Cross-cultural psychiatry and the DSM-IV

Cross-Cultural

Psychiatry

and the DSM-IV

Dan J. Stein This report attempts to provide a theoretical framework for exploring the intersection between current work in psychiatric nosology and cross-cultural psychiatry. Three positions at this intersection are constructed and contrasted-a clinical approach, an anthropological approach, and a synthetic clinical-

I

N RECENT DECADES, nosology has become an increasingly important area in psychiatry. Publication of the DSM-III1 and its revision2 by the American Psychiatric Association was instrumental in providing an impetus for the growth of psychiatric nosology. These manuals have had a major impact on practice, teaching, and research in the United States.3 Furthermore, they have been translated into many languages and are now widely used throughout the world.4 The DSM-IV is likely to be equally influential. Cross-cultural psychiatric investigation, although long outside the mainstream of psychiatry, has also achieved increasing prominence in recent years. The work of Kleinman and his colleagues5-7 has played a major role in the growth of this area, which has been dubbed the “new cross-cultural psychiatry.“8,9 These investigators have not only had an anthropological interest in the psychopathology and psychotherapy seen in non-Western cultures, but have also emphasized the potential contribution of anthropological theories and methods to the Western clinical setting. Cultural heterogeneity of patients in the United States and the hope of increasing convergence between the forthcoming DSM-IV and the 10th edition of the International Classification of Diseases (ICD-10) have resulted in increased focus on the intersection between nosology and cross-cultural studies.‘O-l3 This report attempts to provide a theoretical framework for exploring this intersection. Three pos-

From the Department of Psychiatry, College of Physicians and Surgeons, Columbia University New York; and the New York State Psychiatric Institute, New York, NY. Address reprint requests to Dan J. Stein, M.B., New York State Psychiatric Institute, 722 W 168 St, Box 85, New York, NY 10032. Copyright 0 I993 by W.B. Saunders Company 0010-440X/93/3405-0016$03.00/0 322

Comprehensive

anthropological approach. These positions are used to consider a number of cross-cultural issues in the forthcoming DSM-IV, including a background statement, a cross-cultural axis, diagnostic categories and criteria, and culture-bound syndromes. Copyright 0 1993 by W. B. Saunders Company

sible approaches to this interface are constructed and contrasted.* At the outset it should be emphasized that this delineation constitutes an heuristic device, and that the work of particular nosologists or anthropologists may not fit neatly into one or the other approach. The three positions provide a framework for exploring several cross-cultural issues that have been raised in relation to the DSM-IV. CLINICAL POSITION

The clinical position is occupied by clinicians and anthropologists who are primarily interested in applying Western medical and psychiatric nosologies in post hoc fashion to diverse populations. DSM-IV categories and criteria, for example, constructed in a particular (Western) setting are used to classify psychiatric data obtained in another (non-Western) context.? This position has roots in early investigations in general anthropology, which applied Western classifications to diverse phenomena, and also has a venerable tradition in both medical and psychiatric nosology. Kraepelin, for example, the father of contemporary psychiatric nosology, applied his system of classifying psychoses in German patients to data collected in Java. Kraepelin’s nosology was predicated on a biological hypothesis-that the major psychoses each had a distinctive underlying neuropathogenesis, which accounted for their particular symptom*I have previously used these terms to discuss the relationship between medical anthropology and psychotherapy integration40 but in that report the terms are defined rather differently. The argument here is closer in form to a previous report on philosophy and nosology.26 TThroughout I will contrast Western and non-Western, as this is arguably the predominant dichotomy between anthropologists and their subjects. However, similar dichotomies may also be applicable at times, and have been highlighted in more sociologically influenced literature. These include, for example, the contrast of middle-class with working-class, white with black, or male with female theorists and subjects. Psychiatry, Vol. 34, No. 5 (September/October),

