Dissociative Disorders - Cultural Aspects of Psychiatric Disorders

Dissociative Disorders

Syndromes characterized by pathological dissociation are common worldwide, but the current concepts of dissociative disorders do not appear to account for their phenomenological variety (Lewis-Fernández, 1992; González et al., 1997). For example, a study performed in an outpatient psychiatric clinic in India found that more than 90% of dissociative disorder cases did not fulfill criteria for the specified categories, ironically receiving instead a DSM-III diagnosis of atypical dissociative disorder. Distressing trance states and possession trance episodes constituted most of these cases (Saxena and Prasad, 1989). These instances of misdiagnosis again call to question the usefulness of some of the standard diagnostic categories of North American psychiatry (Kirmayer and Groleau, 2001). Many indigenous illness syndromes around the world display salient features of pathological dissociation. Some of these syndromes are characterized by involuntary possession trance – dissociative alterations in identity attributed to the invasion by external spirits or agents – distinguished from dissociative identity disorder by their episodic and remitting course, the nature and number of their alternative identities and their gradual response to treatment. These syndromes have been identified in India, western Africa, China, Malaysia, Brazil and the Caribbean, among many other settings (Lewis-Fernández, 1994; Ward, 1989; Spiegel and Cardeña, 1991).

Other dissociative syndromes are characterized by alterations of consciousness and memory, during which the person runs around in an agitated state (Arctic pibloktoq); attacks others indiscriminately (Malayo-Indonesian amok); undergoes convulsive movements, screaming fits and aggressive acts toward self or others (Caribbean ataque de nervios); or lies as if dead, suffering from specific perceptual alterations; hears and understands what is happening but cannot see or move (“falling out’’ among the African-Americans in southern USA, Bahamian “blacking out’’, and Haitian indisposition) (González et al., 1997; Cardeña et al., 2002, Weidman, 1979). In a recent study, Lewis-Fernández and colleagues (1997) confirmed the association between ataque de nervios and dissociation. Among the female Puerto Rican psychiatric outpatients, ataque frequency was directly related to self- and clinician-ratings of dissociative symptoms and disorders. Of note, patients with and without ataque did not differ on measures of childhood trauma, which was uniformly high among subjects (Lewis-Fernández et al., 1997). The proposed dissociative trance disorder category in DSM-IV-TR would provide a Western nosological niche for these disorders, although not without the risk of overpathologizing some culturally accepted instances of these behaviors (Lewis-Fernández, 1992).

In fact, extensive cross-cultural research reveals that most dissociative experiences around the world are com-pletely normal, usually forming part of religious and ritual events (Lewis-Fernández, 1994). The Western emphasis on pathological experiences of dissociation that result from over-whelming trauma probably stems from the relative absence of normal dissociation among the dominant Western groups and from the acknowledgment by mental health profession-als of the sequelae of physical and sexual abuse (Ross, 1991; Martínez-Taboas, 1991). Depersonalization, considered one of the most common psychiatric symptoms in the West (Steinberg, 1991), is a greatly desired goal for Hindu yogis, revealing the substantial cultural patterning of dissociative experience (Castillo, 1991).