New issue of Culture, Medicine and Psychiatry

A new issue of  Culture Medicine and Psychiatry has been released. Included are two articles related to recent psychiatric history in Israel and Malaysia. You will also find a Case Study questioning the exportation of the US recovery-oriented mental health system to the rest of the world. Titles, authors and abstracts are listed below.

From Posttrauma Intervention to Immunization of the Social Body: Pragmatics and Politics of a Resilience Program in Israel’s Periphery by Keren Friedman-Peleg and Yehuda C. Goodman

This article traces a critical change in the professional therapy of posttraumatic stress disorder (PTSD): from treatment of a disorder borne by individuals to treatment of an anticipated disorder to be prevented by fortifying the entire population. A community resilience program in the city of Sderot in southern Israel, which has been subjected to Qassam rockets by its Palestinian neighbors across the border, serves as our case study. Drawing on an ethnographic study of this new therapeutic program, we analyze how the social body that the professionals attempt to immunize against trauma was treated. In particular, we follow the various practices used to expand the clinical. We found that the population was split into several groups on a continuum between the clinical and the preclinical, each receiving different treatment. Moreover, the social body managed according to this new form of PTSD was articulated through ethnic and geopolitical power relations between professionals from the country’s center and professionals from its periphery, and between the professionals and the city’s residents. Finally, we discuss how this Israeli case compares with other national sites of the growing globalization of PTSD, like Bali, Haiti and Ethiopia, which anthropologists have been exploring in recent years.

Malaysian Moslem Mothers’ Experience of Depression and Service Use by  Nor Ba’yah Abdul Kadir and Antonia Bifulco

Standard psychiatric criteria for depression developed in the United States and United Kingdom are increasingly used worldwide to establish the prevalence of clinical disorders and to help develop services. However, these approaches are rarely sensitive to local and cultural expressions of symptoms or beliefs about treatment. Mismatch between diagnostic criteria and local understanding may result in underreporting of depression and underutilization of services. Little such research has been conducted in Malaysia, despite the acknowledged high rate of depression and low access to services. This study examines depression in Moslem Malay women living in Johor Bahru, Southern Peninsular Malaysia, to explore depression symptoms using the Structured Clinical Interview for DSM-IV. The 61 women interviewed were selected on the basis of high General Health Questionnaire scores from a large questionnaire survey of 1,002 mothers. The illustrative analysis looks at descriptions of depressed mood, self-depreciation and suicidal ideation, as well as attitudes toward service use. The women gave full and open descriptions of their emotional symptoms, easily recognizable by standard symptom categories, although somatic symptoms were commonly included, and the spiritual context to understanding depression was also prevalent. However, few women had knowledge about treatment or sought medical services, although some sought help from local spiritual healers. Attending to such views of depression can help develop services in Malaysia. 

Cultural Case Study: Culture, Stress and Recovery from Schizophrenia: Lessons from the Field for Global Mental Health by Neely Laurenzo Myers

This cultural case study investigates one U.S. psychosocial rehabilitation organization’s (Horizons) attempt to implement the recovery philosophy of the U.S. Recovery Movement and offers lessons from this local attempt that may inform global mental health care reform. Horizons’ “recovery-oriented” initiatives unwittingly mobilized stressful North American discourses of valued citizenship. At times, efforts to “empower” people diagnosed with schizophrenia to become esteemed self-made citizens generated more stressful sociocultural conditions for people whose daily lives were typically remarkably stressful. A recovery-oriented mental health system must account for people diagnosed with schizophrenia’s sensitivity to stress and offer consumers contextually relevant coping mechanisms. Any attempt to export U.S. mental health care practices to the rest of the world must acknowledge that (1) sociocultural conditions affect schizophrenia outcomes; (2) schizophrenia outcomes are already better in the developing world than in the United States; and (3) much of what leads to “better” outcomes in the developing world may rely on the availability of locally relevant techniques to address stress.

