Traces of culture: The feedback loop between behavior,brain,and disorder

Abstract

Culture is part of an extensive series of feedback loops, which involve multiple organismic levels including social contexts, cognitive mediations, neural processes, and behavior. Recent studies in neuroscience show that culturally contingent social processes shape some neural pathways. Studying the influence of cultural context on neural processes may yield new insights into psychiatric disorders. New methodologies in the neurosciences offer innovative ways to assess the impact of culture on mental health and illness. However, implementing these methodologies raises important theoretical and ethical concerns, which must be resolved to address patient individuality and the complexity of cultural diversity. This article discusses cultural context as a major influence on (and consequence of) human neural plasticity and advocates a culture–brain–behavior (CBB) interaction model for conceptualizing the relationship between culture, brain, and psychiatric disorders. Recommendations are made for integrating neuroscientific techniques into transcultural psychiatric research by taking a systems approach to evaluating disorders.

Keywords

transcultural psychiatry cultural neuroscience fMRI neural plasticity culture–brain–behavior interaction model CBB model cognitive mediation

Culture involves dynamic social processes that influence most psychiatric disorders. Culture can be defined as systems of converging social and contextual elements, in which people within a specific demographic or social group participate (Hong, Morris, Chiu, & Benet-Martinez, 2000; Kemmelmeier & Kühnen, 2012; Markus & Kitayama, 2010; Kirmayer & Ban 2013). Many psychiatric disorders, including schizophrenia, depression, and anxiety, exhibit cross-cultural variations in reported symptoms and clinical presentation (Bhugra, 2006; Kalra, Bhugra, & Shah, 2012; Kirmayer, 2001; Kirmayer & Groleau, 2001). There may also be cultural variations in their etiology and underlying biological mechanisms. However, culture is not simply a discrete set of factors that lead to the emergence of psychopathology; instead psychopathology results from dynamic feedback loops between culture, mind, and brain mediated by processes at multiple levels (Crafa & Nagel, 2014, 2019; Kirmayer & Crafa, 2014; Ryder, Ban, & Chentsova-Dutton, 2011).

Recent findings from non-patient studies using fMRI suggest that some potentially clinically relevant brain-based differences exist across cultural contexts (e.g., Cheon, Mathur, & Chiao, 2010; Chiao & Blizinsky, 2013; Chiao, Cheon, Pornpattananangkul, Mrazek, & Blizinsky, 2013; Meyer, Way, & Eisenberger, 2013; Severance et al., 2013; Wang, Ma, & Han, 2013). The few neuropsychiatric studies that have been conducted transculturally support this claim (e.g., Koh & Milne, 2012). Considering that both psychiatric disorders and related neural events vary by culture, “Western” dominance in neuropsychiatry may produce systematic sampling biases and under-represent the global population in the data and current literature (Crafa & Nagel, 2014). Since neuropsychiatric research is used as a basis for medical practice, the effects of culture on neuropsychiatric processes ought to be examined to ensure that patients from diverse backgrounds receive adequate care. Increasing use of neuroscientific methods in transcultural psychiatric research could expand knowledge to diverse patient populations across social and cultural groups, and potentially help identify important similarities and differences that may be relevant to diagnosis or treatment (Crafa & Nagel, 2014, 2016).

Although this article advocates increased integration of fMRI and other neuroscientific methods, their use in transcultural psychiatric research must be conducted with the utmost care. In particular, implementing these methodologies risks reliance on cultural stereotyping to form hypotheses or to interpret findings, and care must be taken to avoid reinforcing social stigma or cultural prejudices. Current culture–brain interaction models rely on studies comparing ethnocultural groups, which share the risks of stereotyping. Most of these models do not account for issues relevant to cross-cultural studies of psychiatric disorders: for example, the primacy of individual variation and malleability, or the complexity of the culture–brain interaction across the lifespan (Freeman, 2013; Han et al., 2013). New models are needed to address these issues.

By synthesizing the strengths of cultural neuroscience (CN) methodologies with the priorities and considerations central to transcultural psychiatry, many possible pitfalls can be avoided and more mechanisms can be considered. In the following sections, we outline the Culture–Brain–Behavior (CBB) interaction model, a theoretical framework that attempts to avoid neuroreductionism and emphasize individual malleability and diversity across the lifespan (Crafa & Nagel, 2013, 2016, 2019). First, we will illustrate the potential for fMRI research to identify cultural variations in the phenotypes of psychiatric disorders by focusing on recent findings in CN. Second, we outline problems with over-reliance on fMRI, demonstrating the necessity for a refined model for implementing fMRI in transcultural psychiatric studies to achieve a better understanding of patient populations. The reasons that neuroreductionism is problematic for cultural psychiatry are specifically addressed. Finally, the CBB interaction model will be offered as an alternative systems approach to transcultural research.

Potential applications of cultural neuroscience in psychiatry

Perhaps more than any other methodology, neuroimaging research in psychiatry is subject to what is commonly termed “Western” bias (Henrich, Heine, & Norenzayan, 2010), meaning that scientific research disproportionately comes from North American and Western European countries. Despite important contributions from some “Eastern” countries, such as China and Japan, a majority of cultures and subcultures are not represented in neuroimaging studies (Gogolin, 2002; Henrich et al., 2010; Isamah et al., 2010; O’Brien et al., 2006). For example, studies of psychopathology and its treatments are dominated by a handful of countries, leaving their findings potentially biased and of uncertain generalizability. In psychiatry, findings from fMRI studies are increasingly used in efforts to characterize disorder endophenotypes and may be used as theoretical justification for promoting specific medications or therapeutic approaches, but many populations are underrepresented in this research (e.g., Pliszka, 2012).

The emergence of CN over the last decade has brought new approaches to studying cultural diversity by using neuroimaging, especially fMRI. Some CN studies compare groups of people living in “Eastern” and “Western” countries while other studies compare recent immigrants or ethnic minorities to dominant or native populations. These studies have shown that brain activity differs in key areas when participants from different cultures are asked to perform particular tasks (Zhu, Zhang, Fan, & Han, 2007) or when participants from the same culture are placed in different sociocultural situations (Sui, Hong, Liu, Humphreys, & Han, 2013). Although these studies are usually performed with healthy control participants, they have implications for clinical research. In particular, many of the brain regions that have been commonly reported by recent studies as varying in activity across cultures substantially overlap with brain regions that have been repeatedly shown by contemporary research studies to vary for several psychiatric disorders (Table 1). For example, culture-based differences have been reported in areas of the prefrontal cortex (Ray et al., 2010; Han, Mao, Qin, Friederici, & Ge, 2011), cingulate cortex (Harada, Lia, & Chiao, 2010; Ray et al., 2010), parietal lobe (Hedden, Mao, Qin, Friederici, & Ge, 2008), and amygdala (Derntl et al., 2012). These regions exhibit distinctive patterns of activity in many disorders, such as schizophrenia (Mukherjee et al., 2013; Pedersen et al., 2012; Pomarol-Clotet et al., 2010; Torrey, 2007), post-traumatic stress disorder (Stevens et al., 2013), autism (Gilbert, Bird, Brindley, Frith, & Burgess, 2008; Kleinhans et al., 2010), major depression (Korb, Hunter, Cook, & Leuchter, 2011; Murray, Wise, & Drevets, 2011), and general anxiety disorder (Ressler, 2010). Accordingly, the brain activity associated with some psychiatric disorders may also vary across cultural groups (Crafa & Nagel, 2014, 2016).
Table 1.
Examples of regional brain activity and processes that vary across cultures and disorders.

