Evolutionary Theory, Culture and Psychiatric Diagnosis: Horacio Fabrega JR

Psychiatric Diagnosis and Classification.
Edited by Mario Maj, Wolfgang Gaebel, Juan JoseÂ LoÂpez-Ibor and Norman Sartorius
Copyright # 2002, John Wiley & Sons, Ltd. ISBNs: 0±471±49681±2 (Hardback); 0±470±84647±X (Electronic)
CHAPTER
5
Evolutionary Theory, Culture and
Psychiatric Diagnosis
Horacio Fabrega Jr.
Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
INTRODUCTION
Psychopathology is universal, found in all societies regardless of their

ancestry, size, organization, political economy, and culture. The conditions
for it are products of the inherited biology of Homo sapiens. However,
societies differ in terms of such things as language, beliefs, world-views,
notions of personhood and emotion, and rules and standards regarding
social behavior. These cultural factors affect the content of psychopathology.
Moreover, since culture is internalized and enters into the very construction
of human psychology and the experience of bodily functions, it significantly
influences the structure of psychopathology.
This gives rise to two seemingly opposed views about the character of
psychopathology. The first is a culture-free conceptualization based on
generic, biologically rooted mechanisms; the other, cultural relativism based
on historical, national and ideological differences. My goal in this chapter is
to review the two perspectives, compare them using three clinical examples,
and critically discuss their strengths and limitations. Based on suppositions
about the future interplay between psychiatry and society, I will discuss
briefly why evolutionary and cultural tenets need to be incorporated in a
system of psychiatric diagnosis.
ON THE GENEALOGY OF PSYCHIATRIC DIAGNOSIS

AND CLASSIFICATION
All of the traditions of medicine associated with ancient civilizations that

have been studied have developed approaches to the understanding of
Psychiatric Diagnosis and Classification. Edited by Mario Maj, Wolfgang Gaebel, Juan JoseÂ LoÂpez-Ibor and
Norman Sartorius. # 2002 John Wiley & Sons, Ltd.
108 PSYCHIATRIC DIAGNOSIS AND CLASSIFICATION
problems of behavior and sickness that today are classified as psychiatric.

The civilizations of India and China each developed a naturalistic concep-
tion of disease and mental illness which to this day retains a measure of
identity and viability in the respective societies [1, 2]. The contemporary
perspective about psychiatric diagnosis and classification is a product of the
social history of mental illness and of the discipline and profession of
psychiatry in European and Anglo-American societies. Its roots extend
into the medicine of the Greco-Roman period of antiquity exemplified by
the writings of Hippocrates and Galen. Descriptions of symptoms in these
writings (formulated in terms of the four humors) referred to abnormal
forms of experience and behavior that pre-figure descriptions of contem-
porary psychiatric disturbances. During the medieval period, academic
scholarly medicine continued its emphasis on humors, but was also strongly
influenced by Christianity. Conceptions about and approaches to psychi-
atric problems as madness and insanity became associated with notions of
spirituality, sin and punishment. The early modern period witnessed the
eclipse of humoral theory and growth of iatrochemical and mechanical
points of view. This involved a heightening of secular, naturalistic tenets.
Eventually, diseases came to be formulated as separate entities having their
own identity, history or course, and treatment. The central task of medicine
became that of identifying, describing, and understanding these natural
objects or disease entities. The evolving ``modern'' theory of disease even-
tually was applied to psychopathology.
In association with scientific developments in the theory and understand-
ing of disease, changes in society during the early modern and then modern
era came to shape the care of the mentally ill and eventually the evolution of
the profession of psychiatry [3]. These changes are complex and wide-
ranging. From a sociological standpoint, they involved increases in popula-
tion, urbanization and migration, political changes affecting the growth of
liberalism and democracy, and the growth of industrial capitalism. The
changes affected the prevalence and visibility of mental illness, attitudes
about its victims, and changes in social policy.
Starting in the seventeenth century in France and later spreading to other
nations, marginal, impoverished, and dependent segments of the popula-
tions came to pose a major problem in large communities, especially in cities
throughout Europe. Problem populations were placed in institutions and,
with time, victims of mental illness were set apart from the larger class of
disabled, diseased, dependent, and marginal. Eventually, special asylums
were established for their care, while more affluent establishments provided
a ``private trade in lunacy''. Later, during the reform era, the deplorable
conditions existing in public institutions became the concern of municipal
regulatory bodies. Inquiries into conditions of asylums with attempts at
reform culminated in the establishment of more humane conditions of
EVOLUTIONARY THEORY, CULTURE AND PSYCHIATRIC DIAGNOSIS 109
care and treatment of mental illness. In some societies, the central govern-
ment played an influential role in spearheading treatment, education, and
research; in others, universities and faculties of medicine; and in still others,
local municipalities.
The evolution of actual knowledge of clinical psychiatry is largely a
product of developments during the nineteenth century. It involved two
empirically interconnected trends that can be separated only analytically.
One development culminated in the refinement of a system of concepts
about and terms referring to disturbances of human psychology and behav-
ior along with the criteria and principles pertaining to how this descriptive
system was to be used. The other one involved the creation of a science
about the many psychiatric disorders that came to be named and described,
disorders that were delineated by means of the descriptive system and
which came to be studied by means of the new science of medicine preva-
lent in the nineteenth century, involving diagnosis and explanation pertain-
ing to causes, lesions, and natural history. The former development
involved the evolution of a science of descriptive psychopathology and the
latter the scientific knowledge linked to the historiography of clinical psych-
iatry [4, 5].
In summary, it was in groups of physicians involved in the study and care
of mentally ill patients, in both private and public institutions, that the
modern approach to mental illness evolved. Different national conceptual-
izations about psychopathology evolved reflecting linguistic, cultural, and
societal experiences and traditions. However, to improve communication
and promote research, there arose a need for the discernment of commonal-
ities. A conviction grew that the various syndromes, disorders, and illnesses
that had emerged in national classification systems exhibited common fea-
tures and conformed to a smaller set of conditions that transcended national
boundaries and cultural experience. The members of this class of disorders
are assumed to be amenable to careful scientific definition and description
in a general language of psychopathology. The traditional view holds that
human populations show different vulnerabilities to disease linked to dif-
ferences in geography, social ecology, and culture, but it does not under-
mine the official position about universals in the pathology and clinical
presentation that underpin the international approach to psychiatric diag-
nosis and classification.
An emphasis on the development of psychiatric knowledge and mental
health services in European and Anglo-American societies is important to
emphasize, because it gained international eminence and now claims alle-
giance across the world. The imperialism and colonialism of the nineteenth
and twentieth centuries had many obvious political and economic reper-
cussions. One of them was the exportation of biomedical knowledge that
initially came to be applied to improve general public health. As the modern
conception of disease became ascendant and with this understandings of

mechanism and control embodied in the biological sciences, biomedicine
attained a major colonizing influence in developing societies. In relation to
this social movement, modern European and Anglo-American knowledge
about psychiatric disorders has attained world significance and along with
this principles of diagnosis and practice that increasingly have come to be
formulated in a common language of nosology.
EVOLUTIONARY THEORY AS A BASIS FOR

