Robert J. Barrett

Clinical writing and the documentary construction of schizophrenia

Psychiatric practice involves writing as much as it involves talking. This study examines the interpretive processes of reading, writing and interviewing which are central to the clinical interaction. It is part of a broader ethnographic study of an Australian psychiatric hospital (which specializes in the treatment of patients with a diagnosis of schizophrenia). The paper examines two major types of written assessment of patients — the admission assessment and the ‘complete work-up.’ Writing is analyzed as performance, thereby focusing on the transformations that are effected in patients, their perceptions of their schizophrenia, and their total identity. One crucial transformation is from ‘person suffering from schizophrenia’ to ‘schizophrenic.’ The paper aims to show that as much as psychiatry is a ‘talking cure’ it is also a ‘writing cure.’

Interpreting culture and psychopathology: Primitivist themes in cross-cultural debate

Interpreting the cross-cultural incidence of psychopathology is a focus of continuing debate. This paper explores the lineaments of that debate and its underlying premises concerning difference and distance. Primitivism-a body of ideas, images and vocabularies about cultural others-is characteristically employed to represent non-Western peoples. But it is more fundamentally concerned with the way the West understands itself in contradistinction to these others. It is shown to be a major source of the images used to think about mental illness, and of the intellectual traditions which have constituted cross-cultural psychiatry as a comparative discipline. Psychiatric primitivism employs two opposing perspectives, which we have labelled ‘Barbaric’ and ‘Arcadian’ respectively. They are the source of contradictory assertions concerning the relationship between culture and mental illness. They provide the framework which structures contemporary research into the crosscultural incidence and course of schizophrenia, shaping its methodology, its rhetoric, the strategies by which data are interpreted, and the conclusions which it draws. We demonstrate a convergence of themes whereby images of society, person and mental illness come to signify each other. This is epitomized in three of cross-cultural psychiatrys principal subject areas:amok, shamanism, and the therapeutic quality of ‘traditional’ society.

Ancestry of the Iban Is Predominantly Southeast Asian: Genetic Evidence from Autosomal, Mitochondrial, and Y Chromosomes

Humans reached present-day Island Southeast Asia (ISEA) in one of the first major human migrations out of Africa. Population movements in the millennia following this initial settlement are thought to have greatly influenced the genetic makeup of current inhabitants, yet the extent attributed to different events is not clear. Recent studies suggest that south-to-north gene flow largely influenced present-day patterns of genetic variation in Southeast Asian populations and that late Pleistocene and early Holocene migrations from Southeast Asia are responsible for a substantial proportion of ISEA ancestry. Archaeological and linguistic evidence suggests that the ancestors of present-day inhabitants came mainly from north-to-south migrations from Taiwan and throughout ISEA approximately 4,000 years ago. We report a large-scale genetic analysis of human variation in the Iban population from the Malaysian state of Sarawak in northwestern Borneo, located in the center of ISEA. Genome-wide single-nucleotide polymorphism (SNP) markers analyzed here suggest that the Iban exhibit greatest genetic similarity to Indonesian and mainland Southeast Asian populations. The most common non-recombining Y (NRY) and mitochondrial (mt) DNA haplogroups present in the Iban are associated with populations of Southeast Asia. We conclude that migrations from Southeast Asia made a large contribution to Iban ancestry, although evidence of potential gene flow from Taiwan is also seen in uniparentally inherited marker data.

Rites of consent: negotiating research participation in diverse cultures.

AbstractThe significance of informed consent in research involving humans has been a topic of active debate in the last decade. Much of this debate, we submit, is predicated on an ideology of individualism. We draw on our experiences as anthropologists working in Western and non Western (Iban) health care settings to present ethnographic data derived from diverse scenes in which consent is gained. Employing classical anthropological ritual theory, we subject these observational data to comparative analysis. Our article argues that the individualist assumptions underlying current bioethics guidelines do not have universal applicability, even in Western research settings. This is based on the recognition that the social world is constitutive of personhood in diverse forms, just one of which is individualistic. We submit that greater attention must be paid to the social relations the researcher inevitably engages in when conducting research involving other people, be this in the context of conventional medical research or anthropological field work. We propose, firstly, that the consenting process continues throughout the life of any research project, long after the signature has been secured, and secondly, that both group and individual dimensions of consent, and the sequence in which these dimensions are addressed, should be carefully considered in all cases where consent is sought.

Problem- versus case-based approaches in teaching medical students about eating disorders: a controlled comparison

Fourth-year medical students were allocated randomly to either problem-based learning (PBL) or case-based learning (CBL) tutorials on the topic of eating disorders during their 6-week psychiatry attachment. All students were evaluated in terms of their tutorial performance and the factual knowledge they had acquired. In turn, students evaluated the performance of the tutors in both the PBL and the CBL process. No significant differences were found between the student groups with respect to their performance or acquired knowledge. Furthermore, there were no significant differences when comparing the PBL format with the CBL format with regard to group functioning or oral interaction between students. Finally, student ratings for tutor performance on feedback, group management skills and personal qualities showed no differences. Implications for education are discussed.

