Chapter 12: Culture and Psychological Disorders PDF

12 Culture and Psychological Disorders CHAPTER CONTENTS Defining Abnormality: Some Core Issues Mental Health of Ethnic Minorities, Defining “Abnormal”...

12 Culture and Psychological Disorders CHAPTER CONTENTS Defining Abnormality: Some Core Issues Mental Health of Ethnic Minorities, Defining “Abnormal” Migrants, and Refugees African Americans Culture and the Categorization and Latino Americans Assessment of Psychological Disorders Asian Americans Culture and Categorization of Psychological Disorders Native Americans Cross-Cultural Assessment of Psychological Immigrants Disorders Refugees Measurement of Personality to Assess Summary Psychopathology C O N CL US I O N Cross-Cultural Research on Psychological Disorders E X PL O R AT I O N A ND D IS C OV E RY Why Does This Matter to Me? Schizophrenia Suggestions for Further Exploration Depression Attention-Deficit/Hyperactivity Disorder Cultural Syndromes of Distress Summary 278 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Psychological Disorders   279 One important goal of psychology is to use the knowledge gained through research to help people suffering from psychopathology (psychological disorders that encom- psychopathology pass behavioral, cognitive, and emotional aspects of functioning) to rid themselves Psychological disorders that encompass behav- of symptoms and lead more effective, productive, and happy lives. Several themes ioral, cognitive, and have guided research and practice in this area of psychology. First and foremost is emotional aspects of the question concerning the definition of abnormality. What is considered abnormal? functioning. When are a person’s behaviors, thinking, and emotions abnormal? A second question concerns the expression of a psychological disorder and our ability to detect it and classify it when it is expressed. These are questions concerning assessment and diag- nosis. A third question concerns how we should treat a psychological disorder when it is detected. This chapter will address the first two questions; the next chapter will address the third. Culture adds an important dimension to these basic questions. Incorporating culture into our psychological theories and concepts raises a number of significant issues with regard to psychological disorders (Marsella, 2000): Do definitions of normality and abnormality vary across cultures, or are there universal standards of abnormality? Do cultures vary in rates of psychological disorders? Are psychological disorders expressed in the same way across cultures, or can we identify culturally distinct patterns? Can the field develop cross-culturally reliable and valid ways of measuring, clas- sifying, and diagnosing psychological disorders? The answers to these questions have important implications for how we identify psychological disorders and intervene to affect change. Ignoring the ways in which psychological disorders are bound within the context of culture may lead to overdiag- nosis, underdiagnosis, and/or misdiagnosis, with potentially harmful consequences to the individual (Marsella, 2009; Paniagua, 2000). This chapter is devoted to the considerable amount of research and writing that seeks to address these questions and concerns. First, we will discuss the role of culture in defining abnormality. Second, we will discuss the role of culture in the assessment of psychological disorders, examine the classification schemes currently in use, and explore issues surrounding the measurement of abnormality. Third, we will look at how the measurement of personality has been used in assessing psycho- logical disorders across cultures. Fourth, we will review studies of the prevalence (proportion of existing cases) and course of several of the most common psychologi- cal disorders (such as schizophrenia and depression) across cultures, and describe cultural concepts of distress. Finally, we will briefly review psychological disorders for traditionally understudied populations such as ethnic minorities, migrants, and refugees. Defining Abnormality: Some Core Issues Psychologists and other social scientists have long been interested in the influence of culture on psychopathology. The literature has been somewhat divided between two cultural relativism points of view. One view suggests that culture and psychopathology are intertwined, A viewpoint that suggests that psychological disorders and that disorders can be understood only in the cultural framework within which can only be understood they occur. This perspective is known as cultural relativism. The contrasting view in the cultural framework suggests that although culture plays a role in determining the exact behavioral and within which they occur. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  280  Chapter 12 contextual manifestations of a psychological disorder, there are cross-cultural simi- larities, even universalities, in the underlying psychological mechanisms and subjec- tive experiences of many psychological disorders. These two frameworks are evident when reviewing how the study of psychopathology across cultures has changed over time. Historically, researchers have defined and described a particular psychopathol- ogy (the symptoms, diagnoses) within a particular culture and then have exported this definition to other cultures for comparative study (Kirmayer, 2007). More recently, researchers have demonstrated a greater commitment to questioning the cross-cul- tural validity of psychopathologies defined in one particular culture and are striving to understand disorders within the context of the local culture. To do so, researchers are paying close attention to how different cultures may have different attributions and beliefs about health, illness, and disease (see Chapter 11). Understanding local, culturally specific aspects of psychopathology as well as universals are important for identifying a common language and knowledge base to advance our understanding of psychopathologies globally (Gone & Kirmayer, 2010). One starting point to under- standing what is culturally specific versus universal is to examine how we define what is abnormal. Defining “Abnormal” Consider, for example, the following scenario: A woman is in the midst of a group of people but seems totally unaware of her sur- roundings. She is talking loudly to no one in particular, often using words and sounds the people around her find unintelligible. When questioned later about her behavior, she reports that she had been possessed by the spirit of an animal and was talking with a man who had recently died. Is this woman’s behavior abnormal? In defining what is abnormal, psychologists often use a statistical approach or apply criteria of impairment or inefficiency, deviance, or subjective distress. Using such a statistical approach, for example, we could define the woman’s behavior as abnormal because its occurrence is rare or infrequent. Being out of touch with your surroundings, having delusions (mistaken beliefs) that you are an animal, and talk- ing with the dead are not common experiences. One