Wolfgang G. JILEK, M.D.,M.Sc.,M.A.,Dipl.Psych.,FRCP(C)
Clinical Professor Emeritus of Psychiatry, University of British Columbia, Vancouver, Canada
Past Chairman, Transcultural Psychiatry Section, World Psychiatric Association
Paper presented at the 26th Congress of the World Federation for Mental Health, July 2001.

Transcultural Psychiatry

It is almost 100 years ago that the founder of modern psychiatry, Emil Kraepelin, envisaged a new discipline of comparative psychiatry, focussed on ethnic and cultural aspects of mental health and illness [KRAEPELlN 1904; JILEK 1995]. This new discipline was eventually organized since 1950 under the term Transcultural Psychiatry, introduced by Eric Wittkower of McGill University, Montreal. His collaborator Henry Murphy defined the principal objectives of the discipline: to identify, verify and explain the links between mental disorder and the broad psychosocial characteristics which differentiate nations, peoples, and cultures [MURPHY 1982a]. Socio-cultural factors exert influence on all psychiatric disorders. Cultural variation is most pronounced in reactive and neurotic disorders but the influence of culture is also significant in the major psychoses and can even be recognized in organic brain syndromes.

Cultural Factors in Schizophrenic Psychoses

In recent decades the influence of culture on symptom profiles, course and outcome of schizophrenic disorders has been demonstrated in systematic comparative research. Most prominent were the international collaborative research projects undertaken by the Mental Health Division of WHO, the International Pilot Study of Schizophrenia (IPSS) and the study of the Determinants of Outcome of Severe Mental Disorders (DOSMED). These studies confirmed that the syndrome originally described by Emil Kraepelin and Eugen Bleuler [KRAEPELlN 1896; BLEULER 1911] exists in very diverse ethnic and cultural groups. However, the studies also revealed that pathoplastic, i.e., illness-shaping, effects of socio-cultural factors are co-determinants of form, course and final outcome of schizophrenic disorders. Pathoplastic effects of socio-cultural factors appear to shape the symptom profiles manifested by sufferers from schizophrenia differently in developed and developing countries. Schizophrenic patients in Western developed countries showed a higher frequency of depressive symptoms, primary delusions, thought insertion and thought broadcasting, while in non-Western developing countries visual and directed auditory hallucinations were more frequent [SARTORIUS et al. 1986; JABLENSKY et al 1992] In a special comparative study of DOSMED conducted in Agra, India, and Ibadan, Nigeria, important differences in the manifestations of schizophrenia were found, which led the investigators to conclude that the content of psychotic symptoms tends to identify critical problems existing in a particular culture [KATZ et al. 1988]. The predominance of persecutory delusions and of auditory hallucinations also in non-schizophrenic disorders suggested to African investigators that these symptoms are not necessarily indicative of schizophrenia in persons of African cultural background [NDETEI & VADHER1984; NDETEI 1988]. That the influence of ethnicity and culture on psychopathology weighs more than geographic proximity, historical relations and racial similarity, became evident in studies which demonstrated significant differences in the symptoms of schizophrenia when comparing patients in Malta and Libya, Japan and China, Korea and China [MASLOWSKI 1986; FUJIMORI et al. 1987; KIM et al. 1993]. Ethnic and cultural differences are reflected in the schizophrenic symptom profiles even if the populations adhere to the same religion, as revealed in the findings of a comparative study of patients in Pakistan and Saudi Arabia [AHMED & NAEEM 1984].

Psychiatrists working in the so-called Third World have often reported the clinical impression of a more favourable prognosis of schizophrenia among nonWestern populations. This issue was for the first time researched in the 1 960s on the island of Mauritius where it was confirmed that schizophrenic psychoses have a better prognosis in Asian and African than in comparable British patient populations [MURPHY & RAMAN 1971]. The task of systematically investigating course and final outcome of schizophrenic illness on a global scale was then taken up by the above mentioned WHO projects. From the point of view of comparative cultural psychiatry, the most important conclusion drawn on the basis of the data obtained in these studies, is that the course and outcome of schizophrenic psychoses has been shown to be more favourable in developing countries than in highly developed countries [SARTORIUS et al 1986; JABLENSKY et al. 1992; JABLENSKY et al.1994; KUCHARA1994]. In fact, this was apparent not only with regard to schizophrenia but also with regard to other major psychiatric disorders [LEFF et al. 1992]. In a global evaluation of the WHO studies, the influence of culture was mentioned as an important determinant of differences in course and outcome, but the specific cultural factors could not be defined [JABLENSKY et al 1992]. While the reports on the WHO studies state that course and outcome of schizophrenia are more favourable in developing countries, further investigations in Japan, Hong Kong and Singapore also demonstrated a more favourable course and outcome of this illness than in Europe and North America [OGAWA et al. 1987; LEE et al. l991; TSOI & WONG l991].

