SPEAKER: AMIT CHOUGULE MBBS, DPM

PG REGISTRAR (MD PSYCHIATRY)

CHRISTIAN MEDICAL COLLEGE, VELLORE

TAMIL NADU, INDIA

IMPACT OF CULTURE ON MENTAL ILLNESS

OVERVIEW

1. What Is Culture ?

2. Transcultural Psychiatry

3. Development Of Transcultural Psychiatry

4. Impact Of Culture On Psychopathology

5. Impact Of Culture On Psychodynamics

6. Impact Of Culture On Major Psychiatric Illness

7. Impact Of Culture On Personality

8. Impact Of Culture On Clinical Practice

9. Future Directions And Developments In Transcultural

Psychiatry

DEFINITION OF CULTURE

• Culture refers to the meanings, values and behavioural

norms that are learned and transmitted in the dominant

society and within its social groups

• Culture powerfully influences cognition, feelings, and self

concept as well as the diagnostic process and treatment

decisions

• It is the lens through which a person registers

experiences that shape his/her perceptions,

understanding and reactions to events

(The National Institute of Mental Health’s Culture and Diagnosis Group, 1993)

COMPONENETS OF CULTURE

1. Culture is learned

2. Culture can be passed on from one generation to the

next

3. Culture involves a set of meanings in which words,

behaviors have meanings agreed upon by the cultural

group

4. Culture acts as a template to shape and orient future

behaviors

5. Culture exists in a constant state of change

6. Culture includes patterns of both subjective and objective

components of human behavior

IMPACT OF CULTURE ON PSYCHIATRY

Culture shapes how and what psychiatric symptoms are

expressed

Culture influences the meanings that are given to

symptoms

Culture also impacts the interaction between the patient

and the health care system

TRANSCULTURAL PSYCHIATRY

“The discipline that deals with the:

description, definition, assessment and

management of all psychiatric conditions

as they reflect and are subjected to the influence

of cultural factors in a biopsychosocial context

while using concepts and instruments from social

and biological sciences

to advance a full understanding of

psychopathology and its treatment”

HISTORY OF TRANSCULTURAL PSYCHIATRY

DIFFERENT WAYS IN WHICH CULTURE IMPACTS PSYCHOPATHOLOGY

1. Patho-genic effects

2. Patho-selective effects

3. Patho-plastic effect

4. Patho-elaborative effects

5. Patho-facilitative effects

6. Patho-reactive effects

PATHOGENIC EFFECTS

• Pathogenic effects refer to situations in which culture is a

direct causative factor in forming or ‘generating’

psychopathology

• Cultural ideas and beliefs contribute to stress, which in

turn produces psychopathology

PATHOGENIC EFFECTS (contd.)

EXAMPLES:

•DHAT SYNDROME

In INDIA ‘Harmful’ wastage of semen can produce

anxiety , depression and somatic symptoms

•KOROPANIC

The folk belief that death will result if the penis

shrinks into the abdomen

Found in Malaysia

•So culture is the direct cause of psychopathology, not of

disease per se

PATHOSELECTIVE EFFECTS

• Tendency of some people in a society, when

encountering stress, to select certain culturally

influenced reaction patterns that result in the

manifestation of certain psychopathologies

• FAMILY SUICIDE’ observed in Japanese society

(Ohara,1963)

• In Japan, cultural influences leads a family to choose,

from among many alternative solutions, to commit

suicide together, forming the unique psychopathology

• Culture selecting certain coping patterns to deal with

stress

PATHOPLASTIC EFFECT

• Pathoplastic effects refer to the ways in which culture

contributes to the modeling or ‘plastering’ of the

manifestations of psychopathology

• The content of delusions, auditory hallucinations,

obsessions, or phobias are subject to the cultural

context in which the pathology is manifested

PATHOPLASTIC EFFECT(Contd.)