PSYCHIATRIC THEORY AND NOSOLOGY
General Remarks
Many psychiatric disorders have a genetic basis. Their prevalence is sub-

stantially higher than average mutation rates. These facts are held to imply
that the responsible genes may have been positively selected during human
biological evolution. Many genes underlying psychopathology may have
benefits in other areas of functioning and their role in psychopathology may
simply reflect a cost incurred as a result of trade-offs. In the case of psycho-
logical mechanisms or personality traits that are due to multiple genes,
instances of psychopathology may simply reflect heavy loading of genes
that in lower amounts or degree of penetrance happen to be adaptive. Not
all psychiatric disorders are the direct expression of genetic coding but are
related indirectly to evolutionary factors nonetheless [6].
Evolutionary Theory, Human Behavior, and Psychopathology
Social relations play a central role in evolutionary theory. Natural selection

did not produce ``logically consistent'' routines of behavior, ``good solu-
tions'' to problems and conflicts, or ``pleasant'' emotions. Instead, inherited
behavior routines, termed psychological adaptations or algorithms, are
responsible for aspects of human behavior. These are the product of a
long history of constraints in the design of hardware (e.g. the brain) that
occurred early in evolution and of a myriad of trade-offs and balances that
were required over hundreds of thousands of years and that were aimed at
solving recurring biological problems that tracked changes in ancestral
environments.
The emotions play an important role in evolutionary accounts of psycho-
pathology. They are behavioral indicators that reflect naturally designed
mechanisms that have a bearing on or relationship to important biolog-
ical functions. When the mechanisms are exaggerated or inappropriately
elicited, psychopathology may result. Positive emotions (e.g. satisfaction,

pleasure) reflect mechanisms and behavior exchanges that in past environ-
ments were associated with fitness and survival, while negative ones (e.g.
anxiety, sadness, anger) are signals of threats and challenges to fitness. Like
adaptations, emotions are evolutionary residuals: the ``leftovers'' of mechan-
isms of social behavior that were naturally designed during evolution in
relation to happenings in ancestral environments. Negative emotions are
not ``bad'' things, but rather ``good'', inherited signals that operate to inform
(though not consciously and willfully) the individual as to the current status
or functioning of adaptive patterns of behavior and about needed choices,
avoidances, and strategies.
Psychiatric Disorders as Harmful Dysfunctions
Evolutionary theory has been used in the study of disease and the general
medical care of patients [7]. A disorder has been defined as a harmful
dysfunction (HD); namely, a failure or breakdown of an internal mechanism
to perform its natural function [8]. Harmfulness is a condition that is painful
and/or detrimental to an individual's well-being and functioning. Harmful
conditions have many causes, being based on environmental happenings
that conflict with biological imperative; however, only dysfunctions of
natural mechanisms are applicable to the evolutionary argument of disorder.
The HD slant on a disorder is compelling. On the one hand, it has general
resonance: a ``natural function'' and a ``failure'' of it are, from a conceptual
standpoint, what persons ordinarily intuitively mean when they think of
disease or disorder involving something that has gone wrong or is not
working properly. On the other hand, it also has a seeming rigor. It rests
on the classical theory of categories (see below) and invokes a scientific
epistemology (i.e. a failure of a naturally designed function). While the HD
approach has general medical implications (e.g. diabetes, hypertension,
kidney failure), it has been systematically applied to psychopathology.
The psychological adaptations singled out by evolutionary psychologists
were naturally designed to solve recurring biological problems during
evolution and hence are examples of ``natural functions''. The HD analysis
holds that true or ``scientifically valid'' psychiatric disorders are based
on harmful dysfunctions of such adaptations. The HD analysis of a psychi-
atric disorder reinforces the link between psychiatry and general medicine
[9, 10].
An evolutionary conception of psychiatric disorder is an essentialist or
classical approach to the definition of a concept. The definition of HD
stipulates two individually necessary and jointly sufficient defining features
of ``psychiatric disorder''. The HD analysis has been the target of critical
analysis by both psychiatrists and social scientists. Whether the concept of

(psychiatric) disorder is ``Roschian'' and conforms to the prototype theory
of concept formation (i.e. any one condition qualifying as a disorder because
it approximates or resembles an ideal or prototype) has constituted one line
of attack [11, 12]. In addition, emphasis has been given to its disregard of
cultural influences, social values, and sheer practical exigencies [6]. Further
critiques of the HD perspective are taken up later in the chapter.
THE THEORY OF CULTURE AS A BASIS FOR

PSYCHIATRIC THEORY AND NOSOLOGY
General Remarks
Culture theory argues for the influence of social symbols and their meanings
on a person's general psychology, outlook and tenor of life, including
psychopathology. There are two ways in which the ideas of culture and
cultural differences have been used in the study of psychiatric disorders.
First, as a marker for a group, like age, gender, social class, religion, or
ethnicity. This demographic view is then used to compare group differences in
psychopathology. A contrast is the psychological view that stresses deter-
minative and constitutive aspects of a person's sense of reality, personal
identity, and behavior.
Psychiatric Disorders as Culturally Constituted Human

Conditions
The cultural theory position stipulates that culture cannot easily be separ-
ated out of the material basis of psychiatric disorders [13]. While disorders
are universal, conditioned if not produced by human biological evolution
(i.e. having a phylogeny), they also are cultural and hence variable. This
position holds human psychology is an essential locus of psychopathology.
The traditional history of psychiatry informs that conditions of interest
involve the ``psyche''. The latter includes cognition, emotion, and motiv-
ation, on the one hand, and social, symbolic behavior, on the other. Together
they constitute essential characteristics of psychopathology (as well as
psyche), however it may be formulated. Culture theory emphasizes and
complements the social mandate that gave rise to the discipline and profes-
sion of psychiatry and that underlies the efforts of all societies to cope with
mental illness. The second conception of culture reviewed above implies
that cultural psychology is a proper locus of psychopathology. It stresses
that language, culture and cognition, realized in world-views, conceptions

of persons and behavior, and ways of understanding self, other, and the
outside, behavioral environment, in their integration, ``make up'' psycho-
pathology.
The vaunted properties of Homo sapiens (e.g. language, cognition, culture)
are assumed to result from a slow process of natural selection during
biological (i.e. genetic) evolution [6]. Rather than subscribing to the view
that these properties are mere by-products of brain size and comparatively
recent in origin, a Rubicon crossing that happened `ònce and for all'' during
the transition to the Upper Paleolithic era, they are assumed to have a much
longer ancestry. Not 50 000 or so years ago but hundreds of thousands of
years mark the gradual, progressive march towards the human symbolic
capacity [14±16]. Coincident with this pattern of slow evolution of symbol-
ization in the hominid line, behavior problems became better differentiated
and began to be accorded a corresponding social and cultural significance.
Varieties of psychopathology, then, were ``natural'' to hominid populations
well before the transition to the Upper Paleolithic [6].
DEPRESSION: CASE NO. 1 IN THE EVOLUTIONARY AND

