so<. su Mcrl Vol. 20. No. 7. pp 725-730. 1985 0277-9536185 S3.00 + O.

lKJ
Printed in Grear Brmm Pergamon Press Lid

ANOREXIA NERVOSA AS A CULTURE-BOUND

SYNDROME
LESLIE SWARTZ*
MRC Clinical Psychiatry Research Unit, Department of Psychiatry. University of Cape Town,
Groote Schuur Hospital, Observatory. 7925 South Africa

Abstract-Current psychological theories on anorexia nervosa share a common assumption that

symptoms of the condition are related to cultural factors. The present article argues that the disorder can
be fruitfully understood in the context of one definition of culture-bound syndromes. By way of
introduction two contrasting models of the cross-cultural study of psycho-pathology are outlined in order
to contextualize the argument in a particular paradigm. Anorexia nervosa is shown to fit the criteria of
the CassidyiRitenbaugh definition of culture-bound syndromes, and the definition is shown to have some
use in elucidating issues.
Implications for a more flexible approach to theory development and therapeutic practice are discussed,
and suggestions are made for further work demonstrating the negotiated nature of the disorder.

Culture-bound syndromes in non-Western societies
have received much attention from medical anthro-
pologists and cross-cultural psychiatrists [l]. More
recently, attention has been given to culture-bound
syndromes within Western society, a move which has
coincided with a more reflexive attitude to looking at
disorders and culture [2-4]. The purpose of the
current article is to explore the implications of view-
ing anorexia nervosa (and by implication its various
cognate disorders) as a culture-bound syndrome. I
shall explore theoretical and therapeutic implications
of considering the disorder in the light of one
definition of culture-bound syndromes.
Approaches to the understanding and treatment of
anorexia nervosa and similar disorders come from
psychodynamics [5], cognitive behaviourism [6] and a
family systems model [7], amongst others. Although
the approaches differ considerably, they are united in
implicating cultural factors in the psycho-genesis or
maintenance of anorexia nervosa. Eminent theories
rely heavily on the assumption that culture is in-
volved in the disorder [8,9], and I have argued
elsewhere that a useful basis for feminist theory is to
view anorexia nervosa as a culture-bound condition
[lo]. The current article. ‘however. does not present a
feminist argument as such. and is concerned with
more general issues.
DEFIh’lTIONSOF CULTURE-BOUND SYNDROMES
Kleinman [1 I] has contrasted two approaches to
cross-cultural psychiatry and each of these implies a
certain way of understanding culture-bound syn-
dromes. What Kleinman terms the ‘old transcultural
psychiatry’ is a discipline which uses Western diag-
nostic systems to look for disorders such as depres-
sion and schizophrenia throughout the world.
Though it is true. as Kleinman points out, that this
approach tends to obscure culturally specific com-
plaints (it simply does not look for them). grossly
*Present address: Child Guidance Clinic. University of
Cape Town. Chapel Road. Rosebank. 7700 South
Africa.
725
bizarre behaviour in other cultures will still be no-
ticed. For example, amok in Malaya involves leaving
one’s home village for a while, returning and running
about seemingly indiscriminately killing animals
and people. The challenge for the ‘old transcultural
psychiatry’ is to explore carefully whether such dis-
orders can in fact be related to extant classification
systems. Leff [l] has argued, for example, that amok
is not dissimilar from the French crime passionel. A
further concern of Leff’s (and of proponents of the
‘old transcultural psychiatry’) is to explore whether in
fact culture-bound syndromes constitute a form of
madness or psychosis. Once again, the focus in this
approach is on the Western diagnostic system. By
looking for ways in which behaviour however bizarre
can be fit into this system, Leff (and by implication
the ‘old transcultural psychiatry’) can conclude that
“to date no psychotic condition has been identified
that is peculiar to one particular culture” [1, p. 221.