These findings from Japan, Hong Kong and Singapore are of special interest as they derive from countries of advanced technological development but from cultures that are still quite different from those of modern Western societies. We have to conclude, therefore, that the crucial difference co-determining course and outcome of schizophrenic, and probably also of other major psychiatric illness, is not the difference between societies of high or low technological development but between modern Western societies and non-Western societies that were able to preserve important elements of their traditional culture. The question then arises: What specific aspects of modern Western societies may exert effects conducive to a chronic course and poor final outcome of mental disorders? Among the socio-cultural factors that have been identified by various researchers as in general of negative influence on the prognosis of schizophrenia, we can cite here those that appear peculiar to Western societies in their present development, namely: Extreme nuclearization of the family and therefore lack of support for mentally ill members of the kin group; covert rejection and social isolation of the mentally ill inspite of public assertions to the contrary; immediate sick role typing and general expectation of a chronic mental illness if a person shows an acute psychotic reaction; and the assumption that a person is insane if beliefs or behaviour appear somewhat strange or "irrational"; further, the unclear and uncertain role expectation of the young in Western societies.

Social Change and Psychopathology

The effects of socio-cultural factors on form, course and outcome of major psychiatric disorders can be considered as pathoplastic, i.e., shaping rather than causing psychopathology. However, there are situations of socio-cultural change in which the stress of acculturation or deculturation exerts pathogenic effects which lead in a hitherto traditiondirected population to the appearance of types of psychosocial pathology previously unknown in that population. Such a pathogenic process is the rapid socio-cultural change through overwhelming or imposed Westernization of small scale non-Western societies, as Henry Murphy already demonstrated in 1959 on the basis of the first available data [MURPHY 1961] The impact of rapid Westernization transforms small tradition-directed communalist societies, consolidated over many centuries, within a very short time into modern mass societies [WEBER 1972] This process of rapid socio-cultural change creates an anonymous impersonalization of social relationships which generates anomie, the loss of guiding norms of behaviour [DURKHEIN 1897] It also leads to a conflict between modern Western notions and traditional nonWestern values which in turn creates cultural confusion and a widening gap between the models of an affluent Western life style as propagated by the media, and the often bleak socio-economic reality, thus causing feelings of relative deprivation. Anomie, together with cultural identity confusion and relative deprivation, are the principal pathogenic factors operating in the development of the psychosocial syndrome which I have described as anomie depression among indigenous populations of North America. The experiences of loss of traditional culture and of social marginalization under imposed Westernization have in many of the aboriginal First Nations of North America, including Alaska and Greenland, been reflected in a relatively high incidence of alcohol abuse and of juvenile suicide. The situation is very similar in some regions of the South Pacific [JILEK 1974; JILEKAALL 1974; KRAUS & BUFFLER 1979; HOCHKIRCHEN JILEK 1985; JILEK 1987; JILEK AALL 1988; THORSLUND 1990; RUBINSTEIN 1992; HEZEL 1993; KIRMAYER 1994].

