I have been surprised by the level of interest that my recent postings under Ethics and Morality (Psychology Today) have generated.
My first post in this series got about 1300 hits to date (the post has been up for a bit less than a month), with the two following posts also wrapping up hits pretty quickly: as of now the second post is at 600 hits, and the third one (that’s been up for about a week) is already at 650.
This was an interesting and unexpected trend. It seems like mental illness and psychiatry remain quite fascinating (albeit controversial at times) topics of interest for the collective imagination. This being the case, I thought a discussion about the intersect between psychiatry and culture would also be of interest to this readership.
But first here is the context of our discussion.
The modern Western psychiatric classification of mental distress uses a descriptive approach to diagnosis. This is shared by the American Psychiatric Association DSM III onwards psychiatric diagnostic system as well as the World Health Organization ICD-10. The descriptive aspect is emphasized by both systems, meaning that current diagnoses are not meant to explain the brain deficits underlying psychiatric signs or symptoms.
However, when it comes to psychiatric practice, as discussed in numerous treatment guidelines. descriptive diagnoses do not exit in a vacuum, but instead inform treatment together with a biopsychosocial formulation of the issues at hand.
There is an appearance of worldwide agreement and homogeneity when it comes to psychiatric diagnosis and even intervention. But appearances might be deceiving. As it turns out, even within the fairly homogeneous Anglo-American psychiatry, the way similar formulations have been applied over time varies greatly, with cultural factors being an important, yet frequently under-appreciated, contributor.
For example, the influence of Adolf Meyer’s, one of the forefathers of modern American psychiatry and a pioneer of the biopsychosocial model, gathered more following in the British psychiatry than in the United States, which has been Meyer's adoptive country for most of his life. Europe, where psychoanalysis fell on harder times after the Second World War, made space for the Meyerian ideas, while in the United States the same ideas were almost wiped out by the alternating preeminence of the more extreme theoretical formulations of psychoanalysis and biodeterminism.
At the same time, the Kraepelinian backbone of American DSM III and its successors faced multiple challengers in its own homeland. A number of eminent German psychiatrists including Eugene Bleuler, Kurt Schneider, and Karl Jaspers went head to head with Kraeplin's procustian descriptive approach to psychiatric diagnosis. Yet this did not deter American psychiatry to dust it off and put it back on the shelf.
To conclude, the history of psychiatric nosology seems to indicate that cultural preferences appear to inform the biological agenda of research as much, if not more, as the other way around.
Psychiatry—culture interactions also manifest in cultural differences that are not easily captured by fixed descriptions. Any constrained, pre-defined description is of limited use when it comes to capturing fluid differences, which is the case with cultural factors. For example in a typical Western culture, the lack of independence that is usually part of a depressive presentation is highly problematic and will be an aggravating factor for the clinical presentation and course. Compare that with a typical Eastern culture, where group identity and connection are valued above individual autonomy, which in turn makes dependence more acceptable and thus less probelmatic.
Cultural bound syndromes further challenge the limits of a strict classification system. Panic attacks, described in the United States, and ataques de nervios, described in the Latino cultures, share a number of commonalities, but are also different in a number of important aspects. For example fainting and amnesia are associated with ataque de nervios but not with panic attacks. The complicated dynamics between cultural influences and psychopatholgy are further illustrated by the fact the Latino culture based ataque de nervios seems to reach its peak in the United States, i.e. Latinos are most likely to report ataques de nervios when they are U.S. citizens, born in the United States, have spend more of their life in the United States, and speak more English (Gurnaccia et al., 2010).
The bottom line? The "culture effect" on psychiatric pathology is an important reminder about the complexity of the human psyche, this puzzling and somewhat fluid constuct emeging at the cross between genes and memes.
As we are continuing our amazing discoveries in the brain-mind field, psychiatrists as well as neuroscientists need to remember that theoretical slicing, while necessary for “cutting” the overwhelming complexity in smaller pieces, also carries the risk of producing simplistic and thus inaccurate representations of the whole.
GuarnacciaPJ, Lewis-Fernandez R, Martinez Pincay I, Shrout P, Guo J, Torres M, Canino G,Alegria M. Ataque de nervios as a marker of social and psychiatricvulnerability: results from the NLAAS. Int J Soc Psychiatry. 2010May;56(3):298-309. Epub 2009 Jul 10.
© Copyright Adrian Preda, M.D.