The globalization of psychiatry reveals a fascinating discourse between maintaining cultural specificity and achieving universal applicability. At the heart of this is Soyoung Suh's analysis of han in the Korean hwa-byung, in which she highlights the fundamental challenge facing medical professionals. There is a "twofold desire to situate han in a specific time and place while simultaneously universalizing it," and more broadly, this tension reflects a dilemma in global mental health (Suh 88). How does a psychiatric diagnosis honor culturally specific elements and simultaneously facilitate medical dialogue on an international platform? To answer this question, I will demonstrate the fundamental tension between cultural authenticity and international recognition that shapes the globalization of psychiatry. Drawing from Suh’s analysis of hwa-byung, Prince & Tcheng-Laroche’s analysis of cultural symptom presentation, and Kleinman’s critique of psychiatric classification, I will explore how psychiatric categories are translated, institutionalized, and negotiated across cultures. By examining how Korean doctors navigated hwa-byung’s recognition in global diagnostic frameworks, I aim to convey that the very process of seeking international legitimacy through Western psychiatric institutions is paradoxical. It undermines the cultural authenticity that these doctors initially sought to preserve and reveals how the fundamental tensions in global mental health classification extend beyond mere translation.

This analysis is organized into three sections. First, I will discuss how Korean doctors simultaneously attempted to preserve and translate the cultural specificity of hwa-byung. The second section will use Prince and Tcheng-Laroche’s framework to investigate how this tension manifests in broader debates about psychiatric classification. Finally, the third section will explore the deeper implications of these classification struggles for global mental health practice using Kleinman’s critique.

To begin with the Korean medical discourse, Soyoung Suh’s analysis reveals how Korean doctors have strategically positioned hwa-byung as distinctly Korean and universally relevant. This dual approach is particularly evident in Min Sung-kil's research methodology. By highlighting how hwa-byung emerged from specific social conditions in Korean culture, such as the Japanese occupation or the Korean War, Min characterized the condition as "a uniquely national expression of suffering" (Suh 87). He believed that han, "the supposedly Korean way of holding grudges and experiencing anger," and the symptom presentation, prognosis, and treatment of hwa-byung were closely interrelated, sharing an etiological relationship (Suh 87). However, this meant Korean doctors were challenged to faithfully translate the conceptual and cultural meaning of han without distorting cultural significance.

From literal linguistic translation of symptoms and diagnostic criteria to conceptual translation across medical traditions and cultural translation of patient experiences, the meaning of diagnoses shifts when moved between cultural contexts. For this reason, Min criticized "the limits of psychiatric language" and called for an "ethnic psychiatry that deals with the Korean nation's neuro-psychiatry'" (Suh 87). To elaborate, the power of language in shaping medical discourse has consequences at every level of clinical encounter. As patients, translation affects how their voices are heard, their suffering is understood, and their treatment within different medical systems. From the doctor’s perspective, translation raises concerns about diagnostic validity and appropriate treatment approaches across cultures. Finally, for researchers and scholars, translation challenges assumptions about the universality of psychiatric categories and prompts novel research methodologies. As such, translation is not merely a technical process but an ideological one that shapes which disorders gain recognition and remain marginalized.

That said, to address the limitations of local language barriers and garner international recognition of hwa-byung, Min opted for Western psychiatric frameworks with validated research methodologies. For instance, Min systematically interviewed 287 outpatients using the Diagnostic Interview Schedule, 3rd edition developed by the United States National Mental Health Institute (NIMH). Consequently, the international psychiatric community recognized Min’s acknowledgment of standardized clinical studies. Thus, hwa-byung was successfully classified as a culture-bound syndrome in the 1994 DSM-IV. Still, Suh noticed that this success meant "the goals of Korean psychiatric research have become focused on gaining even more international recognition" (Suh 89). Interestingly, Suh’s observation of this “twofold desire” reveals an important dynamic in the global institutionalization of psychiatry. On the one hand, Korean doctors sought to classify hwa-byung as a "uniquely Korean malady," avoiding universal categorization. However, they increasingly tried to include it in international diagnostic manuals under Western frameworks, which have gained a reputation for "guaranteeing a tool for gaining circulation and foreign recognition" among Korean doctors (Suh 100). To that end, how does the “twofold desire” shape when cultural variations in symptom presentation warrant distinct diagnostic categories? Conversely, when are they better incorporated into broader psychiatric frameworks?