1993: pp 322-329

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atology and course. Thus psychotic symptomatology had universal forms, which were biologically determined, but diverse contents, which were colored by cultural factors.9 DSM-111(-R) categories and symptoms have been used in both everyday practice and in psychiatric research in diverse cultures.4 However, the fact that much of this work acknowledges the limitations of post hoc application suggests that an undiluted clinical position is perhaps more of a theoretical endpoint than a stance consistent with good clinical research. Straightforward adoption of the DSM-111(-R) is perhaps even less likely to be seen in the studies of anthropologists. Nevertheless, cross-cultural psychiatrists such as Prince and Tcheng-Larouche’” have stated that relatively minor alterations in the DSM-III would result in a truly international classification of diseases. The strength of the clinical approach lies in its willingness to extend a particular theoretical framework to diverse settings. The position highlights the scientific process of nosology construction. Indeed, international use of the DSM-111(-R) has allowed the work of different clinicians to converge and has contributed to increased knowledge of psychiatric disorders. Nevertheless, the position may be criticized on a number of fronts. Routinized application of one theoretical framework may prevent the nosologist from recognizing the existence or appreciating the character of unfamiliar categories and symptoms. DSM-111(-R) systems give short shrift to the so-called culture-bound syndromes and pay little attention to differences in psychopathology between different cultures. Conversely, this approach downplays the possible contribution that cross-cultural theories and methods make in helping us recognize the particular sociocultural influences on our own nosology. Indeed, the authors of the DSM111(-R) go so far as to state that the manual takes an atheoretical approach toward psychopathology. In short, the clinical position cannot account for the relationship between psychopathology and the social forms in which it is produced. ANTHROPOLOGICAL

POSITION

The anthropological position is occupied by clinicians and anthropologists who focus primar-

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ily on medical and psychiatric nosologies as cultural artifacts. These investigators are interested in exploring, for example, the relationship between construction of the DSM-IV and its forerunners and their particular sociocultural setting. Again, this position has a long history. Boas, a pioneering figure in American anthropology, wrote that, “If it is our serious purpose to understand the thoughts of a people the whole analysis of experience must be based on their concepts not ours” (pp. 314).15 Furthermore, Boas increasingly came to believe that an appreciation of the historical and environmental factors that shaped a culture was required to understand these psychological forms.lh These ideas have also been applied in medical and psychiatric anthropology, and an extensive literature devoted to the cultural meanings of disease and to the social construction of disease has emerged.“-lY Early critics of the DSM-111(-R) analyzed the manual as a particular social construction.“‘.” Whereas such work is more likely to be performed by anthropologists or sociologists, some clinicians have taken a similar stance. Szasz”’ and Laingz3 are perhaps the best known; Szasz has proclaimed that mental illness is a myth, whereas Laing has focused on the creative aspects of psychosis. The anthropological approach has a number of strengths. It emphasizes the relationship between psychiatric nosology and the social forms in which it is produced. It therefore points to the importance of considering the ways in which cultural factors determine the experience and perception of mental disorder (rather than simply influencing its form). Kleinman.5 for example, has suggested that the emphasis in DSM-III on psychological rather than somatic symptoms of depressive-spectrum disorders makes sense only within Western culture and is not universally applicable. Furthermore, this position points to the importance of thinking through the relationship between our nosology and our particular sociocultural setting in a self-reflexive process. The exclusion of homosexuality from the DSM-III-R provides just one exemplar of the political aspects of psychiatric nosology.24 Perhaps, as Young25 intimates, the focus of the DSM-111(-R) on the individual and

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his or her biology reflects the individualistic technological aspects of Western society. It is arguable that there is a relative failure of the DSM-111(-R) to include constructs from family and social studies. Nevertheless, the anthropological position also falls prey to a number of criticisms. A view of mental disorder as merely a social construction undermines the existence of mental disorders in the DSM-111(-R) as real phenomena that are generated by underlying biopsychological mechanisms. A view of nosology as simply a cultural product undermines the importance of scientific explanation as a component of clinical investigation. Indeed, important strengths of the DSM-111(-R) are its inclusion of advances in contemporary psychiatric science (e.g., recognizing panic disorder as a separate entity with a specific phenomenology and pathophysiology) and its explicit attitude that further editions of the DSM will need to change to incorporate new findings. Thus, the anthropological position tends to neglect the reality of the entities and processes of mental disorder and the validity of our explanations of their mechanisms. CLINICAL-ANTHROPOLOGICAL

