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Salsa y Control – Attaque de Nervios in Between any Categorization?

Anthropological Thoughts on Culture Bound Syndromes and Classificatory Systems like DSM-V.


Text by Julia Baumann (Free University Berlin)


© Simina Pătrășcoiu


“Suffering is one of the existential grounds of human experience” (Kleinman and Kleinman, 1997:1).

For years “western” psychologists have tried to categorize mental illnesses over the world’s cultures: afflictions need to be comparable, human experiences explicable, and emotional outbursts reasonable. However, analyzing the ways in which (mental) illnesses are locally understood provides insight into cultural perceptions of the self.


Can world cultures and the entities of human minds really be forced into any kind of categorization? Biomedical diagnostic clarification systems, like DSM or ICD try to: they offer a strict universal template on diagnostic procedures and treatments. Put simply, if a disease is not cataloged, a diagnosis is not possible, and the illness is not considered to exist. Treatments or cures for something that does not exist are simply impossible. As part of a globalized and rapidly changing world, the DSM undergoes a continuous revision process, which leads to “new” diseases being added to the canon, such as attaque de nervios, a so called cultural bound syndrome (CBS).


This essay uses an anthropological perspective to consider how DSM-V shapes mental illnesses particularly in the context of CBS and offers attaque de nervios as an example. I will show that the admission of CBS has been an overdue step in the right direction but problematics of essentialisation, categorising and biologisation persist.


Between experiences, cultures and languages: The DSM-V and its power dynamics

„What distinguishes the western tradition is, on the one hand, the progressive authority to neuroanatomy, neurophysiology, and scientific psychology, and on the other, the absence of moral considerations” (Fabrega 1996: 5).

Though often criticized (eg. Kleinmann 1996, 1997, Fabrega 1996, Lewis-Fernandez and Aggarwal 2015) the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-V), serves as the psychiatric classification system of the American Psychiatric Association (APA) and plays a crucial role in diagnosing and treating mental illnesses. As Horacio Fabrega explains, systems like DSM are born out a historical tradition aimed at classifying the “increas[ing] number[s] of poor, marginal, ill and socially dependent persons who were unable to fit into the newly established occupational structures of modern society” (Fabrega 1996: 6). Classifying their suffering meant a return to former order and a clearly defined hierarchy of power: Experts decide on whether you are suffering or not, whether you are ill or not, and whether you deserve treatment or not. Power relations identified by Foucault (1973) persist in classification systems like DSM reproduce and institutionalize hierarchies of inequity in US-influenced societies (Fabrega 1996, Gaines 1992). Moreover, a study by the University of Massachusetts Boston showed that nearly 70% of the DSM-V-committee- members had connections to pharmaceutical industries (Cosgrove and Krimsky 2012). In some cases, this number is still higher, such as the category on insomnia, whose authors were proven to have these industrial ties in an astonishing amount – up to 100%.


A symptom enters the DSM if it is (1) persistent or recurring; (2) it may not be attributed to the consumption of substances, as in the case of drug abuse for example; and (3) the patient needs to “be recurrently suffering by the illness in a clinical signifying way” (Falkai and Wittchen 2015: 26). Unfortunately, it is not described how this very certain kind of suffering is measured.


Diseases that are particularly disputed in the DSM-V are culture bound syndromes[1] (CBS) – illnesses that combine psychiatric and somatic symptoms and only appear within a specific cultural or social circle. This diagnosis is a reaction to critiques of earlier DSM versions and applies an interdisciplinary triangulation model, which combines findings from sociocultural contextual analysis, neurobiological substrates of mental illness, and psychological dimensions. But CBS are a debatable category as it is f. ex. difficult to attribute a special epidemic to cultural patterns. They might also be related to social behaviour (such as the personal circumstances of a social class) or to special environmental conditions. Roberto Lewis-Fernandez[2] and Neil Aggarwal, both clinical psychiatrists with interdisciplinary backgrounds, argue the form of illness and biology are influenced by local sociocultural contexts in which individual biology develops. Their hypothesis is that the same type of mental illnesses manifests itself across cultural contexts but as certain types of local varieties, very similar to the development of different languages (Lewis-Fernandez and Aggarwal 2015)[3]. Lewis-Fernandez and Aggarwal propose a cultural variety of illnesses, but their critique has yet to find its way into the manuals.


