All posts by Angela Ray

C-Section Rates in Alabama (1996)

This is from nearly two decades ago, and the literature was concerned that c-section rates were as high as 25%. Now the rate in Alabama overall is 38% and in some counties it’s as high as 68% (per the Alabama Public Health Department link I also posted). C-sections vs vaginal birth isn’t what I was considering when I wrote the proposal, but upon reconsideration it would be worth it to include vaginal birth vs c-section in the study, not just home birth vs hospital birth. This would require further research into why c-sections happen when not medically necessary and the literature on VBACs, etc.

edit, corrected link:

http://onlinelibrary.wiley.com/doi/10.1111/j.1523-536X.1996.tb00456.x/abstract

 

Effects of Maternal Stess on Birth Weight

“Independent of biomedical risk, each unit increase of prenatal life event stress (from a possible sample range of 14.7 units) was associated with a 55.03 gm decrease in infant birth weight and with a significant increase in the likelihood of low birth weight (odds ratio 1.32), and each unit increase of prenatal pregnancy anxiety (from a possible sample range of 5 units) was associated with a 3-day decrease in gestational age at birth.”

 

http://www.ajog.org/article/0002-9378%2893%2990016-C/abstract

CDC Birth Rates

My best friend for a bit, this page on the CDC website is an easy to understand and nicely presented data sheet on out-of-hospital births in the United States from data collected from 1990-2012.

Notes: Out-of-hospital birth rate is low but rising (1.36%); Alabama is the 3rd lowest in the country, at only 0.39%.

http://www.cdc.gov/nchs/data/databriefs/db144.htm

Alabama Public Health Pregnancy Stats

Lots of interesting stats on birth in Alabama. Not sure if any are relevant at this stage, but could be more useful in a discussion, depending on the results. Many different stats here are noteworthy and could lead to additional parts of this study or a new study altogether (for example what is contributing to the  50-70% c-section rates throughout different counties?!).

http://www.adph.org/healthstats/index.asp?id=1513

“Cultural models, pregnancy, and stress: examining intracultural variation in Jalisco, Mexico”

This is a PhD paper that is nearly 500 pages long and not worth reading entirely at this stage in the process, but the abstract offers some insight and the table of contents helps with finding more relevant pieces. The author measures similar ideas but in Mexico and a more thoroughly pluralistic setting, and also uses a Pregnancy Related Anxiety scale I have not before seen.

Linear regression models indicate that participants who are more consonant in the model have lower levels of both PSS and PRA. Consonance is not associated with EBV antibody levels. Perceiving social support from family and non-family enhances the effect of consonance on PRA, unless perceived family support is above the mean. In this case, the effect is blunted. Social support does not moderate the effect of cultural consonance on PSS.

http://purl.lib.ua.edu/2170

A Dissertation on Midwifery & Women’s Autonomy

This is a dissertation on midwifery and it feminist power. It turned up in my search queries on “midwifery” and “Alabama” because it was published at UA, but I don’t think it’s quite what I’m looking for — bit more focused on reproductive rights, feminism, and destroying the medical-industrial complex.  However, some paragraphs provide some useful statistics and information, and also point to other sources that could be useful.

Prime usefulness is in the section starting on page 40. I didn’t read much before or beyond that section, to be honest.

http://purl.lib.ua.edu/13873

 

Split Personalities: The Conflict Between Psychiatric and Anthropological Approaches to Dissociation

Dissociation is something everyone is familiar with, but thinks of in different ways: movie plots about Dissociative Identity Disorder and amnesia, possession and trances stories in textbooks and online threads, that blocks of time unremembered from last Friday night, that daydreaming you’re already doing while you’re supposed to be reading this blog post. Anthropology and psychiatry also study dissociation in two different ways, but by not joining forces, they are hurting their own research.

One of those movies I was referencing.
One of those movie plots I was referencing.

