Tuesday, 4 November 2014

Transcultural psychiatry, cultural formulation and validity in DSM-5

(This is a second draft paper written whilst my mind has been dominated by feelings of dullness and misery. I have at least found trying to concentrate on philosophy some consolation.)

Transcultural psychiatry, cultural formulation and validity in DSM-5
DSM-5 puts greater emphasis than previous editions non-Western cultural idioms of mental distress but without making explicit the relation between these and the psychiatric scientific aspirations, such as for their reliability and validity, of the rest of the taxonomy. The first section of this chapter outlines three possible views of the nature of transcultural psychiatric taxonomic concepts: a two factor view of underlying pathology overlain by a cultural shaping presupposed by one view of the role of cultural formulation and two versions of a one factor view, radical and conservative. But I argue in the second section that establishing the correctness of any one is none too easy. Two influential approaches to the nature of the concept of disorder – Wakefield’s harmful dysfunction analysis and Fulford’s failure of ordinary doing – can be pressed with only minor tweaking to support any of the a priori models of transcultural concepts. In the final section I examine one such idiom: khyal cap or wind attacks, a syndrome found among Cambodians. I argue that this does not fit any of the ways of domesticating variation from standard DSM-5 categories and that this suggests that the very idea of transcultural psychiatric diagnostic concepts fits uneasily with the rest of DSM-5.

Introduction: cultural factors in DSM-5
DSM-5 introduces a more explicit treatment of cultural factors in psychiatric diagnosis than previous editions of the DSM. In Section III, there is a discussion of the role of what is called a ‘Cultural Formulation’ including a semi-structured interview to help investigate cultural factors. In the Appendix, there is a ‘Glossary of Cultural Concepts of Distress’ which describes nine common conditions (though see below). In the Introduction, a number of suggestions are made as to how cultural factors might affect diagnosis and prognosis and thus should be investigated in a cultural formulation [APA 2013: 14]. Culture may affect:
·         The boundaries between normality and pathology for different types of behaviour.
·         Vulnerability and suffering (by amplifying fears that maintain panic disorder).
·         The stigma of, or the support for, mental illness.
·         The availability of coping strategies.
·         The acceptance or rejection of a diagnosis and treatments, affecting the course of illness and recovery.
·         The conduct of the clinical encounter itself thus affecting the accuracy of diagnosis, acceptance of treatment, hence prognosis and clinical outcomes.
The Introduction also summarises (in fact at greater length than the later discussion of the cultural formulation in the main text) three distinct ways that culture can impact on diagnoses. The single idea of culture-bound syndromes from DSM-IV is replaced by three notions: cultural syndromes, cultural idioms of distress and cultural explanations (or perceived causes) of illnesses (or symptoms). It is worth quoting the summary in full:
1. Cultural syndrome is a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context (e.g., ataque de nervios). The syndrome may or may not be recognized as an illness within the culture (e.g., it might be labeled in various ways), but such cultural patterns of distress and features of illness may nevertheless be recognizable by an outside observer.
2. Cultural idiom of distress is a linguistic term, phrase, or way of talking about suffering among individuals of a cultural group (e.g., similar ethnicity and religion) referring to shared concepts of pathology and ways of expressing, communicating, or naming essential features of distress (e.g., kufiingisisa). An idiom of distress need not be associated with specific symptoms, syndromes, or perceived causes. It may be used to convey a wide range of discomfort, including everyday experiences, subclinical conditions, or suffering due to social circumstances rather than mental disorders. For example, most cultures have common bodily idioms of distress used to express a wide range of suffering and concerns.
3. Cultural explanation or perceived cause is a label, attribution, or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms, illness, or distress (e.g., maladi moun). Causal explanations may be salient features of folk classifications of disease used by laypersons or healers. [ibid: 14]
Although the authors distinguish between these different ideas, they concede that the same elements may play a role in all three categories. For example, in the West, depression is used as an idiom of distress whether of an illness or pathology or of mere normal but significant sadness. But it is also recognised as a mental illness syndrome gathering together a number of symptoms. Finally, it is taken to be the cause of those symptoms. Just as depression can play the role of syndrome, idiom of distress and explanation, so can other concepts local to other cultures. Given this complication, although the ‘Glossary of Cultural Concepts of Distress’ describes nine common culture-bound syndromes, the concepts described may also play a role as idioms of distress and purported explanations or causes of experiences. The cultural concepts described are khyal attacks or khyal cap, ataque de nervios (‘attack of nerves’), dhat (‘semen loss’), kufungisisa (‘thinking too much’ in Shona), maladi moun (‘humanly caused illness’) nervios (‘nerves’), shenjing shuairuo (‘weakness of the nervous system’ in Mandarin Chinese), susto (‘fright’), taijin kyofusho (‘interpersonal fear disorder’ in Japanese). Each is related to similar but different concepts found in other, including Western, cultures. Khyal cap, for example, is linked to panic disorder.
