The existence of culture bound syndrome

This essay will explore whether culture bound syndrome exist or not. First, the essay will first define what culture bound syndromes are and how they are categorised. Then this is followed by a discussion of arguments supporting the existence of CBS and arguments challenging their existence.

Introduction

Most mental health disorders are based on the Western scientific model of medicine. It is assumed that mental health disorders stem from a biological basis and that they are found in all cultures. The view that mental health problems are culture free is a universalist perspective. However a universalist perspective ignores the role of culture on mental health. Ignoring the role of culture can lead to misdiagnosis and lack of understanding about mental health problems in general.

Definition

Classification systems like the DSM IV ( Diagnostic and Statistical manual of mental health disorders)are a diagnostic tool for psychiatrists. The current DSM is the DSM IV, where “Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) has been designed for use across clinical settings (inpatient, outpatient, partial hospital, consultation-liaison, clinic, private practice, and primary care), with community populations. It can be used by a wide range of health and mental health professionals.” The current edition of the DSM has made modest attempts to include mental health disorders from other cultures in order to address cultural issues. These are known as culture-bound syndromes and are defined as;

Culture Bound syndromes are a culturally relative approach to mental health disorders in which specific symptom are unique to that particular culture. recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be “illnesses”, or at least afflictions, and most have local names

The word culture refers to the beliefs, norms and also values that govern the way people that are within a defined group such as a certain society or nation that interact with each other and these must be in a standard of acceptable behaviours and thoughts and each new member of the society has to learn these beliefs and understandings. This links to culture bound syndromes since as mentioned before, Culture bound syndromes are syndromes in which are very unique to a certain culture only which would mean that their symptoms are only seen and experienced within that culture.

An examples of a culture bound syndromes is Amok found in Malaysia. This CBS is where “this is a dissociative episode featuring a period of brooding followed by an outburst of aggressive, violent or homicidal behaviour aimed at people and objects.  It seems to occur only among males, and is often precipitated by a perceived slight or insult.  It is often accompanied by persecutory ideas, automatism, amnesia or exhaustion, following which the individual returns to their pre-morbid state.  The victim, who is almost always a male between 20-45, has often experienced a loss of social status or a major life change.  It is now rare, and occurs primarily in rural regions.” 4

Another culture bound syndrome would be Dhat which occurs in India. Dhat is defined as “vague somatic symptoms of fatigue, weakness, anxiety, loss of appetite, guilt and sexual dysfunction attributed by the patient to loss of semen in nocturnal emissions, through urine and masturbation.”  The anxiety related to semen loss can be traced back thousands of years to Ayurvedic texts, where the loss of a single drop of semen, the most precious body fluid, could destabilize the entire body.”

These examples of culture bound syndrome represent some syndromes are found in Asia. Culture bound syndromes also exist in Western society – one of the most well known ones is anorexia. It is “an eating disorder in which people intentionally starve themselves. It causes extreme weight loss, which the National Institute of Mental Health (NIMH), part of the National Institutes of Health (NIH), defines as at least 15 percent below the individual’s normal body weight.”

Categorizing culture bound syndromes

Culture bound syndromes have been categorised by McCajor Hall (1988) in the six following ways:

• The first way is that he believes that in order to be a culture bound syndrome, it must be a psychiatric illnesses that has not been originally caused and it must be recognised as an illness locally, however it must not be matched within a recognised category.
• The second way is that, it must be a psychiatric illness that has not been originally caused and is also recognised as an illness locally but it must also resemble a western category though it may lack some symptoms that are usually regarded as the important part within other cultures.
• The third way is just simply that the psychiatric illness has not yet been recognised in the west.
• The fourth way is that the psychiatric illness that is found in many cultures may be originally caused but must be only regarded as an illness in one or a few of the cultures.
• The fifth way is that the psychiatric illness is accepted culturally as a form of illness but it would still not be regarded as an acceptable illness in the mainstream of western medicine.
• The sixth way is that the psychiatric illness or syndrome supposedly occurring in a given culture, but in fact does not exist at all in reality but is used to justify the expulsion and execution of an outcast in the same way witchcraft was.

