Major contributions of anthropology to psychiatry Cultural critique of biomedicine

Theory is downplayed in academic psychiatry, although there is much more of it than the naƮve positivist view of atheoretical psychiatric diagnosis portrayed in DSM-IV allows. Yet, one of the crucial contributions of anthropology is theoretical, namely a critique of the theoretical biases inherent in psychiatric science and clinical practice. And how could this not be? For unlike any other branch of medicine, there is no blood test, biopsy, or radiograph to diagnose psychiatric disorder (leaving aside Alzheimer's disease, which is after all a neurological disorder). That means that psychiatric diagnosis is based on the establishment of symptom and syndromal criteria, which are based in turn in language, lay categories, and everyday social experience. In other words, there is no biological validity but only psychosocial reliability in psychiatric assessment. Cultural bias can enter this process in several ways. Anthropologists have shown that this can happen when diagnostic criteria which have been developed in one society are applied to another where they lack validity. This is called a 'category fallacy,' a term introduced by KleinmanA1.,) Classic examples include trance and possession states in many non-Western societies, which are frequently normative and normal experiences. Failure to recognize this phenomenon, and therefore the diagnosis of persons in religious trance as psychotic, creates a category fallacy in the application of the diagnostic criteria of psychosis to normal people. In a related manner, anthropologists have faulted international diagnostic criteria for failing to take into account indigenous syndromes (such as ataques and nervios among Puerto Ricans), and thereby either underdiagnosing indigenously defined psychopathology that may (or may not) have a family resemblance to established professional categories, or overdiagnosing (ICD- or DSM-defined) psychopathology. What they are hearing are collective idioms of distress that are culturally patterned and socially shared ways of complaining about social or personal problems in an idiom of bodily and psychological terms, which do not necessarily signify psychiatric disease. The cultural critique has been applied to personality disorders as well, because this category of disorder models self-processes on a decidedly Euro-American, middle-class, and usually male behavioural type and lifestyle. Anthropologists argue for a much more flexible and interactive understanding of subjectivity that changes in basic ways in response to different social circumstances. Extremely high rates of sociopathy among adolescents from ethnic minorities in the inner city, they argue, is the result of such cultural bias in diagnosis. The anthropological framework for understanding personality and pathology sets the conditions in the conjunction of changing cultural representations, collective processes, and individual experience. Anthropologists are divided on the issue of human nature. Some see human conditions as a continuous process of change without a fixed 'nature'; others deem human nature only one element in the process. Yet, on the whole, even anthropologists who draw on the idea of human nature regard it as historically and cross-culturally malleable. They try to avoid naturalizing or essentializing human nature by emphasizing its inseparability from particular contexts.

In the 1990s, cultural critique has been deployed by anthropologists and ethnic psychiatrists to examine the influence of institutional racism in psychiatric diagnosis, referral, and treatment. Leading examples are the overdiagnosis of African-Americans and African-Caribbean Britons with schizophrenia, the tendency to perceive them as more dangerous and less amenable to psychotherapy, and differences in the way their discharge and aftercare are organized. Anthropologists have examined how racism is unwittingly built into psychiatric categories and infiltrates the model cases used to illustrate diagnostic criteria, and also the way that psychiatrists are trained to replicate such patterns in the practice of triage.

Cultural critique, informed by the cross-cultural and international data, is the basis for anthropologists' doubts about the validity of many of the psychiatric conditions detailed in DSM-IV and ICD-10. The idea that there are no stable psychiatric syndromes cross-culturally is an idea few psychiatric anthropologists would advance, although in an earlier era of the most radical cultural relativism in the field, this idea had more than a few supporters. But the ethnographic database strongly suggests that, apart from brain tumours and infections, Alzheimer's disease, metabolic encephalopathy, substance abuse, and other well-documented brain-based disorders such as certain sleep disorders, only five psychiatric syndromes of adults can be found cross-culturally; i.e. only these have stability as syndromes outside the cultural mainstream of Euro-American societies. The conditions are schizophrenia, brief reactive psychoses, major depression, bipolar disease, and a range of anxiety disorders from panic states through phobias to obsessive-compulsive disorder. Most of the other hundreds of conditions described in DSM-IV, for example, are culture bound to Euro-America. This point has also led many medical anthropologists to be suspicious about the idea of culture-bound disorders generally. Why should railway psychosis, shenjing shuairuo (neurasthenia as diagnosed by Chinese psychiatrists), and pathological trance and possession states in China be listed as culture-bound syndromes, when at the very least they are stable syndromes among one-fifth of the world's population? These anthropologists also ask: When many conditions listed in the DSM and ICD systems that are found in Europe and America are not to be found in China, or in most of the rest of the non-Western world, why should they not be regarded as culture bound?

Related to these contributions of cultural critique, anthropologists have also contributed to the development of culturally informed diagnostic criteria, questionnaires, structured interviews, and guidelines for working with translators. Globalizing and indigenizing psychiatric approaches is an even more general emphasis in anthropology. Largely because of the politics of ethnicity and the worldwide movement of globalization, psychiatric researchers and practitioners must pay attention to the international database and to the concerns of ethnic communities and individual patients. Yet, few seem to be serious readers of relevant anthropological literature, which after all is the basic science in this field. Anthropology contains numerous concepts and methods that might be tried out, but relatively few have been experimented with or adopted. Besides those described below, several examples of the concepts, methods, and findings from anthropology that await trial in psychiatry are listed in Table 1..

Table 1 Anthropological concepts, methods, and findings that await trial in psychiatry

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