But given that, in the years leading up the publication of DSM-5, much emphasis was placed on the attempt to increase the validity of psychiatric diagnostic categories, by contrast with their reliability which had already been increased by the stress on aetiologically minimal operationalised criteria, what stance does DSM-5 have to the content of the cultural concept? Are they, too, supposed to possess validity, to be genuine descriptions of real features of mental pathology? Or does the cultural sensitivity aimed at in a formulation and the semi-structured interview protocol require the adoption of a kind of anthropological relativism? Can the aim of cultural sensitivity and the articulation of non-Western idioms go hand in hand with the scientific ambitions of twenty-first century western psychiatry? Or does it require a kind of liberal irony towards the rest of the diagnostic manual?
In the next section I will outline three general ways of thinking about the cultural dependence of mental illness categories and hence the possible role of cultural formulations. Then in the subsequent section I will explore the merely loose connection between these and two broad approaches to the concept of mental illness. In the final section, I will return to reconsider the status of the cultural concepts actually listed in DSM-5 through consideration of one of them: khyal cap.

Three models of cultural concepts of distress
A two factor model of cultural variation
One way to understand how culture affects mental illness would be to think of the expression of mental illness as the result of two factors: an invariant endogenous factor and a cultural shaping. On such a view, mental illnesses either are, or are underpinned by, pathologies of some sort of universal substrate such as an essential human nature. This is the first factor.
Perhaps the most obvious candidate for such a substrate is human biological nature. This would fit a common emphasis within mental healthcare on the centrality of biological psychiatry especially for accounts of the aetiology of mental illness. It would also be consistent with Jerome Wakefield’s analysis of the concept of disorder as a harmful dysfunction (although the next section argues against any close connection or implication) [Wakefield 1999]. Setting aside the role of the value term ‘harm’ for the moment, the first factor in a two factor account of culture-bound syndromes might be a biological dysfunction picked out or explained in evolutionary terms.
Whilst biological nature is the most obvious candidate for the first factor, others are also possible. Consider Louis Sass’ account of Schreber’s delusions in Paradoxes of Delusion [Sass 1994]. The main claim of the book is summarised in an early passage thus:
[Schreber’s] mode of experience is strikingly reminiscent of the philosophical doctrine of solipsism, according to which the whole of reality, including the external world and other persons, is but a representation appearing to a single, individual self, namely, the self of the philosopher who holds the doctrine… Many of the details, complexities, and contradictions of Schreber’s delusional world… can be understood in the light of solipsism. [ibid: 8]
But the elucidation or understanding that Sass seeks isn’t merely aimed at one particular delusional experience or even at all of Schreber’s experiences considered as a whole. It is meant to shed light more generally on the nature schizophrenia itself. The reason it can (according to Sass) is that the experiences that characterise schizophrenia derive from a general and abstract feature of rationality:
[Madness] is, to be sure, a self-deceiving condition, but one that is generated from within rationality itself rather than by the loss of rationality. [ibid: 12]
So one might take the first factor of a two factor theory of cultural psychiatry to be an invariant feature of human mindedness whether unified as a biological dysfunction or more generally characterised in mental terms: in Sass’s case as a feature of rationality. It might, in other words, attach to the nature of rational subject-hood however that is (biologically) realised or underpinned. This would form the basis or underpinning of mental illness across cultures and not specific to any one of them.
Cultural variation enters this (two factor) picture only with the second factor. Culturally invariant pathologies of underlying human nature are overlaid by local cultural variation in how they are expressed. ‘Expressed’ could carry either of two meanings. First, it might mean that standing possibilities for biological dysfunction or failings of rational subjectivity might be differently prompted by different social or geographical contexts. This would be akin to akin to variation in heart disease rates and causes in different cultures and hardly merits the label ‘cultural concept’. (I will return to this possibility a little later and will suggest it is better thought of as a one-factor model.)