Psychiatrist, Berry et al (1992) has argued that there are three types of syndromes. Firstly, absolute syndromes where the same symptom and incidence rates are found around the world. The second is universal syndromes where the same symptoms are found around the world but where the incidence rates may vary between culture to culture and lastly culturally relative syndromes where the symptoms are unique to a particular culture.

However there remains speculation about the existence of culture bound syndromes, some psychologists take a universalist position and maintain they don’t exist, whilst others take a relativist position and argue they do.

Culture Bound syndromes do exist

Culture bound syndromes are unique in their own way since it can only be seen within specific cultures. People who support this idea are psychologists like Pfeiffer and McCajor Hall. Hall believes that in order for a syndrome to be considered a culture bound syndrome, the syndrome itself must essentially be recognised by the locals of the specific culture and must be not known by another category like from the western culture. If it is recognised as or resembles a western mental illness, then the syndrome should at least have a few of its symptoms but not all.

Pfeiffer has argued that culture bound syndromes might not be at home in the classification system such as the DSM IV. He believes that culture bound syndromes should be viewed at a level of the culture individually itself and not just from one specific place like the vantage point of Washington DC ( the home of the American Psychological Association) and believes that it is specific in the following four aspects. The first aspect is that he believes that cultures differ in those things that place people under unbearable stress, for example, in one culture it may be due to work, status or health issues while in another culture it may be due to family relations.

The second aspect he proposed was that different cultures allow and ban certain expressions and behaviours and what might be permitted as a culturally acceptable release mechanism in certain cultures may perhaps not be allowed in others if they do not accept it. For example within some cultures, drinking alcohol is prohibited. Without this release mechanism certain frustrations may be expressed in certain ways that are disguised in cultures where drinking alcohol is viewed as a acceptable behaviour. Therefore a behaviour may be unique to that behaviour.

The third aspect is that we may have culture- specific interpretations within us; this would mean that a behaviour is one thing, however what we take it to mean for ourselves and what sense we make from it, can be a totally different thing. An example of this would be that back in the past, certain women were ‘discovered’ or rather accused of being witches because of culturally specific interpretations of their behaviour (Ussher 1992).

The fourth aspect that Pfeiffer proposed was that we have not explored the variety of culturally specific ways of treating disorders, but folk medicine is a good example of the ways in which indigenous people treat their illnesses. Another good example would be that through western sciences, people can be cured from their illness like fever, cough and so on though the usage of drugs but in the Asian culture, the Chinese use natural sources such as herbs or use acupuncture to cure the same illness the western culture is curing but the only difference between the two cultures is the method that is being used. From this, if it is true that Culture bound syndromes are a form of folk illness that are to be treated by folk medicine, then this would mean that they are qualitatively inconsistent with the aims and purpose of the ICD and DSM.

Though Pfeiffer’s view was different compared to Hall’s view, there are some similarities, and the most obvious one would be the fact that the syndrome is determined by the culture itself. This shows that both psychologists view believe that not every culture bound syndrome has to be under Western science and that it can be unique in its own way.

Behaviours can be misunderstood and misinterpreted. What is considered normal in one culture may not be in another and vice versa.

“In a study in the early 1960s, Lee noted that out of a random sample of Zulu women more than a third had reported visual and auditory hallucinations involving ‘angels, babies and little short hairy men’. In the same study he found that more than half of the women engaged in ‘screaming behaviour’, often yelping for hours, days and even weeks. Either of these reported behaviours would be viewed as grossly abnormal in the west. Yet few of these women showed any other signs of mental disorder. Within their own culture their hallucinations and screaming were legitimate.” Such a study shows that though not accepted globally, different societies have different morals and different beliefs. Zulus considered having hallucinations and screaming as acceptable and normal however such behaviours would be pathologised in the West. The opposite then can be true, behaviour can be deemed unacceptable or a mental illness if it violates a society’s norms.