CULTURAL STUDY OF PSYCHOPATHOLOGY
General Remarks
Disorders associated with the mood of depression are firmly placed in the
history of psychiatric nosology and systems of classification [17]. They have
a complex etiology, pathogenesis, set of manifestations, and natural history.
Many contemporary conditions (e.g. chronic anxiety, somatoform disorders,
fibromyalgia, irritable bowel) resemble or overlap with depression. The
medical authenticity of depression is beyond reproach: it enjoys a universal
prevalence in human societies and presence in medical traditions of the
world [1].
Evolutionary Theory Considerations
Evolutionary psychiatrists have made depression an object of analysis. Its

genetic basis and high frequency have implied positive selection and raised
the question of it constituting an actual adaptation. For example, its emotional
manifestations have suggested a warning function that the victim's current
strategies are failing; its physiological signs of slowing, withdrawal, and
seeming conservation as prompting that the individual shift to more profit-
able environments and enterprises; and its external, behavior/demeanor
characteristic signs as communications designed to elicit others' help. How-

ever, several factors about depression have argued against a strict adapta-
tionist interpretation. Its protean character is one and another is the possibility
that each of its sets of manifestations has diverse origins and functionsÐsome
maladaptive [18]. That the depression spectrum or ``phenotype'' seems to
constitute a ``common final pathway'', the resultant of many causes, and a
variable course (e.g. remitting spontaneously or responding only to some
medications) has suggested that it is not unitary and homogeneous and thus
unlikely to constitute an adaptation per se. Some hold that depression is the
result of disruption of a maturation program [18, 19].
The social competition hypothesis is the most systematic evolutionary for-
mulation of depression [20, 21]. It posits that humans share with their
primitive ancestors an involuntary strategy of subordination, a mechanism
for yielding in situations of competition. The theory draws on ideas from
ethology and the social biology of behavior about how individuals compete
for rank. The functions of the strategy are to inhibit aggression towards
rivals and superiors by creating a subjective sense of incapacity, to commu-
nicate a lack of threat and a yielding, and to facilitate function by putting the
individual into a ``giving up'' frame of mind that encourages acceptance
and voluntary yielding. The features of depression and the situations and
circumstances surrounding its victims are all explained in terms of etho-
logical notions of group dynamics and rituals of behavior.
Nesse [22] has recently offered a critical analysis of the idea that the
depression spectrum constitutes an adaptation. Based on much earlier
work involving the evolutionary function of emotions and the biological
basis of responses linked to general medical disease, he offers a summary of
the possible functions of low mood (states in the common range of normal
experience) and depression (severe states of negative affect, usually patho-
logical). He sees these as pleas for help, the elicitation of help from group
mates, and also as a communication designed to manipulate others to
provide resources and then conserve them. Depression is part of a motiv-
ational package to plan and reassess a course of action with a possible view
to change or alter goals. Even some conditions of frank clinical depression,
Nesse implies, can be explained as serving evolutionary functions. How-
ever, his analysis and experience lead him away from explaining depression
in terms of one function and instead to view the spectrum as states shaped
to cope with a number of unpropitious situations.
Culture Theory Considerations
While the universal prevalence of depression constitutes an indisputable

generalization in psychiatric epidemiology, that these conditions are brought
on, shaped, expressed, and interpreted in culturally specific terms constitutes

an axiom of cultural psychiatry that is also beyond dispute. Nowhere is this
better illustrated than with respect to China. There is much evidence, as well
as controversy about, the presentation of depression in China. It has been
claimed that in China depression manifests in a ``somatized'' as compared to
a ``psychologized'' way [23]. Many explanations have been invoked, includ-
ing innate patterns of physiological response, culturally shaped processes in
brain/behavior, linguistic conventions pertaining to self and emotion, social
attitudes about emotional expression, and political strictures affecting how
one should explain and communicate hardship. The idea that in some coun-
tries like China mental disorders take a somatized form as compared to a
psychologized one has also been attributed to sheer educational factors and to
the possibility that the attitudes of the doctor (`àccepting'' or ``rejecting''
psychological complaints from patients) are determinant of the form of pre-
sentation of distressing experiences. Of course, as indicated above, some
conventions regarding self-expression through language favor the use of
examples (`Ì feel as bad as . . . '') whereas others do not and this may be a
consideration as well. All of these factors, it has been stated, shape, color, and
configure the depression in a distinctly Chinese pattern.
The complex association between culture and the depression spectrum is
illustrated by the findings, and subsequent responses to their dissemination,
of the study by Kleinman [24] of neurasthenia and depression in China. He
studied 100 patients there who were diagnosed as showing neurasthenia.
This is a ``condition'' coined by American neurologist George Beard to
denote `èxhaustion of the nervous system''. It consisted of a mixture of
fatigue, weakness, impaired concentration and memory, headaches, poor
appetite, and any number of variegated ``physical'' symptoms. It is interest-
ing to note that the concept of neurasthenia appears to have been introduced
into China via the training of psychiatrists in the former Soviet Union and
the model of neurasthenia as presented in the former Soviet Union was
different from that of European countries and the United States. The even-
tual translation of neurasthenia into Chinese (as shenjing shuairuo) is signifi-
cant, since it drew on important local concepts of vitality, cognitive activity
or `ènergy'', and motivation (shen), and the traditional medical knowledge
of meridians or channels of the body ( jing) which carried ``vital energy'' (qi)
and ``blood'' (xue). ``Conceptually, shen and jing are treated by Chinese people
as one term (shenjing), that means `nerve' or `nervous system'. When shenj-
ing becomes shuai (degenerate) and ruo (weak) following undue nervous
excitement, a variety of psychic and somatic symptoms may reasonably
ensue'' [25]. The Chinese interpretation of neurasthenia encapsulates in a
succinct way a whole tradition and theory about self, experience, sickness,
bodily experience, and psychopathology that is integral to its native systems
of medicine.
Not surprisingly, then, because the diagnosis of neurasthenia as shenjing

shuairuo is connected in vital ways with deeply rooted, traditional notions
and idioms of well-being, it consequently ``caught on'' in Chinese medicine
soon after it spread there during the nineteenth century. What Kleinman
showed was that 87% of neurasthenic patients met criteria for depression
and moreover on follow-up appeared to respond to antidepressant medica-
tion. Not all who were biomedically improved, however, necessarily de-
fined themselves as not sick, a fact that underscored the political economic
embedment of sickness including depression in China as well as its ``nat-
ural'' fit with Chinese cultural psychology. Personal and culturally rooted
political economic factors, it would appear, strongly influence whether a
diagnosis pertaining to the depression spectrum embodies a condition of
sickness and maladaptation as the individual, at any rate, defines this.
One obvious implication of Kleinman's study was to demonstrate that
local conventions of meaning and traditions pertaining to body, emotion,
self, and situation profoundly determine how aspects of the depression
spectrum play out in relation to culture and society. A complex amalgam
of factors, which include biology, culture and local experience, shape how
the depression spectrum is configured and enacted. The influence of cul-
tural factors in the depression spectrum has been studied in other social
groups. Manson et al. [26] studied the links between depression and several
indigenously defined conditions of sickness among members of the Hopi
Nation of American Indians. The similarities and differences between scien-
tific definitions of depression and those representative of the residents of the
region were discussed. Manson makes clear that general characteristics of
the various sickness conditions differ as a function of culture, but so do also
the phenomenology, putative cause, duration, and circumstances surround-
ing actual episodes. An argument can be made that among the Hopi people,
no less than among the Chinese, the depression spectrum is configured and
enacted differently. Kinzie et al. [27] have developed and validated a Viet-
namese-language depression rating scale precisely because among refugees
the disorder has a different configuration. There exist numerous other
approaches to the cultural study of depression [28].
SOCIAL PHOBIA: CASE NO. 2 IN THE EVOLUTIONARY

