[OB] Autism and the Kholins

[Jazzy Kandra]

It's been known for awhile that Renarin Kholin has autism, thanks to several WoBs on this topic. I believe its important to have characters that have autism in fiction, but this isn't exactly what this topic is about...

Thanks to Renarin's view point in Oathbringer, we now have a pretty good idea how his autism effects him. He is sensitive to sounds, uncomfortable at large gatherings of people (because of the noise and sound), unable to meet the eyes of others most of the time, and uncomfortable with being touched by those who aren't a part of his family. However, we've talked about this a lot already throughout the years, though this book reveals that Renarin is what many would diagnosis as Extremely High Functioning based on his symptoms and how he views the world (1). There is something more important that Oathbringer reveals, I believe.

Jasnah is on the Spectrum or has a related disorder (such as ADHD).

Quote

Suddenly they were young again. He was a trembling child, weeping on her shoulder for a father who didn’t seem to be able to feel love. Little Renarin, always so solemn. Always misunderstood, laughed at and condemned by people who said similar things about Jasnah behind her back.

Oathbringer, 1132 (emphasis mine)

While one might say this is related to what Dalinar refers to "her lunacy" (493) in one of the Flashbacks, and the earlier (473), when Jasnah recalls a childhood illness -

Quote

Glimmers of memory from a dark room, screaming her voice ragged. A childhood illness nobody else seemed to remember, for all it had done to her. It had taught her that people she loved could still hurt her.

Oathbringer, 478

- which she then says caused her to lose her mind. I don't believe that is all. In WoR, Navani stated that Jasnah was distant even as a child, and came off as someone who was already in their thirties. Often times, those who were diagnosed with Asperger's (which is not exactly the same as extremely high functioning autism, though many will tell you otherwise) in the 90s and 2000s before the DSM-5 was released in 2013, were described as "little professors". This is what I think that Jasnah was like growing up from the in-book descriptions. Plus, Jasnah is off compared to characters who are more neurotypical, like Adolin or Navani. She is really only close to her family (and Shallan to some extent), doesn't express herself openly (she's often seen as stoic and stern by outsiders, solemn), and is highly focused on her special interests (the Desolations and history). These are traits found in those with Autistic Spectrum Disorder (ASD), though I think that Jasnah either has Aspergers or Pervasive developmental disorder (PDD-NOS), which is a diagnosis given to those who have some, but not enough of the traits, for a standard ASD-diagnosis (under the DSM-4).

This isn't just important because it could mean there is another character with autism in the cosmere, it also would say something about the Kholins themselves. ASD commonly runs in families, and with Jasnah being autistic, having Asperger's, or at least, PDD-NOS (that is, some autistic traits), it means that ASD runs in the Kholins. This is important to me, because it runs in my family (both my siblings and a few of my cousins), and that is something I haven't seen done in fiction before. It's awesome, and I hope it's true because I haven't seen families like mine represented in fiction.

And that is super meaningful to me.

(I will bring up the diagnosis definitions later if people ask, but I have to do some chores and things, so please be patient with me. I'll get back to it, promise).

Edited November 19, 2017 by Jazzy-Kandra

[aemetha]

I think Jasnah is a good fit to the symptoms of obsessive-compulsive personality disorder (not to be confused with obsessive compulsive disorder), except that she (from what we've seen) doesn't meet the criteria for significant impairment or distress to be diagnosed with a mental disorder. I think it's a better fit than Aspergers because Jasnah, while obviously not being particularly sociable is unsociable by choice, not by impairment.

Here's a pretty good description of the disorder from http://albertellis.org/personality-disorders/

Quote

Obsessive-Compulsive Personality Disorder (OCPD): Beginning by early adulthood, people with Obsessive-Compulsive Personality Disorder (OCPD) display a persistent preoccupation with themes of order and control. Their perfectionism and focus on organization frequently interferes with their ability to complete tasks effectively or enjoy leisure pursuits. Peers might describe individuals with this disorder as inflexible, stubborn, or closed-minded. Other common features may include “workaholic” tendencies, hoarding, and unwillingness to delegate responsibility to others. OCPD differs from Obsessive-Compulsive Disorder (OCD) because it reflects a general personality style and does not involve specific obsessions or compulsions.

