Psychiatric Times. On DSM-5
The Cultural Dimension in DSM-5: PTSD
By James Phillips, MD | August 15, 2010 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 twofacts. 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 Proposedby 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.3-6Although 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 andcolleagues 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 andcountless 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 ñakary) do not translate readily into Western categories.7-8 Pedersen and colleagues concludethat 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
Psychiatric Times. Vol. No. August 15, 2010 of traumatic experiences found in the discourse of survivors.”9, p 214 Where does this leave us with DSM-5? Inthe 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...