AND CULTURAL STUDY OF PSYCHOPATHOLOGY
General Remarks
Few human conditions embody as much face validity for a form of social
maladaptation as do those marked by worry, fearfulness, psychic pain,
somatic experiences of autonomic hyperactivity, and associated social
avoidance. The distress, misery, and social disruption that anxiety can cause
extend beyond psychiatry to encompass religion and philosophy. Because
of its wide prevalence, anxiety has received attention from evolutionary
and cultural psychiatrists. The anxiety that seems concentrated in social
relations and interactions has evolutionary importance because of the hom-
inid trait of sociality and it has cultural relevance because in personal
experience and human activity one finds concentrated the meanings of any
culture.
Anxiety, like fear, pain, and fever, is a natural defensive response, one of the
body's protective mechanisms [7, 29, 30]. The process of natural selection in
the environment of evolutionary adaptedness (EEA) designed the regula-
tory mechanisms that underlie anxiety so as to enable individuals to avoid
threats and promote survival and reproduction. Anxiety, in other words, is
a ``good thing''. Whenever a threat or the likelihood of harm occurs, anxiety
can be expected to result and its degree will bear a relationship to the
magnitude of harm/threat. However, even if the cost is low, the defense
will be expressed in anxious behavior when the mechanism is operating
normally, much like a smoke detector may be triggered even in the absence
of a real fire. It is assumed that hominid ancestors existed in environments
that had a wide range of levels of danger that were recurrent. Genes that
shaped the anxiety response continued to be adaptive for a very long time
and have left a residue of low threshold for the generation of protective
responses to situations of potential harm and danger.
Many varieties of phobias have been the object of evolutionary analysis
and each one has been explained as the outcome of ``the smoke detector
principle'' in response to an evoking situation that had fitness implications
in EEA. In the case of social phobia, threats to reputation and status have
been singled out as important. Drawing on principles from ethology and
evolutionary biology, Stevens and Price [20] emphasize the importance of
contests and tournaments as a way of establishing social rank, something
individuals persist in striving to maintain or improve upon. Success in such
tournaments earns individuals a measure of value and power, termed
resource holding power (RHP). During evolution, hedonic as compared to
strictly agonistic modes of social interaction became increasingly important.
This involved competition not by intimidation but by attraction, with com-
petitors disarming rivals and attracting mates and also achieving status and
rank in the group. This gave rise to a new capacity for self-assessment,
termed social attention holding power (SAHP). According to Stevens and
Price [20], anxiety generally and social anxiety in particular is commonly
released in situations that are perceived to constitute a threat to the individ-

ual's RHP or SAHP.
Social phobia may thus be regarded as a psychiatric disorder that con-
forms to the harmful dysfunction model proposed by evolutionary psych-
ologists and reviewed earlier. Psychological mechanisms and algorithms
serve the natural function of maintaining an individual's sense of compe-
tence and ranking in a group. Through such mechanisms individuals are
able to project and protect their social resources, establish their credibility,
compete, attract mates, and assure the maintenance of their offspring. When
a perturbation of this mechanism takes place, a disorder of behavior results.
Social phobia is assumed to correspond to a dysfunction of mechanisms
promoting social competence in a group setting and in face-to-face relation-
ships. Its presence and definition in international systems of diagnosis attest
to its presumed universal, pan-cultural characteristics.
While the international and evolutionary viewpoints about social phobia

suggest universality, research work from Japan argues the case for cultural
specificity. Kirmayer [31] reviewed characteristics of Taijin Kyofusho (TKS), a
common disorder in Japan featured by fear of offending others through
one's social awkwardness or because of an imagined social defect. In Japan-
ese psychiatry TKS comprises a spectrum of disorders. While symptoms
consistent with social phobia are predominant in all its varieties, their
characteristics in Japan differ significantly. Moreover, while TKS involves
a Japanese set of disorders marked by a unitary and distinctively Japanese
content and meaning, it includes varieties that in the relatively culture fair
nosology of international psychiatry suggest several different disorders.
Social relationships in Japan are systematically shaped into and calibrated
on the basis of emphasis on one's effect on an immediate audience. Parties
to a relationship strive to reduce psychological distance by intuiting what
others are thinking and feeling. Indirect, implicit communication is valued,
the obverse is considered blunt and insensitive. An assumption prevails that
a socially competent person can understand others without having to resort
to words. Even eye contact is regarded as bold and potentially offensive and
averting one's gaze is enjoined, creating a normative basis for concern and
fear of injuring others with one's gaze. It goes without saying that the
expression of negative emotions is restricted and that attributes of the self
and indeed of the body, such as appearance, skin blemishes, and odor are
regarded as potentially offensive to others and the possibility that this
may prevail is a source of obsessive worry if not preoccupation. Cognitive
factors are associated with these interpersonal characteristics; for example,
an emphasis on consciousness of self in social situations, of being on a social

stage, and of having to act appropriately in front of others. Rules of etiquette
include elaborate forms of respect language, awareness of posture, and self-
presentation with respect to management of facial expressions and the mask-
ing of emotions.
In Japan, then, a distinctive social psychological calculus shapes how
selves should behave in public settings. There exists a dictum that one must
search and scan facial expressions so as to anticipate what best to say and
how to ``come across'' so as not to offend. It is no surprise that pathological
deviations of this social language of communication and of interpersonal
relations influence not only the origins of social anxiety and phobia but also
color its manifestations in a significant way. Child rearing and patterns of
social interaction all appear to function so as to create vulnerabilities to
varieties of social anxiety.
TKS is extremely common in Japan and since the 1960s has been regarded
by Japanese psychiatrists as a unique form of psychological disorder. Many
patients fulfill DSM criteria of social phobia. However, fear of eye-to-eye
contact, of physical deformity, and of emitting an unpleasant body odor as
well as of blushing are among the commonest symptoms of TKS, yet were not
especially emphasized in DSM-III [31]. The fear that one has a deformed body
constitutes a subtype of TKS in Japan, yet in DSM-III-R such a dysmorpho-
phobia was classified as a separate condition, namely, as a form of somato-
form disorder. The conviction that one may harm others either by appearance,
behavior, body odor, or physical deformity often appears to reach delusional
proportions, yet this symptom is judged to fall squarely within the TKS
spectrum and is not regarded as a psychosis. It should be noted that the
German introduction of the terms ereuthophobia and erithophobia was
known in Japan and found to be useful; however, the fear of others did not
appear to be extremely common. Moreover, the concept of dysmorphophobia
in its original definition was characterized by the delusional conviction that
one's body is deformed; however, the clarity of that experience did not fall
into the rubric of fear that an organ of the body might be deformed.
The TKS spectrum, then, illustrates rather vividly the role of culture not
only in influencing the origins of social phobia but also its content and
constitution. Socialization and enculturation create expectancies regarding
emotions and personal expression in social relations that predispose indi-
viduals to this variety of anxiety. The semantic content that provides mean-
ing to what is expected of the self and how feelings and actions should be
shaped in social relations create the normative conventions on the basis of
which deviations that constitute the spectrum are calibrated. This endows
those deviations in behavior with a blend of concerns that shape and give a
distinctive meaning to the syndrome in Japanese culture. Its cultural psych-
ology, as it were, shapes social anxiety into a Japanese disorder.
PSYCHOPATHY: CASE NO. 3 IN THE EVOLUTIONARY

