Cross-Cultural Comparison of Mental Disorders (1)
There is only one race . . . the human race. The ideal human beings who can look past race, creed and color is wonderful and wholesome but may be naïve this and could contribute to misunderstandings. We have been equipped with the basics, in this aspect we are alike. When option packages are added, the world of psychology lets the layman know we are not alike. The psychoanalytic realm shows us one must take into account the intricacies involved with the human mind. A case in point and most importantly is cultural background. Yes, we are all human beings but we are very diverse in appearance, cognition, folklore, societal norms, etc. Discrepancies in diagnostic procedures will occur if a doctor is not culturally sensitive. Would this be due to naivete? Are we not all human beings? How can an Occidental psychologist properly diagnose an Oriental patient without comprehension of the person’s cultural background and beliefs? Enter cross-cultural psychology. The following is an examination of three pairs of disorders, (social phobia/taijin-kyofusho, somatization/hwa-byung, major depressive disorder/shenjing shuairuo), with special focus on the culture-bound disorders. In addition, a guide to cultural competency and consequent diagnoses will be discussed. The ultimate goal of this investigation is to provide guidelines for proper cultural diagnosis.
Social Phobia/Taijin-Kyofusho (TKS)
Social gatherings are one of the most important aspects of being human. Socializing is a way of life. We are social animals regardless of cultural background. There is the need to meet and connect with others. But for many people, social life in any context causes great anxiety. Social phobia falls under the category of anxiety disorders and is the fear of embarrassing oneself in social situations. By contrast, taijin-kyofusho or TKS is the fear of embarrassing others in social situations. It is defined in the glossary of culture-bound syndromes in the DSM-IV as “a culturally distinctive phobia in Japan” (DSM p.903). Two different cultures, two different disorders; but are they really different from each other?
The difference stems from two words in particular. Interpreting the disorders from a cross-cultural perspective, social phobia is prevalent to individualistic, ‘self-centered’ societies and TKS is prevalent to collectivist, ‘other-oriented’ societies (Nakamura & others 2002). From this perspective, social phobia and TKS are not alike despite the obvious similarities. Based on this it is questionable to list TKS as a culture-bound disorder. It is mentioned in the section on social phobia that “In certain cultures, individuals with social phobia may develop persistent and excessive fears of giving offense to others in social situations instead of being embarrassed” (DSM p.452). This is a contradiction. If TKS is a culture-bound syndrome, why is the DSM implying TKS is social phobia? Is it suggesting that social phobia metamorphoses into TKS? Results from a recent study conducted by Japanese psychiatrists seem to debunk the culture-bound tag. A total of 65.8% of 38 cases of previously diagnosed TKS, were diagnosed by Japanese psychiatrists as social phobia (Nakamura & others 2002). The irony behind this is Japanese psychiatrists diagnosed 65.8% of Japanese patients in this study with social phobia. That leaves only 34.2% with a diagnosis of TKS. This revelation further clouds the culture-bound tag. How could a Japanese person be diagnosed with social phobia in Japan? Social phobia is prevalent in Western societies not in Japanese society, just as TKS is prevalent in Japan not in Western societies. Further research is necessary to come to a definitive conclusion.