Brain region Differences identified via cross-cultural comparisons Neuropsychiatric conditions associated with regional differences

Medial prefrontal cortex Different activity patterns during social tasks (e.g., self-affiliation)¹ Autism², schizophrenia³, bipolar disorder⁴, general anxiety disorder⁵, major depressive disorder⁶

Rostral anterior cingulate cortex Different activity patterns during social tasks (e.g., self–other representation)⁷ Autism⁸, schizophrenia⁹, bipolar disorder¹⁰, social anxiety disorder¹¹, major depressive disorder¹²

Left inferior parietal lobe Different activity patterns during perceptual tasks and social cognition (e.g., visual attention control)¹³ Autism¹⁴, schizophrenia¹⁵

Amygdala Different activity patterns depending on sociocultural meaning of stimuli (e.g., in-group/out-group)¹⁶ Autism¹⁷, schizophrenia¹⁸, bipolar disorder¹⁹, general anxiety disorder²⁰, major depressive disorder²¹, social anxiety disorder²²

Note. Originally published in Crafa and Nagel, 2016, p. 49. Reprinted with permission, with updated regions and references.

Citations indicated by superscript: ¹Chiao et al., 2009, Huang et al., 2019; ²Gilbert et al., 2008, Padmanabhan et al., 2017; ³Hu et al., 2017, Pomarol-Clotet et al., 2010, Wang et al., 2018; ⁴Herold et al., 2017, Keener et al., 2013, Zhong et al., 2019; ⁵Blair et al., 2017, Kim, Gee, Loucks, Davis, & Whalen, 2011; ⁶Kaiser et al., 2016, Murray et al., 2011; ⁷Pornpattananangkul et al., 2016, Ray et al., 2010; ⁸Abrams et al., 2019, Chan et al., 2011; ⁹Pedersen et al., 2012; ¹⁰Rutherford et al., 2019, Wang et al., 2009; ¹¹Cui et al., 2019, Klumpp, Post, Angstadt, Fitzgerald, & Phan, 2013, 2017; ¹²Cooney et al., 2010, Webb et al., 2019; ¹³Hedden et al., 2008, Moss, 2016; ¹⁴Carlisi et al., 2017, Koshino et al., 2005, Yang & Hofmann, 2016; ¹⁵Fassbender et al., 2014, Jáni et al., 2018, Torrey 2007; ¹⁶Derntl et al., 2012; ¹⁷Kleinhans et al., 2010; ¹⁸Mukherjee et al., 2013; ¹⁹Brotman et al., 2010; ²⁰Usher et al., 2010; ²¹Suslow et al., 2010; ²²Sladky et al., 2012.

Some recent studies already demonstrate how neuropsychiatric research could be informative for transcultural diagnosis and treatment. For example, one study compared visual processing in children with and without autism spectrum disorders in England and Singapore to evaluate Central Coherence Theory (CCT) (Koh & Milne, 2012; Milne & Szczerbinski, 2009). CCT claims that a certain perceptual-cognitive style underlies the disturbances in autism (Frith, 1989; Happé & Frith, 2006). When researchers tested CCT across cultures, Singaporean children—whether autistic or not—displayed a different processing style than expected. This evidence suggests that the trait described by CCT may be culture-specific—and the theory may be too (Koh & Milne, 2012). This finding underlines the powerful influence sociocultural experiences can have on biological processes associated with psychiatric disorders. Similar studies conducted across a variety of disorders and cultures could improve understanding of fundamental variations in disorder phenotypes.

CN research could help clarify many current issues in cultural psychiatry. For example, as Seligman and Kirmayer (2008) point out, many studies of dissociation focus on pathology. It might be helpful to conduct fMRI research in cultural contexts where non-pathological dissociation is prevalent, such as those where spirit possession is commonly practiced, in order to identify neural processes that correlate with pathological dissociation versus non-pathological dissociation. Again, current findings identify relationships between certain patterns of brain activity and cognitive process (such as memory suppression or shifts in self-regulatory attention) that appear to have different consequences across cultural contexts, which might contribute to cultural differences in dissociative processes (Seligman & Kirmayer, 2008).

Improved understanding of functional brain processes across ethnocultural communities will help parse the relationship between cultural context and disorder. CN studies must be designed carefully to avoid oversimplifying the relationship between culture and neural processes. However, if pursued correctly, such studies have the power to use neuroscientific tools to clarify relationships that are currently confounded or conflated and to extend neuropsychiatry to global populations.

Despite the potential it holds for cultural psychiatry, CN is a relatively new field and it is still working out methodological challenges. For example, CN is sometimes criticized for broadly defining culture according to geographic borders and examining poorly defined or uncontrolled cultural variables (Dressler, 2004; Hunt & Bhopal, 2004; Kagawa Singer, 2012; Winker, 2004). CN has also received criticism for the use of East/West dichotomies, which arguably reduces culture to binary categories (Vignoles et al., 2016). Other binary contrasts, including collectivist/individualist, interdependent/independent, and holistic/analytic, are commonly used in these experiments. For example, Koh and Milne’s (2012) autism study described above compared individuals from “Eastern” and “Western” countries to investigate “holistic” versus “analytic” visual processing styles stereotypically ascribed to “collectivist” versus “individualist” cultures. These categories may be especially problematic if they are simply assigned based on previous research on groups from the participants’ birth country and not by measuring the relevant constructs in individual study participants.

Binary categories are not as useful as other systems for describing culture, such as ecocultural approaches (Georgas, van de Vijver, & Berry, 2004) or multidimensional measurements (Choudhury & Kirmayer, 2009). These more nuanced approaches can be used to supplement simpler categorical measures to provide a more complete picture of the cultural context and individual variation. For example, multidimensional measures can be used to describe the diverse social and ecological dynamics within cultural contexts (e.g., the varying degrees of autonomy and relatedness observed in different social situations and cultures, cf. Keller, 2003; Keller, Demuth, & Yovsi, 2008) as well as individual variations in the beliefs and practices that are common within a particular subculture or in bicultural populations (Chiao et al., 2009, 2010). The emphasis on East/West comparisons in CN research leaves much of the global population unexamined and points to the need to expand the study of brain–culture interactions to other populations.

Despite these criticisms, CN has taken important first steps toward integrating the study of neural and cultural phenomena, through studies that provide a foundation for future work (Chiao & Cheon, 2012; Crafa & Nagel, 2014, 2016; Han et al., 2013). Indeed, past criticisms can be seen as opportunities for future growth. By carefully integrating fMRI methods into cultural psychiatric research, knowledge of the patient can be extended to include neurological dimensions that add to our understanding of disorders and their cultural variability.

