Is the Manifestation of PTSD a Culture Bound Syndrome?
Danielle Murri
University of Colorado, Colorado Springs
Trauma is an inevitable concept that individuals find themselves familiar with in one way or another during the course of their lives, but the degree to which trauma or traumatic stress shapes someone’s life depends on both biology and culture. When recovery from traumatic events is prolonged more than “normal” and the fight or flight reaction is not turned off even after some time, traumatic stress may turn into posttraumatic stress disorder (PTSD). This paper will discuss the cultural aspects of PTSD, specifically how trauma is viewed and treated in America, and examine the ways the Western world may be creating a culture bound syndrome with the way that trauma is handled.
“Always alert, and forever safe”, this statement by Confucius, is a simple way to explain the suffering of those who have had profound effects from living through a traumatic experience. Trauma, for those affected with PTSD, does not seem as if it is in the past, only a distant memory. The trauma feels real and is repeated, again, and again causing crippling anxiety, fear, and a constant state of fight or flight. As Adam Cash (2006) states,
There is something inherently powerful about the experiences of trauma that somehow encourages us to separate ourselves from it, either through time, distance, or within the recesses of our unconsciousness. Trauma is something that happens to someone else, right? Murder and violence only happen in the bad parts of town. War happens on someone else’s land, in a far-off country, or on the safe technological distance of our television screens. We want to leave it behind. We want to forget about it. This logic makes sense in our day-to-day lives. Our everyday language reflects this desire in our responses to those wounded and stunned around us: “put it behind you”, “try to focus on the future”, “it happened in the past, and there is nothing you can do to change that (p.4).
In the Western world, it is encouraged that individuals “move on” fairly rapidly from traumatic events, however this is not always possible. For some of us, escaping trauma seems impossible with the intense memories, flashbacks, and hauntings of our own minds and bodies. PTSD is the struggle of trying to forget, trying to heal, trying to not live in a state of constant fear. PTSD is ‘a syndrome of reliving or re-experiencing their particular trauma or traumas again and again’ (Cash, 2006, p. 4). PTSD is an adverse reaction to trauma; these horrifying events have impacted an individual so much that their own brain and mind have created an illness.
PTSD is not a new concept. Officially it was introduced to medical records in 1980, but previous to the formal recognition, many individuals felt the heavy symptoms of an anxiety ridden, trauma related disorder. There have been many minor versions of a PTSD diagnosis. Cash (2006), describes these versions as, “a set of symptoms or syndromes identified more with a specific stressor, rather than as a universal syndrome or disorder resulting from a traumatic stressor of any type, given it is of sufficient intensity” (p. 7). Some of these versions were titled, ‘nerve-trauma hypothesis’, ‘trauma neuroses’, ‘shell shock’, ‘battle fatigue’, ‘Post-Vietnam Syndrome’, and ‘Stress Response Syndrome’. None of these versions summed up all of the experiences and symptoms of reactions to trauma until the description of post-traumatic stress disorder. The concept of PTSD has been long tied to those suffering ill effects of war, but with growing professional interest in the disorder, it has been realized that PTSD applies to a much larger group of stimulus or causal events, including rape, natural disasters, automobile accidents, and child sexual abuse. PTSD can happen to anyone, regardless of age.
According to fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic criteria for PTSD includes history of exposure to certain types of traumatic events and symptoms from four symptom clusters categorized as intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. Additional criteria deal with the length that symptoms are present and how an individual is able to function.
The first section of the criteria is in regards to the traumatic stressor. One must have been exposed to death, threatened death, experienced actual or threatened injury, or actual or threatened sexual violence. One must have had direct exposure with one of the above, witnessed it occurring, been affected indirectly by learning a close friend or relative was exposed to trauma or a violent or accidental death, or with repeated exposure to these events: normally in a professional manner (e.g. first responders or military).
The second criteria states that the traumatic event is persistently re-experienced either with dissociative reactions like flashbacks, involuntary, recurrent, intrusive memories, traumatic nightmares, intense distress after reminders of the trauma, or physiologic reactivity after being exposed to trauma related stimuli.
The third criterion requires avoidance of trauma related situations after the event whether they are trauma related thoughts or emotions, or external reminders like situations, activities, items, people, or particular places.