Somatization/Hwa-Byung
“Serenity now,” the famous line from The Seinfeld Show. Under no circumstances let anyone or anything get you angry. Instead of flipping out, “serenity now.” But how long can “serenity now” go on before physical problems manifest? Is “serenity now” nothing but a façade, hiding the true emotions within? The DSM-IV brings to attention the Korean folk syndrome known as hwa-byung, which literally translates into English as ‘anger syndrome’ and it is attributed to the suppression of anger. Koreans commonly describe anger as fire (Somers 1998). The fire element is excessive in hwa-byung and it corresponds to the five governing bodies of the universe; earth, water, wood, metal and fire. According to Traditional Chinese Medicine, an imbalance in either of the five will constitute sickness and disease. Sometimes referred to as wool hwa-byung, in which wool means dense, thick or pent-up. Many patients relate their condition to the psychology of haan, a traditional culturally determined emotional state. The emotional state being suppression of anger. Because of Korea’s history, the region had a penchant for frequent wars, political and social upheavals. Destruction, suffering, personal loss and unbearable pain have been the norm for many Koreans, who have experienced deep feelings of haan and felt trapped as well as victimized. The Chinese character haan originally symbolized revenge, getting even, and so had a more action oriented, vengeful meaning. But in Korea the vengeful motive or desire, while there, is secondary. The primary meaning of haan is the suppressed, unexpressed anger felt inside. According to patients’ explanations, those with hwa-byung have experiences which ‘cause hurt, damaging, boiling, exploding sensations inside the chest and body.’ Korean patients’ cultural inclinations to keep family in harmony and peacefulness, and not to jeopardize social relationships dictate that anger must be suppressed, pent-up and accumulated. The anger becomes like a dense mass ‘pushing up’ in the chest, resulting in a distinct syndrome whereby most hwa-byung patients are diagnosed according to the DSM-III-R criteria, as having major depression or dysthymic disorder combined with somatization disorder (Somers 1998). The DSM-IV provides no definitive information but simply states ‘the symptom reviews should be adjusted to the culture’ (DSM p. 487).
Somatization, also known as Briquet’s syndrome is a somatoform disorder characterized by numerous recurring physical ailments without an organic basis (Comer p.161). From a cross-cultural perspective hwa-byung looks like somatization. Interestingly enough, the victims of the two disorders overwhelmingly are female. Between 0.2 and 2.0 percent of all women in the United States are believed to experience a somatization disorder, compared to less than 0.2 percent of men (Comer p.161). Hwa-byung is frequently found in middle-aged women of low socioeconomic status but the difference is hwa-byung patients are aware of psychological factors, which contradicts the common Western perception that somatization is something that is either/or (Somers 1998).
Major Depressive Disorder/Shenjing Shuairuo (SJSR)
“You are getting on my nerves!” Is a phrase one would most likely never hear in China. As a matter of fact for most of the last 3,000 years, healers and patients in China had never heard of nerves. Yet today nerve-based disorders rank among the most prevalent complaints in mainstream PRC society (Shapiro p.1). Shenjing shuairuo, or neurasthenia has been made famous by Arthur Kleinman* as the Chinese version of major depressive disorder. It is the second most common diagnosis in Chinese psychiatric hospitals, and one of the most common neuropsychological diagnoses in general. Neurasthenia was created as a diagnostic category in the 19th-century United States by a neurologist, George Beard. 19th-century ‘neurology’ was not based on the same conceptions of biology held by modern neurology and neuroscience. It seems in some cases to have operated on a quasi-humoral theory of ‘vital energy’ in which diseases were caused by ‘exhaustion’ of the ‘nerves’. Often it provided explanations for existing psychiatric syndromes, as in the case of neurasthenia for depression (Kleinman 1986). In 1982, Arthur Kleinman published a seminal study of 100 SJSR patients in the province of Hunan. When he concluded his study, 87 percent of them suffered from major depressive disorder and responded favorably to tricyclic pharmacotherapy (Lee 1997). This brings into question the exclusivity of shenjing shuairuo’s culture-bound title. There is one factor that would seem to keep this exclusive to the Chinese and is similar to the Korean experience: the Cultural Revolution. Chairman Mao changed the whole political, social and philosophical structure of China, and at the same time the lives of many Chinese. Many of the patients Kleinman had examined were survivors of the Revolution. In his view, Kleinman feels the specificity of the Chinese situation should be maintained. For one to gloss over the specific socially experienced trauma of the Cultural Revolution, to pass lightly over the particular subjectivity of the Chinese neurasthenic embedded in a complex web of family, Maoism, and traditional Chinese philosophy, would be to ignore what is important about the Chinese experience of neurasthenia as distinct from Western depression (Kleinman 1986).