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New Yorker Magazine: A Case of Psychopathy in New Zealand

Colin Bouwer

New Yorker magazine this week has a piece by Carl Elliot (“Letter from New Zealand”) entitled “Mind Game.” It chronicles the remarkable story of a psychiatrist, Colin Bouwer, who was convicted of murder and is presently serving a life sentence.  You must subscribe to the magazine to read the full article.  Here is the abstract:

LETTER FROM NEW ZEALAND about a psychiatrist who killed his wife. Dunedin, New Zealand, is an uncommonly peaceful place, yet when it does have a murder, it’s spectacular. What is striking about the case of Colin Bouwer, a psychopathic psychiatrist who was once the head of psychiatry at the University of Otago Medical School and is now a convicted murderer, was the man’s ability to fool his colleagues, many of whom would have studied psychopaths in their medical training. In November of 1999, Dr. Andrew Bowers faced two mysteries. One had to do with Colin Bouwer’s ailing wife, Annette, who had been in good health until a few weeks earlier, when she began having peculiar symptoms. On the morning of November 20th, she slipped into a hypoglycemic coma although she didn’t have diabetes. The second mystery was Colin’s behavior. After a few days in the hospital, Annette was discharged; four days later, she went into another coma. After being discharged a second time, she began having symptoms of hypoglycemia again. Early on the morning of January 5, 2000, Colin called Bowers and told him Annette was dead. Bowers wanted to order a postmortem exam, but Bouwer objected. Bouwer was born in Bloemfontein, South Africa, in 1950. He met Annette at a meeting of Mensa, and they married in 1981. In early 1997, he immigrated to New Zealand; Annette and their two children soon followed. Bouwer quickly rose to the top administrative post at the University of Otago. He told his colleagues that he’d been involved in the South African resistance struggle and tortured. By all accounts, he was charming and an excellent psychiatrist. On September 15, 2000, nine months after Annette’s death, the Dunedin police arrested Bouwer and he was charged with murder. Bouwer had written false prescriptions for glucose-lowering drugs, ground them up with a mortar and pestle, and given them to Annette, most likely in her food. The day before she died, he picked up a false prescription for a thousand-unit vial of Humalog insulin—a dose large enough to kill her. Although Bouwer was indeed a qualified psychiatrist, much of his autobiography was constructed out of lies and half-truths. Bouwer had actually been trained as a doctor by the South African military. By the time the police completed their surveillance after Annette’s death, investigators believe that he was sexually involved with at least four hospital staff members in Invercargill and Dunedin. Bouwer’s behavior prior to the murder was stunningly reckless. What personality type does this kind of thing? In 1941, Hervey Cleckley published a book about psychopaths called “The Mask of Sanity,” which told the stories of charming and friendly men and women who had a kind of moral blindness. The fact that even clever psychopaths show such poor judgment about their own interests suggests a deeper neurological impairment, and at least some aspects of psychopathy appear to be genetically related. Mentions Colin Bouwer, Jr., who was arrested for killing his wife, Ria, in 1999. Colin Bouwer was given a life sentence in November, 2001, with a minimum of thirteen years; he appealed the decision, but his sentence was later increased to a minimum of fifteen.

New York Times: Anti-Psychotic Prescriptions for Pre-Schoolers

The New York Times has posted online a video essay on an increasingly well-documented trend in the United States: prescribing powerful psychotropic drugs to children as young as age 5.

Syllabus: Evans, “Madness and Melancholy”

This is another installment in our series on university and college courses dealing with the history of madness, mental illness, and psychiatry.

Gareth Evans has a Ph.D. in English and a Master’s in Library and Information Science from the University of Wisconsin-Milwaukee.  For some time now, he has been contemplating writing essays about The Bostonians, teaching “Bartleby, The Scrivener,” and the cultural and political significance of the fiction reprinted in the Voice of Industry, an American labor newspaper published in the 1840s. He is currently a Lecturer in the Hutton Honors College at Indiana University Bloomington, where, in addition to his class on Madness and Melancholy, he has taught classes on Henry James, Herman Melville, and 21st-Century American Fiction.

The syllabus for “Madness and Melancholy” is for a revised version of a class I taught four times during the 2009-2010 academic year. In its original version, the class was a sexed-up version of a Western Civilization class that spanned the period between ancient Greece and the Renaissance.  In addition to the readings from and about that period you see below, the class also included extracts from Cicero’s Tusculan Disputations and all of Erasmus’s Praise of Folly.  As it was initially taught, the class did what it was designed to do: fulfill the requirements of the first half of the modernized two class version of the Great Books program offered by the Hutton Honors College at Indiana University Bloomington (IUB); that is, focus solely on work written before and during the Renaissance.   Many students found the reading repetitive in its concerns, and given how little definitions of madness and melancholy change between ancient Greece and the Renaissance, they were correct to do so.  To add variety to the class, and to give students a sense—a sense many of them sorely lack—of how much experts on psychology and psychiatry disagree about how depression and other real or supposed mental disorders are diagnosed and treated, I have added a two-week section that focuses on: (1) contemporary debates about the Diagnostic and Statistical Manual of Mental Disorders (DSM IV); and (2) a recent discussion of an essay by Paul Andrews and Andy Thomson that reiterates age-old claims about the connection between depression and intellect, while also suggesting depression is “an evolved emotional response to complex problems, and its function is to promote changes in body systems that promote analysis of those problems” (http://sites.google.com/site/paulwandrewsphd/).

