بررسی آسیب شناسی روانی در سراسر فرهنگ و در درون فرهنگ: مسائل و یافته ها

Research based information on the impact of culture on psychopathology is reviewed, with particular reference to depression, somatization, schizophrenia, anxiety, and dissociation. A number of worldwide constants in the incidence and mode of expression of psychological disorders are identified, especially in relation to schizophrenia and depression. The scope of variation of psychopathological manifestations across cultures is impressive. Two tasks for future investigations involve the determination of the generic relationship between psychological disturbance and culture and the specification of links between cultural characteristics and psychopathology. To this end, hypotheses are advanced pertaining to the cultural dimensions investigated by Hofstede and their possible reflection in psychiatric symptomatology. It is concluded that the interrelationship of culture and psychopathology should be studied in context and that observer, institution, and community variables should be investigated together with the person’s experience of distress and disability.

Over the last two decades, culture’s interplay with human behavior and experience has moved from periphery toward the center among the concerns of contemporary psychology. Psychopathology has not been exempt from this trend. Against this background, we shall endeavor to provide a concentrated survey of the current state of conceptualization and knowledge in this area of inquiry. Cultural influences will be examined in their dual manifestations, across regions and boundaries around the world and within the ethnoculturally diverse milieus of many contemporary nation states. Accumulated findings will be reviewed, unsolved problems identified, and recommendations for future research and clinical practice formulated. To this end, we embark upon a consideration of the contrasting perspectives that have served as points of departure for the investigation of culture and abnormal behavior. 1.1. Culturalist and universalist orientations and their prospective integration Herskovits (1949) equated culture with the part of the environment that was created by human beings. Marsella (1988, pp. 8–9) provided a more elaborate, psychologically oriented, description of the attributes of culture as follows: Shared learned behavior which is transmitted from one generation to another for purposes of individual and societal growth, adjustment, and adaptation: culture is represented externally as artifacts, roles, and institutions, and it is represented internally as values, beliefs, attitudes, epistemology, consciousness, and biological functioning. This conception overlaps with that of subjective culture as formulated by Triandis (1972). How culture impinges upon and penetrates manifestations of psychological disturbance has been studied from two contrasting points of view. Universalists have focused upon differences in degree and number in preexisting, presumably worldwide, dimensions and categories. Relativists have been impressed with the scope of cultural variation and with the interpenetration of culture and psychopathology. Consequently, they have emphasized the uniqueness of phenomena within any given culture and the need to study them on their own terms. Emil Kraepelin (1904) is usually considered the originator of the universalistic comparison of psychological entities. Specifically, he initiated the observation of the manifestations and incidence of depression in Java. Moreoever, in a remarkably perceptive and prescient statement he anticipated the major tasks and issues of cross-cultural or comparative study of psychopathology: If the characteristics of a people are manifested in its religion and its customs, in its intellectual artistic achievements, in its political acts and its historical development, then they will also find expression in the frequency and clinical formation of its mental disorders, especially those that emerge from internal conditions. Just as the knowledge of morbid psychic phenomena has opened up for us deep insights into the working of our psychic life, so we may also hope that the psychiatric characteristics of a people can further our understanding of its entire psychic character. In this sense comparative psychiatry may be destined to one day become an important auxiliary science to comparative ethnopsychology (Ṽölkerpsychologie), (as quoted by Jilek, 1995, p. 231). A more outspoken, radically relativistic, point of view upon psychopathology has been propounded by Benedict, 1934, Devereux, 1961 and Nathan, 1994; and Nathan and Hounkpatin (1998), among others. These researchers prefer to observe psychological disorders within their respective cultural context and tend to eschew or de-emphasize comparative investigations, especially those of isolated aspects of psychopathology torn out of the matrix of their occurrence. They warn against purportedly universal explanations and are reluctant to impose imported external frameworks. The universalistic and relativistic positions show overlap with the etic and emic orientations, which focus upon the origins of the concepts to be investigated. The emic point of view capitalizes upon notions and labels derived from the experience within a culture. Etically oriented theoreticians and researchers concentrate their efforts upon the purportedly universal rubrics and continua of experience. Thus, the study of the consequences of parental rejection around the world (Rohner, 1986) is an eminently etic undertaking while the description of the uniquely Japanese pattern of lifelong dependence or amae (Doi, 1973) exemplifies an emic inquiry. An etic orientation, however, can also be applied to disentangling relationships within a culture. In Japan, for example, Kurabayashi (2001) has explored the culturally characteristic interplay of work related stress, depression, and suicide—three variables that tend toward universality. Culture-bound or emic disorders are typically studied at their respective cultural sites and are rarely subjected to quantification. However, in Southern China Tseng, Mo, Hsu, Li, Ou, Chen and Jiang (1988) conducted an epidemiological study during an outbreak of koro, an anxiety syndrome over imaginary penis shrinkage. This project was followed up by the collection of biographical and psychometric data, couched entirely in etic terms (Tseng, Mo, Hsu, Li, Chen, Ou, & Zheng, 1992). These admittedly atypical and innovative studies illustrate the potential of combining emic concepts with an etic modus operandi. Switching from one perspective to the other is not only possible but salutary and enriching. Integrative sources on psychopathology across cultures (e.g., Pfeiffer, 1994 and Tseng, 2001) blend and incorporate information from these seemingly opposed, but actually complementary, outlooks. In an ongoing project in France and at four Francophone sites in the Indian Ocean: Madagascar, Mauritius, Comorro Islands, and Reunion, Roelandt (2001) is simultaneously pursuing universalistic and relativistic objectives by investigating the cultural conceptions of depression, mental illness, and madness and by recording the prevalence of mental disorder. In Table 1, the characteristics of the emic and etic approaches are schematically presented and then integrated within a more comprehensive framework in both gathering data on cultural groups and in the assessment of individuals.