Rates of treated schizophrenia and its clinical and cultural features in the population isolate of the Iban of Sarawak: a tri-diagnostic approach

BACKGROUND We present results of a study of treated rates of schizophrenia among the Iban of Sarawak, Malaysia. Most Iban live in longhouses, each comprising a kindred group of up to 300 individuals. Cultural practices such as minimal intermarriage with members of adjacent ethnic groups and in-depth genealogical knowledge make them a population suitable for genetic investigation. Iban culture is conducive to a focus on symptoms and illness, and to patterns of treatment-seeking behaviour that are enthusiastic and persistent. METHOD We identified all known cases of psychotic disorder within a defined catchment area based on an exhaustive survey of available medical records. From corresponding Malaysian census data (91,056 persons), we report rates of treated schizophrenia in the Iban population, using three diagnostic systems, as well as the demographic and clinical characteristics of these individuals. RESULTS The most frequent presenting complaints were insomnia and aggression. We found higher treated rates for narrowly defined schizophrenia among males, but no significant gender difference for age of onset. Estimates of treated rates to age 55 years (per 10,000) for narrow schizophrenia were 41.9 (ICD-10), 56.5 (DSM-IV), and 83 (RDC), while the rates for broad schizophrenia were 105.5, 103.2, and 107.5 respectively. CONCLUSIONS Treated rates of schizophrenia were higher than the reported prevalence for many populations at risk, including many small-scale societies, although different methodological approaches may partly explain these findings. Given the cultural patterns of Iban treatment-seeking behaviour, treated rates of schizophrenia reported here may closely approximate the population prevalence of this disorder.

Conceptual foundations of schizophrenia: I. Degeneration

Objective: This is the first of two papers that aim to identify some of the institutional processes of 19th century European psychiatry, and some prevailing cultural themes of that era that played a role in shaping the development of schizophrenia as a disease concept. Method: Three areas of psychiatric history are examined: the first is concerned with the key figures who coined the concept of dementia praecox; the second with the rise of the asylum; and the third is to do with the ideology of 19th century psychiatric science and its relationship to a broader intellectual milieu. These three literatures are examined for common themes. Results: The theme of degeneration is evident in all three literatures, and denotes both a biological process (neuro-degeneration) and a moral state (degeneracy). Conclusions: The idea of degeneration, a pervasive cultural theme of the 19th century, dominated psychiatric thinking long before schizophrenia was developed as a diagnostic category. It contributed to the ideational form-work that gave foundation, structure and shape to the concept of schizophrenia.

Refining clinical phenotypes by contrasting ethnically different populations with schizophrenia from Australia, India and Sarawak

We contrasted demographic and clinical characteristics in transethnic schizophrenia populations from Australia (n=821), India (n=520) and Sarawak, Malaysia (n=298) and proposed cultural explanations for identified site differences. From these we aimed to identify candidate variables free from significant cultural confounding that are hence suitable for inclusion in genetic analyses. We observed five phenomena: (1) more individuals were living alone in Australia than India or Sarawak; (2) drug use was lower in India than Australia or Sarawak; (3) duration of untreated psychosis (DUP) was longer in India than Australia or Sarawak; (4) the rate of schizoaffective disorder was lower in India than Australia or Sarawak; and (5) age at psychosis onset (AAO) was older in Sarawak than Australia or India. We suggest that site differences for living arrangements, drug use and DUP are culturally confounded. The schizoaffective site difference likely results from measurement bias. The AAO site difference, however, has no obvious cultural or measurement bias explanation. Therefore, this may be an ideal candidate for use in genetic studies, given that genetic variants affecting AAO have already been proposed.

Collective danger and individual risk: cultural perspectives on the hazards of medical research

Abstract

Conceptual foundations of schizophrenia: II. Disintegration and division

Objective: This is the second of two papers that aim to identify some cultural themes and institutional processes that shaped the development of schizophrenia as a disease concept. Method: A number of domains within 19th century European history are explored for evidence of the concept of the divided or disintegrated person. These include German academic psychiatry, Mesmerism and hypnosis, neurology and neurophysiology, psychoanalysis and German Romantic literature, and its descendants within a wider European literature. Results: Representations of division or disintegration are evident in all these domains, enjoying widespread currency and penetration throughout the 19th century. Conclusions: These culturally based ideas, combined with the idea of degeneration, were important elements in the foundation of the schizophrenia concept.