Introduction
Debate has prevailed when considering the nosological role of ‘Culture-bound syndrome’ (CBS) within the DSM and ICD diagnostic classification systems.1
History
While the dimensional DSM-IV classificatory system first included the term ‘Culture bound syndrome’ in its Diagnostic and Statistical Manual of Mental disorders fourth edition, the ICD‐10 Mental and Behavioural Disorders which was categorical found it difficult to include such diverse, ill-defined set of conditions into a single diagnostic entity with diagnostic criteria of its own, and hence left a mention of them under the somatoform disorder, in help-seeking, and illness‐related behaviour categories.
Cultural psychiatrists have 2 argued that due to the significant influence of culture in expression of psychological distress and the evolving diversity in the expressions of these problems, we are left to wonder about the diagnostic validity of these culture-bound syndromes that enable them to be mentioned individually into existing categorical or dimensional classification systems. Few others have argued against the reductionistic approach of cultural diversity into a closed entity in the nosology system.
From an academic and clinical perspective, these debates tend to create confusion in the minds of young psychiatrists and among those who have practiced ICD10 and DSM IV. It is imperative to explore the current status of this ‘Culture-specific/bound syndrome’.
DSM 5
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) surprisingly dropped the term culture-bound syndromes and replaced it as "cultural concepts of distress" or “culture-specific disorders". The DSM-5 prefers the term "cultural concepts of distress" over "culture-bound syndromes" because cultural concepts of distress are the ways that cultural groups experience, understand, and communicate suffering, behavioural problems, or troubling thoughts and emotions. DSM-5 also had reduced the number of CBS in the glossary of cultural concepts of distress from 25 (DSM-IV TR, 2000)20 to only 9 (DSM-5, 2013).3 Some of the explanations for such changes were understood based on expert consensus as follows:
Culture specific psychological distress previously thought to be geographically isolated showed much wider existence in similar distress patterns across many different cultural settings.
The predominant lack of cohesive symptom presentation of one condition in one cultural setting supports its relevance to culture.
While definition of syndrome is a group of signs and symptoms that originate from a single disorder and affects many other organs, such clarity does not exist with the culture-bound syndrome.
Intercultural, ethnic diversities make these conditions very different in their presentation within a larger cultural umbrella.
The lack of consensus on the basic aetiological attributions, vulnerability groups, and symptoms further weakens the argument for a syndromic entity.
Locally expressed illnesses, described as locally expressed illnesses that only appear among certain culturally defined groups and absence among others within the same culture presents doubt on it as a health disorder.
These shortcomings have forced DSM-5 to include a simple list of culture-bound syndromes only giving way to reflect cross-cultural variations in the clinical presentation of this entity. But for this difficulty, DSM-5 has helped clinicians and others interested by creating a Cultural Formulation (OCF) and its operationalization into the Cultural Formulation Interview (CFI), a clinical interview tool that would facilitate comprehensive, person-centered assessments of culture -specific distress conditions.
ICD -11
Firstly, the International Classification of Diseases (ICD)-11 has included a new replaced the somatoform disorder category with a new diagnostic category called the Bodily Distress Disorder (BDD) with no mention of culture bound syndrome in any manner as in ICD-10. ICD-11 has summarized the information on cultural variations in modes of describing the distress, symptom patterns, and dysfunctions of each disorder in order to promote the culturally sensitive application of the diagnostic system. The ICD-11 has been designed to utilize prototypical descriptions of disorders and not just a list of diagnostic criteria, and encouraged consideration of cultural variations in phenomenology, in addition to contextual and, health system factors that impact clinical diagnosis. 4 Although not specific to the culture specific conditions as such, ICD-11 has allowed clinicians to fit their diagnosis by including cultural ramifications of each individual.
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