problem with this approach to abnormality, however, is that not all rare behavior is disordered. Nor is all disordered behavior rare. Composing a concerto and running a four-minute mile are uncommon behaviors, yet we generally view them as highly desirable. Conversely, drinking to the point of drunkenness occurs quite frequently in the United States (and in many other countries of the world). Nev- ertheless, drunkenness is widely recognized as a sign of a possible substance-abuse disorder. Another approach to defining abnormality focuses on whether an individual’s behavior is associated with impairment, inefficiency, deviance, or subjective distress when carrying out customary roles. It is hard to imagine the woman described above carrying out normal day-to-day functions, such as caring for herself and working, while she believes herself to be an animal. In many instances, psychological disorders do involve serious impairments or a reduction in an individual’s overall function- ing. However, this is not always the case. Some people suffering from bipolar dis- order (manic depression), for example, report enhanced productivity during manic episodes. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Psychological Disorders   281 If we examine the woman’s behavior in terms of deviance, we might also conclude that it is abnormal because it seems to go against social norms. But not all behavior that is socially deviant can be considered abnormal or psychologically disordered. For example, the American Psychological Association (APA) classified homosexuality as a psychological disorder until 1973. In China, the Chinese Psychiatric Association (CPA) classified homosexuality as a psychological disorder until 2010. Over time, our notions of what is socially deviant, changes. Thus, using societal norms as a criterion for abnormality is difficult not only because they are subjective (what one member of a society or culture considers deviant, another may accept as normal) but also because they change over time. Reliance on reports of subjective distress to define abnormal behavior is also problematic. Whether a person experiences distress as a consequence of abnormal behavior may depend on how others treat him or her. For example, if the woman just described is ridiculed, shunned, and viewed as “sick” because of her behavior, she may well experience distress. Conversely, if she is seen as having special powers and is part of an accepting circle, she may not be distressed at all. Each of these ways of defining abnormality has advantages as well as disadvantages. These issues become even more complex when culture is considered. As an alternative to these approaches, many cross-cultural scholars argue that we can understand and identify abnormality only if we take the cultural context into account. This viewpoint suggests that we must apply the principle of cultural relativ- ism to abnormality. For example, the woman’s behavior might appear disordered if it occurred on a street corner in a large city in the United States. It could, however, appear appropriate and understandable if it occurred in a shamanistic ceremony in which she was serving as healer. Cultures that believe in supernatural interven- tions are able to clearly distinguish when trance states and talking with spirits are an acceptable part of a healer’s behavioral repertoire and when the same behaviors would be considered a sign of disorder (Murphy, 1976). Examples of such cultures include the Yoruba in Africa and some Inuits in Alaska. Along the same lines, behaviors associ- ated with some religions (e.g., revivalist Christian groups in the United States), that involve speaking in tongues (glossolalia) and seeing visions, are widely practiced and accepted and may not indicate a psychological disorder (Loewenthal, 2007). Abnormality and normality, then, are culturally determined concepts (Marsella & Yamada, 2007). Nonetheless, whether to accept universal or culturally relative defi- nitions of abnormality is a source of continuing controversy in psychology. Examina- tion of the cross-cultural literature provides clues on how to understand the role of culture in contributing to abnormality and psychological disorders. Culture and the Categorization and Assessment of Psychological Disorders Assessment of psychological disorders involves identifying and describing an indi- vidual’s symptoms in the broader context of his or her overall functioning, life his- tory, and environment (Mezzich, Berganza, & Ruiperez, 2001). The tools and methods of assessment should be sensitive to cultural and other environmental influences on behavior and functioning. Although considerable progress has been made in the field over the years, the literature on standard assessment techniques indicates that there may be problems of bias or insensitivity when psychological tests and methods devel- oped in one cultural context are used to assess behavior in a different context. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  282  Chapter 12 Culture and Categorization of Psychological Disorders In assessing psychological disorders, psychologists seek to classify abnormal cogni- tions, behaviors, and emotions into categories—diagnoses—that are both reliable and valid. Reliability, as you will recall from Chapter 2, has to do with the degree to which the same diagnoses would be made consistently over time and by different clinicians; validity refers to the degree to which the diagnosis accurately portrays the clinical dis- order it is supposed to describe. Because culture exerts some degree of influence on the creation, maintenance, and definition of abnormality, cross-cultural issues arise concerning the reliability and validity of diagnoses, and even of the diagnostic categories used. If all psycho- logical disorders were entirely etic in their expression and presentation—that is, entirely the same across cultures—then creating reliable and valid diagnostic catego- ries would not be a problem. But just as individuals differ in their presentation of abnormality, cultures also vary; indeed, some psychological syndromes appear to be limited to only one or a few cultures. Thus, developing diagnostic systems and clas- sifications that can be reliably and validly used across cultures around the world, or even across different cultural groups within a single country, becomes a significant challenge. In the United States, the primary diagnostic classification system is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM, originally published in 1952, has undergone several major revisions and is now in its fifth edition (DSM-V, 2013). Notably, the revisions from the DSM-III to DSM-IV and now to the latest DSM-V represent the field’s increasing recognition that culture is a critical aspect of diagnosis. In response to heavy criticism by cross- cultural psychiatrists that the DSM-III ignored the importance of a patient’s cultural background, a section with a list of 25 “culture-bound syndromes” was added to the DSM-IV, albeit in the appendix. This addition was regarded as a rather weak attempt to acknowledge