AND CULTURAL STUDY OF PSYCHOPATHOLOGY
General Remarks
Antisocial personality traits and behavior constitute a challenge for a nos-

ology of psychiatry. Studies in cultural anthropology suggest that a con-
struct or cognitive category about antisocial behavior is a human universal
[32, 33]. Murphy [34] used antisocial personality as an example of univer-
salism in her study that argued against the view that psychiatric disorders
were culturally variable and relative. These generalizations about views
on antisocial behavior and personality are consistent with the history of
psychiatric thinking. Since the very late eighteenth century, when the
American Benjamin Rush and the Frenchman Philippe Pinel published
their respective dissertations, the antisocial constellation and construct has
fallen within the perimeter of psychiatric attention [35]. Currently, it is
represented in the two international systems but defined somewhat differ-
ently: DSM-IV emphasizing antisocial behaviors and ICD-10 personality
factors.
The history of psychiatry embodies tensions with respect to behavior and
mental illness. As a medical discipline, psychiatry is concerned to develop
and use a system of knowledge so as to diagnose, treat and prevent illness.
Its social functions, on the other hand, are various and they overlap: as a
social medical institution with a distinctive social mandate (i.e. public health
functions), psychiatry seeks to control and regulate social problems associ-
ated with mental illness; as part of the social welfare system, it validates if
not justifies the disbursement of social security and disability payments to
victims of mental illness; and as a sanctioning, disciplining body of the
criminal justice system, its decisions about mental illness appear to absolve,
punish, stigmatize, and/or medicalize.
How antisocial behavior has fared within psychiatry illustrates the quan-
dary presented by psychiatry's dual functions and the goals of its nosology.
While including a disorder whose indicators are socially divisive, contra-
vene social norms, and can include patterns of delinquent and criminal
activity, psychiatry has been accused of mitigating or condoning the behav-
iors of individuals diagnosed as antisocial personality disorder or psycho-
pathic [36]. The relationship between psychiatry and antisocial behavior
and personality thus raises a fundamental challenge to the medical as
compared to the social functions of psychiatry. It is thus important that
one distinguish analytically between the antisocial constellation and con-
struct (a recurring, universal presence in society), its social interpretation
(generally negative, but can lead to positive traits and also fascination), the
species of behavior involving misdemeanors and crimes which the legal
system adjudicates, and what properly belongs in a nosology of psychiatry

considered as a medical discipline or institution.
A disturbance of behavior that is relatively discrete, consists of circum-

scribed signs/symptoms, and can result in social breakdowns, for example,
anxiety and phobia, paranoia, mood related problems, and even schizophre-
nia, would seem to present a ``cleaner'' case for an evolutionary conception
of psychiatric disorder [37, 38]. The abnormal personality constellations do
not readily conform to intuitive notions of disorder and disease. Rather,
they comprise complex programs of behavior, encompass traits and behav-
iors that appear ego-syntonic and by definition presuppose inferred, unob-
servable features of persons.
There are two different and seemingly contradictory ways in which evolu-
tionary theory has approached antisocial behavior. A harmful dysfunction
(HD) formulation would presumably rest on the ``natural function'' of soci-
ality, including competition and mutualism or altruism. A defect of this
function undermines an individual's pursuit of biological goals and causes
``harm'', thus qualifying as a disorder according to the HD formulation.
Problems associated with this perspective are covered later.
The second way in which evolutionary theory has been applied to `ànti-
social'' strays away from the HD disorder conceptualization and views the
antisocial constellation as a lifelong social strategy. It was one of any
number of strategies naturally selected for in the ancestral environment
and can, depending on the circumstances facing an individual early in
development, be adaptive even in the contemporary environment. This
formulation draws on a complex synthesis and interpretation of knowledge
from the fields of biological anthropology, developmental psychology, per-
sonality theory, sociobiology, criminology, and evolutionary ecology [39,
40]. It holds that ecological stimuli or ``clues'' that suggest uncertainty and
risk (e.g. parents' inability or unwillingness to offer support, resources, and
stability) cause patterns of attachment behavior that trigger or elicit (during
early childhood) a social strategy designed to maximize reproduction in
conformance with life history theory. This involves the differential alloca-
tion of resources (e.g. pertaining to survival, growth, repair, reproduction)
throughout the life cycle, affecting the onset of sexuality, the timing of
mating and reproduction, the quality of mating relationships, and the qual-
ity of parenting. This social strategy, by definition, promotes long-term
goals, but in the short run and in some environments can encompass
many of the personality, emotional, and social behavior traits associated
with the antisocial constellation.
The cross-cultural validity of virtually any psychiatric disorder presents

conceptual and methodological problems, but the personality disorders are
more knotty ones since they involve more style of behavior and less psycho-
logical distress and social impairment [38]. Antisocial personality disorder
adds to this a consideration of social norms, rules, and social practices in-
volved in the definition of deviance and criminality. Many questions have
been raised about its cultural validity [41]; for example, whether its essential
properties are culturally invariant or merely reflect Anglo-European stand-
ards of behavior, its relationship to concepts of personhood like ego-centricity
or social-centricity (as seen in individualistic as compared to collectivistic
societies, respectively), and tensions between an underlying trait or construct
compared to sociological and cultural parameters that may hinder or favor its
expression as per self-disclosure (e.g. whether the processes of socialization
and enculturation promote or suppress personality and behavior tendencies
suggesting antisocial personality).
The prevalence and characteristics of psychopathic personality in Scottish
compared to North American samples of psychiatric, forensic and criminal
populations have been studied recently [41± 43]. These authors relied on the
Psychopathy Checklist-Revised (PCL-R) developed by Hare [44], which
consists of two factors that measure personality factors and antisocial be-
havior. Cooke and co-workers employed the item response theory approach
in the measurement of antisocial personality disorder, a strategy that copes
successfully with many of the problems of cross-cultural measurement [43].
In particular, item response theory allows establishing whether the same
trait or phenotype is being measured and by means of the same metric in
two populations, in this case, two cultures.
Results revealed a statistically significant and substantially higher preva-
lence of psychopathy (i.e. based on cut-off scores and mean scores) in North
America compared to Scotland. Even when cut-off points were adjusted so
as to conform to the differences in overall measures, substantially more
psychopaths were found in the North American sample. This parallels
findings that have been obtained in Scandinavian and British samples,
suggesting that enculturation and socialization lead to suppression or exag-
geration of traits of psychopathy cross-culturally. With respect to North
American and Scottish samples, the slope parameters of the measures
obtained did not differ significantly cross-culturally, suggesting that the
disorder is defined by the same characteristics in the two cultures. A
number of items produced significantly different measures in the two
cultures, but most showed cross-cultural equivalence of measurement.
Many of the features of the disorder apparently do not become apparent
among Scottish prisoners until high levels of the trait are present. This
suggests that cultural factors dampen, inhibit, or suppress their expression

in Scotland. For example, the level of the underlying traits of glibness, lack
of remorse, and pathological lying at which the characteristics of the dis-
order become apparent differed in the two cultures: in Scotland those who
show these traits have a higher measure of the underlying trait of psycho-
pathy. Cooke and Michie explain the difference observed as resulting from
cultural differences in pressure for psychopathic behavior. The importance
of differences between levels of individualism in the two societies and
cultures, a factor that has been invoked to explain cultural variability in
the expression and manifestations of psychopathy, was considered as a
possibility but could not be verified. Classically, individualism compared
to sociocentrism is a parameter that has been observed in Anglo-European
as compared to Asian societies.
CRITIQUE OF THE TWO APPROACHES TO DIAGNOSIS

AND CLASSIFICATION
The Evolutionary Conception of Psychiatric Disorder
Many harmful dysfunctions of psychological mechanisms, disorders in the

evolutionary sense, are treatable conditions, but the latter need not constitute
disorders [45]. From an evolutionary standpoint, conditions of potential
psychiatric relevance involve a behavior condition, its evaluation, someone
who evaluates, and an evaluation context. The condition can be positive or
negative; the evaluator can be the subject, an observer, or a reference group;
the evaluation involves whether the condition results from a naturally
designed mechanism that is or is not ``doing its job'' (i.e. is evolutionarily
functional or dysfunctional) or is simply a by-product of a mechanism; and
finally, the environment in which a condition is situated can vary (i.e. the
ancestral or the present one). In this light, a treatable condition is the product
of a decision based on values and conventions, either that of the individual,
significant other, or reference group in society. Some treatable conditions
may arise because a function naturally designed in an ancestral environment
and operating ``naturally'' in the current one nevertheless causes impairment
or suffering (sexual jealousy or predation). The converse is also true: natural
functions may be dysfunctional (e.g. repeated sensation seeking and danger-
ous risk taking) yet produce behavior in contemporary environments that is
satisfying and not impairing (e.g. bold personalities, rock climbing). Finally,
many treatable conditions may have no relationship to a natural function but
are simply by-products of such, or due to simple human variation [1].
Echoing a treatable condition perspective, Kirmayer and Young [46] point
out that the HD analysis is not fully impersonal and objective, but depends
on implicit positions of value, totally disregarding social and cultural con-

