Culture and history in psychiatric diagnosis and practice.

A brief review of the history of Western psychiatry underscores how happenings in Anglo European societies during the early modern and modern era impacted on regional populations in the midst of profound demographic, social and political economic change. Such factors along with cultural conventions created an amalgam of behavior problems: social responses to these under the aegis administrative bodies gave rise to the discipline and profession of psychiatry. Central tenets that we take for granted as facts about psychiatric disorders (e.g., their manifestations, natural history, diagnosis) were shaped by historical and cultural influences. Psychiatry may outline a science of the psyche and its disturbances but it also reflects a cultural interpretation about personal experience, responsibility, social behavior, and the requirements for social order. The cultural character of the psychiatric enterprise itself, just as much as the characteristics of its disorders, constitute the subject matter of cultural psychiatry. Events during the late eighteenth and nineteenth centuries in Anglo European societies gave rise to psychiatry. First, there took place the differentiation of psychiatric disorders from the pool of human social and behavior problems. Second, and in relation to this, a segment of the medical profession was accorded (or appropriated) a social mandate and acquired an obligation to treat victims of mental disorders. The historical sociology of psychiatry constitutes one aspect of cultural psychiatry. The second covers developments during the latter part of the twentieth century. At this juncture, psychiatry became the target of labeling theorists in sociology, cultural relativists in anthropology, antipsychiatrists from within the discipline itself, and revisionist and critical historians of psychiatry. An outgrowth of this is the perspective that underscores the important role played by values, ideas, and world-views in how individuals experience and carry out their lives, phenomena that are critical to the expression, interpretation, diagnosis, and treatment of psychiatric disorders. That the science and practice of modern psychiatry incorporate an ethnocentric, Anglo European bias or slant on psychopathology is an integral assumption of cultural psychiatry. By describing how other non-Western systems of psychiatry have operated, for example, their theories and practices, one gains a further appreciation of the important role of culture in shaping Western psychiatry. This is taken up in an article by Fàbrega elsewhere in this issue where concepts and practices of traditional Chinese and Indian medicine that pertain to mental health and illness are reviewed.

Mental health and illness in traditional India and China.

Biomedical knowledge underlies the science of all national systems of psychiatry and is integral to international psychiatry. It is grounded in Western systems of thought, values, and world views. In assessing the cultural and national presuppositions of contemporary psychiatry, it is desirable to analyze other systems of practice. In this article, some of the characteristics of ancient, non-Western traditions of mental health and approaches to mental illness are discussed. In reviewing salient characteristics of the approach to mental health and illness of India and China, one is provided with a vivid illustration of the interplay between culture and a system of psychiatric practice. The secular and essentially impersonal features of modern biomedical psychiatry contrast with the spiritual, value-laden, but also naturalistic basis of ancient traditions and approaches to mental health and illness.

Cultural psychiatry: international perspectives. Epilogue.

The psychiatry of the 21st century will have to be different from the psychiatry of the 20th century. The latter began its journey in a socially, compartmentalized world in which sharp categories and boundaries for the definition of mental illness were assumed to be relevant. International psychiatry completed its hegemonic hold over the territory of mental health and illness with a commanding home-stretch run of success borne in the confidence and optimism of its neurobiologic and culture free program and agenda. The world in which psychiatry now exists, however is changing rapidly and will continue to change and so of necessity will the practice of psychiatry need to change. This issue offers a guidelines and a vision of the direction that should be followed. Migration and transnational communication and awareness of cultural differences are changing the character of communities around the world. These changes considered in the context of world wide political economic factors are bringing into close physical and symbolic juxtaposition persons from distinct nations and ethnic groups. Clashes in world views, attitudes, spiritual orientation, and general philosophic and moral outlook are becoming ever-present realities of urban centers around the world. In traditional contexts and among persons who do not physically migrate, the power of communications media manages to psychologically migrate them; that is, to challenge their local, native cultural traditions about mental health with the scientific perspectives about mental health and illness. Advances in the social and cultural sciences have underscored ways in which assumptions of reductionism and universalism need to be chastened with an appreciation of human differences and humane considerations as these relate to mental health problems. The science of psychiatry of the 21st century will have to accomodate to this new creolized world of ethnic pluralism, cultural differences, and clashing perspectives between the traditional and the modern. The boundaries, categories, and the conceits governing the closed neurobiologic international program and agenda will need to be modified and broadened by the addition, sensitivity to and appreciation of cultural differences. This issue has reviewed the efforts of scholars around the world who are all deeply committed to the goals of the old international psychiatry but judge that a new vision and idiom is needed. A responsive international cultural psychiatry is based on a blending and integration of all facets of knowledge of the behavioral sciences, from biology, pharmacology, genetics on through sociology and cultural anthropology. In a new idiom it seeks to provide to all communities of the globe the best that the science of psychiatry has to offer in the areas of prevention, diagnosis, and treatment. The best psychiatry possible translates as providing expert scientific diagnosis and therapy in light of an appreciation of the role played by cultural factors in shaping human behavior. Contributors have covered the broad terrain of clinical psychiatry in a selective way giving emphasis to demographic, regional, and national needs in areas of mental health planning and therapy. The reviews of empirical issues and the formulation of conceptual areas needing further clarification provide a perspective of what a culturally sensitive and responsive international psychiatry should consist of.

