Psychiatric Diagnosis and Classification - part 5 doc

1 IN THE EVOLUTIONARY AND CULTURAL STUDY OF PSYCHOPATHOLOGY Evolutionary Theory Considerations Evolutionary psychiatrists have made depression an object of analysis.. The theory draws on

that language, culture and cognition, realized in world-views, conceptions

of persons and behavior, and ways of understanding self, other, and theoutside, behavioral environment, in their integration, ``make up'' psycho-pathology

The vaunted properties of Homo sapiens (e.g language, cognition, culture)are assumed to result from a slow process of natural selection duringbiological (i.e genetic) evolution [6] Rather than subscribing to the viewthat these properties are mere by-products of brain size and comparativelyrecent in origin, a Rubicon crossing that happened ``once and for all'' duringthe transition to the Upper Paleolithic era, they are assumed to have a muchlonger ancestry Not 50 000 or so years ago but hundreds of thousands ofyears mark the gradual, progressive march towards the human symboliccapacity [14±16] Coincident with this pattern of slow evolution of symbol-ization in the hominid line, behavior problems became better differentiatedand began to be accorded a corresponding social and cultural significance.Varieties of psychopathology, then, were ``natural'' to hominid populationswell before the transition to the Upper Paleolithic [6]

DEPRESSION: CASE NO 1 IN THE EVOLUTIONARY AND CULTURAL STUDY OF PSYCHOPATHOLOGY

Evolutionary Theory Considerations

Evolutionary psychiatrists have made depression an object of analysis Itsgenetic basis and high frequency have implied positive selection and raisedthe question of it constituting an actual adaptation For example, its emotionalmanifestations have suggested a warning function that the victim's currentstrategies are failing; its physiological signs of slowing, withdrawal, andseeming conservation as prompting that the individual shift to more profit-able environments and enterprises; and its external, behavior/demeanor

characteristic signs as communications designed to elicit others' help ever, several factors about depression have argued against a strict adapta-tionist interpretation Its protean character is one and another is the possibilitythat each of its sets of manifestations has diverse origins and functionsÐsomemaladaptive [18] That the depression spectrum or ``phenotype'' seems toconstitute a ``common final pathway'', the resultant of many causes, and avariable course (e.g remitting spontaneously or responding only to somemedications) has suggested that it is not unitary and homogeneous and thusunlikely to constitute an adaptation per se Some hold that depression is theresult of disruption of a maturation program [18, 19].

How-The social competition hypothesis is the most systematic evolutionary mulation of depression [20, 21] It posits that humans share with theirprimitive ancestors an involuntary strategy of subordination, a mechanismfor yielding in situations of competition The theory draws on ideas fromethology and the social biology of behavior about how individuals competefor rank The functions of the strategy are to inhibit aggression towardsrivals and superiors by creating a subjective sense of incapacity, to commu-nicate a lack of threat and a yielding, and to facilitate function by putting theindividual into a ``giving up'' frame of mind that encourages acceptanceand voluntary yielding The features of depression and the situations andcircumstances surrounding its victims are all explained in terms of etho-logical notions of group dynamics and rituals of behavior

for-Nesse [22] has recently offered a critical analysis of the idea that thedepression spectrum constitutes an adaptation Based on much earlierwork involving the evolutionary function of emotions and the biologicalbasis of responses linked to general medical disease, he offers a summary ofthe possible functions of low mood (states in the common range of normalexperience) and depression (severe states of negative affect, usually patho-logical) He sees these as pleas for help, the elicitation of help from groupmates, and also as a communication designed to manipulate others toprovide resources and then conserve them Depression is part of a motiv-ational package to plan and reassess a course of action with a possible view

to change or alter goals Even some conditions of frank clinical depression,Nesse implies, can be explained as serving evolutionary functions How-ever, his analysis and experience lead him away from explaining depression

in terms of one function and instead to view the spectrum as states shaped

to cope with a number of unpropitious situations

Culture Theory Considerations

While the universal prevalence of depression constitutes an indisputablegeneralization in psychiatric epidemiology, that these conditions are brought

on, shaped, expressed, and interpreted in culturally specific terms constitutes

an axiom of cultural psychiatry that is also beyond dispute Nowhere is thisbetter illustrated than with respect to China There is much evidence, as well

as controversy about, the presentation of depression in China It has beenclaimed that in China depression manifests in a ``somatized'' as compared to

