Commentary: a culturally invariant neuropsychiatry?
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Brain↗
Biomedical subjects
H Fabrega
Publications and source records attributed to H Fabrega.
The place of culture in DSM-IV.
This paper critically reviews the process and outcome of an effort to enhance the cultural validity of DSM-IV and outlines recommendations to improve future diagnostic systems. An ordered presentation of the antecedents and the main phases of this developmental effort is followed by a content analysis of what was proposed and what was actually incorporated, and a conceptual analysis of underlying biases and their implications. The cultural effort for DSM-IV, spearheaded by a scholarly independent NIMH workgroup, resulted in significant innovations including an introductory cultural statement, cultural considerations for the use of diagnostic categories and criteria, a glossary of culture-bound syndromes and idioms of distress, and an outline for a cultural formulation. However, proposals that challenged universalistic nosological assumptions and argued for the contextualization of illness, diagnosis, and care were minimally incorporated and marginally placed. Although a step forward has been taken to introduce cultural elements in DSM-IV much remains to be done. Further culturally informed research is needed to ensure that future diagnostic systems incorporate a genuinely comprehensive framework, responsive to the complexity of health problems in increasingly multicultural societies.
Culture↗
Earliest phases in the evolution of sickness and healing.
Sickness and healing constitute the root concepts that center medical anthropological inquiry and give the field its identity. Here, they are held to manifest a biological adaptation designed by evolution that requires culture for its final realization. Sickness and healing thus provide anthropology with a biocultural form that has changed in content and expression during cultural evolution. The early phases of this evolution, those bearing the most apparent influences of the environment of evolutionary adaptedness, are reviewed and analyzed in the article. Some of the implications of this for medical anthropology are discussed.
Adaptation, Biological↗
Adolescent psychopathology as a function of informant and risk status.
Adolescents selected for delinquency risk in a community study, their parents, and teachers completed versions of the Child Behavior Checklist, with the raw scores representing the adolescents' level of psychopathology. All three informants rated high risk adolescents as showing higher levels of delinquency as well as other forms of psychopathology, particularly anxiety, aggression, social problems, thought problems, and, to a slightly less consistent extent, withdrawn behavior. In addition, compared with parents and adolescents, teachers rated psychopathology in African-American adolescents higher than that in Anglo-American adolescents. The results are analyzed using knowledge drawn from social and child psychiatry.
Adolescent↗
Adolescent psychiatry as a product of contemporary Anglo-American society.
Societies differ with respect to medical traditions. The kinds of healers and their emphases vary as a function of culture and social structure. In Western nations, a number of specialty disciplines have evolved. Psychiatry is a creation of the nineteenth century and linked to demographic and social changes of the period. Comparatively little attention has been given to the growth of Adolescent Psychiatry, a sub-discipline that has achieved definition in the last two decades. Its dependence on cultural and political economic transformations is unique insofar as it first required construction of its clientele, namely adolescence itself. The 'disorders' that are the focus of Adolescent Psychiatry appear to be very much linked symbolically and structurally to the unique social pressures impacting on this newly constructed group. The historical and cultural determinants of the developments that have culminated in the evolution of Adolescent Psychiatry are reviewed and discussed.
Adolescent↗
Does a clerkship affect students' views of psychiatric patients?
This study deals with the views of medical students toward real psychiatric patients. The students answered seven questions about ten patients who had been interviewed by a senior faculty member. The interviews were recorded on audiovisual tapes. The questions dealt with different aspects of mental illness and included views on how laypersons would evaluate and respond to patients, what it would be like to care for the patients, and whether the patients were potentially dangerous. Answers to questions were correlated. Gender and the student's accuracy in rating psychopathology were used as independent variables to examine students' views and the possible change in these views as a result of participating in a 6-week psychiatric clerkship. The pattern of intercorrelations is reported and discussed. Negative views correlated with anticipated difficulty in caring for patients, and positive views correlated with a higher accuracy in rating psychopathology. In general, student views about mental illness were relatively impervious to the effect of a clerkship. Results are discussed in terms of prior research and knowledge about gender differences in interpersonal sensitivity. Some of the social implications of the results are discussed.
Attitude↗
Disproportionate suicidality in patients with comorbid major depression and alcoholism.
OBJECTIVE: The two purposes of this study were to provide a comprehensive description of the clinical features of patients who presented to an intake psychiatric setting with major depression and alcohol dependence and to determine which clinical features distinguished this dual-diagnosis group from patients with the two relevant single diagnoses. METHOD: During a recent 5-year period, a total of 107 patients who came to a psychiatric facility for initial evaluation were diagnosed as having both major depression and alcohol dependence. The clinical profile of this dual-diagnosis group was compared to that of nondepressed alcoholics (N = 497) and nonalcoholic patients with major depression (N = 5,625), assessed at the same facility, on the basis of information from the Initial Evaluation Form, a semistructured instrument containing a standardized symptom inventory that includes ratings of severity. RESULTS: The psychiatric symptom that most strongly distinguished the depressed alcoholics from the two comparison groups was the level of suicidality. The depressed alcoholics differed significantly from the nonalcoholic depressed patients on only two depressive symptoms, suicidality (59% higher) and low self-esteem (22% higher); they were also significantly distinguished from the nonalcoholic depressed patients by factors such as greater impulsivity, functional impairment, and abnormal personal and social history markers. CONCLUSIONS: Suicidality was disproportionately greater than other psychiatric symptoms in the depressed alcoholics. The clinical profile of depressed alcoholics suggests that they suffer an additive or synergistic effect of two separate disorders, resulting in a disproportionately high level of acute suicidality upon initial psychiatric evaluation.