Regarding the childhood illness, pretty much every mental illness can be explained in the diathesis-stress model. A traumatic childhood experience very often leads to the development of a mental disorder in later life. The Kholins (having three "broken" members that we know of) certainly suggests a hereditary diathesis, in Jasnah's case combined with the childhood illness led to a mental disorder that opened her up to becoming Radiant.

[Argent]

Oh, that's interesting! If autism (autistic disorders?) runs in families - which I don't dispute, I just didn't know that - then put another Kholin at least a little bit on the spectrum not only makes sense, it also makes Renarin's condition appear as less of a token and more as an organic character element. Which is fantastic.

[Mulk]

7 hours ago, Argent said:

Oh, that's interesting! If autism (autistic disorders?) runs in families - which I don't dispute, I just didn't know that - then put another Kholin at least a little bit on the spectrum not only makes sense, it also makes Renarin's condition appear as less of a token and more as an organic character element. Which is fantastic.

There pretty much has to be a genetic component to it given 3-4 boys get it for every 1 girl.

My oldest is, and when he was diagnosed the doc was quick to assure us that one child on his own doesn't make a pattern.  If we'd had more than one, it'd be a different story.  My other two are not.

You can probably guess that Renarin is pretty important to me as well.  My wife too. I loved his little moments in the sun in this book and I admit to freaking a bit when I thought Jasnah might kill him.

[Jazzy Kandra]

8 hours ago, aemetha said:

I think Jasnah is a good fit to the symptoms of obsessive-compulsive personality disorder (not to be confused with obsessive compulsive disorder), except that she (from what we've seen) doesn't meet the criteria for significant impairment or distress to be diagnosed with a mental disorder. I think it's a better fit than Aspergers because Jasnah, while obviously not being particularly sociable is unsociable by choice, not by impairment.

That is not always the case, it depends on the person, and sometimes the choice of being unsociable is encouraged by early childhood social impairment. From a diagnosis point of view, how Jasnah was as a kid is what matters here since some people can easily pass as neurotypical as adulthood. Autism is a developmental disorder, and every case is different. That doesn't mean she can't also have something like OCPD, but I think she has a mild ASD as a comorbid trait (or just an ASD).

Just because an adult handles social situations easier than a kid, doesn't mean that they didn't have a difficult time as a kid when dealing with social situations. We don't know, but I think her ostracization (which she says both Renarin and her felt) is a big clue that she DID have some difficulty in social situations. Secondly, women/girls are often misdiagnosed or just...not diagnosed because it can present differently in girls. Plus, not all people with ASD have a lot of social impairment. My sister does, my brother doesn't, my cousin (who also is autistic) is very social and has a lot of friends. It depends on the person, because ASD is a spectral disorder.

Edited November 19, 2017 by Jazzy-Kandra

[aemetha]

5 minutes ago, Jazzy-Kandra said:

women/girls are often misdiagnosed or just...not diagnosed because it can present differently in girls.

This is an astute point. Diagnosing an ASD in women is absolutely more difficult in females than men because the symptoms women present are quite different and more in conformity with societal norms. I do also know several women that meet this definition. My personal definition hinges more on the point that Jasnah's social withdraw according to the POV aspects and observations of her behaviour is more the result of conscious choice rather than impairment. She makes her choices knowing she will be ostracised for them, not because she is not capable of the social interactions necessary to fit within societal norms. ASD is largely not viewed as a handicap overall, but it is a misnomer to assume that a sufferer is as capable of applying societal norms to their circumstance as a more normally ordered person. The may well exceed at aspects such as numerology and mathematics, but impairment occurs in issues such as social interactions. This is not a choice for someone on the ASD, but it is a choice for someone metally disordered along the OCPD spectrum.

[Jazzy Kandra]

9 minutes ago, aemetha said:

This is an astute point. Diagnosing an ASD in women is absolutely more difficult in females than men because the symptoms women present are quite different and more in conformity with societal norms. I do also know several women that meet this definition. My personal definition hinges more on the point that Jasnah's social withdraw according to the POV aspects and observations of her behaviour is more the result of conscious choice rather than impairment. She makes her choices knowing she will be ostracised for them, not because she is not capable of the social interactions necessary to fit within societal norms. ASD is largely not viewed as a handicap overall, but it is a misnomer to assume that a sufferer is as capable of applying societal norms to their circumstance as a more normally ordered person. The may well exceed at aspects such as numerology and mathematics, but impairment occurs in issues such as social interactions. This is not a choice for someone on the ASD, but it is a choice for someone metally disordered along the OCPD spectrum.