a ``psychologized'' way [23] Many explanations have been invoked, ing innate patterns of physiological response, culturally shaped processes inbrain/behavior, linguistic conventions pertaining to self and emotion, socialattitudes about emotional expression, and political strictures affecting howone should explain and communicate hardship The idea that in some coun-tries like China mental disorders take a somatized form as compared to apsychologized one has also been attributed to sheer educational factors and tothe possibility that the attitudes of the doctor (``accepting'' or ``rejecting''psychological complaints from patients) are determinant of the form of pre-sentation of distressing experiences Of course, as indicated above, someconventions regarding self-expression through language favor the use ofexamples (``I feel as bad as '') whereas others do not and this may be aconsideration as well All of these factors, it has been stated, shape, color, andconfigure the depression in a distinctly Chinese pattern

includ-The complex association between culture and the depression spectrum isillustrated by the findings, and subsequent responses to their dissemination,

of the study by Kleinman [24] of neurasthenia and depression in China Hestudied 100 patients there who were diagnosed as showing neurasthenia.This is a ``condition'' coined by American neurologist George Beard todenote ``exhaustion of the nervous system'' It consisted of a mixture offatigue, weakness, impaired concentration and memory, headaches, poorappetite, and any number of variegated ``physical'' symptoms It is interest-ing to note that the concept of neurasthenia appears to have been introducedinto China via the training of psychiatrists in the former Soviet Union andthe model of neurasthenia as presented in the former Soviet Union wasdifferent from that of European countries and the United States The even-tual translation of neurasthenia into Chinese (as shenjing shuairuo) is signifi-cant, since it drew on important local concepts of vitality, cognitive activity

or ``energy'', and motivation (shen), and the traditional medical knowledge

of meridians or channels of the body ( jing) which carried ``vital energy'' (qi)and ``blood'' (xue) ``Conceptually, shen and jing are treated by Chinese people

as one term (shenjing), that means `nerve' or `nervous system' When ing becomes shuai (degenerate) and ruo (weak) following undue nervousexcitement, a variety of psychic and somatic symptoms may reasonablyensue'' [25] The Chinese interpretation of neurasthenia encapsulates in asuccinct way a whole tradition and theory about self, experience, sickness,bodily experience, and psychopathology that is integral to its native systems

shenj-of medicine

Not surprisingly, then, because the diagnosis of neurasthenia as shenjingshuairuo is connected in vital ways with deeply rooted, traditional notionsand idioms of well-being, it consequently ``caught on'' in Chinese medicinesoon after it spread there during the nineteenth century What Kleinmanshowed was that 87% of neurasthenic patients met criteria for depressionand moreover on follow-up appeared to respond to antidepressant medica-tion Not all who were biomedically improved, however, necessarily de-fined themselves as not sick, a fact that underscored the political economicembedment of sickness including depression in China as well as its ``nat-ural'' fit with Chinese cultural psychology Personal and culturally rootedpolitical economic factors, it would appear, strongly influence whether adiagnosis pertaining to the depression spectrum embodies a condition ofsickness and maladaptation as the individual, at any rate, defines this.One obvious implication of Kleinman's study was to demonstrate thatlocal conventions of meaning and traditions pertaining to body, emotion,self, and situation profoundly determine how aspects of the depressionspectrum play out in relation to culture and society A complex amalgam

of factors, which include biology, culture and local experience, shape howthe depression spectrum is configured and enacted The influence of cul-tural factors in the depression spectrum has been studied in other socialgroups Manson et al [26] studied the links between depression and severalindigenously defined conditions of sickness among members of the HopiNation of American Indians The similarities and differences between scien-tific definitions of depression and those representative of the residents of theregion were discussed Manson makes clear that general characteristics ofthe various sickness conditions differ as a function of culture, but so do alsothe phenomenology, putative cause, duration, and circumstances surround-ing actual episodes An argument can be made that among the Hopi people,

no less than among the Chinese, the depression spectrum is configured andenacted differently Kinzie et al [27] have developed and validated a Viet-namese-language depression rating scale precisely because among refugeesthe disorder has a different configuration There exist numerous otherapproaches to the cultural study of depression [28]

