Cultural adaptations of current psychiatric classifications: are they the solution?

Despite the limitations of modern nosological systems the development of cultural adaptations is a step backward, leading to unavoidable pitfalls in spite of the fact that cultural diversity is imposing new attitudes and demands on psychiatrists. Cultural adaptations challenge the principles of the universality of science and of ethics. ICD-10 and DSM-IV rely on the symptoms present to classify psychiatric diseases. This kind of classification has many advantages: it is a theoretical, close to clinical reality, easy to grasp and less prone to untested hypotheses. But they have some drawbacks: they do not say what diseases are, since the concept of symptom is not totally clear in psychiatry. The greatest disadvantage of this approach is the dispersion of disorders that may be related or even unique. Furthermore, when too many symptoms are present, this method requires a hierarchical structure (as in DSM-III)--unless one is willing to live with multiple diagnoses, the so-called co-morbidities (as in DSM-IV). But at other times, too few symptoms are present, leading to atypical, waste-basket and subsyndromal categories. Another problem is that symptoms may not be consistent across cultures, leading to the need of cultural adaptations. In the case of diseases diagnosed according to symptomatic criteria, cultural adaptations of internationally accepted classifications are often sought because symptoms are deemed to be inconsistent across cultures. But at a closer look, very often the symptoms are not so different and it is only the cultural halo which makes them attractive; even when they are particular to a given culture they can easily be interpreted (e.g., the penis invagination of latah). Indeed, they represent a way of experiencing common feelings such as anxiety (e.g., the susto of Latin America, which is a typical panic disorder) and depression. To put too much emphasis on local symptoms bears the risk of yielding to social and cultural pressure.