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 Table of Contents  
Year : 2018  |  Volume : 34  |  Issue : 5  |  Page : 1-4

Cultural perspectives related to international classification of Diseases-11

1 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
2 Department of Psychology, Virginia Commonwealth University, Richmond, Virginia 23284, USA

Date of Web Publication20-Nov-2018

Correspondence Address:
Prof. Pratap Sharan
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijsp.ijsp_45_18

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How to cite this article:
Sharan P, Keeley J. Cultural perspectives related to international classification of Diseases-11. Indian J Soc Psychiatry 2018;34, Suppl S1:1-4

How to cite this URL:
Sharan P, Keeley J. Cultural perspectives related to international classification of Diseases-11. Indian J Soc Psychiatry [serial online] 2018 [cited 2022 Jan 22];34, Suppl S1:1-4. Available from: https://www.indjsp.org/text.asp?2018/34/5/1/245836

The International Classification of Diseases (ICD)-11, as a product of the World Health Organization (WHO), has the difficult responsibility of attempting to best represent the definition of mental disorders for all people of the world. Cross-national variation in the prevalence of many mental disorders in studies utilizing similar methodologies – for example, a 34-fold difference in the prevalence of social anxiety disorder – has raised the possibility that guidelines developed based on the experience of a few cultures may fail to capture the expressions of some disorders in other cultures.[1] Unfortunately, to date, the bulk of research only includes WEIRD participants (i.e., participants that come from Western, educated, industrialized, rich, and democratic societies).[2] Further, the observation that “witnessing intentional destruction of religious symbols” had as strong an association with mental illness as experiencing torture among Tibetan refugees,[3] and other similar findings have led authors to suggest that the meaning of events within a culture also influences the risk and form of psychopathology. Attention to alternative symptom expressions, variations in the boundaries between disorders, risk moderation, and explanatory models of illness are needed for a comprehensive nosology that aims to have broad national and international relevance.[4] This article will describe some of the ways that ICD-11 has attempted to improve the cultural representation of mental disorders in its classification as well as to point out areas for additional work.

In general, ICD-10 was more attuned to finding transcultural uniformities than to attending to variations in clinical presentations, with the exception that 12 culture-specific disorders were listed in the ICD-10 Diagnostic Criteria for Research.[5] This necessitated a number of national and regional adaptations, for example, the Chinese Classification of Mental Disorders, the Japanese Clinical Modification of ICD-10, the Cuban Glossary of Psychiatry, and the Latin American Guide for Psychiatric Diagnosis, in an attempt to align the international reference with local realities and needs. Contributions and changes – for example, the addition of Qigong-induced mental disorders in the Chinese Classification of Mental Disorders or the retention of a unitary concept of neurosis in the Japanese Clinical Modification of ICD-10 – were incorporated through the employment of fifth digits in the diagnostic code or through the use of codes not used in the ICD-10. In some cases, supplemental text was added.[5] The development of ICD-11 represents an opportunity for the integration of sociocultural information into psychiatric nosology and diagnostic practice to enhance its cross-cultural utility. Most countries have contributed critically to the development of ICD-11 in the hope that its attention to cultural features will obviate the need for regional/national adaptations.

  International Classification of Diseases and Cultural Issues Top

System-wide support

The ICD provides a common classification system that facilitates communication and information exchange across the multitude of countries and health-care systems globally.[6] In the revision of the ICD, the WHO has intensified its commitment to expanding and ensuring substantive engagement of the diverse constituency groups and representation of the wide range of cultures across the globe.[7]

In an attempt to maximize cultural sensitivity and relevance, the WHO prepared international and multilingual literature reviews of mental disorders that were focused on the clinical utility of the ICD in low- and middle-income countries (LMICs). In addition, the WHO conducted in-depth analyses of the ICD system at the country and regional levels to gather information on the clinical utility of ICD in various contexts and recommendations for alternative disorder descriptions. Furthermore, surveys of global psychiatrists[8] and psychologists[9] were conducted in collaboration with the World Psychiatric Association and the International Union of Psychological Science, respectively. The wide international developmental process has led to the infusion of a sociocultural perspective into the entire ICD-11 and to a number of structural features that support its cultural utility.[6],[10],[11]

The definitions of mental disorder in ICD-11[6] and DSM-5[12] are similar and are aimed at exclusion of culturally approved responses to common stressors or losses (e.g., bereavement) and social deviation.[7] These exemptions are mentioned in the definition of mental disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5; in the ICD-11, they are clarified at the level of diagnostic guidelines for specific disorders (e.g., bereavement reactions should not be mistaken for depression; all socially stigmatized sexual behaviors should not be diagnosed as paraphilic disorders).[7]

The ICD-11 utilizes prototypical descriptions of disorders rather than lists of criteria, to facilitate accommodation of both cultural variations in phenomenology and contextual and health system factors that may affect diagnostic practice.[13] In general, clinicians are in favor of incorporating more flexibility in diagnostic guidelines,[10],[11] which is one way to increase the fit of varying patient presentations with diagnostic requirements.

