The effect of culture on the adjustment disorders
is pervasive. Cul-turally based interpretations are essential to the appraisal
of the repertoire of behavioral and emotional responses that pattern both
normal and disordered reactions to stress (Jenkins and Kinzie, 1997). Whereas some
experiences are uniformly stressful (e.g., natural disaster), others may make
sense only within particular cultural contexts (e.g., facing deadlines,
witchcraft accusations) (Fábrega and Mezzich, 1987). In addition, the judgment
of what constitutes a maladaptive response to a stressor must be made in
relation to what exceeds cultural norms (Kleinman, 1988). Diag-nosis of an
adjustment disorder may be a particular problem among refugee populations.
These groups have undergone distressing ex-periences, but their intensively
challenged coping styles may be unknown to caregivers in the host country
(Beiser, 1996).
The current configuration of the personality
disorders has re-ceived substantial cross-cultural challenge. Even the basic con-cept
of personality as a set of individual internal traits is con-sidered
inseparable from the Western cultural assumptions on individuality by many
authors (Lewis-Fernández and Kleinman, 1993). Difficulties in the reliable
assessment of these disorders within the Western cultures may be due to the
degree to which these conditions are determined by social and contextual
factors. These factors include adaptational strategies toward adverse com-munal
environments (including the relative value of aggression or avoidance),
family-based customs and traditions, occupational and educational options and
cultural methods of child-rearing (Alarcón and Foulks, 1997). It is striking,
for example, that the antisocial personality disorder is nearly absent among
the Hut-terites, an ethnoreligious enclave living for more than a century in
the USA and Canada (Favazza, 1985). Intracultural diversity may be more
important in this respect than cross-cultural differ-ence. For example, in his
studies of affective and personality dis-turbances among the Inuit and the
Yoruba, Leighton (1981) was unable to disentangle cultural influences from “the
much more powerful effects’’ of gender, age and class.
Epidemiological assessment of DSM-III antisocial
perso-nality disorder has been performed as part of the Epidemiological
Catchment Area study using a clearly operationalized survey instrument, the
Diagnostic Interview Schedule (Robins et
al., 1984). This yielded similar prevalence rates in the USA and Puerto
Rico (Canino et al., 1987). However,
low reliability rates for the diagnosis of personality disorders across
standardized instruments raise serious doubts about the validity of this aspect
of the Epidemiological Catchment Area study data (Perry, 1992). One World
Health Organization study was able to identify cases of most of the International Classifi cation of Diseases personality disorders
in 15 urban clinic samples in Africa, Asia, North America and Europe (Paris,
1991), but the cross-cultural validity of the definitions of these categories
had been criticized earlier by Shepherd and Sartorius (1974)
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