This review documents substantial advances in research on psychopathology and culture achieved over the recent three decades. Both etic and emic approaches have been operationalized and refined. The bulk of this information has been gathered in the course of cross-cultural comparisons. Time is ripe for a partial shift toward a more emic orientation in conceptualization and data gathering. Eventually, we expect convergence and integration of these two approaches as etic research is informed by greater cultural sensitivity and emic studies become more objective, quantified, and rigorous (Tanaka-Matsumi, 2001 and Tanaka-Matsumi and Draguns, 1997). 2. Cultural research on psychopathology starts with the development of scales and other instruments of assessment. It culminates with their application across and within cultures. The past several decades have seen a major spurt in the standardization, validation, and utilization of such measures. These tools are proving their usefulness in the assessment of help seeking individuals in their respective cultural milieus, as a prelude to more flexible, sensitive, and effective intervention. 3. In epidemiological research, the development of standardized procedures has led to comparisons of data across cultures. In smaller scale cross-cultural studies, both normal and psychopathological samples have been included in a few pioneering investigations. This development has enabled researchers to put to the test two general hypotheses about the nature of the relationship of abnormal behavior and culture. Thus, Marsella’s (1988) expectation that cultural variability decreases as psychological disturbance becomes more severe was tentatively confirmed in a comparison in Sweden and Nicaragua of normal, borderline, and schizophrenic individuals (Sundbom, Jacobsson, Kullgren, & Penayo, 1998). Draguns (1973, 1980) anticipated exaggeration of cultural differences in psychopathology; this notion has received support in one study (Tseng et al., 1990) while two investigations (Räder et al., 1990; Radford, 1989) have yielded ambiguous results. 4. A substantial amount of findings has accumulated on the universal features of psychopathology, especially in relation to schizophrenia and depression. These results invariably coexist with substantial differences in symptomatology and other features across cultures. In line with Marsella’s (1988) hypothesis, such differences appear to be more pronounced as the disorders become less disabling. 5. An open question pertains to the extent and nature of the links between psychopathology and cultural characteristics. Predictions have been advanced about the psychopathological reflections of Hofstede’s (2001) cultural dimensions, but they remain to be systematically tested. 6. Guilt and somatization have emerged as two prominent sources of variation across cultures. Both of these variables, and many others, interact in a complex and shifting fashion with a variety of social, contextual, and psychopathological variables which have not yet been completely disentangled. 7. Culturally characteristic features of abnormal behavior are invariably expressed in the course of an encounter between the patient and the observer(s) in a specified culturally distinctive context. Yet, in most of the research reviewed, “culture of diagnosticians has been forgotten and cultural context has received minimal research attention.” (Tanaka-Matsumi, 1999, p. 24). The challenge remains to recognize the importance of the observer and the milieu and to incorporate these variables into future studies. 8. It is often overlooked that the impact of culture upon psychological disturbance is recorded at a specific point in both space and time. With the fast pace of social transformation and increasing globalization, many of the findings recorded here may become obsolete. Abrupt and unanticipated social change, such as the collapse of the Soviet regime in Russia, is likely to enhance some symptoms and reduce others (cf. Korolenko & Dmitriyeva, 1999). The task of culturally oriented investigators is to follow and document the trends that such events may both shape and provoke, especially in relation to distress and disability. 9. The bulk of empirically ascertained knowledge in this area pertains to the effects of culture upon the manner in which psychological disorder is experienced, expressed, and communicated. As yet, very little is known about any cultural causation of psychopathology, which remains an important if elusive field of investigation (Jilek, 1982 and Tseng, 2001). 10. It should be emphasized that the findings we have reviewed pertain to trends rather than types. Invariably, there is overlap between cultures. Moreover, cultural characteristics described in this article stand in a complex relationship to individual differences with culture. For example, there are many individualists in cultures deemed collectivistic, and vice versa. Taking note of cultural features, we strongly caution against converting them into stereotypes.