Psychiatry, DSM-V, and Japan

Hi all,

It’s been some time since I’ve updated.  I recently had to prepare for the conference, and I’ve been going through draft after draft of my personal statement for med school applications.  The work, I think, is paying off, but it has been a lot of work.  I submit my med school application within the next couple of weeks.

I would like to make a new post about something, something that has been important area of study for me for several years now.  I recently presented at a History of Medicine conference at Berkeley, and I put together the following paper for that.

I did not finish my presentation; my mouth ran dry within the first 15 seconds, and I had to run off to get water.  Also, unlike previous conferences, I went through the paper slowly and emphatically.  This means that I got through a lot less material than I normally would.  I prefer this, as I think it greatly improves the presentation quality.  But it has its drawbacks.

So, with minor modifications, I am attaching only the fragment that I completed in presenting.  The entire presentation, and the argument when put clearly, runs through so many twists and turns that it is impossible to fit it into such a small space of a 20 minute presentation.  I furthermore recognize how much I need to read the more modern, more theoretical historians of psychiatry, like Robert Castel, and others, like Deleuze and Guittari.

If you like what you see, check again every once in a while for the next year or so.  I will continue to post on this subject sporadically.

Here:

The use of DSM since DSM-III is ubiquitous in psychiatric research and practice: it is used for every research study submitted to the FDA to prove drug efficacy for registration; a diagnosis is applied to every patient in order to receive third party reimbursement through insurance, Medicare, or Medicaid; almost all patients come to understand themselves as having a DSM diagnosed disorder.

On the one hand, there is a corpus of research produced by the use of post-DSM-III nosology that is regarded as path-breaking and important–neuroscientific, epidemiological, molecular genetic. On the other, there is the ever-present caveat: are not the many persistent blind spots, perplexities, and limits in psychiatric research produced by the very categories that make it possible? This reflexivity is markedly present in the Research Agenda for DSM-V: “The limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For that to happen, an as yet unknown paradigm shift may need to occur.” Nancy Andreasen–who was a core member of the initial 9-person DSM-III Task Force and Chair of the Schizophrenia Work Group for DSM-IV, wrote in 2007: “DSM diagnoses have given researchers a common nomenclature—but probably the wrong one. Although creating standardized diagnoses that would facilitate research was a major goal, DSM diagnoses are not useful for research because of their lack of validity.”  Andreasen received the National Medal of Science from Clinton in 2000.  She is not a crank.

I could go on for at least an hour with citations of the top guys in psychiatry who say these sorts of things.  The question is, then, how did DSM come about if it’s so poorly regarded by the top researchers in the field?

The immediate historical event that marks the background of practice at the psychiatric hospital as it exists today–and really, psychiatric services at large–is deinstitutionalization. Deinstitutionalization is generally defined as the movement of care for mentally ill from being confined in psychiatric hospitals, to outside of psychiatric hospitals, in outpatient care, prisons, nursing homes, marginal living conditions, the streets, etc. As you know, by the end of the around the time of the French revolution in the West (the years vary by country), the mentally ill had undergone a change in status during what Foucault called the great confinement. The rationale for this was that, by the patient’s being isolated from the community, in a specially created therapeutic environment, the patient could recover and be re-instated as a sane, rational member of the community. Therapeutic optimism was high; the practice was considered an apogee of civilized and humane practice, a capstone of Enlightenment.

In the 1950s and 1960s, this view was completely reversed. What was considered the hallmark of civilized society became the hallmark of its barbarity in a profound reversal.

What caused deinstitutionalization?

The view in psychiatry, among those not so familiar with the history or sociology of deinstitutionalization, the triumphalist view of the psychiatrists, is that the hospitals were emptied by the rise of the new psychopharmacology, the neuroleptics, the antidepressants, lithium, and so on, in the 1950s through the 1980s. This, according to the view, still found in much of the literature, including Edward Shorter’s widely read 1997 history, was the miracle of magic bullet medicine.  This was however refuted as early as 1964.  A list of reasons for refusing this interpretation include the following. First, it has been repeatedly shown that there was no statistical correlation between the introduction of Thorazine and the discharge rate in the hospitals. Second, the rate of deinstitutionalization has been extremely variegated worldwide, even as the introduction of neuroleptics has been relatively consistent—centered around 1955.  Third, Japan is a completely different—and opposite story—with almost as many patients per capita in hospitals as the United States at its peak; Japan probably uses psychotropics even more extensively in its hospitals than does the US—presumably, to make the custodial aspects of its hospitals even more efficient.  Fourth, in the spirit of the 1960s, all institutions were under fire and subject to reforms.  In conclusion, I claim that deinstitutionalization was caused by a broader progressive social trend affecting Western societies in a variety of other profound ways.  The psychopharmacological revolution was related to a third factor, a more fundamental change in psychiatry, which was in turn related to a restructuring of society’s social relations.