I understand, but I'm forced to agree. As again, the amount of social impairment that a person has in an ASD depends on the person. Some nearly have none, and in the case of a diagnosis like PDD-NOS which can include a diagnosis with minimal to no social impairment at all.

Though, really, the only way to know for sure is either via WoB or...in twenty years when we get her flashbacks.

Edited November 19, 2017 by Jazzy-Kandra

[aemetha]

Absolutely agree with that. Our POV interactions with Jasnah are quite limited. Seeing where Brandon takes her is absolutely crucual to understanding where she came from.

[I Am Witless]

12 minutes ago, Mulk said:

There pretty much has to be a genetic component to it given 3-4 boys get it for every 1 girl.

Or is it that fewer girls are diagnosed than boys because there have been few to zero studies of female aspergers? Female aspies are also less noticeable than male because they are less likely to go "train-spotting". Their behavior doesn't stick out as much because they focus on more socially acceptable things (like a boy-band) than males do (train-spotting, obsession lego building). Female aspies also imitate different persona's to fit in with the crowd. I'm not talking slight changes in interactions between friends and employers, I mean huge transitions, like Shallan skipping between Veil and Radiant. Jasnah, as far as we've seen, seems to be pretty constant in who she is and who she views herself to be, so I'm not sure about her being an aspie. Jasnah does focus pretty heavily on her research, but that heavy focus can be passed off as her occupation. If Jasnah is autistic, I think that she has either used a crapload of self control to beat the "strangeness" out of herself, or she recluses herself away so that not that much of it shows.

[Jazzy Kandra]

4 minutes ago, I am Witless said:

Or is it that fewer girls are diagnosed than boys because there have been few to zero studies of female aspergers? Female aspies are also less noticeable than male because they are less likely to go "train-spotting". Their behavior doesn't stick out as much because they focus on more socially acceptable things (like a boy-band) than males do (train-spotting, obsession lego building). Female aspies also imitate different persona's to fit in with the crowd. I'm not talking slight changes in interactions between friends and employers, I mean huge transitions, like Shallan skipping between Veil and Radiant. Jasnah, as far as we've seen, seems to be pretty constant in who she is and who she views herself to be, so I'm not sure about her being an aspie. Jasnah does focus pretty heavily on her research, but that heavy focus can be passed off as her occupation. If Jasnah is autistic, I think that she has either used a crapload of self control to beat the "strangeness" out of herself, or she recluses herself away so that not that much of it shows.

Eh. That can be the case, but once again, it depends on the aspie or girl with autism. My sister doesn't change personas, and I've also known other girls on the spectrum who don't. To name someone from the cosmere who doesn't fit into that idea, Steris is pretty solid, even though she practices jokes and things to fit in. We don't see her changing personas, and she's actually hyperaware of her differences...

[aemetha]

2 minutes ago, Jazzy-Kandra said:

To name someone from the cosmere who doesn't fit into that idea, Steris is pretty solid, even though she practices jokes and things to fit in. We don't see her changing personas, and she's actually hyperaware of her differences.

Right. Any disorder in the DSM has to meet the minimum qualification of being impaired or distressed or suffering. If that is absent, it is not a disorder. It might be a handicap, but it is not a disorder. You can be ASD spectrum without meeting the minimum deviation from a norm to be disordered. And even then, you may not be disordered unless you are assessed in the context of your own cultuire.

[emailanimal]

I did not take Jasnah's thoughts about people saying similar things behind her back as a reference to a similar mental condition.  It has been established that both of them, for different reasons, stood out and did not fit the traditional roles of high-born nobility of respective genders in Alethi society.  Renarin's other ailment (the epilepsy?) is probably the real reason why his was subjected to such treatment (this is a condition with overt and observable symptoms, unlike his autism spectrum condition).