POSITION

The clinical-anthropological position can be seen as attempting to synthesize aspects of the clinical and anthropological positions. Classifications such as the DSM-111(-R), which are based on scientific knowledge, may be argued to have both transitive dimensions (they are always produced in social forms) and intransitive dimensions (they do allow a knowledge of real entities).26 An early Greek classification of infectious diseases, for example, divided these into those that resolve after the krisis and those in which there is deterioration after this turning point. At this point, little was known about the underlying mechanisms of infection, and the classification was primarily informed by a wide-ranging theory, which also pertained to other aspects of social life. As knowledge of infectious entities progressed, so classifications incorporated discoveries about different bacteria, viruses, and more recently, prions. Knowledge about infectious disease continues to be produced in social forms, and may, for example, reflect a Western focus on individual susceptibility to infection

rather than on social responsibility for disease prevention.25 Nevertheless, the structure of classifications of infectious diseases is based on knowledge of real entities and processes. As we increase our knowledge of the entities and processes involved in mental disorders, so this knowledge becomes incorporated into psychiatric nosology. We have, for example, learned about dopaminergically mediated processes in psychosis, which appear to be responsible for similar phenomena throughout the world.27 On the other hand, mechanisms that produce impulsive aggression, perhaps including both serotonergic deficiency and environmental stressors, appear to lead to divergent phenomena ranging from loss of temper to running amok to different kinds of violent and suicidal behaviors.28 It is not that “psychotic” disorders are more biological than “neurotic” ones29-rather, all psychiatric disorders are comprised of psychopathological phenomena that are generated by underlying neurobiological and psychosocial causal mechanisms. Knowledge about psychiatric disorders is always produced in social forms and reflects our particular concerns and values.24 However, the fact that psychiatric nosology is value-laden does not necessarily imply that nosology is irrational. There may, for example, be an interplay between the growth of scientific knowledge and more rational value judgments. For example, the knowledge that homosexuality is not associated with increased personality disorder or decreased intellectual performance may lead to a reevaluation of homosexuality as valuable. These views are undoubtedly not new. Indeed, it is likely that clinicians faced with clinical problems of diversity have implicitly adopted them. Clinicians who use Western psychiatric categories in non-Western settings often acknowledge the limitations of these categories. Anthropologists who explore illness meanings in non-Western settings often acknowledge the scientific validity of biomedical knowledge of these diseases. The DSM-111(-R) is clearly a product of our own particular society, as those within the anthropological position have argued. Nevertheless, the manual has been built on a knowledge of real entities and processes and therefore deserves to be seen as

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scientific, as those within the clinical position have argued. The strength of the clinical-anthropological approach is that it has a place for both scientific knowledge and meaning construction. The reality of disease and its biopsychological underpinnings is emphasized, while the construction of disease within a particular sociocultural context is also incorporated. In the following sections, a clinical-anthropological position is suggested to be advantageous in thinking through several cross-cultural issues that have been raised with reference to DSM-IV. BACKGROUNDSTATEMENT The introduction to the DSM-111(-R) contains an acknowledgment that the manual was developed in the United States, and that difficulties in applying the manual to patients in other cultures may occur. Although this statement makes a gesture toward the anthropological position by self-consciously acknowledging the sociocultural context of the DSM-111(-R), the statement is perhaps most consistent with the clinical position. The problem raised is that of post hoc application of the DSM-111(-R), and rather than criticizing this endeavor, the statement merely suggests caution. An anthropological approach to the background statement would perhaps emphasize that using the DSM-IV outside of North America involves a “category fallacy.“8 That is, crosscultural use of one ethnocentric classification reifies its categories and criteria as universal natural kinds. The mistake is of the same order as researching the epidemiology of the South Asian construct of “semen loss” with its symptoms of weight loss, weakness, sexual fantasies, hypochondriasis, night emission, and urine discoloration in North America.“” From a clinical-anthropological perspective, further elaboration of the introductory statement is perhaps necessary. The necessity for developing different diagnostic schemas in diverse cultures needs to be emphasized. Just as there is a conservative emphasis in the DSM-IV on the necessity of empirical support before changes are made from DSM-111(-R),“’ so the application of the DSM-IV in non-Western settings requires systematic support. On the other hand, the scientific basis of the DSM-IV

and the inclusion of minority subjects in empirical research of the DSM-IV field trials’” do encourage that work to proceed. DIAGNOSTIC