The more interesting idea is that variation in ‘expression’ picks out the way in which underlying pathologies might be plastic to the different self-interpretations that different people in different cultures come to possess and thus the way the pathologies are experienced and avowed. This would be an example of a cultural idiom of distress in the vocabulary of the DSM-5. But whereas for physical illness, how one understands one’s illness might be thought to be an accidental superficiality compared with the real underlying condition (as understood, perhaps, by the medical profession), one might argue that for mental illness its esse is percipi: how it is perceived at least partly constitutes it. Thus in the case of Sass’ account of schizophrenia, a two factor model would be premissed on the idea that cultural variation might make it difficult to realise that the symptoms reported in different cultures resulted from something like the same failure within rationality. Identifying the common element would require significant interpretative work reflected in a cultural formulation.
I suggested earlier that on a two factor model, mental illnesses either are, or are underpinned by, pathologies of some sort of universal substrate. The difference between these options is the difference between thinking that the alloy of an invariant underlying pathology and a varying cultural overlay itself comprises what we mean by mental illnesses themselves. One might think, for example, that khyal cap and panic disorder have the same underlying biological mechanism but that the characteristic way in which the former carries its own ontology (ie that subjects think of their distress through the conceptual lens of a wind-like substance) is sufficient to mark it off as a different kind of mental illness. Biological dysfunction is then the common cause of two distinct illnesses depending on cultural context. On the other hand, one might think that the real illness is whatever is common to khyal cap and panic disorder. It is merely that the form that that single illness takes can vary.
Whichever view is taken of whether the first factor is the illness or merely the common underpinning of different illnesses, a two factor view of cultural concepts of mental illness suggests a particular view of the aim of a cultural formulation in psychiatric diagnosis. It is a way of reverse engineering, from locally divergent symptoms, the common underlying nature or the underlying causes of mental illness. The aim of sensitivity to cultural difference would be to find a way to penetrate beneath it to a common substrate appropriate for scientific psychiatric research.
This seems to be the view of the ex-president of the World Psychiatric Association Juan Mezzich et al. in their discussion of ‘Cultural formulation guidelines’ when they say:
The cultural formulation of illness aims to summarize how the patient’s illness is enacted and expressed through these representations of his or her social world. [Mezzich et al 2009: 390]
Performing a cultural formulation of illness requires of the clinician to translate the patient’s information about self, social situation, health, and illness into a general biopsychosocial framework that the clinician uses to organize diagnostic assessment and therapeutics. In effect, the clinician seeks to map what he or she has learned about the patient’s illness onto the conceptual framework of clinical psychiatry. [ibid: 391]
These passages suggest that there is a division between how an illness is enacted and expressed and the underlying framework set out by Western psychiatry. The former is locally culturally shaped. The latter is invariant. On Mezzich et al’s  account, the only positive role cultural factors can then play is as a source of contingent health promoting resources:
The aim is to summarize how culturally salient themes can be used to enhance care and health promotion strategies (e.g., involvement of the patient’s family, utilization of helpful cultural values). [ibid: 399]
In other words, ‘culturally salient themes’ do not reveal the shape of mental illnesses in themselves but can, contingently, be used to promote health because of their effects on how people understand their own illnesses. All this suggests that this underlying view of the role of a cultural formulation is determined by a two factor view. Such a view is, however, merely one of several possible. I will argue that it is a half way house between two more radical views of the possibilities for cultural psychiatry both of which of versions of a single factor which I will now outline.
Two versions of a one factor model of cultural variation
A two factor model of the nature of transcultural psychiatry requires a distinction between surface appearance and underlying pathology. But it might be that this distinction cannot be drawn. The various ways one might attempt to flesh out the contrast between underlying pathology – for example as biological or some other underpinning notion of universal human nature – and surface appearance might fail.
