Do you let me symptomatize? The potential role of cultural values in cross-national variability of mental disorders’ prevalence

Abstract

Background:

Mental disorders may show inherent cross-national variability in their prevalence. A considerable number of meta-analyses attribute this heterogeneity to the methodological diversity in published epidemiological studies. Cultural values are characteristically not assessed in meta-regression models as potential covariates.

Aim:

Our aim was to conduct a meta-regression analysis to explore to what extent certain cultural values and immigration rates (as indicator of cultural diversity) might be associated with the cross-national heterogeneity of prevalence rates.

Method:

To minimize methodological differences that may exert a confounding effect, prevalence rates were obtained from the World Health Organization’s (WHO) World Mental Health Survey Initiative. Cultural indices (overall emancipative values; overall secular values) were collected from the World Value Survey, while immigration rates were registered by utilizing the data of the United Nations’ World Population Policies 2005 report.

Results:

Meta-regression analysis indicated that overall emancipative values (i.e. promoting self-expression, non-violent protest) showed significant connection with lifetime and last year prevalence of any mood disorders (Z = 4.71, p = .001; Z = 2.35, p = .02) and any internalizing disorders (a merged category that combined mood and anxiety disorders; Z = 2.82, p = .004; Z = 2.34, p = .02). Overall secular values (i.e. rejecting authority and obedience) were negatively associated with last year prevalence of depression (Z = −2.75, p = .06). Multistep regression analysis indicated that immigration rate moderated the connection between cultural values and mental disorders. Countries with higher immigration rates showed higher emancipative and secular values.

Conclusion:

Our findings might function as potential foundation for formulating hypotheses regarding the cultural context’s influence on the population’s mental health.

Keywords

Mental disorder prevalence WMH cultural values depression immigration rate

Introduction

The prevalence of mental disorders shows inherent cross-national variability. To understand potential reasons of such variability, numerous systematic reviews and meta-analyses have been published, making attempts to provide an explanation for the worldwide heterogeneity of distinct psychiatric disorders. A considerable number of these papers, for example, in case of attention deficit hyperactivity disorder (ADHD; Faraone, Sergeant, Gillberg, & Biederman, 2003; Simon, Czobor, Bálint, Mészáros, & Bitter, 2009; Van Emmerik-van Oortmerssen, 2012; Polanczyk, Willcutt, Salum, Kieling, & Rohde, 2014; Thomas, Sanders, Doust, Beller, & Glasziou, 2015; T. Wang et al., 2017b), mood disorders (Cameron, Sedov, & Tomfohr-Madsen, 2016; Clemente et al., 2015; Ghaemmohamadi et al., 2017; J. Wang et al., 2017a), anxiety disorders (Baxter, Scott, Vos, & Whiteford, 2013; Guo et al., 2016; Miloyan, Bulley, Bandeen-Roche, Eaton, & Gonçalves-Bradley, 2016), psychotic disorders/symptoms (Clancy, Clarke, Connor, Cannon, & Cotter, 2014; Jääskeläinen et al., 2018), substance use (Fan et al., 2017; Feng & Newman, 2016; Hunt, Malhi, Cleary, Lai, & Sitharthan, 2016; Lemstra et al., 2008) or ‘common mental disorders’ in general (Steel et al., 2014) – emphasized that the estimated prevalence differences between countries might be highly influenced by both the assessment protocol (e.g. different measures, difference in applied diagnostic criteria) and the characteristics of the recruited samples. This explanation highlights the relevance of operationalization but does not add novelty neither to the etiological models of the genesis or expression of psychiatric symptoms nor to the deeper understanding how country-specific factors may exert an impact on the prevalence of these disorders.

Therefore, to control for methodological differences, it is necessary to find cross-national data that derive from the same methodology. The World Health Organization’s (WHO) Global Burden of Disease Study estimated the prevalence of mental disorders (Whiteford et al., 2013) using mainly literature reviews and not cross-national epidemiologic surveys. To date, only one international research project assessed the global prevalence of psychiatric disorders, using the exact same methodology (i.e. in terms of measures, sample selection protocol) throughout data collection in every participating country: the WHO’s World Mental Health (WMH) Survey Initiative (Kessler et al., 2009).