CATEGORIES

In the introduction to the DSM-111(-R) there is an acknowledgment of the difficulty in determining where disease and health begin and end. This statement appears again to be a nod in the direction of the anthropological position that disease (and health) are socially constructed. The statement falls within the clinical position, emphasizing how difficult objective science can be, rather than acknowledging that science is always value-laden. An anthropological approach to the questions of where disease begins and health ends and which categories belong in the DSM manuals would focus again on the value-laden nature of all classification systems. Thus disorders that are commonly diagnosed in other parts of the world (e.g., neurasthenia) are not included in the manual, whereas disorders that are rarely seen in non-Western cultures (e.g., anorexia nervosa) are included. Similarly, certain nonWestern cultures may have much higher tolerance for certain symptoms (e.g., of dependent personality disorder) and much lower tolerance for others (e.g., of substance abuse). From the clinical-anthropological viewpoint, the role of science is to determine the biopsychosocial mechanisms responsible for clinical and nonclinical psychological phenomena. The question of which phenomena to regard as disease depends on whether we value their absence and on whether they deserve clinical intervention (rather than, e.g., religious or legislative intervention) to manage or change these underlying mechanisms. Despite the diversity of human culture, the relative universality of the human condition leads to correlatively few crosscultural disagreements about whether a particular phenomenon is pathologically Even dissociative symptoms or dependent traits are judged pathological within a culture when they result in social or occupational deterioration. Thus there is often cross-cultural diagnostic agreement.iQ7 As mentioned earlier, social values should not simply be thought of in pejorative terms as irrational and therefore incomparable. For the clinical anthropologist, then, exclu-

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sion and/or inclusion of particular entities is based both on scientific knowledge and rational value judgments. The goal of the clinical anthropologist is to avoid both underdiagnosis of disorders that deserve treatment and overdiagnosis of conditions that do not deserve treatment. There are a number of ways in which the DSM-IV might be modified to help advance this goal. One possibility is to add an exclusionary criterion to certain disorders, noting that if the symptoms are culturally acceptable the diagnosis should not be made. Alternatively, a crosscultural note in the text of these disorders could emphasize that in particular cultural settings they are not pathological. These options may be particularly useful in some dissociative and personality disorders; however, they may also require further study and justification. Thus, for example, even if a culture tolerates excessive alcohol use, if drinking is associated with medical or psychiatric complications, then the diagnosis of a substance disorder should be made. Conversely, even if a culture regards behaviors such as political deviance as evidence of psychopathology, this should not simply be accepted as valid in the absence of good support. Indeed, further study of these disagreements is a central contribution of work at the interface of nosology and anthropology. “Culture-bound” syndromes, i.e., disorders that are recognized in some cultures but not in others, are discussed in a later section. MULTIAXIAL

APPROACH

The DSM-IV takes a multiaxial approach to psychopathology. Syndromal disorder diagnoses are made on axis I, personality disorder diagnoses on axis II, and physical disorder diagnoses on axis III; acute and chronic stressors are described on axis IV, and psychosocial functioning is described on axis V. The question has been raised of whether.an additional axis should be used to describe anthropological data.13 All three positions favor the idea of adding information about culture to clinical assessment. However, the clinical viewpoint is that this information simply comprises additional demographic facts about the patient; thus it is unlikely to require an additional axis. The