Consider the two versions of the first factor outlined above: biological dysfunction cashed out in accord with evolutionary theory and a pathology of the structure of rationality as such. In the first case, drawing a distinction between surface form and underlying invariant function or dysfunction might seem unproblematic for physical illnesses. But in the case of mental dysfunctions there may be no principled way of drawing a distinction between ways of thinking, for example, that are problematic within a particular culture and some underlying cognitive function underpinning several different forms. The surface form may simply be the dysfunction. Why? Whilst it is unlikely that there is no such thing as biological human nature and hence some shared biological underpinnings for human mentality it might not, unaided, determine mental pathology because it might not – without education and enculturation, for example – determine the kind of mindedness that mental illness threatens. Mental illness might be a feature of what McDowell calls our ‘second nature’, or, in German, bildung by contrast with biological first nature [McDowell 1994: 183]. Perhaps learning a language is necessary for some, at least, forms of mental illness such as thought disorder. Perhaps there is no principled way to factor conditions like depression into those aspects that require conceptual thought or language and mere biological underpinnings.
A one factor model need not imply that there is any cultural variation of mental illness. It might be that our second nature, or rather that aspect of it relevant for the formation of mental illnesses, is universal. If so, mental illness would be akin to heart disease, varying only in external features such as rates and superficial and unimportant local understandings of it. Any apparent deeper variation would be a mark of our ignorance, our misdiagnosis. So a conservative version of the one factor model likens mental illness to heart disease with no significant space for cultural variation and no need for a cultural formulation to extract or excavate the underlying commonalities because they are open to view.
But it is also possible that, because second nature depends on enculturation and because cultures vary, second nature also varies. If so, the richer notion of human nature, beyond mere biology and sufficient for a conception of mental illness, might not be universal. Cultural variation might go ‘all the way down’. Genuinely different forms of mental illness would emerge from different ways of living in different societies.
To flesh this example out it will be helpful to consider again but in more detail Sass’ account of schizophrenia according to which it is a failure of rationality from within, or driven by, rationality itself rather than a mere absence of rationality. The symptoms of schizophrenia are a kind of lived experience of the philosophical theory or stance of solipsism according to which only the subject of experience – for me: I – exists. Everything else is merely an idea (for me: one of my ideas). Solipsism is thus idealism whose implicit consequences have been explicitly adopted since if everything that exists is merely an idea only the first person subject of thought (for me: I) can have those ideas. But as Wittgenstein argued, solipsism is then strictly nonsensical because it presupposes a contrast between self and other (in the claim that everything is merely an idea) which it cannot consistently draw (since everything is an idea) [Wittgenstein 1929]. Sass, controversially, embraces this further feature of solipsism – that it is nonsense – to shed light on the pathological status of schizophrenia with the hope of solving ‘simultaneously for understanding and strangeness’ in Naomi Eilan’s useful phrase [Eilan 2000: 97]. (For criticism of just this point see [Read 2001; Thornton 2004].)
Such an account can be used to illustrate both the conservative and the radical version of the one factor model of cultural concepts. If one thinks that the history of Western philosophy merely illustrates and unpacks conceptual connections implicit in the rationality of any possible thinker then solipsism is also a standing possibility for any thinker and hence, on Sass’ account, so is schizophrenia as its lived version. That would be a conservative one factor model. Any apparent culturally determined local variation in the experience of schizophrenia, such as the specific contents of delusions by contrast with invariant forms, would be merely superficial, requiring no great cultural sensitivity to detect. (It is the thought that it is merely or trivially superficial which distinguishes this from a two-factor model with its demand for a cultural formulation to penetrate surface features.)
If, on the other hand, one thinks that Western philosophy has been driven not merely by the abstract demands of rationality but by historically contingent assumptions about the nature of subjectivity and the connection of mind and world then the temptation towards solipsism will seem to be a merely local cultural matter. At the risk of being glib, had Descartes not existed, there would have been no such thing as schizophrenia.
This version of the one factor model is more radical than the two factor model even though both agree on the need for some sort of cultural formulation. A radical one factor model of a cultural formulation is more radical because it does not enable one to dig beneath surface difference to find underlying common pathologies but would instead be an articulation of the genuinely different ways people can be ill in different cultures. According to it, there are genuinely different forms of mental illness which need have nothing substantial in common across different cultures.

The loose connections between different models of cultural idioms and rival accounts of mental disorder
Prima facie a two factor model and two versions of a one factor model – according to one of which (the radical version) there is radical cultural variation all the way down and according to the other (the conservative version) there is no cultural variation, akin to heart disease – are all possible approaches to the role of culture in psychiatric diagnosis. Given that the one factor model is coherent, at least, is there any reason to think the two factor model holds good, as Mezzich et al seem to assume in their account of the purpose of a cultural formulation? To repeat, the two factor model postulates a set of invariant underlying pathologies which are overlaid by cultural variation in the way they are expressed. What independent support can be given to that notion?