ventions. Sadler [47] has emphasized that the HD position started out as a
prescriptive formula validating what a disorder constituted. Its exponents
seem now to be concerned mainly with descriptive questions (why and how
generally held psychiatric disorders conform to a HD analysis) and less so
with prescriptive ones that clarify what and why a condition (e.g. hyper-
activity, premenstrual syndrome) should or should not constitute a dis-
order. It is clear that in the debate about prescriptive questions regarding
a particular condition, one can point to fuzzy concepts about what constitute
natural functions and, thus, whether the condition constitutes a disorder.
Sadler, like Kirmayer and Young, then, makes clear that despite the seeming
rigor of the HD formulation, its application can entail messy questions of
politics, values, and conventions and standards about normality, deviance,
adaptation, and natural functions.
There are several additional reasons why a HD prescription cannot be
expected to neatly serve the needs of diagnostic systems, at least in the
foreseeable future. Most diagnoses that have emerged in psychiatry do not
conform in point-for-point way with failures or breakdowns of a natural
function. Entities like depression, schizophrenia, anxiety, and somatization
disorder embrace many levels and layers of social and psychological func-
tion, and there is little evidence that they can be reduced to or equated with
failures of one or even a few adaptations or mechanisms [9, 10]. Most em-
body complex behavior phenomena that are the outcome of failures of
several natural functions and mechanisms. Furthermore, many of the func-
tions or mechanisms governing pathological behavior involve the interplay
of hierarchically arranged levels of functions. Perturbations and dysfunc-
tions in one level can be propagated up and down the hierarchy and at
different levels may be subject to positive or negative feedback. If a systems
view is used to conceptualize individual functioning and what constitutes a
disorder, the elegant solutions that a HD analysis promises become opaque
and fuzzy.
Many so-called psychological adaptations are really descriptions of
domains of biologically significant but highly complex social behavior.
They may have promoted the solution of biological problems, for example,
mate selection, acquisition of rank, and social competition; however, they do
not readily map on to well-demarcated spheres of behavior (other than
tautologically) nor can they be equated with conditions or ``disorders'' as
classified in psychiatry. Other adaptations, while certainly fundamental in
promoting fitness and adaptation, really refer to rather narrowly defined
(i.e. content specific) cognitive/perceptual functions that serve or contribute
to the solution of many biological functions. For example, mate selection,
achievement of high social rank, solution of subsistence problems, and/or
ability to avoid predators in the hominid environment of evolution required
adaptive functions in many areas of perception, cognition, recognition of

emotion, linguistic and/or emotional communication. Some of the evolu-
tionary arguments that have been developed for psychiatric disorders (de-
pression, schizophrenia) embody whole packages of maladaptive behavior
that can be reduced or fitted into a HD analysis only with great difficulty.
Problems in the evolutionary conception can be illustrated by considering
psychopathy. It obviously incorporates many so-called psychological mech-
anisms and does not easily or neatly profile a disorder as per the HD
analysis. Mechanisms pertaining to care giving, mating, social commitment,
and social responsibility come to mind and these can apply to kin, non-
kin group mates, competitors, strangers, and/or potential mates. Where and
on what basis does one place the antisocial in this array of behavior and
experience? Moreover, there is in evolutionary biology a well-established
``theory'' about the complexities of social relationships. Emphasis is placed
on the intricacies of competition and trade-offs which of necessity must take
place across different spheres of relationships and behaviors, for example,
between giving and taking, between differences in what it is adaptive for
parents to `ìnvest in'' or ``hold back from'' offspring compared to the
unlimited demands that the latter make, and between the obvious residuals
of sexual selection that involve sharply divergent mating strategies of males
(i.e. impregnate and if necessary coerce many) and females (i.e. select few on
the basis of their resources and commitment). Finally, there is the quandary
raised by the trait not only of selfishness/competition but also of social
cunningness and dissimulation in the service of personal goals, aptly
termed Machiavelianism. Behavior meriting this qualification has been
described for primates attesting to its presumed adaptive, selective basis.
Thus, while on first impression the HD formulation of disorder appears
relevant and valid to the antisocial constellation and construct, closer analy-
sis reveals problems. There is a great deal of complexity and ambiguity
regarding what is ``social'' and altruistic/responsible compared to `ùn-
social'' or selfish/expedient. Consequently, where and on what basis the
calibration of antisocial fits within the domain of social activity is problem-
atic. Unambiguously disentangling what is evolutionarily prudent from
what is antisocial, and from whose standpoint will the latter be calibrated,
all would seem to present problems to the HD formulation of the antisocial
constellation/construct.
In summary, there are reasons to be cautious with respect to the proposed
evolutionary conception of psychiatric disorder generally and on the HD
formulation in particular. While the classic theory of categories that support
the HD formulation is theoretically compelling and aesthetically pleasing,
its use for deciding whether any one condition of psychiatric relevance is,
is not, or should be defined as a disorder raises numerous problems.
Nevertheless, evolutionary biology and psychology generally, and the HD
analysis of disorder more specifically, embody insights that should be

included in a science of psychiatric diagnosis and classification.
The Cultural Conception of Psychiatric Disorder
It can be argued that evolution provided conditions for the emergence of

culture but the latter was not naturally selected. Mechanical and physical
changes affecting the brain (e.g. size and/or structure) and/or an exaptation
and not an adaptation [48] may explain the behavioral plasticity that makes
culture possible. Behavioral traditions and systems of communication ob-
served in higher primates, likely features of hominids and earlier varieties
of species Homo, can be regarded as qualitatively different from human
language, cognition, and culture. These traits may constitute, on the one
hand, either a singular, unique development of the final phase of human
biological evolution, integral to what brought about the emergence of Homo
sapiens and the move out of Africa some time after 100 000 or so years ago;
or, on the other hand, merely a set of traits that were conditioned by social
ecological exigencies. Thus, culture may merely add surface manifestations
to behavior and psychopathology, constituting mere epiphenomena rather
than essential features. One could argue that a vulnerable Japanese subject
raised in America is not ``prepared'' to develop manifestations resembling
Taijin Kyofusho but is instead vulnerable to whatever variety of social phobia
is present in the local culture.
In summary, one can argue that essential behavioral properties of Homo
sapiens (including their vulnerability to suffer from psychopathology) may
reside in psychological mechanisms (or algorithms) but that characteristics
linked to culture are largely evoked, learned, and/or acquired. The HD
position, for example, underscores natural functions that are culture free.
Essential aspects of ``cultural psychology'' that shape a culturally specific
psychopathology may not be part of an ensemble that in any way was
naturally selected for and genetically based. Whether human language,
cognition, and culture constitute capacities that were naturally selected
gradually or merely a by-product of a unique event or `èxplosion'' of
comparatively recent origin, is highly contested and cannot be discussed
further here [6]. However, even if human language, cognition, and culture
do not constitute naturally selected and genetically based traits, one can still
claim that they constitute essential features of Homo sapiens and are neces-
sarily implicated in psychopathology.
Psychiatry seeks a universal science about the functioning of the ``psyche''
and its disturbances. However, how the mind works involves an amalgam of
two sets of factors: conceptual models and reasoning principles, on the one
hand, and features of language and culture, on the other. The two are very
difficult if not impossible to untangle [49±53]. Anthropologists and linguists

