Mujica-Parodi and Sackeim's paper brings into focus misconceptions about the differences between the tenets of neuropsychiatry and those of cultural psychiatry. In seeking to formulate delusions so as to avoid taking into consideration the content of beliefs in a patient's culture, a requirement stipulated by the DSM system, they propose a model of rationality that is allegedly universal and not subject to cultural variation. How well they succeed depends on whether application of their model of concept formation and restriction manages to really avoid quandaries of meaning and semantics. The latter are central considerations in the study of psychiatric disorders in cultural psychiatry. What follow are comments on some of the basic assumptions and claims of the Mujica-Parodi and Sackeim formulation.

The evolution of knowledge of clinical psychiatry is largely a product of developments during the nineteenth century that took place in Anglo-European societies and began in general medicine. It involved two empirically interconnected trends that can be separated only on analytic grounds. First, there took place systematic observation of patients that culminated in the refinement of a system of concepts about and terms referring to disturbances of human psychology and behavior, along with the criteria and principles pertaining to how this descriptive system was to be used. Second, there took place the creation of a science about the many psychiatric disorders that came to be named and described by means of the descriptive system, using the science of medicine that evolved to predominate in the nineteenth century.⁺¹ The first development involved the evolution of a science of descriptive psychopathology and the latter the scientific knowledge referenced by the historiography of clinical psychiatry.^+2,+3 The paper by Mujica-Parodi and Sackeim grows out of this tradition of clinical scholarship.

How cultural assumptions and values have influenced the development of descriptive psychopathology and the generation of knowledge about psychiatric disorders is a relatively neglected topic, and only the bare outlines can be drawn here. To begin with, a cultural rationale rooted in middle-class values and standards set apart individuals worthy of study by the budding proto-psychiatrists or "alienists" during the eighteenth and nineteenth centuries.^+4—+6 The rationale consisted of Anglo-European values and norms about normality and deviance as applied to rationality and social conduct and responsibility. In essence, it created the population and standards of reference on the basis of which a science of psychiatry was formulated and could evolve.

In their efforts to clarify parameters of "pathology" of behavior alienists drew on notions of "common sense" pertaining to mental characteristics, since these are what the prevailing view in medicine and in the culture at large stipulated were responsible for behavior. Beliefs, emotional experience, and modes of reasoning constituted dominant areas of investigation. Here, an appeal was made to categories of mind tempered by and filtered through the prisms of inherited cultural knowledge about behavior. The tradition of faculty psychology, with its emphasis on cognition, affection, and conation or will, functioned as a source of knowledge.⁺⁷ So did the writings of John Locke (1632—1704) pertaining to the association of ideas in the construction of an individual's picture of social reality and the self. Finally, ideas about form and content expounded by Immanuel Kant (1724—1804) were also influential. The form as compared with the content inherent in a feature of mind came to play a determinate role in the delineation of signs and symptoms of mental illness.

Wilbush⁺⁸ emphasizes that a clear separation between signs and symptoms even in general medicine was not satisfactorily arrived at until well past the middle of the nineteenth century and still remains elusive. He presents an analysis of the channels of clinical information (i.e., how persons and bodies "communicate" disease and pathology) in general medicine that is equally germane to psychiatry. It draws a distinction between symptoms (e.g., spontaneously volunteered verbalizations of patients steeped in cultural values and semantic habits), semeions (i.e., patient answers to specific questions posed by the clinician based on his or her culturally specific theory of pathology and physiology), and signs (e.g., clinician-observed or -elicited physical changes or responses of the body of the patient). Wilbush's analysis is highly consistent with the methodology of Mujica-Parodi and Sackeim, for they begin with possible symptoms and seek semeions, items of knowledge based on a rationalistic theory of the mind, and claim for one of these (i.e., delusion) the status of a sign of brain pathology.

