10.1: Culture and Mental Health

What is Mental Illness?

A psychological disorder is a condition characterized by abnormal thoughts, feelings, and behaviors. Psychopathology is the study of psychological disorders, including their symptoms, etiology (i.e., their causes), and treatment. The term psychopathology can also refer to the manifestation of a psychological disorder. Although consensus can be difficult, it is extremely important for mental health professionals to agree on what kinds of thoughts, feelings, and behaviors are truly abnormal in the sense that they genuinely indicate the presence of psychopathology.

Certain patterns of behavior and inner experience can easily be labeled as abnormal and clearly signify some kind of psychological disturbance. The person who washes his hands 40 times per day and the person who claims to hear the voices of demons exhibit behaviors and inner experiences that most would regard as abnormal. Abnormal refers to beliefs and behaviors that suggest the existence of a psychological disorder.

On the other hand, consider the nervousness a young man feels when talking to attractive women or the loneliness and longing for home a freshman experiences during her first semester of college—these feelings may not be regularly present, but they fall in the range of normal. So, what kinds of thoughts, feelings, and behaviors represent a true psychological disorder? Psychologists work to distinguish psychological disorders from inner experiences and behaviors that are merely situational, idiosyncratic, or unconventional.

Historical Explanations

Throughout history there have been three general theories of the etiology (causes) of mental illness: supernatural, somatogenic, and psychogenic.

• Supernatural theories attribute mental illness to possession by evil or demonic spirits, displeasure of gods, eclipses, planetary gravitation, curses, and sin.
• Somatogenic theories identify disturbances in physical functioning resulting from either illness, genetic inheritance, or brain damage or imbalance.
• Psychogenic theories focus on traumatic or stressful experiences, maladaptive learned associations and cognitions, or distorted perceptions.

Etiological theories of mental illness determine the care and treatment mentally ill individuals receive. Modern treatments of mental illness are mostly associated with the establishment of hospitals and asylums, beginning in the sixteenth century, to house and confine the poor, homeless, unemployed, criminals and those with mental illness. While inhumane by today’s standards, the view of insanity at the time likened individuals with mental illness to animals (i.e., animalism) who did not have the capacity to reason, could not control themselves, were capable of violence without provocation, did not have the same physical sensitivity to pain or temperature, and could live in miserable conditions without complaint.

Etiological theories coexist today in what the psychological discipline holds as the biopsychosocial model of explaining human behavior. While individuals may be born with a genetic predisposition for a certain disorder, certain psychological stressors need to be present for the development of the disorder. Sociocultural factors such as sociopolitical or economic unrest, poor living conditions, trauma or problematic interpersonal relationships are also viewed as contributing factors. As much as we want to believe that in present day we are above the historical treatments now considered inhumane, or that the present is always the most enlightened time, we should not forget that our thinking today continues to reflect the same underlying somatogenic and psychogenic theories of mental illness discussed throughout this superficial and brief history of mental illness.

Diagnosis

Progress in the treatment of mental illness necessarily implies improvements in the diagnosis of mental illness. A standardized diagnostic classification system with agreed-upon definitions of psychological disorders creates a shared language among mental health providers and aids in clinical research. While disorders have been recognized as far back as the ancient Greeks, it was not until 1883 that German psychiatrist Emil Kräpelin (1856–1926) published a comprehensive system of psychological disorders that centered on a pattern of symptoms (i.e., syndrome) suggestive of an underlying physiological cause. Other clinicians also suggested classification systems that became popular but the need for a single, shared system paved the way for the American Psychiatric Association’s 1952 publication of the first Diagnostic and Statistical Manual (DSM). The most recent version is the DSM-5 (2013). Each revision reflects an attempt to help clinicians streamline diagnosis and work better with other diagnostic systems such as health diagnoses outlined by the World Health Organization (WHO).

While the concept of mental or psychological disorders is difficult to define, and no definition will ever be perfect, it is recognized as an extremely important concept and therefore psychological disorders (aka mental disorders) have been defined as a psychological dysfunction which causes distress or impaired functioning and deviates from typical or expected behavior according to societal or cultural standards. This definition includes three components (3 Ds)

• Dysfunction
• Distress
• Deviance

Dysfunction includes disturbances in a person’s thinking, emotional regulation, or behavior that reflects significant dysfunction in psychological, biological, or developmental processes underlying mental functioning. In other words, dysfunction refers to a breakdown in cognition, emotion, and/or behavior. For instance, an individual experiencing the delusion that he is an omnipotent deity has a breakdown in cognition because his thought processes are not consistent with reality. An individual who is unable to experience pleasure has a breakdown in emotion. Finally, an individual who is unable to leave her home and attend work due to fear of having a panic attack is exhibiting a breakdown in behavior.

