a proxy: genetic ancestry versus social classification.”

This type of collaborative research can be crucial to getting the data to answer complicated questions. Connie Mulligan and Lance Gravlee deserve credit for taking the time to discuss how to bring together their respective approaches before going out to do research. In this case, the data come down more on the nurture (or social) side. As they write:

Our preliminary results provide the most direct evidence to date that previously reported associations between genetic ancestry and health may be attributable to sociocultural factors related to race and racism, rather than to functional genetic differences between racially defined groups.

Before someone gets all hot and bothered, Lance has also shown how to bring nurture back to nature. In Gravlee’s recent paper, How Race Becomes Biology: Embodiment of Social Inequality (pdf), he gives us following: “Drawing on recent developments in neighboring disciplines, I present a model for explaining how racial inequality becomes embodied – literally – in the biological well-being of racialized groups and individuals. This model requires a shift in the way we articulate the critique of race as bad biology.”

In the PLoS paper, Lance, Amy and Connie are aiming squarely at the use of race in medicine, where it has become common in some circles to use racial classification as a proxy for genetics. Basically this research destroys the proxy notion, since social classification turns out to be a better predictor of blood pressure than genetic ancestry.

Yet the research also highlights that genetics does play a role, just not in the broad way we normally think (nature as cause). Specifically the data revealed an association between systolic blood pressure and a specific polymorphism, α2C adrenergic receptor deletion, only when social classification and socioeconomic status were included in the analysis.

This research also reveals social complexity. As the figure from the PLoS paper above indicates, there are interactions between racial classification, socioeconomic status, and systolic blood pressure in Puerto Rico. The basic conclusion is the opposite of what many of us might expect – those perceived as darker (negro) have higher blood pressure when in a higher social class. Conversely, those with lighter skin have higher blood pressure with lower SES. These results can be related to complex social dynamics. Darker colored individuals likely face more racial discrimination when in a higher SES because Puerto Rico is still a racially divided country, with wealth and status running lighter to darker. Here is the PLoS paper:

The pattern we observe is consistent with the hypothesis that social classification based on color entails differential exposure to social stressors related to blood pressure. In particular, there is ethnographic evidence that Puerto Ricans perceived as negro, as compared to trigueño or blanco, may encounter more frequent frustrating interactions in high-SES settings due to institutional and interpersonal discrimination.

Put in a broader sense, this paper points to the need to actively consider social inequality and discrimination as causes of health problem, something the “race as genetics” idea completely fails to do. Along with colleagues, Gravlee has made this point forcefully in a previous paper, Race and Ethnicity in Public Health Research: Models to Explain Health Disparities.

At the end of the PLoS paper Lance, Amy and Connie highlight an important direction for future research: “Although our measure of social classification improves on existing approaches, further research is needed to assess how well it approximates the ascription of color in everyday social interaction. Future research could build on our measurement approach by testing whether non-biological markers of social status (e.g., hair style, dress, speech) influence social classification.”

I’d also encourage Lance and his colleagues to look more closely at perceived discrimination, that this is also a crucial mediator of how race ends up driving biology. It’s not just consensus about racial classification, but how an individual person reacts to that. This point is made broadly by Robert Sampson when he discusses perceptions of disorder as an important force behind disparity. Building an ethnographically informed measure of subjective discrimination could add an important link in the pathway from social inequality to changes in blood pressure.

But this paper also challenged me. What is particularly good is that Lance builds on previous research that established how social classification according to “color” trumps actual skin pigmentation in establishing race and in impacting health. Now he and Connie have taken that a step further to get the data and test both biological and cultural ideas.

So this morning I am thinking more seriously how I could better examine the nature/nurture debate around addiction (quite similar in form to the race and health debate – biology does it; no, it’s inequality). How can studying sin become a closer look at how people get engaged in destructive behaviors, and which factors (working together, I’d say) are most important? Because right now the biologists are going to say, well it’s dopamine (or glutamate or whatever neurotransmitter is the flavor of the day) and the anthropologists are going to say, well it’s meaning. I’m still stuck at saying “holistic interactionism” (as Pinker would put it) rather than showing more concretely how the two come together and then relating both to genetics and to symbolism.

Lance Gravlee, Amy Non and Connie Mulligan have already taken that next concrete step. Kudos!

For more on Lance Gravlee’s work, please visit his website. For more on Connie Mulligan’s work, here’s her UF website.

For those looking for coverage of some of the paper’s highlights, you can check out the University of Florida’s press release, Socio-cultural, genetic data work together to reveal health disparities.

Gene Expression also provides a useful summary with Hypertension, Race, Class and Puerto Rico, including a comment by Lance clarifying a couple points.

And here’s the link for the PLoS full text of Genetic Ancestry, Social Classification, and Racial Inequalities in Blood Pressure in Southeastern Puerto Rico.

Gary Evans and Michelle Shamberg recently published a PNAS paper, Childhood Poverty, Chronic Stress and Working Memory (pdf). Here’s the abstract:

The income–achievement gap is a formidable societal problem, but little is known about either neurocognitive or biological mechanisms that might account for income-related deficits in academic achievement. We show that childhood poverty is inversely related to working memory in young adults. Furthermore, this prospective relationship is mediated by elevated chronic stress during childhood. Chronic stress is measured by allostatic load, a biological marker of cumulative wear and tear on the body that is caused by the mobilization of multiple physiological systems in response to chronic environmental demands.

The Evans and Shamberg paper has gotten prominent media attention. Over at Wired, Poverty Goes Straight to the Brain got an enormous number of diggs. Brandon Keim’s opening lines are, “Growing up poor isn’t merely hard on kids. It might also be bad for their brains. A long-term study of cognitive development in lower- and middle-class students found strong links between childhood poverty, physiological stress and adult memory.”

Jonah Lehrer wrote Stress, Poverty, Working Memory which includes this effective summary, “The scientists uncovered a statistically significant link: the longer children had been poor, the worse their working memory. Furthermore, levels of chronic stress seemed to be the causal factor.”

The Economist also covered the PNAS paper, and wrote about how stress does its damage. “Stress also suppresses the generation of new nerve cells in the brain, and causes the ‘remodelling’ of existing ones. Most significantly of all, it shrinks the volume of the prefrontal cortex and the hippocampus. These are the parts of the brain most closely associated with working memory. Children with stressed lives, then, find it harder to learn.”

Lehrer, in his 2006 Seed article Reinvention of the Self about the work of primatologist/psychologist Elizabeth Gould, presents us with one of the main “take home” messages of work that links stress, poverty and development:

The social implications of this research are staggering. If boring environments, stressful noises, and the primate’s particular slot in the dominance hierarchy all shape the architecture of the brain—and Gould’s team has shown that they do—then the playing field isn’t level. Poverty and stress aren’t just an idea: they are an anatomy. Some brains never even have a chance.

This work by Evans and Shamberg is important, another step forward in showing that inequality matters and that it works through specific processes that directly shape individual development and function. But this line of work also has some limitations because it lacks a critical side – do we really need 500+ diggs to know that poverty is bad?

One piece that raises important critical questions is Michelle Chen’s The Impoverished Mind over at RaceWire. She writes, “Put simply, if your childhood is consumed by a constant struggle to survive day-to-day, your brain is less likely to develop the abilities you need to succeed tomorrow, compared to your economically better-off peers. This is empirical evidence that nature-versus-nurture is not an either or, but that social factors interplay with the brain’s biology throughout life.”

Then Chen goes further:

Empirical research on the connection between poverty and intellectual development can cut both ways—leading some to write off poverty as biological destiny, and others to look deeper into missed opportunities to lift youth over economic barriers… The policy implications for the growing body of achievement-gap research are [also] fraught with the same tensions straining other civil rights issues: how do you emphasize systemic impediments without pathologizing communities and cultures? How do you make the case for structural inequalities without fueling reactionary accusations of victimology?

Some of my own concerns focus on the biology side. Take a section from Lehrer’s Seed piece, “From the brain’s perspective, stress is primarily signaled by an increase in the bloodstream of a class of steroid called glucocorticoids, which put the body on a heightened state of alert. But glucocorticoids can have one nasty side-effect: They are toxic for the brain.”