Adult↗
Toward a more comprehensive medical anthropology: the case of adolescent psychopathology.
This article argues for a more comprehensive analytical approach in medical anthropology than is currently followed, one that combines attention to structural factors (political, economic, medical/psychiatric), experiential/symbolic expressions and meanings, and biological/bodily features of disorders. We show how subject matter that may be defined as "adolescent psychopathology" would be better understood by a comprehensive approach than by partial views. Three areas within adolescent psychopathology are chosen as illustrative: anorexia nervosa, dissociation, and social aggression. Each of these, like adolescence itself, is powerfully shaped by historical and contemporary cultural influences, and each implicates important theories in medical anthropology.
Adolescent↗
Tlaxcalan constructions of acute grief.
In rural Tlaxcala, Mexico, the sudden and unexpected death of infants and young children was a relatively common occurrence during the time when this study was conducted. Not surprisingly, the deaths constituted major social tragedies and operated as psychological traumas to the family, especially the parents. Acute grief reactions inevitably resulted and these were suffused with bodily and psychological disturbances of different types, some of which were handled in the society as illness. The article grows out of a longitudinal study about these tragedies to families of the region. Attention is given to the grief reactions of parents, with special emphasis placed on psychological and behavioral manifestations. Of particular interest is the way local, cultural symbols pertaining to the cause of the deaths, which involved the malevolent attack of blood-sucking witches, were configured in the verbalizations and behavioral reactions that comprised the grief reactions. Details of the way symbols entered into the construction of meaningful accounts of the tragedies during the ordeal of the grief reactions are discussed and analyzed. Although the manifestations of grief could be said to have clinical, psychiatric implications, it is the way these manifestations served to explain the tragedies, in the process regulating and restoring social relations, that is given principal attention. A description of one mother's grief reaction is provided as a case illustration.
Attitude to Death↗
Ethnicity and psychopathology in an aging hospital-based population. A comparison of African-American and Anglo-European patients.
This study analyzes the effect of ethnicity, classified as African-American and Anglo-European, on diagnosis, symptomatology, and response to inpatient treatment in a sample of geriatric patients of a research unit of a tertiary care facility. Variables that might confound the effects of ethnicity, such as age, gender, education, and associated diagnoses, were statistically controlled. Psychotic diagnoses were significantly associated with ethnicity, being higher in African-Americans, weakening the claim that such an association stems from the confounding effects of social class. Variability in the ratings on the Brief Psychiatric Rating Scale and Hamilton Depression Scale was significantly associated with ethnicity in several instances. African-Americans appeared to obtain comparatively higher therapeutic benefits from hospitalization. Results are discussed using knowledge of the field of cultural and social psychiatry.
Black or African American↗
International systems of diagnosis in psychiatry.
International standardization of diagnosis is the culmination of developments set in motion in Europe during the first half of the 19th century. Its ultimate rationale has been the science of descriptive psychopathology. The enterprise implies that a common way of defining, describing, identifying, naming, and classifying such disorders is possible and that a common system of psychiatric diagnosis constitutes a first step toward dealing with them. Its natural science approach implies that social and cultural factors are extraneous. Yet, as discussed, the enterprise is based upon unique historical and cultural responses to human behavioral individuality. Cultural aspects of psychiatric phenomena create tensions in the application of the internationalist enterprise: Although in theory applicable to all people regardless of populational/genetic, national, or cultural background, it is used by clinicians of highly specific cultural origin and in settings characterized by distinctive cultural traditions about sickness, healing, nonsickness or health, and social behavior. Tensions created by the international enterprise are discussed and illustrated by drawing attention to how cultural factors impact on its basic assumptions and by a selective review of literature.
Cross-Cultural Comparison↗
Gender differences in how medical students learn to rate psychopathology.
The aim of this study was to examine factors influencing medical students' learning of psychopathology assessments during the psychiatric clerkship. The subjects included 122 third-year medical students participating in a 6-week psychiatric clerkship. They completed Brief Psychiatric Rating Scale ratings on short, focused interviews in a balanced design before and at the end of the clerkship. Deviation of their ratings from standard ratings by experienced psychiatrists constituted the dependent variables. Female medical students showed a clear significant improvement during the clerkship, whereas male students tended to experience a significant reduction in their accuracy. We conclude that there may be gender-related differences in these medical students' ability to assimilate and cope with the clinical experience of the psychiatric clerkship. The implications of these findings for psychiatry training are discussed.
Attitude↗
Sudden infant and child death as a cultural phenomenon: a Tlaxcalan case study.