anthropological viewpoint, on the other hand, is that information about culture is central. However, this information is unlikely to be readily stated on a separate axis. The use of operational definitions, for example, is inconsistent with the anthropological focus on illness meanings. Furthermore, it is paradoxical to note both diagnosis and culture on separate axes, for diagnosis is constructed within a particular culture. From a clinical-anthropological viewpoint, culture is more important than mere demographics, and yet need not be the royal road to understanding the patient. However, it is unclear that formalizing an additional axis for cultural information would be helpful in applying cross-cultural knowledge. An analogy with psychodynamic knowledge may be made here. Psychodynamic knowledge is important in understanding patients and may even underly certain diagnostic categorizations (e.g., borderline v narcissistic personality disorder). Nevertheless, the operational definition of psychodynamic constructs (e.g., particular defenses) may not necessarily be helpful in applying psychodynamic knowledge in clinical practice. An anthropological perspective should be used to understand both Western and non-Western patients, and should not be restricted to noting the presence or absence of particular subcultural characteristics on a separate axis. CULTURE-BOUND

SYNDROMES

Culture-bound syndromes have constituted an important construct in cross-cultural psychiatry. The term was coined by Yap, a Chinese psychiatrist who wrote a report entitled “Mental Diseases Peculiar to Certain Cultures” in 19513* and who later termed these diseases “culture-bound.“33*34 Prince and Tcheng-Larouchei4 have suggested that culture-bound syndromes are signs and symptoms of disease that are restricted to a limited number of cultures primarily on the basis of their psychosocial features. Culturebound syndromes should not be assigned on the basis of differential distributions of disease secondary to geographical accidents or local labels or notions of cause. Culturally determined illness meanings should not be confused with syndrome descriptions or be used as crite-

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ria for disease classification. This position is perhaps most consistent with a clinical position insofar as the assumption is made that many diagnoses (perhaps those already in the DSMIII[-R]) do not have important and distinctive psychosocial features. Prince and TchengLarouche conclude that relatively minor alterations in DSM-III categories and criteria would allow a truly international classification of diseases. l4 Kleinman and others have opposed this suggestion; for them, all diseases are culture-bound in an important sense. Furthermore, certain symptoms in non-Western societies cannot directly be translated into Euro-American languages. In his commentary on the report by Prince and Tcheng-Larouche, Kleinma+ therefore writes that transforming culture-bound syndromes into signs and symptoms as a way out of the thicket of conceptual issues that surround them only begs the question. From a clinical-anthropological perspective, there do appear to be universal disease processes, but cross-cultural factors do result in different manifestations of psychopathological phenomena. Thus although DSM-111(-R) diagnoses are culture-bound, this appears to be characteristic of all psychiatric diseases. To define a particular psychiatric disease as culturebound is to lose sight of the psychosocial factors in all such diseases. Furthermore, while psychiatric nosologies ought to be applied tentatively, with self-reflexive criticism,35 this should be a feature of all psychological science. Thus the clinical-anthropological position suggests that research may succeed in delineating continuities and contrasts between DSM-111(-R) syndromes and other cultural categories in terms of phenomenology and underpinning. Such empirical work may yield several theoretical possibilities. First, two disorders may be sufficiently similar for the DSM-111(-R) syndrome to include the cross-cultural category with only minor modifications. For example, there appears to be overlap between the DSM-111(-R) diagnosis of somatization disorder, the Chinese category of neurasthenia, and various other diagnoses such as brain-fag and chronic fatigue syndrome.3h Within the anxiety disorders, the DSM-111(-R)

