Delusions, odd and common: Living in the prodrome, part 2 (originally 10 January 2011)

(We are republishing ‘legacy content’ from our PLOS Neuroanthropology weblog, which has been taken down, along with many of the other founding PLOS Blogs. Some of these, I am putting up because I teach with them. If you have any requests, don’t hesitate to email me at: greg.downey @ mq (dot) edu (dot) au. I suspect many of the links in this piece will be broken, but I will endeavour to try to slowly rebuild this content. I originally published this on 1 January, 2011. Comments have been pasted in at the end of the post from the original.) 

Author Rachel Aviv talked at length with a number of young people who had been identified as being ‘prodromal’ for schizophrenia, experiencing periodic delusions and at risk of converting to full-blown schizophrenia, following some of the at-risk individuals for a year.  In December’s Harper’s, Aviv offered a sensitive, insightful account of their day-to-day struggles to maintain insight, recognizing which of their experiences are not real: Which way madness lies: Can psychosis be prevented? (Freely accessible pdf available here.)

Psychiatric Research by Ted Watson

Aviv’s piece was really moving and inspired this post and an earlier one. The first part (Slipping into psychosis: living in the prodrome (part 1)) provides some sense of Aviv’s interviews, especially the story of ‘Anna,’ a woman who feared that she, like her mother before her, might be losing her grasp on reality.  In addition, the earlier post covered the controversy surrounding the attempt to formalize a diagnosis in the DSM-V of ‘prodrome’ and the ethical problems created by trying to identify who is at risk of ‘going mad.’

This post is my more speculative offering, contemplating the relation of the content of delusions to the cultural context in which they occur. How do the specific details of delusions arise and how might the particularity of any one person’s delusions affect the way that a delusional individual is treated by others?  Are you mad if everyone around you talks as if they, too, were experiencing the same delusions?

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Slipping into psychosis: living in the prodrome (part 1, originally 5 January 2011)

(I am republishing ‘legacy content’ from our PLOS Neuroanthropology weblog, which has been taken down, along with many of the other founding PLOS Blogs. Some of these, I am putting up because I teach with them. If you have any requests, don’t hesitate to email me at: greg.downey @ mq (dot) edu (dot) au. I suspect many of the links in this piece will be broken, but I will endeavour to try to slowly rebuild this content. I originally published this on 5 January 2011. Part 2 is here: Delusions, odd and common: Living in the prodrome, part 2 (originally 10 January 2011).

How might it feel to sense your own sanity eroding? Would you realize it? How might you sift the phantoms from physical reality, daydream from delusion, the irrefutable from the implausible? Or, as author Rachel Aviv puts it,

When does a strong idea take on a pathological flavor? How does a metaphysical crisis morph into a medical one? At what point does our interpretation of the world become so fixed that it no longer matters “what almost everyone else believes” [part of the definition of ‘delusion’ in the DSM]? Even William James admitted that he struggled to distinguish a schizophrenic break from a mystical experience. (Aviv 2010: 37)

Aviv wrote in the December issue of Harper’s MagazineWhich way madness lies: Can psychosis be prevented? (UPDATED: The original is now locked, but you can download a pdf of the story here. Thanks, Deidre!)  As Aviv told me in an email, the story arose, in part, out of following young patients at clinics who might be in the prodrome to psychosis, the early stages of experiencing intermittent breaks from shared reality that might lead up to schizophrenia.  Based on interviews with patients and clinicians, Aviv explores how both seek to cope with the warning signs that someone may be sliding toward a definitive break, or ‘conversion’ as it is termed in psychiatry, bolstering the individual’s sense of self and reality against corrosion.

The piece is a powerful, troubling, and thought-provoking read.  Aviv explains:

It is impossible to predict the precise moment when a person has embarked on a path toward madness, since there is no quantifiable point at which healthy thoughts become insane. It is only in retrospect that the prelude to psychosis can be diagnosed with certainty.  (36)

What I particularly appreciate about Aviv’s account is that she writes extensively about the nature of the delusions themselves, about the flow of delusional ideas, their relation to the collapse of a clear sense of self, and the challenges facing an individual who begins to feel the implausible welling up in everyday reality.  She writes that much of psychiatry has tried to get around the specificities of the delusions — Who’s putting thoughts in your head?  How are you being watched?  What sort of ghosts or angels or aliens are following you?

Patients and some clinicians alike have a vested interest in discrediting the content of delusions, dismissing the ideas as errant chemicals or glitches in brain function.  But as Aviv so clearly demonstrates, the specificities of the delusions are both what the patients struggle with daily and the source of the leverage that some of them find to fight off further drift into idiosyncratic worlds.  The delusions matter, both because patients search in them for signs of their truth or unreality, but also because the details of the delusion, not just the fact of having them, arise from our shared reality.

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Psychopathy: Is It In You?

By Kevin Brandenberg & J.P. Malette

When one considers crime and its relationship to society, psychopathic behavior remains one of the most mysterious and intriguing conditions of the human mind. Psychopathy describes individuals who, put simply, don’t have a conscience and thus commit actions, often times illegal, without any moral consideration.

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

Psychopathy: What Is It?

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

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

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Public Release of the DSM-5 Draft

The draft of the DSM-5, the Diagnostic and Statistical Manual, was released this week. This guide to the diagnosis of mental and behavioral health problems will shape the delivery of psychological, psychiatric, and social care for years to come.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cross-Cultural Psychiatry: A Special Report from Psychiatric Times


Psychiatric Times issues periodic special reports, and the latest one features a wealth of articles and ideas on cross-cultural psychiatry.

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

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

Three main articles comprise the special issue:

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

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

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

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

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

Exporting American mental illness

The New York Times Magazine has a great discussion of the effects of the exportation of American ideas about mental illness, titled appropriately, The Americanization of Mental Illness by Ethan Watters, based on his forthcoming book, Crazy Like Us: The Globalization of the American Psyche, coming out this month from Free Press. The article is quite good, offering some intriguing cases, such as the rise of virulent, American-style anorexia nervosa in Hong Kong, the effect of possession beliefs on communities’ reactions to schizophrenia, and how the narrative of mental illness as ‘brain disease’ might actually lead to great stigma as it spreads and replaces local understandings. The article is well worth a read, and I’m looking forward to the book.

graphic by Alex Trochut, NYTimes

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

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

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PTSD and Traumatic Brain Injury: Trauma Inside Out

by Drew Matott and Drew Cameron

by Drew Matott and Drew Cameron

By Zoë H. Wool

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

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

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

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

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

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

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

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

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