Segment 3:

Culture-Bound Syndromes

by Rob Kopiec

Part I: Introduction

This next section of my thesis is based on research that I did from June 12th-July 15th 2000. The research that I did was not primarily centered on ADHD, but instead was mainly on the Culture-Bound Syndrome or CBS. All of the literature that I reviewed on the CBS defined the CBS differently. Despite the varying definitions, one definition by Raymond Prince, in his work, “The Concept of Culture-Bound Syndromes: Anorexia Nervosa and Brain-Fag,” incorporates all of the important elements of the different definitions. Prince defines the CBS as “a collection of signs and symptoms, which is not to be found universally in human populations, but is restricted to a particular culture or groups of cultures. Implicit in the notion is the view that cultural factors play an important role in the genesis of the symptom cluster (though cultural factors are not necessarily the only determinants)” (Prince 198).  Prince’s definition incorporates all of the important elements of the different definitions because it discusses the fact that all of the definitions at least partially define the CBS as being something that is influenced by culture. Although Prince’s definition does not discuss the role of biological factors in the genesis of the symptom cluster, biological factors are implied in his allusion to the fact that cultural factors are not solely the determinates. His definition allows for the diversity of the different definitions where those who defined the CBS did not find one main underlying factor to cause the emergence, and instead a combination of biological and cultural factors. Furthermore, the most important aspect of this definition is the fact that the CBS is specific to one culture, which means that any given culture might have a group of behaviors that they diagnose as being abnormal. These behaviors would then be labeled as culture-bound to that particular culture.

There are many different examples of the CBS. Although none of the research that I performed discussed ADHD as being a CBS, I found connections between ADHD and many groups of behaviors that were considered abnormal and labeled as culture-bound. The CBS that I found most similar to ADHD is anorexia nervosa. The reason why I found anorexia nervosa to be most similar to ADHD is because like ADHD, anorexia nervosa is gender specific, and centered on the notion of trying to control one’s environment because of the expectancy in Western culture to be able to control one’s environment. In my research, I learned of many different CBS’s that were in a sense endemic to one particular culture. Anorexia nervosa is the only CBS that I researched that is endemic to Western culture. Since I am going to place ADHD in the category of a CBS which is specific to Western culture, a discussion of a Western CBS is necessary for me to conclude that ADHD is in fact a Western CBS.

Part II: The CBS: Biological ,Cultural, or Both?

In my research on the CBS I found differing opinions on whether CBS’s are the product of something biological or cultural. Most opinions were either that one or the other has a larger influence, and it was rare that one would categorize biology and culture has having an equal influence on the CBS. Every definition included the notion that both biological factors and cultural factors contribute in some fashion to the CBS. The individuals who believe that the CBS is mainly biological criticize the labeling of the CBS, and believe that since the behavior exhibited is due to mainly biological factors, a labeling that incites a strictly cultural origin is a misnomer. On the other hand, individuals who believe in a mainly cultural origin of the CBS are in concordance with the label.

Because of these two belief systems, I enacted a categorization system to describe these varying beliefs. Furthermore, since I found no individual in my research who completely rejected either biological or cultural influences, a classification system was needed so as to not posit any individual falsely into one extreme direction. The classification system is composed of two categories, the culture-bound disease theory, and the culture-bound diagnosis theory. The culture-bound disease theory is the belief that the CBS is a real medical condition (ie., a chemical combination), but the probability of contracting that condition is culturally influenced. The culture-bound diagnosis theory is the belief that the CBS is a real medical condition (i.e., a chemical combination), but the probability of having that condition diagnosed as a CBS is culturally influenced. Importantly, the classification system has loosely bound borders, meaning that individuals may in fact fall into not only one of the categories, but into both of the categories.

