Variations in frequency across cultures
Whereas neither the form nor the incidence of psychoses vary much across cultures, neuroses show dramatic variations in both respects. So-called culture-bound syndromes are an extreme example of variation in frequency since it is claimed that they are confined to specific cultural groups (see Ch§pter 4.16). However, even with common conditions such as depression, the range of prevalence rates from studies across cultures is extremely wide. A review of 19 studies mostly conducted in developing countries found a difference in prevalence of neuroses of more than 300-fold from the highest to the lowest. (19. There are at least three plausible explanations. Unlike psychoses, there is no clear boundary between depressive symptoms severe enough to constitute an illness and subclinical depression. Shifting the threshold for a depressive illness towards the milder end of the spectrum will automatically increase the prevalence rate. Few comparative studies of neuroses across cultures have been conducted with the rigour of the WHO projects on schizophrenia using standardized clinical interviews and diagnostic techniques. Higher prevalence rates usually result from surveys in which every subject is interviewed with a standard clinical schedule, rather than relying on key informants and non-standardized clinical judgements.
A second possibility is that the neuroses take markedly varied forms in different cultural groups, giving rise to problems of recognition and hence of counting. Early European clinicians in Africa claimed that depression did not occur among the indigenous people. This was probably due more to ethnocentric blinkers than to the existence of a different form of the condition. However, there is evidence that there is a greater focus on bodily symptoms in patients in developing countries. Somatization is by no means uncommon in patients in developed countries, particularly those of lower socio-economic status, but somatic symptoms are more likely to dominate the picture in patients in a developing country. This is determined partly by beliefs about illness and partly by mutual expectations of patients and doctors, issues which will be discussed later. The significance of somatic symptoms may well be missed by standardized interviews designed to detect the cognitive experiences of depression.
A third explanation assumes that the differences in prevalence are genuine and are ascribable to cultural influences on the origin and course of the neuroses. The emphasis on the measurement of prevalence of neuroses as opposed to incidence for the psychoses is due to the small proportion of new cases of the former that present to psychiatric services. Hence it is necessary to conduct population surveys, which are costly in terms of time and trained personnel—a prohibitive expense for most developing countries. The few population surveys that have been conducted in both developed and developing countries using the same methods of interviewing and case ascertainment have shown either no difference in the prevalence of neuroses (1 ,12) or a higher rate in the developing country. (.l I4)
One of the most striking transcultural aspects of the neuroses is the great variation in the frequency of classical conversion hysteria. Whereas this condition is rarely seen in psychiatric and neurological services in developed countries today, it is still a common form of presentation in developing countries. Of the first 1000 patients attending the University Psychiatric Clinic in Cairo in 1966, 11.2 per cent were suffering from a hysterical condition. (15) Hysteria constituted 8.3 per cent of all first attenders at an outpatient clinic in Eastern Libya(!6) and 8.9 per cent of outpatient contacts with the psychiatric service in Chandigarh, North India, in 1977. (1.Z) Conversion hysteria used to be relatively common in Europe during the last century, as we can infer from Charcot's demonstrations in Paris and Freud's early clinical practice. It was also a frequent diagnosis in soldiers during both World Wars, but has subsequently become a rarity. Its disappearance from developed countries over the last 50 years contrasted with its persistence in developing countries poses an intriguing question about the influences at work. The most likely explanation is that there has been a shift in the presentation of neurotic distress from the bodily form of hysteria to the more cognitive forms of depression and anxiety, and that this process has occurred more rapidly in developed countries. There are important consequences of this interpretation for both help-seeking behaviour and the concept of depression.
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