the role of culture in defining psychological disorders as it perpetu- ated the idea that only some, mostly non-Western, disorders are culture-bound, and not all (Hughes, 1998). In the most recent version, the DSM-V, the section on culture-bound syndromes has been revised and replaced by three key concepts: (1) cultural syndromes of distress, patterns of symptoms that tend to cluster together for individuals in specific cul- tural groups, communities, or contexts; (2) cultural idioms of distress, ways that ­cultural groups and communities communicate and express their distressing thoughts, behaviors, and emotions; and (3) cultural explanations of distress, what cultural groups and communities believe is the cause of the distress, symptoms, or illness. In other words, how cultural groups and communities explain why symptoms are occurring. Together, the concepts of cultural syndromes, cultural idioms of distress, and cultural cultural concepts of explanations represent cultural concepts of distress (CCD). Cultural concepts of distress The shared ways distress is a broader and more comprehensive construct than the DSM-IV’s previous in which cultural groups or communities experi- label of culture-bound syndromes. Importantly, the tenets of cultural concepts of dis- ence, express, and interpret tress are relevant for understanding all psychological disorders, not just those limited distress. to the non-Western world (see Figure 12.1). Another modification to the DSM-V to more comprehensively address culture is the inclusion of a reconceptualized and more detailed Cultural Formulation Inter- view (CFI). The CFI is a tool that clinicians can use to assess an individual’s experi- ence within his or her specific social and cultural context. Figure 12.2 shows the first page of the CFI. On the left hand side are notes for the interviewer outlining the rationale behind each question. On the right hand side are questions for the client. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Psychological Disorders   283 Figure 12.1 Cultural Concepts of Distress A Revised Formulation of Culture in Relation to Cultural Patterns of symptoms that tend to cluster Diagnosis: The Construct Syndromes together for individuals in specific cultural of Cultural Concepts of of Distress groups, communities, or contexts. Distress in the DSM-V. Cultural Concepts of Cultural Ways that cultural groups and communities Distress Are Based on Idioms communicate and express their distressing These Three Aspects of of Distress thoughts, behaviors, and emotions. Cultural Understanding Cultural What cultural groups and communities believe Explanations is the cause of the distress, symptoms, of Distress or illness. Through these questions, the clinician elicits an individual’s perspective on how he or she views and experiences his or her distress, paying special attention to the social and cultural context. This valuable information provides a stronger founda- tion for the clinician to diagnose and treat the person’s distress. One study reviewed over 300 medical records of clients with ethnic minority or immigrant backgrounds (­Adeponle et al., 2012). When these cases were reevalu- ated using the cultural formulation interview (from the DSM-IV-TR), about half of the cases with a referral diagnosis of a p­ sychotic disorder (e.g., schizophrenia) were rediagnosed as a nonpsychotic disorder (e.g., major depression, posttraumatic dis- tress disorder). In other words, reevaluating the cases while taking a deeper account of culture led, in some instances, to a different conclusion concerning a diagnosis of psychosis. These findings suggested that use of the cultural formulation inter- view can be a useful tool for evaluating a person’s symptoms and perspectives on distress. Studies with the newly revised DSM-V version of the cultural formulation interview are just beginning. In sum, after over a decade of revisions, the DSM-V aims to offer a more inclu- sive account of psychological disorders that go beyond North American and Western European descriptions and experiences. Over the years, with each revision, the DSM has taken steps to incorporate the role of culture in understanding the expression and reliable classification of psychological disorders. Clearly, a better understanding is required for more effective treatment. The other main classification system in use today is the International ­Classification of Diseases, 10th edition (ICD-10), endorsed and published by the World Health ­O rganization (WHO, 1992). It is currently the most widely used classification sys- tem around the world and is used for global health reporting. Unlike the DSM-V, the majority of the ICD-10 focuses on physical diseases (e.g., infectious and parasitic dis- eases, diseases of the circulatory system), with one chapter focusing on “mental and behavioral disorders.” The first time the ICD included psychological disorders was in 1949, in the ICD-6 manual. The ICD is intended to be descriptive and atheoretical. Although the ICD-10 is used around the world, reviews have suggested that it falls short of incorporating the importance of culture in influencing the expression and presentation of psychological disorders (e.g., Mezzich et al., 2001). Nonetheless, the 194 member states of the WHO are required by international treaty to gather health statistics using the ICD. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  284  Chapter 12 Figure 12.2 First page of the Cultural Formulation Interview (CFI) in the DSM-V (APA, 2013). On the left hand side is information for the interviewer that provides a rationale for each question. On the right hand side are questions to ask the individual being interviewed. The purpose of the CFI is to help the clinician understand a person’s own perceptions of his or her distress, which is rooted in social and cultural contexts. To see the full cultural formulation interview, go to this website: http://www.psychiatry.org/practice/dsm/dsm5/online- assessment-measures#Disorder. If you want even more detail on additional questions to follow up the CFI (such as specific areas of cultural identity, or a cultural assessment of groups such as children, immigrants, and caregivers), go to the 12 supplementary modules on that website. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Psychological Disorders   285 Figure 12.3 Website of the International Classification of Diseases (ICD). On this website you can access the ICD-10 online. According to their website, the ICD has been translated into 43 languages and is used by the world health organization members states to “monitor the incidence and prevalence of diseases and other health problems, providing a picture of the general health situation of countries and populations.” http://www.who.int/classifications/icd/en/ The ICD-10 is undergoing revisions for a new edition, ICD-11, to be published in 2018. One of the main goals of the current revision is to develop a diagnostic system that has improved clinical utility. In other words, the revised ICD-11 should be able to be used effectively by all World Health Organization (WHO) countries to more reliably assess and diagnose health and mental health disorders. As we have learned throughout the chapter, the interpretation and experiences of health and illness are deeply rooted in culture. Creating a diagnostic manual that is reliable and valid for the almost 200 WHO member countries is quite a challenge. Nonetheless, it is a neces- sary step to better meet international public health goals. The DSM and ICD diagnostic systems are similar in disorder categorizations, yet there are differences in what disorders are included, how disorders are named and defined, and how the categories are organized (Reed, 2010). A study with Sri Lankan Tamil immigrants in Canada, for instance, found that the lifetime prevalence rate of posttraumatic stress disorder was 5.8% based on DSM-IV criteria and doubled (12%) based on ICD-10 criteria (Beiser, Simich, Pandalangat, Nowakowski, & Tian, 2011). Rates of agreement in diagnosis using the DSM-IV and ICD-10 can range widely, from Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  286  Chapter 12 83% agreement for depressive episodes, 64% for obsessive-compulsive disorder, and only 35% for posttraumatic stress disorder (Andrews, Slade, & Peters, 1999). These findings show that diagnosing psychological disorders may not be consistent across the two widely used systems of classification, at least for some disorders (Hyman, 2010; Reed, 2010). With the recent revision of the DSM-V and undergoing revision of the ICD-10, there have been efforts to align the two systems, with the recognition that each country may have country-specific versions of the ICD. To address the problem of the lack of cultural considerations in the assessment of psychological disorders, local diagnostic systems have also been created. The Chinese Classification of Mental Disorders (CCMD), for example, has been heavily influenced by the DSM-IV and ICD-10 but has culture-specific features that do not exist in the other systems. The most recent edition, the CCMD-3, was revised in 2001. This manual includes disorders distinctive to Chinese culture, such as lutu jingshen bing (traveling disorder). Traveling disorder is a psychotic condition that occurs when people travel over long distances in overly crowded, poorly ventilated trains. Symptoms include illusions, delusions, hallucinations, panic, suicidal acts, and harming others (Lee, 2001). The CCMD also excludes disorders found in the previous DSM-IV and ICD-10 such as pathological gambling and some personality and sexual disorders (Mezzich et al., 2001). One study found that in 10% of the cases, there was a difference in the diagnosis of depression with Chinese patients using the DSM-IV versus CCMD-3 (Wang, Yang, & Zhang, 2008). Because there is no one-size-fits-all approach to the assessment and diagnosis of psychological disorders across cultures (Reed, 2010), international classification systems such as the ICD-10 should not replace local classi- fication systems such as the CCMD-3 (Lee, 2001). Indeed, a recent survey of clinicians around the world found that those living and working outside the United States and Europe report the greatest need for country-specific diagnostic systems, beyond what the DSM and ICD can offer (Reed et al., 2013). For all health professionals and the people they seek to help, having a reliable and valid classification system of diagnoses is essential. The DSM-V and ICD-10 have made major strides toward creating such a system. Still, work in this area is continu- ally evolving, and we will see changes in this and other classification systems in the future. Hopefully, those changes will be informed by meaningful and relevant cross- cultural research. One such attempt to develop more culturally sensitive, valid, and reliable diagnoses can be found in Culture, Medicine and Psychiatry, an international research journal that devotes a special “Clinical Cases Section” to case studies of indi- viduals within their specific cultural context. The case narratives include a clinical case history, cultural formulation, cultural identity, cultural explanation of the illness, cultural factors related to the psychosocial environment and levels of functioning, cultural elements of the clinician–patient relationship, and overall cultural assess- ment. Attempts such as this to document in detail how psychological disorders are embedded in and defined by culture should benefit the development of more cultur- ally valid classification and diagnostic systems. Cross-Cultural Assessment of Psychological Disorders Not only is it important to have a reliable and valid system of classification of psycho- logical disorders, it is also crucial to have a set of tools that can reliably and validly measure (assess) behaviors, feelings, and other psychological parameters related to mental illness. Those tools may include questionnaires, interview protocols, or stan- dardized tasks that require some sort of behavioral and emotional response on the part of the test taker. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Psychological Disorders   287 Needless to say, many of the issues that concern the valid and reliable measurement of any psychological variable cross-culturally for research purposes (see Chapter 2) are also relevant to discussions of measurement tools for abnormality. For instance, it may be difficult to adequately transfer and use a psychological assessment that has been developed in one culture to another because of culture-specific expressions of distress. Kleinman (1995) points out that many items of an assessment instrument may use wording that is so culture-specific (e.g., “feeling blue”) that directly translat- ing them to another culture would be nonsensical. Green (2009) reviewed a number of issues in developing culturally appropriate psychological assessments, including test construction, measurement error, construct validity, translations, social desirability, test administration, and interpretation. These issues, and others, make valid and reli- able measurement of pathology across cultures difficult and complex. A critical examination of how the tools in use fare across cultures provides a stark glimpse of reality. Tools of clinical assessment developed in one culture are based on that culture’s definition of abnormality and use a set of classification criteria relevant to that culture for evaluating problematic behavior. Therefore, the tools may have lit- tle meaning in other cultures with varying definitions of abnormality, however well translated into the native language, and they may mask or fail to capture culturally specific expressions of disorder (Marsella, 2009). The World Health Organization’s (WHO) large-scale global studies of schizo- phrenia that started in the 1970s (described in detail later in this chapter) used the Present State Examination (PSE) to diagnose schizophrenia. At the time, the use of the PSE cross-culturally was criticized for the ethnocentric bias of procedures (Leff, 1986). In a psychiatric survey of the Yoruba in Nigeria, for instance, investigators had to supplement the PSE to