Culture-bound syndromes, idioms of distress, and cultural concepts of distress: New directions for an old concept in psychological anthropology

Abstract

This issue of Transcultural Psychiatry showcases some recent work on idioms of distress – the latest in a long line of anthropological research concerned with cross-cultural concepts and experiences of distress.¹ Mark Nichter’s (1981) seminal paper introducing idioms of distress has become a cynosure for psychological anthropology and transcultural psychiatry. A growing body of work has since accumulated; however, the last time a collection of such research was brought together was the 2010 publication of a special issue in the journal Culture, Medicine and Psychiatry organized by Devon Hinton and Roberto Lewis-Fernández. In the decade since, new questions have arisen about the boundaries and applications of idioms of distress research. In this introduction, we provide a brief history of work on idioms of distress and related concepts. Then, we introduce several major themes explored by the papers in this special issue.

Idioms of distress: History of a concept

Early cross-cultural psychiatry was concerned with the study of cultural difference to make possible the application of biomedical psychiatric categories in non-Western settings. In the mid-twentieth century, however, transcultural psychiatry emerged as a named field and shifted away from treating culture as merely a confounding factor and toward recognizing it as constitutive of different world-views with impact on illness experience (Kirmayer, 2006). This shift helped promote new understandings of mental health and illness and was further advanced by the “new cross-cultural psychiatry”, which saw mental disorders as contingent, constructed, and related to broader political and economic processes (Kleinman, 1977). As part of this shift, Mark Nichter (1981) introduced idioms of distress in his now classic paper. His study, based on work among rural high-caste women in India, drew attention to the specific words, phrases, and even actions that people use in different cultural contexts to express and respond to distress.

Nichter developed the notion of idioms of distress in response to – and to complement the emphasis on – “culture-bound syndromes” or “folk illnesses” (Simons & Hughes, 1985). These were illness categories that were believed to be specific to certain societies; classic examples include susto, dhat syndrome, hwa-byung, and nervios (Bhatia & Malik, 1991; Guarnaccia, Lewis-Fernández, & Rivera Marano, 2003; Lin, 1983; Rubel, O’Nell & Collado-Ardon, 1991). The idea gained significant traction in psychiatry, so much so that the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV; American Psychiatric Association, 1994) included a list of culture-bound syndromes as an appendix. But Nichter and other anthropologists were concerned that the syndromes were presented uncritically as static and timeless entities, almost as museum exotica separated from their contexts of origin (Hughes, 1998). Moreover, this conception of culture-bound syndromes had limited power for exploring how some conditions that had once appeared to be confined to specific groups in specific locations, such as anorexia nervosa, were becoming globalized through the influence of media and the spread of biomedical psychiatry.

As an alternative to culture-bound syndromes, the construct of idioms of distress provided a way to study culturally specific forms of distress without resorting to categorization and reification. The guiding principle of research on idioms of distress research is simple, yet effective: to explore how people experience distress, we can examine how they talk about it and act around it. After Nichter’s original introduction (1981), it was quickly implemented. Kleinman’s (1988) Illness Narrative Interview Guide and Weiss’s (1997) Explanatory Model Interview Catalog, for instance, directly incorporated the assessment of idioms of distress as part of their interview templates for eliciting explanatory models of illness across cultures. Dozens of studies in the intervening years have used this concept to foreground the diverse ways in which people understand, express, detect, and respond to distress outside of biomedical frameworks (e.g., Abramowitz, 2010; Guarnaccia et al., 2003; Keys, Kaiser, Kohrt, Khoury & Brewster, 2012; Hinton & Lewis-Fernández, 2010; Yarris, 2014).