The attaque de nervios and the DSM – a classificatory and anthropological challenge

In this section, I would now like to elaborate on the criticism mentioned above using the example of attaque de nervios (AN), which does not fit existing diagnostic categories. AN, also known as Puerto Rican Syndrome, is an illness mostly associated in migratory contexts and is often compared to panic attacks. Although AN appears in different forms, it is described as

„A sudden fit of acute emotionality during which the person feels out of control (…); the person usually disavows the episode as something unintended, frequently something performed ‘not by me’” (Lewis-Fernandez and Aggarwal 2015: 441).

Symptoms can be categorized in four dimensions: (1) emotional, which includes uncontrollable screaming, crying, anxiety, and anger; (2) bodily experiences like chest pain, trembling, palpitations, heat flashes, dissociative experiences; and (3) behavioral episodes distinguished by high aggression or suicidal ideation. A final fourth dimension includes a certain kind of disorientation with alterations in consciousness, amnesia, fainting, hallucinations and more. It very often appears along with stressful moments, especially those connected to the affected person’s family or social background. These moments accumulate to the point at which sufferers literally feel that they cannot hold back anymore and experience one big outbreak of emotion and suffering (Lewis-Fernandez and Aggarwal 2005).


As Lewis-Fernandez and Aggarwal explain, the sociocultural background of AN is based on a cultural concept of Latin-Americans, who believe that emotional control is highly desirable and that one should always try to preserve social harmony. Uncontrolled emotional states are inappropriate and dangerous, sometimes harmful: emotions like anger, jealousy and envy are considered especially negative for individuals as well as the community and can even result in death. The idea of emotional control, or the “control-tranquilidad”-balance, is made manifest in various cultural forms. For example, during salsa performance, musicians stop after a committed play and shout “salsa y control” – the music and the dancers hold on for a moment before coming back to their activities. “Salsa y control” is the desired balance between passion and emotional control (Lewis-Fernandez and Aggarwal 2015). Other explanations for the illness as pointed out by anthropologists include the relationship between “the nerves” and structural inequalities in society (Guarnaccia et al. 1988, Jenkins 1988). Although painful, AN can also be an empowering moment, as an everyday form of resistance and as acting out of “hidden transcripts” (Lock 1993, Scott 1990).


Conclusion

AN shows the “intimate relationship between illness and politics” (Lock 1993: 144) and, I would add, the relationship between categorizations and power dynamics. As Foucault (1972) suggests, the language of “Western” medicine is produced through discourse creating its own object of analysis. Classificatory diagnostic canons, therefore, neglect their own history of origin. The creation of the DSM should give a tool to somehow depict “reality”; unfortunately, as I see it, the DSM merely shapes a single reality—one that does not allow any kind of cultural or individual characteristics of illnesses and refuses to consider the power dynamics intrinsic to words and categorizations. The creation of CBS, born out of DSM-criticism and the inherent wish to systemize new discoveries of new illness occurrences, are well-intended but are still based on the idea that human bodies are shaped the same way no matter local worlds. DSM´s basis is biomedicine – a western cultural construct on how we perceive human bodies and illnesses. DSM and CBS therefore too easily stumble over the pitfalls of essentialism. From my point of view, they also lack one important point: social constructions. As anthropologists argue, cultures are constituted by local worlds of everyday experiences, so bodies and illnesses and classificatory systems are as well. Can we really assume that diseases always exist in a single form as opposed to them having different manifestations? Are not cultural differences more important than categorization systems like the DSM would indicate? How do diseases enact themselves? Maybe every phenomenon has a bio-psycho-social pattern, and navigating through those patterns is a balancing act, or as Kleinman puts it:

“(…) culture is more than what is meant when we talk of rates, symptoms, or treatment of psychiatric conditions in exotic places or special groups (…). That is to say, the cause of mental illness is social, not natural” (Kleinman 1996: 16-19).