include culture-specific symptoms such as feeling “an expanded head and goose flesh.” The assessment problems encountered in studying schizophrenia globally illustrated the limitations of transporting assessment meth- ods across cultures. Transporting assessment methods within a multicultural country may also be problematic. In an extensive study of depression among Native Americans (­Manson & Shore, 1981; Manson, Shore, & Bloom, 1985), the American Indian Depres- sion Schedule was developed to assess and diagnose depressive illness. The investi- gators found that depression among the Hopi includes symptoms not measured by standardized measures of depression such as the Diagnostic Interview Schedule and the Schedule for Affective Disorders and Schizophrenia. These measures, based on diagnostic criteria found in the DSM-III (American Psychiatric Association, 1987), failed to capture the short but acute dysphoric moods sometimes reported by the Hopi (Manson et al., 1985). Concerning children, the Child Behavior Checklist (CBCL) (Achenbach & Rescorla, 2001) is one of the most widely used measures to assess behavioral, emo- tional, and social problems of children around the world. The CBCL assesses both internalizing behaviors (e.g., withdrawn behavior, depressive symptoms, somatic complaints) and externalizing behaviors (e.g., attention problems, delinquent behav- ior, aggressive behavior). Informants, who are usually the parents or teachers, are asked to think about the child they are assessing and report whether behaviors described in the CBCL are not true (coded as 0), somewhat/sometimes true (coded as 1), or very/often true of the child (coded as 2). Some sample items are “Can’t sit still, restless, or hyperactive,” “Impulsive or acts without thinking,” and “Gets into many fights.” Higher scores, then, indicate greater behavior problems. In the last two decades, researchers have conducted several major reviews of the use of this scale cross-culturally. The first set of reviews examined the CBCL Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  288  Chapter 12 (for children 6–17 years) across 12 countries—Australia, Belgium, China, Germany, Greece, Israel, Jamaica, the Netherlands, Puerto Rico, Sweden, Thailand, and the United States (Crijnen, Achenbach, & Verhulst, 1997, 1999). While these reviews showed the scale to be reliable and valid across these different cultures, they also show that clinical cutoff points (e.g., the threshold for what is considered a clinical disorder versus normal behavior) may vary by culture. A second set of reviews of the CBCL confirmed that the factor structure (e.g., the existence of specific dimen- sions such as being withdrawn, depressive symptoms, and somatic complaints, and two broader dimensions of internalizing and externalizing behaviors) was simi- lar for studies of children and adolescents (6–18 years) from 20 to 30 countries rep- resenting Asia, Australia, the Caribbean, East, Western, Southern, and Northern Europe, the Middle East, and North America (Ivanova et al., 2007a, 2007b). Finally, the most recent review examined over 19,000 parent-ratings of their young children (1.5–5 years) using the CBCL across 23 countries (Ivanova et al., 2010). As with the previous reviews, this study confirmed a similar factor structure across the 23 coun- tries for a younger sample. Thus, it appears that the CBCL can be appropriately used in many diverse cultures to capture behavioral, emotional, and social problems of children and adolescents. Nonetheless, studies have also shown that the CBCL may not capture culture- specific dimensions of problematic behaviors. For instance, studies conducted in Thailand by Weisz and colleagues (2006) found other behavioral dimensions, such as delayed maturation and indirect aggression, not seen in the U.S. comparison group (Weisz, Weiss, Suwanlert, & Chaiyasit, 2006). Acknowledging that the CBCL may be missing culture-specific behaviors, additional culture-specific items have been devel- oped that are not meant for cross-cultural comparison purposes (Achenbach, Becker, Dopfner, Heiervang, Roessner, Steinhausen, & Rothenberger, 2008). In sum, even when assessment tools appear to be reliable and valid for use in many different cul- tures, adopting an emic approach (review Chapter 1 for definitions of etic and emic) to identify culture-specific elements is still needed. In addition to issues concerning the cross-culturally validity of assessment tools, other research has found that the cultural backgrounds of both therapist and client may contribute to the perception and assessment of psychological disorders. Li-Repac (1980) conducted a study to evaluate the role of culture in the diagnostic approach of therapists. In this study, Chinese American and European American male clients were interviewed and videotaped, then rated by Chinese American and European American male therapists on their level of psychological functioning. The results showed an interaction effect between the cultural backgrounds of therapist and client on the therapists’ judgment of the clients. The Chinese American clients were rated as awkward, confused, and nervous by the European American therapists, but the same clients were rated as adaptable, honest, and friendly by the Chinese American therapists. In contrast, European American clients were rated as sincere and easygo- ing by European American therapists, but aggressive and rebellious by the C ­ hinese American therapists. Furthermore, Chinese American clients were judged to be more depressed and less socially capable by the European American therapists, and ­European American clients were judged to be more severely disturbed by the C ­ hinese American therapists. Another study of mostly European American teachers showed that their assess- ments of normal behavior depended on the ethnicity of the child (Chang & Sue, 2003). In this study, teachers were presented with vignettes of overcontrolled (e.g., being anxious to please, feeling the need to be perfect, clinging to adults, and being shy and timid), undercontrolled (e.g., being disobedient, disrupting the class, Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Psychological Disorders   289 talking out of turn, fidgeting), and normal (e.g., generally following rules, demon- strating normal play, having some friends) school behaviors that were paired with a picture of an European American, African American, or Asian American male child. Findings showed that teachers rated overcontrolled behaviors for Asian American children as more normative than for European American or African American children. The authors argued that if Asian American children are seen as typically overcontrolled, teachers may be more likely to miss problems associ- ated with overcontrolled behaviors in this population compared to the other two. Thus, assessments of appropriate, healthy psychological functioning may differ depending on the cultural background, notions of normality, and cultural images and stereotypes of the person making the assessment, particularly if the person’s sociocultural background