Transcultural PsychiatryDr. Naresh K. ButtanM.B.B.S., D.P.H.,D.P.M., D.N.B. (Psy), C.C.S.T., Sec 12 (2) Approved
Consultant Psychiatrist, PCH-CIC
Hon’ Fellow-PCMD, AT & Psychiatry Locality Lead- PMS
TPD (CT)- Health Education England South West (HEE-SW)
E-mail: [email protected], [email protected]
Training Requirement, RCPsych (CT)
Intended learning outcome 1 Be able to perform specialist assessment of patients and document relevant history
and examination on culturally diverse patients to include:Presenting or main complaintHistory of present illnessPast medical and psychiatric historySystemic reviewFamily historySocio-cultural historyDevelopmental history
Training Requirement, RCPsych (CT)…Intended learning outcome 2Demonstrate the ability to construct formulations of patients’
problems that include appropriate differential diagnoses
Intended learning outcome 3Demonstrate the ability to recommend relevant investigation and
treatment in the context of the clinical management plan. This will include the ability to develop & document an investigation plan… & then to construct a comprehensive treatment plan addressing biological, psychological and socio-cultural domains
Intended learning outcome 8Use effective communication with patients, relatives and
colleagues. This includes the ability to conduct interviews in a manner that facilitates information gathering and the formation of therapeutic alliances
18 learning outcomes- importance of communication & cultural awareness !!!
What is Culture ?
“Man is an animal suspended in webs of significance that he himself has spun, and the threads of web are but the strands of culture”
- Max WebberCulture: Sets of standards for behavior that govern people’s way of life- shared customs &
beliefs.Race: Individuals grouped according to shared
genetic characteristics- shared genotypeEthnicity: Races or large groups of people classed
according to common traits- shared phenotype.
Culture & Values
World- a Global Village
Acculturation
Acculturation…..
Transcultural Psychiatry• Psychiatry- a product of modern
Western medicine ?• Emil Kraepelin’s Java visit in 1896.• ‘Civilization & its Discontents’- Freud
(1930).• US-UK Project- 60’s• IPSS of WHO in 1973.• ‘Culture Bound Syndromes’-Yap, Hong
Kong.
Transcultural Psychiatry….• Discipline that deals with description, definition,
assessment & management of all psychiatric conditions as they reflect and are subjected to influence of cultural factors in a biopsychosocial context while using concepts and instruments from social & biological sciences to advance a full understanding of psychopathology and its treatment.
• In order to better evaluate effect that culture has on a patient and their illness-not enough to have factual knowledge about a patient’s culture without having it in context of how people view themselves in it & its role in their lives.
Culture in Diagnostic Systems-ICD-10
Dev. by WHO in consultation with nosologic experts & collaborating centers across world.
• Used in rest of the world, culture is mentioned least !!!
• Culture Specific Disorders in “Diagnostic Criteria for Research”.
• Multiaxial Presentation of ICD-10:
1. Axis I: Clinical Diagnoses
2. Axis II: Disablement
3. Axis III: Contextual Factors
Culture in Diagnostic Systems- DSM IVAxis IV: Psychosocial & Environmental Problems
Cultural Formulation Guidelines: 5 Elements of DSM-IV in appendix 9-1. Cultural Identity of individual.2. Cultural Explanations of individual’s illness.3. Cultural factors related to psychosocial
environment & level of functioning.4. Cultural elements of clinician- patient
relationship.5. Overall cultural assessment for diagnosis &
care.
Cultural Formulation
• Cultural Identity.• Preferred language.• Acculturation.• Culturally determined psychosocial factors.• Social stressors.• Community support.• Availability & accessibility of appropriate
services.
Cultural Formulation (contd..)• Culturally determined illness beliefs &
behaviours.• Insight by illness model.• Expression of symptoms.• Family/ community’s viewpoint.• Cultural meaning of illness/ treatment.• Doctor-patient relationship:
1) Symptom elicitation & significance.
2) Therapeutic alliance.
3) Discussions of treatment options.
Culture Bound Syndromes• Littlewood & Lipsedge (1987)a) Young males/ females-’powerless’ &
socially neglected.b) Dramatic with indiv. unaware /not
responsible.c) ‘Mystical sanction’- symbolic cultural
significance.d) Triphasic pattern- dislocation→
exaggerated symptoms →restitution.
Culture Bound Syndromes- Subtypes• Startle reaction- Latah.• Genital reaction- Koro.• Sudden assault- Amok.• Running- Pibloktoq.• Semen loss- Dhat.• Spirit possession- Spell.• Obsession with dead- Ghost sickness.• Exhaustion- CFS, ME.• Suppressed rage- Bilis.