Adequacy of cultural neuroscience models for transcultural psychiatric research

While fMRI research is not inherently incompatible with the aims of cultural psychiatry, the current methods and interpretations of fMRI findings contain theoretical biases that preclude the recognition of patient individuality, changeability, and perspective. In particular, current models describing the relationship between brain and culture—the neuro–culture interaction (NCI) model being among the most prominent (Kitayama & Uskul, 2011)—because they do not account for neurocognitive flexibility, seem to treat the relationship between culture and neural events as fixed or immutable. Current CN models describing human cultural development in terms of feedback loops can provide a more adequate model (e.g., Crafa & Nagel, 2013; Han & Ma, 2015). However, some of these models (e.g., Han & Ma, 2015) rely heavily on binary East/West, individualist/collectivist distinctions and do not acknowledge the range of contextual, biological, and individual dimensions that are necessary to account for diverse populations including migrants and patients with psychopathology (Crafa & Nagel, 2013; Vogeley & Roepstorff, 2009; see Maruyama, 1977, for historical background).

In current CN models, culture is usually defined as collectively shared meanings, beliefs, behaviors, and conventions (Kitayama & Uskul, 2011). Individual psychological processes are influenced by the collective culture that the individual is exposed to, and the act of repeating adopted attitudes and practices directly alters the brain: “the brain acts as a crucial site that accumulates the effects of cultural experience” (Kitayama & Uskul, 2011, p. 422). According to Kitayama and Uskul, after culture-specific attitudes and practices have been adopted, they become “embrained” and are no longer cognitively mediated.¹ In the NCI model, neural events initially reflect cultural learning and subsequently, behavioral practice. Although we initially act according to our values, repeating these actions causes deep neural changes so that the culturally shaped behaviors or patterns of response eventually become automatic (Kitayama & Uskul, 2011).

Although careful to acknowledge individual behavioral diversity and malleability elsewhere (e.g., Kitayama, Park, & Cho, 2015), the NCI model does not describe mechanisms of this diversity and is nonetheless presented as universally applicable. The model also posits that, “Culturally shaped activation patterns of the brain… enable the person to perform culturally scripted behaviors… both automatically and seamlessly” (Kitayama et al., 2011, p. 424). Statements such as these imply, first, that culturally scripted behaviors can be prescriptively learned and, second, that once learned, the cultural script becomes automated. Although the authors may not intend this to be a rigid description, the eventual automaticity of these processes nonetheless presumes a degree of stability that seems too inflexible to capture most culturally influenced actions.

Current literature calls the assumptions of both prescriptive learning and automaticity into question (see e.g., Bohn, 2010; Chiu, Gelfand, Yamagishi, Shteynberg, & Wan, 2010; Li, Wang, Wang, & Shi, 2010; Pecchioni, 2012). Many psychiatric disorders are characterized by inappropriate social behaviors, suggesting that culturally scripted behaviors may have been incorrectly learned or that some process is interfering with their performance (see Crafa, Schiff, & Brodeur, 2019). Most psychiatric disorders, for example, are characterized by social behaviors that are considered socially unacceptable or maladaptive in some way, which indicates that some cultural scripts dictating appropriate social behavior may have been violated. In some countries approximately half of the population experiences a mental disorder during their lifetime, suggesting that there is substantial population-wide variability in learning social behaviors (Reeves et al., 2011). Moreover, there is a difference between understanding cultural scripts and emulating them (Thomas, 2010).

The assumption of automaticity in performing according to cultural norms also runs contrary to some of what is currently known about neural and social and cultural change across the lifespan (e.g., Canu, Coq, Barbe, & Dinse, 2012). While some automaticity may occur, both cultural scripts and neural events are highly variable and change dynamically across the lifespan (for reviews of change in cultural scripts see: During, Elahi, Taieb, Moro, & Baubet, 2011; of neural plasticity see: Buonomano, 1998; Jäncke, 2009; Pascual-Leone, Amedi, & Fregni, 2005; Poldrack, 2000). In fact, the human brain exhibits pervasive neural plasticity, which is reflected by sometimes dramatic changes in neural network processes in response to individual social experiences (Burke & Barnes, 2006; Thomas & Baker, 2012) even late into adulthood (Dinse, 2006; Gould, 2007; Kempermann, 2012; Rakic, 2002; Thomas & Baker, 2012). Experience-dependent neural plasticity occurs when brain events are changed through practice or observational learning (Kleim, 2008; Yu, Roland, Xu, & Stein, 2013). It has been theorized that personal changes resulting from self-reflection, such as may occur in psychotherapy, can also bring about brain-based changes; however, this research is still in the early stages (Frewen, Dozois, & Lanius, 2008; Linden, 2006; Morgiève et al., 2013; Roffman, Marci, Glick, Dougherty, & Rauch, 2005; Zaman, 2010).

Three sets of conceptual problems occur when designing and interpreting fMRI studies in CN: (1) neuroreductionism; (2) attempts to “locate” culture in the brain; and (3) reliance on cultural stereotypes to form hypotheses or interpret results. These problems are particularly important for cultural psychiatry because they undermine recognition of patients’ social circumstances. By providing a more nuanced framework describing the relationship between culture and disorder, the CBB model aims to avoid these problems.

In the context of fMRI studies, neuroreductionism is seen in the assumption that our brains solely determine our actions, thereby attributing beliefs and behaviors entirely to neural events (Choudhury & Kirmayer, 2009; Choudhury, Nagel, & Slaby, 2009; Gold, 2009; Kirmayer & Gold, 2012). Neuroreductionism can preclude consideration of dynamic “human factors,” such as meaning, experience, and culture, and ignores other organismic levels such as physiology and perception, which may be reflected in neural events but are not necessarily reducible to them (Kirschner, 2010).² Although fMRI and other neuroimaging methods can provide information about changes in individuals’ internal states, these are only part of the larger organism–environment interaction to which the brain adapts, which must be included for ecologically valid research and clinical applicability (Fuchs, 2011).

A second major set of issues arise from trying to “locate” culture in the brain. Brain-based measures of cultural traits sometimes downplay both the brain’s plasticity as well as the diversity and changeability of culture. The neural processes examined in CN studies may change within an individual’s lifetime or from one social situation to the next or over time as cultures change (e.g., Chiao et al., 2009, 2010). Although some brain-based commonalities among individuals may reflect the influence of similar sociocultural experiences, these similarities are not identical with “culture” and are more parsimoniously described as byproducts of specific sociocultural learning.

Reliance on crude ethnocultural categories and stereotypes is another issue sometimes encountered in CN research. Choudhury and Kirmayer (2009) point out the problem of conflating culture with nationality, for example. Individuals residing within the same national borders are all too often assumed to belong to the same culture. Attention to the ascription of cultural identities is essential for the study of cultural differences, given the history of marginalizing minority groups and reinforcing racist stereotypes (Chen, 2008; Choudhury & Kirmayer, 2009; Kagawa Singer, 2012; Schouten & Meeuwesen, 2006). Some studies in CN include recent immigrants (e.g., labelled in terms of their geographic origin, e.g., an “East Asian” sample), without acknowledging either the heterogeneity of the population or the fact that immigrants may be experiencing acculturation (e.g., Gutchess, Hedden, Ketay, Aron, & Gabrieli, 2010), which can occur rapidly and result in great variability in culturally-related behaviors (Yorulmaz & Işık, 2011). Considering that people experience and subscribe to different cultural domains to different degrees and may display different degrees of cultural fit in different domains (Crafa, Liu, & Brodeur, 2019; Weller, 2007), experiments designed in terms of specific cultural domains rather than “culture” as a general category will produce more meaningful results (Greenfield, Keller, Fuligni, & Maynard, 2003; Keller, 2006).