differs from his or her client’s. Culturally responsive assessment, then, requires more than an acknowledgement of the client’s cultural background, but rather it needs an in-depth understanding of that client’s culture, and, importantly, an understanding of one’s own possible cultural biases (Okazaki, Okazaki, & Sue, 2009). Finally, one interesting topic concerns language issues in psychological assess- ment. In more and more cases around the world today, patients or clients have a first language and culture that differ from the diagnostician’s or clinician’s. For instance, evaluation of English language learners as well as bilingual patients should be done in both languages, preferably by a bilingual clinician or with the help of an interpreter trained in mental health issues (Okazaki et al., 2009). The reason, as was discussed in Chapter 10, is that cultural nuances may be encoded in language in ways that are not readily conveyed in translation. That is, translations of key psychological phrases and constructs from one language to another may give the closest semantic equivalent, but may not have exactly the same nuances, contextualized meanings, and associa- tions. Administration of assessments bilingually or with an interpreter may help to bridge this gap. Researchers have also suggested that assessing which language(s) the client is most comfortable with should be determined first before any assessment or therapy is started (Lim, Liow, Lincoln, Chan, & Onslow, 2008). All of these issues of assessment (using culturally appropriate assessment tools, understanding a client’s cultural background, being aware of one’s own cultural biases, assessing client’s level of comfort in language) are central for making appro- priate diagnoses. Failure to address these issues may result in overpathologizing or underpathologizing (Lopez, 1989). Overpathologizing may occur when the clinician, overpathologizing unfamiliar with the client’s cultural background, incorrectly judges the client’s behav- Misinterpreting culturally sanctioned behavior as ior as pathological when in fact the behaviors are normal variations for that indi- expressions of pathological vidual’s culture. Underpathologizing may occur when a clinician indiscriminately symptoms. explains the client’s behaviors as cultural—for example, attributing a withdrawn and underpathologizing flat emotional expression to a normal cultural communication style when in fact this Attributing pathological behavior may be a symptom of depression. An important requirement to avoid over- symptoms to normative cul- or underpathologizing is a deep understanding of the client’s cultural background tural differences. that is woven throughout the assessment process. Measurement of Personality to Assess Psychopathology One of the interesting ways in which personality tests are used cross-culturally involves the assessment not only of personality but also of clinical states and psy- chopathology. The most widely used scale in such cross-cultural assessments is the Minnesota Multiphasic Personality Inventory (MMPI). Two versions, the second edi- tion of the MMPI (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  290  Chapter 12 and a revised formulation of the second edition (MMPI-2-RF; Ben-Porath & Tellegen, 2008) are currently in use. The MMPI tests for the presence of abnormal behaviors in areas such as paranoia (level of trust), hypochondriasis (concern for own health), and social introversion (orientation toward people). If you were to take the MMPI, your score could be compared to scores based on a clinical population (those with a diagnosed psychological disorder) and a nonclinical population. In other words, a clinician could evaluate whether your score fits the profile of someone who may have a diagnosable psychological disorder versus someone who does not. Although originally developed with a predominantly European American sam- ple in Minnesota, the MMPI has been used extensively around the world. Butcher and colleagues (Butcher, Cheung, & Kim, 2003; Butcher, Derksen, Sloore, & Sirigatti, 2003; Butcher, Lim, & Nezami, 1998) have examined the use of the MMPI-2 in various cultures including countries in Asia, Europe, Australia, and the Middle East. They reported on the procedures most researchers used in adapting the MMPI-2 for use in their particular cultural milieu, including translation and back-translation, bilingual test–retest evaluation, and equivalency tests. They concluded: Clinical case studies involving the assessment of patients from different cultures have shown that MMPI-2 interpretations drawn from an American perspective generally produce congruent conclusions about clinical patients tested in other countries.... Computer-based MMPI-2 interpretations appear to have a high degree of accuracy when applied to patients from other countries. Computer-based reports derived on interpretive strategies developed for the United States were rated as highly accurate by clinicians when they were applied in Norway, Australia, and France. (Butcher et al., 1998, p. 207) Thus, clinical studies involving personality scales such as the MMPI have been shown to be quite reliable and valid in assessing psychopathology and abnormal behavior across various cultures. This finding is once again consistent with the premise of a universal underlying personality structure that can be reliably and validly assessed by methods typically developed and refined in the United States or Europe. If such a universal personality structure exists and can be measured by some means, then deviations from that personality structure in the form of psychopathology should also be measurable using those same means. Nonetheless, other research has strongly cautioned against the use of the MMPI-2 for specific populations. Pace and colleagues (Hill, Pace, & Robbins, 2010; Pace et al., 2006) have argued that the MMPI-2 may not accurately assess psychopathology for Native Americans. These researchers found that Native Americans score higher on several of the MMPI-2 scales compared to MMPI-2 norms. The researchers suggest that rather than implying higher levels of pathology in the Native American popula- tion, higher scores may reveal particular worldviews, knowledge, beliefs, and behav- iors that are rooted in a history of trauma and oppression. To examine the cultural validity of the MMPI-2 for Native Americans, the researchers adopted a mixed method approach (using surveys and interviews) to closely examine the items of the MMPI-2. In the interviews, they asked Native Ameri- cans to explain their responses to some of the MMPI-2 items. Through this analysis, the researchers argued that the set of items in the MMPI-2 assessing psychopathol- ogy if the person is preoccupied with contradictory beliefs, expectations, and self- descriptions could be interpreted by participants as the difficulty of living within and between two worlds—the white world and the Native American world—which are contradictory in their values, behaviors, and social norms. Another set of items in the MMPI-2 assesses psychopathology by feelings of