Cultural Biases Surrounding the Diagnoses of Mental Illness

Introduction: 

Being biased is a part of human nature. Humans have shown biases throughout history with the creation of distinct stereotypes and reputations for groups of people. Biases in a society can be considered a part of the functioning of that society, until it negatively affects the health and well-being of the individual. Not only recognizing, but also terminating biases is one of the most prominent issues in the field of medicine. How can a medical professional give a proper diagnosis based on the patient if they maintain their personal biases towards the patient’s race, ethnicity, cultural group, or economic standing? It is the biases of the medical professional that contribute to an unjust health system that lacks holistic understanding of the patient. In order to remove these biases when stepping into a medical building, a medical professional must not only recognize the unique background of a patient, but must also determine what biases they as an individual have towards any aspects of that background. 

Globalization has resulted in the rapid integration among people, businesses, and societies [1]. That said, it has also led to cultural and ethnic tensions among groups [2]. Culture highly influences the way in which a society and the individual functions. Unfortunately, a negative aspect of globalization has been a major source of unfair stereotypes about various groups of people [3]. In some situations, stereotypes are false judgments that can hurt an individual's sense of identity and negatively impact the functioning of the society as a whole[4]. Stereotypes result in a range of biases that influence the diagnosis and treatment of individuals across cultures in a variety of medical settings such as hospitals, doctor’s offices, and psychiatric wards [5]. Despite the universal symptoms that result from the suffering of mental illness, there are significant differences amongst cultures that Western diagnostic models do not take into account. In this article, the influence of culture, race, and socioeconomic status on the diagnosis and treatment of mental illness will be thoroughly contemplated and discussed. 

Progression of Diagnostic Methods 

20th Century Diagnostic Methods 

Before the 20th century, mental illness was believed to have supernatural causes [6]. It was not until the beginning of the 20th century that a more comprehensive understanding of mental illness emerged, specifically through the psychodynamic theory established by Sigmund Freud and the theory of behaviorism by John B. Watson [6]. Freud’s psychodynamic theory focused on the unconscious mind rather than the conscious mind [7]. Freud believed that everyone possessed repressed emotions and memories, and that with the use of psychoanalysis, these could be brought to the surface of the conscious mind in order to bring about healing[7]. Unfortunately, there were some issues with this theory. First, it was not a universally used approach, but rather, it predominated in Western cultures. Lastly, the approach overemphasized biology, and failed to recognize the influence of the conscious mind [8]. In comparison, Watson’s theory of behaviorism suggested that all behaviors were learned through conditioning, as a result of interactions with a person’s environment [9]. An issue with this approach is that it only recognized the environment and the patient’s experience as a contribution to mental illness and failed to address potential biological factors [9]. With both theories, there was a lack of a proper method to lead to a diagnosis [10]. Instead, both of these methods were geared towards therapeutic practices, and the goal of healing [6]. 

Beginning in the 1950s Western psychiatrists began diagnosing mental disorders as “diagnostic entities” based on a medical model [10]. According to this medical model, the diagnostic entity, which can be a disease, syndrome, or disorder, has three parts: “an etiological agent, a pathological process, and symptoms and signs” [10]. In other words, it had a cause, an effect, and evidence that revealed its existence. Compared to the psychoanalytic approach, the medical model consisted of multiple measures, increasing the validity of the assessment. In addition to the wide use of this model, the World Health Organization (WHO) worked towards the publication of a diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, that could be used by medical professionals universally [10]. 

Modern Diagnostic Methods

In Western societies, most diagnostic models are based on the medical model, which has been developed by various organizations and research institutions, such as The Mayo Clinic. The Mayo Clinic states that the process of a psychiatric diagnosis begins with a physical examination, a laboratory test, and a psychological evaluation [12]. First, a medical professional conducts a physical examination. Following which, laboratory testing is conducted to determine drug/alcohol use and hormonal issues. Lastly, a medical examiner carries out a psychological assessment through the thorough observation of a patients’ behaviors, thoughts, actions, and symptoms [12]. Additionally, today, the DSM-5, is the standard by which mental health diagnoses are made. This manual contains descriptions of symptoms and standard criteria for making a diagnosis of mental illnesses [13]. It should be noted, however, that medical and psychiatric diagnoses are different in many ways. Medical professionals focus on a person’s description of their symptoms, observation, and past family history [14] In comparison, psychiatric diagnoses are evaluated based on these descriptions with the addition of past experiences, biological markers, as well as brain scans [15]. However, in some cases, there is an overreliance on the method of solely considering the physical examination, description of symptoms, and laboratory examinations alone [16]. In addition to these examinations, culture, as well as epigenetics need to be given a greater emphasis [17].