 

As for Jasnah... I do not  perceive her as being on the autism spectrum, nor do I think she has Asperger's.  I would like to find out more about what happened to her when she was six, but it appeared to be something else entirely. Her thoughts on this matter and Dalinar's thoughts about it seem to match - it appears to have been a really unpleasant episode. However, the short conversation between Dalinar and Navani ("how did you mother her?" "by not letting her feel that she is being mothered")  omits any references to it - perhaps Navani is thinking of a much older Jasnah (teenage years).  Jasnah's flashbacks probably won't come for another 20 years or so. Makes me feel really old )-:

[MoS03]

I think Jasnah is just smart, really smart, and is similar to Taravangian on a smart day.  Someone can be smart and overly logical without having some kind of "disorder".

[aemetha]

10 hours ago, MoS03 said:

Someone can be smart and overly logical without having some kind of "disorder".

Yes and no. That depends on the cultural norms.

Mental disorders are largely social constructs. They are defined by behaviour that falls outside the norms of accepted social behaviour and which causes impairment or suffering. Schizophrenia for example is rarely considered a disorder in certain cultures where hallucinating is considered a blessing. That doesn't make it not a disorder in a culture that doesn't value those same features of the disorder.

That's not to be mistaken of course for there being physically no difference in the individuals neural circuitry. All mental disorders and behaviours consistent with mental disorders by the definitions of a particular culture have structural differences in neural functioning. That's just the way the brain works, learning physically alters the structure of the brain, and so learning disordered behaviours results in physical differences.

So yes, a person can be very intelligent and logical, without being considered disordered in the context of a culture which views intelligence and logic as normal and not impairing at all. If her behaviours and thoughts fall outside the norms of the culture she would be considered disordered. Whatever affects Jasnah though, would be considered a disorder somewhere, or perhaps even most places - because she is broken. A person can only access investiture if they are broken, and in all cases we've seen so far that involves a measure of impairment and suffering.

• Kaladin - Seasonal affective disorder. Perfectionism that is unreasonable and impairing.
• Shallan - Repressed memories. Psychotic breaks. Fractured personality.
• Dalinar - Early Dalinar is very consistent with antisocial personality disorder. Later Dalinar is overcome with grief and guilt.
• Renarin - Autism. Severely impaired social skills.
• Lift - Oh dear, where to start with this one? She thinks her spren is a voidbringer, is a kleptomaniac, continually looks for potentially fatal situations and never wants to grow up.

The same applies to people of other worlds who access investiture. There is always something that could be defined as a disorder. In some cases they learn to cope well with it, but it's still there.

 

[Fifth of Daybreak]

10 hours ago, MoS03 said:

I think Jasnah is just smart, really smart, and is similar to Taravangian on a smart day.  Someone can be smart and overly logical without having some kind of "disorder".

This seems to be a Nightwatcher thing, not a general people thing.

Quote

He’d asked for the capacity to save his people. He’d begged for compassion and acumen—and he’d gotten them. Just never at the same time.

122 Debt Repaid.

 

[Leyrann]

20 hours ago, Argent said:

Oh, that's interesting! If autism (autistic disorders?) runs in families - which I don't dispute, I just didn't know that - then put another Kholin at least a little bit on the spectrum not only makes sense, it also makes Renarin's condition appear as less of a token and more as an organic character element. Which is fantastic.

Either I have a very special family, or it indeed runs in families... But it's a good thing, as my family typically understands me a lot better than non-autistic people do (even though I try my best ).

21 minutes ago, aemetha said:

Mental disorders are largely social constructs.

As an autist, I disagree. I am simply worse at social contact than most people, and I actually spend quite a bit of my time (most that isn't used for gaming, study, discussing Cosmere or writing) just thinking about how to handle social contact. It's something I've learned to do subconsciously, just playing out conversations in my mind, because if I don't practise it, I just can't manage to have conversations with people without autism, as I simply don't have the social skills needed for that. Yes, I can manage to have friends and a life and everything, but it does not come nearly as easy as for most people. I am worse at social contact than other people, and therefore autism is not a social construct. Yes, you could argue that "autists" are simply the edge of the spectrum of "ability to have social contact", but that doesn't make it any less real. Calling something a construct implies that it doesn't actually exist, and that's just not true.

Okay, I think that's enough rant, hope my intention got through even though it's a mess of a paragraph.

[aemetha]

@Leyrann I think you misunderstand my point. I am absolutely not saying that the suffering or impairment you experience isn't real. Quite the opposite actually.

