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Three Models of Cultural Concepts of Distress

A Two-Factor Pathogenic-Pathoplastic Model

One way to understand how culture affects mental illness would be to think of the expression of mental illness as the result of two factors: an invariant endogenous factor and a local cultural appearance: ‘pathogenic’ versus ‘patho- plastic’ factors (Birnbaum 1923). The psychiatrist and anthropologist Roland Littlewood stresses the connection between this distinction and the longstanding distinction in psychiatry between the form and content of mental illness.

To deal with variations in the symptoms between individuals, whilst maintaining the idea of a uniform disease, clinical psychiatry still makes a distinction between the essential pathogenic determinants of a mental disorder—those biological processes which are held to be necessary and sufficient to cause it—and the pathoplastic personal and cultural variations in the pattern. Those two are still distinguished in everyday clinical practice by a particularly nineteenth-century German distinction being made between form and content (Littlewood 2002, p. 5).

This distinction needs handling with some care. Littlewood suggests that the pathogenic factor is a necessary and sufficient cause of mental disorder. But the notion of cause suggests a state distinct from the mental disorder it causes. Further, the requirement of a sufficient cause is difficult to attain as causes are only sufficient relative to an assumed causal field (Mackie 1993). The connection to the distinction of form and content suggests a better interpretation is not what causes mental disorder but what constitutes it. The pathogenic factor is then the set of essential properties of disorders, the properties that are necessary and sufficient for a state to count as a disorder. The pathoplastic factor is the contingent variation of inessential properties of the disorder.

Littlewood reports that in the biomedical view of psychiatry, the pathogenic factor is a biological process. In other words, the essential features of mental disorder can be described in biological terms. Such a view fits an influential analysis of mental disorder in general articulated and defended by Jerome Wakefield (Wakefield 1999). According to Wakefield, a disorder is a harmful dysfunction, where function and hence dysfunction is picked out in accordance with evolutionary theory. Evolutionary theory specifies the biological functions of the traits of the human mind and body. Note that the focus on social dysfunction in the DSM is not the same as biological dysfunction. In fact, it better accords with Wakefield’s invocation of harm. But central to his attempt to offer a unified account of both mental and physical illness, biological functions include evolutionarily selected mental functions, both cognitive and affective. On this model, the essential or pathogenic properties of a disorder can be described not just in biological terms but, more specifically, as biological dysfunctions explicated through evolutionary theory. (The mental character of the biological dysfunctions which constitute mental disorders will be discussed shortly.) In the case of illnesses where there remains ignorance of biological mechanisms, the idea of a pathogenic factor is an article of faith: a commitment to there being some universal underlying nature to the illness in question.

Although biomedical psychiatry favours a biological characterization of pathogenic factors, other candidates are possible. Consider Louis Sass’ account of Schreber’s delusions in Paradoxes of Delusion (Sass 1994). Schreber was a German judge diagnosed with dementia praecox, now classed as schizophrenia, who wrote a first-person account of his illness, including his delusions, called Memoirs of My Nervous Illness, at the start of the twentieth century.

Sass attempts to shed light on the nature of Schreber’s delusions by comparing them to philosophical solipsism.

Solipsism is the view that the only thing that exists in the world is the self of the person who thinks about it. It is expressed in the necessarily first person thought: ‘Only I and my mental states exist’. Everything else is merely an idea (for me: one of ‘my ideas’). Solipsism is thus a form of idealism—according to which only ideas exist—taken to the logical limit. If everything that exists is merely an idea only the first person subject of thought (for me: ‘I’) can have those ideas. So only one person exists. This is used by Sass to shed light on the paradoxical quality of schizophrenic delusions:

[Schreber’s] mode of experience is strikingly reminiscent of the philosophical doctrine of solipsism, according to which the whole of reality, including the external world and other persons, is but a representation appearing to a single, individual self, namely, the self of the philosopher who holds the doctrine ... Many of the details, complexities, and contradictions of Schreber’s delusional world ... can be understood in the light of solipsism. (ibid., p. 8)

The elucidation or understanding that Sass seeks isn’t merely aimed at one particular delusional experience or even at all of Schreber’s experiences considered as a whole. It is meant to shed light more generally on the nature of schizophrenia itself. The reason it can (according to Sass) is that the experiences that characterize schizophrenia derive from a general and abstract feature of rationality:

[Madness] is, to be sure, a self-deceiving condition, but one that is generated from within rationality itself rather than by the loss of rationality. (ibid., p. 12)

Although a general feature of rationality, Sass himself does not think that the failure within rationality that amounts to schizophrenia is culturally universal. Rather, he thinks that is the result specifically of modernism (Sass 1992). But if, contra Sass, solipsism were not merely the product of recent European culture but rather a standing universal possibility suggested by the abstract structure of rationality itself, then its corresponding disorder—schizophre- nia—would be a risk for any rational subject, human or alien, whatever their biology or evolutionary history. The pathogenic factor is, on this model, an abstract feature of rationality rather than a particular biological process or dysfunction.