The fourth criteria category requires negative changes in mood or cognition as a result of a traumatic event. This may mean inability to recall certain aspects of the event (not due to drugs, alcohol, or brain injury), negative beliefs of oneself or the world, distorted blame of others or self for causing the event or persisting consequences, negative trauma related emotions, diminished interest in activities previously enjoyed, feeling isolated, or consistent inability to experience positive emotions.
The last significant criteria category refers to alterations in arousal and reactivity. These alterations must have begun after the traumatic event or have worsened significantly. Alterations may be aggressiveness or irritability, recklessness or self-destructive behaviors, hyper vigilance, exaggerated startle response, problems concentrating, or changes in sleep patterns. The final criterion are involved in monitoring how long symptoms persist, as they must be present for longer than one month for an official diagnosis; and how impaired an individual is due to symptoms, whether socially, academically, or in their occupation. (American Psychiatric Association, 2013).
As seen in the description of PTSD by the DSM-5, this disorder is an illness that affects individuals socially. Gilbert Reyes (2008) states,
Perhaps more than most mental diagnoses, posttraumatic stress disorder represents a complex code of social and contextual values and expectations regarding the ways in which people are likely to be affected by their experiences and how their reactions are commonly expressed.
This complex code that Reyes speaks of, is culturally affected. In analyzing posttraumatic stress disorder, the concept of stress and stressors must be considered, which is dependent on culture. McDade (2002), explains,
Anthropology is marked by a diversity of conceptual and methodological approaches to stress research, with levels of analysis that range from global political economy to local social or ecological disruption, individual mental and physical health, and human physiology, Although the methods and goals of these approaches vary, they all share an interest in the human stress experience across cultures and the specific cultural, ecological, and historical contexts that give it meaning. Of most relevance to the analysis presented here is the work of medical and biological anthropologists who have reposted quantitative associations between exposure to nontraditional, Western ways of living – through migration or local change- and self reported symptoms of physical and emotional distress or physiological measures of stress.
The human stress experience varies and expected levels of emotion to trauma, death, or other significant stressors are heavily dependent on culture. Since PTSD is conceptualized as a disorder formed by fear and stress dysregulation, the question is then, is posttraumatic stress disorder a universal phenomenon due to high levels of trauma, or is it a culture bound syndrome?
A culture bound disorder or syndrome is an illness that is a combination of psychiatric and somatic symptoms that is recognized within a specific culture. Finding just one definition of this concept is difficult, as anthropologists and psychologists will not agree completely. According to the American Psychiatric Association, “The term culture-bound syndrome denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be "illnesses," or at least afflictions, and most have local names. Although presentations conforming to the major DSM-IV categories can be found throughout the world, the particular symptoms, course, and social response are very often influenced by local cultural factors. In contrast, culture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations.”
There is considerable debate as to whether PTSD should be considered a Western-linked culturally bound syndrome or if it is a universal reaction. Hinton and Lewis-Fernandez (2010) approached the DSM-5 with questions regarding the cross-cultural validity of posttraumatic stress disorder. In their study, the validity of the DSM-5 was examined when it was applied to traumatized members of culturally diverse groups. The researchers sought to answer questions like, “Does PTSD as currently defined apply equally well across cultures? Is it found with equivalent frequency? Do the symptoms that currently compose the syndrome cluster together in the same way? Or, instead, do cultural factors pattern alternate presentations of PTSD?
In the study, both biological and cultural factors were examined in regards to the development of PTSD. The main biological factor examined was that of biomarkers. A biomarker is a characteristic that is measured and evaluated objectively as an indicator of a biological state, including pathological conditions such as PTSD. Possible biomarkers for PTSD are startle responses, exaggerated physiological reactivity, and MAO-B platelet activity. Cultural factors examined were severity of trauma, as multiple studies in various countries and ethnic groups have indicated that the severity of a trauma can predict the severity of PTSD, rate of trauma, and the global presence/probability of PTSD after trauma.
