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Nobody, I think, would doubt that the diagnosis and management of some mental illnesses, perhaps PTSD especially, is culture-bound. However, I think the paper on flashbacks by Jones et al (2003) is misleading.

A flashback is not defined in the glossary of technical terms in either DSM–III (American Psychiatric Association, 1980) or DSM–III–R (American Psychiatric Association, 1987). The only mention of flashbacks in DSM–III is as a complication of hallucinogen hallucinosis. It does appear in the diagnostic criteria (B3) for PTSD in DSM–III–R (in parenthesis) but the reader is referred in the index to post-hallucinogen perception disorder. Thus, while DSM–III refers to dissociative states and DSM–III–R refers to ‘dissociative (flashback) episodes’, both, in the context of the diagnosis, are described as rare. Thus, at the time of publication of these manuals, they were not a ‘core symptom of PTSD’.

DSM–IV (American Psychiatric Association, 1994) retains ‘dissociative flashback episodes’ (without parenthesis) as one of the ways a traumatic event is persistently re-experienced, and in the glossary of technical terms defines a flashback as ‘a recurrence of a memory, feeling, or perceptual experience from the past’. Thus, flashbacks, unless they are qualified as dissociative, have become synonymous with ‘recurrent and intrusive distressing recollections of the events including images, thoughts or perceptions’. They do not even have to be intrusive. Such unpleasant memories are universal in combat veterans of any war. What has changed in this instance is how the term is used – not the phenomenon itself.

That ‘earlier conflicts showed a greater emphasis on somatic symptoms’ (Jones et al, 2003) indicates more clearly the impact of social values on symptomatology. Where a particular manifestation of distress meets with disapproval – the suggestion in these cases of lack of moral fibre or worse – somatic symptoms could be expected. In the early 1970s a Thai psychiatrist returning to Thailand from training in the USA indicated to me that he had to educate his patients before he could diagnose depression (P. Chaowasilp, personal communication, 1972). At that time, all his patients with depression presented with somatic complaints.