Culture-specific psychiatric illness?

Littlewood states, “In his rephrasing, content is merely the ‘subjective complaint’ or ‘illness behaviour’, form the ‘objective symptoms’ ”. This is a misunderstanding of what I have tried to emphasise in my editorial. One of the major points in my work is that the patient's subjective complaint belongs to ‘illness behaviour’, which is different from ‘objective symptoms’ assessed by psychiatrists, preferably using a standardised procedure.

Littlewood mentions the Western patterns of eating disorders, multiple personality disorder, overdosing, shoplifting, agoraphobia and school refusal. Many of these, if not all, are also found in non-Western societies (e.g., see Kleinman & Lin, 1981). Furthermore, school refusal is not a formal diagnosis in either the ICD—10 or the DSM—IV; rather, it is a behavioural problem possibly with underlying ‘etic’ psychopathology (depression, separation anxiety, phobia, learning disorders and so forth) and socio-environmental factors. In any society, primitive or modern, there are certain forms of teaching activity not run by modern school institutions. Presumably, the same refusal to attend these various forms of ‘school’ exists, with similar underlying psychiatric and socio-environmental factors. The ways of this refusal and the context of the socio-environmental factors are likely to be ‘emic’. For effective management of school refusal, both the underlying potential etic psychopathology and the emic illness behaviour and socio-environmental factors must be carefully examined. This is an alternative example of what I intended to elaborate using the example of koro.

The long-standing debate over etic/emic and semantic issues in cross-cultural psychiatry is unlikely to be satisfactorily resolved in the near future. However, it is believed that the development of standardised clinical interviews with emphasis on cross-cultural equivalence at the level of symptoms (e.g., Cheng et al, 2001) helps to avoid the so-called “category fallacy” (Kleinman, 1987).

It should be stressed that the under-reporting of psychological symptoms by interviewees from developing nations that I mentioned in my editorial does not mean that these people do not have, or cannot differentiate, emotions. People are people, and the very low rate of reporting of psychological symptoms to doctors by people in developing countries may be due to greater social stigma towards mental illness, their lack of knowledge about mental illness and a much less psychologically oriented medical practice. More studies into this area are needed, and I believe that anthropologically oriented researchers can make a great contribution to this endeavour.

The etic/emic approach to psychopathology does not imply that psychiatry is confined only to biology. The emic pathoplastic shaping and illness behaviour closely associated with different sociocultural settings are equally important in psychiatry and require culture-specific approaches in combination with biological treatment. After all, mental disorders are believed to be the product of gene/environment interaction (Cheng & Cooper, 2001).