Your diagnosis may depend on where you’re from

Ethnicity researcher Anna Bredström has spent hours poring over the 1000 pages of DSM-5, the Diagnostic and Statistical Manual of Mental Disorders, investigating how the manual treats culture and ethnicity. She suggests that the manual is blind to the fact that the western world also has a culture, and that this may lead to different patients being assessed by different criteria.

Anna Bredström at her deskAnna Bredström at her desk Photo credit: Pia MolinIt’s not easy to see from outside whether Anna Bredström is in her office or not. The glass wall that separates her office from the corridor is covered by photos that prevent anyone seeing in. This attempt at a shielded environment is where she has read a 1000-page manual for mental disease in great detail.

Anna Bredström has been occupied for many years with the most recent version of DSM, the Diagnostic and Statistical Manual of Mental Disorders, used all over the world in the diagnosis of mental disease. If you visit a psychiatrist in the US, your symptoms will be classified according to the DSM. Sweden uses the WHO codes for statistics and follow up, but in clinical psychiatry the DSM is principally used, since it gives a more detailed description of each diagnosis.

A new version of the manual was issued in 2013, after 10 years’ work by hundreds of international experts. The publisher at the time stated that it had been an intention to give the manual what was called “higher cultural sensitivity”. The previous version, DSM-IV, had been criticised for “exotifying” certain diagnoses. For an ethnicity researcher this, was, of course, extremely interesting, and Bredström wanted to see how the new version differed from the previous one.

“This is one of the most important documents for how we are to understand these diagnoses, and how we can compare the way in which different diseases present themselves in different countries. I just couldn’t resist taking a look,” she says.

She emerges from her bookish scholarly space and walks along the corridor to the coffee room.

The significance of social and cultural context for a certain condition is an issue that is hotly debated within psychiatry. Bredström’s research has shown that the manual is inconsistent in the significance it gives to the surroundings and context when determining a diagnosis. Since it’s not possible to take a blood sample to determine the mental health of a patient, a certain amount of context for the symptoms is necessary, in order to understand why a patient has these symptoms. Anna BredströmPhoto credit: Pia Molin

“The DSM gives greater significance to the context for certain patients – those who were not born in the western world. This may mean that someone from Latin America who visits a psychiatrist in the US will be assessed on different grounds than an American person, born in the US,” says Bredström.

At first sight, you may expect that depression and other forms of mental ill-health show the same symptoms all over the world. But that’s not the case. Some of the symptoms we demonstrate are specific to the culture in which we grew up. A panic attack, for example, can be expressed in different ways. Patients in Sweden often describe how a panic attack manifests itself as chest pain and breathing difficulty, while for patients in other parts of the world it may also involve tinnitus, headache and uncontrolled screaming.

“The manual describes the symptoms that the western world experiences as the ‘correct’ symptoms of a panic attack. The symptoms that other cultures experience are described in a separate paragraph further down, and are called ‘culture-specific symptoms’. The manual ignores the fact that also patients in the western world live in a cultural context,” says Bredström.

Psychiatry in recent years has placed increasing emphasis on studying people’s thoughts, feelings and behaviour based on a perspective in which biological mechanisms and activity in the brain are central aspects. When it was decided to revise the DSM, the publishers decided that this way of looking at things would be more prominent.

“But how can this more biological way of looking at things be united with the idea that culture influences us? The manual takes what is known as a rather biopsychiatric line, apart from when it comes to ethnicity.”

Anna Bredström believes that ethnicity will become a dividing line within psychiatry – and for the patients.

“The publishers have considered the criticism and made some improvements. But the manual still clearly takes the western world as the norm and assumes that ‘everywhere else has a culture, but not us’. This leads to the risk that patients are not assessed by the same criteria.”

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