Given that I have illustrated the two factor approach, above, by appealing to Jerome Wakefield’s harmful dysfunction analysis, it might be hoped that settling on a satisfactory understanding of the concept of illness or disorder will also determine the correct view of transcultural psychiatry. But although there are connections, they are not as simple as they might at first appear. I will explain this by sketching the implications of two rival models of (mental) illness.
According to Wakefield, a disorder is a harmful dysfunction, where a dysfunction is picked out, it turns out, in accordance with evolutionary theory. (I say ‘it turns out’ to mark the fact that function is supposed to be a ‘back box concept’.) Evolutionary theory specifies the biological functions of the traits of the human mind and body. On this picture, there are evolutionary facts about mental function, from which deviations are failures of function, and these facts should hold universally. This approach might thus support the universal substrate necessary for a two factor model.
But, on reflection, it need not. It will only support a two-factor model if the underlying dysfunctions – identified via failure of biological functions – can also be culturally moulded or shaped. Suppose that there is no way to separate an underlying mental function or dysfunction from its surface appearance. One reason for thinking this might be a commitment to a difference of kind between the personal level and the sub-personal combined with the idea that there is no depth dimension to the personal or mental. If so, such a view does not fit a two factor model. How might this be? Consider the following description of a symptom (typical of psychotic conditions) in DSM-5.
Disorganized thinking (formal thought disorder) is typically inferred from the individual's speech. The individual may switch from one topic to another (derailment or loose associations). Answers to questions may be obliquely related or completely unrelated (tangentiality). Rarely, speech may be so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its linguistic disorganization (incoherence or "word salad"). Because mildly disorganized speech is common and nonspecific, the symptom must be severe enough to substantially impair effective communication. The severity of the impairment may be difficult to evaluate if the person making the diagnosis comes from a different linguistic background than that of the person being examined. Less severe disorganized thinking or speech may occur during the prodromal and residual periods of schizophrenia. [APA 2013: 88]
Influenced by Wakefield, derailed switching from one thought to another could reasonably be construed as a failure of biological function: a function of the cognitive system. But it is not clear that it is susceptible to any significant cultural shaping. Whilst the subject matter, for example, of jumbled thoughts will depend on the circumstances, including broader cultural circumstances, of the person who experiences them, that seems to be a merely superficial surface colouring of the condition. So in the case of this symptom, the harmful dysfunction model of disorder seems to support a conservative one factor model of cultural psychiatry.
Could the harmful dysfunction analysis of illness be used to support the third option: the radical one factor view according to which mental illnesses are cultural shapings ‘all the way down’? Not, I think, on Wakefield’s own approach which is founded on a historical biological conception of function and dysfunction. But only two changes are necessary to fit that model. First, it requires changing the underlying analysis of function from a historical approach following Wright to a present functioning account following Cummings [Wright 1973, Cummins 1975]. Second, the context of such functions would have to be widened to take account of social functioning. Taken together, such a modification would suggest the possibility of conditions which impaired the local social functioning of individuals. Furthermore, both modifications seem plausible in the light of existing criticism of Wakefield’s precise view [eg Bolton 2008].
The harmful dysfunction account of disorder is consistent with all three models of cultural concept. Thus a defence of harmful dysfunction as a general analysis of mental disorder does not itself determine a view of cultural psychiatry. Wakefield’s position contains a value-free core. There are opposing views that hold that mental illness is evaluative through and through. Can such a ‘values-in’ view determine the correct account of cultural concepts in psychiatry?
On Bill Fulford’s version of a ‘values-in’ theory, illness corresponds to an endogenously caused failure of ordinary doing, an inability to do the sort of things that one should just be able to get on and do [Fulford 1989]. The analysis aims to capture both mental and physical illness. Both are value-laden. Fulford thus challenges an assumption about physical illness shared by both Thomas Szasz and Robert Kendell [Szasz 1960; Kendell 1975]. But he also stresses a contingent difference between mental and physical illness which is relevant here. We typically disagree about the values relevant to mental illness, and hence of the sort of impediments to ordinary doing, whilst we typically and contingently agree in the case of physical illness. We agree about the contribution of a heart to healthy ordinary doing, and hence about heart disease, but not mental flourishing and hence mental illness.
