Cultural issues affecting the validity of diagnosis

  1. Why might cultural differences make a valid diagnosis unachievable?
  2. What evidence exists to suggest that the DSM is valid in non-US cultures?
  3. What evidence is there to suggest that cultural differences affect diagnoses? You need to read the long R and V essay to help you answer this question. How does this link with the 4Ds of diagnosis?
  4. How has section 3 is the DSM5 helped practitioners in their diagnosis of people from diverse cultural backgrounds?

A useful clip about DSM 5 and cultural issues:

A fact-sheet published by the APA about the changes to DSM 5 re cultural considerations: apa_dsm_cultural-concepts-in-dsm-5

A fascinating study about diagnosis of survivors in the aftermath of the Rwandan genocide: Bolton (1999)

Recognizing the need for a more emic approach to diagnosis, the researchers worked with World Vision in rural areas to help investigate mental health problems resulting from the horrific trauma that many people had observed firsthand. Rather than simply using the DSM as it was, (imposed etic), the researchers wanted to know whether the local people felt that the symptoms relating to depression and PTSD for example actually fitted with what they themselves were experiencing and seeing in their friends and family members.

Procedure: An emic approach was achieved by interviewing 40 locals about all the problems that had resulted from the genocide. An inductive content analysis was used to develop an understanding of local terms used for mental health symptoms and disorders. Further interviews took place with some of the original sample who then went onto name others in the community who were knowledgeable about the specific problems (snowball sampling, purposive sampling). 7 traditional healers and local leaders were named and interviewed. The researchers created a set of cards detailing mental health symptoms identified in interviews and symptoms of depression from the DSM. These were used in a technique called  “pile sorting” which is used in qualitative research to determine how participants perceive relationships between items. The healers had to sort the symptoms and disorder cards based on similarity. From this three additional symptoms were added to the DSM diagnosis of depression: lack of trust in others, loss of intelligence, and mental instability. The researchers then used these local symptoms to adapt and translate an existing questionnaire (derived etic) and develop new culturally-relevant instruments to determine the prevalence of depression in the community.




In addition to the Western DSM categories of depression and PTSD, the Pps also described two other syndromes:

  • Guhahamuka: PTSD symptoms + some depression symptoms + some local symptoms: Failure to sleep, hopelessness, anger, failure to eat, loss of intelligence, acting like a crazy person, feel like you have a cloud within yourself, inability to pray, too many thoughts, to keep dreaming of events that you went through, fleeing away from people and hiding, feeling like fighting, making a lot of noise, acting without thinking, feeling like you are having an epileptic episode, lack of trust, attempting suicide.
  • a grief syndrome called “Agahinda gakabije” that included other depression and local symptoms: Isolation, lack of self-care, being very talkative, not working, drunkenness, feeling life is meaningless, excessive alcohol use, not pleased by anything, burying your cheek in your palm, difficulty interacting with others, sadness.

93 members of the community were identified as having mental health issues. Following interviews with the lcoal healers, 70 were diagnosed with agahinda gakabije. On completion of  the new checklist (derived etic), 30 of them showed symptoms of depression. Agahinda seems to be synonymous with the depressive symptoms relating to grief in the West. The checklist was then used more widely with a larger sample of 368 adults. 18% met the DSM criteria for depression and 42% described themselves as having agahinda gakabije.

  1. What evidence is there that an emic approach has been used in this study?
  2. What evidence is there of data triangulation?
  3. What evidence is there of credibility in this study?
  4. The data collection relied on interviews; what factors would have improved the quality of the interview data that was collected?
  5. What practical issues would there have been with conducting this study?
  6. Find out what is meant by back translation and how this relates to credibility
  7. To what extent could the findings of this study be said to be generalisable?