Culture-Bound Syndromes

The term culture-bound syndromes was first coined in 1951 to describe mental disorders unique to certain societies or culture areas. The syndromes may include dissociative, psychotic, anxiety, depressive, and somatic symptoms and do not necessarily fit into contemporary diagnostic and classification systems of Western nosology.

Although there is no consensus among mental health professionals about the extent and ways in which cultural factors influence the manifestation and diagnosis of mental disorders, the American Psychiatric Association’s inclusion of a Glossary of Culture-Bound Syndromes within the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM) constitutes a significant step toward addressing the difficulties encountered in the application of DSM criteria across cultural boundaries and suggests a concerted effort to increase universal utility of diagnostic and classification systems of Western nosology by integrating a group of mental disorders long marginalized as culture-specific. The inclusion of these categories also reflects an increasing recognition of the important role of culture in assessment and treatment as well as a growing acceptance of cultural differences in the diagnostic process. It should be noted that these syndromes were compiled on the basis of decades of interdisciplinary research (i.e., anthropology, psychiatry, and psychology).

According to the DSM, culture-bound syndromes refer to “recurrent, locality-specific patterns of aberrant behavior and troubling experience that may not be linked to a particular DSM diagnostic category. Many of these patterns are indigenously considered to be ‘illness,’ or at least afflictions, and most have local names” (p. 898). The glossary included in the DSM lists more than 20 culture-specific diagnoses along with descriptive features.

These syndromes can be categorized into the following major definitional iterations:

  1. A mental illness that is not attributable to an identifiable organic cause, is often recognized locally as an illness, and does not correspond to a recognized Western medical category
  2. An illness that is not attributable to an identifiable organic cause, is recognized within local culture as an illness, and resembles a Western disease category but may lack some symptoms considered as salient in Western culture
  3. A discrete disease entity not yet recognized in Western culture
  4. A nondescript illness that may or may not have an organic cause and may correspond to a subset of a Western disease category
  5. Illnesses in the idiomatic rhetoric category that represent culturally accepted explanatory mechanisms but may not correspond with Western idioms and, in Western culture, may suggest culturally inappropriate thinking and perhaps delusions or hallucinations
  6. Illnesses in the category of generalized culture-bound syndromes that are characterized by behaviors such as trance, hearing, seeing, or communicating with the dead or spirits, which may or may not be seen as pathological within local culture but could indicate psychosis, delusions, or hallucinations in Western culture
  7. Unreal syndromes that allegedly occur in a given cultural setting, which, in fact, does not exist

As an example, shenjing shaijo (“weakened nerves” or “neurasthenia”) is on the list of culture-specific diagnoses in the DSM and also is included in the Chinese Classification of Mental Disorders, Second Edition. It is characterized by a set of symptoms, including fatigue, headaches, concentration difficulties, sleep disturbance, and memory loss, and, in many cases, the symptoms would meet the criteria for DSM Mood or Anxiety Disorder. An apparent psychiatric illness with no identifiable organic cause, shen-jing shaijo is recognized in the Chinese culture but has locally salient features different from Western diseases and does not typically have symptoms considered critical in Western psychiatry.

Another example is rootwork. In the southern United States and in Caribbean societies, rootwork is a set of cultural interpretations that explain illnesses such as generalized anxiety, fear, and dizziness, in terms of hexing, witchcraft, voodoo, or the influence of an evil person. It is not so much an actual illness as a locally accepted explanatory mechanism of “illnesses.”

Points of Tension

Defined as a network of domain-specific knowledge structures shaped by members of a given cultural group, culture is internalized into each individual’s self-concept and functions as a template to guide one’s expectations, perceptions, and interpretations. Culture exerts its influence over individuals through regulating notions of self, reality, social behaviors, and patterns of emotional expression. As such, culture shapes the experience, expression, and meaning of illness by offering specific contents to thoughts and feelings, which, in turn, manifest as psychological discomfort.

Developing a universally applicable set of descriptive criteria of mental disorders thus remains a daunting task, resulting in much dispute about the utility of the concept.