If Fulford is correct about that difference and its significance then his account might seem to undermine the universality of the underlying pathology necessary for a two factor model. (I suspect that that is what Fulford himself would think.) There would be no underlying universal substrate of pathologies because different cultures would have different values and thus quite different ways of failing to be able to act. This would support the radical version of the one factor model.
But that model of cultural psychiatry is not a necessary consequence of a ‘values-in’ view of mental illness. One might think that mental illness and mental health are essentially evaluative notions but that, on a proper view, the values involved are (that is, ought to be) universal. On such a view, there is a rich value-laden notion of the proper way for a human to be, for human flourishing, and deviations from it are value-laden mental illnesses. This might amount to either a two factor or a conservative one factor model. The difference depends on whether one thinks that the kinds of actions one should ordinarily be able to do can be common components within importantly different broader culturally determined contexts (the two factor model) or whether one thinks that the same basic actions, undermined by illness, are visible across different (the conservative version of the one factor model). On the former view there is a need for a cultural formulation to investigate common factors within apparently different practices whilst on the latter the commonalities are clear and hence there is no such need.
My aim so far has been to investigate different possible views of trans-cultural psychiatry. Three different views seem to make sense, each with different implications for the need for a cultural formulation. But there do not seem to be close connections between general accounts of the nature of mental illness and disorder and any one of the three. In other words, there do not seem to be very strong a priori arguments for any particular view. Given this, the only alternative is to look to the actual examples in DSM-5 and examine which model they fit and hence the implicit view of transcultural psychiatry.

The status of Khyal cap
Having sketched some abstract models of ways to understand cultural concepts of mental distress and their merely loose connections to rival accounts of mental disorder in general, I will now turn to one particular example from DSM-5 to see which model applies.
Khal cap is described in the following way. (It will be helpful to quote this one example in full to suggest the kind of description offered in the other cases too).
Khyal cap
‘Khyal attacks’ (khyal cap), or ‘wind attacks,’ is a syndrome found among Cambodians in the United States and Cambodia. Common symptoms include those of panic attacks, such as dizziness, palpitations, shortness of breath, and cold extremities, as well as other symptoms of anxiety and autonomic arousal (e.g., tinnitus and neck soreness). Khyal attacks include catastrophic cognitions centered on the concern that khyal (a windlike substance) may rise in the body—along with blood—and cause a range of serious effects (e.g., compressing the lungs to cause shortness of breath and asphyxia; entering the cranium to cause tinnitus, dizziness, blurry vision, and a fatal syncope). Khyal attacks may occur without warning, but are frequently brought about by triggers such as worrisome thoughts, standing up (i.e., orthostasis), specific odors with negative associations, and agoraphobic type cues like going to crowded spaces or riding in a car. Khyal attacks usually meet panic attack criteria and may shape the experience of other anxiety and trauma- and stress or related disorders. Khyal attacks may be associated with considerable disability.
Related conditions in other cultural contexts: Laos (pen lom), Tibet (srog rlunggi nad), Sri Lanka (vata), and Korea (hwa byung).
Related conditions in DSM-5: Panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, illness anxiety disorder. [ibid: 834]
I raised the question at the start of the chapter of whether cultural sensitivity requires the adoption of a kind of anthropological relativism or whether it is consistent with the privileging of a particular cultural standpoint: that of twenty-first century western psychiatry?
In this case, at first sight no such relativism seems necessary. Khal cap can serve as an ‘idiom of distress’: the conception of an experience had by a subject. If someone describes their experience as the rising up of a wind-like substance then that is simply an anthropological fact about the culture. It can serve as a ‘cultural explanation’ because, again, that is a fact about how a culture explains particular experiences without implicit endorsement of that theory of aetiology by the ascriber. But, by the standards of twenty-first century western psychiatry, it can even be described as a ‘cultural syndrome’ since that is defined as ‘a cluster or group of co-occurring, relatively invariant symptoms found in a specific cultural group, community, or context’. If, for whatever reason, the symptoms described co-occur then it is reasonable to call them ‘khal cap’. In other words, the sincere use of ‘khal cap’ by a transcultural psychiatrist need not cause any intellectual difficulty.