Furthermore, since ICD-11 intends to enhance the validity and reliability of psychiatric diagnosis across cultural groups around the world, its field testing program has been designed to examine linguistic and regional differences in the accuracy, consistency, and clinical utility of the diagnostic guidelines to maximize their global applicability before the revision is finalized.[11]

Specific cultural features

The Gender and Cross-Cultural Issues Working Group for the ICD-11 is charged with the task of harmonizing the various cultural issues related to ICD-11. Compared to the ICD-10, the ICD-11 describes in more detail the ways in which sociocultural processes affect the onset and form of mental illness. Examples of some salient changes that may have relevance for cross-cultural application of ICD-11 are described below. These are intended as illustrations of the kind of changes that are envisaged and should not be construed as exhaustive or final because the Gender and Cross-Cultural Issues Working Group is still in the process of finalizing its recommendations.

Introduction of new categories

It is well recognized that there are a number of clinical presentations of mental health disturbances that are currently not well categorized. It is hoped that the inclusion of some new categories in ICD-11 will contribute to better recognition of such mental health disturbances transculturally, for example, the inclusion of avoidant/restrictive food intake disorder (ARFID). Although there may be a superficial similarity between anorexia nervosa and ARFID in that both involve dietary restriction or food avoidance, individuals with ARFID do not share the core disturbance in the way in which one's own body weight or shape is experienced in anorexia nervosa.[14] There may be a number of factors contributing to the eating disturbance in ARFID. These include having little interest in eating and/or avoidance of multiple types of food. The avoidance of specific types of food may be based on specific sensory properties (e.g., color, appearance, texture, taste, temperature, or smell) or on perceived adverse consequences of eating such food (e.g., feared health problems, vomiting, or choking). The importance of somatic factors as causes of restrictive eating has been emphasized in descriptions from LMICs.[15]

Similarly, a new category of “partial dissociative identity disorder” has been added, based on observations that many patients present with two or more distinct, nonintegrated, or incompletely integrated dissociative identities, each of which exhibits a distinct pattern of experiencing, interpreting, and relating to itself, others, and the world. However, they cannot be diagnosed as dissociative identity disorder as only one identity is dominant.[16] The specific diagnosis of dissociative identity disorder was rarely made in LMIC settings; the presence of “partial dissociative identity disorder” may provide a better opportunity to categorize the disturbances seen in clinical practices across the globe.

Modifications of diagnostic guidelines

Sometimes, changes were proposed at the level of diagnostic guidelines, for example, in the case for social anxiety disorder. Cross-cultural research with taijin kyofusho in Japan and taein kong po in Korea had suggested that the fear of negative evaluation by others can take the form of fear that the individual will offend others, in addition to or instead of the fear that the person will feel embarrassed or humiliated as a result of engaging in the social behavior. However, fear of offending others is also observed among individuals with social anxiety disorder in Western cultural settings.[4] To account for this broader conceptualization, ICD-11 has accounted for the transcultural presentation of social anxiety disorder by including a perception of being offensive within the diagnostic guidelines.[7]

Culture-related features for specific disorders

Accompanying text on cultural considerations for all disorders in ICD-11 summarizes information on cultural variations in modes of describing distress, symptom patterns, dysfunctions, and course to promote culturally sensitive application of the diagnostic guidelines.[13] For example, the proposed ICD-11 guidelines for depressive episode prioritize sadness and anhedonia as the principal symptoms of depression. However, clinicians are informed that somatic symptoms can predominate in depressive episodes or that there may be cultural variability in whether and how patients discuss emotions with clinicians.

The section on culture-related features on posttraumatic stress disorder (PTSD) in the ICD-11 states that culturally sanctioned and recognized expressions or idioms of distress, explanatory beliefs, and cultural syndromes may be a prominent part of the trauma response. They may influence PTSD symptomatology and comorbidity particularly through somatization as well as other emotional, cognitive, and behavioral expressions of distress. For example, cultural idioms of distress following exposure to trauma may manifest through somatic symptoms, such as ohkumlang (tiredness) and bodily pain among tortured Bhutanese refugees; symptoms such as possession states in Guinea Bissau, Mozambique, Uganda, and Bhutanese refugees; susto (fright) among Latino populations; and kit chraen (thinking too much) and sramay (flashbacks of past traumas in the form of dreams and imagery that spill over into waking life) in Cambodia. These cultural idioms are not equivalent to PTSD, but influence its presentation and interpretation.[13]