Whether the pathogenic factor is thought of as a biological or a more abstract feature of rationality, on the pathogenic-pathoplastic model the variation in presentation centres on the pathoplastic factor i.e. culturally invariant pathologies of underlying human nature are overlaid by local cultural variation in how they are expressed. ‘Expressed’ could carry either of two meanings. First, it might mean that standing possibilities for biological dysfunction or failings of rational subjectivity might be differently prompted or caused by different social or geographical contexts. The idea that mental illness has social determinants is, however, akin to socially caused variation in heart disease rates in different cultures and hardly merits the label ‘cultural concept’.

The more interesting idea is that variation in ‘expression’ picks out the way in which underlying pathologies might be plastic to the different selfinterpretations that people in different cultures possess and thus the way the pathologies are experienced and avowed. This would be an example of a cultural idiom of distress in the vocabulary of the DSM-5. But whereas for physical illness, how one understands one’s illness might be thought to be an accidental superficiality compared with the real underlying condition (as understood, perhaps, by the medical profession), one might argue that for mental illness its esse est percipi: how it is perceived at least partly constitutes it.

On a two-factor pathogenic-pathoplastic model, mental illnesses either are pathologies or are underpinned by pathologies of some sort of universal substrate. The difference between these options is the difference between thinking that the alloy of an invariant underlying pathology and a varying cultural overlay itself comprises what we mean by a mental illness, and on the other hand, thinking that the mental illness proper is identical with the pathogenic factor only.

One might think, for example, that khyal cap and panic disorder have the same underlying biological mechanism but that the characteristic way in which, in the former, subjects think of their distress through the conceptual lens of a dysfunction of the flow of wind-like substance is sufficient to mark it off as a different kind of mental illness from the latter. Biological dysfunction is then the common component of two distinct illnesses depending on cultural context. Boorse’s (1975) distinction between disease and illness, where the latter is tied to the subject’s experience of it, implies a difference in illness in such a case. On the other hand, one might think that the disease is whatever is common to khyal cap and panic disorder: the pathogenic factor. It is merely that the appearance that the single disease takes can vary in its experience as illness.

Whichever view is taken of whether the pathogenic factor is the illness or merely the common disease underpinning different illnesses, a two-factor pathogenic-pathoplastic view of cultural concepts of mental illness suggests a particular view of the aim of a cultural formulation in psychiatric diagnosis. It is a way of inferring, from locally divergent symptoms, the universal underlying nature of mental illness. The aim of sensitivity to cultural difference would be to find a way to penetrate beneath it to a common substrate appropriate for scientific psychiatric research.

This seems to be the view of the ex-president of the World Psychiatric Association Juan Mezzich et al. (2009) in their discussion of ‘Cultural formulation guidelines’ when they say:

The cultural formulation of illness aims to summarize how the patient’s illness is enacted and expressed through these representations of his or her social world. (Mezzich et al. 2009, p. 390)


Performing a cultural formulation of illness requires of the clinician to translate the patient’s information about self, social situation, health, and illness into a general biopsychosocial framework that the clinician uses to organize diagnostic assessment and therapeutics. In effect, the clinician seeks to map what he or she has learned about the patient’s illness onto the conceptual framework of clinical psychiatry. (ibid., p. 391)

These passages suggest that there is a division between how an illness is enacted and expressed and the underlying biological mechanisms explored by biomedical psychiatry. The former is culturally shaped, the latter is invariant. On Mezzich et al.’s (2009) account, the only positive role cultural factors can then play is as a source of contingent health-promoting resources:

The aim is to summarize how culturally salient themes can be used to enhance care and health promotion strategies (e.g. involvement of the patient’s family, utilization of helpful cultural values). (ibid., p. 399)

In other words, ‘culturally salient themes’ do not reveal the shape of mental disorders in themselves but can, contingently, be used to promote health because of their effects on how people understand their own illnesses. All this suggests that the underlying view of the role of cultural formulation is determined by a two-factor view. Such a view is, however, merely one of several possible. I will argue that it is a half-way house between two more radical views of the possibilities for cultural psychiatry both of which are versions of a single factor which I will now outline.

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