The fundamental change in psychiatry, about which discussion of deinstitutionalization is, I’d venture to claim, a mystification, is as follows.  Where psychiatry as a marginal medical specialty relegated exclusively to the administration of total institutions in 1900, with a fraction of a percent of the population in hospitals, to today, where 1 in 5 people are undergoing some sort of psychiatric treatment at any given time.  In a word, it is not so much that psychiatric patients have been mainstreamed, but that the mainstream has become psychiatric patients.  The notion of deinstitutionalization around which this contemporary discourse operates conceals its dialectical opposite in material reality.

What is it that changed fundamentally in society that caused the change in psychiatry, of which I claim that discourse on deinstitutionalization was a mystification?  To answer this question, let’s backtrack.

Japan, as I have said, is the only country of its level of development not to have pursued deinstitutionalization.  This is the exceptional case that will show the reason for the rule.

When other countries were criticizing the asylum, Japan was doing much the same.  Except in the case of Japan, what was criticized as inhumane was the practice of families locking up their mentally ill members in special rooms and cells at home. In Japan in 1950, legislation was passed to transfer patients from home care to the hospital setting.  Keeping mentally ill family members at home was outlawed.  In 1965, and several times thereafter, more legislation was passed to deinstitutionalize these asylums in turn, to no effect: while the legislation is on the books, the situation does not change. Today, there are over 350,000 hospital beds in Japan, often built up in remote mountain regions, secluded from society—13.5 times the number per capita as the US and 4.5 times the UK. This is almost as many as in the US, per capita, in 1955.

I claim that this configuration of the Japanese is not unrelated to other aspects of Japanese society that are unusual by Western standards.  The Japanese solution to the problem of the severely mentally ill is not unrelated to the mandatory confinement of lepers until 1996 on secluded island colonies, the notorious Japanese xenophobia, the almost neo-feudalist structure of society, the rigidity and polarity of gender roles, the strict conformism.

To have eccentric schizophrenics pursuing distinguished scholarly careers—as we know that Elyn Saks did in the past few decades (get her book, called The Center Won’t Hold; you can also see her TED talk)—while in the midst of intermittent psychosis would be unthinkable in Japan.  To have psychiatric services that attempt to re-shape subjectivities that diverge in wide variations to a basic cultural standard (as in the West) is unthinkable.  Such a wide range of subjectivities simply does not exist; social and moral authorities remain strict and immanent within Japanese society, not outsourced, as it were, to technical interventions in psychiatry.  When one’s desires do not match propriety, as they did for Confucius in old age, one represses oneself.

Not so in the West.  If the 1960s was the time in our history where universality was extended to an unprecedented multiplicity of groups, then it was also a time when no longer could we as a society comfortably define abnormality as merely a kind of moral and cultural “Other.”  Moral authority, the authority of the Father, was completely rejected at this time—we now live, as some call it, in a post-Oedipal age.  Recall Foucault’s indictment of Pinel, Pinel the Father, near the end of the History of Madness. With the abolition of Pinel, or the Father in general— (Foucault, in a move characteristic of his critique of psychiatry standing for a critique of society, conflates the two) — as the nodal points of morality, you also lose a unary notion of madness, you lose anything apart from the notion of a pragmatic, technical intervention into the problem behaviors of another.  This relativization, this critique of psychiatry was more than a critique of psychiatry, but a critique, as the 1960s radicals had it, of bourgeois morality as such.

Because of this collapse of the buttressing of psychiatry from the point of view of a uniform, homogeneous societal moral authority, Western psychiatry took a sharp turn; DSM-III is the outcome of that. As psychiatrist David Healy notes, the 1973 extirpation of homosexuality from consideration as a category in DSM-III was the crowning symbolic event of this change. The shift from DSM-II in 1968 to DSM-III in 1980 was a shift from a relatively unified psychoanalytic theoreticization of disorders numbering in the dozens, to the technical, atheoretical description of diverse aberrant behavioral domains numbering in the hundreds. (Although DSM-III was a manual produced in the 80s, it had its origins in 1967, with the Feighner criteria–which had all the main features of DSM-III categories.)  We are instead now encouraged to see a patient as mentally ill more primarily for the purposes of that context-specific intervention that suits them, not in the psychoanalytic framework of DSM-II, which, though less specific than DSM-III still implies a lot more that is claimed hard and fast about human nature.  If old moralities are still present (the moralities of the Father, that target of Foucault), each is today split and scattered about in dozens of pragmatic pieces.
…

The talk ended here, as I had a couple minutes left, and the following would have delved into deeper socioeconomic explanations.  I’m satisfied, well enough, as is.  With the next post that I make on the subject, I will discuss these socioeconomic explanations, flesh out the history of Japan in further detail (as it is relevant to my argument), and deploy a range of other evidence and examples.  I’m, however, in no hurry, and, in the meantime, will be posting on other things.

Norwegian Wood, Narcissism, and Social Change

“I guess I’ve been waiting so long I’m looking for perfection. That makes it tough.”

“Waiting for perfect love?”