The researchers found that the DSM-5 for PTSD is valid cross-culturally. They do stipulate their findings with this statement,
The review suggests that cultural syndromes may shape symptom comorbidities and symptom profiles in important ways that should be assessed and documented to increase content validity in the assessment of trauma-related disorder. Assessing patients for somatic symptoms and cultural syndromes may also be needed to better attain content validity when PTSD is evaluated cross-culturally. A chapter on cultural aspects of psychiatric diagnoses and/or an expanded Glossary of Cultural Syndromes that describe the relationship of specific syndromes and DSM-5 disorders would help to address this issue (Hinton and Lewis-Fernandez, 2010).
Another study of the cultural aspects of PTSD proposed that the concept and definition of culture should be presented as a foundation for understanding the many influences cultural factors have on the perception, experience, clinical expression, treatment responses to trauma. Marsella (2010) calls attention to ‘healing principles’ used by the Western world as well as more traditional approaches, and emphasizes the importance of ethnocultural variables. He states, “…in spite of what appears to be common neurological processes, correlates, and consequences in the initial response to trauma exposure, ethnocultural variables exercise major influence on perceived causes, symptom manifestations, clinical parameters (i.e., onset, course, and outcome), interventions, and societal responses.”
Marsella discusses the history of PTSD, specifically among veterans, and the questions that arose with the early ‘existence’ of the anxiety bound illness. He mentions the inevitable questions that arose about the etiology, diagnosis, expression, and treatment of stress disorders, but many of these questions were ignored, because trauma and the reaction to it were assumed to be universal to all humans. In the beginning it was assumed that the human neurological response to traumatic events affected the brain’s emotional centers; specifically the hypothalamus-pituitary-adrenal axis, the amygdala, and endocrine areas. Eventually, research showed activity in the central nervous system and long-term biological consequences of severe trauma. Some of these consequences were lowered thresholds for anxiety, atrophy of the hippocampus, and atrophy of the cingulate cortex. As more research was established variations in traumatic related consequences began to arise. The idea that PTSD could be culturally variable was not widely accepted (Marsalla, 2010).
The reason culture variability was not widely accepted was because it challenged biological assumptions of psychiatric disorders and challenged ideas about the universal human experience of trauma and trauma reactions.
If ethnocultural variations in trauma and PTSD existed, this would call attention to the plasticity of the human mind and brain, especially the role of cultural factors in causing and shaping disorders and diseases. This relativity would contradict the ‘disease’ model of psychiatry... (Marsalla, 2010).
Summerfield (1999) challenged the Western assumptions about trauma and PTSD. He believed that the codified description of PTSD was wrongly being prescribed to non-Western settings, specifically after natural and man-made disasters. He, along with others challenged the normally regularly accepted concepts of the Western diagnosis of PTSD. Bracken, Giller, and Summerfield (1997) wrote:
Trauma projects which seek to objectify “suffering” as an entity apart, converting it into a technical problem to which are applied technical solutions like Western talk therapies, are discounting indigenous knowledge, capacities, and priorities. Such projects aggrandize the Western expert who defines the problem (e.g., PTSD) and brings the cure; too often it is the same problem and the same cure, whether to Cambodia, Rwanda, or elsewhere.
Resistance to the previously accepted notions that psychiatric disorders were affected by biology and not culture began to grow, and the idea that PTSD might be a culture bound disorder has grown. Suffering is clearly present in other cultures, as are emotional reactions to traumatic experiences. Marsalla previously studied prevalence rates of PTSD in other cultures in 1996 with a team of researchers. He found that prevalence rates of PTSD varied widely between cultures and that the diagnostic criteria being used at the time was not sufficiently sensitive to cultural aspects of health and could not then detect PTSD in other cultures, as it may be manifested differently. Findings from Marsalla’s studies were that some re-experiencing and arousal symptoms were more easily identified in some cultures than the avoidance and numbing systems, indicating that the experience of PTSD involves both culture bound aspects, universal aspects, and a relationship between biological and cultural influences. He also proposed that symptoms described as arousal or re-experiencing symptoms tended to have a greater biological basis with changes noted in brain function, and avoidance and numbing symptoms seem to have a significant cultural influence. Marsalla and his team concluded that “the prevalence of PTSD is highest among cultures in which avoidance and numbing are common methods of dealing with distress” (Reyes, 2008).