Robert A. Hahn, in his work “Culture-bound syndromes unbound,” can be grouped into the category of the culture-bound diagnosis theory. Hahn believes in the influence of biology as well as culture, but he believes that humans are too attached to their culture. He states “Culture is not the only binding principle; body, mind, society and the broader environment also bind…anthropologists claim too much for culture-bound syndromes and too little for the ‘diseases’ staked out by Biomedicine”(Hahn 165). In this discussion, Hahn exposes his deep seeded belief in the medical system. His critique of anthropology is very important because he is using anthropology as an example of a discipline that does not follow the medical model and therefore he believes that its belief system is not valid. As surveyors of culture, Hahn views anthropologists as individuals who do not explore other realms, and therefore are very exclusionary in their belief systems of culture-bound syndromes. Hahn’s use of anthropology as the epitome of what he feels is the incorrect way to diagnose behavior is important because through example, he shows his rejection of the belief in strong cultural influence, and furthermore his main belief that the CBS is an incorrect way in which these patterns of behavior are labeled and described.

In his deconstruction of the CBS and his critique of anthropological cultural labeling, Hahn uses a diagram to dissect how one labels a set of behaviors as being a CBS. In the section of his work “Hypothetical Ethnography of the Diagnosis, Culture-Bound Syndrome,” Hahn draws this diagram. He outlines his theory by stipulating that if one reads the ethnographic sources of how culture-bound syndromes have been diagnosed, then they can begin to see the flaws in the diagnosis. He outlines his “hypothetical ethnography,” by using six steps where the person trained in Western medicine, which he feels is someone who is trained in “psychology, anthropology, and the broader principles and strains of Western culture,” would travel to a foreign place, or an “ethnic” place in the West, and see behaviors that would appear abnormal to them. After staying in the place where the abnormal behavior took place, Hahn states “The observer returns home with his prized possession: a new syndrome which, because it seem to be found only in the cultural setting from which he has returned, is labeled as culture-bound. Culture-bound syndromes are residual categories; they are conditions which do not fit the nosological scheme of Western tradition”(Hahn 166). In this six-step explanation, it is apparent why Hahn falls into the culture-bound diagnosis theory category. He believes that these conditions are real medical conditions, but because the individuals who survey the behavior do not feel that these conditions fit into what has been categorized as biological disorders in Western society, then they are labeling them as being culturally specific conditions whose biological significance is almost completely ignored. Hahn feels that the label of culture-bound is a misnomer because these conditions are not completely cultural conditions, and instead they are mainly biological conditions.

Ivan Karp, in his work, “Deconstructing Culture-Bound Syndromes,” falls into both the category of the culture-bound diagnosis theory and the category of the culture-bound disease theory. Like Hahn, Karp believes that one’s culture causes the labeling of the CBS. In his discussion of the difference between universalists (individuals who argue that CBS’s are not limited to one particular culture), and particularists (individuals who do argue that CBS’s are designated to one particular culture), Karp exposes his belief that one’s particular culture does cause the labeling of the CBS. He states “If anything I favor the particularist position with respect to the impossibility of directly applying diagnostic categories across cultural boundaries”(Karp 221). In this work, Karp is demonstrating that he understands the fact that there are universalities, but that in terms of a specific type of behavior being labeled, he feels that this is relative to particular cultures.

Where Karp differs from Hahn is in the notion of the importance of culture. Both Hahn and Karp believe that individuals are quick to label a pattern of behavior as being culturally abnormal if the behavior exhibited appears foreign to that culture, but unlike Hahn, Karp also falls into the cultural-bound disease theory category because he feels that culture does play a significant role in the emergence of the CBS. This belief is demonstrated in Karp’s deconstruction of the CBS. Unlike Hahn, he does not deconstruct the CBS because he believes that culture does not play a large role in the emergence of the CBS, on the contrary, he feels that culture is the main factor that causes the emergence, and because of this fact he believes that “[t] here may be such things as culture-bound syndromes. The existing literature, however, makes a better case for the existence of local idioms in which universal syndromes are interpreted and manifested”(Karp 222). This discussion by Karp demonstrates the fact that he does believe in the CBS. He believes that there are groups of behavior patterns that are caused by culture, but the problem arises when one assesses the diagnosed culture-bound syndromes because he feels most of these diagnosed syndromes are not endemic to one culture. Karp does believe that there are syndromes that are endemic to one culture, but many of the CBS’s are diagnoses of universal behavior. Although he is rejecting current labeling of the CBS, he believes in the notion of a CBS, and feels that it is a real medical condition whose emergence is caused by culture.

Part III: No Concrete Definition of the Culture-Bound Syndrome.