Here stress “from the brain’s perspective” is taken to be entirely physiological. In general, stress is often made out to be psychobiological, an internal and individual state largely shaped by “fight-or-flight” ideas about activation of the stress system. As I’ve argued before, stress is actively social and intimately meaningful. These are not outside the perspective of the brain – they become part of how the brain functions. In this way stress becomes a process and not simply a state, either of mind or body.

But the more problematic area is that the brain becomes a fetish: Oh, see the neuroanatomical changes there, this stuff about poverty being bad for you must be true…

Recall the opening of the Wired piece, “Growing up poor isn’t merely hard on kids. It might also be bad for their brains.” Here children become a mere token, placed to one side in favor of our new marker of individual self, the brain.

While I advocate for the role that brain processes can play in social theory, the sword cuts both ways. Referencing the brain as central mediator of poverty hides the truth, and distorts our understanding. To take a more extreme example to illustrate the same point, it’s like saying that slavery is both harmful to people and morally wrong because it impacts brains.

The brain becomes rather like property in this approach, something a person possesses and that poverty – somehow separate from the person, a naturalized thing that causes stress – negatively impacts. But that approach avoids the radical implications here on both sides.

First, that poverty literally can be anatomy, which means we need to fundamentally rethink the token brain metaphor and actual functioning of the brain. Second, that taking the neuroscience results seriously means that social environments, in all their complexity, become as important as any brain function. Indeed, many would argue that in this case, social inequality is more important than brain function, since it is what is driving the system.

To bring a critical approach into better view, I have found it useful at times to watch the following video of Paul Gilroy speaking on slavery, ignorance, and property. Rather than just working memory, Gilroy brings the larger picture into focus: “[We often] think that ignorance is a kind of vacuum into which truth can get stuffed at the right moment. And I think that we need a better account of the politics and the meaning of ignorance in our time than that. We need to think about ignorance in a different way. We need to think about ignorance as a systematic product.”

By excessively focusing only on the brain, we miss doing what Gilroy advocates for truly understanding ignorance and inequality — engaging in “critique of life as property, of humanity as property, of history as property.” We need to move beyond seeing the brain as a physical thing, similar to a book we can reference to say poverty is bad or a kind of currency that we carry around and barter to show off we’re smart and current. Or worse, something to manipulate through pharmaceuticals and computers and emerging types of neuroengineering. As Gilroy says, we need to become more critical while also realizing the dignity and meaning of people’s lives.

The Wrong Box Score

Besides being a great read about Shane Battier and success in professional basketball, The No-Stats All-Star article by Michael Lewis in last Sunday’s New York Times Magazine carries a larger lesson about how our understanding of the world is shifting. One of its main points is that we are becoming increasingly statistics driven, with sports at the leading edge of this transformation. We can spend lots of money on stars, like the New York Yankees, or we look more closely at what actually leads to success and how we can achieve that with less money. Shane Battier epitomizes this change because his individual stats are rather mediocre, his physical skills rather normal for an NBA player. But he makes his team win.

The key question becomes, how does he do this? That is where Michael Lewis mixes qualitative research (interviews) and ethnographic insight (coming from Battier’s own experience) with an examination of new ways of measuring everything that might count about a basketball game. It’s a powerful mix.

For me it illustrates two important points about how we can develop better measures, ones that are closer to what actually determine outcomes and that don’t fall into so easily into measuring our own beliefs about the world. And yes, by “our own” I mean the researchers who come up with the measures. Here’s a relevant section describing Daryl Morey, the man behind the Houston Rockets new approach to figuring out what works:

What [Morey] will say, however, is that the big challenge on any basketball court is to measure the right things. The five players on any basketball team are far more than the sum of their parts; the Rockets devote a lot of energy to untangling subtle interactions among the team’s elements. To get at this they need something that basketball hasn’t historically supplied: meaningful statistics. For most of its history basketball has measured not so much what is important as what is easy to measure — points, rebounds, assists, steals, blocked shots — and these measurements have warped perceptions of the game. (“Someone created the box score,” Morey says, “and he should be shot.”) How many points a player scores, for example, is no true indication of how much he has helped his team.

Here is how it makes a difference. Battier doesn’t get great traditional stats – points scored, shots blocked, and so forth. But he does things that, on aggregate, make a bigger difference.

The reason the Rockets insist that Battier guard Bryant is his gift for encouraging him into his zones of lowest efficiency. The effect of doing this is astonishing: Bryant doesn’t merely help his team less when Battier guards him than when someone else does. When Bryant is in the game and Battier is on him, the Lakers’ offense is worse than if the N.B.A.’s best player had taken the night off. “The Lakers’ offense should obviously be better with Kobe in,” Morey says. “But if Shane is on him, it isn’t.” A player whom Morey describes as “a marginal N.B.A. athlete” not only guards one of the greatest — and smartest — offensive threats ever to play the game. He renders him a detriment to his team.

And if you knew none of this, you would never guess any of it from watching the game. Bryant was quicker than Battier, so the latter spent much of his time chasing around after him, Keystone Cops-like. Bryant shot early and often, but he looked pretty good from everywhere.

How did Battier himself achieve this? The Times gives us a photographic summary, amd this photo is just a great shot of the Bryant-Battier battle. But overall, Baitter has done it by being rather like the ideal participant observer.

Losing himself in the game meant fitting into the game, and fitting into the game meant meshing so well that he became hard to see. In high school he was almost always the best player on the court, but even then he didn’t embrace the starring role. “He had a tendency to defer,” Keener says. “He had this incredible ability to make everyone around him better”… Even when he was clearly the best player and could have shot the ball at will, he was more interested in his role in the larger unit.

–//–

When Daryl Morey spoke of basketball intelligence, a phrase slipped out: “the I.Q. of where to be.” Fitting in on a basketball court, in the way Battier fits in, requires the I.Q. of where to be. Bang: Alston hit Battier with a long pass. Bang: Battier shot the 3, guiltlessly. Nothing but net.

Much of this comes down to a simple fact about how both our brains and our modern world work – inter-related systems built on complex interactions defined more by the processes involved rather than through any specific “cause” or “great man of history.” Battier illustrates this perfectly: “Battier can pursue an inherently uncertain strategy with total certainty. He can devote himself to a process and disregard the outcome of any given encounter.”

So what does this have to do with measurement and neuroanthropology? Let me take stress as an example. Most measurements of stress reveal more about our cultural approaches to the mind than they do about stress itself. For example, stress measurements generally focus on “psychosocial stress” or get at physical stressors, thus recreating our old mind/body problem. From there, our cultural notions of self and our evolutionary view of stress dictate a great deal of how we think about and thus measure stress. In the evolutionary view, it’s “flight-or-fight” (which I’ve critiqued here with Sapolsky and more importantly here with Blakey). On the cultural side, we can look more specifically at one example. The 4-item perceived stress scale uses the formula, “how often have you felt…”

Here self is identified with a perceiving, feeling individual in this approach, for example, “how often have you felt confident about your ability to handle your personal problems.” It’s about the box-score approach to our pick-up game of life. It’s not about the processes where self and stress intersect. It’s about someone trying to match up to Kobe Bryant, the supreme ball player – capable, in control, supremely confident. It’s not about zones of efficiency, meshing with the game, and a total commitment to the process. We need a Shane Battier of stress.

How would he or she play the game? Like Shane Battier, mixing some ethnographic street ball with some polished lab play, or more broadly moving between different worlds of academic success and meshing them together into something unique. I know my own moves best (not that I’ve schooled anyone… yet), so here’s how I covered a neuroanthropological approach to measuring craving and compulsive involvement, with a subsequent post that details how I meshed neurological processes, subjective experiences and specific problems into a reliable scale. I believe the same approach can be developed for a wide range of psychosocial or neuroanthropological processes. For a broader view on this problem, see my post on the subjective brain or how Greg came to understand balance as a neuroanthropological process.

But there is another way to approach this same problem – and that is of relevance. Relevance pushes people to measure things that matter. Oftentimes that gets at process. Mind Hacks recently pointed us to a great video interview series with the neuropsychologist Elizabeth Warrington. Here’s the most important one forwhat I am discussing here. Getting at real-world problems in ways that are useful for clinical or applied practice, that forces us away from our own box-score approach and towards what really matters to living life.

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.

–//–

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.

There are only a few websites I could find covering the relationship between mental health and global warming. They look at how certain aspects of the decline of mental health in the future will be attributable to the increase of global warming.  At best, these are passing comments in articles about general health concerns.

I have to admit, I’m more into preventative medicine than medical prophecy.

