Psychiatry and Culture

United Nations. Martin Swart. Wikipedia Commons

I have been surprised by the level of interest that my recent postings under Ethics and Morality (Psychology Today) have generated.

My first post in this series got about 1300 hits to date (the post has been up for a bit less than a month), with the two following posts also wrapping up hits pretty quickly: as of now the second post is at 600 hits and the third one (that’s been up for about a week) is already at 650.

This was an interesting and unexpected trend. My other posts, while generating enough hits, have done so over time, suggesting not nearly as high a level of interest as these more “philosophical” posts.

It seems like mental illness and psychiatry remain quite fascinating (albeit controversial at times) topics of interest for the collective imagination.

Of course, these posts were published by a popular American magazine, on a western Internet sit. I have no idea who my readers are but it’s fair to assume that the majority are from the USA or other western countries.

This being the case I thought a discussion about the intersect between psychiatry and culture would be of interest to this readership.

But first here is the context of our discussion.

The modern Western psychiatric classification of mental distress uses a descriptive approach to diagnosis. This is shared by the American Psychiatric Association DSM III onwards psychiatric diagnostic system as well as the World Health Organization ICD-10. The descriptive aspect is emphasized by both systems, meaning that current diagnoses are not meant to explain the brain deficits underlying psychiatric signs or symptoms.

However, when it comes to psychiatric practice, as discussed in numerous treatment guidelines. descriptive diagnoses do not exit in a vacuum, but instead  inform treatment together with a biopsychosocial formulation of the issues at hand.

There is an appearance of world wide agreement and homogeneity when it comes to psychiatric diagnosis and even intervention. But appearances might be deceiving. As it turns out, even within the fairly homogeneous Anglo-American psychiatry, the way similar formulations have been applied over time varies greatly, with cultural factors being an important, yet frequently under-appreciated, contributor.

For example, the influence of Adolf Meyer’s, one of the forefathers of modern American psychiatry and a pioneer of the biopsychosocial model, gathered more following in the British psychiatry than in the USA, which has been Meyer's adoptive country for most of his life. Europe, where psychoanalysis fell on harder times after the Second World War, made space for the Meyerian ideas, while in the USA the same ideas were almost wiped out by the alternating preeminence of the more extreme theoretical formulations of psychoanalysis and biodeterminism.

At the same time, the Kraepelinian backbone of American DSM III and its successors faced multiple challengers in its own homeland. A number of eminent German psychiatrists including Eugene Bleuler, Kurt Schneider and Karl Jaspers went head to head with Kraeplin's procustian descriptive approach to psychiatric diagnosis. Yet this did not deter American psychiatry to dust it off and put it back on the shelf.

To conclude, the history of psychiatric nosology seems to indicate that cultural preferences appear to inform the biological agenda of research as much, if not more, as the other way around.

Psychiatry - culture interactions also manifest in cultural differences that are not easily captured by fixed descriptions. Any constrained, pre-defined description is lousy way to capture fluid differences, which is the case with cultural factorors. For example in a typical Western culture, the fact that the lack of independence that is usually part of a depressive presentation is highly problematic will be an aggravating factor for the clinical presentation and course.Compare that with a typical Eastern culture, where because group identity and connection are valued above individual autonomy, dependence is more acceptable and thus less probelmatic.

Cultural bound syndromes further challenge the limits of a strict classification system. Panic attacks, described in the USA, and ataques de nervios, described in the Latino cultures, share a number of commonalities, but also are different in a number of important aspects. For example fainting and amnesia are associated with ataque de nervios but not with panic attacks). The complicated dynamics between cultural influences and psychopatholgy are further illustrated by the fact the Latino culture based ataque de nervios seems to reach its peak on the USA soil, in that Latinos are most likely to report ataques de nervios when they are US citizens, born in the US, have spend more of their life in the US and speak more English (Gurnaccia et al., 2010).

