The interpretation of emotional expression, and the conclusions that clinicians draw about the affective state of client, impacts on diagnosstic and treatment considerations.
Understanding that some mental distress may have unique presentations that are cultural in origin can assist with mental health screening and help avoid misdiagnosis. Cultural understanding of these symptoms can help build a therapeutic alliance with a client.
Just as standard screening instruments can sometimes be of limited use with culturally diverse populations, so too are standard diagnoses. Expressions of psychological problems are, in part, culturally specific, and behaviour that is aberrant in one culture can be standard in another. For example, seemingly paranoid thoughts are to be expected in clients who have migrated from countries with oppressive governments. It’s important to consider that behavioural phenomena that may be defined as mental illness in a Western context may be cultural in origin and understood differently in this context.
Culturally rooted groups of symptoms previously referred to as “culture-bound syndromes,” are called “cultural concepts of distress” in DSM V (Kohrt et al., 2014). These cultural concepts of distress may or may not be linked to particular DSM V diagnostic criteria (APA 2013a). DSM V lists some cultural concepts of distress but other concepts exist that are not recognized in DSM V (APA 2013d). Cultural concepts of distress comprise three areas (APA, 2013a, p.758):
- Cultural syndromes: Clusters of symptoms that tend to co-occur in certain cultural groups, communities, or contexts.
- Cultural idioms of distress: Ways of communicating emotional suffering that do not refer to specific disorders or symptoms, yet provide a way to talk about personal or social concerns. Frequently these manifest as physical symptoms (somatisation).
- Cultural explanations: Symptoms, illness, or distress are perceived by a culture as having specific, local origins or causes.
Depression is an example of a cultural concept. For Western clinicians, major depressive disorder (MDD) can be considered a “syndrome,” or cluster of symptoms that appear to “hang together”. But depression can also be considered an “idiom of distress,” in the sense that Westerners commonly talk of feeling depressed in everyday life. The label "depression" can imbue a set of behaviours with a particular meaning. No single concept maps onto a specific psychiatric disorder, and conversely, no single psychiatric disorder (eg MDD) maps onto a cultural concept (eg Shenjing shuairuo-neurasthenia). Each illness has to be assessed in its own right. Clinicians must not only draw from diagnostic experience, available categories of illness, and the various dimensions along which aspects of the illness may range, but also recognise and try to understand the client’s cultural understanding of the illness. The information provided throughout DSM V, and particularly in the cultural formulation chapter, can help practitioners avoid misdiagnosis, obtain clinically useful information, improve clinical rapport and promote therapeutic efficacy (APA, 2013a).
Examples of APA (2013d) defined cultural concepts of distress are:
Shenjing shuairuo (neurasthenia) - Chinese
- A condition characterised by physical and mental fatigue, headaches, difficulty concentrating, dizziness, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and autonomic nervous system disturbances.
Taijin kyofusho - Japanese
- Avoiding interpersonal situations due to intense fear that one’s appearance or actions give offense to others. “Sensitive type” relates to anxiety about interpersonal interactions, while “offensive type” relates to concern about offending others. Related DSM disorder: Social anxiety disorder and obsessive-compulsive disorder
Kufungisisa-Shona - Zimbabwe.
- Kufungisisa (“thinking too much”) is an idiom of distress and a cultural explanation among the Shona of Zimbabwe. As an explanation it is considered to be causative of anxiety, depression and somatic problems (eg “my heart is painful because I think too much”). As an idiom of psychosocial distress, it is indicative of interpersonal and social difficulties (eg marital problems, having no money to take care of children). Kufungisisainvolves ruminating on upsetting thoughts, particularly worries. Kufungisisa is associated with a range of psychopathology including anxiety symptoms, excessive worry, panic attacks, depressive symptoms and irritability.