What Kleinman [l l] terms the ‘new cross-cultural
psychiatry’ is more interested in the way categories
are made by those within cultures. According to this
approach, culture-bound syndromes are often exam-
ined not for whether they are similar to others or even
for whether they constitute ‘madness’ in any general
normative sense. Instead these syndromes are looked
at in terms of the cultural pre-occupations and mean-
ing that they may reflect. There are two related
consequences of this approach which a proponent of
the ‘old transcultural psychiatry’ may find un-
fortunate. The first of these is that relativism leads to
a fragmentary state of affairs where it is not possible
to compare easily across cultures, and the second is
that any.disorder even if it does occur universally has
culture-specific features in different societies. The
question then becomes: what does nor constitute a
culture-bound syndrome? The answer to both these
criticisms lies in a different emphasis in the ‘new
cross-cultural psychiatry’-ultimately, the quest for
universals which fit one diagnostic system is inci-
dental to the business of elaborating disorders within
cultures. It is true that the edges become blurred
between culture-bound and other disorders, but once
again the distinction between them is not part of the
126 LESLIE SWARTZ

Table I. Defimtmn of culture-bound syndrome The term culture-bound syndrome may. if defined appro-
A culrure-boundsyndrome is a constellation of symptoms wluch has priately, be construed as applying in a wide range of settings
been categorized as a dysfunction or disease. It is characterized by rather than in the narrow sense that it has been used
one or more of the followmg: historically. This and the accompanying paper by Cassidy
(I) It cannot be understood apart from its specific cultural or
propose and illustrate a definition of culture-bound syn-
subcultural context drome which in effect subsumes all diseases in all cultures
(2) The aetiology summarizes and symbolizes core meanings and to varying degrees. Rather than blurring important dk-
behavioral norms of that culture tincrions, this approach provides a clar[fjYng ,/bcus. for tt
(3) Diagnosis relies on culture-specific technology as well as makes biomedicine accessible to our analysis (p. 350. my
ideology emphasis).
(4) Successful treatment is accomplished only by participants in
that culture
Ritenbaugh’s argument is clear: the object of a
Corollaries cultural analysis of illness or disease is not the
(I) The symptoms may be recognized and similarly organized creation of a taxonomy which distinguishes between
elsewhere but are not categorized as the same dysfunction or culture-bound and non-culture-bound conditions. On
‘disease’ the contrary, the business of this cultural analysis is
(2) Treatment judged as successful in one cultural context may not
be understood as successful from another perspective to provide a uniform framework within which to
(3) The fact that biomedicine does not include culture in its basic consider all disorder, and which specifically disallows
explanatory model leads to: the splitting off of exotic or apparently bizarre condi-
(a) a failure to recognize culture-bound syndromes within tions. Ritenbaugh is not calling for an abandonment
Western cultures and within the biomedical system;
(b) a redefinition of syndromes from other cultures into of biomedical language in its appropriate context. but
biomedical terms so that potentially important cultural she is asking firstly that the preemptive use of
patterns (may) become irrelevant to diagnosis or biomedical discourse be questioned and secondly that
treatment
a different kind of language (that of ‘meaning’) be
From Ritenbaugh [3]. adopted more generally.
It is clear that the CassidyiRitenbaugh definition,
though not universalistic in the sense used by Klein-
focus of convenience of the discipline. This does not man in his attack on the ‘old transcultural psychiatry’
imply that the distinction is not valid or important in is all-embracing in the sense that it takes as funda-
other contexts. mental that all disorders mean something to sufferers.