SOCIAL PHOBIA: CASE NO 2 IN THE EVOLUTIONARY

AND CULTURAL STUDY OF PSYCHOPATHOLOGY

General Remarks

Few human conditions embody as much face validity for a form of socialmaladaptation as do those marked by worry, fearfulness, psychic pain,somatic experiences of autonomic hyperactivity, and associated social

avoidance The distress, misery, and social disruption that anxiety can causeextend beyond psychiatry to encompass religion and philosophy Because

of its wide prevalence, anxiety has received attention from evolutionaryand cultural psychiatrists The anxiety that seems concentrated in socialrelations and interactions has evolutionary importance because of the hom-inid trait of sociality and it has cultural relevance because in personalexperience and human activity one finds concentrated the meanings of anyculture

Evolutionary Theory Considerations

Anxiety, like fear, pain, and fever, is a natural defensive response, one of thebody's protective mechanisms [7, 29, 30] The process of natural selection inthe environment of evolutionary adaptedness (EEA) designed the regula-tory mechanisms that underlie anxiety so as to enable individuals to avoidthreats and promote survival and reproduction Anxiety, in other words, is

a ``good thing'' Whenever a threat or the likelihood of harm occurs, anxietycan be expected to result and its degree will bear a relationship to themagnitude of harm/threat However, even if the cost is low, the defensewill be expressed in anxious behavior when the mechanism is operatingnormally, much like a smoke detector may be triggered even in the absence

of a real fire It is assumed that hominid ancestors existed in environmentsthat had a wide range of levels of danger that were recurrent Genes thatshaped the anxiety response continued to be adaptive for a very long timeand have left a residue of low threshold for the generation of protectiveresponses to situations of potential harm and danger

Many varieties of phobias have been the object of evolutionary analysisand each one has been explained as the outcome of ``the smoke detectorprinciple'' in response to an evoking situation that had fitness implications

in EEA In the case of social phobia, threats to reputation and status havebeen singled out as important Drawing on principles from ethology andevolutionary biology, Stevens and Price [20] emphasize the importance ofcontests and tournaments as a way of establishing social rank, somethingindividuals persist in striving to maintain or improve upon Success in suchtournaments earns individuals a measure of value and power, termedresource holding power (RHP) During evolution, hedonic as compared tostrictly agonistic modes of social interaction became increasingly important.This involved competition not by intimidation but by attraction, with com-petitors disarming rivals and attracting mates and also achieving status andrank in the group This gave rise to a new capacity for self-assessment,termed social attention holding power (SAHP) According to Stevens andPrice [20], anxiety generally and social anxiety in particular is commonly

released in situations that are perceived to constitute a threat to the ual's RHP or SAHP.

individ-Social phobia may thus be regarded as a psychiatric disorder that forms to the harmful dysfunction model proposed by evolutionary psych-ologists and reviewed earlier Psychological mechanisms and algorithmsserve the natural function of maintaining an individual's sense of compe-tence and ranking in a group Through such mechanisms individuals areable to project and protect their social resources, establish their credibility,compete, attract mates, and assure the maintenance of their offspring When

con-a perturbcon-ation of this mechcon-anism tcon-akes plcon-ace, con-a disorder of behcon-avior results.Social phobia is assumed to correspond to a dysfunction of mechanismspromoting social competence in a group setting and in face-to-face relation-ships Its presence and definition in international systems of diagnosis attest

to its presumed universal, pan-cultural characteristics

Culture Theory Considerations

While the international and evolutionary viewpoints about social phobiasuggest universality, research work from Japan argues the case for culturalspecificity Kirmayer [31] reviewed characteristics of Taijin Kyofusho (TKS), acommon disorder in Japan featured by fear of offending others throughone's social awkwardness or because of an imagined social defect In Japan-ese psychiatry TKS comprises a spectrum of disorders While symptomsconsistent with social phobia are predominant in all its varieties, theircharacteristics in Japan differ significantly Moreover, while TKS involves

a Japanese set of disorders marked by a unitary and distinctively Japanesecontent and meaning, it includes varieties that in the relatively culture fairnosology of international psychiatry suggest several different disorders.Social relationships in Japan are systematically shaped into and calibrated

on the basis of emphasis on one's effect on an immediate audience Parties

to a relationship strive to reduce psychological distance by intuiting whatothers are thinking and feeling Indirect, implicit communication is valued,the obverse is considered blunt and insensitive An assumption prevails that

