12.4.1 Anxiety disorders.

Many people suffer from anxiety disorders in a variety of cultures. The symptoms of anxiety emphasize feelings and perceptions of danger not necessarily related to any objective threat. A state of constant worry can produce many concomitant physiological consequences. Typically, the anxious individual also complains of fatigue and an inability to concentrate on tasks at hand. Anxiety may be related to impression formation when people desire to convey a favorable the image to others. Anxiety can also be culturally context-related and dependent on the ecological and economic context of life, for example agoraphobia is more prevalent among Africans (Chambless & Williams, 1995). In Western societies many people have anxieties related to economic survival and people who are successful economically are anxious about social accomplishments. Achievement anxieties are well understood from the cultural values of individualistic societies. The anxiety experienced by people everywhere is related to the cultural context. For example people in collectivistic societies may be more anxious about inclusion in the family, the community and other valued associations. Nevertheless there is also strong evidence in some cases for universally similar anxiety symptoms including those caused by traumatic events (Koopman, 1997).

12.4.2 Regulation of mood: Depression.

Disorders of mood described as melancholia or depression have been found in the literature for centuries. Significant evidence for the universality of depressive afflictions was found in a large cross-cultural comparative study (Tanaka-Matsumi & Draguns, 1997). The study found the presence of anxiety symptoms in all cultures studied with concomitant reports of lack of energy and dysphoria. However, peripheral symptoms of depression including headaches and bodily weakness were found only in some societies. Differences in the rate of depression diagnoses in a society might be an artifact of cultural stigma, and clinicians in Japan are reported to avoid the diagnostic category to spare the negative evaluations (Neary, 2000). Lack of insight produced by cultural frames may also prevent patients in some cultures from accurately reporting symptoms. For example Chinese in one study did not recognize depression as being tied to feelings of hopelessness, lack of joy, or loss of self-esteem (Kleinman, 1986). In fact patients in some cultural groups see the reason for their depression distress in physiological symptoms, whereas patients in other societies believe that psychological factors are paramount (Ulusahin, Basoglu, & Paykel, 1994). Cultural values come into play in beliefs about the etiology of depression disorders since a psychological explanation may seem self-centered to patients in China and other collectivistic societies and somatic symptoms are therefore more acceptable (Ying, Lee, Tsai, Yeh, & Huang, 2000).

The psychopathology of depression includes subjective feelings of sadness and generally a lack of enjoyment of life. Physiological concomitants of depression include a lack of energy, loss of appetite and sleep disorders. Depression impacts the self-concept producing low self-esteem and feelings of hopelessness and helplessness that in extreme cases may predispose the patient to suicide. Countries vary widely in the rate of diagnosis of depression (Leff, 1977) with for example 24 percent diagnosed with the disorder in Great Britain and only 4.7 percent in the U.S. It would appear that the local cultural assumption about depression, and the stress associated with the insecurity in Western individualistic societies and economies drives the diagnosis rates. Other cultures value extended family structures and that help buffer the individual from the effects of environmental stress and disappointments. Individualistic cultures with an atomistic family structure has produced societies where large numbers of adults live alone and the predisposition for depression is greater and the social support less compared to collectivistic societies (Marsella, 1980).

A World health Organization study (2012) projected that depression would be the second leading cause of disability in the world’s population. Gender differences in depression are important as twice as many women as men are affected and experience depression independent of other contributing factors. The gender gap is consistently found across different cultures, racial or ethnic identification and even socio-economic differences (Weissman, Bland, Canino, Faravelli, Greenwald, Hwu, Joyce, Karam, Lee, Lellouch, Leping, Newman, Rubin-Stiper, Wells, Wickramaratne, Wittchen, & Yeh, 2006). For large a group of people depression becomes a lifelong companion as about 20 percent of women and ten percent of men retain depression symptoms across the lifespan (Weissman & Olfson, 1995).

Cultures affect the expression of symptoms. As noted, Chinese patients with depression are more likely to report somatic symptoms (Kleinman, 2004). On the other hand patients in Uganda see depression in cognitive terms as a consequence of obsessive thinking rather than feeling sad or melancholic (Okello & Ekblad, 2006). Rates also appear to vary across cultures although different diagnostic procedures and assessments make cross-cultural comparisons difficult and unreliable. Cultural values play a role as depression is seen as primarily emotional in individualistic cultures. However, as we noted a self-focus is less acceptable in collectivistic societies and in these the blame is often placed on physiological problems like headaches (Marsella, Kaplan, & Suarez, 2002; Arnault, Sakamoto, & Moriwaki, 2006). This research on somatization seem incongruent and contradictory with the supposed underlying cultural values since the somatization of symptoms is actually based on Western conceptions of duality of mind and body whereas Eastern philosophy is more holistic (Lee, 2001). Rate variations in depression are also influenced by unique cultural sources of stress like constant war in the Middle East or Africa, or stress in societies that are impacted by economic crisis, or in countries trying to adjust to rapid change from globalization.

Chronic depression causes feelings of hopelessness and predisposes some patients to commit suicide. The practice of suicide is also influenced by cultural values. Japan, a high achievement oriented culture, has the highest suicide rate in the world. In other cultures like Sri Lanka high rate of suicide is linked to hopelessness from ethnic strife and war. Eastern Europe has experienced rapid change from the period of Stalinism that may have contributed to high suicide rates. Cultural values expressed in religion that condemn suicide can contribute to lower rates. In Japan on the other hand committing suicide is consistent with personal honor, whereas in religiously dogmatic countries of either Catholic or Islamic persuasion rates are lowered by religious objections of the clergy (Barraclough, 1988).