Culture-Bound Psychiatric Disorders

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Culture-Bound Psychiatric Disorders
Can DSM diagnostic criteria be applied cross-culturally?
A relativist-universalist debate has emerged in cross-cultural studies of psychopathology.
Relativists argue that diagnostic systems are culturally specific and that therefore the
DSM is inherently ethnocentric. The universalists, on the other hand, argue that there are
psychiatric disorders whose symptomatology is invariant from culture to culture.
As is often the case in such debates, evidence supports a middle position between the
extremes. Studies of prevalence rates in various cultures show that the major forms of
mental illness--schizophrenia, depression, and bipolar disorder--are found in all cultures.
Some behaviors are regarded as disturbed regardless of culture. However, there is also
evidence of “culture-bound” syndromes found only in specific cultures.
Specific changes have been made in the DSM-IV to enhance its cross-cultural
applicability. In recognition of the fact that its system of evaluation is applied to
culturally diverse populations in the United States and internationally, the authors include
the following general cautionary note:
A clinician who is unfamiliar with the nuances of an individual’s cultural frame of
reference may incorrectly judge as psychopathology those normal variations in
behavior, belief, or experience that are particular to the individual’s culture. For
example, certain religious practices or beliefs (e.g., hearing or seeing a deceased
relative during bereavement) may be misdiagnosed as manifestations of a Psychotic
Disorder (p. xxiv).
Included under each diagnostic disorder is a new section which describes the available
information on prevalence rates within particular cultures and the ways in which varied
cultural contexts influence both the content and form of the symptoms presented. For
example, in the discussion of Obsessive-Compulsive Disorders, one finds the following:
Culturally prescribed ritual behavior is not in itself indicative of ObsessiveCompulsive Disorder unless it exceeds cultural norms, occurs at times and places
judged inappropriate by others of the same culture, and interferes with social role
functioning. Important life transitions and mourning may lead to an intensification of
ritual behavior that may appear to be an obsession to a clinician who is not familiar
with the cultural context (p. 420).
In the discussion of Major Depressive Episodes, the preferred cultural idioms for
expressing the particular distress are also noted:
Culture can influence the experience and communication of symptoms of
depression....For example, in some cultures, depression may be experienced largely in
somatic terms, rather than with sadness or guilt. Complaints of “nerves” and
headaches (in Latino and Mediterranean cultures), of weakness, tiredness, or
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“imbalance” (in Chinese and Asian cultures), of problems of the “heart” (in Middle
Eastern cultures), or of being “heartbroken” (among Hopi) may express the
depressive experience (p. 324).
A second new feature in the DSM-IV is a listing of specific culture-bound syndromes.
These are disorders identified and described in specific societies or cultural areas. It is
important to recognize, however, that these syndromes are not simply to be understood as
diagnostic categories of limited distribution. As the authors note, these “are localized,
folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned,
and troubling sets of experiences and observations” (p. 844). In other words, the culturespecific syndromes involve a qualitatively different, contextualized approach to the
symptoms of distress. They are identified and understood (and therefore traditionally
treated) in light of the specific context of culturally prescribed meaning.
For example, in collectivist cultures like Japan, being shamed or disgraced functions as a
basis for abnormal reactions. The culturally distinctive phobia taijin kyofusho “refers to
an individual’s intense fear that his or her body, its parts or its functions, displease,
embarrass, or are offensive to other people in appearance, odor, facial expressions, or
movements. This syndrome in included in the official Japanese diagnostic system for
mental disorders” (p. 849).
Other culture-bound syndromes listed in DSM-IV include:
brain fag: A term initially used in West Africa to refer to a condition experienced by
high school or university students in response to the challenges of schooling. Symptoms
include difficulties in concentrating, remembering, and thinking. Students often state that
their brains are “fatigued.” “Brain tiredness” or fatigue from “too much thinking” is an
idiom of distress in many cultures (p. 846).
ghost sickness: A preoccupation with death and the deceased (sometimes associated
with witchcraft) frequently observed among members of many American Indian tribes.
Various symptoms can be attributed to ghost sickness, including bad dreams, weakness,
feelings of danger, loss of appetite, fainting, dizziness, fear, anxiety, hallucinations, loss
of consciousness, confusion, feelings of futility, and a sense of suffocation (p. 846).
koro: A term, probably of Malaysian origin, that refers to an episode of sudden and
intense anxiety that the penis (or, in females, the vulva and nipples) will recede into the
body and possibly cause death. The syndrome is reported in south and east Asia, where it
is known by a variety of local terms.....At times, koro occurs in localized epidemic form
in east Asian areas. This diagnosis is included in the Chinese Classification of Mental
Disorders, Second Edition (CCMD-2) (p. 846).
mal de ojo: A concept widely found in Mediterranean cultures and elsewhere in the
world. Mal de ojo is a Spanish phrase translated into English as “evil eye.” Children are
especially at risk. Symptoms include fitful sleep, crying without apparent cause,
diarrhea, vomiting, and fever in a child or infant. Sometimes adults (especially females)
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have the condition (p. 847).
susto: (“fright” or “soul loss”) A folk illness prevalent among some Latinos in the
United States and among people in Mexico, Central America, and South America. Susto
is an illness attributed to a frightening event that causes the soul to leave the body and
results in unhappiness and sickness. Symptoms may appear any time from days to years
after the fright is experienced. In extreme cases, susto is often believed to result in death.
Typical symptoms include appetite disturbances, inadequate or excessive sleep, troubled
sleep or dreams, feelings of sadness, lack of motivation to do anything, and feelings of
low self-worth or dirtiness. Ritual healings are focused on calling the soul back to the
body and cleansing the person to restore bodily and spiritual balance. Similar etiological
beliefs and symptom configurations are found in many parts of the world (pp. 848-849).
zar: A general term applied in Ethiopia, Somalia, Egypt, Sudan, Iran, and other North
African and Middle Eastern societies to the experience of spirits possessing an individual.
Persons possessed by a spirit may experience dissociative episodes that may include
shouting, laughing, hitting the head against a wall, singing, or weeping. Individuals may
show apathy and withdrawal, refusing to eat or carry out daily tasks, or may develop a
long-term relationship with the possessing spirit. Such behavior is not considered
pathological locally (p. 849).
Some conditions and disorders have been conceptualized as culture-bound syndromes
specific to industrialized culture (e.g., Anorexia Nervosa, Dissociative Identity Disorder),
given their apparent rarity or absence in other cultures (p. 844).
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