I still remember the day we went through the ICD- 10 in the clinical psychology class. Our professor, a practicing and competent clinical psychologist, talked us through the various symptoms that constituted a mental illness. Mental illnesses such as PTSD (Post Traumatic Stress Disorder) schizophrenia and depression were assumed to be universal. Extensive studies have been conducted around the world documenting these illnesses. We finally got to the section on culture bound syndromes.

Presented as mental illnesses of the global south, most conditions seemed like glorified superstition, the workings of an uneducated mind. After all, people imagining they were going to die or men believing they were losing energy as a consequence of semen loss, sounds like superstition. One can disprove the existence of these symptoms easily.

I remember as a class we laughed at some of these culture bound syndromes. They seemed silly to be quite honest. Schizophrenia and depression by comparison were well established, we had biological evidence to support the existence of these conditions. Yet the more one looks at the research on these conditions, the more it falls apart. Mental illness unlike other illnesses cannot be explained through biology alone.

Psychiatrist Simon Wesley argues that Post Traumatic Stress Disorder (PTSD) is not the same as shell shock. Victims of 20th century conflict undoubtedly suffering the after effects of combat suffered different symptoms. Wesley argues that soldiers from the First World War displayed symptoms we don’t classify as PTSD today. We assume PTSD is the inevitable fallout from war or other traumatic events. Yet the evidence points otherwise.

Jason Crowley like Wesley argues against anachronistic understandings of PTSD in his article titled ‘Did Achilles have Post Traumatic Stress Disorder?’. Explaining how the idea of applying a retrospective diagnosis to soldiers of the past does not do justice to the culture in which they lived:

 

“Unlike modern soldiers, Greek men believed that enemies existed simply to be killed and that a man’s worth could be valued by the number of enemies he had slain. In addition, soldiers in ancient Greece didn’t suffer from social isolation, prolonged artillery bombardment or exhaustion in the way that their modern-day counterparts do.” – Jason Crowley.

 

Given this information, studying modern PTSD becomes interesting. It challenges several ideas about mental illness, the chief being that mental illness is contained in the brain and that it is universal. When put into context PTSD becomes a culture and history bound syndrome. It emerges in a war weary Europe dealing with the horrors of mechanised warfare a century ago. While European nations had waged war in the past, this four year long conflict was more brutal than ever seen before.

Since then war has become increasingly mechanised. The killing process becoming more sophisticated, being able to kill your enemy swiftly, remotely and in large numbers has never been easier. Sadly this has not made the moral decision to wage war any easier. Mechanised warfare has come at a cost, killing takes a toll on the soldiers who are living in a society that does not revel in their killings. Modern society generally does not valourise war. While we do laud the sacrifice made by them we have moved on from glorifying war.

An example of this can be seen in how poets writing about the First World War differed from an earlier generation. Soldier poets wrote about the horrors they encountered in the trenches, Wilfred Owen’s poetry is brutal in its description of the war.

Owen was 10 when he started writing poetry with his style developing during the war, he was 25 when he died 1918 (a week before the war ended) on the battlefront. Britain was at the height of her empire, yet there were those who began to question colonisation and the lack of equality. Pacifists and conscientious objectors refused to fight citing several moral grounds for refusing war. War had ceased to be glorious.

Constant bombardment from shells, gunfire, unhealthy living conditions in trenches, witnessing constant death left a lot of soldiers psychologically disturbed. The term shell shock was coined to describe symptoms soldiers displayed which included the following-

• Hysteria and anxiety
• Paralysis
• Limping and muscle contractions
• Blindness and deafness
• Nightmares and insomnia
• Heart palpitations
• Depression
• Dizziness and disorientation
• Loss of appetite

Flashbacks, considered to be a clinical symptom today, only entered into the diagnostic criteria in 1987 (in the DSM-III-R). DSM–III–R included the term ‘flashback’, however the 1980 DSM–III contained a more detailed description of flashbacks. Intrusive memories of traumatic events coming back into daily life and haunting ones present are a considerable problem.

While this article critiques the symptoms it does not claim that the trauma is unreal. Trauma manifesting itself in a culturally coded manner is not an indication of the traumas non-existence, but that the symptoms may be shaped by the understanding and expectations of those who suffer. Flashbacks as a symptom of PTSD can only occur in a culture where cinematic portrayals depict PTSD through flashbacks but it is a response that can be understood by those who suffer.

Psychiatrist Dinesh Bhugra often points out that the term culture bound syndrome is misleading as diagnoses considered to be non-culture bound also differ in symptoms around the world. Others have also critiqued this term on the grounds that it implies ethnocentrisms orientalism or is plain wrong. The use of the term culture is contestable, does it imply culture only exists in certain parts of the world where mental illnesses do not fit into neat diagnostic categories, or does it ignore the role of culture in other mental illnesses.

Raymond Williams has argued that ‘culture’ is one of the few difficult to define words in the English language. Its use in psychiatry is no less complicated. On the one hand there are those who advocate for a deeper cultural understanding of mental illness, on the other we have those who advocate for a biologised explanation. Neither group is wrong. To say mental illness is complex is stating the obvious. Behaviour that seems bizarre in some cultures may not be to those in another culture. Even history and technology affect the manner in which symptoms manifest themselves.

In their paper ‘Flashbacks and post-traumatic stress disorder: the genesis of a 20th-century diagnosis’ Jones et al conclude.

 

Our findings imply that the psychopathology of trauma is not static and that culture has an impact on the expression of distressing memories. There is no single way for human beings to respond to the terrifying events of war, and the concept of a ‘universal trauma reaction’ appears flawed. We suggest that PTSD is one more phase in the continually evolving picture of human reaction to adversity.

Perhaps disorders such as Amok and PTSD are not that dissimilar then. They can only occur and be understood within a certain culture and within a certain time.

Reference and further reading:

• A. Sumathipala, S. H. Siribaddana and Dinesh Bhugra REVIEW ARTICLE Culture-bound syndromes: the story of dhat syndrome. The British Journal of Psychiatry Feb 2004, 184 (3) 200-209; DOI: 10.1192/bjp.184.3.200 http://bjp.rcpsych.org/content/184/3/200
• Crowley, J. (2014) Combat trauma is nothing like in classical antiquity – so why are we still treating it as such? The Conversation. http://theconversation.com/combat-trauma-is-nothing-like-in- classical-antiquity-so-why-are-we-still-treating-it-as-such-30955 (hyperlinked in article)
• Jones, E., Vermaas, R. H., McCartney, H., Beech, C., Palmer, I., Hyams, K. and Wessely, S. (2003) ‘Flashbacks and post-traumatic stress disorder: the genesis of a 20th-century diagnosis.’ The British Journal of Psychiatry, 182(2) pp. 158- 163.
• Ronald .C. Simons – Introduction to Culture-Bound Syndromes – http://www.psychiatrictimes.com/cultural-psychiatry/introduction-culture-bound-syndromes-0
• Williams, R. (1985) Keywords: A vocabulary of culture and society. New York: Oxford University Press.

Keywords: culture bound syndromes, critical psychology

Author Biography : Sonia Soans has recently been awarded her PhD. Her interests are in psychology, gender, popular culture and cats.