agree that through an amalgam of meaning-creating systems individuals
fashion their personal experience, sense of reality, social behavior, and the
requirements for social order. According to culture theory, systems of mean-
ing are crucial. It does not posit an opposition or exclusivity between the
domains of brain function and cultural meaning systems. Both together form
an integral whole and are products of the evolutionary process.
Psychopathology, then, arises only in a symbolically determined setting
of behavior. There are good reasons to presume that even were psychiatric
disorders to be conceptualized in purely neurobiological terms, cultural
factors have to in some way be taken into account in making sense of
them. The three test cases discussed earlier illustrate that social conventions
and cultural meanings about behavior and deviance of necessity come into
play in decisions regarding how psychopathology is configured, enacted,
and accorded significance in a society. Elsewhere I have argued on general
grounds that what constitutes a psychiatric disorder, who should be treated,
and what constitutes the proper domain of a medical psychology, all require
taking into consideration cultural conventions [6, 54].
Another criticism of the cultural conception of psychiatric disorder is that it
may rely on a view of culture that is losing ground and eventually may
become outdated. The importance of cultural psychologies in the constitution
of psychopathology is best visualized for members of monolithic cultures that
contrast sharply with one another. The examples discussed earlier involved
Japan and China and to this could be added India, societies of the African
continent, and of course members of isolated, non-industrial societies. It is
among people holding traditions and conceptions that articulate self-
contained and integrated world-views that differ sharply from society to
society and that speak different languages that one finds contrasts in cultural
psychologies that, in turn, would configure different constitutions of psycho-
pathology. In the modern world, a global, capitalist culture holds sway,
communication of traditions is widespread, and migration very prominent.
This criticism, then, stipulates that modernity melts away cultural heterogen-
eity and that, in the long run, truly contrastive constructions of cultural
psychologies and psychopathology will lessen. However, this argument
does not contravene the importance of culture: while suggesting the possible
erasure of cultural differences, it actually reinforces the importance of sym-
bols and meaning (see below).
That a system of psychiatric diagnosis and classification is first and
foremost a practical enterprise designed to facilitate international communi-
cation and comparability of clinical practice and research is another argu-
ment that challenges the cultural conception. A practical argument for
universality weakens the position that cultural differences should be ac-
corded primacy. This is consistent with the point mentioned earlier; namely,
that in the modern world science, secularism and rationalism have become
so integral to the idiom of contemporary societies and of medicine more
generally that these developments undermine monolithic cultural differ-
ences, homogenize world-views, and create internationalist cultures and
human psychologies that a science of descriptive psychopathology has
evolved to cope with [4, 5]. In this view of the matter, holding on to the
reality and importance of cultural variability becomes an impediment and
distraction. All of this would appear to demand a common language of
psychopathology and undermine the cultural conception.
IMPLICATIONS FOR THE FUTURE OF PSYCHIATRIC

DIAGNOSIS AND CLASSIFICATION
Theoretical Perspective
Psychopathology is one of the social problems that societies cope with. Insti-
tutions for this are diverse and include social welfare, religion, medicine, and
the systems of social control that embrace ethics, morality and criminal
adjudication. Depending on context, any particular variety of psychopath-
ology can be interpreted as a condition of disadvantage requiring support
and assistance, a condition of wickedness and impiety requiring spiritual and
religious counseling, a type of sickness requiring medical treatment, a special
category of sickness as per psychiatry, or a moral transgression and offense
that needs control, correction and/or incarceration. Provided it takes
into consideration culture and language, a science of diagnosis seeks to
address universal characteristics. It allows determining exactly where in the
social spaces and institutions of any society conditions of psychopathology
are situated, keying in on essential characteristics. A culturally sensitive
science of diagnosis allows claims that some members of devotional sects
of ancient India or medieval Islam may have been victims of psychopath-
ology whereas many dissidents labeled as schizophrenic in the former Soviet
Union decades ago were not. Such claims are possible because the system
would handle specific disorders as tokens of types defined on the basis of a
theory or nosology that incorporates biology, neurobiology, language, and
culture.
Generalizations About the Character of Psychopathology
Evolutionary conceptions of psychopathology can be nothing if not elabor-

ate, complex, and also variable. At other times, they are direct, trim, and un-
complicated; sometimes, they seem like `às if'' stories. Nevertheless, such
conceptions cannot be ignored and should be represented in a diagnostic

system; either prescriptively, stipulating which complex of behavior should
be included in the system (e.g. those that constitute breakdowns of a natural
function) or at least descriptively, illustrating why a treatable condition is a
disorder. Ideally, evolutionarily conceived biological goals that a psychiatric
disorder undermines should be represented as criteria in a psychiatric noso-
logy.
The theory of culture authorizes equally compelling claims about psychi-
atric disorders. It certainly challenges the notion that their phenomenology,
interpretation, and social effects are universal and pan-cultural. The fact of
cultural differences also renders problematic the very enterprise of diagno-
sis by emphasizing how aspects of personal experience and behavior that
shape a clinical condition are based on culturally constituted world-views.
This is clearly the case with depression and social phobia. Yet, even the
make-up of psychopathy is in some ways different in Scotland and America,
two ``cultures'' that share many traditions. One cannot but expect that in
societies with more divergent histories and cultural traditions differences in
psychopathy would be greater. It would seem to follow that culture theory,
like evolutionary theory, makes claims about psychiatric disorders that a
system of diagnosis should incorporate.
Generalizations About the Future of Human Societies
Given the apparent trends in migration and immigration and the possible
future weakening of totalitarian/autocratic governmental controls as a
function of the spread of modern ideas of individualism and liberalism,
one would argue that human populations are likely to manifest greater
genetic mixing and assimilation in the long run. Since evolutionary biology
points to the innate bases for human psychology, it can safely be assumed
that a view about the universality or essentialism of psychopathology will
continue to be relevant. Furthermore, given modern developments in trans-
portation and communication, one may assume the continued spread of an
internationalist political economy and associated values of capitalism. In the
long run, this should lessen cultural boundaries and distinctions, contrib-
uting however slowly to the homogenization of human beliefs, values,
traditions, and outlooks. Barring major collisions among large and small
national powers, with consequent time-limited reactions of insularity and
isolationism, the pace of social and cultural change in the direction of a
common global culture can be expected to continue. Events in recent history
both support and challenge these generalizations [55, 56].
Prospects of future social change may be anticipated. The role of cul-
tural factors in critically influencing political economic developments in
Western and non-Western societies has been emphasized [57]. Social crises
undermine traditional institutions of social control and legitimate structures
of authority, with consequent loosening of psychological controls and the
hold of traditional systems of morality and conscience [58±60]. Modern
societies show waxing and waning of the hold of traditional values, grud-
ging tolerance of social deviance seen in juxtaposition to racial hatreds
and divisive competition, openness to differences in lifestyle and religion
yet increased distrust, and suspicion; they resort to adversative modes of
conflict resolution, and a heightening of narcissism. Modernity tends to
increase interpersonal self-disclosure along with an awareness and open-
ness to cultural differences, sometimes including sexual experience and
behavior.
One can assume that such features of culture will not only continue to
influence the character of personal experience and social behavior, but will
also sharply influence interpersonal conflicts in circumscribed communities.
Migration and cultural pluralism will likely increase and this implies not
only a clash between `òld'' traditions and the ``new'' narcissism and inter-
nationalism of the culture of capitalism, differences between host and
parent country, but also clashes between competing traditions, values, and
sects in large urban ``melting pots''. In other words, individuals come to be
influenced by global, secular trends and migrate to foreign soils where they
then interact with other immigrant, minority populations.
Here it is important to keep in mind the distinction between the two
conceptions of culture mentioned earlier. While the demographic (demar-
cating) view of culture may diminish in importance because of the assimila-
tion of modernity, culture as lived reality shaped by diverse and even
competing tenets and feelings (and different in emphasis from that of
other citizens) will continue to be important. Even if one agrees that a
brain-based model of rationality and belief formation is an innate property
of Homo sapiens, ascertaining its workings necessarily enmeshes the diag-
nostician in a complex exegesis that requires knowledge of his/her and
client's language and culture. How items of information are labeled, con-
firmed, disconfirmed, and incorporated into meaningful social discourse
constitutes the essence of culture and language and of higher cortical func-
tions. Consequently, while cultural differences across societies may lessen in
importance, intra-societal differences between an individual in work and
institutional settings, including psychiatrist/patient dialogues, are likely to
increase in societies of the future. It is thus to be expected that symbols,
meanings, and world-views will continue to be influential in shaping per-
sonal experience and behavior, constituting aspects of social reality that
systems of psychiatric diagnosis should contend with in the future, if such
systems are to realistically incorporate important characteristics of the indi-
vidual.
Incorporating Evolutionary Theory in a Psychiatric Nosology
Although the HD formulation may not serve as the ultimate ``scientific''