Within the context of the ‘old transcultural The continuum concept introduced by Ritenbaugh
psychiatry’, then, one would seek epidemiological (‘varying degrees’) is useful in that it does not make
evidence for the existence of anorexia nervosa in for unnecessary categorical distinctions between
particular parts of the world [12]. This quest, though classes of disorders, but it does leave open the
by no means irrelevant to the ‘new cross-cultural question of the criteria by which one is to decide
psychiatry’ is to some extent tangential to the attempt whether one condition is ‘more culture-bound’ than
to understand anorexia nervosa in cultural context. another. These criteria would be extremely difficult to
It is with this ‘hermeneutic’ or meaning-centred define and may well rely to some extent on whether
aspect of the ‘new cross-cultur;il psychiatry’ rather a constellation of physical symptoms occur at all in
than with epidemiology that this article is concerned. different cultures. For example, there are those who
A definition of culture-bound syndromes which is would argue that there are societies in which the
concerned very strongly with the issue of meaning is symptoms of anorexia nervosa do not occur at all,
that developed by Ritenbaugh [3] and Cassidy [13]. but that there are no societies in which myocardial
This definition is reproduced in Table 1. infarction does not occur; therefore anorexia nervosa
The most fundamental point about this definition may be seen as essentially more ‘culture-bound’
is that it does not attribute to the syndrome a reality than heart disease. This form of argument, which
apart from that which is negotiated between those reintroduces epidemiological evidence into the
who treat it and those who suffer from it. This does culture-bound syndrome arena, but from a different
not imply that ‘symptoms’ do not exist apart from perspective, needs to be considered carefully on its
this negotiated reality. For example, it is possible for own merits and is beyond the scope of this article.
a woman of 1.7 m to weigh 70 kg; whether one Because the Cassidy/Ritenbaugh definition does
considers this as contributing to a syndrome of not claim to exclude any disorders, the proper ques-
obesity is another matter. A second feature of the tion to be asked when applying the definition to a
definition is that it is very broad, particularly in disorder is not, “Is this disorder a culture-bound
that only one of the criteria mentioned is sufficient syndrome?“, but rather, “Does the culture-bound
for defining a syndrome as culture-bound. Both syndrome concept provide a framework for a useful
Ritenbaugh and Cassidy are keen to demonstrate way of considering this syndrome?“. It is with this
that what have been seen as pure biomedical con- second question in mind that I shall proceed in the
ditions may fall under the rubric of culture-bound rest of this article.
syndromes. However, mental disorder is generally
viewed as being optimally treated by members of
ANOREXIA NERVOSA AS A CULTURE-BOUND
the sufferer’s culture, in spite of the proliferation
SYNDROME
and success of purely biomedical treatments [l].
Hence, the definition is most easily applied to mental Anorexia nervosa usually presents with weight loss
disorder of almost any kind. and endocrine disturbance, and often shares with
The objection that the definition is very broad is in similar disorders symptoms such as binge eating,
fact anticipated by Ritenbaugh [3]: self-induced vomiting and purgation [14]. There is
 Anorexia nervosa as a culture-bound syndrome
debate as to whether anorexia nervosa and similar
disorders are increasing in prevalence, but what is
certain is that the volume of writing about the area
is expanding rapidly [IS]. If we examine the process
of categorization of dysfunction or disease in itself
(the introductory rubric to the Cassidy/Ritenbaugh
definition) we may conclude that symptoms that
appear in anorexia nervosa but can occur in the
absence of a full-blown picture are at present constel-
lating into other culture-bound syndromes. These
have various names, such as bulimia [16], bulimia
nervosa [17], bulimarexia [8] and so on. It is im-
portant to note that the popular media often run
articles on anorexia nervosa and similar disorders
and the categories are known not only to bio-
medicine. I shall now consider the implications for
anorexia nervosa for each of the four criteria men-
tioned by Cassidy and Ritenbaugh.
It cannot be understood apart from its spect@c cultural
or subcultural context
The obvious value of taking cognisance of social
trends such as emphasis on thinness and con-
sumerism when talking of anorexia nervosa makes
this point seem rather trivial. However, if we concede
its validity we may conclude that the meaning of
anorexia nervosa may change over time as cultural
pre-occupations change. The identical symptoms now
may mean different things from what they may have
meant in the late 19th century when the disorder was
first documented in the form we now recognize. This
implies that it may be valid to relate symptoms now
occurring to social factors which may not have
existed in the same form years ago.
