FPR-UCLA 4th Interdisciplinary Conference - Summaries

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Session 5 Summary: Cultural and Biological Contexts of Schizophrenia

The film covers Pak Kereta’s personal history of trauma (stemming from political violence in 1965 after a purported Communist coup), the loss of a child, and exposure to pesticides, all of which may have contributed to his illness experience. Importantly, the film places his experience in the context of local community and cultural beliefs and practices and the social and political history of the region. Additionally, it draws on family members and local mental health practitioners’ observations and perspectives. In this way, the film explores how Pak Kereta’s experiences can be arranged and interpreted in multiple ways.

In terms of treatment, an Indonesian psychiatrist describes how she diagnosed Pak Kereta with paranoid schizophrenia. In a follow-up visit, she meets with him and adjusts his medication (Thorazine). Pak Kereta also visits two healers, the first of whom douses his head with an elixir and diagnoses a stress-related problem (based on the location of the illness in the center of the chest). The second healer said Pak Kereta was “mute” and living “in fear” at the beginning of treatment 25 years ago, which involved a 3-month stay. In a follow-up visit he identifies Pak Kereta’s illness as ngeb, a condition caused by people, i.e., witchcraft, the treatment for which is a traditional mantra or verbal incantation and medicinal drops in the eyes and nose. In a subsequent interview, both Pak Kereta and his wife say they prefer the Western pills, which “work,” as opposed to the drops, which “burn.”

The film concludes with a consideration of how Pak Kereta has adapted to his illness and hallucinations (he and his wife claim the illness has brought them closer). “There are other people who are sick and, until they die, nobody cares for them,” he said. “They just disappear.” Lemelson describes how he came to realize that Pak Kereta’s “experiences with spirits could not be viewed purely as a psychiatric illness.” He said it was “the lack of a label of madness with its attendant social meanings that allowed Kereta to exist and find a small measure of peace in his own world.” In the end, Lemelson said, “Kereta still had to come to his own understandings and ways of co-existing with his ever-present spirits.”

Commentaries

In the first commentary, Caltech neurobiologist Paul Patterson discussed the “seemingly unrelated and very diverse risk factors” associated with schizophrenia, such as maternal infection, maternal malnutrition, obstetric complications, being born in the winter/spring months, and being born and brought up in an urban environment. Common to all these factors is an association with an inflammatory response, he said, in particular an elevated level of a specific cytokine known as interleukin-6.

Patterson cited epidemiological work by Alan Brown and colleagues at Columbia on the significant increase in schizophrenia risk following prenatal influenza exposure. The group’s “calculation of attributable risk” indicates that some 15–20 percent of schizophrenia cases could have been prevented if the infection had not occurred. Attributable risk increases to approximately 30 percent with the inclusion of other, non-overlapping infections that have also been associated with schizophrenia risk, such as other viral, bacterial, and parasitic infections. “And the important thing about that,” Patterson continued, “is that we’re not just thinking about potential causes and risks factors, the important thing is that these are in some sense preventable. There are public health and personal measures one can take to try to prevent maternal infection.”

Patterson then discussed his own recent work on mouse models of maternal infection. A respiratory infection mid-gestation in the mother results in a number of behaviors in the offspring that are consistent with those found in schizophrenia and even autism, such as social interaction deficits and anxiety under mildly stressful conditions, as well as differences in objective measures like pre-pulse inhibition and latent inhibition. The offspring have enlarged ventricles, as seen in schizophrenia, and a loss or deficit in Purkinje cells, one of the most common neuropathologies found in autism.

Patterson and others have also found that many of these behavioral deficits are post-adolescence in onset. Treatment of adolescent animals with antipsychotic drugs prevents the onset of these abnormal behaviors as well as ventricular enlargement. These findings suggest that public health measures (to prevent maternal infection) as well as medical or biological approaches to prevent conversion in at-risk individuals all hold promise.

In his concluding remarks he said that work by Alan Brown’s group suggests schizophrenia can be subdivided according to potential causal factors; persons with schizophrenia who were exposed to influenza prenatally display distinct pathologies and cognitive deficits from schizophrenics whose mothers were not infected.

Mary-Jo DelVecchio Good, a professor of social medicine at Harvard, presented the last commentary of the session. She reflected on how beautifully Elyn Saks conveyed the love she received from her friends and the support she received from mental health practitioners during her terrifying experiences with psychosis. She also noted the many levels through which Pak Kereta’s experiences can be interpreted, particularly the sinister overtones of the spirits when the story is presented in a political context.

She described the amazing complexity (of both stories) in terms of looking through so many layers of narrative. She compared Elyn’s narrative, in which she is controlling the story she is telling us, to the different versions of Pak Kereta’s story, noting that Shadows and Illuminations is a far more personal story than the narrative that appears in 40 Years of Silence, another ethnographic film by Robert Lemelson that focuses on the events of 1965, in which Pak Kereta’s psychosis might be considered a protective mechanism in reaction to the horrors he experienced.

In closing she said one of the questions we need to ask is, how these various narratives (the neuroscientific, the ethnographic, the political, the personal, and so on) are structured. She said that a common thread among them is emotion, noting the affective power of brain images, as well as personal stories. She also asked the audience to consider how the stories we tell relate to ourselves as subjects and to others, like Pak Kereta, as subjects and to remain mindful of the moral consequences of our interpretations.

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