The Problem with Diagnosing Depression Across Cultures Part 2: Why is it difficult to diagnose depression outside Western contexts?

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The reason that Western categories such as Depression are inapplicable when it comes to diagnosing mental illness in these societies, is due to conflicting ideas of what constitutes depressive emotions between these societies and the psychiatric paradigm with its roots in Western biomedicine.  This results in discrepancies in what are normative and deviating cultural scripts between Western and Asian societies.  In addition, their contextual appropriateness of expression, as well as the resulting perceptions and connotations concerning this expression, vary cross-culturally.

For instance, according to Jenkins, Kleinman and Good (1991), expressions of despair that correspond with the diagnostic criteria for Depression are often glorified and encouraged in Iran.  Good, Good and Moradi (1985) point out that suffering is a highly elaborated and even ritualised constituent of Shia Islam:

‘For Shi’ite Muslims in Iran, grief is a religious experience, associated with recognition of the tragic consequences of living justly in an unjust world; the ability to experience dysphoria fully is thus a marker of depth of person and understanding.’ (Kleinman and Good 1985 p.3)

However, while idioms used to express despair and other emotions differ worldwide, this does not mean that different emotions are felt entirely.  The famous anthropologist Clifford Geertz claims that as children we are socialised to express certain points along a spectrum of possible emotions, and these points constitute a ‘vocabulary of emotion’ that varies cross-culturally (Geertz 1959).  This idea is mirrored by Jenkins, Kleinman and Good, who go as far as saying that different cultures feel different emotions.  However the evidence they provide (1991) only suggests that emotions are idiomatically expressed differently.  I have yet to come across any material that examines the neurological activity of the human organism which proves that different emotions are felt altogether: the idea that individuals from different cultures only have the ability to feel a certain set of emotions which is culturally delineated, is at best, a conjecture.

On the other hand, the opposite claim, which suggests that all humans are predisposed and preprogrammed, in a sense, to feel from an identical set of emotions, assumes that we have a predetermined range of ‘emotional presets’.  However it may well be the case that certain emotions are produced and expressed through the activation of different areas of the brain,  and different combinations of areas at specific times; therefore the concept of ‘emotion’ itself is a culturally and contextually constructed category, albeit a common one cross-culturally.

Emotions are a complex set of conceptions which manifest through a plethora of combinations of neural impulses, through various areas of the brain: the amygdala, hippocampus, orbitofrontal cortex and anterior cingulate cortex, among others.  Feeling anything, is a much more complex neurological process than selection from an abstract neurological spectrum ranging from euphoria to dysphoria, which may or may not be a biological reality to begin with.  Moreover, these biological processes need not be only neurological.  Endocrinal functions are also often involved in feeling states of depression and despair.  Unfortunately I am unable to say more on the topic, as validating this is a task for neuroscience and biology, rather than an anthropologist or psychoanalyst studying surface realities.

What I can say is that these surface realities are expressed in the form of cultural scripts (Tsai et al 2015).  Cultural scripts are bridges between ‘culture in the head’, as norms and behaviour, and ‘culture in the world’, as institutions such as family and legal systems (Kroeber and Kluckhohn 1952, quoted from Tsai et al 2015).  Cultural scripts provide ‘sequenced patterns of meaningful ideas’ that lead to ‘observable actions in the world’, which in turn reproduce the ideas held by actors and observers, in the same way the anthropological concept of habitus functions as a self-reproducing system of bodily dispositions, which perpetuates itself through mimesis, and dictates bodily actions, habits and dispositions, such as chewing with ones’ mouth closed, or walking in a certain gender-specific way (Bourdieu 1987).  Cultural scripts likewise have the ability to not only reinforce but also challenge and change cultural contexts (Kashima 2000).

There are two kinds of cultural scripts:  normative and deviant.  Normative cultural scripts define and reproduce what is ‘normal’ in a given society, whereas deviant cultural scripts define and reproduce what is abnormal.  This results in an ironically normative mediation for the abnormal, which is tremendously useful when describing distress perceived by an individual to be abnormal.

The result is a set of culturally fossilised idioms of distress, which varies from one society to the next.  In the example of Iran that I mentioned before, distress resembling the DSM symptoms of Depression is recognised as a normal part of the human experience, and is therefore expressed through normative scripts.  The poetry of Rumi and Hafez, with lovesickness, heartbreak, loss, despair, nihilism and emptiness as common themes, actually constitutes an integral part of the Iranian cultural norm, rather than deviates from it.  And so every Spring, a book of Hafez’s poems can be found in almost every Iranian household on the Haft Seen, the Nowruz table.  Conversely in the West, the same kind of distress expressed in Iranian poetry, is expressed through the deviating script of an abnormal biological disease.

