From diversity to unity. The classification of mental disorders in 21st-century China.
Psychiatric disease constructs represent social constructs and genuine states of distress that have biopsychosocial sources. As such, they have social uses peculiar to the social groups in which they are created and legitimized. This is as true in the United States as in the rest of the world. The DSM schema, for instance, is so organized that every possible mental condition is listed as a disease to legitimate remuneration to practitioners from private medical insurance and government programs. This particular social use may be irrelevant to other societies where health care is financed differently. The CCMD-3 system represents an attempt at global unification and preservation of features that are salient for local application. Compared with its previous editions, noticeable changes have been made to render it in tune with international usage. This remarkable speed of adaptation speaks to the global flows of information technology and China's openness under rapid economic reform. It also demonstrates that the middle-aged cohort of more pragmatic Chinese psychiatric leaders who headed the CCMD-3 task force are now less vulnerable to the domination of the most senior generation of Chinese psychiatrists. Having been trained in the Russian system of psychiatry and gone through the various periods of national shame that traumatized China, they used to be very cautious about adopting foreign technology in general. This is why much less harmonization with the ICD-10 occurred with the CCMD-2-R, when the responsible task force was, for better or worse, dominated by these senior psychiatrists. Nonetheless, as Stengel and Sartorius remarked, an international classification must not aim to oust or replace regional classifications that serve valuable functions in the local contexts. No single classificatory system, Kirmayer submits, will suffice for all purposes--the correct diagnostic scheme is the one that accomplishes its explicit pragmatic aim by addressing the relevant level of description. The particular additions (e.g., travelling psychosis, culture-related mental disorders), deletions (e.g., depressive neurosis, pathologic gambling, avoidant and borderline personality disorders), retentions (e.g., unipolar mania, neurosis, hysteria, homosexuality), and epistemologic variations (e.g., somatoform disorder, neurasthenia) of diagnostic categories reflect exactly this simultaneous need to globalize and to take account of the changing reality of illness in contemporary China. Stengel advised that "no psychiatric classification can help being partly etiological and partly symptomatological, because these are the criteria by which psychiatrists distinguish mental disorders from each other." To an extent, the CCMD-3 is a critique of certain nosologic assumptions of Western psychiatry, such as the feasibility of a neo-Kraepelinian taxonomy grounded exclusively in symptomatology across all diagnostic categories, and the validity of syndromic architectures based on a firm adherence to the mind-body dichotomy. From this angle of vision, local systems of classification such as the CCMD-3 may offer an opportunity for needed reflections by North American psychiatrists who have simply taken the DSM-IV schema for granted. Sartorius reckoned that a classification is a way of seeing the world at a point in time. A deep study of the CCMD-3 is thus an avenue for achieving an understanding of the contemporary Chinese mind and the social realities in China. The remarkable diversity of China at present, namely, a Communist Party dominated state socialist political structure but the most rapidly growing capitalist economy in the world, guarantees that Chinese people's social and moral experience of illness will continue to change. The study of such culture-specific categories as travelling psychosis, neurasthenia, qigong-induced mental disorder, and dysfunctional homosexuality sheds light on the larger sociomoral processes and destabilizing changes in subjectivity that are occurring in this most populous country in the world.
Lee
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Department of Psychiatry, Chinese University of Hong Kong, Shatin, Hong Kong, China.
D002681:China; D003431:Cross-Cultural Comparison; D018864:Cultural Diversity; D003906:Developing Countries; D005544:Forecasting; D006801:Humans; D007391:International Cooperation; D001523:Mental Disorders / Q000145:classification* / Q000175:diagnosis / Q000523:psychology; D011569:Psychiatric Status Rating Scales / Q000706:statistics & numerical data; D011594:Psychometrics; D015203:Reproducibility of Results