With these caveats in mind, useful insights can be gained from current CN models. In particular, the NCI model describes practiced behaviors as leading to neural changes which reflect sociocultural differences (Kitayama & Uskul, 2011). While the initial changes are flexible they may become automatized—an order of events that agrees with evolutionary theories of adaptation to the environment, and with developmental studies of children across cultures (Kärtner, Keller, & Yovsi, 2010; Greenfield, 2009). The CBB model, described below, takes a systems approach to the relationship of culture and the brain, accounting for behavior as a means of cultural learning. Figures 1 and 2 depict the similarities and differences between the NCI and CBB model. The CBB model aims to avoid the pitfalls of other models through carefully interpreting recent findings to clarify the relationship between culture, brain, and disorder. The CBB model diverges from central claims of previous models of culture–brain relationships by rejecting the assumptions that 1) cultural scripts are performed automatically and seamlessly and that 2) after culture-specific attitudes and practices have been adopted, they are no longer cognitively mediated. Instead, the CBB model posits that 1) cultural scripts are not always correctly performed and 2) cognitive mediation is an ongoing mechanism of change across the lifespan (Figure 2). In fact, cognitive mediation is integral to the rich interplay between culture, “mind,” and brain in everyday life and to the effectiveness of many forms of clinical intervention. Finally, the CBB model offers ways to define cultural and pathological behaviors that complement existing descriptive definitions while being more easily operationalized for quantitative research. These definitions are meant to replace the binary categories used in previous studies.
Figure 1.
The NCI model proposes many useful basic components of the brain and behavioral processes that occur once novel sociocultural information is encountered. This model acts as the foundation of the CBB model described in the present article.

Figure 2.
The CBB model builds upon the NCI model’s basic framework to further specify the dynamic and fluctuating processes that account for individual heterogeneity, lifespan change, population variance, and instances of poor cultural fit or changes to cultural fit (e.g., acculturation) across the lifespan. In the CBB model, cognitive mediation is a key mechanism of the feedback loop that can initiate these changes and which does not rely upon the introduction of new sociocultural information to be integrated.

The CBB approach agrees with other models that present culture, “mind,” and brain as multiple levels of a single, organic system (e.g., Fuchs, 2011; Ryder et al., 2011). Further, this model extends the endeavor to consider individual behaviors and clinical variations within cultures by integrating neuroscientific tools into the repertoire of methods used to build a comprehensive and globally oriented understanding of the patient. Ultimately, the CBB model is designed to provide a conceptual foundation for neuroscientific research in cultural psychiatry.

Central tenets of the CBB model

The central tenets of the CBB model can be summarized as follows: 1) the ability to change in response to the environment at any time during the lifespan is central to all organismic levels of organization; 2) fluctuations at multiple levels create feedback loops, allowing the levels to inform and change each other; and 3) individual variations fall along cultural continua of common behaviors within a defined group (see Table 2). Each of these tenets emphasizes the flux that all organismic levels are constantly undergoing. Although embracing the complexity of human phenomena raises difficult questions, such as how to operationally define culture, it avoids the three pitfalls described in the previous section and provides alternative paths to understanding the impact of cultural variations. Replacing the idea that culturally scripted behaviors are performed “automatically and seamlessly” after being acquired through cognitive mediation (Kitayama & Uskul, 2011, p. 424), the CBB model proposes that cognitive mediation reoccurs across a person’s lifetime and participates in a feedback loop between brain, behavior, and experience that propels learning and leads to fundamental changes in beliefs, intentions, or behaviors that may substantially deviate from previously learned cultural scripts and that are reflected in biological changes (for initial findings see Crafa, Schiff, & Brodeur, 2019).
Table 2.
Central tenets, caveats, and characteristics of the CBB model.

Central tenets

Tenet 1 The ability to change in response to the environment at any time during the lifespan is central to all organismic levels of organization.

Tenet 2 Fluctuations at multiple levels create feedback loops, allowing the levels to inform and change each other.

Tenet 3 Individual variations fall along cultural continua of common behaviors within a defined group.

Caveats

Caveat 1 Cultural scripts are not always correctly performed.

Caveat 2 Cognitive mediation is a recurring mechanism of change across the lifespan.

Characteristics of proposed methods

Characteristic 1 Taking a systems approach to the study of culture, brain and behavior avoids overemphasis on a single organismic level.

Characteristic 2 Grounding the approach in neuroplasticity and epigenetic mutability acknowledges individual variation and lifespan change.

Characteristic 3 Defining cross-cultural groups in terms of multiple domains and dimensions rather than discrete categories or binary oppositions.

The first tenet of the CBB model recognizes that neuroplasticity is a prerequisite for all learning. The process of cultural acquisition and individual change may be based on a dynamic interplay between social learning and behavioral observation (Gergely & Csibra, 2005; Meltzoff, 2007a, 2007b). Infants show measurable culture-specific behaviors (Kärtner et al., 2010; Tomasello, Carpenter, Call, Behne, & Moll, 2005) and these behaviors often become more entrenched but, as the individual progresses toward adulthood, a sophisticated repertoire of behaviors may develop that are distinct from those of other members of the same culture (e.g., Arnett, 2006, 2007; Côté, 2000; Krings, Bangerter, Gomez, & Grob, 2008; Nelson & Chen, 2007; Scharf & Mayseless, 2010; Seiffge-Krenke & Gelhaar, 2008; Shanahan, 2000).

Self–other mapping, for example, is one potential mechanism underlying cultural differentiation and its diversity (Losin, Dapretto, & Iacoboni, 2009; Meltzoff, 2007a, 2007b; Paulus Hunnius, & Bekkering, 2012). Self–other mapping refers to the processes of learning the behaviors of others by mapping their actions onto oneself through observation and mimicry (Brooks & Meltzoff, 2002, 2005; Gallagher & Meltzoff, 1996). Previous research demonstrates that self–other mapping engages brain regions including the prefrontal cortex (PFC), which exhibits different activity patterns relative to sociocultural identity (Losin et al., 2009; Saito et al., 2010). The latest studies suggest that physiological or neural synchronization between two or more people may also contribute to ease of learning from others (Bevilacqua et al., 2019; Davidesco et al., 2019; Wass et al., 2019). This self–other mapping helps a person to understand others and acquire new behaviors, and it is hypothesized to be at the heart of learning culture-specific behaviors (e.g., Brooks & Meltzoff, 2002, 2005; Gallagher & Meltzoff, 1996; Gergely & Csibra, 2005; Tomasello, Hare, Lehmann, & Call, 2007).