“No, even I know better than that. I’m looking for selfishness. Perfect selfishness.  Like, say I tell you I want to eat strawberry shortcake.  And you stop everything you’re doing and run out and buy it for me.  And you come back out of breath and get down on your knees and hold this strawberry shortcake out to me. And I say I don’t want it anymore and throw it out the window. That’s what I’m looking for.”

“I’m not sure that has anything to do with love,” I said with some amazement.

“It does,” she said. “You just don’t know it.  There are times in a girl’s life when things like that are incredibly important.”

“Things like throwing a strawberry shortcake out the window?”

“Exactly.  And when I do it, I want the man to apologize to me. ‘Now I see, Midori.  What a fool I’ve been! I should have known that you would lose your desire for the strawberry shortcake. I have all the intelligence and sensitivity of a piece of donkey shit.  To make it up to you, I’ll go out and buy you something else.  What would you like?  Chocolate mousse? Cheesecake?'”

“So then what?”

“So then I’d give him all the love he deserves for what he’s done.”

“Sounds crazy to me.”

“Well to me, that’s what love is. Not that anyone can understand me though.  For a certain kind of person, love begins from something tiny or silly.  From something like that or it doesn’t begin at all.”

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“Girls my age never use the word “fair.” Ordinary girls as young as I am are basically indifferent to whether things are fair or not.  The central question for them is not whether something is fair but whether or not it’s beautiful or will make them happy. “Fair” is a man’s word…”

=====

It’s best to see that scene within the correct context.  At the beginning of the movie, you have major student protests, confrontations between faculty and students over the relevance of Greek literature to political life–not seeing anything that isn’t immediately personally relevant as relevant at all.  The book, then, presumably takes place in ’68 and I think should be taken as an exploration of that massive event.  The political upheaval, the sexual liberation and libertinism, the conflict between traditional and modern values, the sense of alienation, the narcissism of Midori.  As you know, second wave feminism was born from the 60s; in one of the early conversations I had with my girlfriend (not yet a girlfriend), I asked her if she knew what feminism is, and she responded, “it says that women should be better than men.”  I laughed, quite shocked.

This is the proper context and way to read the scene: 1960s narcissism.  In this sense, the movie is a very typical, perhaps even ubiquitous, exploration (and critique) in Japanese cinema between tradition and cultural change.  You know that the title Norwegian Wood is taken from a 1965 Beatles song.

Where Toru’s relationship to Naoko seems to represent tradition (by way of his virtuous sense of obligation), Toru’s relationship to Midori is much more modern.  First, Midori is definitely much more dynamic, aggressive, forward than Naoko: Midori is something of a modern Japanese young woman trying to find her way.  And second, and more obviously, the relationship between Toru and Midori comes at the end of a spate of Toru’s womanizing.  Reinforcing these themes is the subplot between Nagasawa and Hatsumi–Hatsumi ultimately committing suicide because of the infidelity and coldness of Nagasawa, whom she loves.  So, on the surface, Naoko represents tradition, which ultimately becomes schizophrenic and commits suicide, and Midori represents the vitality, although uncertain, of the future.

But note that Midori redeems herself by waiting for, and ultimately forgiving Toru for rejecting her in favor of his traditionally Japanese obligation toward Naoko; this ushers in a new beginning, on the note of which the film ends.  How to account for the capitulation of the narcissistic ethos–in the name of love?  Read at a deeper level, Naoko rather than Midori is the true exemplification of uncompromising narcissism.

First, note that one of the central plot elements (at least in the film) is that Naoko can’t have intercourse because her pussy can’t get wet.  She never had it with Kizuki, whom she insisted on several occasions to have genuinely loved; she had it only once with Toru.  Ultimately, this incapacity for sexual intimacy is a significant contributor to her madness.  But, when is the one time when she can get wet, when she has intercourse with Toru?  It’s prior to her commitment to Toru: it is prior to the commitment to genuine emotional engagement.  The only time that she is capable of vaginal wetness is in the fulfillment of bodily pleasure, in the absence of emotional bond to the Other, in a situation where she does not wither in self-consciousness in the gaze of the Other: narcissism sine qua non.  Ultimately, her incapacity for physical intimacy is inextricably linked to her madness: her incapacity for physical intimacy mirrors her simultaneous rejection of relationships with others–with her hyperreflexivity, constantly talking about herself, driving herself mad with thoughts about her own self and own feelings, etc.–and ultimate suicide.

Here we are starting to see most clearly the focus on the thematic of alienation–of separation of person from person, of personal isolation–that is one of the major subjects of the film, whether through sexuality, through madness, or in extreme conceptions of love.  Midori, although appearing to be a real fucking bitch on first sight, forgives Toru, so we should be inclined to forgive her.  She is a young woman who struggles with contrary conceptions of self, but unlike Naoko, who uncontrollably spirals into herself, escapes into the fantasmal past, and toward suicide, she ultimately compromises with her emotions, and indeed her stated ideal of love–and in a rather conservative conclusion, fulfills the classical motif of the woman faithfully waiting for her man while he is away on a personal journey (seen first in Odysseus and recapitulated throughout the Western literary patriarchy).

