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Culture and Diagnosis: A Set of Iron Laws?

Charcot and Hysteria
What did culture have to do with 19th century neurologist Jean-Martin Charcot's theories about hysteria?

Kim Puchir, Communications Coordinator, NAMI

What would we learn about mental health care in the U.S. if we were to turn the tables—what kind of patient history would we find? Our modern understanding of schizophrenia began with German psychiatrist Emil Kraeplin’s investigations of the 1880s—when bustles were the style and Wagner was popular music. While many of the views of mental illness from that time have been discarded along with the fashions, they were part of the cultural formation that shaped some of the beliefs and practices of today.

The National Institute of Mental Health’s Culture and Diagnosis Group defines culture as the “meanings, values and behavioral norms that are learned and transmitted in the dominant society and within its social groups. Culture powerfully influences cognition, feelings and self-concept as well as the diagnostic process and treatment decisions.” Since culture is not static, mental health treatment does not remain the same. In an article for Psychiatric Clinics of North America, Horacio Fábrega, a professor of psychiatry and anthropology, writes:

"The psychiatry of the 21st century will have to be different from the psychiatry of the 20th century. The latter began its journey in a socially, compartmentalized world in which sharp categories and boundaries for the definition of mental illness were assumed to be relevant."

Mental health care in the United States bears the mark, or “accent”, of its origins, which is perhaps most easily noticed by people with roots in another nation or culture. Whether these people have lived in this country all their lives or come from somewhere else, our mental health system is struggling to develop assessment tools, research and treatment standards that can accommodate cultural variations. We are discovering that when standards developed from the dominant American culture are applied to many minority groups, it can lead to misdiagnosis, improper treatment and frustration.

If it sounds unusual to us, we call it psychotic,” said Michael Smith, a psychiatrist at the University of California at Los Angeles who studies the effects of culture and ethnicity on psychiatry. Manuel Trujillo, a professor of psychiatry and the director of the Program for Public and Global Psychiatry at New York University School of Medicine, described the case history of a Latino woman who was mistakenly diagnosed—and treated for—schizophrenia while her depression was left untreated. Since she spoke little English, it was easy for caregivers to mistake her speech as disorganized, one of the markers for schizophrenia. To complicate matters further, research has shown that people who are trying to communicate in a second language may exaggerate their gestures for emphasis—making their behavior more likely to be seen as bizarre. In reality, schizophrenia may present differently within different cultures. Within  the Mexican American culture, for instance, people are more likely to describe their symptoms in physical terms.

Even in the absence of language differences, cultural differences can affect the way some groups, like African Americans, receive mental health care. “Although schizophrenia has been shown to affect all ethnic groups at the same rate, [scientist John Zeber] found that blacks in the United States were more than four times as likely to be diagnosed with the disorder as whites,” according to research cited in the Washington Post. Some have questioned whether historical and social challenges uniquely affecting the African American community have contributed to a lack of trust known as “cultural paranoia,” distinct from the paranoia involved with conditions like schizophrenia. There are documented disparities in the way individuals of different cultures receive treatment.

Lest we begin to think that some other factor within these cultures makes mental illness more prevalent, consider World Health Organization findings that people who are diagnosed with a mental illness in a developing nation like India tend to do better than those in some Western nations like the U.S. or Denmark. It has been suggested that this is due to better family networks and the fact that people are less likely to be socially isolated, homeless or jailed. As people assimilate to Western ways, they tend to display similar levels of mental illness as those found in the dominant culture. For example, “people of Mexican descent born in the United States have twice the risk of disorders such as depression and anxiety and four times the risk of drug abuse, compared with recent immigrants from Mexico.”

Care providers’ training should inform them of cultural differences that, while subtle, can make communication easier. For instance, nonverbal signals like eye contact, conversational turn-taking and personal space are far from universal. They should also be alerted to diagnostic pitfalls that may occur when observing someone of another culture. Between European American psychotherapists and African Americans a phase known as “sizing up“ can occur, which “refers to refers to the client behaving in a reserved manner, not asking many questions and attempting to ‘feel out’ the clinician and his or her intentions.” More investigation into culture- and language-specific diagnostic procedures and tools would benefit individuals from other cultures who seek mental health care.

No one expects there to be one definitive version of the DSM—our understanding of mental illness will always need refining. The 19th century neurologist Jean-Martin Charcot, instrumental in the description of conditions such as multiple sclerosis believed in “observation, experiment and reasoning.” Yet he is perhaps best known for leading some of the brightest minds of his day in the wild goose chase after the disorder known as hysteria—what has been called a “disaster“ for the field of French psychiatry.

Hysteria seemed to have a good pedigree—descriptions of an illness that gave women bizarre symptoms like heart palpitations and loss of voice go back to Plato’s time. Using the best scientific investigative methods of his day, Charcot's "failure to make accurate medical diagnoses...led, almost inevitably, to the massive inflation of a pseudo-diagnosis—‘hysteria.’" After “an entire generation of physicians and patients had been gulled into believing …the symptoms of a set of iron laws that never existed,” we can look back and see that much of what Charcot was describing was in fact his own cultural setting. Mark S. Micale, an associate professor of history and the history of medicine at the University of Illinois, wrote of Charcot’s efforts:

The large number of Charcot's cases involving this form of travel almost certainly register contemporary cultural anxieties about rapid mechanized transportation and the unprecedented and uncontrollable technological change that it symbolized.” 

Rigorous research and openness to outside ideas are key for improving our mental health system. Perhaps if Charcot’s “iron laws of hysteria” had not been so iron-clad, he would have been receptive to alternative explanations and thousands of men and women would not have been misdiagnosed. Questioning mental health care’s "one-size-fits-all" mentality can only help refine the field’s larger understanding of mental illness.

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