In their search for the pathology of mind, alienists brought to bear standards and conventions about speech, about the deployment of language including semantic knowledge, and about the character of thought, rationality, and memory, as well as notions pertaining to emotional balance and regulation. While elements of human psychology continued to be important (and still are) for neuropsychiatry, by the end of the nineteenth century other parameters became important. Aspects of personal identity (e.g., age, phase of life) and features of disorders viewed in a temporal frame of reference (e.g., rate of evolution of symptoms, clinical course) became important. Interestingly, a cultural and linguistic factor in this broadening of emphasis is evident in the case of Kraepelin: his lack of proficiency in the native languages of patients at the Estonian asylum he worked in made psychological examination difficult, leading him to concentrate on items of information that did not require assessments dependent on his own language and culture.⁺⁹

The cultural logic of Western medicine required alienists to look also for lesions and pathologies of the brain, a topic that cannot be dealt with fully here. The importance of brain function and lesion is a feature that underpins the logic of Mujica-Parodi and Sackeim. Suffice it to say that this emphasis is linked to cultural ideas and interpretations about the importance of the nervous system and of pathological anatomy—ideas that had formed an integral part of the ethos of Western medicine since the eighteenth century, before alienists were really in the picture.^+10,+11 Great ancient traditions of medicine that addressed psychiatric phenomena naturalistically (e.g., India, China) used analytic constructs and did not rely on the nervous system or brain anatomy.

All traditions of medicine concentrate on physical changes in the body, and Western medicine is no exception here. With respect to budding alienists, this led them to search for body markers of mental illness. Considerations that were initially important involved facial appearance, complexion, color, temperature, and texture of skin, bodily gestures, voluntary and involuntary movement, pain, general level of energy and motivation, and parameters of respiration, pulse, digestion, and excretion.⁺³ By the end of the nineteenth century, these "signs" of mental illness lessened in importance and aspects of pathological psychology increased. A return to the somatic sphere is evident in recent psychiatric theory involving indicators of somatoform disorders, a task that brings into play the ideas of Wilbush⁺⁸ described earlier.

Psychiatry seeks a universal science about the functioning of the "psyche" and its disturbances. However, how the mind works involves an amalgam of two sets of factors: conceptual models and reasoning principles (like those of Mujica-Parodi and Sackeim), on the one hand, and features of language and culture, on the other. The two are very difficult if not impossible to untangle.^+12—+16 Anthropologists and linguists agree that through an amalgam of meaning-creating systems, individuals fashion their personal experience, their sense of reality, their social behavior, and the requirements for social order.

Systems of meaning are crucial in cultural psychiatry. It does not posit an opposition or exclusivity between the domains of brain function and cultural meaning systems. Both together are products of the evolutionary process. Generalizations from knowledge in primatology, biological anthropology, cognitive archeology, evolutionary biology, and evolutionary psychology underscore the phylogeny of human traits like cognition, culture, and language, including psychopathology.^+17,+18 This base of knowledge indicates that all facets of human behavior are a product of natural selection. The mechanisms responsible for human behavior (termed adaptations or algorithms) unite aspects of brain and culture.

A central concern of cultural psychiatry is grappling with the quandary created by the Western (i.e., cultural) conception of mind/body dualism. The quandary encompasses issues like mind, semantics, meaning, and relativism, on the one hand, compared with brain mechanism, physiological pathology, and physical irreducibility, on the other. Dualism figures centrally in the analysis provided by Mujica-Parodi and Sackeim. They imply that culture is something external that is merely "added to" the brain's operations. The latter, they imply, is the organ that natural selection has perfected and is where traits like delusion come from or are situated (i.e., embodied). Their proposal stipulates that one of the purely "natural" functions and operations of the brain is to produce rationality. In describing this, they imply that culture can be detoured around, thereby avoiding the pitfalls of having to deal with "vague," opaque, and ambiguous stuff like symbols, meaning, and values that vary significantly across languages and cultures.

