Mental health professionals have been frustrated for some time about the lack of understanding of culture in the classification of disorders. For example, a common critique of DSM-IV was that it lacked cross-cultural validity and was based on ethnocentric assumptions “of culture-related diagnostic issues about the nature of human activity, the self, emotions, the mind and body, society, normality and pathology” Although there have been changes made to DSM-5 to recognise the impact of culture on diagnosing mental health problems – for example, the inclusion of culture-related diagnostic issues for each diagnosis – it is difficult to avoid the ethnocentric frame of Western culture. Although there is a broader appreciation of culture in DSM-5, the structure and criteria remain relatively unchanged.
The DSM-5 and ICD-10 classification systems assume the universality of mental health disorders. Information on disorders has been gathered mostly from research conducted in the Western world, and yet this body of knowledge about mental illness is expected to generalise to other populations. Andary et al. (2003) suggest that the expectation of universality is misguided in mental health.
For example, the World Health Organisation (WHO) conducted international studies on depressive and schizophrenia spectrum disorders in 10 countries over decades (Andary et al., 2003). Standard Western assessment tools were used, which may have influenced the researchers to look for certain ‘core’ symptoms. While similarities across countries were found, there were also significant differences. The cross-cultural findings suggest that how people present to services, the course of the illness and the treatment outcomes are dependant on the cultural setting.
In the research on depression, in so-called developed countries higher levels of guilt and self-reproach were found, while in developing countries, somatic symptoms were reported more frequently such as lack of appetite, loss of weight and loss of libido. The study on schizophrenia found that people in developing countries were more likely to have an acute onset and to experience a single episode followed by complete remission. Those in developed countries more frequently had a gradual onset and went on to have a chronic disorder. Symptoms were similar across countries, although people with schizophrenia in developing countries were more likely to have auditory hallucinations while in developed countries, depressed mood was more common
An extension and analysis of the international schizophrenia studies found that outcomes were better for people in the developing world. The majority of people who experienced psychosis were married and employed at follow-up. The support of families and inclusion in society in general was the most likely contributor to these positive outcomes. Andary et al. question whether they are really the same disorder, if prevalence, onset, symptoms, course and recovery differ across cultures.
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