Tag Archives: psychiatric anthropology

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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Toward an Applied Neuroanthropology of Psychosis: The interplay of Culture, Brains, and Experience

About the author

Neely  Anne Laurenzo Myers is an assistant professor at Southern Methodist University.  She received her PhD from the University of Chicago’s department of Comparative Human Development in 2009.  Dr. Myers specializes in psychiatric anthropology and applied neuroanthropology with interests in mental health especially among underserved populations.

Applied Neuroanthropology of Psychosis

The purpose of applying neuroanthropology to psychosis or to mental health more generally is really to understand the interplay between one’s culture, neurodevelopment, and life experiences.  This case study examines how everyday experiences can be integrated into neurodevelopment and lead to psychosis in certain contexts.  Applied neuroanthropology can make improvements on the current recommendations for psychotic disorders by understanding how neurodevelopment during certain life stages and relevant life experiences can interact to affect biologically vulnerable individuals.  Hopefully, new treatments and interventions can be developed to treat people earlier in the course of their psychotic disorder as people in the west typically have a lower rate of recovery than patients in non-western countries.  Another distinct advantage of neuroanthropology is that it can look at psychotic disorders cross-culturally.  By doing so it becomes clear that psychotic disorders do not mean the same thing to people everywhere.  They are experienced quite differently and understandably treated with different approaches.

Introducing Psychosis

While you may not know someone with any type of psychotic disorder it effects around 1% of the global population and even more people experience more mild psychotic episodes at some point in their life.  Psychosis is severely disabling in that the person loses touch with reality, they have delusions, and sensory hallucinations.  You are probably most familiar with the idea that these people hear voices in their head and may talk to those voices.  The voices can vary in who and what they are saying but it can be very frightening.  The patient, family, and friends may become afraid.  The experience is different for every person because everyone has a different brain and for this reason the illness can be very isolating.  I’ve personally seen what psychotic illness can do to a person and their loved ones and it is incredibly devastating and life altering.  Part of this may have to do with the way we view and treat this type of mental illness in this country.  The other symptoms essentially changes the person’s personality and further isolate them from any existing close relationships they had left.  These symptoms include loss of emotional response, little motivation, socially withdrawing, and cognitive problems which can all easily interfere with seeking or adhering to treatment.

This clip summarizes the symptoms of schizophrenia and their impact on the patient and family.

Summary of the Case Study

Dr. Myers spent time at a clinic for psychiatric disabilities in New York where she used a mixed methods approach, including participant observation and interviews, to understand the experiences of a patient named Leroy.  Leroy was in his thirties and had been diagnosed with schizoaffective disorder.  People with schizoaffective disorder frequently have the symptoms of schizophrenia with the symptoms of a mood disorder like depression.  Leroy was also an alcoholic and a felon.  Dr. Myers believed that his neurodevelopment may have been effected by institutional participation and led to the development of his psychotic events.  She detailed his history with psychotic events as well as his beliefs surrounding them.  He had had at least two mild psychotic events as a child.  His Aunt had explained to him that he may be hearing spirits and also told him a story about his birth and that his grandmother thought he might be susceptible to such things.  He seemed to accept this explanation and didn’t have problems for a while because his aunt put something in his water to help.  He explained these ideas to his doctors but they dismissed it completely.  When he was incarcerated he eventually became paranoid.  At some point he ended up serving eighty days in solitary confinement because of disobedience.  His psychotic problems became constant at this point.  He began hearing voices, talked back to the voices, became fixated on things he read in a bible, and ended up being taken to a psychiatric treatment center.  In the center they treated him with anti-psychotics but he felt he was denied the chance to truly face his illness because of this.

Psychotic Disorders: A Neuroscience Perspective

It really isn’t clear what causes Schizophrenia or any of the related psychotic disorders.  The models range from genetic to epigenetic to purely environmental.  The reason for this is that they can see some evidence of the disease in some patient’s brain such as a changing of certain structures or pathways but can’t definitively say it causes the disease.  They can only say it is probably part of the disease.  At this point a mix of genetic predisposition and environmental factors seem like the best explanation.  What has been suggested is that people with Schizophrenia may be biologically susceptible to social stresses and that as these build up they are unable to withstand it and develop psychotic symptoms.  Another idea suggests that is completely normal to experience mild psychotic events during certain stages of neurodevelopment but it only becomes pathological in these supposed biologically susceptible people.  Other models suggest that the reason psychotic symptoms become evident during the young adult years is because of the multitude of social stressors associated with life changes and certain susceptible people cannot handle that and develop psychotic disorders.  Something else that is clear that Leroy was an example of is that certain contexts raise the risk of psychotic illness.  These contexts include urban environments, social disadvantage, adverse life events, and poverty which can all cause prolonged stress.  Which brings us to the last possible explanation which is allostatic overload.  This model suggests that psychotic disorders may result from neural changes due to allostatic overload but specifically due to inflammatory cytokines and glucocorticoids and their effects on the brain.  The cause and mechanism for schizophrenia has yet to be discovered but it is likely a combination of these explanations which include genetic and environmental causes.

Toward an Applied Neuroanthropology of Psychosis

Neroanthropology can be used to better understand how experience is incorporated into neurodevelopment to alter pathways or structures that lead to psychosis.  In Leroy’s case certain episodes in his life (solitary confinement) led to the exacerbation of an underlying issue.  He also came from a disadvantaged background and had previous mild psychotic episodes with certain beliefs about them.  Could this information have been used to intervene and prevent full blown schizoaffective disorder?  We don’t know.  However, continuing applied neuroanthropological research into psychotic illness can provide the insight to answer those kinds of questions.  It can also help us to understand the stages of development, at-risk populations, and biological vulnerabilities that need intervention and what that intervention should look like.  Research experiences like this case study also make it clear that to dismiss the beliefs an individual holds about their illness can be a mistake.  A person’s cultural beliefs surrounding their illness can end up being a vital tool in fighting psychotic disorders.  In the U.S. this could lead to cognitive behavioral therapy as a resource for people who want to try something with or instead of traditional anti-psychotics.

A new form of Cognitive Behavioral Therapy (Facing the voices) to complement anti-psychotics.