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Correspondence |
Royal Free and University College London Medical School, Department of Psychiatry and Behavioural Sciences, Wolfson Building, 48 Riding House Street, London WIN 8AA, UK
Andrew Cheng's contribution (2001) to the debate on the universality v. cultural particularity of psychopathology follows the conventional distinction between the pathogenic form of the illness, presumed to be biological, and its pathoplastic content of psychological or social origin (Littlewood, 1996). In his rephrasing, content is merely the "subjective complaint" or "illness behaviour", form the "objective symptoms". He then dissects such culture-specific patterns as koro into the ‘real’ illness (panic attacks) and the ‘false belief’ apparently found in people of "low intelligence" with "limited knowledge of mental disorders", thus proving his case.
His procedure is an act of faith in the possibility (and usefulness) of this Kantian distinction, which has been an article of psychiatric belief since Kraepelin and Birnbaum (Littlewood, 1990). While possibly of some utility for the major psychoses where we may trace some biological aetiology, it seems bizarre to assume that we will find universality in all patterns of psychiatric interest. Eating disorders, multiple personality disorder, overdosing, shoplifting, agoraphobia, school refusal, to mention some Western patterns alone: each is constructed by context and meaning as it is constructed by biological difference. Could we consider school refusal as a universal pattern in the absence of elementary schools in certain societies? What would be left here without social context? What then our analogues of school refusal?
To assert that the business of psychiatry is only the biological (and why should that presume the universal?) is to restrict our discipline to veterinary science. To ignore meanings as potentially causal is to offer an etiolated psychopathology, one presumed to be ‘scientific’ in advance (Kleinman, 1988). To offer a general model of all psychopathology with fixed relations between the social and the biological is certainly non-empirical, and only potentially redeemed if we then exclude the social a priori from any potential patterns. To search for universality is doubtless laudable: to presume it is not.
REFERENCES
Cheng, A.T.A. (2001) Case definition and
culture: are people all the same? British Journal of
Psychiatry, 179,
1-3.
Kleinman, A. (1988) Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: Free Press.
Littlewood, R. (1990) From categories to
contexts: a decade of the ‘new cross-cultural psychiatry’.
British Journal of Psychiatry,
156,
308-327.
Littlewood, R. (1996) Psychiatry's culture. International Journal of Social Psychiatry, 42, 245-268.
Institute of Biomedical Sciences, Academia Sinica, Taipei 11529, Taiwan
Littlewood states, "In his rephrasing, content is merely the ‘subjective complaint’ or ‘illness behaviour’, form the ‘objective symptoms’ ". This is a misunderstanding of what I have tried to emphasise in my editorial. One of the major points in my work is that the patient's subjective complaint belongs to ‘illness behaviour’, which is different from ‘objective symptoms’ assessed by psychiatrists, preferably using a standardised procedure.
Littlewood mentions the Western patterns of eating disorders, multiple personality disorder, overdosing, shoplifting, agoraphobia and school refusal. Many of these, if not all, are also found in non-Western societies (e.g., see Kleinman & Lin, 1981). Furthermore, school refusal is not a formal diagnosis in either the ICD—10 or the DSM—IV; rather, it is a behavioural problem possibly with underlying ‘etic’ psychopathology (depression, separation anxiety, phobia, learning disorders and so forth) and socio-environmental factors. In any society, primitive or modern, there are certain forms of teaching activity not run by modern school institutions. Presumably, the same refusal to attend these various forms of ‘school’ exists, with similar underlying psychiatric and socio-environmental factors. The ways of this refusal and the context of the socio-environmental factors are likely to be ‘emic’. For effective management of school refusal, both the underlying potential etic psychopathology and the emic illness behaviour and socio-environmental factors must be carefully examined. This is an alternative example of what I intended to elaborate using the example of koro.
The long-standing debate over etic/emic and semantic issues in cross-cultural psychiatry is unlikely to be satisfactorily resolved in the near future. However, it is believed that the development of standardised clinical interviews with emphasis on cross-cultural equivalence at the level of symptoms (e.g., Cheng et al, 2001) helps to avoid the so-called "category fallacy" (Kleinman, 1987).
It should be stressed that the under-reporting of psychological symptoms by interviewees from developing nations that I mentioned in my editorial does not mean that these people do not have, or cannot differentiate, emotions. People are people, and the very low rate of reporting of psychological symptoms to doctors by people in developing countries may be due to greater social stigma towards mental illness, their lack of knowledge about mental illness and a much less psychologically oriented medical practice. More studies into this area are needed, and I believe that anthropologically oriented researchers can make a great contribution to this endeavour.
The etic/emic approach to psychopathology does not imply that psychiatry is confined only to biology. The emic pathoplastic shaping and illness behaviour closely associated with different sociocultural settings are equally important in psychiatry and require culture-specific approaches in combination with biological treatment. After all, mental disorders are believed to be the product of gene/environment interaction (Cheng & Cooper, 2001).
REFERENCES
Cheng, A. T. A. & Cooper, B. (eds) (2001) Genome and envirome: their roles and interaction in psychiatric epidemiology. British Journal of Psychiatry, 178 (suppl. 40).
Cheng, A. T. A., Tien, A. Y., Chang, C. J., et al
(2001) Cross-cultural implementation of a Chinese version of
the Schedule for Clinical Assessment in Neuropsychiatry (SCAN) in Taiwan.
British Journal of Psychiatry,
178,
567-572.
Kleinman, A. (1987) Anthropology and
psychiatry. The role of culture in cross-cultural research on illness.
British Journal of Psychiatry,
151,
447-454.
Kleinman, A. & Lin, T. Y. (eds) (1981) Normal and Abnormal Behaviour in Chinese Culture. Dordrecht: D. Reidel.
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