Global Warming, greenhouse gases, climate change, these are all with us today. We are past the point of any hope of prevention, but we must look to possibilities of minimising the damage and sequestering the problem. Being anxious about the problem, is obviously not going to be good for anyone’s mental health and general wellbeing. But working towards solutions will.

My biggest concern with contemporary neuroscience and psychology is the lack of awareness about the influence of context in the operations of the brain. It is what pulled me out from neuroimaging and neurobiology laboratories and out into the world of ethnographic fieldwork. It was my sneaking suspicion that mental disturbances, particularly those prevalent in developed countries, are linked in shape and form to our environmental and socio-cultural context.

My experiences in several countries lead me to affirm that if we have a narrow window upon the world, a restricted perception of and limited attention to the world, then our mental health and everyday wellbeing is less robust. People who I have met, who have widened the world they live in by living in an expanded universe of attention, perception and consciousness are quite often much healthier and happier. I have very much come to agree with the Buddhist notion that “With your thoughts you create the world.”

Maybe some of you can see where I am going with this. Global Warming, in a poetic sense can be thought of as a symptom of a distorted style of mental health that has neglected the world that our thoughts have created. The world we create feeds back upon the thoughts we have. The reiterative causality between brain and culture is spiralling towards an uncertain future. It’s time to step outside of the spiral for a second, and assess where we want to go, and the kind of people we want to be when we get there.

Now, not all the happiest people I know are doing something about climate change, and not all the people I know who are concerned about climate change are the perfect example of mentally balanced. But I have seen, and do see, that contributing to the social and environmental world, in the best way you know how, will bring positivity into your life. It might be the simple act of picking a piece of rubbish up, using a recyclable coffee cup, walking to the train station rather than driving, or even hanging washed clothes out on a clothes-line rather than drying them in an electric drier. Positive reinforcement people! Feel good about contributing something to the world you live in; the world you create with your thoughts!

My take-home message is: Look after your environment, and you will be looking after your mind too!

As I pointed out in the previous post, however, many commentators suggest that it is not the gap in average test scores that really matters; rather, these critics argue that the different variance in boys’ and girls’ scores explains the disproportionate number of boys who produce exceptional scores (as well as exceptionally bad scores), and thus the marked gap of men and women in PhD math programs, in prestigious prizes for physics and related subjects, and in related fields like engineering. In the earlier post, I argued that even if this greater variance showed up reliably across all testing populations, what exactly was being illuminated was still not clear; that is, many other explanations–other than that men had better ‘math modules’ in their brains, or greater ‘innate’ mathematics ability, or something like that–could explain even very stable differences in math performance. At the time I suggested a number of other possibilities, such as sex differences in stress response during testing, as other possible explanations for even a universal ‘math gap’ (which still had to contend with studies like the two in Science which severely undermined the assertion of universality).

As if on cue, I stumbled upon a video and accompanying article in Science Daily on differences in stress responses among men and women: Neuroscientists Find That Men And Women Respond Differently To Stress (but don’t click on that link — keep reading!). Stress is a good candidate to explain a test-taking gap because the observable physiological processes offer abundant evidence that men and women don’t respond to stress in exactly the same way (although there are underlying commonalities). For example, stress causes different diseases in men and women, and some long-term psychological disorders that demonstrate sex-linked disparities seem to emerge from stress.

Unlike the ‘black box’ explanation that boys and simply better at math or evidence greater variability in innate ability, with no observable neural correlate or plausible explanatory mechanism, in variation in stress response we have a clear candidate for male-female difference that plausibly affects their performance and even physiology (for example, in different stress-related diseases).

Ironically, when I tracked down the original article that the Science Daily piece was likely based on (there’s no citation, so I can’t be certain), I had to delete all the quotes from the Science Daily article from the draft I was writing for this post (that’s why you shouldn’t link to it).

I give science writers a bit of stick from time to time, but in this case, the explanation of the research was not merely misunderstood, it was simply wrong, not even consistent with the abstract from the article I think the popular piece is based on (Wang et al. 2007). So even though the erroneous Science Daily article put me onto this thread, I’m only going to work from the piece published by Jiongjiong Wang and colleagues at the end of 2007 in the journal, Social, Cognitive, and Affective Neuroscience.

Stress responses in men and women to arithmetic tasks

In the abstract, Wang and colleagues explain that they tested 32 subjects using both fMRI and endocrine salivary screening. In the experiment:

Psychological stress was elicited using mental arithmetic tasks under varying pressure. Stress in men was associated with CBF [cerebral blood flow] increase in the right prefrontal cortex (RPFC) and CBF reduction in the left orbitofrontal cortex (LOrF), a robust response that persisted beyond the stress task period. In contrast, stress in women primarily activated the limbic system, including the ventral striatum, putamen, insula and cingulate cortex.

The researchers also found that the men tended to have more intense responses in the hypothalamic-pituitary-adrenal (HPA) system (e.g., the release of cortisol). According to the researchers, the increased activity in the men’s right prefrontal cortex (RPFC) under the acute stress condition was the most significant finding of their experiment, forming a biomarker for a distinctly masculine acute stress response.

What to make of all this? The researchers use a general description of these two different stress responses, first proposed by Taylor et al. (2000), as ‘flight-or-fight’ in men and ‘tend-and-befriend’ in women. At first read, I just groaned, and I’m still opposed to the essentialist and evolutionary mythology being touted as explaining an observable difference in performance. I’m not even going to start down the well-trod path I’ve beaten criticizing ‘evolutionary psychologists’ for naturalizing observed differences between men and women, simultaneously conjuring away the problem of explaining these differences by assuming that they are ‘inherent’ and attributing them to some dramatic fantasy of evolutionary selection — we’ve been here before (say at Girls gone guilty: Evolutionary psych on sex #2 or Chicks dig jerks?: Evolutionary psych on sex #1).

In fact, their data is much more interesting. For example, Wang and colleagues point out that the difference in brain activation patterns might result from different stress coping strategies or from different response to high- and low-stress situations (see Wang et al. 2007: 237-8). Ironically, as Wang and colleagues discuss, the difference in men’s and women’s stress responses depended upon the stimulus being used to produce stress: some experiments used social rejection; others, like the Wang-led team, use arithmetic problems to create stress. Likely, different sorts of stressful situations produce subtle distinctions in stress responses, some evoking more social anxiety, for example, and others creating a greater sense of physical peril. The group offers a path for future research, suggesting that neuroimaging studies of stress responses on different sorts of cognitive tasks might help sort out what’s specific to mathematical problems or might be more general difference between men and women: ‘Given the sensitivity of stress responses to specific context and intensity, we are cautious to generalize the current finding to different types of stress’ (ibid.: 238).

These different stress responses likely affect other mental activities in a variety of ways; we know that not all responses, in parallel fashion, affect health or cortisol production or other physiological correlates of stress. In addition, it’s quite likely that men and women don’t read the situations as equally stressful, either for innate reasons or for encultured ones–the two would be very difficult to disentangle in adults as the physiological effects would be identical. For example, girls and boys might interpret a testing situation in different ways because of peer, family, social, or other dynamics.

But I’m just going to hold my nose about the ‘ev psych’ part of this and plow onward (my objection being the ontogenetic simplifications of how a trait might emerge rather than a phylogenetic objection to saying that men and women might have been subjected to different evolutionary pressures — someday I’m going to have to do a post on this). So, onward with nose held…

Differing stress responses: ‘fight-or-flight’ or ‘tend-and-befriend’

The ‘fight-or-flight’ response ‘invokes resources that increase focus, alertness and fear, while inhibiting appetitive goals to cope with the threat or challenge’ (Wang et al. 2007:236). This pattern shows up in the increasingly active RPFC, associated with vigilance and negative emotion, and the suppression of activity in the LOrF, linked to hedonic behaviour and positive feedback. In other words, in the ‘fight-or-flight’ response, according to this interpretation, an individual becomes very alert to potential dangers and anticipating dire consequences, much less capable of focusing on pleasure-seeking.

Female response, in contrast, ‘primarily involves the limbic system including ventral striatum, putamen, insula and cingulate cortex’ (ibid.). This pattern was labeled by Taylor and colleagues ‘tend-and-befriend,’ and included parts of the brain receptive to oxytocin, vasopressin, dopamine and endorphin, systems that have been linked in previous research to social relations, attachment, and maternal behaviour. The researchers suggest that this social rewards system may blunt the acute stress response, leading women to respond in similar fashion to both high- and low-stress situations.

