CERTAIN MEN in Malaysia are driven by a fear that their genitals could retract up into their bodies. They even believe that the perceived condition, called koro, can be deadly. To prevent it, the men apply weights to their penises or take other extreme measures. The fear, and the uncomfortable antidote, is not common, yet it is accepted in this long-standing culture. But in a Western country, an adult male who acted on such a belief would certainly be labeled as emotionally disturbed.

This contradictory assessment and many others that arise between distant cultures put in sharp relief a strongly influential yet rarely discussed fact of psychology: cultural norms and values determine which behaviors are socially acceptable. In setting these standards, each society determines which mind-sets and actions may constitute a psychological disorder. And societies do not necessarily agree.

[break] Cult of Thinness

Ethnologists have described a wide variety of culturally dependent syndromes, many of which can be categorized as anxiety or compulsive disorders. Whereas koro seems psychotic to Westerners, Malaysians would most likely find very strange the American “cult of thinness” that seems to underlie a personality disorder that prompts women to deprive themselves of food.

Some basic behavioral symptoms could be considered central to any kind of personality disorder, regardless of culture: Does an individual exhibit self-destructive behavior? Are symptoms intense and long-lasting? The real signature of a personality disorder, however, is a steady, long-held belief that makes it difficult for an individual to maintain his or her emotions, thoughts or actions at a socially acceptable level.

But what constitutes “socially acceptable”? In some Central and South American native tribes, adolescents cut their arms and wrists with sharp blades—an ancient initiation rite that leaves scars that mark them as members of the adult community. Though perfectly normal along the Amazon River, “cutting” in the U.S. has been established as a “personality disorder”—a pattern of emotional instability in relationships, self-image and mood that is marked by impulsiveness. Less exotic, local peculiarities can complicate the assessment of personality disorders, too. Taken out of their cultural contexts, the narcissism of the “Latin lover,” the fanatical work hours of the Japanese businessman, and the screaming hysteria of British pop music fans at a live concert could all be taken as signs of trouble.

Researchers around the world have at times attempted to classify disorders and criteria to determine their diagnosis. Two resulting compendiums are now widely consulted: the International Classification of Diseases and Related Health Problems, published by the World Health Organization, now in its 10th edition, and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, its most recent revised fourth edition released in 2000. The ICD-10 and DSM-IV-TR are far-reaching, yet even they do not satisfactorily take into account the diversity of the world's societies.

A few specialists known as cultural relativists are trying to fill the void by expanding the relatively new field of “transcultural psychiatry.” Their efforts to organize the multiculturalism of mental illness will have to overcome the prevailing universalist perspective of traditional psychology: a patient's culture does not play a major role in the development of psychological disorders. In this view, fundamental illnesses are the same the world over and vary only in how frequently they occur in a given culture.

By publishing its huge reference volume, the World Health Organization seems to share this assumption. Experts such as Cornell University psychiatrist Armand W. Loranger, who have tested the DSM-IV-TR and ICD-10 criteria by interviewing patients from varied international backgrounds, have also concluded that cultural traits hardly play a role.

Yet one line of questioning in Loranger's work revealed that avoidant and borderline personality disorders were not found in patient groups from India and Kenya, respectively, even though these are two of the most common syndromes worldwide. The reason is not clear, but it is possible those from these cultures were loath to admit to symptoms, choosing instead to answer the related questions in what they thought was a socially acceptable way. This tendency could explain why a study by psychiatrist Wilson M. Compton of the National Institute on Drug Abuse showed a lower occurrence of antisocial personality disorders among Taiwanese patients than among Western ones. Compton found that politeness and passivity are highly regarded in the Far East and that the Taiwanese would rather not mention contrary impulses.

[break] False Diagnosis

The multitude of differences among cultures clearly shows that mental health professionals are ill advised to apply their classifications of personality disorders to people from other cultures. Chinese doctors have indeed developed their own classification system, and it does not include avoidant or dependent personality disorders. Should conditions such as these, then, be considered normal just because they are prevalent in a society? That could very well be the case. Norms define which types of behavior are acceptable, so if a certain trait is common in a society, then perhaps there is nothing “wrong” with it, regardless of how it might be perceived elsewhere.

According to several studies comparing cultures, personality disorders occur more frequently in industrial countries than in less developed ones, where closer social connections tend to dominate. In large families or village communities, roles are clearly defined and evolve very slowly, if at all. Like a cocoon, the community ensures that no individual experiences isolation or feelings of uselessness. In contrast, life in the modern, developed West is hectic and uncertain. Perhaps personality disorders are one price we pay for individual freedom. A study by Joel Paris of McGill University supports this notion; he found that impulsive and emotionally unstable people—who are more prone to borderline disorders—exhibit clinical symptoms less often in more close-knit cultures.

As globalization steadily spreads, adequate diagnosis of patients from foreign cultures will become a more pressing issue. Therefore, psychologists and psychiatrists will have to become more cosmopolitan in their education; they should possess at least a rudimentary understanding of a patient's culture and language or call on interpreters in their consultations. For example, a Turkish woman new to the U.S. who is suffering from depression would be more likely to complain of pain in various parts of her body rather than expressing feelings of sadness. This tendency toward so-called somatization is common in the Turkish culture yet could lead to a false diagnosis in Boston or Rio de Janeiro.

An understanding of cultural differences is important not only in the diagnosis of mental disorders but also in their treatment. Western-oriented psychotherapy is based on the idea that patients can evolve and are free to determine their own behavior. People from traditional, often highly religious societies are not served as well by such approaches. Their mental well-being stems from fulfilling the expectations of family and community. The goals of therapy for such people must be adjusted to meet their cultural needs.

The question of whether a common multicultural denominator of personality disorders can be expressed remains unanswered. Until that day comes, diagnosis will for the most part remain open to cultural interpretation.