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Are the DSM Disorders Universal Across Cultures? Karen Young Psychology & Health Studies University of Toronto Scarborough Background Adapted from a literature review for a HLTD01 – Directed Readings Study Supervisor: Dr. Katie Kilroy-Marac “Katie Kilroy-Marac received her PhD in Anthropology from Columbia University. Her research considers the social history of psychiatric thought, the evolution and naturalization of psychiatric categories, and the spaces in which local understandings of illness and suffering come into contact with (Western) psychiatric models. ” Inspiration for the content ANTC24 – Culture, Mental Illness, and Psychiatry (another course taught by Dr. Katie Kilroy-Marac) Acknowledgements of My Own Background Middle to upper middle class Cis-gendered Able-bodied University educated Mental Health – recognition challenges pertaining to mental health during my time in undergraduate Globalized ‘cultural’ background – I was born in Canada to parents of both Chinese diaspora. Introduction Given its nature as a “universal language” (Lurhrmann, 2000, p. 231), how does it interact with other cultural belief systems? I argue that the process of interpreting aspects associated with the DSM disorders: a) is adopted or dropped based on its incoherency or lack of coherency over time b) if adopted, the mechanisms underlying the interpretation help or harm the mental health experiences of these societies; c) whose existence is vulnerable to other cultural forces. Another Inspiration Inspired by Gananath Obeyesekere, Emeritus Professor of Anthropology “[t]o study work, one needs a case history approach contextualized in a specific culture. This would enable us to identify the mechanisms involved in symbolic transformation” (1986, p. 148). We will look at the application of Post-Traumatic Stress Disorder (PTSD) in the context in the 1970s and 1980s United States and in the 2000s Sri-Lanka (nonAmerican context) Further Readings All works were originally published in English between the years 1986-2012, by American journalists, American anthropologists, and American and Canadian academics. 1. Watters, Ethan. 2010. Crazy Like Us: The Globalization of the American Psyche. New York: Free Press, pp. 9-63 (“The Rise of Anorexia in Hong Kong”) 2. Watters, Ethan. 2010. Crazy Like Us: The Globalization of the American Psyche. New York: Free Press, pp. 65-125 (“The Wave the Brought PTSD to Sri Lanka”) 3. Obeyesekere, Gananath. 1986. "Depression, Buddhism, and the Work of Culture in Sri Lanka.” In Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. A. Kleinman and B.J. Good, eds. Berkeley: University of California Press, pp. 134-152 4. Young, A. (1997). The harmony of illusions: Inventing post-traumatic stress disorder. Princeton University Press. pp. 89-117 (Chapter 3: The DSM-III Revolution) 5. Young, A. (1997). The harmony of illusions: Inventing post-traumatic stress disorder. Princeton University Press. pp. 145-175 (Chapter 5: The Technology of Diagnosis) 6. Young, A. (1997). The harmony of illusions: Inventing post-traumatic stress disorder. Princeton University Press. pp. 176-223 (Chapter 6: Everyday Life in a Psychiatric Unit) Further Readings 1. Watters, Ethan. 2010. Crazy Like Us: The Globalization of the American Psyche. New York: Free Press, pp. 127-185 (“The Shifting Mask of Schizophrenia in Zanzibar”) 2. Good, B. J. (1997). Studying mental illness in context: Local, global, or universal?. Ethos, 25(2), 230-248. 3. Watters, Ethan. 2010. Crazy Like Us: The Globalization of the American Psyche. New York: Free Press, pp. 187-248 (“The Mega-Marketing of Depression in Japan”) 4. Heine, S. J. (2012). Cultural psychology. New York: WW Norton. pp. 458-490 (“Chapter 8: Mental Health”) 5. Luhrmann, T. M. (2000). Of two minds: The growing disorder in American psychiatry. Alfred A. Knopf. pp. 203-238 (“Chapter 5: Where the Split Came From”) 6. Anderson-Fye, E. P. (2004). A “Coca-Cola” shape: Cultural change, body image, and eating disorders in San Andres, Belize. Culture, Medicine and Psychiatry, 28(4), 561-595. History of Tension of Psychodynamics and Psychiatric Science Both psychiatric science and psychodynamics are cultural belief systems themselves Rise of psychodynamics: end of 19th century to just after WWII, psychodynamics (Freud) offered an elaborate theory in addressing social problems of