There are some known illnesses that resemble the Western definition of PTSD in a different cultural context. Reyes (2008) describes a disorder called Latah. Latah is seen in Malaysia and Indonesia as a condition of distress after someone is startled. A startling trigger causes a half hour display of hysterical laughter, shouted cursing, screaming, and even dancing. The outbursts are described as unpleasant for the sufferer, but the community often finds the outbursts entertaining. This cultural expression of distress is not associated with a single traumatic event causing distress like a death of a child. Reyes also describes distress disorders seen in Latin America. The concepts of Ataque de nervios and Nervios are states of vulnerability in response to a stressful life experience. Symptoms can include uncontrollable shouting, fits of crying and trembling, verbal or physical aggrestion, emotional distress, headaches, irritability, stomach disturbances, sleep disturbances, nervousness, emotional instability, and diminished concentration (Schepher Hughes 1994). Similar symptoms have been described in Greece in a disorder called nevra. Another distress disorder reported among Latinos is susto. Susto is known as soul loss due to traumatic events, which leads to symptoms of unhappiness and sickness.
The symptoms of suffering are universal and when seen in other cultures may be called a distress disorder, but many of the cultures examining the symptoms just see them as a natural reaction to trauma. In the Western world of medicine, it is categorized and stigmatized as an illness, instead of an extreme reaction to an extreme event. For this reason as well as others, I believe a diagnosis of PTSD, and the current treatment model of antidepressants and talk therapy is a culture bound syndrome. The symptoms may be universal and biologically marked, but the consideration of these symptoms as a disorder, and the treatment of a traumatized individual varies dramatically within cultures.
Since the professional interest of PTSD is has continued to rise, researchers have continued to challenge preconceived ideas of universal causes, manifestations, and treatment responses and have started to note that exposure to traumatic events might actually result in improved mental status for some trauma survivors. This phenomenon is called “post-traumatic growth” (PTG). PTG is the belief that a crisis might also be an opportunity since endurance and courage in the face of adversity and extreme stress is admirable and valued. Additional research about PTSD, and its relationship to culture is still ongoing, so it cannot be conclusively said that PTSD is a culturally bound syndrome, however there is a question that needs to be considered. Can any psychological illness escape cultural influence? No, it cannot.
While there may be epigenetic factors contributing to the risk factors of developing PTSD, it is likely that culture has a heavier influence on how an individual reacts to a traumatic situation. It has not been conclusively verified that all cultures experience all symptoms of PTSD, indicating that it may be extremely cultural based with some biological backbone, or a culture bound syndrome. As Schepher Hughes (1994) states,
From the phenomenological oriented perspective of some medical anthropologists (concerned with the “lived-in” sense of illness), pain, disability, and other forms of human suffering are habituated bodily expressions of dynamic social relations. Sickness is more than just an unfortunate brush with nature. It is more than something that “just happens” to people. Sickness is something that humans do in uniquely original and creative ways. Illness is a form of body praxis, of bodily action.
The idea of illness, and PTSD being a form of body praxis is important in realizing that PTSD may be a Western culturally bound syndrome. The medical anthropology perspective of a body is that it is representative of an individual (self), social, and political aspects that are not separate but rather intertwined. This anthropological body feels cultural pressures to either express or hide emotion, and in my opinion, I believe trauma related emotions are encouraged in the Western culture to be suppressed, causing psychological distress, and the criteria necessary for the arbitrary diagnosis of PTSD. PTSD is a conceptualization of a distress reaction, just like the concepts of nervios, sustos, and latah. These cultural reactions to trauma are viewed as culture-bound syndromes, just as the manifestation of PTSD in Western culture should be viewed as one.
There are significant differences in the ways in which trauma is viewed and handled cross culturally ,especially in regard to the expectations of reactions and emotions following trauma which can contribute to the severity of expression as well as which symptoms are expressed. I believe that the cultural pressures in America to not slow down and experience things, but rather hide pain and discomfort, as well as admit that suffering is part of the human experience, has contributed significantly to the formation of PTSD as a culture bound illness. As research on PTSD and treatment types continues to progress, I hope the current views on trauma and ‘normal’ reactions to trauma adapt. Traumatic experiences reap traumatic outcomes and emotions. These emotions and outcomes do not need to be stigmatized, diagnosed as an illness, and medicated, but rather accepted as unpleasant suffering due to unpleasant events, and an unfortunate part of the human experience.
References
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