The place of culture in DSM-IV.

This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.

Age effects on the clinical presentation of alcoholics at a psychiatric hospital.

Little is known about the effects of age on the clinical presentation of alcoholism in various treatment settings, despite the clinical importance of this factor. This study evaluates the effects of age on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. Young alcoholics displayed the most prominent substance use, antisocial behavior, depressive symptoms (including suicidality), and impulsivity. Early middle-aged alcoholics displayed the highest levels of drinking. Elderly alcoholics displayed the highest levels of cognitive dysfunction, although some level of cognitive dysfunction was present among even the youngest alcoholics. These findings confirm and clarify the effects of age on the clinical profile of alcoholics presenting for initial evaluation at a psychiatric hospital.

Earliest phases in the evolution of sickness and healing.

Sickness and healing constitute the root concepts that center medical anthropological inquiry and give the field its identity. Here, they are held to manifest a biological adaptation designed by evolution that requires culture for its final realization. Sickness and healing thus provide anthropology with a biocultural form that has changed in content and expression during cultural evolution. The early phases of this evolution, those bearing the most apparent influences of the environment of evolutionary adaptedness, are reviewed and analyzed in the article. Some of the implications of this for medical anthropology are discussed.

Racial effects on the clinical presentation of alcoholics at a psychiatric hospital.

Despite the clinical importance of race effects on comorbidity and symptom patterns in recent community studies, little is known about such effects in various treatment facilities. This study evaluated the effect of race on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. The factor that most strongly distinguished the racial groups was socioeconomic status (SES). After controlling for SES and other factors, no significant difference was noted between ethnic groups in the prevalence of major depressive disorder (MDD) or antisocial personality disorder. However, after controlling for SES and other factors, alcohol and drug use were more severe in African-American alcoholics, along with four symptoms associated with alcohol and drug use. In contrast, reversed neurovegetative symptoms, anxiety-related symptoms, and some personality-related symptoms were more severe in white alcoholics.

Adolescent psychopathology as a function of informant and risk status.

Adolescents selected for delinquency risk in a community study, their parents, and teachers completed versions of the Child Behavior Checklist, with the raw scores representing the adolescents' level of psychopathology. All three informants rated high risk adolescents as showing higher levels of delinquency as well as other forms of psychopathology, particularly anxiety, aggression, social problems, thought problems, and, to a slightly less consistent extent, withdrawn behavior. In addition, compared with parents and adolescents, teachers rated psychopathology in African-American adolescents higher than that in Anglo-American adolescents. The results are analyzed using knowledge drawn from social and child psychiatry.

Does a clerkship affect students' views of psychiatric patients?

This study deals with the views of medical students toward real psychiatric patients. The students answered seven questions about ten patients who had been interviewed by a senior faculty member. The interviews were recorded on audiovisual tapes. The questions dealt with different aspects of mental illness and included views on how laypersons would evaluate and respond to patients, what it would be like to care for the patients, and whether the patients were potentially dangerous. Answers to questions were correlated. Gender and the student's accuracy in rating psychopathology were used as independent variables to examine students' views and the possible change in these views as a result of participating in a 6-week psychiatric clerkship. The pattern of intercorrelations is reported and discussed. Negative views correlated with anticipated difficulty in caring for patients, and positive views correlated with a higher accuracy in rating psychopathology. In general, student views about mental illness were relatively impervious to the effect of a clerkship. Results are discussed in terms of prior research and knowledge about gender differences in interpersonal sensitivity. Some of the social implications of the results are discussed.