a socially competent person can understand others without having to resort

to words Even eye contact is regarded as bold and potentially offensive andaverting one's gaze is enjoined, creating a normative basis for concern andfear of injuring others with one's gaze It goes without saying that theexpression of negative emotions is restricted and that attributes of the selfand indeed of the body, such as appearance, skin blemishes, and odor areregarded as potentially offensive to others and the possibility that thismay prevail is a source of obsessive worry if not preoccupation Cognitivefactors are associated with these interpersonal characteristics; for example,

an emphasis on consciousness of self in social situations, of being on a socialstage, and of having to act appropriately in front of others Rules of etiquetteinclude elaborate forms of respect language, awareness of posture, and self-presentation with respect to management of facial expressions and the mask-ing of emotions.

In Japan, then, a distinctive social psychological calculus shapes howselves should behave in public settings There exists a dictum that one mustsearch and scan facial expressions so as to anticipate what best to say andhow to ``come across'' so as not to offend It is no surprise that pathologicaldeviations of this social language of communication and of interpersonalrelations influence not only the origins of social anxiety and phobia but alsocolor its manifestations in a significant way Child rearing and patterns ofsocial interaction all appear to function so as to create vulnerabilities tovarieties of social anxiety

TKS is extremely common in Japan and since the 1960s has been regarded

by Japanese psychiatrists as a unique form of psychological disorder Manypatients fulfill DSMcriteria of social phobia However, fear of eye-to-eyecontact, of physical deformity, and of emitting an unpleasant body odor aswell as of blushing are among the commonest symptoms of TKS, yet were notespecially emphasized in DSM-III [31] The fear that one has a deformed bodyconstitutes a subtype of TKS in Japan, yet in DSM-III-R such a dysmorpho-phobia was classified as a separate condition, namely, as a form of somato-form disorder The conviction that one may harm others either by appearance,behavior, body odor, or physical deformity often appears to reach delusionalproportions, yet this symptom is judged to fall squarely within the TKSspectrum and is not regarded as a psychosis It should be noted that theGerman introduction of the terms ereuthophobia and erithophobia wasknown in Japan and found to be useful; however, the fear of others did notappear to be extremely common Moreover, the concept of dysmorphophobia

in its original definition was characterized by the delusional conviction thatone's body is deformed; however, the clarity of that experience did not fallinto the rubric of fear that an organ of the body might be deformed

The TKS spectrum, then, illustrates rather vividly the role of culture notonly in influencing the origins of social phobia but also its content andconstitution Socialization and enculturation create expectancies regardingemotions and personal expression in social relations that predispose indi-viduals to this variety of anxiety The semantic content that provides mean-ing to what is expected of the self and how feelings and actions should beshaped in social relations create the normative conventions on the basis ofwhich deviations that constitute the spectrum are calibrated This endowsthose deviations in behavior with a blend of concerns that shape and give adistinctive meaning to the syndrome in Japanese culture Its cultural psych-ology, as it were, shapes social anxiety into a Japanese disorder

PSYCHOPATHY: CASE NO 3 IN THE EVOLUTIONARY

AND CULTURAL STUDY OF PSYCHOPATHOLOGY

General Remarks

Antisocial personality traits and behavior constitute a challenge for a ology of psychiatry Studies in cultural anthropology suggest that a con-struct or cognitive category about antisocial behavior is a human universal[32, 33] Murphy [34] used antisocial personality as an example of univer-salism in her study that argued against the view that psychiatric disorderswere culturally variable and relative These generalizations about views

nos-on antisocial behavior and persnos-onality are cnos-onsistent with the history ofpsychiatric thinking Since the very late eighteenth century, when theAmerican Benjamin Rush and the Frenchman Philippe Pinel publishedtheir respective dissertations, the antisocial constellation and construct hasfallen within the perimeter of psychiatric attention [35] Currently, it isrepresented in the two international systems but defined somewhat differ-ently: DSM-IV emphasizing antisocial behaviors and ICD-10 personalityfactors

The history of psychiatry embodies tensions with respect to behavior andmental illness As a medical discipline, psychiatry is concerned to developand use a system of knowledge so as to diagnose, treat and prevent illness.Its social functions, on the other hand, are various and they overlap: as asocial medical institution with a distinctive social mandate (i.e public healthfunctions), psychiatry seeks to control and regulate social problems associ-ated with mental illness; as part of the social welfare system, it validates ifnot justifies the disbursement of social security and disability payments tovictims of mental illness; and as a sanctioning, disciplining body of thecriminal justice system, its decisions about mental illness appear to absolve,punish, stigmatize, and/or medicalize

