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Culture and Psychiatric DiagnosisReview - Culture and Psychiatric Diagnosis
A DSM-IV Perspective
by Juan E. Mezzich, M.D., Ph.D., Arthur Klienman, M.D., Horacio Fabrega, Jr. M.D., and Delores L. Parron, Ph.D.
American Psychiatric Press, 1996
Review by G.C. Gupta, M.D.
Nov 2nd 2000 (Volume 4, Issue 44)

Culture and Psychiatric Diagnosis: A DSM -IV Perspective is developed from the National Institute of Mental Health (NIMH) and American Psychiatric Association's Conference on culture and psychiatric diagnosis. The conference held in Pittsburgh, Pennsylvania in April 1991 was organized to enhance the cultural validity of DSM-IV. The volume, proceedings of a conference, is a collaborative effort of cultural experts, members of the NIMH Culture and Diagnosis Group, nosologists, and members of the DSM-IV Task Force and Work Groups. There are 54 contributors to the volume, divided into eleven sections, in addition to a Foreword by Leon Eisenberg and an Introduction written by the four editors as listed above.

The work reviews and discusses the relationship between culture and psychiatric diagnosis within the framework governing an effort to enhance the cultural sensitivity and validity of DSM-IV. The primary concern has been that "taking culture into account is not simply an issue of whether it is legitimate to apply mainstream schemata to people from other cultures. Diagnosis itself is a cultural issue in mainstream society. All medical diagnoses are socially constructed" (Eisenberg, 1996, from the Foreword to this book).

The volume is organized according to several principles. The most apparent one, as  displayed in the List of Contents, corresponds to the components of DSM-IV to which cultural determinants have been made. Section 1, "General Issues," is particularly pertinent for text of the DSM-IV Introduction. Chapter 1 on "Cultural and Historical Foundations of Psychiatric Diagnosis has been written under several sections, the important ones of which are " A Cultural Approach to Psychiatric Classification", " The Western Cultural Approach to Psychiatric Classification, " Is Universalistic Language of Psychiatric Illness and Psychopathology Possible? and " Culturally Sensitizing Psychiatric classifications Systems," Chapter 2 on "How is Culture Important for DSM-IV? has one important section on "Steps Toward a Culturally Valid DSM-V" which should provide a good extrapolative reading in the light of DSM-IV experiences. Chapters 3 to 7 examine various perspectives, as for example, African American Perspectives, Asian American Perspectives, and so on.

Section II is on Organic and Psychotic Disorders. Chapter 8 presents a perspective on " Cultural Influences on the Diagnosis of Psychotic and Organic Disorders, the main emphasis being on " The Universality of Psychotic Experiences and Schizophrenia, Ethnicity and the Pathogenesis of Psychotic Disorders, and The Pathoplastic Effects of Culture." Pathoplastic effects are reflected in following two ways: One, hypotheses other than biological heterogeneity have also been formulated to explain cross-cultural epidemiological data (Murphy's (1982) work for instance). Second, Studies have suggested that culturally prevalent symptoms either are an extension or an exaggeration of culturally -valued beliefs and behaviors."  Drawing lessons from cross-cultural variations in terms compatible with DSM philosophy is not a simple matter. Some findings can be translated into concrete warnings or recommendations, whereas others imply that practitioners or researchers adopt a certain stance in the diagnostic process as well as in the interpretation of observed behavior.

Reflections about cultural influences on the diagnosis would not be complete without mentioning another debate not alluded to by Lin regarding the cultural relativity of the diagnosis of schizophrenia itself (pp. 67, Corin, 1996 in the present Volume). Chapter 10 " Cultural Comments on Organic and Psychotic Disorders: II", Chapter 11, on "Nosological Comments on Culture and Organic and Psychotic Disorders," Chapter 12, on "Culture and the Diagnostic Classification," Chapter 13,on Cultural Comments on Substance-related Disorders as also Chapter 14, present a similar perspective.

This is the presentation style followed in other sections too on Substance-Related Disorders, Mood and Anxiety Disorders, Somatoform and Dissociative Disorders, Eating and Sexual Disorders, Adjustment and Stress Disorders, Personality Disorders, and Childhood-Onset Disorders. According to this reviewer, one does not get much information, except for bearing that culture has on that group of disorders. The reader must not forget that the volume is a compilation of papers presented, as said above.  Sometimes, a chapter is just a page and a half in length. If one gets anything that is from the last sections on Culture-bound Syndromes and Multiaxial Issues.  According to Charles C Hughes, the author of " The Culture- Bound Syndromes and Psychiatric Diagnosis, the first chapter of the section X, the core concern is " to direct attention toward a core meaning and critique the label's indiscriminant application to what often turns out to be incomparable phenomena" (pp. 289). " When discussed at all in a psychiatric text, the culture-bound syndromes receive only perfunctory recognition," as has been the situation even in the present volume in the earlier sections. Rarely even indexed, their discussion typically consists of only a page or two -- so slight as to be useless for either research or clinical applications"(pp.290). These syndromes have sometimes been included in discussion of cultural psychiatry. However, for an anthropologist (as well as for the late H.B. M. Murphy. 1977), this raises question of why the "psychiatry" institutionalized in DSM-III-R and DSM-IV (American Psychiatric Association, 1987, 1994) is not in itself also considered "cultural psychiatry," in this instance a psychiatry having a Eurocentric heritage. Why are these particular syndromes thus differentiated, they alone being set apart as examples of " cultural Psychiatry"? Indeed which is the "set" and which is the "subset" in the relationship between "psychiatry" and "cultural psychiatry"….(pp. 290). Consider also Bruner (1990) in this context, specifically his concern on Cross-cultural psychology and Cultural Psychology.

Chapter 41 On Cultural Comments on Culture Bound Syndromes: II by Ronald Wintrob is a continuation of Hughes Chapter. He introduces "Considerations Concerning Normal and Abnormal, A Cultural Psychiatrist's Clinical Experience, and Culture-Bound Syndrome of Spirit Presentation as a Paradigm." These are interesting aspects and need examining. Section XI on Multiaxial Issues has 4 chapters of which the first chapter, the Chapter 43 has elaborated the concept of multiaxiality. "The chapter is broadly organized by comments on the international roots and overall architecture of the multiaxial model and on key individual axis, particularly those contained in DSM-IV" (pp. 327). Subsections on "Cultural Considerations for the Design of Multiaxial Systems and Cultural Considerations and Proposals, Axis by Axis ought to form good readings.

On the whole, the present reviewer has a mixed response to the present volume, Proceedings of a Conference held in 1991. After several years of publication of DSM-IV, those who have read it should have formed their respective opinions on it. The experience gathered on the use of DSM-IV must have crystallized, even cross-culturally. This time accumulated experience and wisdom ought to have been reflected by the volume.

It ought to form a good reading to reflect upon, especially in the light of last two sections for all those who have had the good fortune of having had the experience of making use of DSM-IV cross-culturally.

Professor G.C. Gupta (Now Retired); University of Delhi, Delhi, India; Department of Psychology.
Owner of the egroup on "mind-in-brain" and member of several other egroups<


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