During the last decades, along with advances in the understanding and treatment of mental illness, transcultural psychiatry has undergone a conceptual reformulation. The purpose of this review is to scan some of transcultural psychiatry's contributions to the epidemiology and clinical facts of mental disorders. I will also outline some of the main theoretical constructs of the discipline. Finally, I will deal with the place of transcultural psychiatry within the DSM.
Broadly speaking, transcultural psychiatry deals with how social and cultural factors create, determine or influence mental illness. In doing so, new and innovative treatment strategies are created. Despite influences of human and social sciences, transcultural psychiatry is rooted in medicine, especially in the biopsychosocial model. Contemporary developments such as globalization, massive migrations and the uprooting of populations (Kirmayer and Minas, 2000) put into focus questions of mental health of minorities. This has become a major focus of concern in the United States as well in other Western countries.
The Foundations
Since the inception of psychiatry as a medical science, along with innovative trends in sociology and anthropology, there was a change in transcultural psychiatry. Those changes have been extensively surveyed in two seminal papers that outlined the differences between what was termed the "new" and the "old" approaches in transcultural psychiatry (Littlewood, 1990a, 1990b). Whereas the old transcultural psychiatry focused on comparing psychiatric disorders across different cultures while maintaining the universal validity of theoretical models developed in Western countries, the new transcultural psychiatry asserts that the aforementioned models are culturally constructed and thereby only applicable mostly to Western populations. Examples that have been documented in the psychiatric literature have been those of neurasthenia and depressive disorder in China (Kleinman, 1986), or ataques de nervios in Hispanic patients in the United States (Guarnaccia et al., 1989).
Today, transcultural psychiatry has a broad scope of interests, ranging from biology to the place of spirituality in mental life and disorders. Its main focuses are: cultural factors and specific psychiatric disorders; human universals (e.g., gender, age) of psychiatric disorders in different societies and cultures; culture and personality development; healing systems and social roles; culture and psychotherapy; and race and ethnicity in psychopharmacology and treatment compliance.
Basic Concepts
Disease and illness. In the context of transcultural psychiatry, disease pertains not only to the biological changes underlying behavior, but mainly to health practitioners' constructions of clinical realities according to their models. Whereas disease falls in the category of "the culture of the clinician," illness lies in a different domain. It refers to the patients' and families' recognition, labeling and experience of behavior. The importance of identifying and acknowledging the social and cultural course of disease is stressed in cross-cultural settings (Kleinman, 1988a, 1988b).
Validity and reliability. Reliability refers to the degree of consistency of observations made by different clinicians. However, validity is a more important construct for transcultural psychiatry. This has been highlighted in the literature since Kleinman (1988a, 1988b) coined the concept of category fallacy (Littlewood, 1990a). Overvaluing a construct, be it a diagnostic category, therapeutic technique or questionnaire, without testing its validity in different cultures, creates the problem of category fallacy.
Culture. This can be defined as a set of beliefs, norms and values that have symbolic value and shape the networks in which human interactions take place. The concept of cultural identity, central for the cultural formulation in the DSM, refers to the culture with which someone identifies and looks for standards of behavior.
Some constructs relevant to psychiatry, such as self, adaptation, adjustment and bodily processes, are closely related to culture. They have not only biological meaning, but social and cultural meaning. Culture influences psychopathology through pathways like stresses, chronic social conditions (e.g., poverty, deprivation), protective factors, modulation and promotion of change, tolerance for particular behaviors, and sanction of specific idioms of distress.
Race and ethnicity. Race is a problematic construction, both from biological and sociocultural points of view. Ethnicity is the concept preferred by cross-cultural researchers. It means groups of individuals sharing a sense of common identity, ancestry, beliefs and history.
Idioms of distress. These are the ways in which people in different cultures express, experience and cope with feelings of distress. One idiom prevalent almost universally is somatization.
