FPR-UCLA 4th Interdisciplinary Conference - Summaries
Session 2 Summary: Cultural and Biological Contexts of Autism
Session 3 Summary: Beyond Categories: Dimensions, Thresholds, Contexts, and Trajectories in Mental Health and Illness
Session 4 Summary: Cultural and Biological Contexts of Bipolar Disorder
Session 5 Summary: Cultural and Biological Contexts of Schizophrenia
Session 6 Summary: Cultural and Biological Contexts of Anxiety-Related Conditions
Session 7 Summary: Integrating Biology into DSM-V
Session 8 Summary: Integrating Culture into DSM-V
Session One Summary
The fourth FPR-UCLA interdisciplinary conference was held at UCLA on January 22–24, 2010. The basic aim of this series is to create, nourish, and sustain connections among scientists from anthropology, psychiatry, the neurosciences, and related fields in order to address topics of fundamental social or clinical concern.
In her opening remarks, UCLA’s Vice-Chancellor of Graduate Studies Claudia Mitchell-Kernan noted the timeliness of the conference, which focuses on the cultural and biological contexts of psychiatric disorder and precedes publication of the DSM-V in 2013. “I think a good deal is at stake,” Dr. Mitchell-Kerman said. “The diagnostic criteria established in the fifth edition will in many ways establish how society views various forms of emotional and psychological conditions, and, just as important, what kind of treatment is available and what kind of access insurance programs will offer.”
“The current focus on culture, the brain, and mental illness,” FPR founder and UCLA anthropologist Robert Lemelson said in his opening remarks, “is one that is certainly close to my interests and my heart. I’ve been studying this topic for the last two decades in Indonesia, [and it’s one in which] biology, culture, history, and political economy all play central roles.” One of the objectives of the conference, he continued, is to highlight the intersection of culture, biology (particularly neurobiology) and social and political ecologies in the origin, presentation, and outcome of mental illness. He quoted from a critical article that appeared in the New York Times Magazine; the article by Ethan Watters is based on his book, Crazy Like Us, and concerns the export of a DSM-based framework for categorizing and treating mental disorders across the globe. Although, based on his fieldwork in Indonesia, Dr. Lemelson has found that such a biologically based model can be useful at times in dispelling “prescientific myths and harmful stigma,” he noted the extent to which (directly quoting from Ethan Watters) “in the process of teaching the rest of the world to think like us, we’ve been exporting our own western symptom repertoire as well.” (This theme recurs throughout the conference and is highlighted in particular in the last roundtable session on Day 3.)
Introductory remarks to the first session of this conference were presented by UCLA’s department of neurobiology chair, Marie-Françoise Chesselet, who studies the basal ganglia, with special focus on Parkinson’s disease. “When we were trying to conceptually frame this conference,” she said, “a discussion erupted about the broadness of psychiatric illnesses versus the more focused definition people have of neurological disorders.” During that discussion, as well as in her opening remarks, Dr. Chesselet used Parkinson’s as an example of a neurological disease for which there was a very "reductive" (in the positive sense) explanation, what biological psychiatry now strives for vis-à-vis mental disorders. In the case of Parkinson’s, the disease is best conceptualized as a complex, multi-dimensional condition. (As will be highlighted in later sessions, most of the mental disorders are now presumed to have similarly complex neurobiological etiologies.) Long considered to be a disease of the dopaminergic neurons with a well-defined set of motor disorders, she explained, Parkinson’s is now understood to involve almost every area of the brain, as well as the peripheral nervous system, and to affect many aspects of psychological functioning. “Now that we know that all those other brain regions are affected and that rather than being a disease of cell death, it is a disease of dysfunction of many circuits in the brain,” she said, “neurologists [have become] a lot more attuned to the patients’ predicament which goes well beyond the narrow list of symptoms that were used to recognize and treat.” Although psychiatric symptoms are now considered to be a major component of the disorder, culture has yet to be integrated, just as culture has yet to be considered a major component in western psychiatric nosology.
Session Four Summary
Participants in this session discussed the biological, personal, cultural, and social dimensions of bipolar disorder. The session was chaired by UCLA anthropologist Douglas Hollan. Speakers and commentators included Kay Redfield Jamison, professor of psychiatry at Johns Hopkins University and author of An Unquiet Mind: A Memoir of Moods and Madness, neuroscientist Mary Phillips of University of Pittsburg, and anthropologist Emily Martin of New York University, author of Bipolar Expeditions: Mania and Depression in American Culture.
In the first talk of the session, Kay Redfield Jamison spoke eloquently and movingly about the personal experience of living with bipolar illness (BPI). Jamison described BPI as a chronic relapsing illness involving “cyclic upheavals” of mania and depression, which she first experienced at age 17. BPI presents a special dilemma since moods are essential to a sense of self, which affects the willingness or motivation to seek treatment (“it’s very hard to tell an 18-year-old, who’s feeling better than he’s ever felt in his entire life that he’s sick”), to stay on medication, and to stay alive. Mild elated states pose a particular set of clinical, theoretical, and scientific problems. She described these states as addictive, at the biological as well as psychological level. Like depression, the manic states (or more generally positive affective states) can be ranged along a continuum, she said, with positive implications for learning, creativity, exploration, and risk taking. (She addressed “the fiery aspects of thought and feeling” in a previous book, Touched with Fire: Manic-Depressive Illness and the Artistic Temperament.) On the other hand, the pain of severe depression and severe mania “are not comprehensible to people who have not experienced them,” a gap she began to address as a young clinician and researcher at UCLA, when she wrote a series of anonymous accounts of her own illness experience for the benefit of the residents and the psychology trainees in the affective disorders clinic.