diagnosis of social phobia appears to be similar to the Japanese category of tuzjin-kyofi-sho. Similarly, the proposed DSM-IV”’ categories of trance and possession states may subsume a variety of cross-cultural syndromes. However, it should be noted that not all patients who receive a culture-bound diagnosis will meet criteria for the overlapping DSM category. Simons,38 for example, notes that patients with taijin-kyojiksho may occasionally be best diagnosed as having a psychotic disorder. Second, a culture-bound category may not match any particular DSM-111(-R) diagnosis. The alternatives are then to classify the crosscultural category using more than one DSM111(-R) diagnosis or to consider adding the culture-bound category as a separate diagnosis. Body dysmorphic disorder and Koro, for example, overlap insofar as a concern with a body defect is present in each. Nevertheless, Koro is often accompanied by panic, and the concern with penile shrinkage is often relatively transient. Perhaps Koro overlaps with body dysmorphic disorder and/or panic disorder; alternatively, the constehation of symptoms in Koro may be sufficiently distinct to warrant a separate diagnosis. While further empirical work on the mapping of DSM-111(-R) diagnoses to other cultural categories remains to be performed, these kinds of possible relationships deserve perhaps to be noted in the text describing each particular DSM-111(-R) disorder or in an appendix to the manual. DIAGNOSTIC

CRITERIA

From a clinical position, diagnostic criteria can be straightforwardly applied to patients from different cultures. From an anthropological position, diagnostic criteria, which focus on operational definition rather than meaning, miss the kernel of illness. Similarly, from a clinical position, stressors and functioning on axis IV and V are universally applicable, whereas the anthropological position states that cultures differ widely in terms of these descriptors.34 From a clinical-anthropological position, while certain mechanisms may be the same in different cultures, differences in other mechanisms may result in quite different signs, symptoms,

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and stressors. These may range from simple differences in form to more substantial differences in experience and perception. The meaningful forms through which distress is articulated and constituted as social reality vary significantly. Operational definitions capture meanings only incompletely, and they may not be readily translatable. Nevertheless, operational criteria are important insofar as they point to the presence of particular underlying mechanisms. The question of which particular operational criteria serve better to indicate the presence of an underlying disease process is an empirical one. For example, on a worldwide basis, it may be mistaken to make the psychological symptoms of depression the defining characteristic of this disorder.5 However, this question is only resolvable by empirical investigation. While this work progressesI it may be helpful to

add a cautionary statement to the text describing depression. CONCLUSION

This report has constructed three positions from which the intersection between nosology and medical anthropology can be considered. A comparison and contrast of these positions provides a framework for considering various cross-cultural issues that have been raised in relation to the DSM-IV. Cross-cultural psychiatry serves to focus us self-reflexively on the limitations of our nosology, but also provides a challenge to understanding the universality of psychiatric disorders. While further empirical investigation is paramount for advances in crosscultural nosology, a rigorous theoretical framework may be helpful in encouraging that work to proceed.

REFERENCES 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Ed. 3. Washington, DC: American Psychiatric, 1980. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Ed. 3. Rev. Washington, DC: American Psychiatric, 1987. 3. Klerman GL. The significance of DSM-III in American psychiatry. In: Spitzer RL, Williams JBW, Skodol AE (eds): International Perspectives on DSM-III. Washington, DC: American Psychiatric, 1983. 4. Spitzer RL, Williams JBW, Skodol AE (eds): International Perspectives on DSM-III. Washington, DC: American Psychiatric, 1983. 5. Kleinman A. Patients and Healers in the Context of Culture: An Exploration of the Borderland Between Anthropology, Medicine, and Psychiatry. Los Angeles, CA: University of California Press, 1980. 6. Kleinman A. Rethinking Psychiatry: From Cultural Category to Personal Experience. New York, NY: Free Press, 1988. 7. Good BJ, Good MD. Towards a meaning-centered analysis of popular illness categories: “fright-illness” and “heart distress” in Iran. In: Marsella AJ, White GM (eds): Cultural Conceptions of Mental Health and Therapy. Dordrecht, The Netherlands: Reidel. 1982. 8. Kleinman A. Depression, somatisation, and the “new cross-cultural psychiatry.” Sot Sci Med 1977;11:3-10. 9. Littlewood R. From categories to contexts: a decade of the “new cross-cultural psychiatry.” Br J Psychiatry 1990;156: 308-327. 10. Fabrega H. Psychiatric diagnosis: a cultural perspective. J Nerv Ment Dis 1987;175:383-394. 11. Westmeyer J. Cultural factors in clinical assessment. J Consult Clin Psycho] 1987;55:471-478. 12. Kroll J. Cross-cultural psychiatry, culture-bound syndromes and DSM-III. Curr Opin Psychiatry 1988;1:46-52.