In its original version, the class worked well with students who excelled in the class.  And in the Honors College “excelled” means received an A. Such students excelled largely because they matched their ability to respond to Euripides and Shakespeare with their ability to understand, pick apart, and analyze the arguments made by Burton, Erasmus, Ficino, and Plato.  As that comment suggests, what separated, and is likely to continue to separate, the excellent from the good and the mediocre, is the ability to comprehend, engage with, and thoughtfully analyze the philosophers of madness and melancholy.  Students who excelled also did so because they were able to set aside the widespread contemporary assumption that mental disorders of all kinds are bred in the brain, passed down from generation to generation in the same way forms of cancer and heart disease seem to be. That assumption has been an issue in the class, and I attempt to address it with the contemporary material I have added to the syllabus.  I chose madness and melancholy as a topic in part because I wanted students to read material they had not read before.  What is more, even if they have read the material–and many of the students have already read Hamlet and King Lear–the nature of the course forces them to read and write about the material through the lens provided by the other work—work concerned with madness and melancholy, anger and folly—they have read during the class.  Some students coped well with the demands of the class last year, but others flounder because they are unable to cope with material that makes assumptions so alien to their own.  Once again, then, the material I’ve added to the class seeks to bridge that gap, make students engage with the significance of that gap, between what passes for common sense in contemporary American discussions of, say, depression, and what passed for common sense in ancient, medieval, and Renaissance reflections on melancholy.  What I want students to do is feign the impossible and think like an ancient Greek, a medieval Abbess, or a renaissance philosopher.  Whether the changes to the syllabus will enable more students to perform such a trick remains to be seen.

I’ll return to the reading for the class later, but now I am going to write a little about the writing workshops, the abstract presentations, and the visits to libraries that are part of “Madness and Melancholy” and of almost every class I teach.  The number, HON H-211, under which “Madness and Melancholy” is taught, is defined by the Hutton Honors College as a “writing intensive” course, which means that every student in the class must write at least twenty pages during the semester—a breathtaking amount to be sure.  In the version of the syllabus my students receive, I explain that I expect them to write analytical essays that support their claims by quoting and paraphrasing the work they are analyzing.  Before the first writing workshop, I also hand out, and discuss with, my students, a writing sample that contains all of the features I expect an essay to contain if I am to give it an A.  If they worked as they are intended to work—and how rarely they do—the writing workshops would help students learn how to write the kind of essay I want them to write. The workshops are peer response sessions in which students are divided into groups of three or four. Each student brings a copy of his/her essay for the other members of the group and then twice reads that aloud, before listening to the responses and suggestions made by the other students in the group. The workshops are, in addition to their primary intent, a way of getting students to make an early start on their essays, while they also point to the process by which writers revise their work in response to the suggestions of people who read it in draft form or listen to it as a conference presentation.  The five minute abstract I ask each student to present at the end of the semester is, again, partly an attempt to get students to make an early start on an essay, but it is also designed to get them to do what graduate students and faculty do every time they propose a conference paper: summarize their argument, explain how they will make that argument, and clarify the relationship of that argument to current arguments made about the topic they are addressing.

In addition to its emphasis on writing, the class seeks to promote information literacy through visits to the main university library and to the Lilly Library, which is the special collections library at Indiana University Bloomington. In their visit to the Lilly, students learn about the policies of the library and its collections as a whole are shown. During much of the class, however, they are able to look at and handle some of the primary sources for the course, including a First Folio of Shakespeare, and first editions or first English translations of material they read for the course.  In their visit to the main library, I show students how to search the university catalog, WorldCat, and a variety of subject specific databases. The class is accompanied by a ten-question exercise designed to enable students to demonstrate they know how to use and search the catalogs and databases they are shown during the class.  I only began to teach such classes after I got a Master’s in Library and Information Science.  It was only while I was getting that degree that I realized that I, like most of the current and former academics I knew, had taught themselves how to use a library.  That academics had been forced to teach themselves how to use a library struck me then, and now, as an unconsciously constructed barrier to student learning. By taking my students to the libraries, I try to make drown that barrier. It also seems to me particularly important now, in the day of rampant plagiarism and Wikipedia, that students be shown how to use and find reputable sources, the kind of sources that academics and students should routinely use when they work.