Does not, then, Midori in fact fulfill a traditional female role, or at least move toward it in a modern way, whereas Naoko is the one who exemplifies inflexibility and the descent into the self and self-destruction?  Midori shows herself as a maturing young woman, originally with flawed views and an egregious and possibly insulting stated worldview, but who ultimately compromises her own narcissism for her love of Toru–even as she claims not to understand Toru’s commitment to Naoko.  Like in Pulp Fiction, the vision of the film points toward the future rather than the past, but it simultaneously recognizes the logic of the traditional past without inflexibly adhering to it–as when Butch cuts down The Gimp and incapacitates Zed with a samurai sword but rides away on a motorcycle.

Status of the Blog, & On the Evolution of Schizophrenia

This blog will now be on a weekly posting schedule.  This will allow me to improve the quality, depth of research, and length of my postings.  All postings will be submitted on Saturday or Sunday each week.

In the next couple of weeks, I am going to post two movie reviews: one of Schindler’s List, and the other of The Dark Knight.  Please stay tuned for the one on Schindler’s List: it will be good, and hopefully it will be next week.  If not, there will be an analysis of the Dark Knight, and Schindler’s List will come the week after.

The following post is a copy of a paper that I wrote when I was 20.  Because this paper was crucial to the development of my understanding of psychiatry, I am leaving it here to pave the way to a more advanced and sophisticated understanding reflected in future posts.  After the paper, there is a short afternote, where I briefly summarize my current position on the paper.  Although the paper is itself crystal clear (assuming a grasp of the technical vocabulary), my current position as reflected in my afternote will not be completely comprehensible until I write several more posts.

Schizophrenia’s Evolution as Shamanism

Introduction

Recent evolutionary theorists on the origin of schizophrenia have posited that the relatively high incidence of schizophrenia, combined with the low fecundity rate of schizophrenics and high heritability of schizophrenia, cannot be explained by any other means but by genetic selection for schizophrenia (Crow, 1995).  Theories by Polimeni, et al. (2002), have suggested a link between group selection for the schizophrenic genotype and shamanism, believing the perpetuation of shamanism to be related to group advantage but also to the advent of schizophrenia in modern societies.  Indeed, Polimeni, et al. have shown that if the size of hunter gatherer groups was 120-160, and with schizophrenia reaching incidences of 1% today, then every hunter-gatherer group would likely have a shaman.

This paper examines the hypothesis that schizophrenia is an evolutionary result of selection for shamanism.  Since the vast majority of evolution occurs within the context of hunter-gatherer society, the validity of this hypothesis must be ascertained through the examination of hunter-gatherer societies.  Several arguments underlie this broader hypothesis and elucidate the evolution of shamanism:

First, shamanism shares many behavioral parallels with schizophrenia; second, shamanism epitomizes the religious experience and provides critical religious guidance in hunter-gatherer societies; third, religion is an evolutionary adaptation necessary to deal with anxiety; fourth, shamanism, as a specialization in receiving religious experience, is also characterized by functional neurobiological alterations with an identical genetic basis to schizophrenia but a distinct and disparate etiology; last, the etiology of schizophrenia mirrors that of the etiology of religion, primarily derived from anxiety, stress, and loss of control.

What is schizophrenia?

First extensively studied and classified into mental disorder dementia praecox by German psychologist Emil Kraepelin (1896) and later re-termed schizophrenia by Eugen Blueler (1911), schizophrenia is characterized by an extended duration of two (or more) symptoms including “social withdrawal, depersonalization (intense anxiety and a feeling of being unreal), loss of appetite, loss of hygiene, delusions, hallucinations (e.g., hearing things not actually present), and/or the sense of being controlled by outside forces” (American Psychiatric Association, 1994).  These symptoms must be precipitated by “social or occupational dysfunction” and not be the result of a general medical condition or the use of psychotropic drugs (American Psychiatric Association, 1994).

What is shamanism?

Shamanism exists worldwide almost universally among hunter-gatherer groups (Eliade, 1974).  Ethnologists have historically interchangeably utilized the terms “shaman,” “medicine man,” “sorcerer,” and “magician.”  Shamanism, while incorporating a vast number of practices, including magic, medicine, poetry, storytelling, and mysticism, cannot be defined in terms of these practices alone (Eliade, 1974).  Instead, shamanism must be defined in terms of what its core function for the community is, and that is the specialist of religious experience (Eliade, 1974) and purveyor to the broader community the information gleaned from this exclusive experience (Krippner, 2000).

Varying sorts of religious experience are involved in shamanic trance.  Three major varieties are visions, soul flight, and transformation into animal spirits.  Soul flight, according to Eliade, is a form of “trance during which [the shaman’s] soul is believed to leave his body and ascend to the sky or descend to the underworld” (pg. 5).  The means by which this journey occurs depends largely upon the cultural context.  Khant shamans walked up a branch lowered from the sky; Ninets, a bridge made of smoke; the Chukchi would ride on a reindeer (Vitebsky, 2001).

