The Matter Of Cultural Reality

Making a diagnosis is making an evaluation and, at times, a value judgment. When a Western system of labeling mental or emotional illness is utilized, it is presumed that the system is loaded with certain cultural norms and values. There are certain illnesses, notably those organically caused, which present nearly identical and recognizable manifestations wherever they are encountered. Cultural factors bear little on the form of the symptomatology. In the functional disorders, cultural realities play a bigger role in shaping the patients’ reactions. In some patients in this study, these cultural factors spelled the difference between a diagnosis of a malignant disorder and that of a more benign nature.

All personality formation, or the psychodynamics of well or ill alike, rely in the last analysis upon symbolic forms of communication and self-expression in which what is human and cultural is shared, while that which is bizarre and autistic is closer to raw impulse or guarded illusion. A psychiatry, or a behavioral science, which credits human being with a dynamic life biography and with conditions of existence in communicated and felt socio-cultural settings, but which ends by denying reality of the social and cultural groups, cannot move from case A to case B, or indeed fully asses the impact of other people on either A or B (Opler 1967).

Cultural symbols and value systems were necessarily considered in mapping our diagnostic formulations. They were especially crucial in instances where there was serious doubt as to whether the patient was psychotic or not. These will be mentioned here briefly and will be described in more detail under the section on sympathology.

1. The elaboration of paranoid-like ideas could be mistaken for delusions unless one looks deeper and closer into them. These ideas stem from private ego-fostering fantasies of the patient. They flourish in the patient’s mind either as persecutory thoughts, often to make himself an object of pity or sympathy, or as grandiose ideas making him a person of power, in control of the situation and whose pity, leniency or nurturance is sought by others. Under great stress, the patient might seize factual incidents and weave them with accepted cultural probabilities to present what on first glance would appear to be a delusional system. The patient, with great ambiguity and emotive reaction, then presents the story as if it were completely true. On close scrutiny, the elaborations are not delusional. The fact that he will not present anything culturally alien is a clue to the still intact reality boundaries. Furthermore, he is at all times playing to an audience, as it were, and is ever-watchful of and reactive to responses from the audience.

2. Severe regression in depressions giving an appearance of complete helplessness is not always indicative of a psychotic process. The factor of secondary gain being actively promoted both by the patient and his loved ones may be present.

3. Bizarre-sounding descriptions of somatic complaints, depersonalization syndromes and catatonic-like phenomena should be looked into carefully before taking them as suggestive of psychosis.

Cultural linguistic handles and culturally known and accepted ways of reacting to emotional stress have to be kept in mind. For example:

“Nawala ako sa sarili ko” is not an unusual expression in the vernacular. Literally, it means “I lost myself.” When prolonged, these feeling states may represent degrees of depersonalization. Usually described as fleeting reactions, they may last for five minutes or so. They are always reacted to with fright. Catatonic-like phenomena are reactions in patients whereby they stare for some minutes into space (in Tagalog, “natigilan”) or simply look stunned. They can be snapped from this state, usually by gentle prodding from the parents. In some, the appearance of being stunned may be combined with much blocking, but again with help from the family, the patient is rendered accessible to communication.