To date, this body of work on cross-cultural differences in the experience and expression of distress has impacted both clinical and academic work. Researchers have shown how idioms of distress can be productively incorporated into mental health assessment tools and complement the use of adapted psychiatric screening tools (e.g., Fabian et al., 2018; Ice and Yogo, 2005; Kaiser, Kohrt, Keys, Khoury & Brewster, 2013; Kaiser et al., 2019; Kohrt, Luitel, Acharya & Jordans, 2016; Miller et al., 2006; Rasmussen et al., 2015; Roberts, Han & Weed, 2006; Weaver and Kaiser, 2015). The Global Mental health Assessment Database (GMhAD) assembles tools that have been developed, adapted, and/or validated for use in low-income settings – many by anthropologists and many incorporating idioms of distress. Scholars like Devon Hinton (Hinton, Pich, Marques, Nickerson & Pollack, 2010; Hinton, Reis & de Jong, 2015) have proposed extensive research agendas to incorporate and test the use of idioms of distress in interventions. And in the most recent version of the DSM (5th edition, 2013), the term “cultural concepts of distress” has replaced the outdated terminology of culture-bound syndromes (Lewis-Fernández & Kirmayer, 2019). This change was intended to signal a broader, more inclusive understanding of culturally specific distress as something that changes over time and does not represent place-specific “exotica.” Much of the impetus to do so arose from research on idioms of distress by anthropologists and cultural psychiatrists. These efforts contribute to a more critical, decentered literature on mental health and illness, one which takes seriously local conceptualizations of distress. It is out of this tradition that the articles collected here arise.

This issue

The articles in this special issue advance research on idioms of distress in several new directions. First, this collection contributes to theory about the nature and function of idioms of distress. Several articles support one of Mark Nichter’s (1981) key arguments by describing how idioms of distress may reflect not only individual suffering but also social complaints and anxieties. For example, Yahalom shows how Oaxacan caregivers use idioms of distress to explain elders’ forgetfulness and push back against an Alzheimer’s diagnosis. By contesting diagnoses like Alzheimer’s that are associated with modernization, and by producing socially embedded avenues to respond to forgetfulness, these idioms do more than just protect the individual. They ultimately provide a means to resist the neoliberal reforms that are a root cause of distress among rural Mexican communities. Along with Yahalom, other authors (Cassaniti, 2019; Gibson, Haslam & Kaplan, 2019) show how idioms of distress can facilitate socially acceptable and indirect complaints – indirect in that they do not draw explicit attention to structural violence, yet they point obliquely to the drivers of distress at the heart of these complaints. Gibson and colleagues note how, in Tuvalu, concerns around climate change have become a central and explicit part of local explanations for broad forms of distress such as manavase (anxiety, worry). However, as Cassaniti (2019) points out, at the same time that “idioms of distress offer acceptable ways to couch personal and social struggles within larger systems of structural inequality […] Inequalities, however, can also be perpetuated through the use of idioms like mindlessness, as well as countered by them” (original emphasis) (p. 703). She describes the Thai government’s use of the language of “restoring mindfulness” to the people as justification for the coup that brought them to power and to urge people not to become overly attached to their own political party. In this way, the authors demonstrate how idioms of distress have come to be used in both new and familiar ways – as implicit challenges to socio-political forces, but also as a means of quelling the exact forms of resistance that idioms of distress may express.

The articles in this special issue also advance theorization and engagement with clinical psychiatric concepts of mental illness. This is an area of growing interest and a key avenue for critical anthropological engagement with biomedical concepts and global mental health interventions. For example, Snodgrass and colleagues’ (2019) findings about the potential emotional value of intensive online gaming suggest that psychiatric categories – such as the recent inclusion of Internet Gaming Disorder in the DSM as a form addiction – fail to capture the full range of lived experience and frameworks used by gamers themselves. This fits with prior research regarding the problematic relationship between psychiatric categorization and idioms of distress, particularly where idioms of distress are problematically co-opted and ultimately displaced by psychiatric categories (Abramowitz, 2010).