Toward a more comprehensive medical anthropology: the case of adolescent psychopathology.

This article argues for a more comprehensive analytical approach in medical anthropology than is currently followed, one that combines attention to structural factors (political, economic, medical/psychiatric), experiential/symbolic expressions and meanings, and biological/bodily features of disorders. We show how subject matter that may be defined as "adolescent psychopathology" would be better understood by a comprehensive approach than by partial views. Three areas within adolescent psychopathology are chosen as illustrative: anorexia nervosa, dissociation, and social aggression. Each of these, like adolescence itself, is powerfully shaped by historical and contemporary cultural influences, and each implicates important theories in medical anthropology.

Gender effects on the clinical presentation of alcoholics at a psychiatric hospital.

Despite the clinical importance of gender effects on symptom patterns and comorbidity patterns in alcoholics, little is known about such effects in treatment facilities other than alcoholism treatment centers. This study evaluated the effect of gender on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. It demonstrated that major depression and accompanying depressive and anxiety-related symptoms are more prominent in female alcoholics than in male alcoholics, whereas antisocial personality disorder and antisocial symptoms are more prominent in male alcoholics presenting to a psychiatric hospital. The study also demonstrated that reversed neurovegetative symptoms are more severe in female than in male alcoholics.

Cultural challenges to the psychiatric enterprise.

Two challenges to psychiatry emanating from the study of cultural differences in mental illness are reviewed. The first challenge, conducted under the banner of cultural relativism, appeared to undermine the validity of psychiatric disorders. The misconceptions of this challenge, as embodied in the excesses of the labeling theory of sociology, were associated with the writings of antipsychiatrists and rejection of the community mental health movement. The result of all this was a devaluation of insights inherent in the cultural perspective. The second challenge draws emphasis to the pervasive role played by cultural differences in every facet of the psychiatric enterprise. Its relevance and contributions are briefly summarized. The study of the cultural sciences as they pertain to psychiatry offers a necessary corrective to the increasing impersonality and reductionism that is coming to characterize the neurobiologic approach.

Adolescent psychiatry as a product of contemporary Anglo-American society.

Societies differ with respect to medical traditions. The kinds of healers and their emphases vary as a function of culture and social structure. In Western nations, a number of specialty disciplines have evolved. Psychiatry is a creation of the nineteenth century and linked to demographic and social changes of the period. Comparatively little attention has been given to the growth of Adolescent Psychiatry, a sub-discipline that has achieved definition in the last two decades. Its dependence on cultural and political economic transformations is unique insofar as it first required construction of its clientele, namely adolescence itself. The 'disorders' that are the focus of Adolescent Psychiatry appear to be very much linked symbolically and structurally to the unique social pressures impacting on this newly constructed group. The historical and cultural determinants of the developments that have culminated in the evolution of Adolescent Psychiatry are reviewed and discussed.

Disproportionate suicidality in patients with comorbid major depression and alcoholism.

OBJECTIVE: The two purposes of this study were to provide a comprehensive description of the clinical features of patients who presented to an intake psychiatric setting with major depression and alcohol dependence and to determine which clinical features distinguished this dual-diagnosis group from patients with the two relevant single diagnoses. METHOD: During a recent 5-year period, a total of 107 patients who came to a psychiatric facility for initial evaluation were diagnosed as having both major depression and alcohol dependence. The clinical profile of this dual-diagnosis group was compared to that of nondepressed alcoholics (N = 497) and nonalcoholic patients with major depression (N = 5,625), assessed at the same facility, on the basis of information from the Initial Evaluation Form, a semistructured instrument containing a standardized symptom inventory that includes ratings of severity. RESULTS: The psychiatric symptom that most strongly distinguished the depressed alcoholics from the two comparison groups was the level of suicidality. The depressed alcoholics differed significantly from the nonalcoholic depressed patients on only two depressive symptoms, suicidality (59% higher) and low self-esteem (22% higher); they were also significantly distinguished from the nonalcoholic depressed patients by factors such as greater impulsivity, functional impairment, and abnormal personal and social history markers. CONCLUSIONS: Suicidality was disproportionately greater than other psychiatric symptoms in the depressed alcoholics. The clinical profile of depressed alcoholics suggests that they suffer an additive or synergistic effect of two separate disorders, resulting in a disproportionately high level of acute suicidality upon initial psychiatric evaluation.

