Let us now turn to the analysis of the revision, beginning with the conceptualization of culture. One of the key points that the cultural expertise put forward to the DSM-5 Task Force was that the new manual would need a more dynamic concept of culture than its predecessor. Several of the reviews referred to how DSM-IV rested upon a static understanding which tended to represent “other cultures” as “distorted reflections of our own cultural preoccupations” (Kirmayer and Minas 2000, 439) or “to ‘exotize’ the cultural approach by ascribing it only to ethnic minorities” (Alarcón et al. 2002, 222), and thus to rest upon an “undeclared ethnocentrism” (Alarcón 2009, 133), referring to how it uses western cultural norms as a tacit measure.
In a white paper on culture and psychiatric diagnoses, Alarcón et al. (2002) refer particularly to López and Guarnaccia’s (2000) critical scrutiny of how culture has been conceptualized within the field of cultural psychiatry generally and in DSM-IV and the World Mental Health Report from 1996 specifically. López and Guarnaccia argue that the way culture is being defined in DSM-IV as “values, beliefs, and practices that pertain to a given ethnocultural group” indeed has advantages over earlier definitions of culture within the field of cultural psychiatry, in particular those that located certain expressions of distress within a given ethnocultural group. The “values, beliefs and practices – definition” starts to unpack culture they argue and thus acknowledges heterogeneity. That is to say, it shifts the focus from “belonging to an ethnocultural group” to the value-system of the individual (which might or might not be related to a person’s ethnic identity).
This notwithstanding, López and Guarnaccia underline that the “values, belief and practices-definition” still holds major weaknesses. First of all, it “depicts culture as residing largely within individuals” and thus adheres to an understanding that emphasizes the “psychological nature of culture” (2000, 574) that de-emphasizes the importance of social context. Secondly, Lopez and Guarnaccia argue, the “value, belief and practices-definition” tends to portray culture as a static phenomenon rather than a process. And thirdly, López and Guarnaccia point out that despite opening up for a more heterogeneous understanding of ethnocultural groups that acknowledges intra-group variation, the “value, beliefs and practices definition” does not adequately clarify how individuals negotiate and move between different cultural spheres.
What López and Guarnaccia advocate is a more dynamic understanding of culture that pays attention to both the link between culture and people’s social world and to intra-cultural diversity (class and gender aspects in particular). Other cultural experts have also spoken in favour of a more dynamic concept of culture in DSM but have targeted the issue from another angle. Kirmayer and Sartourius (2007), for instance, take to task the way culture is conflated with ethnicity by questioning the ways in which race or ethnicity are being used as proxy for cultural factors. The usage of “crudely defined” ethnic groups such as African American, Hispanic or Asian American in epidemiological studies, does not, they claim “shed much light on the impact of culture on psychopathological processes” (Kirmayer and Sartourius 2007, 832) as even seemingly well-defined ethnic groups are too heterogeneous. “Current anthropological views,” they contend, demand a focus on how the individual makes use of, and negotiates between, cultural resources, rather than simply assuming a set of values shared by all members of an ethnic or racial collective. Similar to López and Guarnaccia, Kirmayer and Sartourius thus argue that culture needs to be understood as a hybrid system of knowledge that is intertwined with power-relations and reproduced through discourse as well as institutions.
Returning to DSM-5, it is obvious that the revised manual strives towards a more dynamic concept of culture. To a much larger extent than DSM-IV, DSM-5 elaborates how culture is to be understood:
Culture refers to systems of knowledge, concepts, rules, and practices that are learned and transmitted across generations. Culture includes language, religion and spirituality, family structures, life-cycle stages, ceremonial rituals, and customs, as well as moral and legal systems. Cultures are open, dynamic systems that undergo continuous change over time; in the contemporary world, most individuals and groups are exposed to multiple cultures, which they use to fashion their own identities and make sense of experience. These features of culture make it crucial not to overgeneralize cultural information or stereotype groups in terms of fixed cultural traits. (American Psychiatric Association 2013a, 749)
Further down is also underlined that “Culture, race, and ethnicity are related to economic inequities, racism, and discrimination that result in health disparities,” which may be interpreted as an understanding of culture, race and ethnicity as socially shaped categories that are intimately related to socio-political matters.
