Culture-bound syndromes and international disease classifications

An important endeavor in the world psychiatric community is the development of an international classification of psychiatric disorders that will be more culture-free than either the current DSM-III or ICD-9. This classification should be clinically useful and relevant to psychiatric experience in all countries of the world. A major problem in this endeavor is the existence of the so-called culture-bound syndromes syndromes (CBS's) which reflect cultural influences on disease patterns and render them difficult to place in disease classifications which have their origins in Western cultures. Literally dozens of disorders have been labelled CBS's around the world, and considerable looseness has developed in the use of the CBS rubric. Recently it has been proposed that all illnesses (both physical and psychiatric) are in fact culture bound. In reaction to this drift towards meaninglessness, a new definition for CBS's is proposed - a collection of signs and symptoms (excluding notions of cause) which is restricted to a limited number of cultures primarily by reason of certain of their psychosocial features. In this definition, notions of etiology and illness labels are excluded because these are highly variable and change over time. On the other hand, collections of signs and symptoms (i.e., syndromes), insofar as they are reasonably complete descriptions of nature, remain constant over time and are verifiable by all investigators. Using two CBS's from the Pacific basin area - taijin-kyofu-sho and latah - as examples, the following conclusions are drawn: CBS status should not be assigned on the basis of differential distribution of illnesses because of accidents of geography or on the basis of local labels or notions of cause; epidemiological features of diseases such as global prevalence or age/sex differentials of those affected should not be used as basis of CBS status; the meaning of illness, both for individuals and for cultures, is an important area of study in its own right but such meanings should not be confused with syndrome descriptions or used as criteria for an international disease classification; a truly international classification of diseases is close to realization through relatively minor alterations in the Axis I designations and descriptions of DSM-III. Few entirely new categories would be required.