• Religious delusions and delusional guilt are primarily

found in Christian societies than Islamic, Hindus or

Buddhist

• Patients from developing countries reported visual

hallucinations more frequently than those from

developed countries (Varma et al., 1997)

[Kala and Wig (1982), Kim et al., 2001; Murphy (1967), Stompe et al (1999, 2006), Tateyama et al(1998)]

PATHOELABORATING EFFECTS

• Certain behaviour reactions (either normal or

pathological) may be universal

• These behaviours may become exaggerated to the

extreme in some cultures through cultural reinforcement

(Simon,1996)

• Phenomenon of “Trance and possession state”

– It is a culturally sanctioned

– This could be described to the religious elaboration

of association with ‘Atman’ and ‘Deities’

• Culture elaborating mental conditions into a unique

nature

• In western countries there is increasing

concern with body weight

• Culture-shaped body image belief that

“slim is beautiful" may cause “body

weight anxiety”

• Common reason for eating disorders in

developed countries

PATHOFACILITATIVE EFFECTS

• Facilitating effects of culture makes it easier for certain

psychopathologies to develop and increase their

frequency in certain cultures

• A liberal attitude towards weapons control may result in

more weapon-related violence or homicidal behaviour

(Westermeyer,1973)

• Cultural permission to consume alcohol freely may

increase the prevalence of drinking problems

PATHOREACTIVE EFFECTS

• Culture influences:

How people perceive pathologies and label disorders

How they react to them emotionally

Guides them in expressing their suffering

• Culture shape folk responses to the clinical condition

• Better prognosis of schizophrenia in developing

countries like India

• Family, social and cultural factors have Pathoreactive

effects on schizophrenia resulting in different

prognosis (Sartorius et al., 1978)

IMPACT OF CULTURE ON PSYCHODYNAMICS

CULTURAL VARIABLES RELATED TO PSYCHODYNAMICS

1. Dependency versus autonomy

2. Linguistic competence

3. Cognitive style

4. Social support system

5. Material culture

6. Psychological sophistication

DEPENDENCY VERSUS AUTONOMY

DEPENDENCE PRONE

SOCIETY AUTONOMY PRONE

SOCIETY

Interdependence Clearly demarcated ego-

boundaries

Strong sense of identity with the primary group

Control over one’s body, action, thoughts and

emotions

Lesser idea of individuality, of individual rights and

responsibility Greater self reliance

Pity, sacrifice, submission and gratitude as character traits

An acute sense of one’s rights , duties and

responsibilities

“Shame prone society” “Guilt prone society’’

INDIAN SOCIETY

• Indian tradition attaches little importance to the

development of a unique, distinctive personality and to

individual self realization (Hoch,1990)

• Most patient approach the doctor with the expectation of

getting advice and guidance

• This is similar to getting guidance from their parents and

family elders

• Indian patients expect a caring, concerned and nurturing

attitude (Roland, 1995)

LINGUISTIC COMPETENCE

LANGUAGE:

•Language is itself the shaper of ideas, the programmer

and guide for the individual mental activity (Whorf 1961)

•Language is a determinant of the conception of reality, a

model shaping the mind as well as a code connecting

minds (Brown 1965)

•Language and thought develop together (Brown and Lennenberg 1954)

LINGUISTIC COMPETENCE

• Linguistic “competence" is the speaker - hearer's

intrinsic knowledge of his language

• Linguistic “performance" is the actual use of language in

a given situation

• Linguistic competence is an innate attribute of mind

(Chomsky,1965)

LINGUISTIC COMPETENCE AND SCHIZOPHRENIA

1. Mental illness and languages are inter-related

2. Linguistic competence determines the phenomenology

of schizophrenia

3. Language seems to be an essential prerequisite for:

1. Manifestations of schizophrenic symptomatology

2. Outcome of schizophrenia across cultures (World Health Organization, 1973; 1979) (Varma

(1982)

LINGUISTIC COMPETENCE AND SCHIZOPHRENIA(contd.)

