Affect and its disorders in a Northern Plains Indian community: Issues in cross-cultural discourse and diagnosis.

摘要

Situated within an NIMH-sponsored study of psychiatric epidemiology in an American Indian community on the Northern Plains, this study examined the cultural patterning of reported experience in the context of standardized diagnostic interviewing. More specifically, analytic attention to the discursive construction of self among Indian respondents promised insight into the unusually low rates of statistical concordance between diagnoses obtained by community members employing the Composite International Diagnostic Interview (CIDI) and a non-resident clinician employing the Structured Clinical Interview for the DSM (SCID). Interviews with 75 tribal members from a single reservation revealed that respondents diagnosed with Posttraumatic Stress Disorder (PTSD) when interviewed by a community member using the CIDI were much more likely to be diagnosed instead with a Depressive disorder when interviewed by an outside clinician using the SCID. It is argued here that the "lay" interviewers found higher rates of PTSD and lower rates of Depressive Disorder because they invoked (and could not circumvent) the local cultural discourse linking trauma and fortitude. As a result, CIDI responses were channeled into culturally appropriate self-representations that primarily associated personal distress in terms of the traumatic social disruptions that respondents had experienced as opposed to the more direct acknowledgment of relatively decontextualized and internalized mood states that the community emphasis upon fortitude precludes in such discursive encounters. In contrast, as a non-tribal interviewer and a trained clinician, I disrupted this local cultural discourse by actively contesting and reorganizing the respondents' own constructions of their distress into established psychiatric categories, thereby facilitating a displacement of CIDI PTSD diagnoses among this sample by the substantial increase in SCID depression diagnoses. Insofar as sustained attention to the sociolinguistic practices of a cultural community may illuminate perplexing epidemiological findings, including the difficult challenges posed by incommensurate ontologies of distress, the implications of this kind of analysis for cross-cultural psychiatric epidemiology are discussed.