But such a reading of the description carries some implications when it comes to understanding the nature of culturally sensitive psychiatry. If the concept of a khyal attack is only ever used within the (intensional) context of what someone from that culture believes – his or her conception of the nature and explanation of their experiences – rather than as an objective description of what is really causing the attack, then that suggests a distinction of kind between cultural concepts (or culture-bound syndromes) and the main elements of DSM-5’s taxonomy.
Consider the question asked from a traditional Western psychiatric standpoint: ‘But from what are they really suffering?’. The description above suggests a ready answer selected from the list of related conditions in DSM-5: ‘Panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, illness anxiety disorder’. Such a response suggests that a culturally sensitive psychiatry might be merely a sensitivity to other cultures’ errors: the truthful ascription of a false belief about the causes of abnormal experiences.
With that worry in the background, I can approach the example of khyal attack through the range of options explored above. Recall Mezzich et al’s suggestion that the role of a cultural formulation is to ‘map what he or she has learned about the patient’s illness onto the conceptual framework of clinical psychiatry’. I suggested that this reflected a two factor model. If so, the underlying invariant factor is whatever is picked out by ‘panic attack, panic disorder, generalized anxiety disorder, agoraphobia, posttraumatic stress disorder, [or] illness anxiety disorder’. The varying local cultural shaping is the ‘catastrophic cognitions centered on the concern that khyal (a windlike substance) may rise in the body’.
The example fits the two factor model. But if so there remains an asymmetry between khal cap and panic attack because, from the perspective of the rest of the DSM, the former involves an error about the real aetiology of the condition. Dividing the condition between two factors does nothing to change this perspective.
Nor does it help to adopt the conservative one factor model. That presents a stark choice for any putative newly discovered mental illness. On this conservative view, culture-bound syndromes such as khyal cap can have either of two statuses. They are either really other names for universal conditions also picked out by the vocabulary of Western psychiatry such as ‘panic disorder’. Or they do not exist. For example, if it is an essential part of the theoretical apparatus of khyal cap that it is caused by the rising up of a wind-like substance then given that on our best account of physiology there is no such substance then, equally, there is no such condition. Those who self-report it, or its characteristic symptoms, are in some sense in error about their own conditions.
Could khal cap be understood in accord with the radical one factor model? Again, it seems not. That would require thinking of it as a genuinely different way of being ill resulting from being in a different culture. One way that might come about (influenced by the harmful dysfunction approach to disorder) is if it impedes a social function which has no echo in Western society. Or, drawing on Fulford’s work, it might be that there are local standards for what counts as ordinary doing and hence novel possibilities for endogenously caused failures of such doing. But khal cap does not seem to differ from health in respect of any novel social function or ordinary doing. It does not fit this more radical idea of transcultural psychiatry.

This chapter was written whilst a fellow of the Institute for Advanced Study, University of Durham. My thanks both to the IAS, Durham and the University of Central Lancashire for granting me research leave.

One of the criticisms of western psychiatry has been its cultural narrow mindedness, reflecting only a particular socio-cultural perspective [eg Watters 2010]. Thus the idea that DSM-5 contains a wider range of cultural idioms of mental distress than previous editions might suggest progress has been made in addressing this criticism.
Further, there are ways in which the existing DSM diagnostic categories could be augmented by other culturally-specific concepts. On a two factor model, the same underlying illnesses – or the same underlying causes of illness – might be experienced in different ways in different societies. Perhaps the disturbances of self that underpin schizophrenia with its characteristic delusions might be experienced differently in a culture not so influenced by the individualism imparted to the west by Descartes. On a radical one factor model, genuinely distinct conditions might be possibilities in virtue of different conceptions of flourishing, or ordinary actions, or societal functions (depending on the view taken of the concept of disorder). A compendious version of the DSM might chart conditions whether or not they were possible in every society.
However, the conditions set out in DSM-5, exemplified by khyal cap, do not fit either of these possibilities in a way that suggests cultural even handedness. If khyal cap is understood in accord with a two factor approach, the second factor nevertheless involves a kind of mistake. And it does not fit the radical one factor model.
This result is, perhaps, unsurprising. Although these cultural concepts of distress are flagged in the Introduction and discussed in the main body of DSM-5, their articulation and description is restricted to an appendix. They do not form a part of the taxonomy of mental illnesses proper, the taxonomy whose aims included validity. The very idea of transcultural psychiatric diagnostic concepts does not fit easily into DSM-5.

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