What I am referring to here is that whether you are considered "disordered" is defined by your cultures norms. Thought and behaviour just is, it needs no labelling. We label patterns of thoughts and behaviours that are inconsistent with the majority of our culture as disordered so we know who needs help, or to explain their behaviour in the context of the majority of the culture.

If you take a disordered person from American culture, who experiences hallucinations and placed them into a traditional Maori culture, unless they are having particular difficulty as a result of their hallucinations, they would no longer be considered disordered. American culture considers hallucinations to be a serious deviation from cultural norms. Maori culture considers it to be a blessing. The actual labelling of a person is therefore a social construct. At no point does it change the fact that the person suffers hallucinations or anything else about them, it simply changes the social context.

[Fifth of Daybreak]

23 minutes ago, aemetha said:

@Leyrann I think you misunderstand my point. I am absolutely not saying that the suffering or impairment you experience isn't real. Quite the opposite actually.

What I am referring to here is that whether you are considered "disordered" is defined by your cultures norms. Thought and behaviour just is, it needs no labelling. We label patterns of thoughts and behaviours that are inconsistent with the majority of our culture as disordered so we know who needs help, or to explain their behaviour in the context of the majority of the culture.

If you take a disordered person from American culture, who experiences hallucinations and placed them into a traditional Maori culture, unless they are having particular difficulty as a result of their hallucinations, they would no longer be considered disordered. American culture considers hallucinations to be a serious deviation from cultural norms. Maori culture considers it to be a blessing. The actual labelling of a person is therefore a social construct. At no point does it change the fact that the person suffers hallucinations or anything else about them, it simply changes the social context.

If there are hallucinations there is an underlying pathophysiology that can be measured with an EEG and diagnosed. I'm not sure I agree with this from a medical standpoint. There are definitely proven pathophysiologies for mental and behavioral disorders. There are certain specific instances where else might agree on this, but changing culture doesn't change underlying medical conditions.

Edited November 19, 2017 by Fifth of Daybreak

[aemetha]

3 minutes ago, Fifth of Daybreak said:

I'm not sure I agree with this from a medical standpoint. There are definitely proven pathophysiologies for mental and behavioral disorders

This is true in the biomedical model of mental disorders. The biomedical approach is heavily criticised as not including enough attribution of psychological and social factors and the biopsychosocial model attempts to address that. There are underlying pathophysiologies for every single aspect of thought and behaviour. Thinking structurally changes the brain. The brain is a plastic organ that constantly reinvents itself in response to how it is used.

Put another way though, one can be neurologically disordered in the view of a medical doctor without being considered mentally disordered in the view of a psychologist. One is about having a brain structure that is abnormal and impairing, the other is about having a thought process that is abnormal and impairing. A psychologist would ask, does the hallucination cause significant suffering and impairment in the psychosocial environment of the person? If not they aren't disordered. A neurologist would ask, is the structure of the brain causing abnormalities? If so they would be disordered.

[Calderis]

9 minutes ago, Fifth of Daybreak said:

If there are hallucinations there is an underlying pathophysiology that can be measured with an EEG and diagnosed. I'm not sure I agree with this from a medical standpoint. There are definitely proven pathophysiologies for mental and behavioral disorders. There are certain specific instances where else might agree on this, but changing culture doesn't change underlying medical conditions.

That's not what @aemetha is saying.

The physiological reasons are there, regardless of where a person lives. 

Their classification as "disordered" or abnormal will change though, depending on what the culture accepts. That's has zero bearing on the underlying cause. 

[Fifth of Daybreak]

21 minutes ago, aemetha said:

A psychologist would ask, does the hallucination cause significant suffering and impairment in the psychosocial environment of the person? If not they aren't disordered. A neurologist would ask, is the structure of the brain causing abnormalities? If so they would be disordered.

I think we might be arguing over specific definitions here. I find it hard to believe that a psychologist would argue that hallucinations would not have a disorder associated. Not a behavioral impairment, but physicians do the same thing all the time. I diagnosed myself with a heart disorder, but had to prove to the cardiologist it was symptomatic before they would treat it, that doesn't mean there wasn't an underlying disorder if it didn't cause me symptoms and wasn't worth treating. Being asymptomatic does not dismiss an underlying disorder.

Maybe I'm not understanding the biopsychosocial approach. Do you have any sources you'd recommend?

