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Idioms of Distress Revisited

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Notes

  1. One would hope that the term cultural bound syndrome currently used in DSM IV will, at the very least, be replaced by “cultural syndrome.” Like many anthropologists, I have found the term cultural bound syndrome to be problematic for reasons summarized by anthropologists critiquing its inclusion in DSM IV (e.g., Hahn 1995; Hughes 1998; Kleinman 1997).

  2. The “work of culture” (Hollan 1994; Obeyesekere 1985, 1990) refers to the process whereby distressful states, perceived risk and motives, negative affects and sensations are transformed into publicly accepted sets of meanings and symbols that can be manipulated or dealt with in some culturally salient manner. Importantly, Obeyesekere notes that “where subjective experience is often articulated through the medium of cultural symbols, cultural symbols are only ever imbued with significance once they are internalized and integrated into the context of an individual’s emotional and motivational concerns” (see Throop 2003, p. 112).

  3. See Hinton et al. (2010) for a detailed description of the clinical utility afforded by an assessment of a sufferer’s idioms of distress.

  4. Metacommunication refers to anything that contextualizes or frames a message such that it assists the participants to understand the communication event (Wilmot 1980, p. 64).

  5. Stating that biomedicine or the discipline of psychiatry is ethnomedical does not devalue it as an evidence-based scientific endeavor or privilege inquiry into cultural relativity above universal human processes. Use of the term draws attention to both the production of knowledge in cultural and historical contexts and the “action in the interaction” between culture and biology. See Kirmayer (2006) on the contribution of "cultural biology" to the new cross-cultural psychiatry.

  6. A transactional assessment of communication views it as a negotiation of meaning between parties responding to their environment and each other.

  7. I refer here to early studies such as those carried out by O’Nell and Selby (1968) and Rubel et al. (1985). More sophisticated cultural epidemiological studies also attend to “how” questions: how the afflicted and concerned others come to recognize, define and treat a condition (see, e.g., Kohrt et al. 2004).

  8. I use the term pragmatics in two distinct ways. The first indexes Charles Morris’s (1971) juxtaposition of the terms semantics and pragmatics. While semantics refers to the study of the signification of verbal and nonverbal signs, pragmatics refers to the study of the origins, uses and effects of signs. Morris defines a sign as any preparatory stimulus that produces a disposition in the interpreter of the sign to respond to something that is not at the moment a stimulus. Second, I use the term pragmatics to refer to a consideration of how a given context can have an influence on the meaning (and inferred meaning) of messages intentionally and unintentionally being communicated. Pragmatics in psychiatry is most closely associated with the Palo Alto school and the work of such researchers as Bateson, Watzlawick, Beavin and Jackson (see, e.g., Watzlawick et al. 1967). I was exposed to this school of relational communication theorists during my postdoctoral training in psychiatry.

  9. Following Nerlich and Clarke (2001), I think it is important to acknowledge that just as people who engage in conversations do not always strive for relevance, or intend words to have particular meaning, calling attention to a generalized state of distress may involve “purposive ambiguity” that serves subtle and emergent ends. On this point, see Mimi Nichter’s (2000) writing on “fat talk.” Speech actors also produce meaning in contexts of divination and diagnosis without intention other than recognition of distress and an overture being made for engagement (Du Bois 1993).

  10. In a forthcoming article on the localization of healing in a global environment, Jen Thompson, Cheryl Ritenbaugh, and I argue that Gardner's (1993) concept of “multiple intelligences” needs to figure into our consideration of why individuals experience and express distress in particular ways and gravitate toward particular types of healing modalities and healers.

  11. For example, Kirmayer and Young (1998) have documented cases in which somatic states may be indicative of any combination of seven things: an index of a disease or disorder, a symbolic expression of intrapsychic conflict, an indication of specific psychopathology, a culturally salient idiom of distress, a metaphor for experience, an act of positioning within a local world or a form of social commentary or protest. See also Hinton and Good (2009).

  12. Medicine exchanges may also constitute an idiom of concern (Nichter 2008a), and medicine requests may also be an idiom for establishing a positive identity associating pain with hard work and sacrifice for one’s family (Trnka 2007).

  13. Non-biomedical practitioners may borrow from biomedical or psychiatric registers as a means of bolstering their own social status or providing patients with new or hybrid illness identities, a process know as "enregisterment" (Wilce 2008). In this case, biomedical terms take on local meaning. Notable shifts in the classification of mental states have occurred within psychiatry, influenced by historical factors, social and economic exigencies, and advances in scientific research. These shifts in turn influence the way in which the public labels, interprets, experiences, and responds to distress. For example, see Horwitz (2010) on shifts in the boundaries between anxiety and depression over the last 50 years in the USA, and the way in which depression has come to eclipse anxiety in both biomedical practice and the public imaginary.

  14. For example, I know of ritual specialists in South India (Mantra Vaidi) who are currently using psychoactive drugs in their practice, and find that they enhance their work of culture.

  15. On the medicalization and pharmaceuticalization of idioms of distress, see the work of Rozemberg and Manderson (1998) in Brazil and Ecks and Basu (2009) in India. Ecks and Basu document the floating market and increasing demand for psychopharmaceuticals in India. Rose (2006) provides a useful discussion of the pharmaceuticalization of problems of living and bracket creep of psychiatric diagnosis. Applbaum (2006) provides a sobering account of the pharmaceutical industry's crusade to raise public awareness about psychiatric diagnosis and willingness to take psychoactive drugs to manage an increasing array of life problems.

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Nichter, M. Idioms of Distress Revisited. Cult Med Psychiatry 34, 401–416 (2010). https://doi.org/10.1007/s11013-010-9179-6

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