Visions consisted of seeing spirits or seeing the souls of observers.  The shamans would often consult with spirits, to plead with them to return to a sick body or to ensure good weather.  Occasionally, the shamans would battle with malevolent spirits or enlist the aid of beneficial ones (Vitebsky, 2001).

Adolescent pre-shamans often become meditative, seek solitude, sleep a great deal, seem absent-minded, and have prophetic dreams and sometimes seizures (Czaplicka, 1914).  These pre-shamanic behaviors are reminiscent of minor schizophrenic behaviors.  And as with schizophrenia, the activation of shamanism (i.e. “a call from the gods”) is precipitated by stress and anxiety.  Additionally, the capacity for this activation is often hereditary for shamanism (Eliade, pg. 15).

The becoming of a shaman; how a shaman guides society

Shamanistic initiatory practices, like shamanism itself, vary in traditions from culture to culture.  In a great many cultures, a call from the gods is necessary, which at a young age, among the Siberian Vogul, may consist of a number of “exceptional traits,” such as nervousness and sometimes epileptic seizures (Eliade, pg 15).  Oftentimes the call from the gods is marked with a certain degree of derangement (pg 17).

Following the recognition of the pre-shaman as “called upon by the gods” due to idiosyncratic behaviors and experiences, the pre-shaman undergoes an extensive initiatory tutelage, in which he learns two important aspects of shamanism: the extensive folklore and rituals of the group and the capacity to invoke ecstasy, which is the vessel of religious experience.  As a result of this training, the shaman is prepared to provide a number of functions for their society, such as medicine, religious guidance, and the perpetuation of a group’s myths.  Without shamanism, a society would be left without a compass for religious activity.

But why is religious activity so important?  What advantage does religiosity confer to a hunter-gatherer group?  To answer this question, the motive behind the formation of religion must be ascertained.

Origins of religion

In order to understand the function of the shaman within a broader religious context, we must understand the psychological origin of religion and what this origin entails about the shamanic experience.  Throughout history, the broad general consensus regarding the psychological origins of religion entails that religion is spurned from the fears and needs of man in the face of an unpredictable world.

David Hume writes in 1757:

[U]nknown causes…become the constant object of our hope and fear; and while the passions are kept in perpetual alarm by an anxious expectation of the events, the imagination is equally employed in forming ideas of those powers, on which we have so entire a dependence…though [man’s] imagination, perpetually employed on the same subject, [they] must labour to form some particular and distinct idea of [unknown causes]. The more they consider these causes themselves, and the uncertainty of their operation, the less satisfaction do they meet with in their researches; and, however unwilling, they must at last have abandoned so arduous an attempt, were it not for a propensity in human nature, which leads into a system, that gives them some satisfaction.”

In 1891, anthropologist R.H. Codrington stated in his anthropological study in Australia:

The Melanesian mind is entirely possessed by the belief in a supernatural power or influence, called almost universally mana.  This is what works to effect [sic] everything which is beyond the ordinary power of men, outside the common processes of nature; it is present in the atmosphere of life, attaches itself to persons and to things, and is manifested by results which can only be ascribed to its operation.

Several other theorists posit similar explanations (Frederick, 1919; Buck, 1939).

These theorists all centrally establish fear and uncertainty in the face of the unpredictable, dynamic power of nature.  Indeed, Freud (1913) asserts that the totemization (read: deification) of animals, plants, or other natural forces coincides with the peculiar power relation that this object has with the group.  This power relation always relates abstractly to the unpredictability of nature and what we desire from the element of nature that this totemization/deification represents.  The types of objects totemized/deified include the sky, animals, volcanoes, rain, the moon, and the sun, (Freud, 1913) all objects that have a critical influence on the livelihood of the group (excepting some other kinds of deified creatures, such as birds, but even in this case, the bird’s wisdom is often consulted to deal with the rigors placed upon a people by other forces).  P.H. Buck (1939) elaborates in his study of the Polynesians:

In this early form of supernatural government by the gods, special departments were created for the major gods.  The major gods became departmental gods and were appealed to according to the particular desires of the people.  Takne was given Forestry and hence controlled trees, birds, and insect life.  He naturally became the tutelary deity of wood craftsmen.  Before a tree could be felled in the forest for a voyaging ship or an important house, Tane had to be placated with a ritual chant or invocation; and before commencing an important task, an offering was made to Tane by the craftsmen…Rongo presided over Horticulture and Food and, as a plentiful supply can be produced by cultivation only in a time of peace, Rongo became the God of Peace.  Tangaroa ruled over the Marine Department and hence was appealed to by deep-sea voyagers and fishermen.

