I am sure you have realized that it can be difficult to get a professional consensus on the definition of a disorder and whether it exists outside of a cultural context. Universal disorder refers to the incidence of a particular set of symptoms as occurring across various cultures and circumstances and includes mental illnesses. Universal disorders focus on the genetic and biological factors contributing to the condition, in addition to cultural and contextual factors.

While the debate about culturally specific versus universal conditions continues in regard to clinical diagnosis, most experts agree that viewing illness through the lens of culture is imperative when addressing symptoms, societal stigma, and treatment options. In this chapter, we will explore the symptoms and diagnostic criteria of four mental health categories seen across the globe:

• Major Depressive Disorder (MDD)
• Anxiety Disorders
• Eating Disorders
• Psychosis

Major Depressive Disorder

Everyone experiences brief periods of sadness, irritability, or euphoria. This is different than having a mood disorder, such as MDD or Bipolar Disorder (BD), which are characterized by a constellation of symptoms that causes people significant distress or impairs their everyday functioning.

A major depressive episode (MDE) refers to symptoms that co-occur for at least two weeks and cause significant distress or impairment in functioning, such as interfering with work, school, or relationships. Core symptoms include feeling down or depressed or experiencing anhedonia—loss of interest or pleasure in things that one typically enjoys. According to the DSM-5 (APA, 2013) the criteria for an MDE require five or more of the following nine symptoms, including one or both of the first two symptoms, for most of the day:

• depressed mood
• diminished interest or pleasure in almost all activities
• significant weight loss or gain or an increase or decrease in appetite
• insomnia or hypersomnia
• psychomotor agitation or retardation
• fatigue or loss of energy
• feeling worthless or excessive or inappropriate guilt
• diminished ability to concentrate or indecisiveness
• recurrent thoughts of death, suicidal ideation, or a suicide attempt

These symptoms cannot be caused by physiological effects of a substance or a general medical condition (e.g., hypothyroidism).

Cross-Cultural Considerations

In a nationally representative sample, the lifetime prevalence rate for MDD is 16.6% (Kessler, Berglund, Demler, Jin, Merikangas, & Walters, 2005). This means that nearly one in five Americans will meet the criteria for MDD during their lifetime.

Although the onset of MDD can occur at any time throughout the lifespan, the average age of onset is mid-20s, with the age of onset decreasing with people born more recently (APA, 2000). Prevalence of MDD among older adults is much lower than it is for younger cohorts (Kessler, Birnbaum, Bromet, Hwang, Sampson, & Shahly, 2010). The duration of MDEs varies widely but MDD tends to be a recurrent disorder with about 40%–50% of those who experience one MDE experiencing a second MDE (Monroe & Harkness, 2011). An earlier age of onset predicts a worse course.

Women experience two to three times higher rates of MDD than do men (Nolen-Hoeksema & Hilt, 2009). This gender difference emerges during puberty (Conley & Rudolph, 2009). Before puberty, boys exhibit similar or higher prevalence rates of MDD than do girls (Twenge & Nolen-Hoeksema, 2002). Major Depressive Disorder (MDD) is inversely correlated with socioeconomic status (SES), a person’s economic and social position based on income, education, and occupation. Higher prevalence rates of MDD are associated with lower SES (Lorant, Deliege, Eaton, Robert, Philippot, & Ansseau, 2003), particularly for adults over 65 years old (Kessler et al., 2010). Independent of SES, results from a nationally representative sample found that European Americans had a higher prevalence rate of MDD than did African Americans and Hispanic Americans, whose rates were similar (Breslau, Aguilar-Gaxiola, Kendler, Su, Williams, & Kessler, 2006). The course of MDD for African Americans is often more severe and less often treated than it is for European Americans, however (Williams et al., 2007) Native Americans have a higher prevalence rate than do European Americans, African Americans, or Hispanic Americans (Hasin, Goodwin, Stinson & Grant, 2005). Depression is not limited to industrialized or western cultures; it is found in all countries that have been examined, although the symptom presentation as well as prevalence rates vary across cultures (Chentsova-Dutton & Tsai, 2009).

