Culture and classification: The cross-cultural application of the Dsm-IV

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Abstract

Changes incorporated into the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) include a number of features designed to enhance its cross-cultural applicability. However, the overt move toward a culture-sensitive nosology is undermined by an implicit assumption of the universality of its primary syndromes. In this review we argue that the DSM-IV’s underlying thesis of universality based on Western-delineated mental disorders is problematic and has limited cross-cultural applicability. Research on the cross-cultural manifestation of schizophrenia and depression shows that presentation of these disorders varies significantly across cultures. We conclude by discussing the research and clinical implications of these findings.

Section snippets

The development of the dsm-IV

It was not until the appearance of the DSM-III that the American Psychiatric Association became a significant force in psychiatric nosology. Published in 1980, the third DSM (American Psychiatric Association, 1980) extended use of descriptive diagnostic criteria with the aim of multitheoretical compatibility. It was broadly based on a biopsychosocial model of psychopathology, reflecting developments in psychopharmacology and growth in cultural understanding (Alarcon, 1995). Yet its aim was to

The theoretical basis of the dsm-IV

The cultural additions in the DSM-IV demonstrate a move toward a general acceptance of differences in psychopathology across cultures. However, this move is undermined by the assumption that disorders included in the main text are essentially universal. Such incongruence is indicative of general theoretical uncertainty in the manual. While the DSM-III and III-R claimed to be atheoretical with regard to etiology and psychophysiological processes, the DSM-IV provides no such acknowledgment, yet

What is Culture?

Culture provides people with a framework within which they can relate to one another and co-exist. It is a medium for the transmission over time of ideas, values and customs, and, more generally, ways of living. While for some, the primary manifestations of culture are manmade objects, such as architecture and automobiles (Herskovits, 1948), for others, they are the less tangible correlates of humanity, such as beliefs, values, and norms (Triandis, 1972). According to Fabrega (1992)(p. 91)

Schizophrenia

Late last century, Kraepelin (1902), who was the first to formally identify schizophrenia, put it under the heading of “metabolic diseases.” Although he referred to it as “dementia praecox,” his characterisation of the disorder is similar to contemporary descriptions and has directly influenced recent versions of the DSM system (Jablensky & Sartorius, 1988). Interestingly, although Kraepelin (1902) believed that dementia praecox was primarily due to biological dysfunction, he was also mindful

Depression

Of all the mental disorders listed in Western diagnostic manuals, affective disorders are the most prevalent Gupta 1993, Lehtinen & Joukamaa 1994. It is for this reason, and because depression is often claimed to be significantly influenced by cultural factors Draguns 1995, Sartorius et al. 1980, Westermeyer 1989, that a brief summary of research on depression across cultures is included.

Like schizophrenia, depression has a significant genetic component (Allen, 1976), although bipolar

Conclusions

In this paper, we have argued that although the DSM-IV has moved overtly toward an acknowledgment of the cultural dimension of mental disorders, it has retained an underlying theoretical framework that asserts the primacy of the biomedical model. This is consistent with the implicit proposition that disorders listed in Axis I are essentially universal, with only slight and superficial cross-cultural variation. Research on the manifestation of schizophrenia across cultures has revealed some

Acknowledgements

We would like to thank Dr. Steve Hudson for his thoughtful comments on an earlier draft of this paper.

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