How antisocial behavior has fared within psychiatry illustrates the dary presented by psychiatry's dual functions and the goals of its nosology.While including a disorder whose indicators are socially divisive, contra-vene social norms, and can include patterns of delinquent and criminalactivity, psychiatry has been accused of mitigating or condoning the behav-iors of individuals diagnosed as antisocial personality disorder or psycho-pathic [36] The relationship between psychiatry and antisocial behaviorand personality thus raises a fundamental challenge to the medical ascompared to the social functions of psychiatry It is thus important thatone distinguish analytically between the antisocial constellation and con-struct (a recurring, universal presence in society), its social interpretation(generally negative, but can lead to positive traits and also fascination), thespecies of behavior involving misdemeanors and crimes which the legal

quan-system adjudicates, and what properly belongs in a nosology of psychiatryconsidered as a medical discipline or institution.

Evolutionary Theory Considerations

A disturbance of behavior that is relatively discrete, consists of scribed signs/symptoms, and can result in social breakdowns, for example,anxiety and phobia, paranoia, mood related problems, and even schizophre-nia, would seem to present a ``cleaner'' case for an evolutionary conception

circum-of psychiatric disorder [37, 38] The abnormal personality constellations donot readily conform to intuitive notions of disorder and disease Rather,they comprise complex programs of behavior, encompass traits and behav-iors that appear ego-syntonic and by definition presuppose inferred, unob-servable features of persons

There are two different and seemingly contradictory ways in which tionary theory has approached antisocial behavior A harmful dysfunction(HD) formulation would presumably rest on the ``natural function'' of soci-ality, including competition and mutualism or altruism A defect of thisfunction undermines an individual's pursuit of biological goals and causes

evolu-``harm'', thus qualifying as a disorder according to the HD formulation.Problems associated with this perspective are covered later

The second way in which evolutionary theory has been applied to social'' strays away from the HD disorder conceptualization and views theantisocial constellation as a lifelong social strategy It was one of anynumber of strategies naturally selected for in the ancestral environmentand can, depending on the circumstances facing an individual early indevelopment, be adaptive even in the contemporary environment Thisformulation draws on a complex synthesis and interpretation of knowledgefrom the fields of biological anthropology, developmental psychology, per-sonality theory, sociobiology, criminology, and evolutionary ecology [39,40] It holds that ecological stimuli or ``clues'' that suggest uncertainty andrisk (e.g parents' inability or unwillingness to offer support, resources, andstability) cause patterns of attachment behavior that trigger or elicit (duringearly childhood) a social strategy designed to maximize reproduction inconformance with life history theory This involves the differential alloca-tion of resources (e.g pertaining to survival, growth, repair, reproduction)throughout the life cycle, affecting the onset of sexuality, the timing ofmating and reproduction, the quality of mating relationships, and the qual-ity of parenting This social strategy, by definition, promotes long-termgoals, but in the short run and in some environments can encompassmany of the personality, emotional, and social behavior traits associatedwith the antisocial constellation

``anti-Culture Theory Considerations

The cross-cultural validity of virtually any psychiatric disorder presentsconceptual and methodological problems, but the personality disorders aremore knotty ones since they involve more style of behavior and less psycho-logical distress and social impairment [38] Antisocial personality disorderadds to this a consideration of social norms, rules, and social practices in-volved in the definition of deviance and criminality Many questions havebeen raised about its cultural validity [41]; for example, whether its essentialproperties are culturally invariant or merely reflect Anglo-European stand-ards of behavior, its relationship to concepts of personhood like ego-centricity

or social-centricity (as seen in individualistic as compared to collectivisticsocieties, respectively), and tensions between an underlying trait or constructcompared to sociological and cultural parameters that may hinder or favor itsexpression as per self-disclosure (e.g whether the processes of socializationand enculturation promote or suppress personality and behavior tendenciessuggesting antisocial personality)

The prevalence and characteristics of psychopathic personality in Scottishcompared to North American samples of psychiatric, forensic and criminalpopulations have been studied recently [41±43] These authors relied on thePsychopathy Checklist-Revised (PCL-R) developed by Hare [44], whichconsists of two factors that measure personality factors and antisocial be-havior Cooke and co-workers employed the item response theory approach

in the measurement of antisocial personality disorder, a strategy that copessuccessfully with many of the problems of cross-cultural measurement [43]