Sam (1996) states that western psychological explanations don’t account for all the experiences and behaviour of people from other cultures, psychology being western culture bound and blind to influences from elsewhere

Culture-bound syndromes do not exist

Yap (1974) has argued that human mental disorders are very broad and span across all culture and so it could be argued that the symptoms emerge from within the individual and these symptoms cluster together to form discrete categories of mental illness. The second point is that he believes comparative psychiatry aims to establish common links across cultures in a similar manner to the way in which comparative psychology explores links within humans which could be seen as culturally specific expressions of common human problems and disorders that are addressed by the ICD and the DSM. Yap also mentions that he believes that a CBS such as Latah is a local cultural expression of ‘primary fear reaction’.

There are also other arguments which show that culture bound syndrome in fact do not exist. One example is that of ‘Dhat’, mentioned earlier. ‘The British Journal of Psychiatry’includes a study called “Culture-bound syndromes: the story of Dhat syndrome” The study had two objectives; the first was to gather information on studies which were clinical and empirical about the syndrome called Dhat and to review the literature that was done. The second was to extract the information on historical data in different countries at different periods. The method in which they decided to do it was by manual literature searches and electronic literature searches in order to gain information. They did it on the existence and description of the semen-loss anxiety in different cultures and also settings. The result was that although Dhat syndrome usually came from Asia, the syndrome’s concepts, historically have been explained by other cultures in Britain, USA and Australia for example. This shows that from the sources gained, the symptoms show “global prevalence of this condition”, even though it’s mostly seen as a syndrome from the east. The conclusion they came up with was that “It appears that dhat (semen-loss anxiety) is not as culture-bound as previously thought. We propose that the concept of culture-bound syndromes should be modified in line with DSM-IV recommendations.” Also when they were collecting and analysing the results they found out that semen loss anxiety in Western culture, Chinese culture and in the Indian subcontinent were the same and what their views on the loss of semen meant to them within the culture. In fact the historical information could be traced back to Aristotle’s time whilst on the Indian subcontinent this view could be found “In Ayurvedic texts which are dated between the 5th millennium BC and the 7th century AD “. This show that people think alike about same but it’s just called in different names. This is very significant as this supports with the universal idea where it is proposed that mental health disorders are universal and that culture bound syndromes are in fact just variations of the mental health disorders depending on what sort of symptoms they have. This supports the view that culture bound syndrome should not need a new diagnostic criteria due to it being variations as mentioned before.

‘The British Journal of Psychiatry’argues that the syndrome called ‘taijin kyofusho’ from Japan is similar to the western category of social phobia. Both syndromes cause the patients to suffer an intensive fear about their bodies, body part or even body functions in which may be displeasing to other people. If we compare the syndrome taijin kyofusho with social phobia, both have symptoms like anxiety, although to different degrees, so we can say it’s the same syndrome or mental illness. Culture bound syndrome may in fact only be considered a syndrome for a specific culture in that it may not have all the symptoms from the western culture.

Thomas Szasz an American psychologist also believed that the idea of culture bound syndromes existing is obsolete though he also believed that the idea of mental health disorders existing is also obsolete too. The idea on mental illnesses or mental health disorder in which Thomas Szasz has came up with is the idea in which that these don’t really exist. He believed that these are just a myth as all the mental illnesses has no real evidence in which show they are a biological cause of mental illnesses.

In a article about him by ‘the new atlantis’, ” Szasz mocked the efforts of almost every major American psychiatrist back to Benjamin Rush, the profession’s founding father. “The subjects [mental diseases] have hitherto been enveloped in mystery,” Rush wrote in the late eighteenth century. “I have endeavored to bring them down to the level of all other diseases of the human body, and to show that the mind and the body are moved by the same causes and subject to the same laws.” This was the error Szasz aimed to correct.”