Since I demand clarity from my students, I will be honest and say that, last year, my description of “Madness and Melancholy” was not as clear as it needed to be.  Much of the material was new to me when I first taught the class, and it was only through teaching the class that I was able to clarify and describe all of its central concerns. My emphasis on context, however, has been clear from the start in the class description and in the opening reading from Padel and Watters, both of whom stress the centrality of context to the ways in which madness, melancholy, and contemporary American mental disorders are described, treated, and defined. That said, my current class description differs from its predecessor by making it clear: (1) that the class is far less concerned with psychology and psychiatry as they are currently defined than it is with questions of moral philosophy; (2) that students will learn as much, or more about ancient and Renaissance medicine as they do about contemporary science; (3) that for much of its history, doctors, philosophers, and playwrights were far less interested in genetics than they were with the humors, the planets, the gods and God; and (4) that much of the writing on madness and melancholy is far less focused on what it means to be well than on what it means to be “good.”  It is now clear, too, that “Madness and Melancholy” is not a class that uncritically endorses any of the ways—ancient, medieval, renaissance, or contemporary—madness or melancholy, depression or anger, mood disorders or social phobia have been viewed, treated, and defined.   Instead, the class description now makes it clear that debate and disagreement are at the heart of the class.

New Issue of History of Psychiatry

The September 2010 issue of History of Psychiatry is available online and contains seven articles. Titles, authors and abstracts are listed below.

From stack-firing to pyromania: medico-legal concepts of insane arson in British, Us and European contexts, c.1800-1913. Part 1 by Jonathan Andrews (Newcastle University)

This article surveys evolving and competing medico-legal concepts of pyromania and insane arson. Exploiting evidence from medical jurisprudence, medico-legal publications, medical lexicography and case histories, it seeks to explicate the key positions in contemporary professional debates concerning arson and mental derangement. A major focus is the application of the doctrines of moral and partial insanity, monomania, instinctive insanity and irresistible impulse to understandings of pyromania and insane arson. The limited extent to which mental defect provided a satisfactory diagnosis and exculpatory plea for morbid arson is also explored. Additionally, this article compares and contrasts contemporary debates about other special manias, especially kleptomania. Part 2 will be published in the next issue, History of Psychiatry 21(4).

Illness of the will in ‘pre-psychiatric’ times by Kathleen Haack (University of Rostock, Germany), Ekkehardt Kumbier (University of Rostock, Germany) and Sabine C Herpertz (University of Heidelberg, Germany)

Since its emergence as a medical discipline in its own right, i.e. since the end of the eighteenth century, disorders of the will have constituted a major area of interest for psychiatrists. But even before then, in ‘pre-psychiatric’ times so to speak, there were occasional descriptions of illnesses of the will or, in the nomenclature used at the time, ‘ambiguous emotional states of minds’. This study presents some very early attempts to tackle and explain the problems of amentia occulta, manie sans délire and monomania in German literature, concentrating on works written from a medical and philosophical perspective. Beginning with the differentiation between will and reason, this study explores some concepts in which the will was perceived as a possible cause of mental illness and thus became a topic of medical interest.

The face of madness in Romania: the origin of psychiatric photography in Eastern Europe by Octavian Buda (‘Carol Davila’ University / ‘Mina Minovici’ National Institute of Legal Medicine, Bucharest)

In 1870 the Romanian physician Nicolae G. Chernbach published a photographic atlas of the main types of mental alienation, a collection of twelve plates depicting mentally ill patients from the Marcutza Asylum in Bucharest. Each photograph included a diagnosis based on the clinical nosography and theories of the physiognomy of insanity acknowledged during the period. The publication of the atlas — just a few years after Hugh W. Diamond’s initial use of photography for this purpose in Britain in the 1850s — means that the photographs were not only the first taken in Romania, but among the first photographs of the mentally ill. This study provides an insight into the origins of modern clinical psychiatry and medical advances in Romania, and the contemporary personalities in Romanian and Eastern European medicine.