The Korean syndrome of hwabyung (‘fire illness’) is expressed through deviating scripts that accentuate anger, unfairness, bodily sensations of heat, dry mouth and bloating and burning sensations in the lower abdomen.  These scripts also intricately describe the healing process, which involves a ‘gradual progression from these symptoms to sorrow, self-blame, and acceptance.’  (Choi & Kim 1993; Min et al 2009, quoted from Tsai et al 2015)  Laurence J. Kirmayer, MD, of McGill University points out that these idioms also convey social and interpersonal issues, and clinicians have to be knowledgeable enough to recognise these when they are expressed somatically (Kirmayer 2001).  Going back to Kleinman’s study of neurasthenia in China, we see that Chinese contexts discourage scripts of emotions that are self-oriented, instead encouraging the emphasis of social references (Dere et al 2012, Tsai et al 2004).  That neurasthenia and not depression is diagnosed in China for what is potentially the same condition, shows the conflict between which symptoms respectively constitute normative and deviating scripts across cultural contexts.

Continued in Part 3:  What difficulties arise from applying Western categories of mental illness to Asian societies?

References

Freud, S. (1917). Mourning and Melancholia in Freud, S. (1917). On Murder, Mourning and Melancholia. Trans. Shaun Whiteside (2005). London: Penguin Books.  Pp.201-18

Healy, D. (2004). Shaping the Intimate: Influences on the Experience of Everyday Nerves. Social Studies of Science 34(2) (April 2004).  Pp. 219-245

Horowitz, A. (2014). The Social Function of Natural Kinds. The Case of Major Depression.  in Kincaid, H. & Sullivan J.  (eds.) (2014).  Classifying Pychopathology: Mental Kinds and Natural Kinds. Cambridge Massachusetts:  MIT Press.  Pp. 209-227

Kleinman, A. & Good, B.  (1985). Culture and depression: Studies in the Anthropology of Cross-Culture Psychiatry of Affect and Disorder. Berkeley: University of California Press.

Jain, S., & Orr, D. M. (2016). Ethnographic perspectives on global mental health. Transcultural Psychiatry.  53(6).  Pp. 685-695. doi:10.1177/1363461516679322

Jenkins, H.  Kleinman, A.  Good, B. (1991). Cross-Cultural Studies of Depression. in Becker, J. & Kleinman A. (eds.) (1991). Psychosocial Aspects of Depression.  London:  Lawrence Erlbaum Associates, Publishers. Pp.67-99

Kirmayer, L.  (2001). Cultural Variations in the Clinical Presentation of Depression and Anxiety: Implications for Diagnosis and Treatment. Journal of Clinical Psychiatry 62 (suppl. 13): Pp. 22-30

Kleinman, A.  & Kleinman J. (1985).  Somatization: The Interconnections in Chinese Society among Culture, Depressive Experiences and Meaning of Pain. in Kleinman, A & Good B. (eds). (1985). Culture and depression: studies in the anthropology of cross-culture psychiatry of affect and disorder. Berkeley, California: University of California Press.

Kleinman A. (1986).  Social Origins of Distress and Disease: Depression, Neurasthnia and Pain in Modern China. New Haven, Connecticut:  Yale University Press.

Loo, P., & Furnham, A. (2013). Knowledge and Beliefs about Depression among Urban and Rural Indian MalaysiansMental Health, Religion & Culture,16(10), Pp. 1009-1029. doi:10.1080/13674676.2012.728579

Sood, A. (2016). The Global Mental Health Movement and its Impact on Traditional Healing in India: A Case Study of the Balaji Temple in Rajasthan. Transcultural Psychiatry,53(6), 766-782. doi:10.1177/1363461516679352

Summerfield, D.  (2006). Depression: Epidemic or Pseudo-epidemic? Journal of the Royal Society of Medicine 99 (March):  Pp. 161-162

Ta, T. M.  Zieger, A., Schomerus, G., Cao, T. D., Dettling, M., Do, X. T…. Hahn, E. (2016). Influence of Urbanity on Perception of Mental Illness Stigma: a Population Based Study in Urban and Rural Hanoi, Vietnam. International Journal of Social Psychiatry, 62(8).  Pp. 685-695. doi:10.1177/0020764016670430

Varma, S. (2016). Disappearing the Asylum: Modernizing Psychiatry and Generating Manpower in IndiaTranscultural Psychiatry,53(6), 783-803. doi:10.1177/1363461516663437

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