In particular, item response theory allows establishing whether the sametrait or phenotype is being measured and by means of the same metric intwo populations, in this case, two cultures

Results revealed a statistically significant and substantially higher lence of psychopathy (i.e based on cut-off scores and mean scores) in NorthAmerica compared to Scotland Even when cut-off points were adjusted so

preva-as to conform to the differences in overall mepreva-asures, substantially morepsychopaths were found in the North American sample This parallelsfindings that have been obtained in Scandinavian and British samples,suggesting that enculturation and socialization lead to suppression or exag-geration of traits of psychopathy cross-culturally With respect to NorthAmerican and Scottish samples, the slope parameters of the measuresobtained did not differ significantly cross-culturally, suggesting that thedisorder is defined by the same characteristics in the two cultures Anumber of items produced significantly different measures in the twocultures, but most showed cross-cultural equivalence of measurement.Many of the features of the disorder apparently do not become apparentamong Scottish prisoners until high levels of the trait are present This

suggests that cultural factors dampen, inhibit, or suppress their expression

in Scotland For example, the level of the underlying traits of glibness, lack

of remorse, and pathological lying at which the characteristics of the order become apparent differed in the two cultures: in Scotland those whoshow these traits have a higher measure of the underlying trait of psycho-pathy Cooke and Michie explain the difference observed as resulting fromcultural differences in pressure for psychopathic behavior The importance

dis-of differences between levels dis-of individualism in the two societies andcultures, a factor that has been invoked to explain cultural variability inthe expression and manifestations of psychopathy, was considered as apossibility but could not be verified Classically, individualism compared

to sociocentrism is a parameter that has been observed in Anglo-European

as compared to Asian societies

CRITIQUE OF THE TWO APPROACHES TO DIAGNOSIS AND CLASSIFICATION

The Evolutionary Conception of Psychiatric Disorder

Many harmful dysfunctions of psychological mechanisms, disorders in theevolutionary sense, are treatable conditions, but the latter need not constitutedisorders [45] From an evolutionary standpoint, conditions of potentialpsychiatric relevance involve a behavior condition, its evaluation, someonewho evaluates, and an evaluation context The condition can be positive ornegative; the evaluator can be the subject, an observer, or a reference group;the evaluation involves whether the condition results from a naturallydesigned mechanism that is or is not ``doing its job'' (i.e is evolutionarilyfunctional or dysfunctional) or is simply a by-product of a mechanism; andfinally, the environment in which a condition is situated can vary (i.e theancestral or the present one) In this light, a treatable condition is the product

of a decision based on values and conventions, either that of the individual,significant other, or reference group in society Some treatable conditionsmay arise because a function naturally designed in an ancestral environmentand operating ``naturally'' in the current one nevertheless causes impairment

or suffering (sexual jealousy or predation) The converse is also true: naturalfunctions may be dysfunctional (e.g repeated sensation seeking and danger-ous risk taking) yet produce behavior in contemporary environments that issatisfying and not impairing (e.g bold personalities, rock climbing) Finally,many treatable conditions may have no relationship to a natural function butare simply by-products of such, or due to simple human variation [1].Echoing a treatable condition perspective, Kirmayer and Young [46] pointout that the HD analysis is not fully impersonal and objective, but depends

on implicit positions of value, totally disregarding social and cultural ventions Sadler [47] has emphasized that the HD position started out as aprescriptive formula validating what a disorder constituted Its exponentsseem now to be concerned mainly with descriptive questions (why and howgenerally held psychiatric disorders conform to a HD analysis) and less sowith prescriptive ones that clarify what and why a condition (e.g hyper-activity, premenstrual syndrome) should or should not constitute a dis-order It is clear that in the debate about prescriptive questions regarding

con-a pcon-articulcon-ar condition, one ccon-an point to fuzzy concepts con-about whcon-at constitutenatural functions and, thus, whether the condition constitutes a disorder.Sadler, like Kirmayer and Young, then, makes clear that despite the seemingrigor of the HD formulation, its application can entail messy questions ofpolitics, values, and conventions and standards about normality, deviance,adaptation, and natural functions

