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Does Culture Influence the Expression of Symptoms?

Does Culture Influence the Expression of Symptoms?

Both the biomedical and cultural idioms of distress perspectives acknowledge that culture may influence the expression of symptoms. For example, culture may influence the frequency with which specific symptoms are expressed. Biomedical perspectives view cultural differences in symptoms as peripheral aspects of universal syndromes. Cultural idioms of distress perspectives, however, view such differences as evidence that the disorders themselves are distinct.

Schizophrenia.Findings from the WHO study revealed interesting cultural variation in schizophrenic symptoms. Although schizophrenic patients of ‘‘developed’’ and ‘‘developing’’ countries reported having their thoughts stopped, taken away, ‘‘read’’ by alien agents, and ‘‘broadcast’’ publicly, the relative frequency of other symptoms varied across cultures. In ‘‘developed’’ countries, patients were more likely to manifest depressive affect, whereas in ‘‘developing’’ countries, patients were more likely to experience visual hallucinations. The latter findings were consistent with those of Ndetei and Vadher, which suggest that auditory and visual hallucinations were more common in African, West Indian, and Asian schizophrenic groups than in English (i.e., from England) schizophrenic groups. Despite the fact that the WHO study is the most widely cited cross-cultural study of schizophrenia, critics argue that the differences between ‘‘developed’’ and ‘‘developing’’ countries in the WHO study are at most speculative. These critics argue that the WHO study did not measure specific cultural variables, wrongly assumed that countries within the ‘‘developing’’ and ‘‘developed’’ groups were more similar than different, and did not provide any compelling explanations for the cultural differences found (Edgerton & Cohen, 1994). More recent studies have provided clearer cultural explanations for cultural differences in symptomatology. For example, Tateyama, Asai, Hashimoto, Bartels, and Kasper compared schizophrenic patients (according to ICD-9 criteria) in Tokyo, Vienna, and Tubingen matched by sex, duration of illness, and mean age at onset and on admission. They found that across the three cities, similar percentages of patients reported having delusions (89.5%, 91.1%, and 87.3%, respectively). Furthermore, there were no cultural differences in the frequency of delusions of persecution/injury or of grandeur. City differences emerged in delusions of ‘‘belittlement’’ (e.g., being dead, feeling guilty or sinful), which were attributed to cultural differences in religion. Specifically, non-Christian Tokyo patients reported fewer delusions regarding guilt and sin than patients from European cities who were more influenced by Christianity.

Not surprisingly, the specific religious figures in the delusions were culturespecific: whereas patients of European descent spoke of ‘‘Jesus Christ’’ or ‘‘The Father of Europe,’’ Tokyo patients spoke of ‘‘Shakyamuni’’ or ‘‘Nichiren.’’ Furthermore, when Tateyama, Asai, Hashimoto, Bartels, and Kasper used a different classification scheme to decompose delusions of persecution/injury, Tokyo patients reported ‘‘being slandered by surrounding people’’ more than Europeans. The authors interpreted this difference as reflecting a greater desire for social approval in Japanese than in Western cultures. In a similar vein, Phillips, West, and Wang  observed that Chinese schizophrenic patients (according to DSM criteria) are more likely to manifest ‘‘erotomania,’’ the delusion of being loved by another person from afar, than Western patients. They also attribute these differences to cultural factors: in general, Chinese may be more concerned with social approval and have greater restrictions on sexual expression than Westerners. Other studies conducted before the WHO study proposed that cultural values and beliefs influenced the expression of schizophrenia. For example, Opler and Singerpredicted that Irish and Italian patients would differ in their schizophrenic symptoms because of cultural differences in their expression of emotion and views of sex, and in which parent assumed the dominant role in the home. Their findings supported their predictions for a male sample and were subsequently replicated in a female sample by Fantl and Schiro. For example, consistent with notions that Italians accept more emotional expression and impulsiveness than the Irish, these researchers found greater behavioral problems such as impulsiveness, open rebellion and physical assault among Italian patients than Irish patients. Unfortunately, these studies relied primarily on diagnoses that were not based on standard classification criteria; therefore, it is unclear whether members of the cultural groups would be diagnosed similarly according to ICD or DSM criteria.