Building on Suh’s discussion of the local-global tension, Prince and Tcheng-Laroche’s framework from "Symptom Differences that Make No Difference” evaluates how similar psychological distress manifests differently across cultures. In other words, how do we categorize hwa-byung as a specific Korean social condition but simultaneously a universal human experience of anger and suppression? To investigate psychiatric classification across cultures, Prince and Tcheng-Laroche examined specific cases of hwa-byung in Korea, neurasthenia in China, and brain-fag in Nigeria. In any case, they discovered that while each condition presents distinct clusters of symptoms, these variations may not necessarily warrant separate diagnostic categorization. For instance, Korean women described their symptoms of hwa-byung as "fullness in the epigastrium, indigestion, dyspnea, diffuse muscle and joint pain and fatigue," all of which are somatic complaints found internationally, not bound to one specific culture (Prince & Tcheng-Laroche 8). This directly connects to the challenges Korean doctors encountered when attempting to translate the vernacular experiences of han to a global audience. Indeed, Prince and Tcheng-Laroche admit cultural variations in symptom presentation are "highly interesting” (Prince & Tcheng-Laroche 8). Nevertheless, international classification systems like the DSM or ICD must balance recognizing cultural specificity and practical diagnostic utility. While a distinct diagnostic category may better reflect the individual patient narratives of hwa-byung, “yet, for an international classification, it would appear that these somatic complaint syndromes should be included under one rubric” (Prince & Tcheng-Laroche 8). Broader rubrics under “somatization disorder,” for example, must offer versatility and functionality to the greater public, which inevitably requires negotiation to some degree. Of course, this reveals a critical caveat underlying the power dynamics inherent in global psychiatric classification that often privilege Western frameworks.

After all, who decides when a disorder is culturally distinct or simply a variation of an existing psychiatric condition? Prince and Tcheng-Laroche discovered that non-Western psychiatrists feel "ill-at-ease" when local conditions are relegated to "atypical" categories (Prince & Tcheng-Laroche 9). This discomfort in adhering to Western classification systems suggests persisting inequalities in the global psychiatric discourse. More importantly, it reveals how the institutionalization of psychiatry shapes how certain diagnoses are legitimized. Illustrated by Arthur Kleinman's ethnographic study on neurasthenia in China, the crisis of authority is fundamental for understanding the "desire among medical professionals to make the indigenous meaningful" (Suh 100). Namely, Kleinman’s case study of Mrs. Lin demonstrates how psychiatric diagnoses function as cultural interpretations rather than purely objective categories. For instance, the Chinese understanding of neurasthenia and the approach to treating the condition significantly differs from Western psychiatric frameworks. Although Chinese doctors viewed Mrs. Lin's condition through the lens of neurasthenia, which is considered a legitimate diagnostic category in Chinese medicine, Kleinman points out that Western psychiatric frameworks would likely classify her symptoms as depression. Kleinman’s concept of “category fallacy” illuminates how the very act of translating han into Western psychiatric categories risks stripping away the culturally specific meaning the Korean doctors aimed to preserve (Kleinman 14). Furthermore, this paradox exemplifies how pursuing international recognition can inadvertently reinforce Western psychiatric hegemony, causing misinterpretation and pathologizing of what may be considered a normal response in other cultural contexts.

Likewise, this disconnect is the challenge that Suh identified with attempts to situate hwa-byung both locally and universally. While Korean doctors positioned hwa-byung within international diagnostic manuals, achieving institutional recognition is not neutral. That is, validation through DSM recognition implies the relegation of non-Western conditions to "atypical" categories in international classification systems. Global psychiatric institutions often privilege Western diagnostic models over local frameworks, and this dynamic is why Kleinman argues that psychiatric categorization inherently reflects cultural interpretations rather than objective classifications. Therefore, while institutional recognition may validate hwa-byung, it concurrently reshapes cultural-bound syndromes within dominant psychiatric paradigms.

Looking forward, these viewpoints have practical implications for managing the tension between local and universal approaches to psychiatric diagnosis. Rather than maintaining strict cultural boundaries or achieving complete universalization, future psychiatric practice could benefit from finding a middle ground between these opposing approaches. Using inclusive frameworks and flexible operational definitions could allow us to accommodate both the universal experience of human suffering and the culturally specific manifestations. This could facilitate cross-cultural communication and research while avoiding Prince and Tcheng-Laroche's concern of forcing diverse conditions into Western categories. Another promising approach is Kleinman's suggestion to develop frameworks explicitly acknowledging and working with cultural differences rather than eliminating them altogether. Like how some East Asian countries continue to recognize neurasthenia while supplementing with DSM categories, this could signify a shift towards maintaining local diagnostic categories alongside international classifications. Implementing this multifaceted approach could significantly change how psychiatric knowledge is produced and circulated, building upon the Korean doctors' strategies of conceptualizing hwa-byung.

In conclusion, this analysis traced the journey of hwa-byung into global psychiatric discourse, followed by an examination of symptom universality and critique of categorical thinking. The case of hwa-byung demonstrates that the path to international recognition inevitably transforms the cultural specificity it seeks to preserve. This local-universal tension shapes the very nature of psychiatric knowledge production, suggesting that no one framework best serves diverse populations while maintaining professional standards and facilitating international collaboration. Ultimately, the answer lies neither in strict cultural relativism nor complete universalization but in a collective effort to integrate diverse perspectives and develop more sophisticated ways to better serve our increasingly interconnected yet culturally diverse world.