Culture is traditionally defined as a set of shared beliefs, behavioral norms and values (Alarcón, 2009), which play an important role in the creation of a collective identity that shapes the course of permitted or expected behavior. Culture surrounds the individual as part of the ecology of one’s development (Bronfenbrenner, 1979). The individual is constantly affected by the leading values of the society as transmitted either by the family members, peers, teachers or colleagues, subcultural communities, religious groups (i.e. participants of the microsystem) or – at a broader meso or exosystem level – by political parties, neighbors, social services, the industry or mass media. Importantly, the cultural values of certain subcultures may also affect how the majority thinks or feels about various social phenomena, especially when the minority is perceived as consistent in the support of their views (Wood, Lundgren, Ouellette, Busceme, & Blackstone, 1994).

The occurrence of distinct psychopathologies might also be influenced by the norms, beliefs and values of a given social group. Tseng (2001) described six potential ways how culture may affect the expression of a mental disorder: (1) pathogenic effect (i.e. culture as direct causative), (2) patho-selective effect (i.e. culture influences the reaction which may result in mental disorder), (3) patho-plastic effect (i.e. culture affects the shaping of symptoms), (4) patho-elaborating effect (i.e. culture reinforces exaggerated reactions), (5) patho-facilitative effect (i.e. culture has an impact on the frequency of certain mental disorders) and (6) patho-reactive effect (i.e. culture affects both perception and reaction). Leighton and Hughes (2005) explained further associations between culture and the pathogenesis of psychiatric syndromes, including culture-specific mental disorders (e.g. ‘amok’, ‘koro’ or ‘arctic hysteria’), culture-supported model personalities that may be vulnerable to mental disorders or culture-affected child-rearing practices that might produce psychiatric symptoms.

Out of all the major mental disorders, mainly affective disorders and especially depression are thought to be a culture-bound syndrome (Dowrick, 2013). As Dowrick (2009) accentuated, Western Anglophone culture promotes an ethic of constant happiness (‘keep smiling’) and within this cultural framework, any aberration from this norm might be perceived as a manifestation of a disorder, such as depression. Viswanath and Chaturvedi (2012) provided a review on the cultural aspects of mental disorders and highlighted that in eastern cultures (e.g. Tehran, India) guilt and suicidal ideation are less common features of a depression syndrome, as the unpleasant state of the disorder may rather be attributed to ‘Karma’ and not to self-failure (Ananth et al., 1993).

A classic distinction between cultures is based on the self-construal style of certain communities and how individuals in these social groups relate to others (Markus & Kitayama, 1991). According to this outlook, the most frequently applied classification approach divides cultures into individualistic and collectivistic ones. Individualism is usually connected to an increased prevalence of depression (Hidaka, 2012), by stressing the relevance of personal control and responsibility. Collectivistic orientation, on the contrary, is considered to alleviate depression by reducing acculturative stress (Du, Li, Lin, & Tam, 2015). Some authors (Chiao & Blizinsky, 2010) linked individualism/collectivism to allelic frequency of 5-HTTLPR and therefore stated that the association between cultural values and the prevalence of affective disorders can be mediated by genetic susceptibility.

These studies characteristically used a classification method (e.g. individualism vs collectivism) that extensively relied on scientific consensus, instead of operationalizing the constructs. Our study aims to assess cross-national differences in mental disorder prevalence rates as measured by the WMH Survey Initiative (Kessler et al., 2009) and explain the observed variance with cultural values and immigration rates (potential indicator of cultural diversity) based on nationally representative data. We chose to use meta-analytic techniques on the WMH results instead of running a systematic review and meta-analysis on all the relevant published papers on psychiatric disorders’ prevalence, to rule out the methodological differences that usually lead to heterogeneity. So far, only one study (Heim, Wegmann, & Maercker, 2017) has examined WMH data with similar goals. The authors, however, compared prevalence data collected after the year 2001 with national cultural values as indicated by Schwartz in 1994 and not based on nationally representative samples (note that the authors only used the data of a subsample of teachers to provide cultural values). To gain representative cultural data from the same time period (or as close in time as possible) as the WMH survey, our goal was to utilize the database of the World Value Survey (WVS; 2015) and employ it to gain country-specific value variables. Using secondary data analyses (meta-analysis and meta-regression), our goal was to establish a novel hypothesis and potential explanation for the cross-national variability of mental disorders’ prevalence.