In contrast, Hinton and colleagues (2019) demonstrate how idioms of distress can be taken seriously – rather than reduced to DSM categories – with the goal of advancing therapeutic engagement and outcomes. They demonstrate how the incorporation of idiom of distress items into the Hopkins Symptoms Checklist increases the sensitivity of depression and anxiety screening among a nationally representative sample of Cambodians. Without the addition of idioms of distress that assess khyâl attacks, for instance, part of the variation in human experience gets lost – and, they note, this is a serious threat to content validity. Similarly, Lewis-Fernández and Kirmayer (2019), in their commentary, detail several important considerations for psychiatrists as they engage with cultural concepts of distress, as well as calling for work on “how to use this narrative material to identify intervention goals, negotiate treatments, promote engagement, and agree on desired outcomes for recovery” (p. 797).

Several articles in this issue raise the important question of a complementary concept of idioms of resilience or wellness (Cassaniti, 2019; Kim, Kaiser, Bosire, Shahbazian & Mendenhall, 2019; Snodgrass, Dengah, Polzer & Else, 2019). Are idioms of distress inherently about suffering, or is it possible to explore locally situated means of experiencing and expressing positive outcomes – like resilience, wellbeing, and mental health – in local worlds? If yes, what would this look like conceptually? What would be the bounds of such concepts? Authors in this collection make compelling arguments for why it is as important to consider resilience and wellbeing within local worlds as it is to consider distress. Kim and colleagues specifically frame their contribution – a study among cancer patients in South Africa – as an anthropological heuristic for such studies, particularly for differentiating idioms of resilience (e.g., acceptance) from other concepts related to resilience (e.g., social support).

Similarly, Snodgrass and colleagues (2019) describe how emerging adults “cultivate the good life” through gaming: “express[ing] via videogames their life passions and commitments, using games to cultivate positive states of flow, immersion, and euphoria; to create culture-game identities and communities with likeminded individuals; and to communicate competency, skill, and status with these important social others, but not necessarily in order to avoid or resolve life problems” (p. 751). Just as idioms of distress provide an avenue for expressing distress that would be potentially problematic or stigmatizing to express otherwise, Snodgrass et al. argue that this applies also to positive inner experiences expressed through gaming, opening avenues for what they, and others, suggest might be “idioms of wellness.” We look forward to future work that advances theorization around idioms of resilience and wellbeing.

Furthermore, the articles in this special issue explore idioms of distress beyond a specific cultural context, considering what happens when global meets local. For example, Mendenhall and colleagues’ (2019) descriptive study of Kenyan ethnopsychology explores in detail two specific Kiswahili idioms (huzuni, sadness or grief, and dhiki, stress or agony) plus the biomedical terms “depression” and “anxiety,” which many individuals have adopted and blended with local understandings of distress. Cassaniti (2019) describes how mindfulness as a practice and idiom of resilience is becoming globalized, yet its significance is selectively borrowed and altered in the process. She recounts hearing that mindfulness-based stress reduction was being taught in a Thai psychiatric hospital and her surprise at learning that it was being delivered using an English-language approach, “couched in the logic of global, western-scientifically-validated biomedicine” (p. 709).

Finally, at a more foundational level, the articles in this special issue contribute rich, contextualized descriptions of idioms of distress in global settings in line with both classic and recent work on idioms of distress (De Jong & Reis, 2010; Hinton et al., 2010; Kaiser et al., 2014; Keys et al., 2012; Kohrt & Hruschka, 2010; Pedersen et al., 2010; Weaver, 2017). This descriptive and ethnographic content can contribute to a more holistic, comparative understanding of the varied ways in which idioms of distress are understood, employed, interpreted, and even misused globally. For example, Kaiser and colleague’s (2015) review of idioms of distress such as “thinking too much” drew on 138 largely descriptive studies from dozens of countries across all world regions. Their findings revealed significant heterogeneity, despite surface similarities, among “thinking too much” idioms of distress, and they advocated for careful attention to such variability, particularly when idioms are used to inform interventions. Such comparative projects depend on a robust literature of ethnographic descriptions.

Where do we go from here?