Wang and colleagues do point out that there are a lot of parallels between male and female responses, including very similar endocrine response, in spite of the predictions of the ‘fight-or-flight’/'tend-and-befriend’ contrast. The point being that, as in many human traits, male and female differences tend to appear in some lights as oppositions, but upon closer examination often reveal instead a largely common, underlying pattern (although the RPFC response was distinctive of their male subjects). Even the differences that do exist, such as a divergence in cortisol feedback due to the effects of reproductive hormones, may or may not be linked to observable differences, such as patterns of ‘ruminative thinking,’ as the researchers discuss. And the study itself didn’t turn up some patterns of activation that the researchers expected, such as a more prominent role for the amygdala (see, for example, Paul Mason’s discussion of the Role of Emotions in Brain Function).

Stress and cognitive function

Turning away from the more general effects of stress, focusing instead on the parts of the stress response that might affect must profoundly cognitive processing, we find that:

Activation of RPFC and right parietal regions [the pattern more pronounced in men] has been associated with various cognitive control tasks, including working memory, response selection and task switching, as well as inhibitory functions …. Ventral striatum along with several limbic regions [both pronounced in women under stress] have also been involved in learning in addition to tasks related to reward, motivation and emotion…. The different computational roles subserved by these brain regions may contribute to the observed gender differences in central stress responses. Although somewhat controlled in the regression analyses, this possibility (e.g. inhibiting incorrect responses in males and updating task strategies in females) cannot be completely ruled out, especially in the direct comparison of average stress responses between men and women.

Wang and colleagues specifically indicate recent research on mathematics and science ability (Hyde and Linn 2006) and suggest that the variation in stress response might underwrite pronounced differences in test results.

The RPFC, for example, is especially associated with executive functions (such as inhibiting emotional responses) and with strategic thinking, which might suggest a particular pattern of responding to stress. If women were more likely to focus on updating the possibility of reward, their own emotional states, and their motives while under stress, this might lead to lower scores when they were stressed by a time-constrained testing format. I’m still not persuaded that this is innately male or inherently impossible for women to achieve. If this is a pattern of brain activity especially likely to lead to certain test scores, and if some women are able to achieve extremely high test scores, than perhaps some women are able to learn this cognitive strategy. After all, it’s not like women don’t have these same parts in their brains. Likewise, I suspect that you could train patterns of response to stress in boys; certainly, the people I work with in sports training are convinced this is the case.

Implications for test-taking

First off, the experiment was ideal for exploring a possible stress-related contributor to the ‘math gap’ because it actually used mental arithmetic as the stimulus. Although not a perfect fit for a test-taking environment (where you don’t do the arithmetic in your head while holding still in a giant fMRI scanner), I doubt we’re going to get much better than this until the imaging technologies make some major jumps.

Second, in general, women after puberty have a lower threshold for perceived stress. The irony is that perceiving that one is stressed can often exacerbate one’s stress response. If you think you are anxious, you can make yourself more anxious. One can easily see how this might affect women’s performance on standardized tests. I never recall being all that stressed out on things like the SAT or GRE (I think I fell asleep during the GRE when I finished one section early), but for some people, this significantly influences their performance. I need to point out that Wang and colleagues specifically controlled for this effect in their research, so it’s not such a factor in their data, but it’s not hard to imagine that, especially given the length of a standardized test and the possibility that difficult questions might heighten stress during the course of an exam, this might become a factor in test score differences.

But the bottom line is that, if boys’ and girls’ brains respond differently to stress, this might disproportionately affect tests exploring various subjects. Female stress response might make their mathematics problem solving drop off more than men’s in timed tests (of course, we still have the much-less-discussed ‘reading gap’ to deal with, too). This sort of pattern does seem to show up in the gap between women’s performance on standardized testing in relation to men’s, and their across-the-board higher averages in marks on university courses (since broader admission of women into universities).

But stress might also lead to a narrowing of girls’ variance on standardized tests. It might diminish ability to perform at an extremely high level, but it also might lift the scores of the lowest scoring, least-motivated individuals. Lack of stress on a standardized math test — the situation boys might be more likely to find themselves in — might improve some young men’s scores, but it also might lead low performers to be even more blasé about their situation. Even the high RPFC activation in men might show up in boys as a clear-headed strategizing about the irrelevance of doing well on a standardized test if they know that they are not high performers in mathematics.

In other words, even a different pattern of brain activation (elevated activity in the RPFC) may simply provide the emotional environment in s stressful environment in which a boy might perform especially well, or calmly assess that the exercise was pointless given what he already knew about his ability. The result would be indistinguishable from an innatist argument that ‘boys have higher variance in innate math ability,’ but the underlying causal mechanism would be subtly different (and thus require different remedial projects if someone tried to address the variation).

One indicator of the possibility of these sorts of subtle mechanism that a Scientific American article by Halpern and colleagues cites is the fact that preschool children score similarly on cognitive tests of quantitative thinking and geometrical reasoning. The start to diverge when the children get to school. Innatist explanations suggest that the ‘true nature’ of boys and girls emerges when they enter school, but it’s just as likely that peer dynamics, including strong sex-stereotyping among kids, starts to really kick in when they are exposed to school. My point is not to argue that an innatist position is untenable, only that the pattern we see is equally consistent with other ways of thinking about how differences might arrive.

More on higher variance arguments

The Scientific American article also looks at the ‘higher variance’ of math ability argument that a number of proponents of innate ability gaps put forward (which I discuss at length in the previous post on math tests). The gap is profound, but the trend in that gap is also interesting. The authors reflect on data that was first assembled in the early 1980s on SAT scores:

There were twice as many boys as girls with math scores of 500 or higher (out of a possible score of 800), four times as many boys with scores of at least 600, and 13 times as many boys with scores of at least 700 (putting these test takers in the top 0.01 percent of 12- to 14-year-olds nationwide).

Although it has drawn little media coverage, dramatic changes have been occurring among these junior math wizards: the relative number of girls among them has been soaring. The ratio of boys to girls, first observed at 13 to 1 in the 1980s, has been dropping steadily and is now only about 3 to 1. During the same period the number of women in a few other scientific fields has surged. In the U.S., women now make up half of new medical school graduates and 75 percent of recent veterinary school graduates. We cannot identify any single cause for the increase in the number of women entering these formerly male-dominated fields, because multiple changes have occurred in society over the past several decades.

Although 3 to 1 is still a very large gap, it’s also startling to see that the gap can close from 13 to 1 to as little as 3 to 1 in a bit more than two decades. There may be an innate gap in math ability, but with all the change in these figures, it seems a bit premature to suggest that we know for certain that we’ve ascertained it and cannot affect change in the performance gap any further.

In addition, specialized courses designed to remedy the women’s specific deficits in visuospatial skills at the Michigan Technological University led to marked improvement among women in this area, one of the abilities considered to be strongly sex-linked, and to higher retention of women in university science and math programs. (I don’t have specifics on this intervention yet, but I will post more information when I get it.)

Again, this doesn’t prove that there are not innate differences between men and women: the origin of the gap in visuospatial skills is not at all clear. Because I’m more of a developmental systems theorist than an innatist, I would tend to look in the developmental trajectory of boys and girls for the difference rather than assume math ability springs from a gene or hormone. Thinking of the child as a developmental system, the gap may arise in an odd, indirect way; for example, boys relatively lower verbal abilities might lead them to compensate by developing visuospatial skills, or girls play patterns — whether due to innate tendencies or socialization — may give them less experience with visuospatial manipulation. Because the gap is mutable and the skills deficits at least partially remediable, I’d say that the burden of proof starts to fall on the innatists; show us where the innate visuospatial ability actually lives in the brain and how it comes into the world pre-destined if a whole host of studies are showing gaps are mutable.

In the end, I suspect that there are biological differences in girls’ and boys’ brains that contribute to differences in test score variance, but these differences may not be where we expect them. For example, they may have more to do with something that indirectly affects math testing like stress response or motivational structure in education. Innatist thinking is too easy, too inconsistent with the actual way that brains and cognitive abilities develop in an unfolding of the human organism in relation to a social and learning environment. There’s a lot of ‘mights’ in my account, but the fact that there are other plausible explanations for something like the math gap — even if it is universal (which the Science papers question) — shows overly glib assertions of innate difference to be a sloppy way out of what are really a whole set of interesting theoretical and empirical questions.