To what extent aspects of human language, cognition, and symbolization—and along with this, culture—constitute true (i.e., naturally selected) adaptations in the classic sense, as compared with exaptations that proved favorable or the passive interplay of independent physical brain changes with selective pressures based on contingencies of social ecology, is highly contested in evolutionary biology and psychology, linguistics, biological anthropology, and cognitive archeology.^+19—+26 Nevertheless, that mind, behavior, culture, and brain have a long prehistory and in their integration figure in the equation of adaptation and maladaptation or psychopathology seems incontrovertible.^{+19,+27—+30} Generalizations about the integrated character of human biological evolution anchor the conviction of cultural psychiatrists that handling aspects of culture/mind and biology/brain in an either/or manner is unproductive.⁺¹⁸

Mujica-Parodi and Sackeim's informative article ventures into the complicated terrain surveyed by both cultural psychiatrists and neuropsychiatrists. In a succinct and elegant way they propose that diagnosing delusion involves analysis of how beliefs are formed, confirmed, and disconfirmed, and come to represent the fixed "reality" of the outside world. Like neuroscientists, they equate their rational model with the workings and malfunctioning of the brain (i.e., "physical irreducibility" and "physiological pathology"). Yet a brain that is independent of experiences through enculturation, as mentioned above, is inconceivable, its possibility certainly contradicted by what is taken for granted in evolutionary psychology, anthropology, and linguistics. To a cultural psychiatrist, that which makes delusions clinically relevant is part of a larger package: diagnosis involves a careful analysis of the amalgam of meaning-creating systems referred to earlier that includes syntax, grammar, semantics, metaphor, metonymy, imaginative models of reasoning, and conventionally named objects.^+12—+15 This system constitutes knowledge, belief, and an individual's sense of "reality" and has to be understood in order for analysis of mental content and clinical diagnosis to proceed. At stake also is the question of the universalilty of sickness, which is based on cultural standards, compared with disease, pathology, and injury, which are based on biomedical standards.^+31—+33

Mujica-Parodi and Sackeim employ an indirect and, in the end, a not completely satisfactory strategy to avoid the pitfalls of relative meaning. They provide a cogent discussion of how categories and beliefs are acquired, affirmed, disconfirmed, and validated. As their analysis shows, however, to carry out this strategy successfully requires a diagnostician to have knowledge of basic tenets of his or her own culture and language and that of the subject. In other words, the authors' appeals to contextual premises and contextual and concrete examples and counterexamples necessarily plunges them into the "messy," "opaque," and "vague" world of language and culture, namely, calibrating the symbolic meaning and acceptability of items of information. Furthermore, and more importantly, teasing apart theoretical scenarios of how beliefs are formed, disconfirmed, etc., and how rationality operates is comparatively easy when the subjects share the author's own culture, sense of reality, and especially their language, as is the case in their examples. The "problem" about delusion escalates exponentially when features of language and related figurative and imaginative models of reasoning come into play, as they necessarily do in the case of subjects who speak highly different languages and share different epistemic worlds.^+12—+16

The idea of cultural reality goes beyond purely matters of "fact" (sometimes very hard to establish), and well beyond that of spotting a hole in the ground in order to avoid it. Although culture finds its full realization and function in the area of social communication, as Mujica-Parodi and Sackeim correctly point out, social communication entails a consideration of subtle, complex issues involving ethnosemantics and ethnopsychology (including ritual, myth, and cosmology) that incorporate cognitive models shaped by syntax and grammar. Higher primates (and most complex biological organisms, for that matter) reason by means of an apparatus that can be said to seek, pursue, and/or carry out truth-value judgments. However, during human biological evolution, following the pongid/hominid split around five million years ago, the capacity to endow social life with cultural symbols and meaning was further elaborated to this "natural" and social intelligence.^+34,+35 Hominid phenotypes that increased survival and reproduction and met requirements for an adaptation did have to accurately "track" the environment. In other words, based on experience they had to produce more or less truthful accounts about the environment and more or less accurate and valid inferences about its workings. However, in association with and inseparable from such a "model of rationality," biological evolution also produced a capacity for endowing its operation with content and meaning.⁺³⁶ The latter, the creation of a symbolic world or niche,⁺²⁶ organizes cultural material that provides individuals with a sense of group identity, social history, and cosmological placement. Cultural psychiatrists agree that delusions are probably universal markers of some of forms of psychopathology. However, they also believe that it is misleading to claim that delusions are diagnosed by positing a purely mechanical model of rationality that allegedly avoids cultural content.