THE Sudden Death of infants and young children (SICD) constitutes a recurring problem in all societies. In contemporary industrialized societies, many factors known to cause these deaths have been clarified and controlled. Yet, as an outcome of such things as unrecognized disease, accidents, so-called crib death, and parental neglect or abuse, the prevalence of SICD remains relatively stable even in contemporary Western societies (Adams et al. 1990; Campbell 1989; Kyle et al. 1990). The pathophysiology of these human tragedies has received much attention. However, the social, cultural, and psychiatric implications have been relatively neglected. In large part this is because in our secular culture these deaths are explained naturalistically; namely, as the result of disease, biological anomalies, or physiological failures, the meaning of which is not attributed to human or other worldly intervention. A result of this is that such deaths are usually deprived of a framework of meaning that has spiritual and existential connection to everyday affairs. An impersonal, natural way of explaining SICD often deprives the mourner of a meaningful cultural rationale that can facilitate emotional release and spiritual significance.
Attitude to Death↗
Toward a social theory of psychiatric phenomena.
This essay relies on a positivistic/scientific perspective to define psychiatric phenomena. However, it draws a distinction between a biomedical versus a social science approach. The aim is to review some of the theoretical and empirical considerations that pertain to psychiatric phenomena that need to be addressed in order to develop a social theory about them. The object of the theory is to explain how psychiatric phenomena are labeled, interpreted, and handled across societies that differ in terms of social structure and culture. Some of the kinds of variables and questions that would allow for cross-cultural analyses are identified. In addition, two topics that a social theory could address--that of the medicalization and stigmatization of psychiatric phenomena--are introduced. These topics are elaborated by developing propositions that substantively illustrate the questions/hypotheses of a social theory of psychiatric phenomena. The essay illustrates that a social theory constitutes a complex enterprise that requires dealing with philosophical, methodological and empirical issues.
Attitude↗
A cultural analysis of human behavioral breakdowns: an approach to the ontology and epistemology of psychiatric phenomena.
This paper explores the usefulness of a concept of "human behavioral breakdowns" for studying psychiatric phenomena from a cross-cultural standpoint. The kinds of conceptualizations that are available in the English literature about human behavioral breakdowns across societies are reviewed. The way these breakdowns have been handled in the Western European Tradition of medicine is given special emphasis. Attention is focused on schizophrenia as one of the modern "disease" concepts of psychiatry that is a variant of human behavioral breakdowns. The essay then looks at "schizophrenia" using contemporary ideas about cultural relativism as these apply to the study of psychiatric phenomena in relation to society. Perspectives about the variable as versus the invariant in schizophrenia are reviewed.
Cross-Cultural Comparison↗
Witchcraft-explained childhood tragedies in Tlaxcala, and their medical sequelae.
This paper describes results of a study in Tlaxcala, Mexico, involving the sudden death of infants and children that culturally are explained as resulting from the attack of blood-sucking witches. The attacks of the supernaturals are relatively common occurrences and an elaborate ideology has evolved to explain them. Such an ideology serves to explain what constitutes a major trauma of loss and supernatural assault. Data on a total of 47 cases were collected prospectively. The illness experiences of the parents following these traumas were recorded and their nature and consequences analyzed. The results of the study provide a 'folk medical' epidemiology of sudden infant death, a well identified cultural-ecological stressor. Ideas from cultural, psychological and medical anthropology as well as general medicine and psychiatry are used in the interpretation of the results.
Adult↗
Do Caucasian and black adolescents differ at psychiatric intake?
A large sample of adolescents brought for psychiatric evaluation to a public University based facility are the subjects of the study. Material incorporated in a DSM-III multiaxial formulation plus symptoms constituted the dependent variables. Analyses concentrated on ethnic differences, with variation associated with gender and social class controlled statistically. Caucasians showed comparatively greater clinical morbidity: higher number of Axis I definite diagnoses and level of symptoms. Eating disorder diagnoses were more common in Caucasians. There were no significant differences pertaining to level of stress or social impairment. Blacks showed higher levels of symptoms scored as "social aggression" and diagnosed as conduct disorders. The pattern of results raised the question of a possible referral bias, with blacks shunted to the psychiatric facility with lower levels of standard clinical psychopathology, but higher levels of social oppositional behavior. Further research is needed to verify if such a bias does exist.
Adolescent↗
Semantic structures and psychiatric diagnosis.
This study examines psychiatric diagnosis using the concepts and methods of cognitive anthropology. Clinicians are viewed as cultural experts whose knowledge is represented in semantic structures, which are arrangements of diagnostic categories based on similarity of meaning. A test of similarity judgments of diagnostic categories was administered to a group of clinicians to derive two semantic structures of the categories included in axis I and axis II, respectively, of DSM-III. These structures were then compared with actual clinical diagnoses of concurrent disorders, and with the expected incidence of such diagnoses, in order to determine the possible influence of semantic similarity on the diagnostic process. The results suggest that semantic meanings of diagnostic categories influence the use of rule-out diagnoses more than positive diagnoses, and that this influence is more pronounced with respect to axis II than axis I.
Anthropology, Cultural↗