Methods

The data set we used throughout the analysis comprised data from three sources: (1) prevalence data of mental disorders that were collected from the published results of WMH Survey Initiative (Kessler et al., 2009), (2) cultural values that were obtained from distinct waves of WVS (2015) and (3) immigrant rates of each country that were registered using the data of the United Nations’ World Population Policies (WPP) 2005 report. Below we briefly describe these three data sources and the variables we specifically selected from them.

WMH Survey Initiative

The epidemiological study was monitored by the WHO International Consortium in Psychiatric Epidemiology in each participating country, to provide consistency in terms of translation, sample collection and data analysis. Probability household samples from stratified multistage clustered areas were assessed (Kessler et al., 2007). Diagnoses of mental disorders were established using the third version of WHO Composite International Diagnostic Interview (CIDI; Kessler & Ustün, 2004), which were adjusted for this study. In the WMH study, 28 countries participated. Some countries started data collection at the very beginning of the international project in 2001 (e.g. Belgium, France, Italy, Mexico or Spain), whereas other countries began to get involved in later phases of the research. Data collection was finished in Argentina in 2015.

In our study, the following variables were obtained from the WMH project and analyzed: lifetime prevalence (i.e. prevalence of depression, any anxiety disorder, any mood disorders and any substance use disorder), past year prevalence (i.e. any anxiety disorder, any mood disorder) and the overall severity of psychiatric disorders on the basis of availability of prevalence data. In addition to these data, psychiatric prevalence data were separated into internalizing (i.e. depression, anxiety disorders and mood disorders) and externalizing disorders (i.e. externalizing data and substance use disorder) and combined into one variable for lifetime and past 12-month prevalence.

WVS

WVS is led by an international team and organized by the WVS Association and the WVSA Secretariat (Vienna, Austria). The project started in 1981 and involves almost 100 countries worldwide, applying nationally representative surveys. As such, this study is considered to be the largest cross-national time series research of human beliefs and values, reaching approximately 400,000 respondents from the world’s major cultural zones. A standard questionnaire is used in the study and the data set of the project is freely available for researchers. The WVS database – among many other topics – contains items on cultural values, attitudes and beliefs about gender, family, religion, poverty, education, health and security, social tolerance and trust. As we hypothesized that the following variables might have the strongest linkage to mental disorders’ prevalence, we included two indices: (1) overall secular values (sacred vs secular values) and (2) overall emancipative values (obedient vs emancipative values; deeper knowledge on how these indices were constructed might be gained by visiting http://www.worldvaluessurvey.org/WVSContents.jsp?CMSID=welzelidx). Secular-rational values are common in societies that place less emphasis on religion, authority and traditional family values. These cultures also show a more accepting attitude toward divorce, abortion, euthanasia and/or suicide (Inglehart & Baker, 2000). Emancipative values are associated with increased preference for self-expression, lifestyle liberty, gender equality and personal autonomy (Alexander & Welzel, 2010), and as such, they empower people to freely act and decide (Welzel & Inglehart, 2010). Relevant Schwartz values (e.g. the importance of ‘adventure and risk-taking’ or ‘behaving properly’) were not selected as there were not enough data that allowed for inclusion in the meta-analysis.

WVS has been and is still being conducted in distinct waves: Wave 1 (1981–1984), Wave 2 (1990–1994), Wave 3 (1995–1998), Wave 4 (1999–2004), Wave 5 (2005–2009), Wave 6 (2010–2014) and Wave 7 (2017–2018). In this study, we selected Wave 4 and Wave 5 as these years of data collection showed overlap with the WMH data collection process. For the same reasons, we selected only those countries for the analyses in which both WMH and WVS data were available.

WPP

WPP delineates governmental views and policies regarding 194 member and non-member states of the United Nations. Policies in the areas of population size and growth, population structure, health and mortality or immigration rates are all discussed in its report. To assess each participating country’s cultural heterogeneity, we relied on the UN’s 2005 WPP report and used immigration rate as a potential indicator of cultural heterogeneity. We chose to include this indicator over the more sensitive indices of either Alesina, Devleeschauwer, Easterly, Kurlat, and Wacziarg (2003) (i.e. ethnic, linguistic and religious fractionalization) or Fearon (2003) (i.e. ethnic and cultural diversity), as we aimed to utilize data as close in time to both the WMH and WVS data set as possible (note that Alesina et al. and Fearon conducted their analyses on national data derived from a wide time range, for example, 1983 in case of Italy). Based on the WPP report (United Nations, 2006), we considered the total population’s immigration rate (in percentage, for the year 2005) for each country.

