Culture-bound syndromes: Nosological and management issues

Sir,

We read with interest, the article titled ‘Development of cognitive-behavioural therapy intervention for patients with Dhat syndrome’ by Abdul Salam et al., published in your journal in the issue Oct-Dec 2012. Indeed, it is the first study of its kind in which a structured treatment program has been used to treat patients with Dhat syndrome. However, the authors could have used more detailed and specific criteria[1] to bring clarity on the nature of sample. More importantly, in the final CBT module, after collection of the details of patients’ complaints, the authors seem to have rather hurriedly proceed with ‘socializing the patient with a cognitive-behavioural model of psychological disorders’ and cognitive restructuring. Their approach appears to be like that of any other disorder (e.g., Depression). However, in a depressive disorder, the idea of psychological illness is acceptable to the patient and, therefore, he would be more prepared to observe his thoughts in therapy, in sharp contrast, to a patient with Dhat syndrome who comes with an idea of having a physical disorder. It is indeed doubtful that those with true Dhat syndrome would be ready to accept only psychological causation so early in therapy. From our own study of 100 patients,[1] other published literature,[2] and from clinical experience most psychiatrists would know that this is not the case. Indeed, this would invite the risk of patient shifting to another doctor, probably an Ayurvedic one, who would treat it like a physical illness, in keeping with the patient's cultural beliefs. In my humble opinion, the biggest barrier to the treatment of patients with Dhat syndrome is convincing them of the psychological causation, which is culturally alien to them. This would have to be tackled gradually and innovative ways for doing the same are needed. The reattribution model which has been used in Indian settings[3] would be a good example. Once this is done, other interventions listed by the authors could be carried out as for other disorders.

We also read the article titled ‘Diagnostic and Statistical Manual-5: Position paper of the Indian Psychiatric Society’ published in the Jan-Mar 2013 issue by Jacob and colleagues. Indeed, the DSM-5 would have far reaching impact beyond the United States of America across diverse cultures. In this context, the authors have brought in the concept of the ‘form content dichotomy’. They say that clinicians should focus on form and recognize behavioural syndromes across cultures. This view may not be acceptable to many researchers in the area of culture-bound syndromes. The famous cultural psychiatrist Yap[4] suggested that although cultural influences play a role in colouring psychopathology in a number of illnesses, in certain illnesses, they may exert pathoplastic effects to such an extent as to make the illness appear significantly different from the original one. Suggesting that the form of the illness is still recognizably universal would entail the view that any new clinical condition can only be a variation of something already recognized and described. As Yap[4] himself described, two problems would then arise: Firstly, how much do we know about the culture-bound syndromes for us to be able to fit them into standard classification; and secondly, whether such a standard and exhaustive classification in fact exists. Other cultural psychiatrists[5] have also suggested that a culture-bound syndrome (e.g., Ataques de nervios) may have different manifestations which may fall into different sections of conventional classificatory systems such as the DSM IV or DSM 5 which argues against a simplistic reduction of culture-bound syndromes to a category of the conventional classificatory systems. Moreover, the nosological status of culture-bound syndromes has been debated.[1] Therefore, it might not be possible to apply the form content ‘dichotomy’ so liberally to culture-bound syndromes as it could be for schizophrenia or bipolar disorders; doing so might curtail an open inquiry into the nature of these disorders.