Stumble It!

References
Halpern, Diane F., Camilla P. Benbow, David C. Geary, Ruben C. Gur, Janet Shibley Hyde and Morton Ann Gernsbacher. 2007 (November). Sex, Math and Scientific Achievement: Why do men dominate the fields of science, engineering and mathematics?. Scientific American (available online here)

Hyde, Janet Shibley, and Marcia C. Linn. 2006. Gender similarities in mathematics and science. Science 314 (5799): 599–600. (pdf available here)

Phipps, Alison. 2008. Women in Science, Engineering and Technology: Three Decades of UK Initiatives. Trentham Books.

Taylor, Shelley E., Laura Cousino Klein, Brian P. Lewis, Tara L. Gruenewald, Regan A. R. Gurung, and John A. Updegraff. 2000. Biobehavioral responses to stress in females: tend-and-befriend, not fight-or-flight. Psychological Review 107(3): 411–29. (abstract on Pub Med, pdf available here)

Wang, Jiongjiong, Marc Korczykowski, Hengyi Rao, Yong Fan, John Pluta, Ruben C. Gur, Bruce S. McEwen and John A. Detre. 2007. Gender difference in neural response to psychological stress. Social Cognitive and Affective Neuroscience 2(3):227-239. doi:10.1093/scan/nsm018

Image from Good Karma Flags

A recent article on PLoS One by a research team from the Benson-Henry Institute for Mind/Body Medicine at Massachusetts General Hospital (MGH) and the Genomics Center at Beth Israel Deaconess Medical Center (BIDMC) discusses the genetic effects of the relaxation response, a widespread bodily state induced by different mind-body techniques (such as meditation).

The original piece, Genomic Counter-Stress Changes Induced by the Relaxation Response, was published at PLoS One, and the findings are also discussed on ScienceDaily, Relaxation Response Can Influence Expression Of Stress-related Genes. It’s starting to be a bit of a refrain from genetics research, but it still bears repeating: the team is exploring a way that ‘changing the activity of the mind can alter the way basic genetic instructions are implemented,’ as Dr. Herbert Benson explained (in ScienceDaily).

The relaxation response is a bodily state, found in a variety of contexts, characterized by ‘decreased oxygen consumption, increased exhaled nitric oxide, and reduced psychological distress.’ Long-term effects of relaxation exercises include decreased oxygen intake and carbon dioxide elimination; reductions in blood pressure, heart and respiration rate; prominent low frequency heart rate oscillations; and some changes in cortical and subcortical brain regions, including increased thickness of the cortex (see NeuroReport and here also on the effect of meditation on aging).

For about three decades, dependable clinical studies have shown that relaxation response-producing exercises have a range of positive health benefits. What makes the current research distinctive (at least in my reading) is that the team traced this metabolic process to its genetic effects. As the authors write:

This study provides the first compelling evidence that the RR elicits specific gene expression changes in short-term and long-term practitioners. Our results suggest consistent and constitutive changes in gene expression resulting from RR may relate to long term physiological effects. Our study may stimulate new investigations into applying transcriptional profiling for accurately measuring RR and stress related responses in multiple disease settings.

The research team looked at long-term practitioners of mind-body exercises, a group of controls, and a third group that they trained in guided relaxation techniques, using 20 minutes each day of practice. The long-term practitioners were a diverse group, including practitioners of ‘Vipassna, mantra, mindfulness or transcendental meditation, breath focus, Kripalu or Kundalini Yoga, and repetitive prayer.’ I found the manipulation of the short-term group not terribly ambitious — many relaxation regimens around the world, including things like tai chi and compassion meditation, are much more demanding of practitioners. Admittedly, it’s hard to get experimental subjects to commit to arduous regimes; all the more reason to study naturally occurring ‘experiments’ (like the veteran practitioners). The groups weren’t terribly large either (around 60 subjects, in the first round, a bit over 70 all up), but the results were significant and very well documented, nonetheless.

A large number of genes seemed to be affected, with significant overlaps between the long-term and short-term practitioners. 260 genes were up-regulated and 168 genes were down-regulated in both the group of long-term practitioners and the group given short-term training. As the article reports: ‘they represent GEP changes characteristic of RR practice over at least 8 weeks.’ Some of the gene changes seem to cluster in genes expressed in hematopoietic cells, those linked to blood formation, and in genes linked to stress, oxidative metabolism, and primary metabolism. As the abstract reports: ‘gene ontology and gene set enrichment analyses revealed significant alterations in cellular metabolism, oxidative phosphorylation, generation of reactive oxygen species and response to oxidative stress.’

The researchers found that relaxation response was a kind of reversal of the genetic and cellular stress response. As the Discussion of the article suggests, ‘It is becoming increasingly clear that psychosocial stress can manifest as system-wide perturbations of cellular processes, generally increasing oxidative stress and promoting a pro-inflammatory milieu.’ In contrast, their analysis of relaxation response ‘reveals altered gene expression in specific functional groups which suggest a greater capacity to respond to oxidative stress and the associated cellular damage. Genes including COX7B, UQCRB and CASP2 change in opposite direction from that in the stress response.’

Jeffery Dusek, one of the authors explained to Science Daily, ‘Changes in the activation of these same genes have previously been seen in conditions such as post-traumatic stress disorder; but the relaxation-response-associated changes were the opposite of stress-associated changes and were much more pronounced in the long-term practitioners.’

Towia Libermann, director of the BIDMC Genomics, added: ‘This is the first comprehensive study of how the mind can affect gene expression, linking what has been looked on as a ‘soft’ science with the “hard” science of genomics.’ I don’t know about it being the ‘first,’ but it is a compelling exploration of the genetic mechanisms on the pointy end of cultural techniques for changing one’s own mental state.

There’s lots to like in this article, including the team’s recognition that the ‘relaxation response’ can be found in a host of different practices; the authors list ‘various forms of meditation, repetitive prayer, yoga, tai chi, breathing exercises, progressive muscle relaxation, biofeedback, guided imagery and Qi Gong.’ In addition, word repetition can induce the bodily response, so we might add chanting and Qawwali (Sufi devotional music).

I’m a bit less convinced by Benson’s assertion that ‘no matter which particular technique is used — different forms of meditation and yoga, breath focus, or repetitive prayer — the mechanism involved is the same.’ It might be. It might not be. Perhaps because I’m influenced by Gerald Edelman’s discussions of the variability of networks of brain stimulation (for example, in Wider Than the Sky: The Phenomenal Gift of Consciousness), I’d be surprised if variations in these techniques (such as those that use chanting or movement, for example) had no effect at all on the resulting neural, cellular, and perhaps even genetic processes. Although there’s some awareness of cultural variety, there’s no great respect for subtle differences among things like relaxation exercises that might shade some of the analysis. It’s hardly unusual; in a lot of the mind-body discussion, there’s a kind of assumption that all mind-body techniques are only superficially different. Oddly, this universalizing impulse is shared with a lot of New Age synthesis, which also seem to have a very ecumenical disregard for difference (sometimes to the chagrin of those they wish to embrace, such as various Indigenous religious representatives).

The researchers are also adding to our knowledge of variations in genetic expression among healthy subjects due to differences in habits, behaviour, or psychological training (as Libermann points out). Whether or not any of this can make a dent in the popular conception of genes as ‘blueprints’ or ‘programs’ that invariably get expressed in the mature organism, remains to be seen.

Update: find more on meditation on Neuroanthropology at Get into trance: Felicitas Goodman.

References

Jeffery A. Dusek, Hasan H. Otu, Ann L. Wohlhueter, Manoj Bhasin, Luiz F. Zerbini, Marie G. Joseph, Herbert Benson, and Towia A. Libermann. 2008. Genomic Counter-Stress Changes Induced by the Relaxation Response. PLoS One 3(7): e2576. doi:10.1371/journal.pone.0002576

Massachusetts General Hospital. 2008. Relaxation Response Can Influence Expression Of Stress-related Genes. ScienceDaily (July 3). Retrieved July 5, 2008, from http://www.sciencedaily.com /releases/2008/07/080701221501.htm

Image from Good Karma Flags.