Tlaxcalan constructions of acute grief.

In rural Tlaxcala, Mexico, the sudden and unexpected death of infants and young children was a relatively common occurrence during the time when this study was conducted. Not surprisingly, the deaths constituted major social tragedies and operated as psychological traumas to the family, especially the parents. Acute grief reactions inevitably resulted and these were suffused with bodily and psychological disturbances of different types, some of which were handled in the society as illness. The article grows out of a longitudinal study about these tragedies to families of the region. Attention is given to the grief reactions of parents, with special emphasis placed on psychological and behavioral manifestations. Of particular interest is the way local, cultural symbols pertaining to the cause of the deaths, which involved the malevolent attack of blood-sucking witches, were configured in the verbalizations and behavioral reactions that comprised the grief reactions. Details of the way symbols entered into the construction of meaningful accounts of the tragedies during the ordeal of the grief reactions are discussed and analyzed. Although the manifestations of grief could be said to have clinical, psychiatric implications, it is the way these manifestations served to explain the tragedies, in the process regulating and restoring social relations, that is given principal attention. A description of one mother's grief reaction is provided as a case illustration.

Characterizing organic mood syndrome, manic type.

The purpose of this study is to provide the first empirically based description of the clinical features of organic mood syndrome, manic type (OMS-M). During a recent 5-year period, 14,889 new patients presented for initial evaluation and care at our institute. Of these patients, a total of 12 cases of OMS-M were diagnosed. Evaluations were conducted using the Initial Evaluation Form, which was developed to be compatible with the DSM-III. The symptom profile of OMS-M was compared with that of "functional" manics (bipolar disorder, manic type [BD-M]). A variety of associated clinical factors were also assessed. The OMS-M patient demonstrated somewhat less severe acute symptomatology but more longstanding functional impairment than in BD-M. OMS-M patients also displayed a lower age at onset of illness and a higher level of perinatal problems and developmental delays compared with BD-M patients. The OMS-M group displayed a low family burden of mania. The most striking distinguishing feature of OMS-M was the prevalence of neurological disorders, with a surprisingly high prevalence of seizure disorders. Seizure disorders were more prevalent in OMS-M than in other organic brain syndromes (OBS).

Gender differences in how medical students learn to rate psychopathology.

The aim of this study was to examine factors influencing medical students' learning of psychopathology assessments during the psychiatric clerkship. The subjects included 122 third-year medical students participating in a 6-week psychiatric clerkship. They completed Brief Psychiatric Rating Scale ratings on short, focused interviews in a balanced design before and at the end of the clerkship. Deviation of their ratings from standard ratings by experienced psychiatrists constituted the dependent variables. Female medical students showed a clear significant improvement during the clerkship, whereas male students tended to experience a significant reduction in their accuracy. We conclude that there may be gender-related differences in these medical students' ability to assimilate and cope with the clinical experience of the psychiatric clerkship. The implications of these findings for psychiatry training are discussed.

Sudden infant and child death as a cultural phenomenon: a Tlaxcalan case study.

THE Sudden Death of infants and young children (SICD) constitutes a recurring problem in all societies. In contemporary industrialized societies, many factors known to cause these deaths have been clarified and controlled. Yet, as an outcome of such things as unrecognized disease, accidents, so-called crib death, and parental neglect or abuse, the prevalence of SICD remains relatively stable even in contemporary Western societies (Adams et al. 1990; Campbell 1989; Kyle et al. 1990). The pathophysiology of these human tragedies has received much attention. However, the social, cultural, and psychiatric implications have been relatively neglected. In large part this is because in our secular culture these deaths are explained naturalistically; namely, as the result of disease, biological anomalies, or physiological failures, the meaning of which is not attributed to human or other worldly intervention. A result of this is that such deaths are usually deprived of a framework of meaning that has spiritual and existential connection to everyday affairs. An impersonal, natural way of explaining SICD often deprives the mourner of a meaningful cultural rationale that can facilitate emotional release and spiritual significance.