The hunter-gatherer, or at least the pre-agriculturalist, as in Buck’s account, deifies the unpredictable, natural force in order to transform it into an entity with whom the hunter-gatherer can communicate.  This deified natural force, then, is bartered with to confer gifts to the hunter-gatherer.  When the hunter-gatherer supplicates to this deity, it provides him with a form of anxiety relief, insofar as he believes he is doing something productive to alleviate his stressful situation.  The deification, then, serves as a construct through which to habitually relieve anxiety when unpredictable situations in the natural world present themselves.

Appeal to deities, then, corresponds to the extent to which a primitive people need the services the deities control for livelihood.  What must happen if the deities do not oblige?  What if the dynamic power of nature is not forgiving?  This is the very thing the perpetuators of religion fear, for if the gods do not accept their prostrating, then it will be their death.  If the deified sky doesn’t give rain, if the deified tree does not bear fruit, if the volcano explodes in spite of the hunter-gatherers’ sacrifices they make at his feet, they face the prospect of potential imminent mortality.  The origin of religion, then, can be seen as an attempt for the hunter-gatherer to acquire some kind of control over his own mortality in the face of an unpredictable, natural world.

Terror Management Theory

This explanation of the origin of religion posits that fear and uncertainty as a result of chaotic natural processes prelude the conceptualization of an abstracted higher power that symbolizes these processes.  This is precisely what is predicted by what is known as Terror Management Theory, which states that the evolution and acceptance of a shared cultural world view has provided a means by which humans cope with the existential anxiety created by death awareness:

TMT starts with the proposition that the juxtaposition of a biologically rooted desire for life with the awareness of the inevitability of death (which resulted from the evolution of sophisticated cognitive abilities unique to humankind) gives rise to the potential for paralyzing terror. Our species “solved” the problem posed by the prospect of existential terror by using the same sophisticated cognitive capacities that gave rise to the awareness of death to create cultural worldviews: humanly constructed shared symbolic conceptions of reality that give meaning, order, and permanence to existence; provide a set of standards for what is valuable; and promise some form of either literal or symbolic immortality to those who believe in the cultural worldview and live up to its standards of value. Literal immortality is bestowed by the explicitly religious aspects of cultural worldviews that directly address the problem of death and promise heaven, reincarnation, or other forms of afterlife to the faithful who live by the standards and teachings of the culture. Symbolic immortality is conferred by cultural institutions that enable people to feel part of something larger, more significant, and more eternal than their own individual lives through connections and contributions to their families, nations, professions, and ideologies (Solomon, et al., In Press).

This theory predicts that when the salience of mortality awareness is increased in an individual, such as in the situation of resource scarcity, then the individual responds by reinforcing his worldview.  In the case of a hunter-gatherer, this might mean a reaffirming of religious beliefs and a corresponding increase in religious ceremony and appeal to the gods.  In the context of a modern society, this reinforcement of worldview is verified by empirical studies (Solomon, et al., 1997).

One such study, by Altran and Norenzayan (2004), exposed subjects to different stories.  Each story began the same, a narrative of a day of the life of a boy.  Each progressed in different directions, one of a religious nature, one that intimately discussed the death of a person, and one that was neutral and mundane.  Following each story, subjects were asked to divulge the extent of their belief in God through a questionnaire.

The results clearly show that when exposed to the story about a death, the subjects had a significantly strengthened belief in God.  In a separate study, the same thing story scenario was played out, but then, the subjects were given a questionnaire regarding their strength of belief in supernatural power of prayer.

Again, the same sorts of results were gleaned.  Each study provides substantial evidence for the reality of Terror Management Theory.

Terror Management Theory, therefore, holds as a scientifically validated theory: religion is characterized fundamentally as a reaction to anxieties related to death in an uncertain world.  If shamanism is considered the epitome of religious experience in a hunter-gatherer society, shamanism must be inextricably related to these gross mortality anxieties facing the hunter-gathering man in an uncertain world.  Indeed, a large part of the shamanic initiation rituals involves the hallucination of dismemberment, death, and rebirth.

If schizophrenia parallels shamanism, then the etiology of schizophrenia should also be characterized by stress and anxiety.  In order to determine this, the etiology of schizophrenia must be elucidated.

Etiology of schizophrenia

There is widespread consensus that there is a genetic component of schizophrenia, with estimates of heritability around 80% (Owen, et al., 2003).  These estimates correspond well with psychiatric practicioners’ and researchers’ knowledge, and they suggest a significant environmental influence on the genesis of schizophrenia (Rapaport, 2005).  Additionally, this degree of heritability is not contrary to observed ethnographic accounts of shamanistic heritability.  The model describing the interaction between this genetic component and the environmental influence in the etiology of schizophrenia is called the neurodevelopmental model.

The neurodevelopmental model, while recognizing the disorder’s vast heterogeneity (Sperner-Unterweger, 2005), postulates psychosis-predisposing neurophysiological alterations in early neurodevelopment (Murray and Lewis, 1987; Bullmore et al., 1998; McDonald et al., 1999) and activation of the psychotic condition through stressful events in late adolescence or early adulthood (Broome et al., 2005).  This neurodevelopmental model, in other words, proposes structural and/or biochemical changes in development, which predispose the individual to aberrant brain activity (psychosis) later in life.