There are several additional reasons why a HD prescription cannot beexpected to neatly serve the needs of diagnostic systems, at least in theforeseeable future Most diagnoses that have emerged in psychiatry do notconform in point-for-point way with failures or breakdowns of a naturalfunction Entities like depression, schizophrenia, anxiety, and somatizationdisorder embrace many levels and layers of social and psychological func-tion, and there is little evidence that they can be reduced to or equated withfailures of one or even a few adaptations or mechanisms [9, 10] Most em-body complex behavior phenomena that are the outcome of failures ofseveral natural functions and mechanisms Furthermore, many of the func-tions or mechanisms governing pathological behavior involve the interplay

of hierarchically arranged levels of functions Perturbations and tions in one level can be propagated up and down the hierarchy and atdifferent levels may be subject to positive or negative feedback If a systemsview is used to conceptualize individual functioning and what constitutes adisorder, the elegant solutions that a HD analysis promises become opaqueand fuzzy

dysfunc-Many so-called psychological adaptations are really descriptions ofdomains of biologically significant but highly complex social behavior.They may have promoted the solution of biological problems, for example,mate selection, acquisition of rank, and social competition; however, they donot readily map on to well-demarcated spheres of behavior (other thantautologically) nor can they be equated with conditions or ``disorders'' asclassified in psychiatry Other adaptations, while certainly fundamental inpromoting fitness and adaptation, really refer to rather narrowly defined(i.e content specific) cognitive/perceptual functions that serve or contribute

to the solution of many biological functions For example, mate selection,achievement of high social rank, solution of subsistence problems, and/orability to avoid predators in the hominid environment of evolution required

adaptive functions in many areas of perception, cognition, recognition ofemotion, linguistic and/or emotional communication Some of the evolu-tionary arguments that have been developed for psychiatric disorders (de-pression, schizophrenia) embody whole packages of maladaptive behaviorthat can be reduced or fitted into a HD analysis only with great difficulty.Problems in the evolutionary conception can be illustrated by consideringpsychopathy It obviously incorporates many so-called psychological mech-anisms and does not easily or neatly profile a disorder as per the HDanalysis Mechanisms pertaining to care giving, mating, social commitment,and social responsibility come to mind and these can apply to kin, non-kin group mates, competitors, strangers, and/or potential mates Where and

on what basis does one place the antisocial in this array of behavior andexperience? Moreover, there is in evolutionary biology a well-established

``theory'' about the complexities of social relationships Emphasis is placed

on the intricacies of competition and trade-offs which of necessity must takeplace across different spheres of relationships and behaviors, for example,between giving and taking, between differences in what it is adaptive forparents to ``invest in'' or ``hold back from'' offspring compared to theunlimited demands that the latter make, and between the obvious residuals

of sexual selection that involve sharply divergent mating strategies of males(i.e impregnate and if necessary coerce many) and females (i.e select few onthe basis of their resources and commitment) Finally, there is the quandaryraised by the trait not only of selfishness/competition but also of socialcunningness and dissimulation in the service of personal goals, aptlytermed Machiavelianism Behavior meriting this qualification has beendescribed for primates attesting to its presumed adaptive, selective basis.Thus, while on first impression the HD formulation of disorder appearsrelevant and valid to the antisocial constellation and construct, closer analy-sis reveals problems There is a great deal of complexity and ambiguityregarding what is ``social'' and altruistic/responsible compared to ``un-social'' or selfish/expedient Consequently, where and on what basis thecalibration of antisocial fits within the domain of social activity is problem-atic Unambiguously disentangling what is evolutionarily prudent fromwhat is antisocial, and from whose standpoint will the latter be calibrated,all would seem to present problems to the HD formulation of the antisocialconstellation/construct

In summary, there are reasons to be cautious with respect to the proposedevolutionary conception of psychiatric disorder generally and on the HDformulation in particular While the classic theory of categories that supportthe HD formulation is theoretically compelling and aesthetically pleasing,its use for deciding whether any one condition of psychiatric relevance is,

is not, or should be defined as a disorder raises numerous problems.Nevertheless, evolutionary biology and psychology generally, and the HD

analysis of disorder more specifically, embody insights that should beincluded in a science of psychiatric diagnosis and classification.