Diagnosis of Personality Disorders

Although there are various models for classifying personality disorders, there is one common theme amongst most models: they all hold the idea that the way people experience mental illnesses is similar across all cultures. Mental illness is still deemed an illness and thus holds a similar standard to diagnosing physical illnesses. However, unlike physical illnesses, the way in which mental illnesses are experienced across cultures is not universal. 

The general approach for diagnosing personality disorders as included in the DSM-5 is known as the categorical approach [20]. The most widely used personality disorder categorical model, the typological model, has established the idea that mental illnesses are clinical illnesses that can be diagnosed and treated similarly to physical illnesses. This model describes each illness as having specific symptoms and essential treatment. The typological model is commonly used by psychiatrists due to its simplicity, its attempts at being a universal diagnostic system, and its formation of concrete, understandable diagnoses for mental illnesses [21]. These systems are extremely important for the following reasons: access to care, access to funding, continuity of care, documentation of process, and collaboration. This model suggests that there are universal symptoms, means of diagnosis, and treatments that can be used across all cultures [21]. What this model fails to recognize is that different patients have different needs, and each patient must be treated as an individual. Additionally, the typological model restricts diagnosis to just one illness at a time. However, this means of diagnosis should not be considered universal, because it attempts to use a model of diagnosis that was made specifically for Western societies and applies it to other cultures [21]. 

Although there have been developments in psychiatric diagnostic methods, specifically the greater consideration of all criteria, a common misconception still exists that diagnosing mental illness is solely driven by biology. Family history and genetics may play a part in some cases, but there is no reliable way to distinguish a mental illness by only observing genetic markers or chemical imbalances [5]. Moreover, there is no known biological marker that is only used for the identification of mental disorders [10]. In addition to biological and genetic factors, a patient’s environment and traumatic events can heavily influence one’s susceptibility to developing mental illness. For these reasons, when making a valid and reliable diagnosis, a psychiatrist must use all relevant data and information. This includes, but is not limited to: psychological testing, epigenetics, the patient’s clinical picture, culture, and family information. 

As mentioned before, in the category of criterion validity, there is an absence of a universal biological marker that is used by medical professionals to make a diagnosis [10]. This is known as a gold standard, which can be used by psychiatrists as a basis for diagnosis, since it would include all the validity criteria known [10]. In summary, researchers believe that biological markers should be used in conjunction with other methods in the diagnostic process. Additionally, an issue arises when medical professionals restrict their use of external validators, or “elements external to the disease definitions'' to biological markers [10]. Besides biological markers, brain structures and function may need to be studied at the molecular level by utilizing modern-day brain imaging techniques [11]. Although these are new techniques, they provide an extra validator for the identification of a mental illness.

Racial, Socioeconomic, and Cultural Influences 

Systems of psychiatric diagnosis and treatment across different cultures have resulted in varied biases ranging from racial to cultural. In addition, the disregard for the differences in how people of different races, economic standings, and cultures report symptoms and what symptoms they report is a bias within itself. Overall, the unintentional, or, in some cases, intentional, stereotypes of different races, ethnicities, and cultures assumed by medical practitioners, must be taken into consideration. 

Culture, a group that shares beliefs, norms, or values, can influence the meaning of mental illness, where or how cultural groups seek help, coping styles, and the stigma surrounding mental illness in a culture. Despite varying systems of mental health diagnosis and treatment across cultures, one thing remains universal: the symptoms. For example, across the world bipolar disorder and depression, and other mood disorders have similar symptoms. However, the observance of symptoms should not be the only consideration when making a diagnosis--there needs to be a greater consideration for the individual's background and the patient’s cultural context [10]. 

Cultural differences must be recognized due to the unique way a patient describes their symptoms. A specific example is demonstrated in Asian cultures recognized by the differences in the symptoms of somatization [22]. This is where physical ailments are used to explain psychosomatic disease [23]. Overall, Asian patients are more likely to report their physical symptoms rather than emotional symptoms. This is due to the fact that Asian patients are more likely to deny their psychological symptoms and express physical symptoms due to the family structure and stigma surrounding mental illness in Asian societies [5]. For example, China is a collectivist culture, where the group is valued over the individual. Due to this value, most people who deal with mental distress typically don’t seek help due to the “shame” it would bring to their family or relationship [24]. For example, those with schizophrenia in China are often shunned by their families [5].

In India, an East Asian country, there is a similar syndrome to somatization, known as Dhat Syndrome.Although the cultural background of the patient needs to be taken into higher consideration when making a proper diagnosis, an exception occurs within the idea of culture-bound syndromes, which are illnesses that are restricted to specific cultures. One such example is Dhat syndrome in India, an illness that results from the loss of semen. In many cultures, including Indian, semen is a valuable substance, so the loss of semen can cause severe anxiety and distress as well as other symptoms such as guilt and a lack of focus [28]. This is an example of a mental disorder that evolved as a result of a physical ailment. 