From psyche to soma? Changing accounts of antisocial personality disorders in the American Journal of Psychiatry by Martyn Pickersgill (University of Edinburgh)

The history of psychiatry is often portrayed through the metaphor of a pendulum, the profession swinging back and forth between a concern with psyche and soma. Recent work critiquing the pendulum metaphor, however, suggests that it does not account for the complexity of psychiatry.This article explores the metaphor through an analysis of the changing aetiological accounts of personality disorders associated with antisocial behaviour advanced in the American Journal of Psychiatry from 1950 onwards. It is argued that the social, scientific and economic factors which help shape overarching professional trends in psychiatry only partly structure personality disorder discourse. If the pendulum swings, therefore, not all psychiatrists move with it.

Psychiatry in Britain, c. 1900 by Hugh Freeman (University of Oxford)

At this period, British psychiatrists practised in a climate of opinion that was deeply pessimistic, influenced by the views of Henry Maudsley and by the accumulation in asylums of incurable patients. The inflexible Lunacy Act of 1890 tended to encourage chronicity. The terminology both of mental illness and of the doctors who dealt with it was uncertain. Management of these disorders was intimately involved with the operation of the Poor Law. Neurology, on the other hand, carried high prestige and advanced clinically; many patients with neurotic disorders came under the care of neurologists. Postgraduate education and training in psychiatry was practically non-existent, as was academic psychiatry, in contrast notably to Germany, though there was a small professional organization.

The reception of Eugen Bleuler in British psychiatry, 1892-1954 by Thomas Dalzell (St Vincent’s University Hospital, Dublin)

This article draws on over 60 years of British medical journals and psychiatry textbooks to indicate the chronological stages of the reception of Eugen Bleuler in British psychiatry. Bleuler was already well known in Britain before his schizophrenia book appeared, with the journals containing numerous references, mainly positive, to his work. The psychiatry textbooks, however, were slower to integrate his contribution. This paper argues that this was not due to Bleuler’s placing Freud on a par with Kraepelin, but because of the early negative reaction to Kraepelin’s dementia praecox concept, despite Bleuler’s wider and less ominous conception of the illness.

Classic Text No. 83: ‘On Uprootedness’ by Emil Kraepelin (1921) by Eric J Engstrom (Humboldt University, Berlin) and Matthias M Weber (Max-Planck-Institute for Psychiatry, Munich)

Penned at the height of the debate on national regeneration in Germany after World War I, Emil Kraepelin’s study On Uprootedness sets out his views on social psychiatry. More than just a response to critics of his nosology, On Uprootedness outlines a larger political agenda of social governance and ‘inner colonization’. This introduction places Kraepelin’s understanding of social psychiatry in the broader context of social reform debates in the early Weimar Republic.

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Colloquium on the History of Psychiatry and Medicine (McLean Hospital and Center for the History of Medicine)

The Case of Dora on BBC Radio 4

BBC Radio 4 is now streaming “Dora: The Girl Who Walked Out on Freud” on its website for the series Case Study.  The series examines case studies that have made a significant contribution to psychological research.  The website describes the program on Dora this way.

Dora was the pseudonym Sigmund Freud gave to the teenage girl who claimed that her father had offered her to his friend in exchange for the continued sexual favours of the friend’s wife. Freud used this, his first case history, to show how the interpretation of dreams could be used in analysis. Also to illustrate his new theory of infant sexuality, and to explain transference. Although Freud said he believed Dora’s account of the adults’ love triangle, Dora ended the analysis after just 11 weeks. Freud wrote up his account immediately, but didn’t publish it until 1905, as Fragment of an Analysis of a Case of Hysteria.

In the 1970s the case was taken up by feminists to discredit Freud’s theories. Claire Pajaczkowska made a film about it: Dora: A Case of Mistaken Identity. She speaks about it to Claudia Hammond in the Freud Museum, Sigmund Freud’s former London home.

American psychoanalyst, Karin Ahbel-Rappe, asserts that Dora, a vulnerable teenager, was badly let down by Freud. So does Anthony Stadlen, a psychotherapist who has researched the real people behind the pseudonyms in Freud’s case histories. Dora was in fact Ida Bauer, later Ida Adler, and the image of the self-obsessed hysteric perpetuated by Freud and his followers was apparently untrue.

Janet Sayers, Professor of Psychoanalytic Psychology at the University of Kent, and Michael Billig, Professor of Social Science at Loughborough University, also feature in the programme.

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