Therefore Anorexia Nervosa and ADHD, Culture-Bound?

It is difficult to know exactly what patterns of behavior have been labeled as culture-bound due to the fact that the Culture-Bound Syndrome is not a definition found in the Western medical community. Instead, “[w]ithin medicine, cultural and social factors are generally thought to influence the frequency of disease rather than disease syndromes themselves”(Prince 197). In this discussion Prince demonstrates that the allusion of the culture-bound syndrome exists in the medical community, but the acceptance does not exist. His discussion on how the medical community recognizes cultural influences that affect the frequency of the cases, proposes a very important question that arises when one is studying anorexia-nervosa. The question is whether this type of behavior pattern that is considered a dysfunction in many Western cultures, is considered something entirely different in other cultures, and therefore anorexia nervosa exists around the world, but is prevalent in Western cultures because of certain Western cultural factors.

Due to the fact that there is no concrete definition of the culture-bound syndrome in Western medicine, then what is defined as culture-bound can also be subjective. Prince discusses the fact that anorexia nervosa has in fact never been labeled as culture-bound. He states “Anorexia nervosa is not to be found in the usual lists of CBS’s, though cultural and social factors are sometimes noted in medical reports”(Prince 199). Prince’s discussion on the Western medical communities’ acknowledgement of possible cultural and social factors is important because he is setting up the subjectivity involved with defining what is culture-bound. There have been varying definitions of the CBS because of the fact that there is not a written concrete definition in the medical community. Because of this subjectivity what falls under the category of a CBS can in fact vary.

After Prince explains that anorexia nervosa has never been labeled as a culture-bound syndrome because it was viewed as being only a psychiatric syndrome, Prince demonstrates the fact that anorexia nervosa is definitely a culture-bound syndrome. He states “But, if we put such biases aside, it is clear that anorexia nervosa is the CBS which is most understandable to a Western audience”(Prince 199). Prince’s discussion helps reiterate the possibility that ADHD can be placed in the category of culture-bound syndromes. Although there might be oppositions to this categorization, I feel that both anorexia nervosa and ADHD are similar in that they are culture-bound syndromes because they are seen as deviating from the supposed cultural “norm.” Furthermore, aspects in Western culture mainly cause this deviation.

The social “norms” of modern Western culture are not solely centered on one’s behavior. Instead, there are other elements which are deemed important to Western culture, and furthermore also have a strict structure. One of these elements is appearance. More specifically Western culture is very concerned with female appearance.  In fact “[a]s Westerners, we all experience first hand the powerful anorexic influences that are currently playing upon us, particularly upon the Western female. The slim, youthful body is beautiful and healthy: the fat person is slovenly, ugly, prone to disease and lacks self discipline”(Prince 199). The truth remains that in Western society feminine slimness is sought after, and in a sense demanded. Where anorexia nervosa becomes most apparent is in the notion of “self-discipline.” Some women see anorexia nervosa as a way in which they can become slim, and furthermore have this “self-discipline” by asserting control over their body and their environment. Not all women desire to be a Playboy model, or have the “ideal” feminine Western frame, but all women as well as men want to have control over their body and environment, and for women, sometimes anorexia nervosa is a way in which they feel they can assert this control. Women do not willfully choose this controlling mechanism, but the fact remains that this mechanism is a product of Western society that promises a false type of control, and takes control of many female individuals who feel that they do not have this “self-discipline.”

Susan Bordo, in her work “Anorexia Nervosa: Psychopathology as the Crystallization of Culture,” discusses the notion that anorexia nervosa is used as a means of controlling one’s body. She states that anorectics “put…emphasis on control: on feeling their life to be fundamentally out of control, and on the feeling of accomplishment derived from the total mastery of the body”(Bordo 236). Being able to control one’s environment is something that is very important in Western society. Many individuals find themselves in the situation where they feel that they do not fit a certain standard that is set by society. In order to reach such a standard, they feel they have to somehow improve themselves in order to meet such a requirement. In Western culture, for women, looking slim is something that is desired and believed to be the cultural norm. When someone does not fit the supposed correct standards, then many times they will try and attain what is deemed normal and correct by society.