the time Fall of psychodynamics: unverifiable: role of therapist was to interpret the inner understanding of their patients Rise of psychiatric science and the birth of the DSM: Psychiatric science (Spitzer) “addressed” the flaws of psychodynamics Notes on Terminology “Psychiatric science” “v.s.” Psychotherapy distinguish the ideologies in recent/present-day context Diagnostic Statistical Manual (DSM) DSM III, IV, V as psychiatric science took a dominant ideological hold to the creation of these editions DSM Disorders - PTSD Inducted into the DSM-III Ultimately created by the political interests at the time DSM-III definitions decontextualized the distinctive cases of PTSD resulting in a simple theoretical design: Advocates for Vietnam War Veterans and movement later included more advocates creating a timeless and placeless presence (Watters, 2010, p. 115-116) traumatic event must ultimately occur before the symptoms occurs. PTSD as a diagnostic tool has a history of overlooking the experiences of the patients it was supposed to serve, across place and time, both recently after the Vietnam War at an American Veterans Administration psychiatric facility in the 80s as well as more recently after the 2004 tsunami natural disaster in Sri Lanka. PTSD in the United States 1970s and 1980s A series of curious incidents at a Veterans Administration psychiatric facility in the US, the National Center for the Treatment of PTSD, whereby wielders of the adopted psychodynamic theory into practice took form in a way that created an ideology-centric interaction between the cultural expectations and the social experiences of the people who affected by it. Diagnosticians came together between 1986 and 1987, to determine the diagnosis of Vietnam veterans and admissions as inpatients or outpatients, the process of admitting these men into the clinic involved interpreting for content and structure into the psychodynamic narratives, at the same time, disregarding the context of these four men (Young, 1997, pp. 173-174). PTSD in the United States 1970s and 1980s Patients would learn how to socialize with the system’s beliefs (p. 214). Veterans Administration compensation rating board would offer more money for negative clinical evaluations diagnosed patients would want to increase their impairment to obtain a higher compensation. Center was mandated by Congress law to conduct research related to the etiology, symptomatology, and treatment of PTSD, meaning competition with other clinics (p. 184). This competition means incentivizing the practice of the clinic to demonstrate positive clinical evaluations. PTSD in Sri Lanka 2000s After the 2004 tsunami hit Sri Lanka, it triggered the largest psychological intervention ever (Watters, 2010, p. 70). Westerners overlooked key ways of Sri Lankans culturally coping with their own suffering while they were so focused on the practicing their received universalism of PTSD (Watters, 2010, p. 77). This mechanism of blinding oneself to the actual realities and understanding of the realities could eventually lead to the ironic outcome of harming the society that many came so far to serve. PTSD in Sri Lanka 2000s Acting on the false notion that PTSD is not universal, Sri Lankans were more likely to experience physical as opposed to psychological pains after horrible events (p. 91). In addition, the diagnosis of PTSD failed to consider the cultural context of shared cultural suffering in a society sensitive to outbreaks of violence (pp. 103-104). Villagers in a poor Sri Lankan village lived with a complex communication system in which any sensing of moment of terror coming from violence could trigger a fearrelated illness of a “terrified heart” (Waters, 2010, p. 110). Speaking directly about it was considered pathological, so indirect speech was used to manage the triggering of a “terrified heart”. Conclusion The way Spitzer ultimately created them is this: a constellation of symptoms that were to have to meaning in the first place. By deliberately eliminating the feature of interpretation, Spitzer ultimately and ironically left the DSM disorders to the interpretation of many “Affects [that] exist more or less in a free-floating manner, awaiting a different symbolic formulation” (Obeyesekere, 1986, p. 148) Discussion Questions How do the DSM disorders affect the lives of those today who are diagnosed? Are the DSM disorders universal?