Cultural Competence is . . .“The belief that people should not only appreciate and recognize other cultural groups, but also be able to effectively work with them.
Stanley Sue 1998
Physicians must be culturally sensitive when making a diagnosis. What may sound like a figment of the imagination or an over-exaggerated explanation by the patient may in fact be and is most real to the patient. This could be coined as naïve and colorblind in the context of “Regardless of race, we are all human beings so this is your diagnosis.” This will lead to a plethora of problems between the physician and client and will inevitably lead to the client terminating therapy. Some reasons for this include language incongruity, role ambiguities, behavioral misinterpretations, difference in treatment goals, lack of therapist understanding of cultural context and stereotypical cultural understanding of a client (Sue 1998). This does not necessarily mean a physician must immerse himself in every potential client’s culture, but it is important that he/she grasp the relevant material that will be helpful in understanding and correctly diagnosing a client’s disorder. For example, shenkui is a Chinese folk syndrome. In a nutshell, the symptoms deal with excessive semen loss. The loss of semen represents the loss of one’s vital essence or energy. Chinese martial artists that remained celibate through years and years of extensive training were believed to be most powerful, therefore maintaining the power of one’s vital essence. It was the opposite spectrum for those martial artists who engaged in carnal desires. To a Western physician this most likely would sound like a “figment of the client’s imagination” but it is not. What kind of diagnosis would a doctor make upon hearing, “I’m losing my vital essence”? Sadly it would be the wrong one or none would be made because the client left disgusted with the lack of understanding on the physician’s part.
A scenario involving a misdiagnosis than can be easily made deals with TKS. A Western psychiatrist unfamiliar with this disorder in its native context might gloss over the entry in the table thinking it must be “just another name” for “social phobia.” However, there is an important difference in Japan that a treatment approach based on the diagnosis “social phobia” would not recognize (CCMH p 6). As mentioned earlier, thetwo disorders’ cross-cultural differences deal with the “self” and the “other.” Although the “fear of embarrassing others” may not make sense to a Western psychiatrist, it makes perfect sense to a Japanese psychiatrist whom undoubtedly understands TKS much better for the simple fact this disorder is literally in his/her own “backyard.” It is this kind of subtle yet significant nuance that Western psychiatrists need to understand if they hope to serve a multicultural clientele of such differing world views (CCMH p 6).
What is out there that may aide a psychiatrist in making the proper diagnosis of his/her potential culturally diverse clientele? Enter “idioms of distress.” It is a term that will be most helpful to Western psychiatrists. Anthropologists have identified this as a
culturally-sensitive way of talking about culturally different types of interpretations. “Idiom” is another way of saying a culture-specific metaphor or symbol, “distress” covers all the feelings of pain, negative changes, and general “not feeling-myself” ness.
So whether a psychological condition is attributed to the loss of one’s soul (susto), the loss of the vital essence of semen (dhat), the interference of evil spirits or other supernatural forces (hsieh–ping), or problems with the heart (narahatiye qalb), the point is that each culture has, in the course of its unique evolution, come up with an interpretive tool its citizens can accept and use with each other to describe what’s wrong in the head, heart, and body (CCMH p 5). For example, one of the most common idioms of distress is somatization. It occurs widely and is believed to be especially prevalent among persons from a number of ethnic minority backgrounds (Gayton p.5). This critical piece of information will be most helpful to clinicians. To have an understanding of cultural idioms of distress means having an understanding of the clients condition.
Situations will arise when an individual will require some kind of assistance, a road map, a guide, etc. Hence, a cultural competency guideline that is easy to comprehend. It can be stated these guidelines were built on the premise of common sense. They are as natural as a reflexive action. There are times when one delves too deep into an issue and completely misses what is ‘right in front of their face’. For example, the love of ice cream is worldwide. There are many different varieties, tastes, consistencies, and ingredients. It is fair to say Ben & Jerry’s and a store bought brand are not alike, just as just as a Westerner clinician’s description and Eastern patient’s description of a disorder are not alike.