• In Positive Symptom schizophrenia linguistic competence

has: Positive correlation with severity of illness Negative correlation with outcome

• Greater linguistic competence leads to increased

elaboration of positive symptoms

• The positive symptoms cause further anxiety and

excitement thereby producing more complex and

intractable delusions

• This leads to severe form of illness and has influence on

prognosis[Giridhar C, Kulhara P, Varma V K (1992) Linguistic competence in positive and negative

subtypes of schizophrenia, Indian journal of psychiatry,34(4),311-320) ]

LINGUISTIC COMPETENCE AND SCHIZOPHRENIA(contd.)

In patients with negative symptoms of schizophrenia:

1. Positive correlation was observed between outcome

and linguistic competence

2. High linguistic competence was associated with:

Low degree of negative symptoms

Increased chances of recovery

1. Low linguistic competence produces high degree of

negative symptoms which are not easily amenable to

therapeutic change

COGNITIVE STYLES

• Cognitive styles represent the ways in which the mind:

Perceives the environment

Interprets it

Draws conclusions about it

• Individuals and cultures differ from each other in

cognitive styles

• The cognitive style can be characterized as "analytical"

at one extreme and "synthetic " at the other

ANALYTICAL STYLE SYNTHETIC STYLE

Understand a thing or a phenomenon by breaking it

into parts

Tries to see things or phenomena in the totality

The Western mind is classically analytical

The Indian mind is synthetic in its cognitive style

Prevail in autonomous oriented society

More conducive to the development of a unitary,

holistic concept

Consistent with the dependence and loose ego-

boundaries in the relationship of individual with

society

SOCIAL SUPPORT SYSTEMM

• Differences across cultures in the social support system

has impact on course and outcome of mental illness

• The traditional and developing societies which are richer

in social support network have shown to have a better

prognosis of severe mental illnesses (WHO 1973, 1979)

• A very fruitful area of research in this area is expressed

emotions

• Expressed emotions like critical comments and hostility

have been correlated with adverse prognosis

MATERIAL CULTURE

• Culture consists of:

Beliefs, values, norms and myths

Physical environment which is comprised of artifacts like

roads, bridges, buildings, etc.

• The nature of material culture has influence on

psychopathology

• The same malevolent force is perceived as a:

Spirit of a ghost in a developing society

X-rays and radio waves in a technologically advanced

society

(Varma V K. Cultural psychodynamics in health and illness. Indian J Psychiatry 1986; 28:177-186)

PSYCHOLOGICAL SOPHISTICATION

• Psychological sophistication is the ability to see conflicts

in intrapsychic terms

• Conflict is perceived as within the mind or between the

components of the psychic structure

• Psychological sophistication may be related to coping

mechanisms and certain types of neuroses like hysteria

• It may also give rise to high introspection as a mental

attribute to understand and resolve conflicts

IMPACT OF CULTURE ON MAJOR PSYCHIATRIC DISORDERS

1. Schizophrenia

2. Bipolar affective disorder

3. Depressive disorder

4. Anxiety disorder

5. Somatoform and dissociative disorders

IMPACT OF CULTURE ON SCHIZOPHRENIA

• Landmark research projects by the Mental Health Division

of WHO:

1. International Pilot Study of Schizophrenia (IPSS)

2. Study of the Determinants of Outcome of Severe

Mental Disorders (DOSMED)

• These studies confirmed that:

1. The syndrome originally described by Emil Kraepelin

and Eugen Bleuler exists in very diverse ethnic and

cultural groups

2. Pathoplastic effects of socio-cultural factors shape

the symptom profiles differently in developed and

developing countries

IMPACT OF CULTURE ON SCHIZOPHRENIA

Western developed countries showed a higher frequency

of:

1. Depressive symptoms

2. Primary delusions

3. Thought insertion

4. Thought broadcasting

Non-Western developing countries showed a higher

frequency of:

1. Visual hallucination

2. Auditory hallucinations [SARTORIUS et al. 1986; JABLENSKY et al 1992]

IMPACT OF CULTURE ON SCHIZOPHRENIA

• According to IPSS Study:

1. India had highest percentage with best outcome

(66%)