criterion for the definition of a psychiatric disorder, this by no means
implies tenets of evolutionary theory should not be represented in a system
of psychiatric diagnosis. The history of psychiatry and empirical research
underscore the importance that disorders (e.g. Axis I of DSM-IV) will likely
continue to play in future systems of diagnosis. Because of the high preva-
lence of comorbidity and the difficulty of establishing clear boundaries
between disorders [61±63], it seems prudent to hold that individuals in
need of psychiatric care embody a clinical condition made up of one or
several disorders. Moreover, the condition more than the disorders is what
limits an individual's capacity and ability to function [64].
This means that the basic functional capacities to execute behavior as
authorized by evolutionary theory constitute important ``facts'' about a
psychiatric condition of an individual. McGuire and Troisi [19] have pro-
vided a comprehensive listing of these including their behavior compon-
ents. Such functional capacities constitute human universals that could be
incorporated by means of separate axes or numerical coding schemes in a
system of diagnosis. Many of the directives of evolutionary psychiatrists are
highly consistent with basic psychosocial, behavioral, and psychothera-
peutic approaches in psychiatry.
Incorporating Culture Theory in a Psychiatric Nosology
At least for the foreseeable future, settings of evaluation, especially in large

Western cities, will involve individuals from non-Western, less developed
societies. Proficiency in the language of the host country is likely to be low.
The social backgrounds and cultural orientations of potential patients are
likely to: (a) contrast with that of the host country and especially with basic
conceptions about self, experience, and behavior that are integral to scientific
medicine and psychiatry; (b) emphasize more somatic as compared to psy-
chological factors in health and disease; (c) manifest a more social centered as
compared to a person centered orientation regarding the meaning, purpose,
and calibration of behavior; and (d) include a more spiritual emphasis on
experience, purpose, obligation, and personal accounting. The concept of
what is private and hence closed to inquiry will differ as well. Ease of self-
disclosure and openness to questions regarding social, interpersonal, and
spiritual matters are likely to differ from what is regarded as relevant to the
ordinary, typical psychiatric history. The lay conception of a ``mental illness''
will not coincide with that of psychiatry, and the way personal symptoms
and impairments are explained (i.e. explanatory models) will likewise differ
as well. Finally, all of the parameters of social and biological functions

mentioned earlier will require formulation in an idiom that realistically
takes into account the cultural perspective of the patient.
A psychiatric diagnosis should serve to identify and describe a person's
clinical condition in a way that accurately represents his or her disorder or
disorders. It should optimize formulation of an effective treatment plan that
accurately measures the person's condition and merges or translates be-
tween the person's conception of his/her condition with that of the provider
of mental health services. Diagnosis should also facilitate communication
among professionals, staff, patients, and families of patients. Factors listed
above constitute some of the rubrics of information and domains of experi-
ence that psychiatric diagnosis should encompass. The requirements for
reaching a valid psychiatric diagnosis and the functions served by a system
of diagnosis and classification imply that culture will continue to be import-
ant in how psychopathology is assessed and how information about it is
used in a clinically effective and prudent way.
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Psychiatric Diagnosis and Classification.

Psychopathology is universal, found in all societies regardless of their

ON THE GENEALOGY OF PSYCHIATRIC DIAGNOSIS

All of the traditions of medicine associated with ancient civilizations that

problems of behavior and sickness that today are classified as psychiatric.

conception of disease became ascendant and with this understandings of

EVOLUTIONARY THEORY AS A BASIS FOR

Many psychiatric disorders have a genetic basis. Their prevalence is sub-

Evolutionary Theory, Human Behavior, and Psychopathology

Social relations play a central role in evolutionary theory. Natural selection

elicited, psychopathology may result. Positive emotions (e.g. satisfaction,

Psychiatric Disorders as Harmful Dysfunctions

analysis by both psychiatrists and social scientists. Whether the concept of

THE THEORY OF CULTURE AS A BASIS FOR

Psychiatric Disorders as Culturally Constituted Human

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

DEPRESSION: CASE NO. 1 IN THE EVOLUTIONARY AND

Evolutionary Theory Considerations

Evolutionary psychiatrists have made depression an object of analysis. Its

characteristic signs as communications designed to elicit others' help. How-

Culture Theory Considerations

While the universal prevalence of depression constitutes an indisputable

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

Not surprisingly, then, because the diagnosis of neurasthenia as shenjing

SOCIAL PHOBIA: CASE NO. 2 IN THE EVOLUTIONARY

Evolutionary Theory Considerations

released in situations that are perceived to constitute a threat to the individ-

Culture Theory Considerations

While the international and evolutionary viewpoints about social phobia

an emphasis on consciousness of self in social situations, of being on a social

PSYCHOPATHY: CASE NO. 3 IN THE EVOLUTIONARY

Antisocial personality traits and behavior constitute a challenge for a nos-

system adjudicates, and what properly belongs in a nosology of psychiatry

Evolutionary Theory Considerations

A disturbance of behavior that is relatively discrete, consists of circum-

Culture Theory Considerations

The cross-cultural validity of virtually any psychiatric disorder presents

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

CRITIQUE OF THE TWO APPROACHES TO DIAGNOSIS

The Evolutionary Conception of Psychiatric Disorder

Many harmful dysfunctions of psychological mechanisms, disorders in the

on implicit positions of value, totally disregarding social and cultural con-

adaptive functions in many areas of perception, cognition, recognition of

analysis of disorder more specifically, embody insights that should be

The Cultural Conception of Psychiatric Disorder

It can be argued that evolution provided conditions for the emergence of

difficult if not impossible to untangle [49±53]. Anthropologists and linguists

IMPLICATIONS FOR THE FUTURE OF PSYCHIATRIC

Generalizations About the Character of Psychopathology

Evolutionary conceptions of psychopathology can be nothing if not elabor-

conceptions cannot be ignored and should be represented in a diagnostic

Generalizations About the Future of Human Societies

Incorporating Evolutionary Theory in a Psychiatric Nosology

Although the HD formulation may not serve as the ultimate ``scientific''

Incorporating Culture Theory in a Psychiatric Nosology

At least for the foreseeable future, settings of evaluation, especially in large

as well. Finally, all of the parameters of social and biological functions

1. Fabrega H. Jr. (1997) Evolution of Sickness and Healing. University of California

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