These elaborations on how culture is to be defined take place in the specific chapter outlining the manual’s Cultural Formulation, which is located in Section III – “Emerging Measures and Models” – in the manual. Thus one may conclude that as far as the Cultural Formulation goes, the DSM-5 Task Force has attended to the critical remarks summarized above.
At the same time, there are also numerous examples where the critique has not made any visible impact. In fact, looking at the manual as a whole, one is presented with rather mixed messages. The key asymmetry is between Section III and Section II – “Diagnostic Criteria and Codes” where criteria of all DSM-disorders are to be found. Considering Section II, the nuanced and well informed Cultural Formulation found in Section III seemingly loses its weight. Nowhere among the scattered comments on how culture is to be accounted for in relation to specific disorder criteria is it underlined that cultures are to be seen as “open, dynamic, systems that undergo continues change” the way it is expressed in the manual’s own definition quoted above. Neither is it explained how a dynamic understanding of culture as ever changing and heterogeneous would affect the diagnostic procedure itself.
There are, to be fair, some cases that correspond to the spirit of the revision. Let us, for instance, look at how cultural related aspects of Major Depression Episode was formulated in DSM-IV:
… in some cultures, depression may be experienced largely in somatic terms, rather than with sadness or guilt. Complaints of ‘nerves’ and headaches (in Latino and Mediterranean cultures), of weakness, tiredness, or ‘imbalance’ (in Chinese and Asian cultures), of problems of the ‘heart’ (in Middle Eastern cultures), or of being ‘heartbroken’ (among Hopi) may express the depressive experience. […] (American Psychiatric Association 1994, 324)
Compare this paragraph to the corresponding part in DSM-5 that underlines that
[w]hile […] findings suggest substantial cultural differences in the expression of major depressive disorder, they do not permit simple linkages between particular cultures and the likelihood of specific symptoms. Rather, clinicians should be aware that in most countries the majority of cases of depression go unrecognized in primary care settings […] and that in many cultures, somatic symptoms are very likely to constitute the presenting complaint. (American Psychiatric Association 2013a, 166)
Apparently, the authors of this section have explicitly tried to avoid making “other” cultures tantamount to “distorted versions” by emphasising both similarities and problems with linking certain symptoms to particular groups. Also, highlighting the fact of somatization as a general expression of depression could be interpreted as a response to the critique of how western psychiatry tends to incorrectly assign somatization of psychiatric distress as mainly a non-western phenomenon (Kirmayer and Sartorius 2007).
However, looking at Section II as a whole, these examples turn out to be the exceptions to the rule. In general, and in sharp contrast to the dynamic view of the Cultural Formulation, the concept of culture in Section II figures as a static and homogenous group identity that corresponds very much to the “values, beliefs, and practices that pertain to a given ethnocultural group.” criticized by López and Guarnaccia. Under the heading “Culture-Related Diagnostic Issues” of Panic Disorder in DSM-5 one reads for instance that:
[t]he rate of fears about mental and somatic symptoms of anxiety appears to vary across cultures and may influence the rate of panic attacks and panic disorder […]. Also, cultural expectations may influence the classification of panic attacks as expected or unexpected. For example, a Vietnamese individual who has a panic attack after walking out into a windy environment (trúng gió; ‘hit by the wind’) may attribute the panic attack to exposure to wind as a result of the cultural syndrome that links these two experiences, resulting in classification of the panic attack as expected. Various other cultural syndromes are associated with panic disorder, including ataque de nervios (‘attack of nerves’) among Latin Americans and khyâl attacks and ‘soul loss’ among Cambodians … (American Psychiatric Association 2013a, 211)
Here, the “crude categories” (e.g. “Latin Americans,” “Cambodians”), criticized by Kirmayer and Sartourius, that conflate culture with race, ethnicity or nation, or “stereotype groups in terms of fixed cultural traits” (American Psychiatric Association 2013a, 749), are apparently still being used. Moreover, there are no comments on differences relating to class, gender, age, sexuality, migration experience, minority/majority position, transnational and diaspora context and so on.