DISSOCIATION: AN OVERVIEW

First, let’s consider dissociation. Seligman and Kirmeyer define it as, “a term used to describe both a set of behaviors and experiences involving functional alterations of memory, perception, and identity as well as the psycho-physiological processes presumed to underlie these phenomena.” Dissociation can range in severity, from highway hypnosis and daydreaming, to episodes of depersonalization, to full-blown amnesia or Dissociative Identity Disorder (DID). Dissociation takes place in three different contexts: in response to stress or trauma, in ritualistic or artistic ceremonies, or in daily fluctuations in consciousness. Psychiatry tends to only consider the first context, focusing on neurobiology and its biological function; anthropology tends to consider only the second, focusing on social and rhetorical phenomena and its contribution to the self. The two paradigms tend to be non-overlapping, but they shouldn’t be: dissociation should be considered a complex interaction between psychological and cultural interactions with underlying neurobiological mechanisms.

NORMATIVE DISSOCIATION

One context of dissociation is normative dissociation. We do it all the time. I’ve done it at least twice writing this already and I don’t know how many times reading this paper. We space out, we read a whole page and realize we don’t even know what we’ve read, we focus so solidly on writing that we don’t notice the world around us. The paper cites one study found that 90% of people report daydreaming daily, and another study that guesses that half of our  mental activity is spent daydreaming or dissociating. I took a quiz online using the Dissociative Experiences Scale to find my “rating” of dissociation. I scored a 55. This falls into the higher range, much higher than the average population. This was a little bit but not very surprising; I’ve been a daydreamer my whole life, and I have lately been struggling with feelings of depersonalization and derealization since moving to and moving back from Europe. I encourage y’all to check yourselves out. Have no fear if you have a few items or even a high-ish score: 83% of college students in one study had at least one item, and many college students scored close to DID diagnoses. However, most did not find their dissociation distressing or detracting from daily life, and frequency and intensity tends to decrease with age. Based on these results and anecdotes, and many of you would probably agree, absorption can be pleasurable and/or beneficial.

THE PSYCHIATRIC-ADAPTIVE PARADIGM

Psychiatric approaches often favor functional explanations of dissociation, wondering what it is and how it works. These approaches focus on searching for a specific factor or stimulus and consequently a specific purpose or function. Since about Freud, dissociation has been linked to trauma. This theory saw a renaissance in the 1970s during the “repressed childhood memories” boom; has been lately expanded to study natural disasters, war, psychological stress, murder, rape, motor vehicle accidents, and so on; and most recently has been studied as peritraumatic dissociation versus post-traumatic dissociation.

The literature mainly proposes that dissociation evolved as a way to protect the self when coping is difficult or physical escape is impossible. There are two main thoughts on psychiatric: 1) dissociation is adaptive and 2) dissociation is pathological. In terms of adaptive, it is proposed, and widely accepted, that it evolved as a way to filter out non-functional emotions in stressful events, to protect against future phobias, and to help an animal develop and automatic response in dangerous situations. It can also be considered pathological when it interferes with daily life, disrupts memory, causes detachment from self and reality, is distressing to the dissociator, and/or causes dysfunction in society. DID and amnesia probably aren’t as common as movie plots would have us believe, but PTSD and other forms of pathological dissociation are still very common, especially in those who have taken certain drugs.

The adaptive and pathological theories don’t have to be contradictory: dissociation can be beneficial and adaptive to a degree and in the short-term, but pathological and maladaptive if more severe and long-term and in response to situations that aren’t extreme danger. Seligman and Kirmayer take problem with some of these accepted theories, however, and believe that they should not be so readily taken as fact. They offer some counter-arguments: what if some traits increase the likelihood of dissociation and PTSD, without one being related to the other? What if the real problem is suppressed emotion and not dissociation? What if personality differences contribute more than given credit for? It’s important that science and research not start taking things as fact if they haven’t been proven, and kudos to Seligman and Kirmayer for postulating other potential possibilities.

One of the most interesting parts of the whole paper for me was the discussion was the cultural differences in dissociation in terms of function, pathology, and healing. They mentioned that the Western focus on “re-living” and “talking through” traumas might actually be more damaging than healing, especially for certain individuals and cultures. In some cultures, suppressing emotions is actually their way with dealing with traumas, because they believe strong negative emotions bring bad health. They also believe dissociation to be a spiritual event, so it is not as distressing. These can help with the dissociators’ healing more than Euro-American therapy would. In this manner, cultural context is important and should be considered with dealing with dissociation.