In the so-called Third World, acute transient psychotic reactions are known to be more common than chronic schizophrenia; they appear to occur especially frequently in African and Afro-Caribbean populations [JILEK & JILEK-AALL 1970] A variety of diagnostic labels has been applied by anglophone authors to designate these transitory psychotic disorders, but increasingly the French term bouffée délirante, introduced by Magnan in 1886, is used to designate transient psychotic or psychosis-like reactions. The clinical picture of these reactions has been described in detail by francophone psychiatrists working in Africa and by Latin American psychiatrists [MAGNAN 1886; VYNCKE 1957; RAINAUT 1958; SALLES 1961; COLLOMB 1965; BUSTAMANTE 1969; VILLASENOR BAYARDO 1993]: The bouffée délirante reactions are sudden attacks of brief duration with paranoid delusions and often concomitant hallucinations, typically precipitated by an intense fear of magical persecution through sorcery or witchcraft. They are also characterized by a confusional state and by highly emotionalized behaviour and, after the attack, by amnesia, or rather disavowal. In its symptomatology, the bouffée délirante is reminiscent of the transient psychotic reactions occuring in the early phases of industrialization and mass-urbanization in 19th century Europe; described under such names as folie hystérique in Paris and amentia transitonia in Vienna [MOREL 1860; MEYNERT 1889]. Indeed, the concept of hysterical psychosis was revived in the 1960s by American psychiatrists with special reference to transient psychotic reactions in non-Western populations [HOLLENDER & HIRSCH 1964; HIRSCH & HOLLENDER 1969], while Swiss psychiatrists during the same period introduced the label "emotional psychosis" for bouffée délirante-like reactions triggered by the fear of witchcraft, experienced by rural South Italian migrants under acculturation pressure in Swiss cities [LABHARDT 1963; RISSO & BOEKER 1964]. Transient psychotic reactions are of particular interest to comparative cultural psychiatry because they are interwoven with culturally validated beliefs in sorcery and witchcraft which persist even after the traditional resources of protection from, and of therapeutic action against, the assumed persecution by magical or supernatural powers, are no longer available as a consequence of Westernization and urbanization. While the number of individuals experiencing the pressures of rapid social change is steadily increasing, many feel unprotected against magical forces in which they still firmly believe, and react to acculturation stress with transient psychotic symptom formation. As the Nigerian psychiatrist Adeoye Lambo, prominent in WHO, already stated in the 1960s and as other researchers confirmed later-on, the majority of transient psychoses have no toxic-organic cause but are caused by socio-cultural factors [LAMBO 1960; 1965; MURPHY 1982; PFEIFFER 1994]. Among these factors is of increasing importance the stress associated with acculturation and marginalization due to the rapid socio-cultural change in Africa, as again confirmed in the 1990s through a detailed investigation in Swaziland [GUINNESS 1991]. Based on our own observations among tribal populations in Africa we suggested already in 1970 that by reacting with an acute psychotic episode to emotionally traumatizing experiences and to severe social stress, the individual signals a state of emergency to which the human environment responds with sympathy, support, and traditional therapeutic resources, and not with rejection and isolation, as long as the extended kinship network is still operational in a tradition-directed non-Western society. Consequently, the psychotic symptoms tend to be fully remitted in short time [JlLEK & JILEKAALL 1970]. It was later assumed by French researchers in Africa that transient psychotic reactions will evolve into chronic psychoses once the process of Westernizing acculturation has become completely irreversible in an African population [SIZARET et al. 1987].

"Culture-bound Syndromes"

The term and the concept of "Culture-bound Reactive Syndromes" was introduced in the 1960s by Pow Meng Yap [YAP 1969a;b]. Several hundred such conditions have since been cited in the literature under their indigenous names [HUGHES 1985]. Some were listed in a DSM-IV Glossary and in the ICD-10 Diagnostic Criteria for Research. Among the terms listed are universally occuring dysphoric and anxiety reactions with various somatoform symptoms, known in a particular culture under a local name that designates them as appropriate for special treatment by traditional healers. Examples among Hispanic popluations are susto, espanto, or miedo, Spanish words for fear or fright, which may also be used for conditions with an underlying organic pathology, and the ataque de nervios [RUBEL et al. 1985; HOLLWEG 1991;1994; OQUEND0 1994] One group of so-called culture-bound syndromes has in the past been labelled arctic hysterias [FOULKS 1972]. These stereotyped reactions shown by indigenous people living in arctic and subarctic regions under harsh environmental conditions have become extremely rare.

Let us now turn to conditions which are often cited as examples of genuinely "culturebound" syndromes. Upon closer inspection it will become apparent that they are not exclusively linked to a particular culture but rather related to a prominent cultural emphasis, or to a specific social stress situation, which can become important in diverse societies at different historical periods [JlLEK 2000; JILEK & JILEK-AALL 2000].

[1 ] Syndromes related to a cultural emphasis on fertility and procreation: The "genital shrinking" anxiety syndrome known as koro in Malay-lndonesian languages and as suo-yang in Mandarin Chinese [YAP 1965; JlLEK 1986; TSENG et al. 1988] ; and also the "semen loss" anxiety syndrome known as chat or jiryan in India, sukra pameha in Sri Lanka, and shenk'uei in China [PARIS 1992] The "genital shrinking syndrome" has often been viewed as contingent upon popularized traditional Chinese concepts of illness causation through disequilibrium of yin-yang [KORO STUDY 1969; TSENG et al. 1988] ; However, in recent decades the appearance of this syndrome in epidemic form has been observed in populations without any Chinese tradition but with a strong cultural emphasis on fertility and procreation; so in Thailand 1976, in India 1982 and 1985, and in Nigeria 1990. [JILEK & JILEK-AALL1977; 1985; DUTTA & POOKAN 1982; CHAKRABORTY 1984; JlLEK 1986; CHOWDHURY et al. 1988; CHOWDHURY 1991; 1994; ILECHUKWU 1992].