Narrative and memory are interwoven in our consciousness, and thus explorations into trauma from both humanities and social science perspectives almost invariably discuss narrative in one form or another. An ongoing debate within psychological research, for example, ponders whether the coherence of trauma stories is correlated to the amount of emotional distress associated with a given traumatic memory. It is hypothesized that the greater the distress, the less organized the narrative. If this were the case, we might expect that the coherence with which an individual is able to talk about the trauma would increase as the memory is processed and resolved, a finding for which we have some evidence.

We do know – when it comes to Post-Traumatic Stress Disorder (PTSD) – that narrative matters. As I wrote in an earlier post, the most effective therapies yet proven for reducing PTSD symptoms are the exposure therapies, particularly Prolonged Exposure (PE) therapy. These therapies are more effective for reducing the full range of PTSD symptoms than any pharmaceutical yet identified. And the crux of these therapies rests on telling the story of the trauma, sometimes over and over again. This simple practice, this process of speaking, has been reliably demonstrated to result in an improvement of PTSD symptoms for many patients.

But for all its clinical benefit, this extraordinary observation tells us very little about the mechanisms of psychic healing after trauma. Instead, it points to a growing body of evidence that suggests it is not just narrative that matters in PTSD, but, more intriguingly, that it is the type of narrative that matters. Unstructured psychodynamic therapies, for example, have not been demonstrated to lessen the severity of PTSD, even among patients who continue in therapy for years. And yet certain ways of narrating memory do make a difference, and this phenomenon once again points to a role for anthropologists and other culturally-minded researchers in exploring the cultural-emotional-physiological-environmental interactions at play in post-traumatic processing.

Let me give an example. I recently attended a PE training workshop for VA and military mental health clinicians where specific instructions were given as to the essential structure of a patient’s ‘exposure narrative’, the trauma story that must be repeated until the patient becomes acclimated to the associated distress. One clinician raised his hand to ask the question, “So what’s the difference between this kind of talking about the trauma and the war stories a lot of these guys tell down at the bar?”

In this case, the answer the clinician received was strictly in line with the PE model of PTSD: namely, 1) that the types of stories veterans tell at the bar typically do not include the level of intimate and sensory detail that is necessary to process a disturbing memory; and 2) that the stories people tell at the bar are not typically the ones with which the greatest distress is associated (i.e., if they’re talking about the event that freely, it’s probably not that upsetting). Or, to paraphrase what one veteran told me, ‘We keep it superficial. And funny, not sad.’

But what makes the social worker’s question so intriguing is its resonance with work by anthropologist Theresa O’Nell. In a wonderful article , she explores two kinds of talking about the Vietnam war among Northern Plains veterans and the level of what she calls “psychological transformation” associated with each narrative style. She writes that, early on in her research, she was:

…puzzled by an apparent contradiction: on the one hand, it is said that Vietnam veterans have not “come home” from the war because they have not “talked about it.” On the other hand, friends and relatives of veterans know a great deal about the war experiences of veterans – experiences that could not be known unless the veterans had indeed “talked about it.” Moreover, despite their apparent disclosure of wartime experiences, many veterans seemed no closer to forgetting about Vietnam than if they had never “talked about it.” In other words, it seems to me that a lot of the disclosure done by veterans about their wartimes experiences was, at some level, lacking or ineffective, especially regarding the goals of disclosure and forgetting.

She set out to identify the different ways in which these veterans spoke about their wartime experiences, and came to recognize two distinct patterns, iglata (to “brag in excess”) and wagtoglaka (to “retell one’s heroism”). Informal iglata, for example, tends to occur while drinking and joking among peers, while the more formal wagtoglaka takes place in a ceremonial context, generally involving an intergenerational audience who listens in “respectful silence” to the veterans’ words. Thus her ethnography shows the two patterns of speech each have different discursive characteristics, social contexts, and manners of self-presentation.

O’Nell situates these forms of narrative in a way that reveals their meaning for those speaking and those listening, but she also links the experience of speaking in these ways to Northern Plains veterans’ ability to resolve their struggles with the war. She found that, among those who reported only talking about their war experiences while drinking (a context that would suggest iglata), self-reported PTSD symptoms were significantly higher than among those who denied only telling war stories while drinking (suggesting contexts not limited to iglata, although not necessarily indicating wagtoglaka).

O’Nell rightly points out that it is not just narrative that matters for these veterans, it is a specific form of narrative that appears to make the difference, as well as the social venue and the attitude of the listeners. In the context of a Western society in which going to see a therapist is a pretty mainstream response to many life problems, this emphasis on “talking things out” may seem a bit obvious. But what this example suggests is the possibility of cross-cultural variation in narrative forms that bear an essential commonality: they are in some way therapeutic for those struggling with the aftermath of trauma. This begs the comparative question, do narratives exist cross-culturally that may – despite different structures and content – similarly tap into the necessary processes for healing trauma?

In tackling this question, we yet again see how PTSD provides an opportunity for exploring the relationship between individual and environment, and in doing so demands that we consider the type of process Paul Mason writes of so infectiously in his recent post on neuroplasticity. We have had evidence for a while now that PTSD is associated with decreased hippocampal volume, but what will we learn about the structure of the brain through an exploration of the neural changes occurring alongside post-therapy symptom reductions in PTSD?

A study of eye movement desensitization and reprocessing (EMDR) – a therapy with mixed evidence for its efficacy, but which focuses on retelling traumatic memories in accompaniment with a series of eye motions intended to access key networks in the brain – found that, among 6 PTSD-diagnosed police officers who underwent SPECT imaging before and after their treatment, symptom reductions were associated with decreases in the left parietal lobe, left and right occipital lobes, and right precentral frontal lobe.

It’s just a beginning, but as our ability to conduct and comprehend neural imaging and other technologies increases, we will be able to observe the changes that accompany not only stress and PTSD but also the path to healing – that re-wiring of emotional and physiological responses that results in a reduced sense of suffering and distress. This research opens up the examination of narrative in a new way: as a focal point for understanding the practical interaction between communication and the brain, with very real consequences for healthy functioning. How incredible to think of being able to visualize such an internal, intimate relationship between words and illness, language and the body.

In considering the question of healing narratives, however, a series of other inquiries open up, most obviously: how does narrative-focused healing occur? What are the psychological and physiological processes providing the mechanisms for healing? We might also ask what characteristics define the appropriate type of narrative in a given cultural setting. Are there characteristics that appear to be common? And does variability in the nature of healing narratives occur in tandem with, or despite, differences in how closely local ideas of trauma resemble Western notions of PTSD?

Thinking in this way will also require that we navigate some rocky methodological questions. For example, it may be necessary to define traumatic aftereffects in a manner that considers cultural variation and the validity of comparison without limiting the field to PTSD per se. We must also distinguish between narratives that respond to long-term evidence of trauma, narratives that are intended to prevent acute aftereffects from becoming more chronic, and narratives that are useful in managing different types of traumatic events, from rape to war.

Despite its difficulties, such a path of inquiry has enormous potential for integrating neuroscience and some of the great questions of culture and experience.

Early on, however, a psychiatrist whose work on trauma I admire opined to me that crises of meaning belong to the realm of depression rather than PTSD. He suggested that combat PTSD was best thought of as the physiological effects of living under conditions of extreme stress, while more meaning-related struggles were best understood as a symptom of depression. Given the frequency of comorbidity between PTSD and depression, I was for some time inclined to go along with his analysis.

Then two things happened. First, I began the work of talking with veterans themselves about their stories of trauma and PTSD, listening to how they describe their own experiences. And second, I began to explore the increasingly dominant Prolonged Exposure model of PTSD, which views the disorder as a pathology that develops when individuals fail to process their traumatic memories in the normal way.

Some background is important here. A recent RAND report suggests that as many as 18.5% of combat troops have gone on to develop PTSD after serving in Iraq or Afghanistan; alarming as that number is, it nonetheless demonstrates that the vast majority of combat-exposed individuals do not develop PTSD. However, most of the veterans I’ve spoken with – even those without a formal PTSD diagnosis – report experiencing some PTSD symptoms for a period of time following their combat deployment. Many of them dealt with such symptoms for a while – a month, three months, a year – before passing through this period of processing their memories and going on with their lives. They may be changed by their experiences in the war zone, but they are not broken by them, and may even describe them as resulting in personal growth and other positive effects.