This can be seen Within his “The Myth of Mental Illness: Foundations of a Theory of Personal Conduct’ .”It is a “Thomas Szasz’s classic book revolutionized thinking about the nature of the psychiatric profession and the moral implications of its practices. By diagnosing unwanted behavior as mental illness, psychiatrists, Szasz argues, absolve individuals of responsibility for their actions and instead blame their alleged illness. He also critiques Freudian psychology as a pseudoscience and warns against the dangerous overreach of psychiatry into all aspects of modern life.” Thomas Szasz believes that psychiatry is just a social control system and not a truly medical science as he believed that psychiatry is nothing but just for people to deal with other people’s problems in living that has been troubling them in life on and on. Thomas Szasz also feels that psychiatry is nothing but a pseudo science that pretend it’s a medicine by using words in which would make psychiatry sound medical over the last century. From this Thomas Szasz show people that such ideas like mental health disorders and culture bound syndromes do not exist.

Conclusion

In conclusion, the culture bound syndromes do exist to some extent as people such as Yap’s idea believe on the universal approach and believe that culture bound syndromes are just mental health disorders but just at a lower scale. Another psychologists who believe that culture bound doesn’t exist is Thomas Szasz, though he also believes mental health disorders do not exists, his idea still nonetheless show it to be non-existence. However according to the article in the new Atlantic Szasz has been ” passed into legend, bearing little resemblance to reality”. At this time now “Szasz is mostly remembered, if he is remembered at all, as the great silly, a flat-earth adherent in the time of telescopes and globes. Most medical students graduate without ever hearing his name.” They believe that his believes and views are now obsolete and “One can hardly be surprised if Szasz has assumed the role reserved for all failed revolutionaries”.

‘The British Journal of Psychiatry’have also done historical research on the culture bound syndrome Dhat where they looked at how the view of losing semen was approach. They found that the views were the same , where they all believed that semen are very precious and valuable and a undesirable trait. This show and supports the idea of universality where all mental health disorders exist everywhere and they are all the same. This shows that the culture bound syndrome Dhat was not really a culture bound syndrome and it could have been exaggerated. The journal has concluded within their research that since the Dhat syndrome is not really a culture bound syndrome they thought it would be, they suggested that the Dhat syndrome should modify its criteria along the lines which is similar to the DSM IV. This once again supports the universality idea.

Unfortunately despite various arguments showing culture bound syndromes existence to be obsolete, there are still quite a few psychologists who have their own views and believes that show that that culture bound syndrome does in fact exist. A good example would be psychologist McCajor Hall’s believes. Hall believed that since culture bound syndromes are only present in specific cultures; he believed that so long a syndrome does not have all the symptoms that are from a western category it is indeed, a culture bound syndrome.

McCajor Hall with his own views and ways lets people realize that, not all disorders or syndromes in fact have to be compared to western science nor does it have to be under a western category in mental health disorders and the syndromes can be in anywhere in different forms.

The psychologist Pfeiffer also has his own views and believes strengthens the culture bound syndrome furthermore, saying that culture varies from one to another. Pfeiffer believed that one problem in one culture may not have the same problem in another culture and has mentioned that depending on the culture, behaviours can be only acceptable or unacceptable only according to their culture.

From here we see that culture bound syndromes in fact do exists but not entirely and the extent in which it is exist may not be very high. What shows culture bound syndromes do exists, are from psychologists’ ideas such as Pfeiffer and Hall. Their views tells us that even though some culture bound syndromes may have similar symptoms from the western category on mental health disorders, it still is a culture bound syndrome. The reason for this is because the universal approach may lead to misdiagnosis. Also from Pfeiffer’s first point where one cultures problem is may not be the same as the other, we can see that in reality, it’s impossible to say that cultures all around the world have the same problem. This is quite true as there are a lot of mental health disorders in this world which have yet to be discovered and the psychologists and psychiatrists are yet at a level which can understand the human mind completely since it’s so complex. With this we can once again say that culture bound syndromes exist.