isolation, alienation, and persecutory Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Psychological Disorders   291 ideas. In the study, Native Americans reported racism and discrimination on a consis- tent basis that left them feeling isolated, wary, and distrustful. The researchers argue that the responses of Native Americans to these particular sets of items may appear to indicate pathological thinking while in fact, because of the unique and difficult history of Native Americans, the responses could be interpreted as normative. The authors conclude that using this personality assessment with Native Americans may result in pathologizing a Native American person’s indigenous worldviews, experi- ences, and beliefs rather than accurately assess psychopathology. They suggest that the MMPI-2 with Native Americans should only be used by counselors and clinicians who are “well-versed about acculturation issues, who are capable of holistic and con- textual interpretations, who understand the tribal person’s unique medical history, and who are knowledgeable about the person’s tribal affiliation(s) and traditional beliefs” (Pace et al., 2006, p. 331). Because the standard MMPI-2 may not be culturally sensitive for some popula- tions, there are efforts to modify the MMPI to account for cultural variations. One such effort is the development of the Korean MMPI-2 (Roberts, Han, & Weed, 2006). The Korean MMPI has been found to be valid and reliable in predicting hwa-byung, a pattern of symptoms unique to Koreans (Ketterer, Han, & Weed, 2010). Symptoms of hwa-byung include heart palpitations, digestive problems, anxiety, panic, insomnia, and fear of impending death. The development of the Korean MMPI-2 is an attempt to modify the MMPI-2 based on culturally specific conceptualizations of self, health, and abnormality (Butcher, Cabiya, Lucio, & Garrido, 2007). Still others have taken a different approach and instead of revising the MMPI, they have developed culture-specific measures of personality, such as the Chinese Personality Assessment Inventory (CPAI) (Cheung, Kwong, & Zhang, 2003; Cheung, Fan, & To, 2009). The CPAI was created for use specifically with Chinese individuals and includes indigenous concepts from Chinese culture. The CPAI includes meaning- ful personality dimensions (e.g. “interpersonal relatedness”) that are not included in the MMPI-2. The CPAI measure may be more valid and useful in assessing mental health with this population than purely imported assessments. We have thus far reviewed issues of assessing and diagnosing psychological dis- orders. Although there are many critiques of the classifications and assessment tools used, many studies have attempted to compare the prevalence, prognosis, and out- come for people with psychological disorders across various cultures. We now turn to research that has examined psychological disorders cross-culturally. Cross-Cultural Research on Psychological Disorders Cross-cultural research over the years has provided a wealth of evidence suggest- ing that psychological disorders have both universal and culture-specific aspects. In this section, we will look at a number of disorders that have been heavily researched cross-culturally: schizophrenia, depression, attention-deficit/hyperactivity disorder (ADHD), and a number of disorders that are specific to certain cultural groups. Schizophrenia Schizophrenia is characterized by delusions and hallucinations, lack of motivation, social withdrawal, impaired memory, and dysregulated emotions (van Os & Kapur, 2009). There is a common misperception that schizophrenia refers to having multi- ple or split personalities, due partly to the literal translation of the term schizophrenia, Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  292  Chapter 12 which means “split mind.” Some have advocated for changing the term. Indeed, in Japan the term for schizophrenia has been changed from Seishin Bunretsu Byo (mind- split disease) to Togo Shitcho Sho (integration-dysregulation syndrome) (Sato, 2006). Sato reports that the name change has been well-received by clinicians and patients, removing some of the stigma attached to schizophrenia. Some theories concerning the causes of schizophrenia give primacy to biologi- cal factors (e.g., excess dopamine or other biochemical imbalances). Other theories emphasize family dynamics such as parental separation and child trauma (e.g., neglect and abuse) and the broader environment such as living in a dense, urban city, socially fragmented neighborhood, or living in poverty (Morgan & Fisher, 2007; ­Morgan, Kirkbride, Hutchinson et al., 2008; Morgan et al., 2007; van Os, Rutten, & Poulton, 2008). The diathesis-stress model of schizophrenia suggests that it may develop in individuals with a genetic and biological predisposition to the disorder (diathesis) following exposure to environmental stressors (Walder, Faraone, Glatt, Tsuang, & ­S eidman, 2014). In one of the first global efforts to systemically study schizophrenia, the World Health Organization (1973, 1979, 1981) sponsored the Inter- national Pilot Study of Schizophrenia (IPSS) to compare the prevalence and course of the disorder of 1,202 patients in nine countries: Colombia, Czechoslovakia, Denmark, England, India, Nigeria, the Soviet Union, Taiwan, and the United States. Following rigorous training in using the research assessment tool, psychiatrists in each of the countries achieved good reliability in diagnosing schizophrenia in patients included in the study. As a result, WHO investigators were able to identify a set of symptoms present across all cultures in the adults with schizophrenia. These symptoms include lack of insight, auditory and verbal hallucinations, and ideas of reference (assuming one is the center of attention). The WHO studies are widely cited to bolster arguments for the universality of schizophrenia. But some important cross-cultural differences emerged as well. In a finding that took the investigators by surprise, the course of the illness was shown to be more positive for patients in developing countries compared with those in highly indus- trialized countries. Patients in Colombia, India, and Nigeria recovered at faster rates than did those in England, the Soviet Union, and the United States. A study that followed the WHO participants 12–26 years later confirmed the surprising finding that outcomes were better for people in developing rather than developed countries (­Hopper, Harrison, Janca, & Sartorius, 2007). This difference was attributed to factors in developing countries such as the presence of extended kin networks, community support, the tendency for patients to return to work fulltime, and being married (for instance, a majority [75%] of participants with schizophrenia in India were married during follow-up compared to a minority [33%] of patients in other developed coun- tries). Importantly, however, the prognosis for those in developed countries is varied, suggesting that there is improvement for some. The researchers also noted differences in symptom expression across cultures. Patients in the United States