The difference is for those individuals who seem to get, as Dr. David Riggs has described it, “stuck“. Dr. Riggs is Executive Director of the Center for Deployment Psychology and a long-time investigator of Prolonged Exposure therapy, a cognitive behavioral treatment developed by Dr. Edna Foa and colleagues in the 1980s and recognized in a 2007 Institute of Medicine report as best-proven for the reduction of PTSD symptoms. The model underlying this treatment goes roughly as follows: PTSD comes about as the result of an individual’s attempt to learn to avoid danger out in the world. Therefore, when a trauma occurs, the circumstances surrounding that trauma are imprinted on the memory in such a way that those circumstances become associated with high levels of physiological arousal and anxiety – an evolutionary mechanism intended to help the individual avoid similar dangers in future.

As a result, individuals with PTSD are likely to avoid what are called ‘triggers,’ sensory reminders of circumstances in which they experienced a threat. Because these people experience the traumatic memories and their associated triggers with intense anxiety, they avoid rather than processing and integrating them. Thus it is thought, under this model, to be the avoidance of painful memories that results in their uncontrolled intrusion into dreaming and waking life.

But what this model doesn’t explicitly account for is the determination of what memories are experienced as so horrifying, so disturbing, and so unmanageable that they can drive an individual to continually push them out of mind rather than working through them in the normal way. And it is here – it seems to me – that we can begin to appreciate the cultural place of meaning amidst the biocultural interactions at work in the acquisition of long-term PTSD.

For when veterans describe their traumas, they typically describe them in the context of other memories which – albeit difficult – they did not find to be traumatic. The soldier who describes the horror of working on mortuary duty in Iraq may also describe the comparatively mild distress (for him) of being under mortar attack. A soldier who describes seeing dead Iraqis and being unaffected by it – because he viewed Iraqis as the enemy – may then go on to describe being deeply upset by the injury of another American. On the other hand, certain traumas run along common lines. Many veterans narrate incidents involving children hurt or killed in the course of combat action. Frequently these individuals also describe how these children reminded them of a son or daughter, niece or nephew.

Looking at these veterans’ trauma stories as a collective, then, reveals two things. First of all, an event that is pathologically traumatic for one individual may not be so for the next, and as a result, we can conclude that there is considerable individual variation in the experience of trauma. This variation appears to be driven by both life history and genetic factors – e.g., for the veterans traumatized by seeing injury to children, their horror may be exacerbated both by having a beloved child in their own lives and/or by having a genetic vulnerability to experiencing events as traumatic.

Second – and with the potential to affect both individual and group variation in responses to trauma – there may after all be a role for meaning, inevitably embedded in cultural signs, systems, and beliefs, in determining what events are experienced as traumatic. If indeed it is avoidance that leads to the maintenance of PTSD symptoms over time, then what events will be perceived as so grisly, unjust, heart-breaking or shameful that the individual practices continuing avoidance? Culture, with its capacity for shaping the emotional resonance of events throughout the life course, would seem to play a central role in making this determination.

A certain sub-group of these veterans’ trauma narratives illustrates the place for culture – and in particular, meaning – in turning up (or down) the perceived trauma of an event. Many of the veterans in this sample, for example, were non-commissioned officers (NCOs) during their time in the military. The position of NCOs within the social and power structures of the military is marked by a responsibility to preserve the well-being of soldiers under their command. The importance of this responsibility is matched only by NCOs’ duty to complete their mission and to obey their commanders, following the orders that come down the command chain. When these obligations come into conflict the results can be devastating.

The classic example of this, and a running theme in NCOs’ trauma stories, occurs when a lower-ranking soldier is hurt while following orders to which the NCO personally objects. For example, one veteran told me about the day when one of “his” soldiers was wounded while following the unnecessarily risky orders of his superior, orders that he protested at the time but ultimately felt compelled to obey. His story, and others like it, reveal that the trauma of these events lies not only in the wounding of a fellow soldier, but in the inability to protect a subordinate for whom one feels deeply responsible, and the sense that the damage might have been prevented. Thus the meaning of events creates much of their resonance, and their cultural embeddedness – e.g. in the communal socialization and strict power structures of the military – is partially responsible for the emotional overload that defines trauma.

Exploring this thought, of course, leads one to the question: well, but aren’t there many events that would be universally experienced as traumatic? What about rape? Atrocity? The slaughter of children? Two thoughts jump to mind. First of all, I’m reminded of research reporting that certain fears can be acquired more easily than others – even in the absence of a direct threat from the feared object, say, a snake – which suggests there may be some pathway by which specific fears have been passed down over the course of human evolution (for an interesting discussion of these issues, see the February 2002 issue of Behavioral Research and Therapy). It seems likely that certain fears may approach universality, like rape or danger to children, and thus may appear more frequently in trauma narratives.

On the other hand, killing and the participation in atrocity may or may not be universally experienced as traumatic. What constitutes atrocity, for example, seems quite likely to be culturally determined. And while proximate killing, for example, has been argued to be a consistent predictor for PTSD by Lt. Col. Dave Grossman, among others, some veterans make clear distinctions between the ease of killing the ‘evil’ and the difficulty of killing the ‘innocent’, distinctions which themselves are deeply cultural.

In this way, it seems clear that meaning has a place in the conceptual models we build for understanding PTSD risk, with relevance for both domestic and cross-cultural research. In addition, it seems likely that in future it will be increasingly possible to link an appreciation for meaning with more biologically-grounded models for the neural pathways of stress disorders, helping to further bridge the connections between physiological and phenomenological in the processing of trauma.

For more on this research, where Erin Finley covers memory, narrative, healing and PTSD, click to see Part II.

In particular, I found the discussion of ‘psychological kevlar’ to be interesting for neuroanthropology:

In the U.S., where roughly two-fifths of troops returning from combat deployments are presenting serious mental health problems, PTSD has gone political in form of the Psychological Kevlar Act, which would direct the Secretary of Defense to implement “preventive and early-intervention measures” to protect troops against “stress-related psychopathologies.”

Proponents of the “Psychological Kevlar” approach to PTSD may have found a silver bullet in the form of propranolol, a 50-year-old beta-blocker used on-label to treat high blood pressure, and off-label as a stress-buster for performers and exam-takers. Ongoing psychiatric research has intriguingly suggested that a dose of propranolol, taken soon after a harrowing event, can suppress the victim’s stress response and effectively block the physiological process that makes certain memories intense and intrusive. That the drug is cheap and well tolerated is icing on the cake.

With PTSD so prevalent among soldiers, can it be better treated, even if that means blocking the formation of traumatic memories? Daniel did a piece on PTSD rates in soldiers in April, Invisible Wounds of War, and he discussed a RAND Corporation estimate that treatment of soldiers with PTSD would cost ’6.2 billion dollars in the first two years after returning from deployment.’ (Daniel also provided links to a number of articles on Iraq and its psychological effects in Wednesday Round Up #7.) The potential to use drugs to stop the development of PTSD, even if it also blocks normal memory formation, raises a number of ethical and moral questions as well as some interesting neuroanthropological ones.

There’s more information on this line of research from an earlier Nature article, Beta-blockers tackle memories of horror, by Jim Giles. Giles discusses research done on the use of Propanolol on civilian populations experiencing traumatic events (like 9/11 or the London bombings), but specifically sites concerns that the drug might be abused by applying it to soldiers. For example, Paul McHugh, a Johns Hopkins University psychiatrist and member of the US President’s Council on Bioethics, warns: “If soldiers did something that ended up with children getting killed, do you want to give them beta-blockers so that they can do it again?… Psychiatrists are once again marching in where angels fear to tread.” 60 Minutes also did a story in 2007 on the experimental use of Propanolol with traumatized individuals, A Pill To Forget?

Propanolol is marketed under a range of names, including a number of AstraZeneca products (Inderal, Avlocardyl, Avlocardyl, Deralin, Dociton, Inderalici, InnoPran XL, Sumial), others by Wyeth, and as a generic. It was once a first-line hypertension drug, but now most sources say that beta-blockers are not considered the treatment of first choice as others tend to work better. Some performers, such as musicians, use propanolol to deal with stage fright, and students have been known to use it to quiet nerves for exams if they are especially likely to anxiety attacks.