In principle, this mapping may be implicit in the processes of cognitive mediation and “embraining” described by the NCI model. However, the NCI model does not explain how cognitive mediation occurs or how social behaviors are produced prior to “embraining.” We suggest self–other mapping as one possible mechanism for this process. Through exposure to cultural scripts and practiced behaviors, social conventions are learned and the brain changes. However, unlike other models, the CBB model emphasizes that individuals may alter observed or learned culturally scripted behaviors as they are integrated through cognitive mediation and through either imperfect behavioral mimicry or refinement of observed behaviors. For example, evidence suggests that infants generally mimic successful behaviors (Hauf & Aschersleben, 2008; Paulus, Hunnius, Vissers, & Bekkering, 2011). On the one hand, when infants observe someone failing to complete an attempted task, they frequently attempt behaviors that are both different from and more effective than the behaviors they observed (Meltzoff, 2007a, 2007b). On the other hand, disruptions to motor processes or even failure to pay attention to an observed action can result in imperfect mimicry (Cossu et al., 2012). In both cases, the behavior varies but the intention remains the same. However, the demands of different environments may lead to alterations in behaviors by changing intentions (e.g., Hammack, 2008; Koepke & Denissen, 2012; Legare, Wen, Herrmann, & Whitehouse, 2015). Through a mechanism like self–other mapping, it seems likely that cultural behaviors are learned and interact with many other organismic levels and ecocultural pressures. However, these learned behaviors are not direct replicas of the original behavior. Instead, they deviate from the observed or even mimicked behaviors through cognitive mediation and circumstance.

In this instance, the order of events proposed by the NCI model is preserved in the CBB model (see Figure 1). The CBB model adds to this by integrating the literature from neural plasticity and human development regarding the ability to change as a necessary predecessor for social learning and cultural acquisition (Ambady & Bharucha, 2009; Han et al., 2013; Hari, 2009; Greenfield, 2009), which is implicitly assumed but not accounted for in the NCI model. Moreover, the CBB model integrates studies of individual variability and those reporting that social learning behavioral change continues throughout the human lifespan (Caroni, Danato, & Muller, 2012; Pavlowsky, Chelly, & Billuart, 2012; Valnegri, Sala, & Pasafaro, 2012). Evidence from research on neural plasticity during human development demonstrates the prevalence of biological plasticity by showing that the ability to change also holds for biological change, which does not contradict the NCI model but is pervasive and explained in the CBB model. Once learned, cultural behaviors, like all behaviors, must be maintained through repetition (Shors, Anderson, Curlik, & Nokia, 2012). For example, across a lifetime, individuals partially forget unused language skills, migrants who have acculturated partially unlearn certain culturally scripted behaviors (Aslan & Bäuml, 2011; Weltens, de Bot, & van Els, 2012). Analogously, the new skills that replace the old—such as a frequently spoken second language or newly acquired cultural script—arguably lead to neural changes. Considering their respective bodies of work, Kitayama and Uskul are doubtlessly aware of such changes; however, the NCI model itself does not explain how they might occur or how exactly they might alter brain relevant processes. The CBB model adds this component.

The above point can be extended: even for practiced behaviors, the same behavior is not simply replicated but constantly altered and refined over time. Corresponding neural circuits are continuously altered and refined as well. This point is essential to cultural learning and leads to the second tenet of the CBB model: fluctuating organismic levels, which can include socio-environmental changes, biological changes, or self-reflection, may prompt cognitive mediation and constitute the circuitry of the feedback loop between informational output and information processing and neural encoding.

Such changes may accumulate or resonate within us, and eventually feed back into our sociocultural environment in subtle ways. Our behaviors and other actions create sociocultural experiences that can reinforce or help alter the behaviors and neural events of others. In essence, we act as subtle progenitors of cultural change. This second feedback loop between internal processes of cognition and encoding and external processes of behavioral displays and culture is ongoing with each new experience, and research may discover differences in individuals and populations over time.

When considering the application of fMRI to cultural psychiatry, cognitive mediation plays a key role in the interplay between culture and brain by acting as an intermediary during sociocultural learning. Both new and repeated experiences initiate learning processes, which are cognitively mediated. Through cognitive mediation, new experiences can lead to the development of new behaviors. Repeated experiences sometimes reinforce existing behaviors, but they can also reveal qualities that the individual finds imperfect or no longer values and potentially reactivate cognitive mediation and lead to behavioral change.

The CBB model breaks from the view that once culture-specific attitudes and practices have been adopted, they become “embrained” and are no longer cognitively mediated (cf. Kitayama & Uskul, 2011). Instead, it claims that the process of cognitive mediation feeds back into cultural learning, altering both the lessons that have been learned and the corresponding neural changes that occur and “embraining” of discrete cultural attitudes and practices may be altered or incomplete. This accords with the observation that cultural scripts are not always performed “automatically” or “seamlessly.” Furthermore, cognitive mediation is a mechanism that can alter performance of cultural scripts. Such alterations feed back to the other organismic levels, and are reflected in behavioral and neural changes. This claim is supported by recent neuroimaging studies of cognitive behavioral therapy (CBT), a technique that assumes cognitive mediation can alter behavior. These studies demonstrate that cognitive mediation also alters neural activity (Frewen et al., 2008; Linden, 2006; Roffman et al., 2005). The CBB model offers a paradigm shift away from the traditional reductionisms pervasive in neuroscience. Previous models have failed to truly represent the neurology of cultural behaviors, partly because they do not directly discuss the role of plasticity across the lifespan and revisions that may occur to earlier learning—thus simultaneously neglecting the continuous and dynamic link between culture, the brain, and behavior.

Similarly, the failure to address the role of individual diversity within previous models reflects the failure to understand the mechanics of the interplay between culture, the brain, and behavior. As the third tenet of the CBB model holds, individual variations fall along cultural continua of behavioral dimensions common to a defined group. In any population, there is a large amount of individual variation although certain practices clearly vary by cultures that may be common to a geographic region, ethnic group or nation, making cultural phenomena worth studying. However, these broad cultural groupings are too general for research to solely rely on as they neglect the substantial individual variability that exists within delineated groups. The high cultural variability observed in many psychiatric disorders, which is most pronounced in culture-bound syndromes, demonstrates that sharing similar sociocultural contexts can lead to specific behavioral outcomes relevant to psychiatry. Individual diversity reflects the subscription to particular cultural beliefs and practices and in the ways that processes and experiences are recombined.

Definitions of culture used in cross-cultural psychology and cultural neuroscience have tended to equate culture with country or ethnicity and rely on stereotypes to characterize cultural difference. Hypotheses that avoid these pitfalls are usually built upon more nuanced models, such as ecocultural approaches that consider local environmental and social factors, or by methods that assess participants’ values and attitudes to determine variations in cultural domains. Ecocultural approaches that seek to characterize the cultural traits of a population may use more complex methods for assessing culture, such as using semi-structured interviews to describe the local culture or developing questionnaires based on responses from local participants instead of or in addition to using pre-existing materials (Ataca, 1998; Berry, 2003; Dona & Berry, 1994; Georgas et al., 2004; Pruegger, 1993). Such approaches are useful for examining personality traits and values in very specific demographic and geographic contexts. Likewise, studying cultural domains can be more useful for evaluating common behavioral traits and continua of individual variations. Using both ecocultural approaches and cultural domains allows study of individual diversity while still identifying culturally shared traits. Single-subject analyses, a method for statistically evaluating an individual study participant most typically used in clinical research, can further probe diversity within populations (for methods and discussion see Nourbakhsh & Ottenbacher, 1994). By combining ecocultural frameworks with cultural domains, individual variability can be more sensitively characterized for studying the interplay between neurobiology and culture.