2. Nigeria had the lowest percentage with worst

outcome (10%)

3. The major limitation of the study was that the

sample was not an epidemiological sample

• Schizophrenic psychoses have a better prognosis in

Asian and African than in comparable British patient

populations [JABLENSKY et al 1992, OGAWA et al. 1987; LEE et al. l991; TSOI & WONG l991]

IMPACT OF CULTURE ON SCHIZOPHRENIA

• Two thirds of schizophrenia patients in India have partial ‑

to full remission of symptoms

• Demonstrated by:

1. The Madras longitudinal study

2. The study of factors associated with course and

outcome of schizophrenia (SOFACOS)

• The DOSMED study used an epidemiological sample

from 12 centers in 10 countries

CONCLUSIONS OF DOSMED STUDY

1. The content of psychotic symptoms tends to identify

critical problems existing in a particular culture

2. Persecutory delusions and auditory hallucinations are

not necessarily indicative of schizophrenia in persons of

African cultural background

3. Influence of ethnicity and culture on psychopathology

weighs more than geographic proximity, historical

relations and racial similarity

4. Ethnic and cultural differences are reflected in the

schizophrenic symptom profiles even if the populations

adhere to the same religion

[KATZ et al. 1988] [NDETEI & VADHER1984; NDETEI 1988]

5. Studies in Japan, Hong Kong and Singapore

demonstrated a more favourable course and outcome

than in Europe and North America

6. These findings from are of special interest as:

They are derived from countries of advanced

technological development

But from cultures that are still quite different from

those of modern Western societies

What are the specific aspects of

modern Western societies that may

exert effects conducive to a chronic

course and poor final outcome of

mental disorders??

Factors Leading To Chronic Course And Poor Outcome

1. The crucial difference leading to different outcome is not

the difference between societies of high or low

technological development but between modern

Western societies and non-Western societies that were

able to preserve important elements of their traditional

culture

2. Extreme nuclearization of the family leading to lack of

support for mentally ill members

3. Covert rejection and social isolation of the mentally ill in

spite of public assertions to the contrary

4.Immediate sick role typing

5.General expectation of a chronic mental illness if a person

shows an acute psychotic reaction

6.Assumption that a person is insane if beliefs or behaviour

appear somewhat strange or "irrational“

7.Unclear and uncertain role expectation of the youth in

Western societies

CULTURE AND ACUTE TRANSIENT PSYCHOSIS

• Acute transient psychotic reactions are known to be

more common than schizophrenia in developing

countries

• French term bouffée délirante introduced by Magnan in

1886

• Bouffée délirante is reminiscent of the transient

psychotic reactions occuring in the early phases of

industrialization and mass-urbanization in 19th century

Europe

[MOREL 1860; MEYNERT 1889]

CULTURE AND ACUTE TRANSIENT PSYCHOSIS

• Transient psychotic reactions are of particular interest to

comparative cultural psychiatry because:

They are interwoven with culturally validated beliefs in

sorcery and witchcraft

These beliefs persist even after the traditional

resources of protection or assumed persecution by

magical or supernatural powers are no longer valid as

a consequence of Westernization and urbanization

CULTURAL ASPECTS OF ACUTE TRANSIENT PSYCHOSIS

• Number of individuals experiencing the pressures of

rapid social change is steadily increasing

• Many feel unprotected against magical forces in which

they still firmly believe

• The individual reacts with an acute psychotic episode to

react to emotional trauma and to severe social stress

• The human environment responds with sympathy,

support, and traditional therapeutic resources and not

with rejection and isolation [SIZARET et al. 1987]

• This applies as long as the extended primary social

support is still operational in a traditional non-Western

society

• Transient psychotic reactions will evolve into chronic

psychoses once the process of Westernizing acculturation

becomes completely irreversible

[SIZARET et al. 1987]

AFFECTIVE DISORDERS- DEPRESSION

• Culture greatly influences the way in which depressive

symptoms are expressed

• In the WHO collaborative study assessed depressive

disorder in 583 patients at five centers (Basel, Montreal,

Tehran, Nagasaki, and Tokyo)