Statistical analyses

Meta-analyses were conducted with Comprehensive Meta-analysis Version 3.0 software (Borenstein, Hedges, Higgins, & Rothstein, 2004). The confidence intervals (CIs) and z-transformations of the prevalence data were used to determine whether the prevalence data were statistically significant. To assess homogeneity of the effect sizes across studies for each prevalence statistic, the Cochran Q-statistic was used (Hedges & Olkin, 1985). If analysis of the Q-statistic revealed significant within-group heterogeneity, we used a fixed-effects model in meta-regression to estimate the impact of the continuous variables (i.e. cultural variables) on prevalence data (i.e. psychiatric variables). In addition, a multistep fixed-effects meta-regression model was undertaken following the first meta-regression models with immigration rates added as a multistep.

Data analysis was based the following statistical analysis plan: (1) as a first step, we aimed to conduct a meta-regression analysis to explore how cultural values (i.e. overall emancipative and overall secular values) might explain the variance of the outcome measures (i.e. psychiatric disorders’ prevalence); (2) as the next step, our goal was to run a multistep regression analysis in which we entered immigration rates as a potential explanatory variable for cultural values. In this second analysis, we further aimed to include only those psychiatric disorder variables as outcome measures that showed significant association with cultural values during the initial meta-regression analysis, to create a as clear-cut model as possible.

Results

Mental disorder prevalence and cultural values

Overall emancipative values showed significant association with lifetime and last year prevalence of any mood disorders and any internalizing disorders, while overall secular values were negatively associated with last year prevalence of depression. Furthermore, overall emancipative values had a significant negative connection with mild severity of all psychiatric disorders and a significant positive association with moderate severity of the same (Table 1).

Table 1.

Meta-regression models of psychiatric disorders’ prevalence with overall emancipative and overall secular values modeled as independent variables.

	Lifetime prevalence rates of psychiatric disorders
	Any anxiety disorders^a	Any mood disorders^b	Any externalizing disorders^c	Any internalizing disorders^d	Any substance use disorders^e
Overall emancipative values Z	0.29	4.71 **	0.07	2.82 **	0.73
Overall secular values Z	−0.23	−0.29	0.92	−1.38	−1.21
	Last year prevalence rates of psychiatric disorders
	Any anxiety disorders^a	Any mood disorders^b	Depression^f	Any externalizing disorders^c	Any internalizing disorders^d
Overall emancipative values Z	0.29	2.35 *	.22	1.45	2.34 *
Overall secular values Z	−0.23	−0.59	−2.75*	−1.41	−1.26
	Last year prevalence of all psychiatric disorders’ severity
	Mild severity		Moderate severity		Serious severity
Overall emancipative values Z	−4.70***		5.13 ***		0.96
Overall secular values Z	−0.67		1.91		−1.40

Bold values indicate significant associations.

The category consists of agoraphobia, adult separation anxiety disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder, social phobia and specific phobia.

The category consists of bipolar disorders, dysthymia and major depressive disorder.

The category consists of impulse-control disorders which include intermittent explosive disorder and reported persistence in the past 12 months of symptoms of three child-adolescent disorders (attention-deficit hyperactivity disorder, conduct disorder and oppositional defiant disorder).

This category merges the two categories of ‘any anxiety disorders’ and ‘any mood disorders’.

The category consists of alcohol or drug abuse with or without dependence.

In case of this variable, data were obtained from this source (Kessler & Bromet, 2013).

p < .05; **p < .01; ***p < .001.

The prevalence of either any anxiety disorders or any substance use disorders was found to be independent of the assessed cultural values. Figure 1 presents random effects forest plots only for those mental disorders that showed any significant connection with cultural values and only for the time period of the past year (i.e. the year before the WMH study). Similarly, meta-regression plots are depicted in Figure 2 to visualize the relationship between past year mood disorders, internalizing disorders, depression and the assessed cultural indices.

Figure 1.

Forest plots by country and prevalence rate within last year psychiatric disorders with significance.

Figure 2.

Meta-regression values as shown with their relationship with last year disorder and regression continuous variable.

A multistep meta-regression model

Finally, immigration rates were entered in a multistep regression model to assess the connection between cultural heterogeneity and cultural values. Findings showed two significant multistep meta-regression models. First, it was shown that the relationship between overall emancipative value and last year mood disorders is moderated by immigration rates (p = .001). Next, it was found that the relationship between overall secular value and last year anxiety disorders is moderated by immigration rates (p = .001). Finally, countries with higher immigration rates were characterized by higher emancipative and secular-rational values.

