Richard J. McNally


On the roots of mental pathologies

Cover Interview of November 03, 2011

Some conditions arise from a core psychobiological dysfunction, scarcely affected by cultural context.  For example, Western sufferers of panic disorder misinterpret bodily sensations, such as skipped heartbeats, as signs of imminent catastrophe, such as cardiac arrest.  This process heightens fear, creating a vicious circle that culminates in panic.  Cambodian sufferers experience the same vicious circle of sensation, misinterpretation, fear, and panic, but their focus of concern, shaped by culture, differs.  Believing that wind as well as blood travels throughout the circulatory system, Cambodian patients react catastrophically to sudden neck stiffness, for example, believing that it signifies wind blockade that may cause a fatal stroke.  The psychobiological dysfunction in panic disorder seems invariant, whereas the cognitive focus of concern varies by culture.

In contrast, culture has greatly shaped how soldiers have experienced and expressed war-related psychiatric illness throughout history.  Although some symptoms, such as anxiety and nightmares, occur repeatedly throughout history, others occur only in certain places and times.  Although posttraumatic stress disorder first appeared in the DSM-III following the Vietnam War, many scholars believe that victims of shell shock and battle fatigue in World War I and II, respectively, actually suffered from PTSD, but under different names.

Inspection of the historical record tells a different story. Hallmark symptoms of PTSD, such as vivid, sensory recollections of trauma (“flashbacks”), were all but nonexistent among psychiatric casualties of combat until the Vietnam War.  Conversely, pseudoneurological symptoms, such as motor paralysis, were common among shell shock victims, but nearly disappeared in later wars.  The intersection of culture and history furnishes a range of ways that people experience and express the psychiatric consequences of combat.  This does not mean that PTSD is not “real.”  Rather, it implies that the sources of its reality are not purely biological.