The Cultural Dimension in DSM-5: PTSD

Any effort to develop a diagnostic manual for world-wide use must grapple with the question of cross-cultural applicability. The description and diagnostic criteria for schizophrenia must work as well in East Timor as in the US or France. DSM-IV dealt with cultural difference by relegating a number of culture-specific clinical entities to an appendix at the back of the manual. This left untouched the question of whether some of the diagnoses in the main body of the text were compromised by unacknowledged cultural differences. In this piece I choose PTSD to show the complexity of the cultural issue for DSM-5.

Let me begin by noting two facts. First, the authors of the DSM-5 white paper monograph, A Research Agenda for DSM-V, devote a chapter of the text to “Beyond the Funhouse Mirrors: Research Agenda on Culture and Psychiatric Diagnosis,” including a section on PTSD.¹ In this thorough review the chapter authors demonstrate a sensitivity to cultural issues in diagnosis. Second, in the DSM-5 web site section, Criteria Proposed by Outside Sources, the site lists Developmental Trauma Disorder (DTD) and Disorders of Extreme Stress not Otherwise Specified (DESNOS).² Both of these proposed diagnoses were developed to expand the reach of PTSD to victims of early childhood abuse who do not exhibit the classic symptoms of DSM-IV PTSD, but rather a range of symptoms overlapping with those of borderline personality disorder.^3-6

Although the proposed PTSD-related diagnoses represent a broadening of the PTSD diagnostic construct, they do not reach the dimension of cultural difference. The cultural question is raised when we look at trauma, its meaning, and its consequences from the perspective of other cultures. From the extensive literature on trauma in other cultural contexts, I will focus on the work of Pedersen and colleagues from McGill, who have studied the effects of political violence on the Quechua-speaking, indigenous, Andean population of Peru. For more than two decades from 1980 until the early 90s, these mountain people suffered extreme violence both from the Shining Path, a terrorist guerrilla movement, and the Peruvian military counterinsurgency. The violence left 70,000 Andean people dead and countless more terrorized, tortured, and displaced, with massive disruption of their social lives. The McGill researchers found a 25 percent incidence of classic PTSD symptoms among their victim research group, but also a high incidence of depression and anxiety, as well as symptoms whose Quechua names (llaki and akary) do not translate readily into Western categories.^7-8

Pedersen and colleagues conclude that although a quarter of the victims fit the DSM PTSD template, the diagnostic construct does not begin to capture the effects of trauma on the affected population. “When assessing the overall mental health impact of exposure to protracted forms of extreme violence in civilian populations, we need to move beyond the limited notion of PTSD, which is a useful but restrictive medical category, failing to encompass the myriad of symptoms and signals of distress, suffering and affliction, as well as other culture bound trauma-related disorders and long-term sequelae of traumatic experiences found in the discourse of survivors.”^{9, p 214}

Where does this leave us with DSM-5? In the Proposed Revisions section of the DSM-5 web site, the Work Force charged with PTSD emphasizes three areas of proposed change: the effects of trauma and expressions of psychopathology in preschoolers, the effects of trauma and expressions of psychopathology in school-aged children, and consideration of adding a new syndrome, Developmental Trauma Disorder (as discussed above).¹⁰ There is no mention of the cultural dimension in the proposed changes. The 70-page chapter on culture and psychiatric diagnosis in A Research Agenda for DSM-V has apparently fallen on deaf ears.

The authors of DSM-5 are facing a difficult challenge. They aim to construct a diagnostic manual with world-wide applicability, but at least in the area of trauma they are starting with a diagnostic construct that was developed out of the specific posttraumatic experiences of the Viet Nam war. We should not expect that such a narrowly targeted construct would cover traumatic experiences ranging from childhood sexual abuse to natural disasters and extreme political violence in other cultures. That the latter do not fit neatly into the narrow medical confines of the PTSD diagnostic criteria should surprise no one. The proposed inclusion of DTD as a separate diagnosis in DSM-5 would be an acknowledgment that trauma has more than one course in Western countries, but it would leave untouched the much vaster area of cultural differences in the experience, meaning, and consequences of trauma.

What is the DSM-5 Task Force to do in the matter of trauma and culture? Clearly we need more work - empirical and theoretical - both in defining what qualifies as trauma and what qualifies as an effect of trauma, eg how to determine whether symptoms like anxiety and depression, or other culture-specific symptoms like the llaki and akary mentioned above, are effects of trauma or simply comorbid symptoms. With respect to trauma disorders, the very nature of cultural difference tends to defeat the possibility of codifying such difference into a neat, medical nosological category. The notion of a Trauma Disorder NOS category satisfies no one. It’s not surprising that this confusion over PTSD spawns a range of conflicting responses: at one extreme, a charge to tighten and sharpen the criteria, eliminating ambiguity and comorbidity;¹¹ at the other extreme, an argument that the diagnosis is a narrow, culture-bound social construct that should be discarded;^12-13 and in the middle an effort to fine-tune the medical, PTSD construct.^14-15 Either way, in the area of trauma and PTSD, the DSM-5 on the horizon remains, for understandable reasons, a long way from cross-cultural adequacy.

References:

1. Alarcon RD, et al. Beyond the Funhouse Mirrors: Research Agenda on Culture and Psychiatric Diagnosis. In Kupfer DJ, First MB, Regier DA (eds). A Research Agenda for DSM-V. Washington, DC: American Psychiatric Association, 2002, pp 219-282.
2. http://www.dsm5.org/ProposedRevisions/Pages/ConditionsProposedbyOutsideSources.aspx
3. Herman JL. Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. J Traumatic Stress 1992; 5: 377-391.
4. van der Kolk B. Developmental trauma disorder. Psychiatric Annals 2005; 35:401-408.
5. van der Kolk BA, Roth S, Pelcovitz D, Sunday S, Spinazzola J. Disorder of extreme stress: The empirical foundation of a complex adaptation to trauma. J Traumatic Stress 2005; 18: 389-399.
6. Wylie, MS. The Long Shadow of Trauma. The Psychotherapy Networker; March/April 2010, 1-18.
7. Pedersen D. Political violence, ethnic conflict, and contemporary wars: broad implications for health and social well-being. Social Science & Medicine 2002; 55: 175-190.
8. Pedersen D, Kienzler H, Gamarra J. Llaki and Ñakary : Idioms of distress and suffering among the highland Quechua in the Peruvian Andes. Cult Med Psychiatry 2010; 34: 278-300.
9. Pedersen D, Tremblay J, Errazuriz C, Gamarra J. The sequelae of political violence: Assessing trauma, suffering and dislocation in the Peruvian highlands. Social Science & Medicine 2008; 67: 205-217.
10. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=165
11. Spitzer R, First MB, Wakefield JC. Saving PTSD from itself in DSM-V. J Anxiety Disorders 2007; 21: 233-241.
12. Summerfield D. The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal 2001; 322: 95-98.
13. Young A. The Harmony of illusions: Inventing post-traumatic stress disorder. Princeton, NJ: Princeton U Press, 1995.
14. Lanius RA, Vermetten E, Loewenstein RJ, Brand B, Schmahl C, Bremner JD, Spiegel D. Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry 2010; 167: 640-647.
15. Chu JA. Editorial. Posttraumatic stress disorder: Beyond DSM-IV. Am J Psychiatry 2010; 167: 615-617.