Beta-blockers like propanolol block the neurotransmitters involved in laying down memories, especially extremely vivid emotional memories or traumatic memories, the target of most of this research. For example, studies have found that rats who have learned to associate a tone with an electric shock lose their fear of the tone if propranolol is administered after the tone starts. That is, the rats do not demonstrate the normal conditioned response to the stimulus, but they also prove less likely to remember essential information from stressful situations. In another experiment, rats left to swim around in a tank to find an underwater platform that was invisible to them remembered where the platform was when put back in the tank and swam directly to it. That is, unless they were given a beta-blocker which interfered with adrenaline cycles, in which case they were left to wander around again the next time they were placed in the tank until they re-discovered the underwater platform.

The hope of researchers is that propanolol might inhibit PTSD, especially (from the Nature article) ‘panic attacks and flashbacks that are triggered by events associated with memories of the trauma, such as sirens or bangs.’ The President’s Council on Bioethics, in a 2003 report, Beyond Therapy: Biotechnology and the Pursuit of Happiness, discussed the use of ‘memory dampening’ to deal with trauma in general (not specifically in military contexts). The Council reflected on the potential uses but also brought up a number of reservations, including concerns that such use would; 1) discourage us from authentically coping with trauma, 2) tamper with personal identity, 3) demean the genuineness of human life and experience, 4) encourage us to forget memories that we are obligated to keep, and 5) inure us to the pain of others (from Kolber 2006, abstract). Adam Kolber also argues that memory dampening may pit the therapeutic interest of the individual against social interest in reconstructing events: ‘Drugs that dampen traumatic memories may someday test the boundaries between an individual’s right to medically modify his memories and society’s right to stop him from altering valuable evidence.’

Kathleen Logue, a paralegal who had been knocked down in the middle of a Boston street by a bicycle, was asked by a researcher whether or not she thought forgetting would undermine a person’s identity. Logue replied: “A terrible act… Why should you have to live with it every day of your life? It doesn’t erase the fact that it happened. It doesn’t erase your memory of it. It makes it easier to remember and function.” This is another of the key issues for me: how much ‘forgetting’ are we talking about? If it’s just the short circuiting of the psychological processes that produce obsessive revisiting of traumatic memory, but a person still retains some memory of what happened, I don’t really have a problem with this.

The Alternet article points to research done by the US military on the use of these drugs with soldiers, although it’s not clear to me how discriminating their use would be. PTSD seems to arise, not only from horrible events in which one is a passive participant, but also when one is an active agent. The concern is that the drugs will be used, not merely to aid soldiers who are traumatized by violence against them and their colleagues, but also by their own actions: medicating away the pains of conscience, is how the Alternet piece puts it.

I think that this distinction, although very difficult to apply in practice, is at the heart of disagreements about whether these drugs are ethical or moral. Most Westerners, in my opinion, believe that the pain caused by one’s own guilty conscience is one of the few constraints on human barbarity, especially in wartime. We tend to fear those without conscience and worry that certain acts in wartime — torture, war crimes, attacks on civilians — are only prevented by a healthy conscience. Engaging in these acts also allegedly undermines or damages the conscience so that we worry about the chance that a soldier might be unable to return to civilian life, to restore the conscience that restrains violence in everyday life. So one of the causes of disagreement seems to be whether or not the critics or advocates focus on PTSD in circumstances where a soldier is victim of a road-side bombing, a rocket attack, or witnesses a friend killed or if they example we consider is the troubled conscience of a soldier who has engaged in a massacre, seen the effects of his or her own side’s weapons, or been affected by the suffering of civilians. In one set of examples, it’s hard to argue that the individual is responsible, in others, it’s clear that the person to be medicated is guilty on different levels, and in other examples, it’s not really clear who would be considered responsible.

But I’m also not sure propanolol would work on all cases, especially those of the ‘guilty conscience’ variety. In some veterans, it appears that PTSD is at least partially the result of an accumulation of outrage at one’s own actions (or those in which one is forced to participate); would these sorts of processes have the same adrenaline profile as a one-time traumatic event and be susceptible to beta-blockers? That is, if PTSD is caused in some soldiers by the vivid awareness of and discomfort with what they themselves had done, are they to be given propanolol after every encounter with this violence? That is, will a unit be dosed with propanolol when it returns to base every time that the group has seen a dead body, shot near civilian, or see the effects of their own side’s violence? Or would members of the unit be monitored so that, as soon as one of them seemed to be distressed, he or she would be given the drug? That is, is the etiology of PTSD may itself vary in ways that make it more or less treatable with propanolol, and the application of propanolol to what we might call chronic stress PTSD might pose its own problems.

From an ethical perspective, the use of memory dampening drugs by militaries, especially those engaged in actions among civilians (for example, in Iraq), might also make the investigation and prosecution of war crimes, human rights violations, and breaches of the rules of engagement extremely difficult. It’s already extraordinarily difficult to investigate what happened in some fire fights without the soldiers being in a fog of memory-dampening drugs (although some likely self medicate already with traditional memory dampeners, such as alcohol or more common narcotics). Although propanolol might not call wholesale amnesia (it doesn’t), it might make it more difficult to recall dramatic events. Then again, it might make it easier to recall them accurately if they become distorted by stress — I just don’t know.

My attempt to distinguish between ‘PTSD from being victim’ and ‘guilty conscience PTSD,’ a distinction that may not have one shred of support for it (but seems to be assumed in the Alternet piece), would raise virtually impossible practical questions to those medical personnel responsible for administering the treatment. If they were asked to, could they distinguish who needs it because of a traumatic event and who needs it because of a guilty conscience? I can’t imagine that there would be any good way to make this distinction. So even though I might be drawing a difference, I don’t think there’s any way to use that distinction in practice. ‘Stress’ is a pretty broad category, so trying to provide ‘psychological kevlar’ against ‘stress’ might include a number of different phenomena and imply a whole range of preventive mechanisms (like, for example, not going to war in the first place).

On the positive side, stress helps us to learn very quickly. Blocking all the effects of stress is likely to produce a soldier who has a really hard time learning quickly, a tendency that might be severely maladaptive in combat settings.

Finally, one of the other ironies of this discussion is that, after so many wars, forgetting seems to have been one of the few culturally-appropriate coping strategies, and large-scale forgetting did take place. We’ve just had ANZAC Day here in Australia (sort of equivalent to Memorial Day in the US), and one of the things that is constantly discussed is the need to preserve, even to recover memories of the war. Over and over again, we hear about very high functioning veterans of World War II who admit that they returned from war and put it out of their minds, effectively forgetting what happened or at least severely suppressing it. This process seems to be much more difficult for veterans of more recent conflicts, especially Vietnam and Iraq. Some argue that it’s the nature of the public reception upon return, others that it is differences in the nature of the conflict or of their training, that produces the contrasting profiles.

But events like Memorial Day and ANZAC Day, war memorials, and a host of other commemorative practices are specifically about combating forgetfulness, assuring that war will be remembered by society. It’s ironic to me that, at the same time that societies struggle to retain memories of the sacrifices made by servicemen and women, we’re doing research about techniques to suppress their ability to remember war. Couple this with an environment in which many veterans feel ‘forgotten,’ left without sufficient medical care or support when they return from conflict (or are in it, for that matter), and we have a full-blown society-wide ambivalence about memory and forgetting of war.

I’m inherently dubious of violence as a tool for social change, probably because I study violence (in my case, more the sports variety than war), but it seems to me that they battle over how war should be remembered is pretty heated. Although I am excited to hear about the possibility of using propanolol and other drugs to help sufferers of PTSD, I can’t help but think that some of the problems that soldiers experience from remembering war have direct links to the problems our society has with its own memories of war, and those who fight them. The burden of remembering must be greater when one is forced to bear it alone, especially when it is the burden of morally ambivalent action, done on behalf of a society that seems to want to forget what has happened. I suspect that some of the social ambivalence shows up in the symptoms of those who shoulder the burden of fighting war — the soldiers. And I do hope that the military research will also be used in the service of all those who suffer the effects of violence, including the civilians who pay an even higher price than the soldiers.

Acknowledgment:
Graphic by Ben Mills, found in Wikimedia Commons.

References
Kolber, Adam J. 2006. Therapeutic Forgetting: The Legal and Ethical Implications of Memory Dampening. Vanderbilt Law Review 59(5): 1561-1626. Available at SSRN: http://ssrn.com/abstract=887061.

The President’s Council on Bioethics. 2003. Beyond Therapy: Biotechnology and the Pursuit of Happiness. Washington, D.C. (downloadable here)