The Cultural Conception of Psychiatric Disorder

It can be argued that evolution provided conditions for the emergence ofculture but the latter was not naturally selected Mechanical and physicalchanges affecting the brain (e.g size and/or structure) and/or an exaptationand not an adaptation [48] may explain the behavioral plasticity that makesculture possible Behavioral traditions and systems of communication ob-served in higher primates, likely features of hominids and earlier varieties

of species Homo, can be regarded as qualitatively different from humanlanguage, cognition, and culture These traits may constitute, on the onehand, either a singular, unique development of the final phase of humanbiological evolution, integral to what brought about the emergence of Homosapiens and the move out of Africa some time after 100 000 or so years ago;

or, on the other hand, merely a set of traits that were conditioned by socialecological exigencies Thus, culture may merely add surface manifestations

to behavior and psychopathology, constituting mere epiphenomena ratherthan essential features One could argue that a vulnerable Japanese subjectraised in America is not ``prepared'' to develop manifestations resemblingTaijin Kyofusho but is instead vulnerable to whatever variety of social phobia

is present in the local culture

In summary, one can argue that essential behavioral properties of Homosapiens (including their vulnerability to suffer from psychopathology) mayreside in psychological mechanisms (or algorithms) but that characteristicslinked to culture are largely evoked, learned, and/or acquired The HDposition, for example, underscores natural functions that are culture free.Essential aspects of ``cultural psychology'' that shape a culturally specificpsychopathology may not be part of an ensemble that in any way wasnaturally selected for and genetically based Whether human language,cognition, and culture constitute capacities that were naturally selectedgradually or merely a by-product of a unique event or ``explosion'' ofcomparatively recent origin, is highly contested and cannot be discussedfurther here [6] However, even if human language, cognition, and culture

do not constitute naturally selected and genetically based traits, one can stillclaim that they constitute essential features of Homo sapiens and are neces-sarily implicated in psychopathology

Psychiatry seeks a universal science about the functioning of the ``psyche''and its disturbances However, how the mind works involves an amalgam oftwo sets of factors: conceptual models and reasoning principles, on the onehand, and features of language and culture, on the other The two are very

difficult if not impossible to untangle [49±53] Anthropologists and linguistsagree that through an amalgam of meaning-creating systems individualsfashion their personal experience, sense of reality, social behavior, and therequirements for social order According to culture theory, systems of mean-ing are crucial It does not posit an opposition or exclusivity between thedomains of brain function and cultural meaning systems Both together form

an integral whole and are products of the evolutionary process

Psychopathology, then, arises only in a symbolically determined setting

of behavior There are good reasons to presume that even were psychiatricdisorders to be conceptualized in purely neurobiological terms, culturalfactors have to in some way be taken into account in making sense ofthem The three test cases discussed earlier illustrate that social conventionsand cultural meanings about behavior and deviance of necessity come intoplay in decisions regarding how psychopathology is configured, enacted,and accorded significance in a society Elsewhere I have argued on generalgrounds that what constitutes a psychiatric disorder, who should be treated,and what constitutes the proper domain of a medical psychology, all requiretaking into consideration cultural conventions [6, 54]

Another criticism of the cultural conception of psychiatric disorder is that itmay rely on a view of culture that is losing ground and eventually maybecome outdated The importance of cultural psychologies in the constitution

of psychopathology is best visualized for members of monolithic cultures thatcontrast sharply with one another The examples discussed earlier involvedJapan and China and to this could be added India, societies of the Africancontinent, and of course members of isolated, non-industrial societies It isamong people holding traditions and conceptions that articulate self-contained and integrated world-views that differ sharply from society tosociety and that speak different languages that one finds contrasts in culturalpsychologies that, in turn, would configure different constitutions of psycho-pathology In the modern world, a global, capitalist culture holds sway,communication of traditions is widespread, and migration very prominent.This criticism, then, stipulates that modernity melts away cultural heterogen-eity and that, in the long run, truly contrastive constructions of culturalpsychologies and psychopathology will lessen However, this argumentdoes not contravene the importance of culture: while suggesting the possibleerasure of cultural differences, it actually reinforces the importance of sym-bols and meaning (see below)

That a system of psychiatric diagnosis and classification is first andforemost a practical enterprise designed to facilitate international communi-cation and comparability of clinical practice and research is another argu-ment that challenges the cultural conception A practical argument foruniversality weakens the position that cultural differences should be ac-corded primacy This is consistent with the point mentioned earlier; namely,