Monday 14 April 2014

Cultural formulation, diagnosis and validity

The draft start of a draft chapter. (A more recent version of the whole chapter is here.)

Cultural factors in DSM-5
DSM-5 attempts to shed light on the role that culture, and cultural differences, can play in psychiatric diagnosis. This section will outline some of those ways before drawing out their implications.
In Section III of DSM-5 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) including: **.

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: **]. 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’) three distinct ways that culture can impact on diagnoses. The single idea of culture-bound syndromes 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: **]

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 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 distess and purported explanations or causes of experiences.

One example of a cultural concept of distress described is khal cap. Again, 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.

The other main cultural concepts of distress described are 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 cultures.

But the description of khal cap will serve to raise a preliminary interpretative question: what stance does DSM-5 have to the content of the cultural concept, so set out? Does the cultural sensitivity aimed at in a formulation and the semi-structured interview protocol require the adoption of a kind of anthropological relativism? Or is it consistent with the privileging of a particular cultural standpoint: that of twenty-first century western psychiatry?

On the face of it, no such relativism is 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 with it some cost when it comes to understanding the possibilities for 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 the 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 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 is merely a sensitivity to other cultures’ errors: the truthful ascription of a false belief about the causes of abnormal experiences. To avoid that, however, seems to require a willingness to use – in anger, as it were – explanations of experiences as  resulting from an increase in the wind-like khal in the body. What are the options for transcultural psychiatry?