You may not have heard of koro -- a mental syndrome in which a person has an overwhelming belief that his or her genitals are disappearing -- or zar-- a condition that generates dissociative episodes characterized by intense laughter and singing -- but that doesn't mean these are any less universal than, say, anorexia. At least that was the theme of a fascinating article by journalist Ethan Watters about "the Americanization of mental illness," published in the New York Times Magazine in 2010.
One of the primary points Watters makes is that the Western mental-health practitioners behind the Diagnostic and Statistical Manual of Mental Disorders (DSM-4) problematically placed "culture-bound" disorders -- like those mentioned above --in their own section at the back of psychiatry's most definitive diagnostic guide, implying that these syndromes are somehow affected by culture in a way that predominantly Western illnesses are not:
Western mental-health practitioners often prefer to believe that the 844 pages of the DSM-IV prior to the inclusion of culture-bound syndromes describe real disorders of the mind, illnesses with symptomatology and outcomes relatively unaffected by shifting cultural beliefs. And, it logically follows, if these disorders are unaffected by culture, then they are surely universal to humans everywhere. In this view, the DSM is a field guide to the world's psyche, and applying it around the world represents simply the brave march of scientific knowledge.
But Watters disagrees with that approach. "In the end," he concludes, "what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations.... [M]ental illness is an illness of the mind and cannot be understood without understanding the ideas, habits and predispositions - the idiosyncratic cultural trappings - of the mind that is its host."
The American Psychiatric Association (APA), it seems, is heeding that advice. The organization is unveiling DSM-5, the long-anticipated (14 years, to be exact) new edition of its manual, over the weekend during its annual meeting in San Francisco. And based on preliminary information, the task force that wrote it appears to have been more sensitive to the nuances of patient care across countries.
"Rather than a simple list of culture-bound syndromes," reads one statement on the APA's methodology, "DSM-5 updates criteria to reflect cross-cultural variations in presentations, gives more detailed and structured information about cultural concepts of distress, and includes a clinical interview tool to facilitate comprehensive, person-centered assessments."
What exactly will this look like? Instead of relegating cultural expressions of mental disorders to the back of the book, the manual will incorporate these throughout the text. The example the APA provides is for social anxiety disorder. In the new manual, "fear of 'offending others'" will be included in order to reflect "the Japanese concept in which avoiding harm to others is emphasized rather than harm to oneself."
Another example: A preliminary version of the DSM-5, which the APA released for feedback last year, updated the criteria for dissociative identity disorders so that professionals won't need to diagnose practices like shamanism as a mental illness. In the new manual, practitioners are told that if the so-called "disturbance" is actually "a normal part of a broadly accepted cultural or religious practice," then it does not technically constitute dissociative identity disorder.
Changes such as these are definitely a start. But all the medical anthropologists out there need not worry. With ambiguous words like "broadly accepted" and "normal" peppered in the DSM-5, there's certainly still room for criticism.
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