Discussion

We considered cultural values to be important components of the WMH respondents’ exosystem, and as such, we hypothesized that these values might have affected how participants of the WMH study reported on their symptoms. In line with former findings (e.g. Dowrick, 2009, 2013; Du et al., 2015; Heim et al., 2017; Hidaka, 2012), our results may also indicate that among major mental disorders, primarily the expression of mood disorders is formed by cultural impacts. By stating this, we also emphasize that any association found in meta-regression needs to be interpreted as a basis for addressing novel hypotheses, instead of considering these findings as proof of causality (Baker et al., 2009).

An increase in mood disorders’ and internalizing disorders’ prevalence rates showed convergent tendency with the elevation of emancipative values. Emancipative values – as a subset of self-expression values – increase the individual’s aspiration to exercise freedom (Welzel, Inglehart, & Klingemann, 2003) and also promote non-violent protest (Welzel, Inglehart, & Deutsch, 2005) that might result in the repression of anger and tension. We do hypothesize that exercising freedom can also be manifested in disinhibited symptomatizing and thus in higher prevalence rates. But why do mood disorders (or internalizing disorders in general) show significant association with emancipative values, while externalizing disorders do not? We propose a hypothetical explanation that principally lies within the distinction and social judgment of passivity and activity. One of the core differences between internalizing and externalizing disorders is how patients deal with internal conflicts and tensions: is it an inner-directed symptomatization, generating distress in the patient and resulting in behavioral passivity (internalizing), or rather an outer-directed route of expressing his or her problems, usually by ‘acting them out’ (externalizing; Forns, Abad, & Kirchner, 2011). On a higher societal or economic level, perceived activity or even overactivity of an individual might be less criticized, as externalizing behaviors may not be linked to expected work disability or impaired productivity, unless the symptomatology includes aggression or rule-breaking behavior that might produce sickness absence (Narusyte, Ropponen, Alexanderson, & Svedberg, 2017). Internalizing disorders – especially depression – however, are considered to be one of the leading causes of disability worldwide (McLaughlin, 2011), leading to severe social and economic consequences. Therefore, it might be crucial for the individual – and primary the depressed patient – to monitor the cultural context in which he or she lives and works and ask the questions, ‘Do you let me be passive and unproductive?’ ‘Do you let me symptomatize?’ Furthermore, internalizing disorders – as compared to externalizing disorders – are usually thought to be characterized by a more homotypic continuity (i.e. the disorder does not change significantly over time; Copeland, Shanahan, Costello, & Angold, 2009). This phenomenon further refines the individual’s question, ‘Do you let me be passive and unproductive for a longer period of time?’ We hypothesize that emancipative cultures, stressing the relevance of each citizen’s rights, might rather accept – albeit do not support – continuous passivity, creating a pathway for increased prevalence of internalizing disorders. And, another pathway is also conceivable: if emancipative values – by rejecting violence – may increase the possibility of anger suppression, these values might increase the risk of mood disorders as well, especially if we interpret depressive symptomatology in a psychodynamic way (Freud, 1930).

Emancipative values also showed connection with either mild or moderate severity of all psychiatric disorders but not with serious severity. A potential explanation for these results suggests that culture may influence symptom expression only until a certain level of severity, while in case of severe impairment, other factors – such as the patient’s genotype or the gene-environment interaction – may take over (Uher, 2014).

Regarding past year prevalence of depression, overall secular-rational values showed significant negative association with depression rates. This finding indicates that in cultures in which the individuals experience increased sense of existential security (most commonly in industrial societies) and reject respect for authority and obedience (Inglehart & Welzel, 2005), depression less likely occurs. As secular-rational values also support the acceptance of sensitive issues (e.g. abortion or euthanasia) (Inglehart & Baker, 2000), it is presumed that these values may be associated with lower levels of guilt (a core feature of depression) as well (Praglin, 2004). In a way contrary to this result, Roudijk, Donders, and Stalmeier (2017) reported that secular-rational values show negative association with self-reported health.