[2] Syndromes related to a cultural emphasis on learnt dissociation: The stereotyped dissociative reactions to a specific startle stimulus, known as latah in Malay-lndonesian languages, bah-tschi in Thailand, yaun in Myanmar, mali-mali in the Phillippines, miryachit in Siberia, imu among the Ainu, Lapp panic among the Sami, and as jumping among rural populations of French-Canadian background in the Northeast of the USA [WINZELER1995; SIMONS 1996]. In the 1880s Gilles de la Tourette collected reports on latah-type reactions from different culture areas because he assumed they were manifestations of the neurological syndrome that Jean-Martin Charcot had named after him [GlLLES DE LA TOURETTE 1994]. Also related to a cultural emphasis of learnt dissociation are the now rarely occuring genuine amok reactions, reported not only from the Malay-lndonesian region but also from Laos, the Philippines, and Papua New Guinea [VAN WULFFTEN PALTHE 1988; BURTON-BRADLEY 1968;1975; WESTERMEYER 1972;1973; MURPHY 1973; PFEIFFER 1994].

[3] Syndromes related to a cultural emphasis on presenting a pleasing physical appearance: The anthropophobic reactions among Japanese, called taijin-kyOfu, and among Koreans [KIRMAYER 1991; KIMURA 1995; LEE SHIN & OH 1994] derive from the allocentric fear that one's external appearance is offending to others, and are therefore different from Western social phobia, the egocentric avoidance of social contacts in order to avoid unpleasant feelings for oneself.

[4] Syndromes related to acculturative stress: Already mentioned were the anomie depression in North American indigenous peoples and bouffée délirante-type reactions in African and Afro-Caribbean populations under rapid socio-cultural change. Of special interest to educators should be the brain fag syndrome, so first named by Nigerian students suffering from a variety of somatic symptoms in class, especially vision disturbance when reading. Brain fag symptoms have occured in many African students, independent of intelligence, when exposed to acculturative stress in Western education systems emphasizing theoretical book learning, quite different from the time honoured ways of acquiring knowledge in traditional African societies [PRINCE 1960; 1985].

Before Pow Meng Yap introduced the term "Culture-bound Reactive Syndromes", such conditions were considered as phenomena peculiar to non-Western cultures and often designated by the eurocentric label "exotic psychotic syndromes" [ARIETI & METH 1959]. Since then several conditions have been identified as closely related to modern Western culture and its influences; most prominent among these is anorexia nervosa, as Yap had already suggested in 1969. The characteristic clinical picture of anorexia nervosa first appeared among daughters of the Western bourgeoisie in the 19th century, and the typical fatness phobia was not described until 1930 [BRUMBERG 1988; PFEIFFER 1994]. For some time anorexia nervosa remained a condition predominantly afflicting female teenagers in relatively affluent families of Western Europe and North America. However, in the decades following the postwar recovery a veritable psychosocial epidemic of anorexia nervosa developed and spread over Western, then also over Southern Europe, finally involving young women of all socioeconomic classes, emulating the fashionable body shape of movie stars and beauty queens who became ever thinner [SELV'INI-PALAZZOLI 1985; CABALLERO 1995; TORO, SALAMERO & MARTINEZ 1994]. In North America the incidence of anorexia nervosa increased dramatically since the 1960s, coinciding with a drastic change in the feminine body ideal towards thinness, as propagated by the fashion lords and publicized by the media [GARNER & GARFINKEL 1980; JONES et al. 1980; LUCAS et al. 1991]. It is of interest that the weight tables used by American physicians, supposedly objective scientific measures of "normal" standards of health, followed the fashionable downward trend in female body weight [RITENBAUGH 1982]. The increasing frequency of anorexia nervosa is associated with socio-cultural factors such as disturbance of intrafamily relations due to the nuclearization and limitation of Western families, and the penetrant influence of the mass media popularizing Hollywood-type life styles and beauty ideals. Since the 1980s, cases of anorexia nervosa have also become increasingly known in non-Western countries among young women in social strata exposed to heavy Westernizing influence, notably in Japan and Hong Kong [Di NICOLA 1990; LEE et al. 1993]. The epidemic spreading of anorexia nervosa among young females of all Western countries, and among certain Asian populations and immigrants under Westernizing influence, links this syndrome to socio-cultural emphases and developments in modern Western societies [Di NICOLA 1985; 1990; SELVINI-PALAZZOLI 1985; BRUMBERG 1988; GORDON 1990; WEISS 1995].

Biopsychological Universalism vs. Cultural Relativism

The so-called culture-bound syndromes have been the focus of the debate between, on the one side, adherents of biopsychological universalism who interpret these conditions as manifestations of universal human psychopathology, only influenced and modified by particular cultural factors [SIMONS 1980; 1983; 1996] and, on the other side, adherents of an ethnological cultural relativism who see these conditions as engendered or generated by typical aspects of a particular culture [GEERTZ 1968; KENNY 1978; 1983]. However, such a debate appears to be redundant because the syndromes under discussion are not "bound" to a particular culture or ethnicity, rather they are related to special socio-cultural emphases or stress situations that may occur in very diverse societies. Nevertheless, these syndromes testify to the profound influence cultural factors exert on the human mind.

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