Suicide

Suicide is the act of intentionally causing one’s own death. While not everyone who is clinically depressed has suicidal ideation, it is important to recognize that depression, bipolar disorder, schizophrenia, personality disorders, and substance abuse — including alcoholism and the use of benzodiazepines — are risk factors for suicide. Those who have previously attempted suicide are at a higher risk for future attempts. There are a number of treatments that may reduce the risk of suicide for individuals struggling with mental illness.

Resources are also commonly in place at local colleges. Consider searching your school website and/or talking with a trusted faculty/staff member to learn more about resources available to students.

Anxiety Disorders

Anxiety is a natural part of life and, at normal levels, helps us to function at our best. For people with anxiety disorders, anxiety is overwhelming and hard to control. Anxiety disorders develop out of a blend of biological (genetic) and psychological factors that, when combined with stress, may lead to the development of impairment. Primary anxiety-related diagnoses include generalized anxiety disorder, panic disorder, specific phobia, social anxiety disorder (social phobia), post-traumatic stress disorder, and obsessive-compulsive disorder. Anxiety can be defined as a negative mood state that is accompanied by bodily symptoms such as increased heart rate, muscle tension, a sense of unease, and apprehension about the future (APA, 2013; Barlow, 2002).

While many individuals experience some levels of worry throughout the day, individuals with anxiety disorders experience symptoms of a greater intensity and for longer periods of times than the average person. Additionally, they are often unable to control their worry, tension, and/or predictive dread through various coping strategies, which directly interferes with their ability to engage in daily social and occupational tasks.

Characteristic symptoms of anxiety:

• Negative mood state characterized by unease, worry, tension, and/or dread.
• Frequent doubts regarding self-worth and/or ability to handle problems.
• Future-based, “predicative” fears for events.
• Difficulty with cognitive rumination, racing thoughts, and inability to calm the mind.
• Physiological cues (racing heart, sweat, bodily tension, among others) often accompanying cognitive symptoms, resulting in changing sleep/eating patterns.

Anxiety disorders often occur along with other mental disorders, in particular depression, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression and that the same environmental triggers can provoke symptoms in either condition. These factors may help to explain this high rate of comorbidity.

Cross-Cultural Considerations

About 12% of people are affected by an anxiety disorder in a given year, and between 5% and 30% are affected at some point in their life. They occur about twice as often in females as males and generally begin before the age of 25. The most common are specific phobia which affects nearly 12% and social anxiety disorder which affects 10% of individuals at some point in their life. Rates of anxiety appear to be higher in the United States and Europe than other parts of the world.

Schizophrenia

Most of you have probably had the experience of walking down the street in a city and seeing a person you thought was acting oddly. They may have been dressed in an unusual way, perhaps disheveled or wearing an unusual collection of clothes, makeup, or jewelry that did not seem to fit any particular group or subculture. They may have been talking to themselves or yelling at someone you could not see. If you tried to speak to them, they may have been difficult to follow or understand, or they may have acted paranoid or started telling a bizarre story about the people who were plotting against them. If so, chances are that you have encountered an individual with schizophrenia or another type of psychotic disorder.

Schizophrenia is a devastating psychological disorder that is characterized by major disturbances in thought, perception, emotion, and behavior. About 1% of the population experiences schizophrenia in their lifetime, and usually the disorder is first diagnosed during early adulthood (early to mid-20s). Schizophrenia and the other psychotic disorders are some of the most impairing forms of psychopathology, frequently associated with a profound negative effect on the individual’s educational, occupational, and social function. Sadly, these disorders often manifest right at time of the transition from adolescence to adulthood, just as young people should be evolving into independent young adults.

The spectrum of psychotic disorders includes schizophrenia, schizoaffective disorder, delusional disorder, schizotypal personality disorder, schizophreniform disorder, brief psychotic disorder, as well as psychosis associated with substance use or medical conditions. Even when they receive the best treatments available, many with schizophrenia will continue to experience serious social and occupational impairment throughout their lives. In the United States, the cost of schizophrenia, including direct costs (e.g., outpatient, inpatient, drugs, and long-term care) and non-health care costs (e.g., law enforcement, reduced workplace productivity, and unemployment) was estimated to be $62.7 billion in 2002.