20 minutes ago, Calderis said:

Their classification as "disordered" or abnormal will change though, depending on what the culture accepts. That's has zero bearing on the underlying cause. 

'Disorder' has a very specific definition that is unchanged by cultural perceptions of those underlying pathophysiological processes.

Edited November 19, 2017 by Fifth of Daybreak

[aemetha]

1 minute ago, Fifth of Daybreak said:

Do you have any sources you'd recommend?

Well, I'm in New Zealand and my source for that particular bit is my Australia/New Zealand psychology text.

2 minutes ago, Fifth of Daybreak said:

I find it hard to believe that a psychologist would argue that hallucinations would not have a disorder associated.

Well, this kind of gets to the crux of the debate. In America (I'm assuming you're in America?) or in fact most western cultures, a psychologist is very unlikely to argue that, because in the context of that culture someone experiencing hallucinations is disordered.

The example I gave of hallucinations is one that was given in one of my counselling classes. Historically western mental health approaches have been very detrimental to Maori culture, and there is now recognition that Maori are better served with a culture-specific health framework called Te whare tapa wha. Spiritual concepts are included in this framework, which is where the issue of hallucinations is viewed very differently. A Maori psychologist treating Maori clients would be very hesitant to pronounce someone disordered solely on the basis of experiencing hallucinations, there would need to be impairment and suffering to make that leap.

[Fifth of Daybreak]

@aemetha I'm an American, and Midwest at that, so I'm especially insulated from anything except Hispanic culture. I'm going to remove myself from the conversation for now and do some research. You've given me a great starting off point. I'll come back when I feel like I've got a better understanding of the concepts. Thanks for being patient with me.

[Fifth of Daybreak]

Finished researching, sorry for double posting. I also have a bit more time to be more specific in my disagreement 

2 hours ago, aemetha said:

This is true in the biomedical model of mental disorders. The biomedical approach is heavily criticised as not including enough attribution of psychological and social factors and the biopsychosocial model attempts to address that

So from my understanding of the biopsychosocial model, both in mental Disorders and broader medicine, it's not about diagnosis criteria and is more about addressing the broader range of variables that affect treatment and patient outcomes. As I said in the bottom of my earlier post, there are certain mental health situations where I would likely agree there isn't a underlying pathophysiology, but hallucinations have an underlying pathophysiology that causes audio/visual input to the brain that is not caused by outside stimuli. Western medicine, in the broader sense, is not rejecting biopsychosocial approaches to medicine, in fact, as a paramedic, part of my training is to look for signs of some of those behavioral and social factors as one of the only care providers who sees patients in their homes.

2 hours ago, aemetha said:

There are underlying pathophysiologies for every single aspect of thought and behaviour. Thinking structurally changes the brain.

This is not something I agree with, however, your statement leads me to believe you are confusing pathophysiology with physiology.

Physiology is the normal functions of the body whereas pathophysiology is the disordered physiological process associated with disease or injury. Structural changes to the brain as a result of outside stimuli is a physiological response, not a pathophysiology. (It's a feature not a bug.) An example of a pathophysiology would be the occlusion of a blood vessel in the brain from an embolus in a stroke, causing reduced blood flow to the brain.

2 hours ago, aemetha said:

A psychologist would ask, does the hallucination cause significant suffering and impairment in the psychosocial environment of the person? If not they aren't disordered. A neurologist would ask, is the structure of the brain causing abnormalities? If so they would be disordered.

My main problem with this is the use of the term 'disordered.' it implies a medical definition that does not, to my knowledge, exist. Both clinicians would address symptoms and look for a root cause. I don't think either would argue with each other that there is an underlying pathophysiology causing the hallucinations. Can you explain what you mean by calling someone "disordered?" 

 

2 hours ago, aemetha said:

or in fact most western cultures, a psychologist is very unlikely to argue that, because in the context of that culture someone experiencing hallucinations is disordered.

Here again, I'd like to know what you mean specifically by calling someone disordered. The basic definition is a disruption of normal physical or mental functions; a disease or abnormal condition. I cannot fathom a clinician who believes that their patient is experiencing true audio and visual hallucinations and does not have an underlying disorder.

2 hours ago, aemetha said:

A Maori psychologist treating Maori clients would be very hesitant to pronounce someone disordered solely on the basis of experiencing hallucinations, there would need to be impairment and suffering to make that leap.