Jamison movingly described what it was like to have BPI, which she characterized as “recurrent cycles of pain, elation, loneliness, and terror.” She described her unwillingness to accept her illness and take lithium on a regular basis, until repeated psychosis and a nearly lethal suicide attempt convinced “even the slowest of learners.” Although her form of BPI (Bipolar 1 with psychotic features) is well stabilized with medication, she said the illness has a “ghostlike presence,” not only because it can recur but because it can be entwined with a hyperthymic (or “hail-fellow-well-met”) temperament. Psychotherapy may be particularly effective in addressing the erratic flow of experience. Like Elyn Saks, Jamison believes that “psychotherapy has been underestimated in its importance in the psychotic illnesses” and that “it can keep people alive.” Psychotherapy “makes some sense of the confusion, reigns in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Pills cannot and do not ease one back into reality.”
Session Five Summary
Participants in this session discussed the biological, personal, cultural, and social dimensions of schizophrenia. The session was chaired by USC psychologist Steven López. Speakers and commentators included UCLA neuroscientists Robert Bilderand Tyrone Cannon, Harvard professor of social medicine Mary-Jo DelVecchio Good, UCLA anthropologist and documentary filmmaker Robert Lemelson, Caltech neurobiologist Paul Patterson, and USC law professor Elyn Saks.
In his opening remarks, session chair Steven López, USC psychology professor and member of the FPR Advisory Board, reflected on the implications of previous day presentations by Moshe Szyf on epigenetics and Eric Courchesne’s work on the putative correlation between early brain overgrowth and autism. “I am seeing the possibility of a shared narrative between those who are doing the neuroscience and those who are interested in the lived experience, in the cultural and the social experience,” Dr. López said. Dr. Szyf’s talk, in particular, provided a sense of the mechanisms through which trauma (or lived experience more generally) can affect brain structure and function (as well as the course of psychiatric disorders). Neuroscientific and cultural narratives may not overlap, but the new work suggests some “potential bridges,” that could lead to a more complete understanding of mental health and illness.
In the first talk, Robert Bilder, head of UCLA’s Consortium for Neuropsychiatric Phenomics (CNP), described psychiatry as suffering from a “flawed taxonomy” due to lack of correspondence between symptoms of disorders such as schizophrenia (SZ) or bipolar disorder (BPD) – on which descriptive phenotypes are based – and underlying pathophysiological or etiological processes. Instead, he suggested that psychiatric syndromes may reflect “quantitative deviation along continuous trait dimensions that merge imperceptibly from ‘normalcy’ into more ‘pathological’ ranges,” with persistence of genetic diversity implying that certain traits (for example, “magical ideation”) have adaptive advantages. Research programs like the CNP are searching for more “biologically relevant quantitative trait (or neuropsychological) phenotypes” that cut across diagnostic groups.
Dr. Bilder discussed two strategies for organizing disorders more systematically in terms of category or dimension – the taxometric and factor analytic approaches, both of which support a non-categorical diagnostic model for most disorders. A review of the DSM based on psychologist Nick Haslam’s review of taxometric studies indicates that certain subtypes of melancholia, social phobia or inhibited temperament in childhood, bulimia nervosa, dissociative identity disorder, and hypnotic susceptibility appear more categorical (i.e., discontinuous or “taxonic” in nature); however all other types of depression, PTSD, BPD, generalized anxiety, and almost all models of personality function (with the possible exceptions of schizotypal personality disorder and antisocial personality disorder) suggest continua. Regarding ADHD, a factor mixture modeling approach indicates two continuous factors (severity of inattentiveness and hyperactivity or impulsivity) rather than “qualitatively distinct ADHD subtypes.” Regarding the categorization of mental disorders as either diseases or syndromes, he said the “prototypical mental disorders” (including SZ, BPD, and anxiety disorders) “merge imperceptibly both into one another and into normality with no demonstrable natural boundaries or zones of rarity in between,” noting at the same time that genetic and environmental factors are “often non specific,” citing work by Kenneth Kendler, Ezra Susser, Alan Brown, and others.
In support of the concept of continua vs. discrete categories for the psychoses, including SZ, he cited neuropsychological evidence indicating that the reliability of a correct classification (as either a functional or an organic disorder) decreased in relation to the increasing severity of the disorder (non-psychotic psychiatric disorders – BPD – chronic SZ). A similar correspondence occurred for cognitive deficits, which increased in relation to severity of disorder. On the other hand, he said, there is very little evidence that specific structural brain abnormalities (e.g., ventricular enlargement, gray matter deficits, and hippocampal volume reductions) can be used to distinguish between BPD and SZ, other than in terms of severity. He said the genetics risks are “substantially shared” between the two disorders and that a very large number of genes contribute to both disorders, as reported in a recent study by the International Schizophrenia Consortium. He also said there is likely to be a common set of underlying genetic anomalies that dictate “a whole host” of brain development processes shared across neurodevelopmental disorders,“ and that distinctions may be owing more to severity than to discrete pathology.