Practically, mixed-methods approaches are needed to establish converging evidence of cultural differences (for relevant anthropological discussions, see Lieber & Weisner, 2010; Weisner, 2012). Operationally, a statistical definition of culture may be the most useful for conducting neuroscientific research in cultural psychiatry, which approaches like Cultural Consensus Analysis provide (for a complete discussion, see Weller, 2007; for an example of applications to neuropsychiatry, see Crafa et al., 2019). From this perspective, culture can be treated as a set of statistically common beliefs and behaviors within a certain population, region, and time period. Neural activity regularly co-occurring with these behaviors therefore might also be statistically common.

Statistical frequency within a population can be evaluated in narrower frames, for example, by neighborhood, family, or self-defined group membership. Regional subcultures can be viewed either as cultural subsets or as distinct groups. However, in theory, the frequency distributions of common behaviors between the mainstream culture and regional subcultures should be different. Subcultures are influenced by mainstream behaviors common to a region, but may also have a subset of statistically common behaviors that are unique to the specific, and usually self-identified, group (cf. Choudhury & Kirmayer, 2009). For example, Hispanic culture in Southern California differs in many ways from Hispanic culture anywhere else in the world, and the 1960s hippie movement in California was unique even for its time. Both examples identify subcultures that are distinct from the dominant culture, but still uniquely situated within it. In theory, observational and self-report measures can be used to isolate statistical commonalities and help describe various sociocultural similarities and differences between groups. Using a variety of measures as part of a mixed-methods approach may help avoid binary East/West dichotomies and allow for a more complex picture of common sociocultural traits within a population.

Psychiatric disorders in the CBB model

In contrast with the NCI model, which implicitly suggests cultural scripts can be “correctly” learned, the CBB model proposes that cultural scripts are always individually altered, resulting in multiple spectra of culturally-situated practices within any cultural context. Psychiatric disorders can be understood as outliers of these spectra. Most psychiatric disorders are characterized by socially inappropriate behaviors, difficulties with socio-cognitive processing, or, as in the case of certain neurogenetic disorders, reduced neural plasticity (Cramer & Galdzicki, 2012; Gipson & Johnston, 2012; Ramakers et al., 2012).

However, the symptoms and presentations of nearly all psychiatric disorders are influenced by culture, indicating that the processing or developmental pathways giving rise to sociocultural learning occur differently in these clinical populations. These extreme variations exist within culture and are also part of cultural feedback loops. Cultural scripts draw attention to certain symptoms, amplifying some experiences while minimizing others (Ryder et al., 2011) and many cultural scripts interplay simultaneously (Ryder et al., 2008). Individual mechanisms involved in these loops may occur differently from the “statistically common” mechanisms observed in the general population, and an interplay between atypical cognitive processes and cultural scripts could also contribute to clinical symptoms.

This raises the question of whether or not “abnormal” (or statistically uncommon) neural processes are shared across cultures in specific psychiatric disorders. Shared symptoms may or may not reflect shared neural processes. Disorders are largely influenced by cultural norms and certain symptoms and syndromes appear to develop in response to different cultural and environmental stressors; it follows that neural processes formed a posteriori will be unique across diverse psychiatric populations (Escobar & Gureje, 2007). Considering current interest in developing brain-based definitions of various disorders (e.g., Agarwal, Port, Bazzocchi, & Renshaw, 2010; Hyman, 2007; Miller, 2010), these are important questions that the CBB model provides a framework to address.

From a statistical perspective, patients with different psychiatric disorders can be thought of as forming their own subgroups, which are simultaneously culturally influenced yet may be distinct in terms of certain social beliefs and behaviors. While certain behaviors associated with individual disorders may be uncommon relative to the general population, they are common among other patients with the same disorder and may also be geographically or temporally unique, just as subcultures are (e.g., 1960s hippie movement). These definitions are useful for neuroscientific inquiries into the effects of “culture,” because they suggest a framework for defining idioms, symptoms, behaviors, or neural events as common to a certain group within a certain culture and compared to groups across cultures. For example, dissociative phenomena are experienced by people in diverse cultures who may have different culture-specific explanations and symptoms (Seligman & Kirmayer, 2008). By statistically evaluating neural activity, we can evaluate the neural events that may be shared by one group of patients with dissociation but not another. This has the potential to lead to a more nuanced understanding of the neural activity that subserves dissociation and possibly resolve some of the heterogeneity in brain-based findings observed in patient populations.

Testing the CBB model

The proposed methodological components of the CBB model are supported by current literature on culture, neuroscience, and psychiatry (e.g. Chiao et al., 2010; Weller, 2007; Wheeler, DeMarree, & Petty, 2007), but have not been directly tested using the integrated approach proposed in this paper. This opens the door for a rich array of studies investigating claims supporting each of the three central tenets. For example, different cultures are known to have different cultural learning pathways, which are often studied by comparing mother–infant dyads across cultures (Bornstein, Cote, Haynes, Suwalsky, & Bakeman, 2012; Enquist, Strimling, Eriksson, Laland, & Sjostranda, 2010; Graf et al., 2014; Keller, Borke, Lamm, Lohaus, & Yovsi, 2011). Self–other mapping based on imitation is hypothesized to make these interactions effective for cultural learning (Gergely & Csibra, 2005; Shimpi, Akhtar, & Moore, 2013) and some corresponding neural activity has already been identified (Paulus et al., 2012). Complementary studies could investigate the neural events that underlie self–other mapping or alternate theories that explain the neurobiological encoding of observed actions, to determine whether they are active during these cultural exchanges. Such studies could also assess whether different social cues produce this neural activity, identifying 1) neural correlates of different cultural pathways and 2) whether cultural learning can cause certain neural changes (for preliminary methods see Crafa, Schiff, & Brodeur, 2019). This second outcome is particularly salient, because it would help characterize the role of sociocultural events in shaping the brain. Such studies would support the framework for cultural learning proposed in the first tenet of the CBB model. They could be further extended to include children who are at-risk for certain disorders, by identifying differences in sociocultural pathways, neural events, or execution of cultural scripts. For example, mothers across cultures teach behaviors that they want their children to learn, such as saying “thank you” when someone gives them a gift. Children with learning or developmental disabilities may learn different lessons from this maternal modeling than children without disabilities do (Tronick & Beeghly, 2011), for example, they may over- or undergeneralize when to say “thank you” or they may not learn from the interaction at all. Divergences in lessons and learning processes can lead to different behavioral phenotypes emerging across cultures (e.g., Keller et al., 2011; Tronick & Beeghly, 2011). This type of research would be informative for understanding mechanisms that contribute to the development of disorders, and could lead to methods for early diagnosis and intervention.

