Transcultural Psychiatry
Dr. Naresh K. Buttan
M.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 complaint
History of present illness
Past medical and psychiatric history
Systemic review
Family history
Socio-cultural history
Developmental history
Training Requirement, RCPsych (CT)…
Intended learning outcome 2
Demonstrate the ability to construct formulations of patients’
problems that include appropriate differential diagnoses
Intended learning outcome 3
Demonstrate 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 8
Use 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 Webber
Culture: Sets of standards for behavior that
govern people’s way of life- shared customs &
Race: Individuals grouped according to shared
genetic characteristics- shared genotype
Ethnicity: Races or large groups of people classed
according to common traits- shared phenotype.
Culture & Values
Western Values
Non-Western Values
Emphasis on Science &
Emphasis on Nature &
Acausal Principles
Endeavor towards Material
Present & Future Orientation
Endeavor towards Spiritual
Past, Present & Future
Emphasis on Respecting
Emphasis on Newness
World- a Global Village
Transcultural Psychiatry
• Psychiatry- a product of modern
Western medicine ?
• Emil Kraepelin’s Java visit in 1896.
• ‘Civilization & its Discontents’- Freud
• US-UK Project- 60’s
• IPSS of WHO in 1973.
• ‘Culture Bound Syndromes’-Yap, Hong
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 IV
Axis IV: Psychosocial & Environmental Problems
Cultural Formulation Guidelines:
5 Elements of DSM-IV in appendix 91. 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
5. Overall cultural assessment for diagnosis &
Cultural Formulation
Cultural Identity.
Preferred language.
Culturally determined psychosocial factors.
Social stressors.
Community support.
Availability & accessibility of appropriate
Cultural Formulation (contd..)
Culturally determined illness beliefs
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
c) ‘Mystical sanction’- symbolic cultural
d) Triphasic
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
Incidence: DOSMeD- 1.5- 4.2/ 10,000
(both genders) of population at risk (1544 yrs of age). Narrowly defined- 0.71.4/10,000.
Culture and Schizophrenia/ Psychoses…
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
• 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
• Non-white groups –younger, 45% live in
London, Plymouth (4%), bigger households,
majority unemployed, self-reported healthpoor.
• ‘Count Me In’ Census, 2007- 22% inpatients
in MH & 12% LD from BMEs, 1% ↑se /yr., 610% -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
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
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
( ) Conf. London,
March 2012
Exercise: Identify Cultural Barriers in Interviewing Situations
with Person from different cultural background
History Taking
Mental State Examination
Cultural Communication Barriers
1. Language
2. Dialect
3. Colloquial use of language
4. Use of Interpreters
Non- Verbal:
1. Physical Characteristics
2. Appearances
3. Talking style-ascent indicating
4. Body Language
5. Facial Expressions
Overcoming Cultural Barriers in Communication
& respect
Non- Verbal Technique (SOLER)
• Facing patient squarely
• Posture indicating involvement
• Friendly posture
• Non- threatening
• Towards patient- “being with patient”
• Encourages communication
• Regular but not constant (staring!)
Contact • Beware of Cultural meaning
• Beware of your own body language
• Beware of Cultural meaning of nonverbal gestures
• 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:
1. 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
• : Mental Health:
Black and minority ethnic communities
• -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

Transcultural Psychiatry N Buttan 27th September 2013