Culture-Bound Disorders

Psychological disorders considered specific to particular ethnocultural groups because of distinct cultural factors influencing the etiology, meaning, expression, and for treatment of the disorder are referred to as culture-bound activities. The term is used in contrast to those psychological disorders considered to be “universal.” In its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the American Psychiatric Association (1994) states:

Culture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations. There is seldom a one-to-one equivalence of any culture-bound syndrome with a DSM diagnostic entity. (p. 844)

Types of Culture-Bound Disorders

The most thorough discussion and listing of culture-bound disorders can be found in Simon and Hughes (1986). In DSM-IV, the American Psychiatric Association (1994) describes a number of known culture-bound disorders. Table I lists some of the well-known culture-bound disorders with their associated locations and risk populations.

A number of researchers proposed subclassification systems for the culture-bound disorders based on common behavioral and psychological expressions. For example, Ari Kiev (1964) suggested they could be classified as anxiety states (e.g., koro, susto) phobic states (e.g., rnal ojo, voodoo death), depressive disorders (e.g., hiwa itchk), hysterical disorders (e.g., latah). Simons and Hughes (1986) classified the culture-bound syndromes according to different taxons (i.e., taxonomy categories): startle-matching taxon (e.g., latah, irnu). sleep paralysis taxons (e.g., uqarnairineq), genital retraction taxon (e.g., koro), sudden mass assault taxon (e.g., amok, cathard, negi-negi), running taxon (e.g., pibloktoq), fright illness taxon (e.g.. susto, saladera), cannibal compulsion (e.g., windigo).

Kiev (1964) and Simons and Hughes (1986) acknowledge the distinct cultural influences shaping each disorder: however, they also wanted to provide generalizable taxonomical principles by which the disorders could be reconstructed within Western conceptual models of psychological disorders. Thus, for them, koro can be considered an anxiety disorder, latah could be considered a hysterical disorder. Although this approach is viable (i.e., proceeding from emic to etic categories), many researchers now believe there is no one-to-one equivalence of culture-bound disorders to the Western psychiatric disorders represented in DSM-IV and the International Classijcation of Diseases (ICD-10). This has become a major issue in psychiatry because it raises questions about the universality of Western psychiatric disorders and about the principles used for constructing Western psychiatric classifications.

Historical Origins

Marsella noted in an earlier work that over the past century, culture-bound disorders have also been termed culture-specific disorders, exotic disorders, culture-bound reactive disorders, ethnic psychoses, esoteric disorders, hysterical psychoses, and atypical disorders/psychoses (Marsella, 1996). The variations in terms applied to culture-bound disorders reflect some of the important issues associated with their conceptualization in Western psychiatry. Terms such as exotic and esoteric reflect the ethnocentric bias that has accompanied efforts to understand culture-bound syndromes. It must be asked, why it is that non-Western people have “exotic” or “esoteric” disorders while Western people have the real thing? The answer, of course, is simple: Western psychiatry is part of the Western political, economic, and social domination of the world over the past centuries: with dominance comes privilege. Western psychiatry believed its assumptions and practices were “true,” and as such, “universal.” It has only been within recent years, that psychiatry has acknowledged “relativism” as a competing knowledge paradigm, and accepted psychiatry’s ethnocentric roots and ideologically biased foundations.

Culture-bound disorders entered Western psychiatric literature in the late nineteenth century as Western physicians working in colonies in Asia, Africa, and South America reported strange and “exotic” disorders that appeared distinct from disorders reported in Europe or North America. However, reports of these disorders have actually been traced to the historical journals and reports of sixteenth-century European travelers, explorers, and adventurers to distant shores. For example, H. B. M. Murphy (1973), in his scholarly article on culture-bound disorders noted that amok was first reported in 1552 by Portuguese travelers to Southeast Asia who described religious zealots willing to sacrifice their lives in battles with the enemy.

Conceptual Issues

The distinction between “culture-bound” and “universal” disorders has provoked considerable controversy. Essentially, the major issue is whether all mental disorders should be considered culture-bound or whether the term should be reserved for those disorders judged by Western-trained scientists and professional to be localized or folk disorders. For example, some researchers have suggested that anorexia nervosa is specific to industrialized cultures (DSM-IV, APA, 1994, p. 844) because of the excessive valuation of personal control and beauty associated with thinness in these cultures. However, other disorders such as schizophrenia continue to be considered universal. Among the major questions that are still being debated are the following:

1. Should culture-bound disorders be considered neurotic, psychotic, or personality disorders?
2. Should these disorders be considered variants of disorders considered to be “universal” by Western scientist and professionals? (e.g., is susto, soul loss, merely a variant of depression?)
3. Are these disorders variants of common “hysterical,” “anxiety,” “depression,” or “psychotic” processes that arise in response to severe tension, stress, andlor fear, and present with specific culture content and expression?
4. Are there taxonomically different kinds of culture-bound syndromes (i.e., anxiety syndromes, depression syndromes, violence-anger syndromes, startle syndromes, dissociation syndromes)?
5. Do some culture-bound disorders have biological origins (e.g., pibloktoq-screaming and running naked in the Arctic snow-has been considered to result from calcium and potassium deficiencies because of dietary restrictions: amok has been considered to result from febrile disorders and neurological damage)?
6. Are all disorders “culture-bound” disorders since no disorder can escape cultural encoding, shaping, and presentation (e.g., schizophrenia, depression, anxiety disorders)?