13. Mezzich J. Cultural proposals for DSM-IV. Proceedings of the Annual Meeting of the American Psychiatric Association; 1992 May; Washington, DC. 14. Prince R, Tcheng-Larouche F. Culture-bound syndromes and international disease classifications. Cult Med Psychiatry 1987;11:3-20. 15. Boas F. Recent 314.

anthropology.

Science

1943;98:311-

16. Jahoda G. Psychology and Anthropology: A Psychological Perspective. New York, NY: Academic, 1982. 17. Conrad P, Schneider J. Deviance and Medicalization: From Badness to Sickness. St Louis, MO: Mosby, 1980. 18. Wright P, Treacher A (eds): The Problem of Medical Knowledge: Examining the Social Construction of Medicine. Edinburgh, UK: Edinburgh University Press, 1982. 19. Sedgwick P. Psycho Politics. London, UK: Pluto, 1982. 20. Schacht TE. DSM-III and the politics of truth. Am Psychologist 1985;40:513-521. 21. Kaplan M. A women’s ogist 1983;7:786-803.

view of DSM-III.

Am Psychol-

22. Szasz T. The Myth of Mental Illness. New York, NY: Harper & Row, 1961. 23. Laing R. The Politics of Experience. Harmondsworth, UK: Penguin, 1967. 24. Bayer R. Homosexuality and American Psychiatry: The Politics of Diagnosis. New York, NY: Basic Books, 1981. 25. Young A. The discourse on stress and the reproduction of conventional knowledge. Sot Sci Med 1980;14:133146. 26. Stein DJ. Philosophy and the DSM-III. Compr Psychiatry 1991;32:405-415. 27. Murphy JM. Psychiatric labeling in cross-cultural perspective. Science 1976;191:1019-1028.

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28. Coccaro EF. Central serotonin and impulsive aggression. Br J Psychiatry 1989;155:S52-S62. 29. Leff J. The “new cross-cultural psychiatry.” Br J Psychiatry 1990;157:296-297. 30. Good BJ, Kleinman AM. Culture and anxiety: crosscultural evidence for the patterning of anxiety disorders. In: Tuma AH, Maser J (eds): Anxiety and the Anxiety Disorders Hillsdale. NJ: Erlbaum, 1985. 31. Pincus HA, Frances A, Davis WW, First MB, Widiger TA. DSM-IV and new diagnostic categories: holding the line on proliferation. Am J Psychiatry 1992;149:112-117. 32. Yap PM. Mental diseases peculiar to certain cultures: a survey of comparative psychiatry. J Ment Sci 1951:97:313321. 33. Yap PM. Words and things in comparative psychiatry, with special reference to the exotic psychoses. Acta Psychiatr Stand 1962;38:163-169. 34. Yap PM. Classification of the culture-bound reactive syndromes. Aust NZ J Psychiatry 1967;1:172-179.

35. Kleinman A. Culture and clinical reality: commentary on “culture-bound syndromes and international disease classifications.” Cult Med Psychiatry 1987; 11:49-52. 36. Hughes CC. Culture-bound or construct-bound. In: Simons RC. Hughes CC (eds): The Culture-Bound Syndromes. Dordrecht, The Netherlands: Reidel. 1985. 37. American Psychiatric Association. DSM-IV Options Book: Work in Progress. Washington, DC: American Psychiatric, 1991. 38. Simons RC. Sorting the culture-bound syndromes. In: Simons RC, Hughes CC (eds): The Culture-Bound Syndromes. Dordrecht, The Netherlands: Reidel, 1985. 39. Alarcon RD. A Latin American perspective on DSMIII. Am J Psychiatry 1983;140:102-105. 40. Stein DJ. Psychotherapy integration and medical anthropology: a cognitivist approach to diversity. Proceedings of the Annual Meeting of the Society for the Exploration of Psychotherapy Integration; 1992 April: San Diego (CA).