  Comparison with Diagnostic and Statistical Manual of Mental Disorders -5 Top

The DSM-5 attempts a different solution to integrate culture throughout the manual. It provides introductory text on conceptual and practical issues in evaluating the role of culture and context in diagnosis; culture-relevant material in the descriptive text for each disorder; the Outline for Cultural Formulation (OCF) and its operationalization into the Cultural Formulation Interview (CFI); and a glossary on cultural concepts of distress. The main goal of the OCF is to help clinicians identify cultural-contextual factors affecting the patient that are relevant to diagnosis and treatment. The glossary covers three concepts. Cultural syndromes are clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experience. Cultural idioms of distress are ways of expressing distress that may not involve specific symptoms or syndromes, but that provide shared ways of experiencing and talking about personal or social concerns. Cultural explanations or perceived causes are labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for symptoms, illness, or distress.[4] The structure of ICD does not permit additional sections such as emerging measures and models or an Appendix that have been used in DSM-5 to house the OCF, the CFI, and the glossary on cultural concepts of distress. The Gender and Cross-Cultural Issues Working Group for the ICD-11 is currently considering how best to present such issues in the ICD-11.

  Need to Generate Further Scientific Evidence Top

The ICD-11 aims to provide a culture-fair classificatory system that is valid, reliable, and clinically useful. Cultural issues related to classificatory systems may be of clinical and public health importance in LMIC settings. However, there is a paucity of empirical studies on the role of culture in the pathogenesis of illness in LMICs.

International classificatory systems fix the phenomenological boundaries of disorders in order to guide research and clinical practice. This can lead to exclusion of culturally/contextually influenced alternative symptom variants of these disorders.[4] It may be possible to construct alternative culture-based nosologies at various hierarchical levels. At a broad level, alternative models could be considered regarding the separation of affective, anxiety, and somatoform disorders, as this separation universalizes the Cartesian mind–body distinction, which is not shared worldwide.[17] At a narrower hierarchical level, the occurrence of cultural syndromes suggests that the correspondence between local culturally based nosology and official categories may vary.[4],[18] An example is the complex association between ataques de nervios and several official disorders such as panic disorder and dissociative disorder, among others.[4] A similar case could be made for the overlap between dhat disorder and health anxiety, somatoform, depressive, and anxiety disorders.[19]

It may be important to understand that global forces including international classificatory systems (and attendant pharmaceutical marketing pressures) may have substantial impact on the cultural diversity in approaches to health and illness. The previously Western syndrome of “depression” is becoming a master narrative among clinicians in diverse communities, where cultural syndromes are disappearing (e.g., neurasthenia in China, dhat syndrome in India, Hwabyung in Korea, and Taijin-kyofusho in Japan). However, the apparent uniformity in diagnosing patterns may be suppressing the need to solve certain conceptual problems of classification, for example, the validity of completely dichotomizing bodily and psychic symptoms associated with human suffering.[20]

Culture-specific disorders may demonstrate acceptable validity if they are reliably diagnosed through the utilization of appropriate operational diagnostic criteria that include not only symptom constellations, but also clear causal relationships with the purported etiological determinants[19],[21] such that etiological and treatment research conducted using rigorous designs could possibly justify such disorders as authentic entities in future psychiatric classification systems.[21]

Further research on the cultural framework for classification is essential. This research should be organized programmatically and longitudinally, and the validity of alternative categories and guidelines should be explored. This would require development of cultural expertise in the LMICs so that they can contribute to future culture-fair classificatory systems.

  References Top

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Evans SC, Reed GM, Roberts MC, Esparza P, Watts AD, Correia JM, et al. Psychologists' perspectives on the diagnostic classification of mental disorders: Results from the WHO-IUPsyS global survey. Int J Psychol 2013;48:177-93.  Back to cited text no. 9
Reed GM, Rebello TJ, Pike KM, Medina-Mora ME, Gureje O, Zhao M, et al. WHO's global clinical practice network for mental health. Lancet Psychiatry 2015;2:379-80.  Back to cited text no. 10
Keeley JW, Reed GM, Roberts MC, Evans SC, Medina-Mora ME, Robles R, et al. Developing a science of clinical utility in diagnostic classification systems field study strategies for ICD-11 mental and behavioral disorders. Am Psychol 2016;71:3-16.  Back to cited text no. 11
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First MB, Reed GM, Hyman SE, Saxena S. The development of the ICD-11 clinical descriptions and diagnostic guidelines for mental and behavioural disorders. World Psychiatry 2015;14:82-90.  Back to cited text no. 13
Al-Adawi S, Bax B, Bryant-Waugh R, Claudino AM, Hay P, Monteleone P, et al. Revision of ICD – status update on feeding and eating disorders. Adv Eat Disord Theory Res Pract 2013;1:10-20. [doi.org/10.1080/21662630.2013.742971].  Back to cited text no. 14
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Malhotra N, Gupta N. Dissociative disorders: Reinvention or reconceptualization of the concept? Indian J Soc Psychiatry 2018;34 Suppl:S44-8.   Back to cited text no. 16
Kleinman AM. Depression, somatization and the “new cross-cultural psychiatry”. Soc Sci Med 1977;11:3-10.  Back to cited text no. 17
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