The role of cognitive mediation in the feedback loop between social experiences and neural encoding could be tested by studying the effects of social interactions on self-construal or social values (cf. studies by Crafa, 2017). Self-construal and social values are generally assumed to be reasonably stable during adulthood (Markus & Kunda, 1986). However, some studies (e.g., of active self-concepts) have demonstrated dynamic changes in personal identity as a result of new social interactions, information, or contexts (Wheeler et al., 2007), while others have demonstrated that extreme cultural experiences can influence social encoding (Chiao et al., 2010). These studies, however, have not evaluated changes in neural activity as a result of typical social experiences in the general adult population and thus the encoding of social information has not been assessed. Likewise, the role of cognitive mediation in the feedback loop between self-reflection and neural encoding could be tested by studying effects of talk therapy, CBT, journaling, or similar interventions that activate self-reflection or self-concepts. Longitudinal studies that test changes in neural activity and behaviors after controlled social interactions could evaluate the first tenet of the CBB model—the centrality of the ability to change in response to the environment. By testing the ability of cognitively mediated change to influence multiple organismic levels, they would also test the second tenet of the CBB model—that fluctuations create feedback loops that inform and change each other. Testing the CBB model can best be done by using mixed-method designs, which include multiple organismic levels, or at least test a combination of changes in self-perception, behavior, and neural activity.

The third tenet of the CBB model—that individual variations fall along cultural continua of common behaviors within a defined group—can be tested by using Cultural Consensus Analysis to examine the distributions of cultural traits among a population. Cultural Consensus Analysis uses data reduction, such as principle components analysis, to generate a statistical model of a cultural domain and assess cultural fit of each group member individually (Weller, 2007). This analysis is flexible enough to include multiple cultural domains and to be applied to sensitive patient cohorts (Dressler, Balieiro, & Dos Santos, 2014; Dressler, Balieiro, Ribeiro, & Dos Santos, 2007).

The CBB model as a systems approach to transcultural neuropsychiatry

The CBB interaction model proposed in this article can resolve many of the incompatibilities between CN and transcultural psychiatry. Through this systems approach, behavior, brain, and culture become three levels of a flexible feedback loop. The CBB model maintains that the use of neuroscience in cultural psychiatric research must be grounded in recognition of the pervasive changeability and equal importance of each organismic level. Accordingly, it employs a statistical definition of culture that simultaneously considers individual and circumstantial variability while also allowing for generalizations about regional or ethnic groups.

While the CBB and NCI models agree that practiced behaviors can lead to neural changes, the models diverge substantially in other ways. These divergences are reflected in the CBB model’s three central tenets. By taking a systems approach, the CBB model also avoids the three main theoretical pitfalls discussed earlier. First, neural events play key roles in the model, but the individual is not reducible to neural events. Instead, the CBB model acknowledges individuals’ capacity to change, thus altering their behaviors and neural events. Second, the CBB does not view culture as “locatable” in the brain. Although culturally common neural events may be statistically observable on the group level, they cannot be located within individuals who are assumed to change across situations and lifetimes. Third, the CBB model proposes nuanced alternatives to avoid reliance on cultural stereotypes. Some “Western” cultures may share certain cultural domains with some “Eastern” cultures, while other cultures located within the same geographic hemisphere do not. Additionally, subcultures may have notable differences in cultural domains when compared to the surrounding dominant culture. People within the subculture may respond or self-identify differently depending on with whom they are interacting (Matsunaga, Hecht, Elek, & Ndiaye, 2010).

In resolving the incompatibilities of contemporary models with cultural psychiatry, we propose a few additional points: 1) Taking a systems approach to the study of culture and mental health avoids overemphasizing one organismic level, and views the whole patient as a single individual with multilevel organismic pressures. Within such an approach, culture is mediated by behavior, the brain, genes, experience, etc. and is not “unmediated” as other models have proposed; 2) Grounding such an approach in the phenomenon of neuroplasticity acknowledges the patient’s individuality without ignoring related neural events; 3) In line with Choudhury and Kirmayer’s (2009) proposal, culture is not a single entity defined by geographical or political boundaries. Instead, it is composed of sets of cultural domains, which are behaviors and beliefs that are common within a specific historical time and ecocultural group. This conceptualization replaces binary categories like “collectivist cultures,” which are used synonymously with “Eastern” cultures, with more nuanced categories. These categories are based on empirically measured participant-reported values rather than stereotypes and would theoretically be observable in cultures across hemispheres.

Neuroscience and the benefits of a systems approach to transcultural psychiatry

In conclusion, the current dearth of neuroscience in transcultural psychiatry research and of cultural diversity in traditional neuropsychiatry research leave a majority of the global population underrepresented in biomedical research. Extending cultural psychiatric research to include neuroscientific techniques could benefit patients who have immigrated into countries where biomedical psychiatry is practiced or who are receiving treatments through global mental health outreach efforts. Despite underlying theoretical conflicts, many current studies in CN are directly applicable to the patient population (Crafa & Nagel, 2014). They can be modified to provide new insights into disorders and have the potential to better represent diverse patient populations.

Transcultural psychiatry provides an interdisciplinary space that is uniquely suited to debate difficult theoretical questions, such as what it means to say that culture is “stored in people’s brains” (Ames & Fiske, 2010, p. 72) or what the role of specific brain regions like PFC may be in storing or producing “the shared webs of signification that make up culture” (Domínguez, Lewis, Turner, & Egan, 2009, p. 60). Evaluating these questions through the lens of cultural diversity in psychopathology provides a unique framework for identifying answers and developing a richer understanding of neurocultural events.

The overarching conclusion of studies from CN is that culture and neural events are “inextricably linked” (Zhou & Cacioppo, 2010). Although this conclusion is not surprising, it highlights the potential fMRI has for shedding new light on the relationship between culture and disorder. Although neuropsychiatry is an international research enterprise that includes patient populations around the world, very few studies directly evaluate cultural differences in the neural activity of patient cohorts (Hajek et al., 2013; Schlesinger et al., 2013). By applying the CBB model, CN paradigms could be adapted to investigate cultural variations in the psychiatric community. For example, numerous studies of healthy individuals have found differences in neural activity across cultural backgrounds (e.g., Chiao et al., 2008; Goh, Leshikar, & Sutton, 2010; Gutchess et al., 2010; Hedden et al., 2008; Kitayama & Park, 2010). Many of these studies have focused on differences in neural pathways used for language or self-knowledge processes, while others show differential activity in regions like the hippocampus and amygdala that are associated with memory and emotion. Each of these brain processes are commonly associated with features of psychiatric disorders (Carmichael et al., 2012; Liemburg et al., 2012; Lombardo et al., 2010). For example, the high variability of amygdalar responses to certain events or stimuli may have implications for anxiety patients with diverse backgrounds (Sotres-Bayon, Corcoran, Peters, & Sierra-Mercado, 2008).

