Diagnosis of Mental Disorders Among Turkish and American Clinicians

Abstract

Turkish and American clinicians from two centres in each country were compared in terms of diagnosing mental disorders in standard cases and in terms of stereotypes of symptomatology. Statistical comparisons showed that the American clinicians rated higher symptom severity in the cases and in the stereotypes. In the diagnoses assigned the particular orientations of the centres became evident. Confidence in diagnosis was rather high in spite of inadequate information in the short cases. The shortcoming of psychiatric classification due to differences among clinicians and the need for more studies of their inferential strategies were pointed out.

A nomenclature and a system of classification of mental disorders that all countries practice and research. However, the attempts to develop a common language among different coun tries has been made difficult by differences in both the manifestation of mental disorders and the diagnostic practice of clinicians. It appears that there is no disagreement concerning cultural factors in symptomatology: Several authors (Dohrenwend & Dohrenwend, 1974; Egeland, Hostetter, & Eshleman, 1983; King, 1978; Phillips & Draguns, 1971; Strauss, 1979) agreed that culture influences symptom manifestation. It is emphasized in the present research report that, clinicians, as well, are not immune to the influence of culture.

Probably the most well known project that has supported cross-national differences in diagnostic practice is the United States—United Kingdom Cross-National Project (Profes sional Staff, 1973, 1974). In a series of studies significant differences in the diagnosis of schizophrenia and affective disorders had been identified. In terms of the source of the dif ferences in diagnostic criteria, theoretical differences (Professional Staff, 1974) and cultural differences (Gelfand & Kline, 1978) had been suggested. The International Pilot Study of Schizophrenia (Kramer, 1973) provided information outside of North America and Western Europe. Although seven of the countries had similar concepts of schizophrenia, Moscow and Washington had broader concepts. A more recent and striking finding is from a collaborative study of affective disorders among the Amish in the U.S.A. (Egeland et al., 1983). In that project, 79% of the Amish sample of bipolar I subjects, who were diagnosed according to the Research Diagnostic Criteria, previously had received hospital diagnoses of schizophrenia. Misdiagnosis was pointed out to be a function of, among other factors, misinterpretation of symptoms because of cultural factors.

Such studies as mentioned above show that the present classification systems are open to the influence of cultural factors. By means of glossaries, better definitions and criteria, stan dardized data collection techniques, and multiaxial systems the problems can be reduced, but as both Katz, Cole, and Lowery ( 1969) and Kendell (1975) have indicated, clarification of language and use of operational definitions, although they might help, would not totally eliminate conceptual differences. Cultural differences are developed through years and it may be difficult or even practically impossible to modify them. Therefore, as long as psychiatric classification depends on signs and symptoms as the basic classificatory principle we may have to live with such differences in diagnosis. In the future, with increasing knowledge about syndromes at a more basic level, such as biochemistry, classification can become more reliable. In the meantime an important need is to continue identifying the differences and similarities in diagnostic practice among different countries. Studies with such an aim will help a great deal in clarifying communication. Moreover, as a second step, the sources of the differences can be identified and validity studies can show the more useful concepts. If needed, cultural factors and psychocultural syndromes can be included under certain existing diagnostic categories, appropriate axes, or some other suitable section of a classification system, as sug gested by Alarcon (1983) for the DSM-III.

The aim of the present research is to further knowledge about cross-cultural differences and similarities among clinicians. In this research, clinicians from a developing country, Turkey, are compared with clinicians from the U.S.A. As there is almost no comparative study on Turkish diagnostic practice, the areas of inquiry in this research are basically determined by Western psychiatric literature. Although because of this lack of information the study is ex ploratory in nature, tentative hypotheses are stated below.

One area of inquiry concerns the finding of a generally more, or more severe, psychopathology recorded by American clinicians as compared to British clinicians in rating the same cases (Kendell, Cooper, Gourlay, Copeland, Sharpe, & Gurland, 1971; Professional Staff, 1974; Sharpe, Gurland, Fleiss, Kendell, Cooper, & Copeland, 1974). Thus, whether American clinicians would rate, in general, more severe pathology than Turkish clinicians in the same case would be of interest. It was tentatively expected that American clinicians would be likely to assign higher severity ratings than Turkish clinicians. Secondly, as in dicated, research (Kramer, 1973; Professional Staff, 1973, 1974) showed that as compared to some other countries American clinicians had a greater readiness to diagnose schizophrenia. On the basis of this information it was expected that American clinicians would be likely to exhibit the same tendency in comparison to Turkish clinicians as well. Finally, a decision was made to inquire into the stereotypes of symptomatology of some illustrative diagnostic categories to see whether there were differences in the conception of diagnostic categories as well. No hypotheses were formulated on this last area of inquiry.