I guess I don't understand here, and would need a specific case study to fully engage. If someone experiencing hallucinations approaches a psychologist for treatment, I assume there is some impairment. 

 

Does your text give specifics for why the hesitancy? We aren't completely culturally tactless in the US. We don't just tell people who may say that they believe AV hallucinations have a spiritual origin that they are wrong, but our hesitancy comes more from a patient advocacy side as we don't want to break the trust between caregiver and patient and want to ultimately help them by getting past those trust barriers where we can aggregate all the information available to make a complete diagnosis without making the patient feel as though we are dismissing their spiritual beliefs, and then if we see other associated symptoms, we tactfully broach the subject. It also is important to have an understanding of those underlying cultural norms to separate what may be "true AV hallucinations" and what may be religious experiences that are similar in nature. I think it's important that even in these cultures, there are cases where they demonstrate a clear understanding of what demonstrates religious experiences and what constitutes hallucinations. By using the word "hallucinations," it leads me to the assumption that the pt is experiencing "true AV hallucinations" recognized within the culture as abnormal. (https://priceonomics.com/how-culture-affects-hallucinations/) if that's not your intention there, I apologize for misunderstanding. 

 

As far as the biopsychosocial model vs miomedical model for treatment of mental Disorders, I do lean that way, and I wasn't trying to imply that medication is the only way to treat mental disorders. I personally don't treat my own clinical depression with medication, preferring to focus on behavioral and social aspects (I haven't had much luck changing internally through mental exercises.)

 

I was very interested in how the social response to mental illness seems to have a large effect on whether the symptoms were positive or negative, is this possibly what you were getting at? Spoiler for length

Spoiler

In 2014, Tanya Luhrmann and a research team published a study in which they interviewed three groups of twenty people from three different countries. One group was in San Mateo, California; another was in Chennai, India, and the third was in Accra, a city in Ghana. All sixty participants were diagnosed with schizophrenia, and regularly had auditory hallucinations.

One thing they found was -- consistent with prior research -- almost all of the American subjects labeled themselves as ‘crazy’. “[A]ll but three spontaneously described themselves as diagnosed with ‘schizophrenia’ or ‘schizoaffective disorder,’” the paper reads, “and every single person used diagnostic categories in conversation.” In contrast, only four of twenty South Asian subjects used the term ‘schizophrenia,’ and only two of the African patients did. From the paper:

"Although many of the Accra participants understood that hearing audible voices could  be a sign of a psychiatric illness, their social world accepts that there are human-like non-embodied spirits that can talk. ‘Voices [are] spirits,’ one man explained."

Another thing they found was that the subjects in India and Ghana were “not as troubled by the presence of voices they could not control.” And this made sense because the Americans’ hallucinations seemed much more aggressive and violent. Fourteen of the American subjects said their voices encouraged them towards violence (to themselves or others). One described, “Usually, it’s like torturing people, to take their eye out with a fork, or cut someone’s head and drink their blood, really nasty stuff.” Only three Indian subjects said their voices encouraged violence, and only two African subjects.

A man and a woman in Accra, (photo by Adam Cohn)

The African subjects tended to hear God’s voice but, much more than the American’s subjects who a voice as “God’s”, they saw God as their protector. In both the African and Indian group, subjects were more likely to have developed relationships with their voices. More than half of the Indian subjects heard the voices of family members, and most of their voices commanded them towards domestic tasks. (This is in stark contrast to the American subjects -- only two of them heard “family members”, and those cases were complicated. oth these were women molested by [a family member] who heard their (negative) molester’s voice.”)

Five of the Indian subjects had predominantly positive voice-hearing experiences, and a 10 of the African subjects did (fifty percent of the sample). Some even insisted that they had onlypositive interactions with the voices. Not one American reported a predominantly positive experience.

Even still, the issue here isn't that, culturally, they don't have underlying disease processes defined or diagnosed, but that the associated symptoms are positive, and so the biopsychosocial model again here demonstrates not a reluctance to diagnose, but rather that the way diagnosis and cultural response to the symptoms and the diagnosis has a large effect on patient disposition and outcomes. 

Edited November 19, 2017 by Fifth of Daybreak

[Erunion]

@Fifth of Daybreak, @aemetha - can I just say that I love how this book is getting people to nerd out about bio psychology and how it relates to the main characters?