A large body of studies of prenatal complications during neurodevelopment abound.  Rates of schizophrenia have been shown to be increased significantly among individuals exposed to prenatal famine (Susser and Lin, 1992).  Moderate to severe illnesses and infections, death of spouse, and experience of catastrophic events during prenatal periods have been shown to increase risk of schizophrenia in the cohorts studied (Cannon, 2005).  Indeed, in animal models, even mildly elevated maternal stress levels during prenatal development have shown to increase vulnerability to adverse life events (Hougaard, 2005).

Neurodevelopmentally, childhood is a critical moment and aberrant mental states at this time have shown to increase the risk of later development of schizophrenia.  It has been demonstrated that children that later develop schizophrenia are more likely than peers to show subtle developmental delays and cognitive impairments, as well as having the tendency to be solitary and socially anxious (Cannon et al., 2002).  Depression is both one of the first exhibited symptoms in most pre-schizophrenic individuals and is an extremely common comorbidity (a psychopathology that exists along with schizophrenia) (Cannon, 2005).  While up to 25% of all individuals in one study have been found to experience a psychotic symptom by age 26 (Poulton, et al., 2000), only 1% of all individuals actually progresses from this “prodromal” (pre-schizophrenic) symptomology to frank schizophrenia.  Indeed, depression has been theorized as a major factor in this transition (Escher, et al., 2002).

In adulthood, prolonged stress or depression in a predisposed individual can lead to a schizophrenic episode in neurophysiologically predisposed individuals (Murray and Lewis, 1987; Bullmore et al., 1998; McDonald et al., 1999; Cannon, 2005).  An interview with Robert Strong, MSW, a social worker from California yielded the observation that the majority of schizophrenics, directly prior to their psychosis, experienced either a chain of stressful events or one particularly traumatizing event.  He also indicated a pattern of childhood traumatic experiences, such as physical abuse.

The neurobiology of schizophrenia is extensively studied but not well understood.  The reduction in volume of various brain structures has been documented, as well as an increase in ventricular volume–the spaces within the brain between various brain structures, present in all individuals (McDonald et al., 1999; Wright et al., 2000).  The pituitary gland, a major component of endocrine function in the body, has been shown to be enlarged in first-episode schizophrenics, which has been explained to be indicative of hypothalamic-pituitary-adrenal axis (HPA) hyperactivation, which is the biochemical parallel of the stress response.  Higher blood cortisol concentrations are also demonstrated (Pariante, 2004a). These neuroendocrinological markers are also present in depressed patients and shown to exist in a host of other stress conditions (Pariante, 2004b), which reinforces the stress-induced psychosis hypothesis.

Ventricular spaces in schizophrenics are enlarged and the brain has been shown to be several percentage points smaller (Wright et al., 2000).  Excessive apoptosis (programmed cell death) and synaptic pruning (the loss of connections between neurons) during adolescence is postulated as an explanation, each of which normally happen but which happen in excess in schizophrenia (Jarskog et al., 2005).  Both the amygdala and the hippocampus, which together are responsible for maintaining the individual in emotional balance, are found to be reduced in volume by a mean of 5% in schizophrenic patients (Wright et al., 2000).  These two structures play a large role in regulating salience of incoming information.  In other words, they are responsible for determining what we pay attention to.  Dysfunction in these two limbic structures, or lack of regulation by the prefrontal cortex, can result in the dysregulation of dopamine, the principal neurotransmitter governing attention processes.  This dysregulation can cause emotional disturbances and information overload due to increased salience to innocuous information, leading to psychosis (Grace, 2004).  McGhie and Chapman (1961) quote a patient as stating, “My thoughts get all jumbled up…Things are coming in too fast.  I lose my grip and get lost.  I am attending to everything at once and as a result I do not attend to anything.”

Differing phenomenon, differing etiologies

Indeed, then, stress does play a critical role in the pathogenesis of schizophrenia, as would be predicted by the hypothesis of its genetic equivalence to shamanism.  Important, as well, are the religious and morbid ideations of schizophrenia.  According to my friend Robert Strong, MSW, a social worker in California, the vast majority of schizophrenics focus on atypical and intense religious experience.  What, then, differentiates the psychotic from the socially adjusted, albeit occasionally eccentric, shaman?

I argue that the divergence in etiology is grounded on differing socio-cultural environments.  The shaman’s unstigmatizing, encouraging, and accommodating to his pre-shamanic hysteria.  The schizophrenic’s is harsh, condemning, and alienating to his perceived psychopathology.  This disparity in etiology between schizophrenia and shamanism is what, in the case of schizophrenia, results in thought disorder, hallucinations, delusions and crippled socio-functionality, and what in the case of shamanism, results in the seeking of solitude, an occasionally nervous disposition, and the attunement to religious experience.  This is borne out by both psychoanalytic and neurobiological evidence.