An example may prove helpful. Studies of hunter-gatherer communities inform us that its members, as a consequence of securing a livelihood and materially pursuing subsistence, view the physical habitat as peopled by diverse beings with which they are in communion and which participate in the economy of subsistence. Subjects attribute to an animal motives and ways of thinking and behavior that are complementary to their own, and even features of the physical landscape (e.g., mountains, rivers) as well as geophysical agents or forces (e.g., the sun, wind, rain) are regarded as personal powers (i.e., personified), which is to say that they are thought to have awareness, agency, and intentionality.⁺³⁷ What this implies is that daily pursuits can be expected to be associated with forms of experience not unlike those realized by the following statements: "I must be deceptive so as to avoid giving clues to the geese, who are planning to avoid me," "I must be careful in what I do because lions may be watching and spying on me," "The wind and cold have been conspiring against me now for days." This, of course, is my logical, English gloss on the matter. In reality, these beliefs will be intricately textured in a complex grammar and system of lexical units. At issue is the fact that persons "know" the physical habitat and landscape intimately in the way they also "know" close relatives who share life on a day-to-day basis. These hypothetical statements enunciate a cultural phenomenology of "one world" in which persons operate as unitary beings or organisms-persons, relating on a one-to-one basis both to other persons and to nonhuman agencies and entities in their environment, there existing no absolute separation. Such modes of thinking are not merely figurative or metaphorical but in some ways literal, since they reflect the common, shared world in which groupmates and entities of the physical habitat and landscape interact as personalized beings. Hunter-gatherers I am sure develop delusions when psychotic, but spotting them and untangling them from normal animistic beliefs requires sensitivity to and familiarity with complex aspects of language and culture not unlike those entailed by notions outlined by Mujica-Parodi and Sackeim. To conclude that a hunter-gatherer's persistent belief should have been disconfirmed or that it is inconsistent with other beliefs that she or he holds does involve applying a model of rationality but also an understanding of a whole network of concepts and beliefs. In other words, to diagnose a delusion by means of Mujica-Parodi and Sackeim's model is to necessarily involve oneself in and come to understand what culture stands for and how it works to produce meaning.

When one unpacks Mujica-Parodi and Sackeim's protocol, it seems to say the following: a) humans are furnished with a rational apparatus that produces knowledge about the behavioral environment and rules of inference in terms of which individuals understand a fixed "reality" and adapt to it, and b) it is possible to clinically diagnose the functionality, "normality versus pathology," of the apparatus without taking into consideration systems of symbols and their meaning that comprise culture. Even if one agrees with a part of their basic premise, namely, that the model of rationality and belief formation that they propose is an innate property of Homo sapiens, ascertaining its workings necessarily enmeshes the diagnostician in a complex exegesis that requires knowledge of his or her and the client's language and culture. How items of information are labeled, confirmed, disconfirmed, and incorporated into meaningful social discourse constitutes the essence of culture and language and of higher cortical functions. The authors seek to render the task of recognizing a delusion easier by relying on a model of rationality that allegedly does not involve culturally specific knowledge. However, an appeal to such a seemingly universal, pan-cultural model of rationality requires that the diagnostician already "know" his/her own and the examinee's language and culture. The authors' analysis proposes a neuropsychiatric solution to problems of diagnosis but really exemplifies and reinforces essential tenets of cultural psychiatry.

Dr. Fabrega is Professor of Psychiatry and Anthropology at the University of Pittsburgh, Pittsburgh, PA.