• Most of them had common features of sadness,

anhedonia, lack of interest and energy, impaired

concentration, and ideas of worthlessness

• Feelings of guilt and suicidal ideations were least

common in Tehran

INDIAN SCENARIO – DEPRESSION

• Indian studies have found guilt to be less common

among Indian patients than those in the West

• Indian patients reported guilt of an impersonal nature

• The present suffering is attributed to possible bad deeds

of previous life (consequence of “Karma”) rather than

due to self failure as in the West‑

• Physical symptoms are common presenting symptoms

in depression

BIPOLAR AFFECTIVE DISORDERINDIA VS WESTERN COUNTRIES

• Indian bipolar patients have preponderance of mania in

contrast to patients in Western countries

• Higher prevalence of grandiose delusions, delusions of

persecution and reference and those related to sexual

and religious themes than in the West

• Hostile irritability is the predominant affect in Indian

manic subjects

• There are reports of seasonal occurrence of mania in

summer season which is not reported in the west

• Recurrent unipolar mania is commoner in India and

tropical countries

OUTCOME OF AFFECTIVE DISORDERS

• The outcome of affective disorders has been found to be

favorable in India than in developed countries

• In a 4 year follow up of first episode manic patients from ‑ ‑ ‑

Ranchi:

40% of the patients did not have any recurrences

25% had one recurrence

CONCLUSIONS FROM INTERNATIONAL STUDIES

1. Current psychiatric classification schemes adopted

regarding the transcultural variations of BPAD seem to

be inadequate

2. There is no evidence that individuals belonging to

certain ethnic groups present a greater risk of acquiring

BPAD

3. Ethnocultural aspects seem to influence the clinical

presentation, diagnosis and treatment of BPAD

ANXIETY DISORDERS

Results of a study assessing the prevalence rates of

anxiety disorders in U.S population:

1.Asian Americans had symptoms of all four major anxiety

disorders less frequently than other racial groups

2.White Americans reported symptoms of social anxiety

disorder, generalized anxiety disorder and panic disorder

more frequently than other racial groups

3.African Americans more frequently met criteria for post-

traumatic stress disorder (PTSD) as compared to other

racial groups

CULTURAL IMPACT

• These results reflect the sociopolitical history of ethnic

groups in the United States:

1. African American community has shared a

longstanding battle with racism with significant

change in this experience over several centuries

2. Hispanic and Asian Americans have immigrated

relatively recently but have faced their own

individual challenges with integrating into

mainstream society

TRANSCULTURAL ASPECTS OF DISSOCIATIVE AND SOMATOFORM DISORDERS

• Concept of somatization may have arisen from the

Cartesian dualism prevalent in Western societies

• Cartesian Dichotomy may have led to the cleavage of

mental health care from "medical care"

• Transformation of personal or social distress into

somatic complaints is a norm in most cultures

• Patients tend to develop symptoms that are "medically

correct “

• Somatic symptoms tend to be less stigmatizing than

psychological symptoms

(Fabrega, 1991) (Kleinman, 1987)

• Worldwide most common medically unexplained

symptoms are1. Gastrointestinal complaints2. Abnormal skin sensations

(World Health Organization, 1992)

• Most common medically unexplained somatic symptoms

in the United States were gynecological complaints,

followed by gastrointestinal and cardiovascular

symptoms (Epidemiologic Catchment Area study ,Escobar et al.,

1987)

• Nigeria and India common somatic symptoms are:

Feeling of heat Peppery and crawling sensations Numbness Burning hands and feet Hot, peppery sensations in head

• These symptoms are extremely rare in Western

countries

• Indian study observed that most patients with

dissociation presented with a "brief dissociative stupor"

that coexisted with anxiety and panic symptoms

• Multiple Personality Disorder (MPD) is an iatrogenic

disorder largely confined to North America

• MPD is rare or nonexistent in other western and non

western countries

CONCLUSIONS

• Somatoform and dissociative syndromes are:

Heterogeneous

Core of the stress reactive syndromes

Present in all cultures as the most typical sequelae of

trauma

More frequently reported from non-western,

developing societies

Generally framed as exotic culture-bound syndromes

CULTURE AND PERSONALITY

• Culturally determined personality attributes influence

coping mechanisms and mental illness

• When faced with emotional conflict a passive-dependent

person may:

More likely to easily "give up”

More prone to break with reality

Develop psychotic coping behaviour

More likely to turn to society for care

Develop hysterical and somatoform disorders so as

to involve other members of the society in its

resolution

CULTURE AND PERSONALITY

• When faced with emotional conflict an autonomous

individual: May resist his loss of control May reject his dependency needs May try to resolve his conflicts himself at the intrapsychic

level May keep on battling with the anxiety May convert anxiety into development of neurotic-type

distress

• Personality configuration either individually or culturally

influence the choice made

• The subsequent elaboration and proliferation of the

symptomatology depends upon the various socio-

cultural factors

CULTURAL ASPECTS OF INSIGHT

• The traditional uni-dimensional view of insight has been replaced with recent multi-dimensional perspectives

• Three dimensions of insight are:– Awareness of mental illness– Ability to re-label psychotic experience as abnormal– Seeking medical treatment

Multi-dimensional perspectives of insight is criticized for:(i) Employing western concepts of disease(ii) All mental illnesses are considered medical

diseases(iii) Failure to recognize as “Medical Disease” is

considered absence of insight(iv) Alternative local and culture explanations for mental

illness are not considered[The assessment of insight across cultures, K. S. Jacob. Indian Journal of Psychiatry

52(4), Oct-Dec 2010]

PROPOSED CHANGES TO DIMENSIONS OF INSIGHT

Current dimensions of insight

Proposed dimensions of insight

Awareness of mental illness Awareness of non-visible change in body or mind and its relation to their illness

Re-label experience Re-label experience

Seek medical treatment Need for restitutionSeeks any forms of available treatment

NEED OF CULTURAL STANDARD TO ASSESS INSIGHT

If a person acknowledges some kind of non-visible change in his or her body or mind that affects the ability to function socially

and If he or she feels the need for restitution/ restoration

then Irrespective of the attribution and the pathways of care

that the person seeks We could call this as presence of “insight”• The awareness of changes in body or mind has to have

a non-delusional explanation• Diagnosing the non-delusional nature of the explanation

requires an understanding of the local culture• Need to use local and cultural standards rather than

universal yardsticks to assess insight in people with psychosis

CULTURAL CONSIDERATION IN CLINICAL PRACTICE

CULTURAL FORMULATION

• DSM-5 includes an updated version of the cultural

formulation outline

• Presents an approach to assessment using the Cultural

Formulation Interview (CFI)

• Systematic assessment of the following categories:

– Cultural identity of the individual

– Cultural conceptualizations of distress

– Psychosocial stressors and cultural features of

vulnerability and resilience

– Cultural features of the relationship between the

individual and the clinician

– Overall cultural assessment

CULTURAL IDENTITY OF THE INDIVIDUAL

• Describe the individual's racial, ethnic, or cultural

reference groups

• Language abilities, preferences and patterns of use,

identify difficulties with access to care, social integration

and the need for an interpreter

• Religious affiliation, socioeconomic background, personal

and family places of birth and growing up, migrant status,

and sexual orientation

Cultural conceptualizations of distress

• Describe the cultural constructs that influence how the

individual experiences, understands, and communicates

his or her symptoms or problems to others

• These constructs may include cultural syndromes,

idioms of distress and explanatory models or perceived

causes

• Assessment of coping and help-seeking patterns should

consider the use of professional as well as traditional,

alternative or complementary sources of care

Psychosocial stressors and cultural features of vulnerability and resilience

• Identify key stressors and supports in the individual's

social environment

• Identify the role of religion, family, and other social

networks in providing emotional, instrumental, and

informational support

• Levels of functioning, disability and resilience should be

assessed in light of the individual's cultural reference

groups

Cultural features of the relationship between the individual and the clinician

• Identify differences in culture, language and social status

between an individual and clinician that may cause:

1. Difficulties in communication

2. May influence diagnosis and treatment

• Effects may include:

– Problems eliciting symptoms

– Misunderstanding of the cultural and clinical

significance of symptoms and behaviors

– Difficulty establishing or maintaining the rapport

Overall cultural assessment

• Summarize the implications of the components of the

cultural formulation identified in earlier sections of the

Outline

• This will help in diagnosis and appropriate management

Cultural Formulation Interview (CFI)

1. The CFI is a set of 16 questions

2. CFI is used to assess impact of culture on key aspects

of an individual's clinical presentation and care

3. CFI is a brief semi structured interview for

systematically assessing cultural factors in the clinical

encounter

FOUR DOMAINS OF (CFI)

1. Cultural Definition of the Problem (questions 1-3)

2. Cultural Perceptions of Cause, Context, and Support

(questions 4-10)

3. Cultural factors affecting Self-Coping and Past Help

Seeking (questions 11-13)

4. Cultural Factors Affecting Current Help Seeking

(questions 14-16)

Future Directions and Research in Transcultural Psychiatry

FUTURE PERSPECTIVES

1. Identification of specific fields in general psychiatry that

could be the subject of focused research from a cultural

perspective

2. A number of cultural variables should be considered in

conducting cultural psychiatry research like:

Language

Religion

Traditions

Beliefs

Ethics

Gender orientation

Concepts And Instruments For Research In Cultural Psychiatry

• Exploration of key concepts and/or instruments in

culturally relevant clinical research

• There are four key concepts:

1. Idioms of distress

2. Social desirability

3. Ethnographic data

4. Explanatory models

1. Idioms of distress:•Specific ways in which different cultures or societies report:

1. Ailments

2. Behavioral responses to threatening or pathogenic factors

3. Unique style of description, nomenclature, and assessment of stress

2. Social desirability:– Similarities or differences among cultures in actual

experiencing of stressful events– Members show different levels of vulnerability or

resignation, resilience or acceptance

3. Ethnographic data:

1. Should be included together with clinical data and

laboratory analyses or tests

2. Narratives of life that enrich the descriptive aspects

of the condition

4. Explanatory models:

1. Each culture explains pathology of any kind in its

own distinctive way

2. This lead to the culturally accepted clinical

diagnosis

CRITICAL ISSUES IN RESEARCH IN CULTURAL PSYCHIATRY

CONCEPTUAL ISSUES IN CULTURAL PSYCHIATRY

• One of the primary issues is the conceptual differentiation

between culture and environment

• Environment represents a broad and polymorphic concept

and considered opposite of genetics

• Culture and cultural factors in health and disease though

part of environment are unique

• Culture plays a role in both normality and psychopathology

• The role of culture in psychiatric diagnosis is an excellent

example of this conceptual issue

• Culture has an impact on treatment approaches based on

both conventional medical and psychiatric knowledge and

on the explanatory models

Evidence based approach vs Value based approach

• A conceptual debate:

Evidence-based approach to research and practice

versus

Value-based view to clinical presentations which are

influenced by cultural factors

• The value-based approach considers moral issues such

as poverty, unemployment, internal and external

migration, and natural and man-made disasters

• Evidence may be found to support both positions in

scientific research

OPERATIONAL ISSUES IN CULTURAL PSYCHIATRY

• The dichotomy of normality and abnormality in human

behavior is a crucial operational issue

• Relativism is a strong conceptual pillar in cultural

psychiatry

• Normality is a relative idea as it varies in different

cultural contexts

• Research needs to take into account representativeness

of the study populations and generalizability of the

findings

• Research data needs to be collected in a culturally

specific constructs

OPERATIONAL ISSUES

• Many tests and questionnaires used in clinical settings

and research have been developed on English-speaking

Western subjects

• They may not be appropriate for use among ethnic

minority patients or non–English-speaking individuals

due to lack of cultural equivalence

• Translating items is insufficient to achieve linguistic

equivalence

• Norms also may differ between ethnic groups and tests

need to be standardized with representative patients

Topical Issues in Cultural Psychiatry

• Five dimensions are relevant to research in cultural

psychiatry

• These includes consideration of culture as an:

1. Interpretive or explanatory tool of human behavior

2. Pathogenic or Pathoplastic agent

3. Diagnostic and nosological instrument

4. Therapeutic or protective factor

5. Service or management element

• Culture impacts each of these areas

• They are relevant at different stages of the clinical

encounter between patient and clinician

FIVE DIMENSIONS

1. Culture as an Interpretive or Explanatory Tool:

Explanatory models are the ways in which individuals in

different cultures see the core reasons of their suffering

2. Culture as a Pathogenic or Pathoplastic Agent:

Culture may be a pathogenic agent in the construction

of a clinical picture

It may contribute to the production of symptoms

3. Culture as a Diagnostic or Nosological Tool:

The DSM-5 cultural formulation is developed to be used

as clinical instrument and valuable tool for research

4. Culture as a Therapeutic or Protective Factor:

1. Culture can be considered as a healing force

2. A great variety of cultural psychotherapies have

emerged

3. The use of religion and spirituality as clinical

instruments is of great importance

5. Culture as a Service or Management Element:

– The use of providers who belong to the same ethnic

group as the patient is a matter of continuous

debate

– The setting in which the clinical encounter occurs

deserves more research

SUMMARY 1. Definition and components of culture

2. History and evolution of Transcultural Psychiatry

3. Impact of culture on psychopathology: (Patho-genic/selective/plastic/elaborative/facilitative/

reactive effects)

1. Cultural variables related to Psychodynamics:(Dependency versus autonomy, Linguistic competence, Cognitive style, Social support system, Material culture, Psychological sophistication)

1. Impact of culture on major Psychiatric disorders: (IPSS, DOSMED, Madras longitudinal study, SOFACOS)

1. Cultural aspects of Insight

2. Cultural Formulation and CFI(Cultural identity, Cultural conceptualizations of distress, Psychosocial stressors and cultural features of vulnerability and resilience, Cultural features of the relationship between individual and the clinician, Overall cultural assessment)

1. Future directions and research in transcultural psychiatry (Idioms of distress, social desirability, ethnographic data ,explanatory

models) (conceptual issues, operational issues, topical issues)

REFERENCES

1. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th

Edition. Sadock, Benjamin J.; Sadock, Virginia A.; Ruiz, Pedro

2. Cross-Cultural Aspects of Anxiety Disorders. Stefan G. Hofmann1 and

Devon E. Hinton. Curr Psychiatry Rep. 2014 June ; 16(6): 450.

doi:10.1007/s11920-014-0450-3.

3. Cultural Aspects of Major Mental Disorders: A Critical Review from an

Indian Perspective. Biju Viswanath, Santosh K. Chaturvedi. Indian

Journal of Psychological Medicine | Oct - Dec 2012 | Vol 34 | Issue 4

4. Indian culture and psychiatry. Shiv Gautam, Nikhil Jain. Indian J

Psychiatry 52, Supplement, January 2010 S309

5. Transcultural aspects of bipolar disorder. Marsal Sanchesa,b and

Miguel Roberto Jorgea. Rev Bras Psiquiatr 2004;26(Supl III):54-6

INDIAN CULTURE

Dr. Radhakrishnan:

“India has seen empires come and go, has watched economic and political systems flourish and fade. It has seen these happen more than once. Recent events have ruffled but not diverted the march of India’s History. The culture of India has changed a great deal and yet has remained the same over three millennia. Fresh springs bubble up, fresh streams cut their own channels through the landscape, but sooner or later each rivulet, each stream merges into one of the great rivers which has been nourishing the Indian soil for centuries.”