Distress can take the form of psychological or physical pain, or both at the same time. Simply put, distress refers to suffering. Alone though, distress is not sufficient enough to describe behavior as abnormal. Think about it – the loss of a loved one causes even the most “normally” functioning individual pain and suffering. An athlete who experiences a career ending injury would display distress as well. Suffering is part of life and cannot be avoided. Impairment refers to when the person experiences a disabling condition that limits the ability to engage in activities of daily living (e.g., can no longer maintain minimum standards of hygiene, pay bills) or participate in social events (e.g., attending social events), work or school. Impairment can also interfere with the ability to perform important life roles (e.g., student, caregiver or parent).

A closer examination of the word abnormal shows that it indicates a move away from what is normal, typical, or average. Deviance refers to behavior that violates social norms or cultural expectations because culture determines what is normal. When a person is said to be deviant when he or she fails to follow the stated and unstated rules of society, called social norms. As you might expect there is a lot of cultural variation in acceptable behavior.

Earlier we learned about cultural relativism and shat is considered normal by a culture can change over time due to shifts in accepted values and expectations. For instance, just a few decades ago homosexuality was considered taboo in the United States and it was included as a mental disorder in the first edition of the DSM; but today, it is generally accepted. Likewise, public displays of affection, do not cause a second look by most people unlike the past when these outward expressions of love were restricted to the privacy of one’s own house or bedroom. In the United States, crying is generally seen as a weakness for males but if the behavior occurs in the context of a tragedy then it is appropriate and understandable. Finally, consider that statistically deviant behavior is not necessarily negative. Cognitive genius is an example of behavior that is not the norm. Abnormality alone is not an indication of a disorder or problem.

Though not part of the DSM -5 conceptualization of what abnormal behavior is, many clinicians add a fourth D – dangerousness to this list. Dangerousness refers to when behavior represents a threat to the safety of the person or the safety of others. Individuals expressing suicidal intent, those experiencing acute paranoid ideation combined with aggressive impulses (e.g., wanting to harm people who are perceived as being out to get them), and many individuals with antisocial personality disorder may be considered dangerous. Mental health professionals (and many other professionals including researchers) have a duty to report to law enforcement when an individual expresses an intent to harm themselves or others. Individuals with depression, anxiety, and obsessive-compulsive disorder are typically no more a threat to others than individuals without these disorders. It is very important to remember that having a mental disorder does not automatically mean that a person is dangerous and most dangerous individuals are not mentally ill.

References to mental illness can be found throughout history. The evolution of mental illness, however, has not been linear or progressive but rather cyclical. Whether a behavior is considered normal or abnormal depends on the context surrounding the behavior and thus changes as a function of a particular time and culture. In the past, uncommon behavior or behavior that deviated from the sociocultural norms and expectations of a specific culture and period has been used as a way to silence or control certain individuals or groups.

As a result, a less cultural relativist view of abnormal behavior has focused on whether behavior poses a threat to oneself or others or causes so much distress that it interferes with one’s responsibilities or relationships with family and friends.

There has been a recent shift in medicine, psychology and anthropology and the way that we study and evaluate culturally specific forms of distress. Historically, the terms culture – bound syndrome, cultural – specific syndrome, or folk illness were used to categorize symptoms or disorders that we believed to be specific to certain societies or cultures. More recent research (Kaiser, & Weaver, 2019; Ventriglio, Ayonrinde, and Bhugra, 2016) question our perception of truly culturally specific conditions. Expressions and descriptions of disorders once thought to be culturally unique often overlap with symptoms that are seen and described in other cultures; these clusters of symptoms are just called something else.

Cultural Concepts of Distress

Changes to society over the last decade, including technological advancements and increased globalization, has expanded cross-cultural influences and reduced cultural isolation. This means that descriptions of symptoms and expressions of distress that once seemed confined to specific locations in the world are being transmitted through social media and other influences. For example, anorexia nervosa was once thought to be a condition unique to Western cultures but recent psychiatric and psychologial research has identified symptoms of the disorder in other cultures and societies (Kaiser & Weaver, 2019).