Culture and Schizophrenia/ Psychoses
W.H.O.- IPSS’73, DOSMeD’78, ISOS’90:
• Prevalence: 1-2/1000, stable over decades, some pockets of high (Ireland) & low (PNG)→ speculation of western exposure.
• Incidence: DOSMeD- 1.5- 4.2/ 10,000 (both genders) of population at risk (15-44 yrs of age). Narrowly defined- 0.7-1.4/10,000.
Culture and Schizophrenia/ Psychoses…Phenomenology:
1. Symptom Frequencies- IPSS similar symptoms (hallucinations, delusions, social withdrawal & flat affect) common to all cultures, DOSMeD-similar findings except VH more in east & affective Sx more in west.
2. Delusions & Hallucinations: Content dependent on culture, tolerance, expression and emotional control & reaction as well.
3. FRSS: Lower rates in developing countries, ?affected by subcultural beliefs.
4. Subtypes: Catatonia more common in developing world, paranoid and hebephrenia more common in west- ?high lingual competency (Varma et al 1992)
Culture and Schizophrenia & Psychoses...
Course & Outcome:
IPSS & DOSMeD gave better outcome in developing world.
Later studies mixed results. Global Rule of 3rds. Sociocultural factors- EE & Family support. Industrialization- by altering familial & social
structures & by altering environmental factors. Higher rates among migrants.
Culture & Affective disorders• US- UK study (1972)- pioneer study.• WHO study (Sartorius et al,1980): Symptoms
of depression- variations.• DIS study (1985): Lifetime prevalence- 1.5%
(Taiwan)- 11.6% (NZ).• Somatic presentation commoner in primary
care• Bipolar: prevalence 0.5-1.5% - no ethnic
differences. Mood incongruent psychotic symptoms may mislead to diagnosis of schizophrenia in Afro-Caribbean groups (Strakowski et al, 1993, 1996).
• Depression vs. somatization.
Mental Illness & Ethnic Minorities-UK• UK’s Population: 58 m (Census, 2001), BMEs
(7.9%)• Non-white groups –younger, 45% live in
London, Plymouth (4%), bigger households, majority unemployed, self-reported health-poor.
• ‘Count Me In’ Census, 2007- 22% inpatients in MH & 12% LD from BMEs, 1% ↑se /yr., 6-10% -ESL, more referred from legal systems, more detentions, seclusions in BMEs, no difference in rates of physical assault, equal/ lesser incidence of self harms.
Mental Illness & Ethnic Minorities-UK…• Schizophrenia:
Higher rates in Afro-Caribbean people born in UK. Highest rates in UK born 2nd generation subjects. No evidence for greater genetic loading.
• Suicide:
High rates in young Indian women, low in men. Low in Caribbean men & women. Immigrants higher rates of suicide by burning (with 9
X excess among Indian women)-marital/ IPR problems.
So, Where are we now ???
• MHNSF (1999): Services not meeting needs of BMEs and lack of confidence in their use.
• Race Relations (Amendment) Act, 2000.
• Inside Out (2003)- Improving MHS for BME
• Delivering Race Equality (2007), DoH: guidelines for more appropriate & responsive services, community engagement & better information.
So, Where are we now ???...• RCPsych: Position Statement (2007)on
Refugees & Asylum seekers, Equality & Diversity in the college, Special Interest Group, Ethnic issues project group.
• National BME Mental Health Network • World Association of Cultural Psychiatry (
www.wacp2012.org ) Conf. London, March 2012
Exercise: Identify Cultural Barriers in Interviewing Situations with Person from different cultural background
Cultural Communication Barriers
Overcoming Cultural Barriers in Communication
Non- Verbal Technique (SOLER)
Empathy• Different from sympathy• Core message• Feelings- “you feel” to be followed by correct family of
emotions & correct intensity• Experiences & behaviors- “because” to be followed by
Es & Bs• Tips to improve quality of empathy:
Do Don’t1. Take time to think 1. No response
2. Use Short Phrases 2. Ask a question (ignores motions)
3. Gear response to patient 3. Don’t just mimic
4. Validate feelings 4. Use a cliché’
5. Use personal references 5. Move into action immediately
Further reading
• http://www.rcpsych.ac.uk/college/specialinterestgroups/transculturalpsychiatry.aspx
• http://www.kingsfund.org.uk/library : Mental Health: Black and minority ethnic communities
• www.nimhe.org.uk -Inside Outside – Improving Mental Health Services for Black and Minority Ethnic Communities in England
• Delivering Race Equality in Mental Health Care- DH, Jan 2005
• ‘Count Me In’- Commission for Healthcare Audit and Inspection, 2007.
• Positive steps – Supporting race equality in mental healthcare: Dept. of Health Feb, 2007