Julian Silverman’s (1967) psychoanalytic approach perceives schizophrenia and shamanism as internal conflict resolution processes and outcomes that are either condoned or rejected by a given culture.  If condoned, these irresolvable conflicts are consolidated in the person’s psyche, and the new state of shamanism adheres to the expectations of culture while simultaneously serving as an escape mechanism to an acute and irresolvable conflict.  If rejected, contemporary culture denies the legitimacy of this process of escape, and so not only does the schizophrenic have the burden of an illegitimate thought process, but the schizophrenic is burdened by the anxiety resulting from a condemnation of self.  This, according to Silverman, aggravates the problem facing schizophrenics and significantly reduces their potential for a positive prognosis.  Ackerknecht (1943) anticipates Silverman’s psychoanalytic theory by asserting that “in primitive societies there perhaps exist outlets for mental conditions with which we are not able to deal.  It seems as if we will have to accept the fact that shamanism is not a disease but being healed from disease.”

Reinforcing Silverman’s interpretation is neurobiological data.  In an interesting animal analogy, a primate’s standing in the social hierarchy can influence occupancy at dopamine receptors.  Individually housed and socially subordinate macaque monkeys have high levels of synaptic dopamine, whereas those who are able to attain dominance in social housing are able to return to ‘normal’ dopamine levels.  Hence, living alone or being in a lower position in the social hierarchy may be, at least for macaque monkeys, associated with a hyperdopaminergic state (Morgan, 2002).  Clearly, this illustrates that the social condemnation of pre-shamanic behaviors could potentially exacerbate and transform these relatively benign characteristics into a full blown pathology.

Additionally, while a shaman can somewhat attenuate his initially aberrant mental state and high stress levels through the mastery of shamanic practices, the modern day schizophrenic has no such outlet.  Due to social stigma and isolation, the schizophrenic’s stress and anxiety is amplified, leading to hypercortisolism and depression (Steptoe, et al., 2004), two crucial components in the etiology of schizophrenia.

Conclusions

To summarize, I argue that stress and anxiety are critical not only to understanding the religious experience of a shaman but to understanding religion in general, with shamanism being but an expression of broader religion.  Furthermore, I argue that the stress-mediated activation of the schizophrenic condition is a functional adaptation of hunter-gatherer societies and their necessary religious practices.  In hunter-gatherer societies, this stress reflects a reminder of potential imminent mortality and serves to foment both the construction and reinforcement of religious belief.  This is predicted by Terror Management Theory and experimental studies have shown that the salience of mortality awareness significant correlates with the reinforcement of worldview.  The extent to which the threat of imminent mortality governs the lives of individual hunter-gatherers determines the reinforcement of religious worldview.

Therefore, I argue, this reinforcement of religious worldview also corresponds with increased insistency of religious ceremony as a means of catharsis and appeasement toward deified natural forces.  The degree of this insistence of religious ceremony determines the extent to which intense shamanic experience is necessary.  Consequently, the presence of stress as a result of hunter-gatherer uncertainty in subsistence is the direct cause of the selection for shamanism.

Particularly striking is the strong correlation between pre-natal famine and schizophrenia (Susser and Lin, 1992).  Is shamanic activation related to the routine exposure to famine?  This, again, is predicted by the model that shamans serve as communicators and appeasers of the gods and therefore the stressful situation imposed by potential imminent mortality.

Additionally, the religious experience itself is fundamentally distinct from any other sort of human cognitive function necessary for survival.  Hereditary, distinct, prevalent across cultures, highly functional in the context of hunter-gatherer societies, and behaviorally parallel to schizophrenia, shamanism has a genetic basis, and the persistence of its modern analogue, schizophrenia, can be explained on this basis.  Modern stress, a mime to the threat of imminent mortality (social stress is the predominant modern stress form), triggers the shaman genotype, but the development spirals out of control as the individual can find few outlets for shamanistic expression.  This, in turn, perpetuates schizophrenia.  The schizophrenic individual is pathologized, stigmatized, and thrown into insane asylums, a kind of man for which society no longer has a wholesome accommodating function.

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Afternote

While this paper raises several crucial problems, these can only be said to produce further knowledge by reframing and transcending them.  The problems addressed in this paper are central to the theoretical orientation of psychiatry in the 1960s–which I claim has not changed to the present day but rather only brought from latency to full fruition, to a large degree in 1980–and the orientation of late 20th century/early 21st century evolutionary theory.  Since the theoretical orientation discussed here comes from 1960s psychiatry–and this theoretical orientation not been advanced upon in spite of crucial difficulties in contemporary psychiatric theory–the theoretical orientation of this paper is inadequate: it is an incomplete perspective of psychiatry.  Future posts will seek to establish the claim that psychiatry has not changed its theoretical orientation in the 1960s, to establish what precisely that orientation is, and in doing so, overcome or at least make clear the reasons for some of its problems.