The notion of a ‘subcultural context’ can be taken
even further. It is fairly well established for example
that anorectiform symptoms are unusually common
in women involved in image-related careers, such as
beauty therapy, modelling and ballet dancing [ 18, 191.
It is possible that these symptoms may have a
different meaning for members of such groups than
for others. Specifically the notion of ‘severe psycho-
pathology’ often associated with anorectiform symp-
toms [20] may not apply in these groups where the
symptoms are something of a norm. This statement
does provide support for the allegation that the ‘new
cross-cultural psychiatry’ may lead to increasingly
fragmentary understanding of conditions as more
emphasis is placed on specific contexts. More im-
portantly, though, it focuses attention on the profes-
sional discourse surrounding anorexia nervosa and
calls into question the practice of making blanket
statements. This issue will be returned to later.
The aetiologJ* summarizes and symbolizes core mean-
ings and behavioural norms qf that culture
To some extent this feature of the Cassidy/
Ritenbaugh criteria is problematic in itself as it
assumes unitary aetiology. The objection aside, it
throws interesting light on the nature of theorising
about anorexia nervosa. Anorexia nervosa is usually
recognized as a disorder of Western culture (similar
conditions such as the Japanese kibarashi-gui [21]
have a problematic relationship to anorexia nervosa).
If we take this seriously then we can begin to explore
the ways in which it serves as a vehicle for expressing
727
preoccupations of Western culture. It is interesting
that as hysteria has become rare in Western culture,
popular thinking has related it to a particular (not
necessarily accurate) view of Victorian sexuality, but
anorexia nervosa is rarely more than cursorily dis-
cussed as presenting a crystallized caricature of
norms [8,22,23]. In fact, some authors are careful to
dissociate anorexia nervosa from ‘normal dieting’, for
example [24]. I have argued elsewhere that this very
split between normality and abnormality which
amounts to the medicalization of anorexia nervosa
may place the condition in a good position to express
cultural pre-occupations [lo]. Some reasons why dis-
tinctions are made between anorexia nervosa and
‘normality’ may be firstly the physical danger at-
tached to the symptoms and secondly the difficulty an
essentially positivist model of biomedicine has with
social theorizing. A further reason may have to do
with reluctance to discuss cultural issues within our
own culture (see corollary 3a). Some implications of
this for theories of psychogenesis will be discussed
later.
Diagnosis relies on culture-specific technology ai well
as ideology
It was argued above that anorexia nervosa is to
some extent a disorder which gains its reality through
a form of negotiation between the diagnoser and the
sufferer. This observation is reinforced by the current
Ritenbaugh/Cassidy criterion. Ideology in diagnosis
and treatment of anorexia nervosa is an issue which
has been of considerable concern to feminists [8,9].
Successful treatment is accomplished only by par-
ticipants in that culture
The concept of ‘success’ in treatment is of course
a cultural matter in itself (cf. corollary 2). Leaving
this aside, it is clear that the major treatment
modalities for anorexia nervosa, corresponding to the
psychological theories mentioned in the introduction,
all involve communication within a particular cul-
tural context. There is some evidence to suggest that
inedication may remove anorectiform symptoms, and
there is no shortage of physical theories about
anorexia nervosa [25]. However, even the process of
giving and receiving drugs has powerful social ritual
qualities.
Of course, the ‘culture’ mentioned here may refer
in part to a general medical or professional culture
which cuts across regional boundaries and which is
limited more by class and by educational background
than by national origin. There may be a variety of
practitioners from different countries who are able
to deal with anorexia nervosa. This observation
focuses attention firmly on the problem of assuming
that cultural heterogeneity (in the sense of diversity
of national or ethnic origin) necessarily creates
greater divisions than class differences [26]. This
point is alluded to obliquely by Cassidy [ 131 in her
examination of economic factors in protein-energy
malnutrition.