The question of whether anorexia nervosa is in fact endemic to Western society can be seen in the fact that countries which are becoming westernized are beginning to show signs of anorexia nervosa. In fact “[i]t has however been reported as quite frequent in contemporary Japan and may occur in other rapidly Westernizing countries”(Prince 199). The fact that in Westernizing countries like Japan there have been reported cases of anorexia nervosa demonstrates that this disease may be endemic to Western cultures. In a sense with Westernization non-Western nations that are becoming Westernized are experiencing elements that they never experienced before. In these Westernizing countries the desire to control one’s body is beginning to emerge. Furthermore, the ideal feminine slender body is sought after. This notion is extremely interesting because it asks the question of whether Westernization will also produce ADHD in other cultures. One has to ask whether these cultures that are adopting certain aspects of Western culture that either form ADHD or increase the frequency of these ‘societal dysfunctions.’

Part IV: The Historical Shift in Western Education Beliefs in Deviance:

The Culture-Bound Birth of Learning Disabilities?

One of the fundamentally important aspects of Western society is education. Within the importance placed on education has been the historical question of how to treat the children who disrupt the class, and behave in a fashion outside of the “cultural norms.” From the mid-eighteenth century to the end of the nineteenth century, the Western educational system sought to answer this question with a shift in definitions. Now “[w]hat was thought at the beginning of this period to represent explicit and willful recalcitrance on the part of individuals requiring coercive punishment, came to be viewed as implicit and unintentional behavior requiring therapy of one sort or another. What was once characterized as criminal, came to be seen as illness”(Franklin xii). During this shift, a modern Western thought process emerged because now the cry to categorize individuals behaving outside of the “societal norm” as no longer being deviant, but sick, emerged. Now a label not of deviance was enacted, but instead a label of mental illness or dysfunction was enacted.

The historical shift in Western education’s system of beliefs demonstrates the emergence of the learning disability as culture-bound where biological factors as well as cultural factors contribute to the emergence and formation of the disability. In fact “[t]he phenomena that we refer to as ‘learning disabilities’ are derived partially from our own culture, which places so much emphasis on learning academic skills. In a different society, where ‘success’ depends less on the ability to make one’s way through school, such a phenomena may be unknown or unimportant”(Haring 3). The emphasis placed in modern day Western society on the acquisition of academic skills has in fact been part of the reason why learning disabilities such as Attention Deficit Hyperactivity Disorder have emerged. The shift in the mid-eighteenth century was not a shift causing the emergence of the genetic behavior, that behavior existed prior to the shift, but was labeled as deviance. Instead, the shift caused the disorder or disability to emerge. The shift caused the culture-bound disorder to emerge where the genetic behavior was always present, but the disorder was now culturally constructed.

Regardless of whether someone believes that ADHD is strictly genetic, strictly cultural, or both, many individuals conclude that the disorder is at least partially culturally constructed. This notion can be seen through example. In the preface to his work Driven to Distraction, Edward M. Hallowell, M.D. describes his feelings on ADHD. The preface discusses his personal battle with ADHD, and how when he first found out that there was a label for his “abnormal” behavior, he was overjoyed because he found out that his wandering mind was not a form of deviance, but was a true medical condition that other people also had. Although Hallowell is under the firm belief that ADHD is a genetic medical condition, he still disagrees with the label. He states “I don’t like the term ‘attention deficit disorder,’ although it sure beats its predecessor, minimal brain dysfunction….It is an imperfect label for many reasons…Although ADD can generate a host of problems, there are also advantages to having it, advantages …such as high energy…[that] are completely overlooked by the ‘disorder’ model”(Hallowell x-xi). Hallowell’s discussion on ADD (he says he uses the term ADD because the hyperactivity is implied) is very important for many reasons. Like I felt when I first learned of the label, Hallowell describes his happiness when he first learned that there was a category for his behavior. Even more importantly, Hallowell’s discussion also shows a shift similar to mine, when he realized that the label was anything but empowering, and instead was very debilitating because the construction of the disorder does not allow for the positives of the genetic behavior to be seen. Instead, all that is seen is an  “abnormal” individual with a disorder.

Updated by Jeff Tobin on 08/22/05