Psychotic disorders. The International Pilot Study of Schizophrenia, carried out in seven countries, rendered findings relevant to transcultural psychiatry despite methodological problems considered elsewhere (Littlewood, 1990a). Acute and catatonic forms of the illness were more prevalent in developing countries, whereas hebephrenic and chronic forms were more frequently seen in developed countries. Furthermore, patients from developing countries were found as having a better course of this illness (Kleinman and Good, 1985; Littlewood, 1990a). This finding was replicated by another transcultural study of schizophrenia--the Determinant of Outcome Study. These findings take into account issues such as less stigmatization in non-industrialized societies, the presence of extended family networks acting as effective support for patients and fewer societal pressures. These factors allow a more tolerant approach to sufferers and a better recovery process.
Brief reactive psychoses are of interest because some behaviors, otherwise considered normal in developing countries (such as trance or other dissociative-type disorders), overlap. Those brief psychotic states are clearly influenced by sociocultural stressors--and to some extent modified by indigenous healing practices--thus opening the gate for practitioners to research alternative models of therapy (Escobar, 1995).
Depression. Major depression ranks higher for women than for men. Powerlessness and low self-esteem are closely linked to depressive conditions. These are also factors associated with severe social upheavals and major sociocultural changes (Carta et al., 2001; Kleinman and Good, 1985). Minorities, women, and immigrant and refugee populations suffer from depressive states at higher rates than the general population. The predominance of somatic symptoms in patients from developing countries is further evidence of the cultural aspects of depression (Cheung et al., 1980; Ebert and Martus, 1994; Kleinman, 1977). Conversely, feelings of guilt, a core feature of depressive cognition, are less common in these countries. It is possible that those differences are linked to the fact that in specific societies and cultures, guilt plays a less important role as a collective system of meaning (Pewzner-Apeloig, 1993).
Somatization. One of the main issues of transcultural psychiatry is the place of somatization, not only as a nosological entity, but as an idiom of distress. As such, somatization is common in all cultural and social groups (Coler and Hafner, 1991; Escobar et al., 1983). However, a certain bias in Western psychiatry exists against somatization as an inferior way of dealing with emotions and intrapsychic conflicts. Western constructions of the self emphasize independence, autonomy and expressing conflicts in psychological terms (Fabrega, 1990). However, emotions are not only psychological experiences, but sociocultural constructions as well.
The cultural concept of person and self in minorities, immigrants and different ethnic groups emphasizes issues as the family group or bodily themes in the expression of distress (Pang, 1998; Yeh, 2000). The body acts as a metaphor for events of personal and social meaning (for instance, loss and grief) (Pliskin, 1992). For instance, in Hispanic groups, the syndrome of nervios as a somatized state of anxiety and depression may act as a metaphor of the social condition of this ethnic group within U.S. society (Angel and Guarnaccia, 1989; Hulme, 1996).
The predominance of somatic symptoms in immigrant populations may be related to accepted patterns of access to health care (Ritsner et al., 2000). Somatic symptoms in those cases are accepted ways of expressing distress and getting help in a less stigmatic way than usual psychiatric care.
The DSM can provide an outline for a cultural formulation of a case, with the intention of helping the clinician develop a broad sociocultural understanding (Kirmayer et al., 2003; Moldavsky, 2003). I will briefly describe the five items of this formulation, keeping in mind that it is a proposal for enhancing our awareness of aspects that are usually not fully taken into account amidst the pressures of clinical practice.
Cultural identity. Cultural identity includes cultural reference groups, language, cultural factors in development, and involvement with culture of origin and host culture. This dimension is particularly relevant when assessing mental health and disorders in immigrant and refugee patients (Kirmayer et al., 2000).
Cultural explanations of illness. This includes a description of idioms of distress and local illness categories, the meaning of symptoms in relation to cultural norms, the perceived causes and explanatory models, and help-seeking strategies (Kirmayer et al., 1994).
Cultural factors related to psychosocial environment and levels of functioning. This deals with social supports and stressors, as well as the levels of function and disability as they are perceived within a cross-cultural setting.
Cultural elements of the clinician-patient relationship.
Overall cultural assessment for diagnosis and treatment.