In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome, or folk illness is a combination of psychiatric (brain) and somatic (body) symptoms that are considered to be a recognizable disease only within a specific society or culture. There are no objective biochemical or structural alterations of body organs or functions and the disease is not recognized in other cultures. The term culture-bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) which also includes a list of the most common culture-bound conditions.

Recent changes to DSM-5TR and the ICD-11 suggest a trend toward better understanding cultural influences rather than culturally specific disorders. Rather than disorders being confined to specific cultures, the emphasis has changed to better recognition of the expression of symptoms and sources of distress within each culture in order to improve healthcare and treatment. To capture the changes in thinking and understanding, the DSM – 5TR includes a section on Cultural Concepts of Distress, which are the ways that different cultural groups experience, understand, and communicate suffering, behavioral issues, or troubling thoughts and emotions. Cultural concepts of distress include a combination of psychiatric (brain) and somatic (body) symptoms that are considered to be a recognizable disease only within a specific society or culture. There are 3 concepts linked to CCD to help clinicians assess and to formulate a diagnosis:

• Cultural syndrome refers to clusters of symptoms of distress that occur and are understood within specific cultural groups, communities or contexts.
• Cultural idiom of distress  acknowledges that expressions of suffering  may not be syndromes. An idiom of distress in a way of talking about symptoms or experiences among people with similar backgrounds. These words or expressions do not need to be part of a syndrome. For example, consider the phrase, “I feel blue.”  In the United States we would understand that to mean that someone feels sad or depressed but the meaning of the phrase would not translate or be understood in the same way in other countries or cultures.
• Cultural explanation or perceived cause of the disorder. This means that symptoms or suffering are directly attributed to linked to specific causal factors rooted in local beliefs or values. This could include explanations like spirits or failure to follow specific cultural practices. For example, in some cultures being the target of envy or jealousy (mal de ojo) can result in headaches, fever, crying or anxiety.

The three concepts replaced the phrase culture – bound syndrome in the revised version of the DSM.

Some cultural syndromes involve somatic symptoms (pain or disturbed function of a body part), while others are purely behavioral. Some cultural syndromes appear with similar features in several cultures, but with locally specific traits. In general, cultural syndromes meet the diagnostic criterais for several disorders in the DSM but do not correspond directly with any one disorder – this is part of why they are considered a cultural syndrome. The DSM – 5TR includes 10 examples of cultural syndromes that are currently identified in the global community including Dhat, Hikikomori, and Susto.

• Dhat syndrome is a condition found in the cultures of the Indian subcontinent in which male patients report that they suffer from premature ejaculation or impotence, and believe that they are passing semen in their urine.
• Hikikomori is cultural syndrome found in Japan that is characterized by severe isoloation including physical isolation in a person’s home. It is also characterized by extreme psychological detachment from society, and avoiding tasks that require interaction with others. This condition is recognized as a psychological disorder in the Japanese classification system (their equivalent of the DSM).
• Susto is a cultural illness primarily among Latin American cultures. It is described as a condition of being frightened and “chronic somatic suffering stemming from emotional trauma or from witnessing traumatic experiences lived by others.

Within the ICD-10 (Chapter V) framework cultural syndromes are characterized by:

• Categorization as a disease in the culture.
• Widespread familiarity in the culture.
• Complete lack of familiarity or misunderstanding of the condition to people in other cultures.
• No objectively demonstrable biochemical or tissue abnormalities.
• The condition is usually recognized and treated by the folk medicine of the culture.

 

Attributions:

• 10.1: What is Mental Illness? by L. D. Worthy, Trisha Lavigne, & Fernando Romero is licensed CC BY-NC-SA 4.0. Original source: https://open.maricopa.edu/culturepsychology.
• 10.4: History of Mental Illness by L. D. Worthy, Trisha Lavigne, & Fernando Romero is licensed CC BY-NC-SA 4.0. Original source: https://open.maricopa.edu/culturepsychology.
• 10.5: Culture-Bound Disorders by L. D. Worthy, Trisha Lavigne, & Fernando Romero is licensed CC BY-NC-SA 4.0. Original source: https://open.maricopa.edu/culturepsychology.