References


Cosgrove and Krimsky 2012. A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists. PLoS Med 9(3): e1001190: https://www.psychiatry.org/psychiatrists/practice/dsm (last access September 2018).


Fabrega, H.. 1996. Cultural and Historic foundations of psychiatric diagnosis. In: Mezzich, J., A. Kleinman, H. Fabrega and D. Parron. Culture and Psychiatric Diagnosis. A DSM-IV Perspective. Washington: American Psychiatric Press: 3-14.


Falkai, Peter and Hans-Ulrich Wittchen (ed.) (2015): Diagnostisches und statistisches Manual psychischer Störungen DSM-5. Göttingen: Hogrefe.


Foucault, M.. 1972. The Archeology of Knowledge and the Discourse on Language. New York: Pantheon.


Foucault, M.. 1973. The Birth of the Clinic. An Archology of Medical Perception. E-Book: https://monoskop.org/images/9/92/Foucault_Michel_The_Birth_of_the_Clinic_1976.pdf


Gaines, A.. 1992. From DSM-I to DSM-III-R: voices of self, mastery and the other: a cultural constructivist reading of United States psychiatric classification. Social Science and Medicine 25: 3-24.


Guarnaccia, PJ., de la Cancela, V., Carrillo E.. 1988. The multipe meaning of attaques de nervios. In: Medical Anthropology 11: 47-62.


Jenkins, J.. 1988. Ethophysiatrics interpretations of schizophrenic illness as a problem of nerves: a Comparative Analysis of Mexican-Americans and Anglo-Americans. In: Social Science and Medicine 26: 233-43.


Kleinman, A. and J. Kleinman. 1997. The Appeal of Experience; the Dismay of Images: Cultural Appropriations of Suffering in Our Times. In: Kleinman, A., V. Das and M. Lock. Social Suffering. Berkley: University of California Press, 1-24.


Kleinman, A.. 1996. How is culture important for DSM-IV. In: Mezzich, J., A. Kleinman, H. Fabrega and D. Parron. Culture and Psychiatric Diagnosis. A DSM-IV Perspective. Washington: American Psychiatric Press: 15-26.


Lewis-Fernandez, R. and N. K. Aggarwal. 2015. Psychiatric Classification Beyond the DSM. An Interdisciplinary Approach. In L. J. Kirmayer, R. Lemelson and C. A. Cummings: Re-Visioning Psychiatry Cultural Phenomenology, Critical Neuroscience, and Global Mental Health. Cambridge, Cambridge University Press: 434-468.


Lewis-Fernandez, R., Guarnaccia, P. J., Patel, S., Lizardi, D., & Diaz, N. 2005. Attaque de Nervios: Anthropological, epidemiological, and clinical dimensions of a cultural syndrome. In: Georgiopoulos, A. M. & J. F. Rosenbaum (Eds.), Perspectives in cross-cultural psychiatry. Philadelphia, PA: Lippincott, Williams & Wilkins.


Lock, M. 1993. Cultivating the body: Anthropology and epistemologies of bodily practice and knowledge. In: Annual review of anthropology 22 (1): 133-155.


Scott, J. 1990. Domination and the Arts of resistance hidden transcripts. New Haven: Yale University Press.


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[1] The term CBS was included in 1994 in the DSM.

[2] Interestingly, L.-F. has been a member of the Anxiety Disorders Work Group and the Culture and Gender Study Group of the DSM-V.

[3] This idea can be attributed to the theory of multiplicities of languages and so is not new but is especially debatable due to a lack of supportive scientific material, which the authors admit.

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