However, Enright and Jaekle  compared Japanese and Filipino patients in Hawaii who were diagnosed with ‘‘schizophrenic reaction, paranoid type’’ according to DSM criteria and also found ethnic differences in symptomatology that were consistent with cultural differences in emotional expression and control. Filipino patients were more expressive, less restrained, and exerted more primary than secondary control compared to Japanese patients. Affective Disorders.Cultural differences in the expression of bipolar disorder have been documented. For example, Mukherjee and colleagues  found that African-American and Hispanic patients with bipolar disorder manifested more auditory hallucinations than White patients. As a result, they were more frequently misdiagnosed with schizophrenia than White patients. Most research, however, has focused on cultural expressions of unipolar depression. As with schizophrenia, the WHO conducted a study in the 1970s to examine whether the symptoms of unipolar depression varied cross-culturally. This study examined unipolar depression in 573 patients from Canada, Iran, Japan, and Switzerland, using the WHO Standardized Assessment of Depressive Disorders (SADD). Across sites, depressive patients demonstrated a ‘‘core’’ profile of depressive symptoms that included sadness, joylessness, anxiety and tension, lack of energy, loss of interest, inability to concentrate, and feelings of worthlessness. Beiser, Cargo, & Woodbury also found evidence of a core constellation of depressive symptoms in a community sample of 1348 Southeast Asian refugees and 319 Canadians. Participants completed questionnaires that contained items assessing depression, anxiety, and somatization, as well as items that tapped into culture-specific idioms of distress. Using gradeof-membership analysis, Beiser et al. found that for both Southeast Asians and Canadians, items loaded into three distinct categories: Major Depression, Depression with Panic, and Subclinical Depression. Other evidence in support of the universality of depressive symptoms comes from studies of ‘‘culturally bound syndromes.’’ Increasingly, researchers find that syndromes that were previously considered ‘‘culturally bound’’ resemble depressive disorders. For example, ‘‘dhat syndrome’’ in Indian culture, marked by the belief that semen is being lost, was initially regarded by Wig in 1960 as a culturally bound syndrome; however, recent work suggests that it is strongly associated with depressed mood, fatigue, and the DSM-III-R diagnosis of depression. Similarly, ‘‘hwa-byung,’’ considered a ‘‘Korean folk illness’’ marked by multiple somatic and psychological symptoms, is also strongly associated with DSM-III diagnoses of major depression. Cultural variation has been found in the frequency of specific depressive symptoms, however. For example, the WHO study found that feelings of guilt and self-reproach were more frequently reported in Western countries than in nonWestern countries. As in schizophrenia, the lower frequency of guilt-related symptoms has been attributed to cultural differences in religious traditions. Hamdi, Amin, and Abou-Saleh’s findings were consistent with those of the WHO study. Although the general disorder of endogenous depression exists in Arab culture, the loss of libido, a distinct quality of depressed mood, and feelings of guilt are less common in Arab than in Western cultures. Again, these differences may be related to different religious and cultural traditions among the ethnocultural groups.

Other differences have been found between members of Asian and Western cultures. Members of Asian cultures have been described as ‘‘somatizing’’ their depressive symptoms more than members of Western cultures. This may be particularly true for Chinese samples. Ying and colleagues found that compared to Chinese Americans, Chinese who lived in Taiwan reported more somatic symptoms of depression (as assessed by the Center for Epidemiological Studies Depression Scale), despite no differences between the two groups in overall levels of depressive symptoms. Various hypotheses were posited to explain this cultural difference. Compared to their Western counterparts, Asians have been described as using more somatic terms to describe their emotional states  as believing that somatic complaints are a more culturally appropriate way to present their distress , and as suffering from a disorder (i.e., neuraesthenia) that is distinct from depression. Some recent evidence, however, suggests that Asian-Americans may not somatize more than White Americans. For example, Zhang, Snowden, and Sue found that AsianAmericans and White Americans in the ECA data for the Los Angeles community reported similar levels of somatic discomfort.


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