SOME IMPLICATIONS
There are two major valuable consequences of
using the culture-bound syndrome rubric when con-
728 LESLIE SWARTZ

sidering anorexia nervosa. The first of these is in the popular press in particular is often at great pains to
area of theory development and the second, related argue that anorexia nervosa is different in kind from
consequence has to do with clinical practice. normal dieting. This view is probably held by some
psychoanalytic theorists as well. in spite of the fact
Consequences ,for theor? that psychoanalysis as a theory involves social crit-
The notion of a culture-bound syndrome implies icism [28]. The unquestioning belief that symptoms
an element of relativism in theory. This is some- are abnormal in an ultimate sense provides for a neat
what paradoxical, because one does not expect theory but does not allow for any exploration of how
every practitioner dealing with every culture-bound these ‘symbolize core meanings and behavioural
disorder to take a relativistic stance. norms’ (second point of the culture-bound syndrome
For example, though medical anthropology may definition). The culture-bound syndrome approach
recognize amok as a culture-bound syndrome, it can be seen as a call for psychoanalytic theory to use
does not require of practitioners within Malaysian its greatest strength-i.e. to explore symptoms within
culture that they formulate a theory about amok that the framework of a disciplined social theory [28. 291.
is relativistic. The implicit ethnocentrism of this It should be noted that this does not mean that
situation aside, relativism does have benefits for symptoms should be blamed on a cultural conspiracy
psychological theories of anorexia nervosa. 1101.
The many psychological approaches which vie for
the centre of the stage in anorexia nervosa theory Consequences for therapeutic practice
have in common an attempt to explain the disorder There are always problems in extrapolating from
comprehensively. Rychlak [27] has commented that global theory to actual therapeutic procedures.
different psychological theories have different aims; Nevertheless, in spite of the fact that much of
and they may therefore be seen to operate to some what has been argued in this paper has no direct
extent at cross purposes. The culture-bound syn- therapeutic implication, some points need to be borne
drome approach takes this view further in that it in mind.
indicates that the same symptoms viewed at different An important consequence of the relativism im-
times or in different contexts may be construed plicit in the argument of this article is that different
differently. instances of anorexia nervosa may have different
Another important consequence of the culture- meanings and require different treatment approaches.
bound syndrome approach is that it legitimizes and This view is neither a form of theoretical eclecticism
in fact encourages theorists to consider their own role nor simply a truism that one should fit the treatment
in the creation of the disorder. Obviously this does to the patient. The overarching culture-bound syn-
not imply that theorists are responsible for causing drome model calls into question whether it is
individual people to develop anorectic symptoms, but appropriate to offer comprehensive individual
refers instead to the negotiated reality of the devel- psychological treatment to members of certain sub-
opment of the disorder in a global sense. When cultures. If, for example, it is reasonably common
applying labels of pathology to sufferers, theorists for models and ballet dancers to display anorectic
should be careful to recognize their own part in symptoms, then focused. symptom-directed thereapy
creating and maintaining a certain kind of reality. may be appropriate in these groups. More explorative
I am not claiming that anorectic symptoms do not work can be seen as more suitable in other sub-
exist as such and are manufactured purely by cultural contexts. Of course there can be no hard and
the helping professions, but I am suggesting that fast rules about this, and this kind of distinction
patterns of presentation may be affected by profes- raises questions about the ‘pathology’ of entire sub-
sional practice [IO]. groups such as models and dancers. Perhaps it could
Possibly the most fundamental theoretical con- be argued that the choice of a certain career is in itself
sequence of the argument I have been presenting is a sign of problems. The temptation to psychologize
that it militates against a linear cause model for social phenomena (such as career characteristics) is
pathology which resides within the sufferer. This type strong but it is not valid to confuse two levels of
of objection to certain theoretical approaches is not explanation-psychological theory about individuals.