Why Are Culture-Bound Disorders Important for Western Psychiatry?

The existence of culture-bound disorders raises important issues about Western classification systems.

The Nature of Western Psychiatric Classification

Culture-bound disorders raise fundamental questions about the nature of Western psychiatric disorders and their classification. Through the years, Western approaches to psychiatric classification have relied primarily on symptomatology, etiology, and/or treatment responsivity as the basis of classification. This approach is consistent with medical approaches to disease classification. However, these approaches have been subject to considerable criticism because the same etiology can lead to different disorders, different etiologies can lead to the same disorder, and similar treatments are used for disorders with different etiologies and expressions.

These problems are magnified when applied to disorders found in different cultures because different etiologies, symptom patterns, and treatment responsiveness may be operating. Can a common etiology be responsible for amok in Southeast Asia, cathard in Polynesia, and negi-negi in the New Guinea Highlands? Can different etiologies lead to similar explosive and violent behavior in Sweden, Southeast Asia, Polynesia, and the New Guinea Highlands? Is each disorder (explosive violence in Sweden, amok in Southeast Asia, negi-negi in the New Guinea Highlands) unique in its etiological foundations and expressive symptomatology and meanings? These questions go to the core of psychiatry’s foundations as a science and profession. What is a universal disorder? What is a culture-bound disorder?

Decontextualizing Symptoms and Disorders

Taking symptoms and disorders out of their cultural context is a common but unfortunate practice in psychiatry. Koro, the fear that one’s sexual organ is shrinking or withdrawing into one’s body, assumes a different meaning when considered within the context of Chinese cultural views regarding the balance of yin (female) and yang (male) forces in the etiology of disease and the promotion of health. The loss of semen, whether through masturbation, frequent intercourse, or problematic anatomy, assumes a different meaning and consequence in Chinese society than it does in the West. The disorder cannot be extracted from its Chinese cultural context and interpreted in Western society as simply a delusion that occurs in hysterical personalities. The explanatory power of the latter is limited and biased because context is excluded. Imagine the reverse: Based upon treating more than 1,000 Yoruban (Nigeria) women, a Yoruban folk healer considers a severely agitated “depressive” episode in a Western middle-class housewife to be asinwin (i.e., a Yoruban disorder often found in women), and suggests that violations of ancestral spiritual taboos have caused the problem.

The universality view held by many in Western psychiatry is ethnocentric. It is rooted in the assumption that Western science and medicine have discovered universal truths and facts about a universal reality. This can be contrasted to emerging relativistic views that consider reality to be culturally constructed and determined. The latter view argues that each culture constitutes a distinct experiential context in which normal and psychopathological behavior originate, elicit meaning, find expression, and are responded to by culture members. The decontextualization of symptoms or disorders represents a serious conceptual and ethical error that emerges from intellectual bias and the abuse of power rather than the validity of the conclusion.

Cultural Determinants of Psychopathology

Once we acknowledge the existence of culture-bound disorders, it becomes clear that cultural factors constitute critical determinants of the etiology, expression, and treatment responsivity of psychopathology. This fact forces us to reconsider existing views of psychopathology that currently favor biological and/or psychological factors as the essential determinants, independently of the cultural context in which the disorder arises, is experienced, shaped, and treated. The acceptance of the culture-bound disorder as a fundamental reality in psychopathology encourages Western scientists and professionals to broaden their conceptual models to include cultural, environmental, and spiritual forces, and to explore the utility and value of indigenous models of psychopathology.

Cultural factors, including values, beliefs, socialization practices, ways of knowing (i.e., epistemologies, ontologies), consciousness patterns, personality, and social-role expectations all influence psychopathology. In addition, certain cultures may present particular stressors that help shape psychopathology such as cultural disintegration, cultural dislocation, racism, and sexism. Finally, psychopathology in particular cultures may be shaped through preferred breeding patterns, nutritional practices, climate, and other biologically related factors. In brief, culture-bound disorders compel us, as scientists and professionals, to consider cultural factors in our case conceptualizations and deliberations. It is as important to conduct culturological interviews as it is to conduct conventional psychiatric and psychological examinations.