It’s important to remember that the human psyche is a complex construct emerging at the somewhat fluid cross between genes and memes. As we are continuing our amazing discoveries in the brain-mind field, psychiatrists as well as neuroscientists need to remember that theoretical slicing, while necessary for “cutting” the overwhelming complexity in smaller pieces, also carries the risk of producing simplistic and thus inaccurate representations of the whole

References:


GuarnacciaPJ, Lewis-Fernandez R, Martinez Pincay I, Shrout P, Guo J, Torres M, Canino G,Alegria M. Ataque de nervios as a marker of social and psychiatricvulnerability: results from the NLAAS. Int J Soc Psychiatry. 2010May;56(3):298-309. Epub 2009 Jul 10.


© Copyright Adrian Preda, M.D.

Faith in Psychiatry

Van Gogh - Man in Sorrow
Public Domain

Est autem fides credere quod nondum vides; cuius fidei merces est videre quod credis.

Faith is to believe what you do not see; the reward of this faith is to see what you believe.

St. Augustine

In response to one of my prior posts one of my readers commented that “in [the] American society doctors are treated like prophets and religious deities.”

This got me thinking, as my experience as a practicing physician in this country has been quite unlike being treated as a god or a prophet.

Let me set some facts straight.

I am a foreign medical graduate. As such, before coming to the US, I was used to a degree of implicit respect from my patients, which is the norm in other parts of the word. Also, while my European medical background prepared me for the overall practice of medicine in the US, it did leave out a couple of important things. Specifically, it was during my US internship when, for the first time in my professional life, I was exposed to learning about malpractice suits and defensive medicine, learned that physicians fall under one of the many categories of health care practitioners, and heard about patients “firing” their doctors.

Elsewhere the doctor-patient relationship is not just another business contract, essentially no different than the contract that a customer makes with his car mechanic or plumber or traveling agent etc. Elsewhere, the physician is not just another contractor or consultant but has a special role as someone whose intimate knowledge of one’s body and mind lessens one’s pain or nurses one back to health. This implies a certain “magic” to seeing the doctor that often results in the patient’s feeling better the moment they see their physician, which “magic” is both palpable in the medical examination room and acknowledged by the society at large. That is why being a doctor, in many places around the world, tends to have a special social status, even when doctors are not as financially prosperous as other professionals in the same society.

In the Western culture we tend to forget that healing was once part of a sacred relationship between the healer, the sufferer and a god whose discontent with the sinner was the proximate cause of his illness. A healer was then a hierophant and mediator of one’s relationship with God. And to this day, tribal societies see their healers as working with one’s spirit or soul. Arguably this sacred dimension might be at the origin at the “magic” that we now call a placebo effect.

Regardless of its origins the placebo effect turns out to be an essential ingredient in any healing process. 

At the same time it turns out the quality of the physician-patient relationship is the main predictor of the placebo response. What does that mean? The better the relationship is the higher the chance that the patient will feel better (as a result of an enhanced placebo response). It is important to understand that good doctoring will invariably increase placebo effect, while bad doctoring will invariably results in worse outcomes because of the lack of a placebo effect.

In other words, as doctor but also, and this is the most important part of this argument, as a patient, you would want the placebo effect on your side.

Unfortunately, in this day and age, when the divine is no longer part of the allopathic physician toolkit, when a medical malpractice suit can be started anytime by anyone, when patients or rather “medical customers” or “clients” engage in business medical contracts with doctors or rather “medical health care practitioners” who tend to practice defensive medicine, the odds are set against a placebo response.

It is a paradox, as the safeguards put in place to improve the quality of medical care actually hinder the changes of a good placebo response and thus result in poorer outcomes.

Which brings me to my final points.

Psychiatrists and their medications are commonly criticized for the high rates of placebo response as indicative of a lack of true biological effect for commonly prescribed psychotropics. An alternative explanation is that psychotropic medications are prescribed by psychiatrists, a category of physicians who might have a better chance of eliciting a strong placebo response because of a unique set up (longer appointments) and  professional skills that result in better engaging their patients.

We don’t know which explanation is true. But the consequences following these opposite explanations are far reaching: while the former explanation would be a reason for concern, the latter would be a reason for study and emulation.

Finally, a word of advice for the patient in all of us: the better doctor for you is the one that’s going to make your placebo response go way up. Thus the better doctor is not the one with a ton of diplomas on his walls but the one that you feel you can trust and connect with.

© Copyright Adrian Preda, M.D.