new,[7] but lays stress on the diagnostic system itself. and theory about groups. Furthermore. medical-
Many intertwined factors, some personal and some ization of social phenomena is a consequence of a
cultural, operate in the genesis of the disorder in narrow biomedical approach. The use of a more
every case. When the practitioner becomes part of meaning-centred model requires that the social
what is being studied then linear causality cannot content of symptoms not be reduced to psycho-
be applied, because there is no longer the possibility pathology. It is easy for the clinician to convince
of unitary responsibility for or single meaning of sufferers that aspects of their lives are pathological-
symptoms. it is a therapeutic responsibility not to do so
A related issue to this one of that of the necessity indiscriminately.
for theory to grapple with the concept of ‘normality’. None of this undermines the fact that only some
It is easy to call everybody with anorectic symptoms people develop culture-bound syndromes and others
‘abnormal’, but an approach which considers culture do not. The greatest weakness of the definition of
in the way that has been suggested. must allow for the culture-bound syndromes in the therapeutic context
boundaries between ‘abnormal’ and ‘normal’ to shift. is that it does not offer a way of understanding
Once again. this is not a new idea, and I am not individual psychogenesis. This requirement is in fact
arguing that ‘abnormality’ or ‘pathology’ is not a beyond the range of convenience of the definition. so
useful concept. However, it is instructive that the it is no criticism that it is not met. The approach
 Anorexia nervosa as a culture-bound syndrome 729

implicit in the definition can inform the way that presumably, in many others. But the continuum of
interpretations are used in the therapeutic context as disorders from more to less culture-bound as
it does not allow the therapist to view these as the suggested by Ritenbaugh [3] needs to be considered
only truth. The clinician is allowed to operate in what carefully. An argument which is able to demonstrate
Rychlak [27] has termed the ‘as if’ mode. In recog- different degrees of ‘culture-boundedness’ for
nizing that the nature of therapeutic discourse is different disorders could synthesize the best from
metaphorical and related to cultural context, the the ‘old transcultural psychiatry’ and the ‘new
clinician is free to maintain a healthy scepticism cross-cultural psychiatry’. This argument would of
about any model of individual psychological func- necessity focus on the question of which meanings
tioning without feeling that this necessarily (attributed to symptoms or misfortune) can genuinely
invalidates the usefulness of the model for therapy. be seen to be culture-bound and which meanings
Clinicians reproduce ideology and should be aware of approach a level of universality. The interplay be-
this, but self-criticism does not imply that such tween ‘particular’ and ‘universal’ interpretations of
reproduction is necessarily bad. symptoms could form the basis for a position which
neither over-particularizes (the ‘new cross-cultural
psychiatry’ at its pedantic worst) nor over-generalizes
(the ‘old transcultural psychiatry’ at its reductive
CONCLUSION
worst).
The argument in this article can be generalized to It is hoped that the discussion given in this article
other disorders and to some extent anorexia nervosa has not only demonstrated the usefulness of the
has functioned as a vehicle for more wide-ranging Cassidy/Ritenbaugh definition for theory and treat-
comments. The broadness of the CassidyjRitenbaugh ment of anorexia nervosa but has also pointed to
approach is its strength in that it allows for derivative some of the challenges raised by the definition. In
work like the present article but is also its weakness being so clear an example of a Cassidy/Ritenbaugh
in that it is reasonably easy to translate into the culture-bound syndrome, anorexia nervosa may
model in a glib way. provide a basis for considering the far-reaching
The culture-bound syndrome concept is useful in implications of reconceptualizing disorders in terms
the field of anorexia nervosa and similar disorders of the definition.
because it unites a number of disparate psychological
theories. It provides a framework in which both
sufferers and professionals can be understood within Acknowledgements-1 should like to thank Sally Swartz for
numerous helpful discussions, and the anonymous reviewers
the same context. It does not by definition invalidate
of the first version of this article for their incisive criticisms.
any theories of individual psychogenesis, and in fact
can be used as a support to these.
The question may be asked whether the theoretical
baggage of the culture-bound syndrome concept is in
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