ANTHROPOLOGICAL-DISCURSIVE

The anthropological focus is more on how dissociation can help the self and it’s role in society. Oftentimes the neurobiological effects on dissociation are ignored or under-theorized, and instead the social context is focused on. In anthropology, dissociation is often seen as something that helps a person, such as in a healing or spiritual way, rather than harms them. In many cultures, dissociation is normal, expected, and/or encouraged, so it’s not seen as distressing. Instead, it allows individuals to explore and express inner desires, thoughts, feelings, and behaviors while attributing it to someone else. An example of this is in Zar possession: women have very strict societal constrictions, but can explore their self outside of these constructs through “possession”. Anthropology often sees dissociation as playful, voluntary, and useful, rather than a involuntary psychopathology.

The two can come into conflict or cause conflict by not integrating. For example, the authors give the example of Malaysian factory workers: they dissociated as a result of fear and resistance to the factory. The social and cultural context was dismissed by the biomedical community and they didn’t get the attention they deserved. On the flipside, anthropology doesn’t consider the neurobiological mechanisms contributing to social dissociation. For example, some cultural traumas or personality traits could contribute to dissociation.

MECHANISMS

Brain structures involved with dealing with fear and stress
Brain structures involved with dealing with fear and stress

The mechanisms are a bit lengthy and don’t necessarily contribute to the overall message regarding the integration of anthropology and psychology. There are different neurobiological processes that have been found regarding dissociation. For example, some studies support a model that “the prefrontal cortex disrupts the ‘emotional tagging’ of perceptual and cognitive material by the amygdala and related structures … that results in the suppressed autonomic arousal and a sense of disconnection.” These results seem to be supported in studies on PTSD and hysterical conversion (numbness, paralysis, blindness, etc without organic cause). This and further evidence points to high-order inhibitions causing dissociation while low-level cognitions continue functioning. Other evidence suggests DID patients might have a smaller hippocampus and amygdala.

INTEGRATION

Though dissociation seems to be a biological function, it is influenced by culture. In some contexts it is seen as pathological, it is something that needs to be “cured” and violates the self. In other contexts, it is considered powerful, helpful, and an expected life experience; it is something that contributes to the self, in a spiritual, healing, or artistic manner. These different contexts can contribute to a looping system: the symptoms arise, they are considered negative, the individual stresses further about them, they are stigmatized and pathologized, the stress increases, the symptoms increase, and the loop begins. If the context is one that accepts and embraces dissociation, the symptoms and the society do not necessarily exacerbate the problem, or even see it as a problem; they normalize the symptoms, such as in the Candomblé religion in Brazil.

A case study is included in this paper, and it’s worth looking at. However, one issue I had was that the paper was repetitive and rambling in some parts, yet failed to expand upon some other aspects that could have used explaining.  While the paper did provide one example of a case study, it could have done a better job addressing how to diagnose and treat her by incorporating everything the paper was about.

As a pre-health, majoring in psychology, minoring in biology and anthropology, and taking classes in neuroscience, this hit literally every single of my interests. I really like to see all the areas integrated and that’s something I want to focus on through public health or global health measures, or even just on a smaller scale in treating patients, and I’m glad this literature is out there promoting more integrative and inclusive research. This paper is now 6 years old and I’m not sure if it inspired the collaborative research it intended to, but I hope so; the world is changing and becoming more global and medicine needs to adapt to that. Dr. Kirmayer works on integrating culture and health in his research and practices, so I know he actually believes in that and I hope this paper and papers like it encourage more integrative and interdisciplinary approaches. However, this paper alone would make it sort of difficult for a clinician to have an understanding of how to integrate neurobiology and culture, and clinicians would definitely have to take on the added burden of researching different cultures they’re treating, so immediate results in medical practices is unlikely.


Seligman, R., & Kirmayer, L.J. (2008). Dissociative experience and cultural neuroscience: narrative, metaphor and mechanism. Cult Med Psychiatry, 32(1), 31-64.

 

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