Falling-out: A diagnostic and treatment problem viewed from a transcultural perspective

Abstract

The author describes a seizure-like disorder called falling-out by black Americans, blackingout by Bahamians and indisposition by Haitians in Miami. Falling-out is used as a general label for all three variants of what appear to be equivalent syndromes. The state is one in which the individual collapses without warning, occasionally with some degree of salivation but without convulsions, tonguebiting, bowel or bladder incontinence. The person afflicted usually hears and understands what is happening but is powerless to move. Even though his eyes may be open, the individual tends not to see. The condition does not meet the criteria for epilepsy or hysteria: although persons who experience it are sometimes misdiagnosed as epileptics or hysterics. Prevalence indicators are reviewed. The conclusion is drawn that the condition is a significant health problem for black Americans and Bahamians and probably for Haitians in Miami. Preliminary observations on contexts of occurrence are provided. Difficulties of diagnosis are described from both emic (cultural/ "within") and etic (orthodox/"without") positions. The challenge to the orthodox health care system is considered. In its chronic form falling-out is viewed as being psychogenic in origin and a candidate for classification as a "culture-bound" syndrome. The predominant process involved appears to be dissociation in the form of a constricted state of consciousness. The psychophysiological state should be viewed as a means of ego defense and an adaptive response. Its effectiveness should be judged by the degree of psychological and social reintegration achieved following the episodes themselves. Reliance upon dissociation as a means of coping with crisis must be understood within the framework of a view of the world as threatening, unpredictable and potentially harmful to an "acted-upon" self. Such episodes must be judged for their ability to relieve anxiety and also for the degree to which they are successful in bringing about a state of adaptedness at a more effective, equal or reduced level of functioning. The orthodox health institution carries responsibility for reducing morbidity from falling-out and for devising therapeutic approaches which take into consideration both emic and etic etiological and therapeutic assumptions. We do not yet know how to do this, but several therapeutic approaches are mentioned which might be considered. They require both transdisciplinary (social science/medicine) and transcultural (emic/etic) perspectives rather than unicultural ones. Research considerations are briefly discussed.