As discussed earlier in the article, one of the main reasons why biases in Western psychiatric facilities occur is due to the believed-to-be universal medical model of diagnosis. What this model fails to recognize is the differences across cultures. For example, the way patients from different cultures cope and present their symptoms varies immensely. In Thailand, a prominently Buddhist society, controlling your emotions is highly encouraged[25]. This is explained by the concept of karma, which is good or bad intentions that can affect a person’s future life. Bad karma, in Buddhism, can be brought on by many things, one of them being mental illness [25]. 

Similarly, in many African cultures, mental illness is highly stigmatized and viewed negatively. In Uganda, depression was viewed as culturally unacceptable [26]. In Nigeria, a third of Nigerians who responded to a 2002 World Psychiatry study titled “What Causes Stigma?” state that mental illness was caused by drug abuse, divine wrath, and witchcraft [27]. Similar to Asian cultures, people who are diagnosed with mental illness are hidden to prevent them from discrimination. One of the main associations with mental illness in some African societies is its distinct connection to poverty. There is a distinct correlation between people living in poverty and mental illness, making impoverished peoples more susceptible to mental disorders [26]. 

Reparations Being Made

Because of the permanent nature of societal values, some mental health stigmas may continue to exist within societies. Nevertheless, the current system will improve if psychiatric facilities improve the means of diagnoses. This includes a greater emphasis of the criterion discussed in DSM-5, improvements within the training of the clinician, and an exploration of the social-constructionist view. Therefore, it should be the role of the clinician to consider cultural norms and specific cultural experiences of the patient. This can be done by assessing cultural competence in the training of clinicians. 

The fifth edition of the Diagnostic and Statistical Manual, published in 2013, which has specifically placed higher emphasis on the patient’s experiences and background, is a step in the right direction. The new edition of the Diagnostic and Statistical Manual has been highly developed and frequently changed in order to continue its status as a modern diagnostic tool. A new addition to the manual is the wider categories that “capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders.” [13]. In the new edition of DSM, there is a higher emphasis on focusing on the individual’s experiences, specifically their cultures of origin, familial structure, and social lifestyle. The manual even goes as far as to include a section titled “Cultural Formulation” which includes a tool for assessing a patient with the discussion of culture. This section recognizes the stigmas that may result within specific cultures, and how this influences a patient’s coping strategies, and if a patient seeks help [13]. Additionally, the manual includes three distinct concepts that provide a greater basis for making a proper diagnosis: cultural syndrome, cultural idiom of distress, and cultural explanation or perceived cause [29].

Clinicians should place a higher value on communication, understanding the patient’s cultural values and beliefs, and understanding the stereotypes within that society. By utilizing cross-cultural communication, clinicians can have a better understanding of the patient’s cultural influences, and this will build more trust between the patient and the clinician. Additionally, clinicians need to also address their own personal biases before making a diagnosis of a patient in order to eliminate any possibility for misdiagnosis. The problem that arises is due to the existence of implicit biases, or unintentional biases that “exist outside of an individual’s conscious awareness.” [30]. In the medical world, two-thirds of medical professionals hold some form of implicit bias [30]. This causes negative consequences for not only the patient, but the health care world as a whole. An American Psychiatric Association (APA) open forum recommended further research on how inequities propagate bias, as well as the reduction of implicit bias, in order to help medical professionals address their own biases [31]. 

The way in which we can improve the cultural competence of clinicians is by utilizing various assessments and research that draw attention to improvements of the clinician that may result in a better understanding of their own personal biases and the already existing stigmas within cultures. There are many self-assessments that clinicians can take in which they are able to evaluate their cultural competence. For example, the Multicultural Counseling Self Efficacy Scale--Racial Diversity Form is a 60 question self-report instrument that allows clinicians to assess their ability to perform counseling on racially diverse patients [32]. 

Lastly, the social constructionist view can be added to the current diagnosis model in order to further emphasize the influence of external factors on mental illness. This view takes the patient’s culture into consideration. It originated in the 1960s and 1970s and was further developed by researchers, such as sociological thinkers Emile Durkheim, Erving Goffman, and Eliot Freidson [19]. The social constructionist view attempts to remove the ethnocentric bias, a bias that occurs when the “perceptions of others are influenced by the culture of one’s own ethnic group” and focuses on the influence of the external world [33]. This view demonstrates that social constructs influence mental illness [18]. By utilizing the social constructionist view, which emphasizes the influence of external factors, there can be an immense improvement in the diagnosis of patients without the influence of biases.Although this model should not be the sole basis of diagnosing mental illness, as it fails to recognize biological factors, it can be added to current models to increase validity of diagnosis. To review, the medical model assumes diseases are universal across cultures and societies, while the social constructionist view recognizes the influence of culture and social systems on mental illness [19]. Overall, this view recognizes the social and cultural influences on illness. When taken into consideration, a clinician can improve their cultural competency, ideally also improving their diagnostic method as it pertains to mental illness.

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