The main symptoms of schizophrenia include hallucinations, delusions, disorganized thinking, disorganized or abnormal motor behavior, and negative symptoms (APA, 2013). A hallucination is a perceptual experience that occurs in the absence of external stimulation. Auditory hallucinations (hearing voices) occur in roughly two-thirds of patients with schizophrenia and are by far the most common form of hallucination (Andreasen, 1987). The voices may be familiar or unfamiliar, they may have a conversation or argue, or the voices may provide a running commentary on the person’s behavior (Tsuang, Farone, & Green, 1999).

Delusions are false beliefs that are often fixed, hard to change even when the person is presented with conflicting information, and are often culturally influenced in their content (e.g., delusions involving Jesus in Judeo-Christian cultures, delusions involving Allah in Muslim cultures). They can be terrifying for the person, who may remain convinced that they are true even when loved ones and friends present them with clear information that they cannot be true. There are many different types or themes to delusions.

Positive Symptoms

Talking to someone with schizophrenia is sometimes difficult, as their speech may be difficult to follow, either because their answers do not clearly flow from your questions, or because one sentence does not logically follow from another. This is referred to as disorganized speech, and it can be present even when the person is writing. Disorganized behavior can include odd dress, odd makeup (e.g., lipstick outlining a mouth for 1 inch), or unusual rituals (e.g., repetitive hand gestures).

Negative Symptoms

Some of the most debilitating symptoms of schizophrenia are difficult for others to see. These include what people refer to as negative symptoms or the absence of certain things we typically expect most people to have. For example, anhedonia or amotivation reflect a lack of apparent interest in or drive to engage in social or recreational activities. These symptoms can manifest as a great amount of time spent in physical immobility. Importantly, anhedonia and amotivation do not seem to reflect a lack of enjoyment in pleasurable activities or events (Cohen & Minor, 2010; Kring & Moran, 2008; Llerena, Strauss, & Cohen, 2012) but rather a reduced drive or ability to take the steps necessary to obtain the potentially positive outcomes (Barch & Dowd, 2010). Flat affect and reduced speech (alogia) reflect a lack of showing emotions through facial expressions, gestures, and speech intonation, as well as a reduced amount of speech and increased pause frequency and duration.

Cross-Cultural Considerations

It is clear that there are important genetic contributions to the likelihood that someone will develop schizophrenia, with consistent evidence from family, twin, and adoption studies. (Sullivan, Kendler, & Neale, 2003) but there is no such thing as the schizophrenia gene. It is more likely that the genetic risk for schizophrenia reflects the summation of many different genes that each contribute something to the likelihood of developing psychosis (Gottesman & Shields, 1967; Owen, Craddock, & O’Donovan, 2010). Further, schizophrenia is a very heterogeneous disorder, which means that two different people with schizophrenia may each have very different symptoms (e.g., one has hallucinations and delusions, the other has disorganized speech and negative symptoms).

About 0.3% to 0.7% of people are affected by schizophrenia during their lifetimes. In 2013 there were an estimated 23.6 million cases globally. Males are more often affected, and on average experience more severe symptoms. About 20% of people eventually do well and a few recover completely, while about 50% have lifelong impairment. Social problems, such as long-term unemployment, poverty and homelessness, are common. The average life expectancy of people with the disorder is ten to twenty-five years less than for the general population. This is the result of increased physical health problems and a higher suicide rate (about 5%). In 2015 an estimated 17,000 people worldwide died from behavior related to, or caused by, schizophrenia. There is also a higher than average suicide rate associated with schizophrenia.

The term for schizophrenia in Japan was changed from “mind-split disease” to “integration disorder,” to reduce stigma. The new name was inspired by the biopsychosocial model and as a result the percentage of people who were informed of the diagnosis increased from 37 to 70% over three years. A similar change was made in South Korea in 2012. A professor of psychiatry, Jim van Os, has proposed changing the English term to “psychosis spectrum syndrome”.

Individuals with severe mental illness, including schizophrenia, are at a significantly greater risk of being victims of both violent and non-violent crime. Schizophrenia has been associated with a higher rate of violent acts, but most appear to be related to substance abuse. Media coverage relating to violent acts by individuals with schizophrenia reinforces public perception of an association between schizophrenia and violence.