These articles point to several unresolved questions within the idioms of distress literature. For example, to what extent are idioms of distress necessarily linguistic constructions, as opposed to behaviors? When he originally coined the term idiom of distress, Nichter (1981) was describing behavioral means through which Havik Brahmin women expressed distress or displeasure in response to family members’ conduct, such as serving lukewarm tea to their husbands’ guests after a marital disagreement. Indeed, other studies have likewise focused on behaviors as idioms of distress, including in this issue (Snodgrass et al., 2019). Despite this precedent, linguistic expressions remain the key way that idioms of distress are described in the literature.

This question regarding the centrality of linguistic expression to the concept of idioms of distress becomes particularly relevant if we consider the concept of idioms of resilience. For example, in Snodgrass’s example of online gaming, we might ask whether a behavior (online gaming) is itself an expression of distress, a form of coping, or a combination of the two. We might also ask whether such distinctions even matter, and if they do, how we adjudicate what constitute “regular” behaviors and specialized “idiomatic” behaviors? Can we continue to push the boundaries of what is considered an idiom of distress, or will the concept begin to reach the limit of its utility – essentially explaining nothing because it can refer to anything? Similarly, Kim and colleagues explore the concept of idioms of resilience within a linguistically diverse context, identifying conceptual categories and behaviors that represent resilience, rather than particular linguistic constructions.

We argue that to remain relevant, literature on idioms of distress must address the following issues. First, there remains a need for clear theorization of what an idiom of distress is – and is not: How is one employed? What are the results? What are the boundaries? There is a need for such clarity in order to avoid boundary creep. One way to achieve this will be for idioms of distress research to turn its lens onto the Global North – as demonstrated by Carol Worthman’s (2019) analysis of ulcer as an idiom of distress in her commentary – to end the de facto assumption that only the “other” has exotic or non-psychiatric categories of distress. Second, research should continue to focus on the broader structures or forces that are being contested, whether implicitly or explicitly, through the use of idioms of distress. Idioms of distress literature must be careful to avoid presenting distress as reflecting solely individual psychopathology or equitably distributed distress. This is essential to avoid victim-blaming through a myopic exploration of only immediate causes of distress. Attention to the social and the structural are key means of avoiding these pitfalls. Third, this literature must continue to pursue concrete ways to productively critique psychiatry and to develop viable, clinically relevant tools, a process that is already well underway. Finally, although this special issue reflects diversity in geographies and of participant voices, there is not enough diversity in terms of authorship. There is a need for greater inclusion of global authors and authors from underrepresented backgrounds, particularly from the Global South.

If the articles collected here are any indication, research on idioms of distress will continue to develop innovative ways to address these challenges. We look forward to following this research and are grateful to Transcultural Psychiatry for bringing together this latest wave of work.

Biography

Bonnie N. Kaiser, PhD, MPH is an Assistant Professor at University of California San Diego, jointly appointed in the Department of Anthropology and Global Health Program. Her research focuses on cultural models of mental health and illness and their connections to care-seeking; developing and adapting measurement tools for cross-cultural research and interventions; improving cultural adaptation of global mental health interventions; and critically exploring concepts of trauma, risk, and resilience. Her scholarship balances critical and constructive engagement with the field of global mental health. She conducts mixed-methods studies with multidisciplinary engagement, drawing on her training as an anthropologist (PhD), epidemiologist (MPH), and global health implementation scientist (postdoc). Her work is situated in Haiti, Kenya, Nepal, Ethiopia, and Nigeria.

Lesley Jo Weaver, PhD, MPH, is an Assistant Professor in the Department of International Studies at the University of Oregon, where she is an affiliate in the Anthropology, Asian Studies, and Global Health programs. Her mixed-method research explores the causes and correlates of common mental disorders in Brazil and India focusing on cultural models of mental health and illness. Her book with Rutgers University Press, Sugar and Tension: Diabetes and Gender in Modern India, details how women in North India with type 2 diabetes cope with chronic disease and “tension” (an idiom of distress) amid changing gender norms. In addition, she co-hosts the podcast Speaking of Race, a unique collaboration with a historian and a human biologist that explores how ideas about race came to be, and how they affect wellbeing around the globe.