The focus on the debate over the term culture-bound syndromes often centers on confusions or conflations among the various culture-bound syndrome categories. Given the heterogeneity of these syndromes in the DSM, they are loosely connected at best. Questions remain about the elusive nature of the concept and, in particular, about the lack of clarity regarding the inclusion and exclusion criteria. More specifically, for example, to what extent are the defining features based on peculiarities of the diagnostic process used? Some argue that because the criteria for culture-bound syndromes are socially constructed, every diagnosis, however appropriate, occurs in a broad sociocultural context. The principles of diagnostic systems, therefore, need to be flexibly structured so that the inclusion and exclusion criteria can be applied more directly in the context of the local culture. Questions are raised about how essential characteristics of culture-bound syndromes should be understood within the cultural context. Moreover, given that how individuals perceive, interpret, and respond to mental illness is different from the actual symptoms of the disorder, how much emphasis should be placed on subjective complaint as opposed to symptom manifestation?

Another issue concerns the relationship of culture-bound syndromes to standard diagnostic systems, such as the DSM. It has been argued that many mental disorders do not necessarily conform to the categories in the DSM, and significant differences are noted across cultures, in part, because of differing beliefs about self and reality as well as different ways of conceptualizing and displaying mental experiences. In this view, mental disorders are believed to be socially and culturally construed. Although the DSM has some utility across differing cultural boundaries, the reliability and validity of these classificatory systems are inevitably reduced as a result of the nonuniversality of cultural experiences in relation to mental illnesses.

Counseling Implications

With the influx of immigrants from various cultural groups, U.S. society has become more diverse, and greater demands are being placed on counselors in all types of agencies to provide services that are culturally responsive and effective. Because culture is such a rich vein of information, counseling practice is inevitably embedded in multiple sociocultural realities and contexts. As such, the concept of culture-bound syndromes is important for counselors because minority clients, particularly those who are recent immigrants, may bring with them their own indigenous patterns and conceptions of mental illness into the counseling process and relationship. That is, counseling in general, and mental illness in particular, are likely perceived, experienced, and interpreted differently by the client than by counselors. Counselors thus face the challenge of negotiating with their client a diagnosis in the assessment process, which may occur in a number of ways. Some may, for example, share with the client’s view of the illness as a culture-bound syndrome and offer interventions that are consistent with the folk medicine treatment. Others may empathize with the client’s subjective complaint but decide to educate the client about the causes and nature of the illness as they perceive it. Still others may discount the client’s experience of illness as merely exotic, given the imprecise nature of the concept of culture-bound syndrome. The assessment process, the final diagnosis, as well as the interventions are thus dependent, to a considerable extent, upon the multicultural awareness, knowledge, and skills of counselors.

In relation to culture-bound syndromes, multiculturally competent counselors endeavor to become aware of, and knowledgeable about, the location of culture-bound syndromes in their sociocultural context by raising questions such as the following: Who are those who experience the culture-bound syndromes? What contextual factors may affect the manifestation of these syndromes? To what extent do members of some cultural groups complain of somatic discomforts that are, in fact, psychological in origin because their discomfort is locally recognized as an illness? What is the role of culture in the healthcare system? How has Eurocentrism been reflected in the history of the psychiatric diagnostic system most commonly used today?

In an effort to further improve their skills in the assessment of cultural influences on experiences, counselors may need to use the DSM guidelines for assessing cultural context by considering (a) the client’s cultural identity; (b) cultural expressions and explanations of the illness; (c) cultural factors in relation to psychosocial environment and levels of functioning, such as cultural perceptions of social and situational stressors, social support, level of functioning, and disability; (d) cultural similarities and differences (e.g., social status, language preference) between the client and counselors that may affect the development of a collaborative working alliance; and (e) a summary statement that describes how cultural factors and issues influence comprehensive diagnosis and care.

Counselors may also benefit from a holistic approach when formulating and classifying the culture-bound syndromes, particularly in making distinctions between subjective complaints and symptom manifestation. In doing so, counselors will likely reduce diagnostic and interpretational biases during the assessment process.

References:

  1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text rev.). Arlington, VA: Author.
  2. Guarnaccia, P. J., & Rogler, L. H. (1999). Research on culture-bound syndromes: New directions. American Journal of Psychiatry, 156, 1322-1326.
  3. Hughes, C. C. (1996). The culture-bound syndrome and psychiatric diagnosis. In J. E. Mezzich, A. Klienman, H. Fabgrega, & D. L. Parron (Eds.), Culture and psychiatric diagnosis: A DSM-IVperspective (pp. 289-305). Washington, DC: American Psychiatric Press.
  4. Tseng, W. (2001). Handbook of cultural psychiatry. San Diego, CA: Academic Press.

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