A Cultural Critique of the DSM-IV Dissociative Disorders Section

The Dissociative Disorders subcommittee of the National Institute of Mental Health (NIMH)-sponsored Committee on Culture and Diagnosis proposed 36 specific textual recommendations for inclusion in DSM-IV, covering five themes: (i) most forms of dissociation around the world are normal, and must be distinguished from cross-cultural forms of pathological dissociation with the help of specific criteria; (ii) cultural factors influence the attribution of pathology to particular dissociative experiences; (iii) several dissociative illness syndromes were left out of DSM-III-R due to their cultural patterning (e.g. 'possession trance syndromes', ataques de nervios) and should be included; (iv) the inclusion of these syndromes should not be at the expense of subsuming parallel cultural nosologies under psychiatric nosology; and (v) the phenomenology of pathological dissociation across cultures displays considerable diversity. A review of the final text of DSM-IV reveals that 42% of these 36 items were included, 50% were rejected and 8% were incorporated in a simplified form. In general, data in favor of cross-cultural phenomenology were well received, but critique of the universality of DSM-IV diagnoses was not tolerated. Textual proposals presenting psychiatric anthropological issues were not included, whether on the need for cultural experts, the cultural roots of illness forms, or the social function of symptoms. While the inclusion of some cultural items signals a step forward in the cross-cultural validity of the DSM, work still has to be done to ensure the global applicability of the current dissociative disorder diagnoses as well as their social and clinical usefulness.