Schizophrenia provides a second example. Although schizophrenia is globally ubiquitous, its symptoms and outcomes are highly heterogeneous (Kalra et al., 2012; Suhail & Cochrane, 2002). Higher rates of schizophrenia are associated with immigration, social inequality, and racial discrimination (Jarvis, 1998; Kirkbride et al., 2013; Kirkbride, Jones, Ullrich, & Coid, 2012; Smith et al., 2006). Subcortical variations in neural network activity have been observed in individuals with schizophrenia (for review, see Shenton, Dickey, Frumin, & McCarley, 2001), as has abnormal PFC volume (Wible, Anderson, & Shenton, 2001) as well as PFC connectivity and processes (Callicott, 2003; Hill et al., 2004; Tan, Sust, & Buckholtz, 2006). Abnormalities in the PFC predict individual affect and have additionally been tied to altered consciousness and pathological dissociations as well as related symptoms of schizophrenia (Seligman & Kirmayer, 2008; Steiner & Coan, 2011; Winkelman, 2011; for review, see Oertel-Knöchel & Linden, 2011). The PFC also seems to be closely tied to sociocultural self-identity (e.g., Ma et al., 2012; Sul, Choi, & Kang, 2012). Studying the role of the PFC in schizophrenia across cultural contexts may help disentangle some of the cross-cultural heterogeneity observed in this disorder because certain brain processes may be accounted for by culture while others may be common to patients with schizophrenia across cultures (Crafa & Nagel, 2014; LeWinn, Sheridan, Keyes, Hamilton, & McLaughlin, 2017).

CN paradigms may also be used to investigate fundamental controversies, such as the theory of mind debate (Wilkinson & Ball, 2012), and may yield new insights into psychopathology in patients with impaired ability to self-report. For example, many disorders (e.g., schizophrenia, autism) involve disruptions to “self” processes (Lombardo et al., 2010; Stephan, Friston, & Frith, 2009), impairing the ability to self-report and limiting the therapist’s access to the patient’s experience. Some fMRI studies of autism have identified disruptions in the neural networks that are normally active when thinking about oneself (Lombardo et al., 2010). Complementary studies in CN have shown that neural “self” processes exhibit some flexibility across social situations (Chiao et al., 2009, 2010; Ng, Han, Mao, & Lai, 2010), raising the question of whether the same degree of flexibility exists in people with these disorders (Dawson, 2008; Lazar et al., 2011; Meyer-Lindenberg & Tost, 2012). Modifying paradigms used by cultural neuroscientists to study neural flexibility in psychopathology may contribute to understanding the mechanisms behind key aspects of clinical phenomena (Crafa, 2017).

A final benefit of fMRI research for transcultural psychiatry may be the ability to learn more about brain and biological processes through identifying functional similarities across cultures (Ryder et al., 2011). Identification of similar neuroanatomical features or neural processes associated with psychopathology across cultures may help illuminate variations in symptoms. Finding cross-cultural neural similarities in disorders like autism, for example, may help identify biomarkers because sociocultural variations may obscure neurocognitive processes that underlie key symptoms. Thus, determining similar neurological traits between common disorders (e.g., schizophrenia) and culture-bound syndromes could allow analogies to be drawn that improve understanding and, potentially, treatment options for patients with these disorders (Crafa & Nagel, 2014).

The research questions and methods advocated in this paper aim to enrich biomedicine by promoting the inclusion of diverse patient populations in research. Although this perspective should in theory help improve the treatment options available for patients globally, biomedicine is not the only mental health system and it is not always the most appropriate treatment framework (Kirmayer, 2012). The focus on biomedical research in this article is due to the authors’ expertise, and different types of research questions may be needed to accommodate other medical systems.

The CBB model proposed in this article offers an alternative to other contemporary models of brain–culture relationships. Through applying the CBB model, transcultural psychiatry would be uniquely positioned to study the relationship between culture and the brain by making observations on three levels: i) culturally common behaviors and neural processes, ii) individual variations within those behaviors and neural processes, and iii) circumstances in which the individual may behave more or less according to social convention. All three levels are relevant to understanding the relationship between normal functioning and pathology. The use of fMRI provides a way to examine cultural processes that may contribute to variations in symptom experience and may provide new insights to refine nosology and guide the development of interventions. Developments in CN hold promise for new understandings of the relationship between culture and disorder.

Brain region	Differences identified via cross-cultural comparisons	Neuropsychiatric conditions associated with regional differences
Medial prefrontal cortex	Different activity patterns during social tasks (e.g., self-affiliation)¹	Autism², schizophrenia³, bipolar disorder⁴, general anxiety disorder⁵, major depressive disorder⁶
Rostral anterior cingulate cortex	Different activity patterns during social tasks (e.g., self–other representation)⁷	Autism⁸, schizophrenia⁹, bipolar disorder¹⁰, social anxiety disorder¹¹, major depressive disorder¹²
Left inferior parietal lobe	Different activity patterns during perceptual tasks and social cognition (e.g., visual attention control)¹³	Autism¹⁴, schizophrenia¹⁵
Amygdala	Different activity patterns depending on sociocultural meaning of stimuli (e.g., in-group/out-group)¹⁶	Autism¹⁷, schizophrenia¹⁸, bipolar disorder¹⁹, general anxiety disorder²⁰, major depressive disorder²¹, social anxiety disorder²²

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this work was funded by the German Ministry of Research and Education (BMBF / DLR - 01GP1010) and the Sievert Stiftung für Wissenschaft und Kultur (S248/10006/2013).

Notes

Daina Crafa, M.Sc., M.Sc., Ph.D. is Assistant Professor in the Cognitive Science Program and Neuroscientist at the Interacting Minds Centre, School of Culture and Society, Aarhus University. Dr. Crafa is a 2020 SSNAP Fellow (Duke University) and former Vanier Scholar (Canadian Institutes of Health Research). She studies the relationships between culture, the brain, and disorders. Her current projects investigate how social interactions change behavior and neural activation patterns and the role of cognitively mediating self-concepts. Her published work discusses conceptual issues concerning the consideration of culture in neuropsychiatry and experimentally probes clinical and cultural variations in neurobiological processes and social cognition. Follow @dcrafa on Twitter for updates.

Saskia K. Nagel is Professor for Applied Ethics, Faculty of Arts and Humanities, RWTH Aachen University, Germany, working at the intersection of ethics, philosophy, life sciences, and technologies. With a background in Cognitive Science and Philosophy, she develops approaches to individual and societal challenges in a technological culture. Her published work focuses on moral questions, in particular on questions of autonomy and trust, as well as neuroscientific and philosophical work on the relationship between environment, body, and mind. Her recent work concerns questions of self-determination and responsibility throughout the lifespan, especially given the impact of technologies. She has a strong interest in studying public attitudes towards sciences and technology.

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Central tenets
Tenet 1	The ability to change in response to the environment at any time during the lifespan is central to all organismic levels of organization.
Tenet 2	Fluctuations at multiple levels create feedback loops, allowing the levels to inform and change each other.
Tenet 3	Individual variations fall along cultural continua of common behaviors within a defined group.
Caveats
Caveat 1	Cultural scripts are not always correctly performed.
Caveat 2	Cognitive mediation is a recurring mechanism of change across the lifespan.
Characteristics of proposed methods
Characteristic 1	Taking a systems approach to the study of culture, brain and behavior avoids overemphasis on a single organismic level.
Characteristic 2	Grounding the approach in neuroplasticity and epigenetic mutability acknowledges individual variation and lifespan change.
Characteristic 3	Defining cross-cultural groups in terms of multiple domains and dimensions rather than discrete categories or binary oppositions.