Immigration rate was assessed and utilized as an indicator of cultural heterogeneity in our multistep regression model. High immigration rates were associated with enhanced emancipative values, and furthermore, the connection between emancipative values and past year mood disorder prevalence significantly varied by the percentage of the immigration population. These results might underlie the following hypothesis: with the increase in cultural heterogenization, the population itself may show a more accepting attitude and the society may take on a form of modern individualism, propagating a cosmopolitan orientation toward minorities and other people in general (Welzel, 2010).

Bhugra and Becker (2005) state that ethnic density (i.e. the rate of ethnic groups in proportion to the total population) may influence the rates of mental disorders in ethnic minorities. We suggest that ethnic density and cultural heterogeneity also affect the rates of mental disorders in the general population (in the majority group) as mediated by cultural values that are formed by immigration rate.

The association between cultural heterogeneity and a shift toward emancipative values can be explained in various ways, out of which we hereinafter discuss two potential directions. (1) Those countries with higher emancipative values might have a tendency – for example, open border policy – to accommodate and then assimilate people from other countries and cultures, who are seeking better living conditions (i.e. emancipative values as triggers of increased immigration rates). (2) Countries that are characterized by higher cultural heterogeneity may face recurrent conflicts between minority and majority groups. To gain and maintain social balance, these countries may need to attenuate cultural tension by the processes of assimilation and sensitization (Hirschman, 2013; Khanna, Cheyney, & Engle, 2009; Young & Guo, 2016) through programs that might increase emancipative values (i.e. immigration rate as a facilitator of enhanced emancipative values). As we are presently in the middle of a mass migration crisis, the question what will this rapid change in cultural heterogeneity produce society-wise in terms of economics (Taylor et al., 2016), cultural identity/values (Bhugra & Becker, 2005) or – as we also presented – population mental health (Virupaksha, Kumar, & Nirmala, 2014) is truly current and thus needs to provoke further in-depth research in the field of psychiatry.

Limitations and recommendations for future research

Our study has several limitations. We applied a method (meta-regression) that is suitable for producing hypotheses but not for reliably testing theoretical assumptions. Instead of meta-analyzing several studies dealing with the prevalence of mental disorders, we analyzed the findings of a single research (WMH), although conducted in several countries. We tried to find studies (WVS and WPP) as close in time to the WMH project as possible to make data comparable, yet in case of some countries, there were still a few years distance in data collection dates. We aimed to address some hypotheses to be tested and raise awareness about the relevance of the cultural context while acknowledging that the etiology of mental disorders is much more complex than the impact of the individual’s exosystem itself.

Main strength of this study lies in the fact that it (1) made an attempt to rule out methodological differences in the measurement of mental disorders’ prevalence to restrict the number of third factors and therefore the risk of confounding bias; (2) operationalized cultural values based on a research (WVS) using probability samples, instead of simply labeling cultures as individualistic or collectivistic and (3) provided potential explanation for an understudied association between cultural values and the epidemiology of psychopathologies.

The presented findings might raise further questions. How do values and beliefs of a mental health professional affect the establishment of mental disorder diagnosis? Do the values and beliefs of the patient have an impact on the manifestation of his or her symptoms? How can cultural differences influence therapeutic relationships? Many of these or similar questions have already been addressed by others without a significant response. Putsch and Joyce (1990) published a recommendation on how to treat patients from other cultures in the beginning of the 1990s. Almost three decades have passed since then, and there are still a vast number of papers (Constantinou, Papageorgiou, Samoutis, & McCrorie, 2018; Desapriya, Mehrnoush, & Bandara, 2018; Grandpierre et al., 2018) trying to prove that cultural competence would be indeed an important skill/knowledge in our everyday practice. One of the most recent example of this endeavor is the Healthy Diversity Project (http://healthydiversity.eu/our-project/), aiming to expand health professionals’ capacity in meeting the needs of patients with different cultural background.

By contrast, what does reality look like? In many countries, exploring the patients’ personal values or cultural beliefs usually does not form part of the standard assessment procedure (diagnostic interview) in clinical care. Psychiatric nosologies have been (Aderibigbe & Pandurangi, 1995) and still (Alarcón, 2009) are neglecting culture-bound syndromes and cultural differences in the expression of psychopathologies. As Njenga (2007), among others, also raised awareness, the concept of mental disorders is necessarily a dynamic one, changing across time/generation and cultures. By maintaining a similar critical approach, we may also recognize cultural specificities as part of the normal personality and not necessarily as manifestations of certain syndromes.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the ÚNKP-17-4 New National Excellence Program of the Hungarian Ministry of Human Capacities.

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