were less likely to demonstrate lack of insight and audi- tory hallucinations than were Danish or Nigerian patients. These findings may be related to cultural differences in values associated with insight and self-awareness, which are highly regarded in the United States but less well regarded in the other countries. Also, cultures may differ in their tolerance for particular symptoms; the Nigerian culture as a whole is more accepting of the presence of voices. Nigerian and Danish patients, however, were more likely to demonstrate catatonia (extreme with- drawal or agitation). Lin and Kleinman (1988) have discussed some of the methodological problems that plagued the WHO studies—among them, an assessment tool that failed to tap Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Psychological Disorders   293 culturally unique experiences and expressions of disorder. Lin and Kleinman also noted that the samples were made artificially homogeneous because of the selection criteria. They argued that the findings of cross-cultural differences might have been greater still had not the heterogeneity of the sample been reduced. Because the con- clusions of the study emphasized the similarities and not the differences of schizo- phrenia across the various cultures, Kleinman (1995) states that we may have focused on and exaggerated the universal aspects of psychological disorders at the expense of revealing what is culturally specific. In other words, the biases of the investigators may have led them to search for cultural commonalities while overlooking important cultural differences. More recent cross-cultural studies of patients with schizophrenia have tested the theory that expressed emotion—family communication characterized by hos- tility, criticism, and emotional overinvolvement—increases the risk of relapse. The expressed-emotion construct is important because it suggests that family and social interactions influence the course of schizophrenia. These interactions are influenced, in turn, by cultural values. In a review of research on expressed emotion and schizo- phrenia in various cultures, Bhugra and McKenzie (2010) report that expressed emo- tion consistently predicts relapse in Western samples (such as in the United States, United Kingdom, and Australia), but less so for other countries (such as India, Egypt, China, and Israel). One reason for this difference is the difficulties in using this con- struct in different cultures, particularly those that emphasize nonverbal communica- tion (Bhugra & McKenzie, 2010; Kleinman, 1988). Core aspects of expressed emotion may have different meanings in different cultures. For instance, what is considered “overinvolvement” in one culture may be interpreted as normative care in another, and what is considered “high criticism” in one culture may be normative concern in another. These scholars question whether measures of expressed emotion developed in one cultural context have validity in another. Nonetheless, Bhurga and McKenzie’s (2010) and other reviews (e.g., Weisman, 2005) show evidence that expressed emotion does predict relapse in a wide variety of cultures and ethnic groups. In summary, the WHO studies provide evidence of a universal set of core symp- toms that may be related to schizophrenia. Other studies, however, help to temper this interpretation by documenting specific cultural differences in the exact manifes- tations and experience of schizophrenia in different cultural contexts. We now turn to cross-cultural studies of depression, another one of the most common psychological disorders seen around the world. Depression Depression is one of the most widely studied disorders as it is one of the most prev- alent disorders worldwide. By 2020, major depression is projected to be the second leading cause of illness-related disability affecting the world’s population (WHO, 2015). Depressive disorder is characterized by physical changes (such as sleep and appetite disturbances), motivational changes (such as apathy and boredom), as well as emotional and behavioral changes (such as feelings of sadness, hopelessness, and loss of energy). The presence of a depressive disorder is experiencing these symptoms for at least two weeks, according to the DSM-V and ICD-10. Women are more likely to experience depression than men, and this gender dif- ference has held up across race, ethnicity, socioeconomics, and culture (Seedat et al., 2009). Developmentally, the incidence of depression increases dramatically around the time of puberty, and more so for females than for males (Cyranowski, Frank, Young, & Shear, 2000). This gender difference remains throughout adulthood. There Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  294  Chapter 12 is also evidence that the incidence of depression has risen over the past few decades, especially among adolescents (WHO, 2014). A landmark study by the WHO (1983) investigated the symptoms of depres- sion in four countries—Canada, Switzerland, Iran, and Japan—and found that the great majority of patients (76% of the 573 cases) reported cross-­c ulturally con- stant symptoms, including “sadness, joylessness, anxiety, tension, lack of energy, loss of interest, loss of ability to concentrate, and ideas of insufficiency” (p. 61). More than half of this group (56 percent) also reported suicidal ideation. Based on these findings, Marsella (1980; Marsella, Sartorius, Jablensky, & Fenton, 1985) sug- gested that vegetative symptoms such as loss of enjoyment, appetite, or sleep are universal ways in which people experience depression. Nonetheless, Marsella (1979, 1980; Marsella, Kaplan, & Suarez, 2002; Marsella & Yamada, 2007) also argues for a culturally relative view of depression, suggesting that depressive symptom patterns differ across cultures because of cultural variations in sources of stress as well as in resources for coping with the stress. As with schizophrenia, rates of depression also vary from culture to culture. ­Figure 12.4 shows 12-month prevalence rates for depressive episodes across 13 ­countries. Different manifestations of the disorder, however, render it somewhat ­difficult to interpret these differences in prevalence rates. While the DSM-V and ICD- 10 may capture common symptoms across cultures, it may be missing other cultur- ally specific symptoms. Lee, Kleinman, and Kleinman (2007) conducted in-depth interviews with Chinese psychiatric outpatients diagnosed with depression in south- ern China. Their findings support both universal and culturally specific aspects of depression. Patients reported symptoms that were similar to what is described in standard diagnostic systems such as loss of appetite, feelings of hopelessness, and suicidal ideation. Patients also reported, however, symptoms that are not included in these diagnostic systems. We highlight three of them here. Figure 12.4 Twelve- Brazil 10.4 Month Prevalence Rates (percent) of Depressive United States 8.3 Episodes Based on the DSM-IV for Ages 18 and New Zealand 6.6 Above Israel 6.1 Source: Kessler et al. (2010). Age differences in the prevalence and comorbidity France