Psychosomatic symptoms in
Asian populations: more than
a headache?
Presentation by
Dr. Gen Numaguchi, Ph.D.
WCMHT – Queenstown
Southern DHB
Who are New Zealand’s Asian
People?
 Asian people are the New Zealanders who
identify with or feel they belong to one or
more Asian ethnicities. The largest ethnicity
among Asian people is Chinese, followed by
Indian, Korean, Filipino, Japanese, Sri
Lankan, Cambodian, and Thai.
Demographics of Asians in NZ
 4.5 million people live in NZ; up from
4,241,448 in 2013 census.
 European descent = 70%
 Maori = 14.1%
 Asians = 11% (471,708)
 Pacific Islanders = 6.9%
 “Other” = 1.6%
Demographics of Asians in NZ
(continued)
 Assuming a medium level projection, a
further 250,000 Asians migrants are
expected between 2006 and 2026.
Definition
 From the perspective of evolutionary
psychiatry, depression is related to the
response to the loss of significant
interpersonal relationships, social status, or
incentives, while anxiety is related to the
anticipation of threats to safety or integrity of
body or self. (Kirmayer)
Mental Health Service Use –
General Population
 Individuals with mental illness were more
likely to experience unmet health care
needs and less likely to receive quality
medical care compared to the general
population.
 As well, people in most parts of the world do
not view emotional problems as appropriate
issues for health care per se.
Fact Regarding Asian Culture
 Asian American females have the highest
suicide rate among women 65 years of age
or older.
Study in Biological Differences
Tufts University psychologist Nalini Ambady,
Ph.D., conducted a study on how culture
shapes biology. Ambady’s group based the
study on historical data showing that EastAsian cultures value submissiveness, while
Western cultures value dominance. In fact,
they found, they could see this cultural
distinction in the way the brain responds to
visual input.
Biological Differences - 1
When an American thinks about whether he
is honest, his brain activity looks very
different than when he thinks about whether
another person is honest, even a close
relative. That’s not true for Chinese people.
When a Chinese man evaluates whether he
is honest, his brain activity looks almost
identical to when he is thinking about
whether his mother is honest.
Biological Differences - 2
When Americans viewed dominant
silhouettes, but not submissive ones, reward
circuitry fired in the brain’s limbic system.
The opposite happened among Japanese
participants; their reward circuitry fired in
response to submissive, but not dominant,
silhouettes.
Biological Differences - 3
Native Chinese, as opposed to Americans,
are more sensitive to the context in which an
object is embedded, and so focus greater
attention on that object when it’s in an
inconsistent context.
Biological Differences - 4
Westerners process human faces more
actively than East Asians, consistent with
the Western focus on individuality.
Biological Differences - 5
Behavioral work by University of Michigan
psychologist Shinobu Kitayama, Ph.D., and his
colleagues showed that people from Japan are far
better at judging the length of a line relative to the
size of a box in which it’s drawn, while Americans
are far better at judging the absolute length of the
same line. They attribute this difference to
findings from other studies showing that
Americans pay more attention to details and
Asians pay more attention to context.
Biological Differences - 6
Northwestern University’s Joan Chiao,
Ph.D., for example, has found that people
who live in collectivist cultures are more
likely than those in individualistic cultures to
have a form of the serotonin transporter
gene – the S-allele – that correlates with
higher rates of negative affect, anxiety, and
depression.
Biological Differences - 7
In contrast to what you might expect from
the genes alone, she also found that people
from collectivist societies are less likely to
be depressed. This suggests that
collectivism, which tends to produce lower
levels of negative affect, may have coevolved with the S-allele.
Biological Differences - 8
Societies of people with the S-allele
developed a collectivist culture that reduced
stress and, therefore, risk of depression by
emphasizing social harmony and social
support.
Roles of Culture
 Culture has effects on the neural systems,
psychological representations, and
interactional patterns that constitute affect
throughout the life-span.
 Cultural ideologies, institutions, and
practices provide the context and rules for
interactional processes that underlie
complex emotions.
Roles of Culture (con’t)
 Cultural variations in the composition of the
family, maternal-infant interactions, and
child-rearing practices all prime and shape
affect systems.
 Emotion ‘display rules’ and body practices
regulate socially acceptable and deviant
patterns of emotional expression.
Roles of Culture (con’t)
 Culture provides categories and a lexicon
for emotional experience, making some
feelings salient and others more difficult to
articulate.
 Culture sets limits of tolerance for specific
emotions and strong affect; it also provides
lay theories and strategies for managing
dysphoria.
Roles of Culture (con’t)
 Culture influences the sources of distress, the
form of illness experience, symptomatology, the
interpretation of symptoms, modes of coping with
distress, help-seeking, and the social response to
distress and disability.
 Each of these ways in which culture may influence
the regulation of emotion has potential implications
for the expression of dysphoric affect in clinical
settings.
Cultural Differences - 1
People from collectivist cultures, such as
China, think of themselves as deeply
connected to other people in their lives,
while Americans adhere to a strong sense of
individuality.
Cultural Differences - 2
 Asian Americans and Pacific Islanders
(APIs) generally place less emphasis than
Western cultures place on individualism but
more on a collective corporate identify, such
as family reputation.
 In API cultures, the family often is
considered to be more important than the
individual.
Perceptions of Mental Illness
 Stigmatization of people with mental illness
has persisted throughout history and is
especially pronounced in Asian
communities.
 Family members often try to conceal any
history of mental illness within the family to
avoid any negative impact on the family and
potential of the young person to become
married to a suitable mate.
Perceptions of MI (con’t)
 In seeking help for mental health needs,
APIs rely first on themselves to deal with
any distress, and only secondarily consider
seeking help from friends or family
members.
 When these efforts do not work, community
figures such as elders or spiritual healers
are sometimes consulted.
Perceptions of MI (con’t)
 They rarely go to mental health
professionals for help until they exhaust all
other possible resources, often waiting until
their conditions become severe and painful.
 Studies have found that primary care is the
major setting where APIs seek services for
psychological distress and disorders.
Perceptions of MI (con’t)
 Many cultures view nonconfrontation and
social harmony as paramount and
consequently value the suppression or
containment of both interpersonal and
internal conflict.
 As a result, individuals in these cultures are
less likely to open up to health care
providers and to provide details of their
emotional state and social problems.
Perceptions of MI (con’t)
 Instead, emotional difficulties, including
depression and anxiety, are often
understood as sociomoral problems more
appropriate to bring to a family member,
elder, spiritual or community leader, or
someone else who is familiar with the
complex web of social ties, past and
present, that define a relational self.
Expressions of Mental Illness
 APIs tend to seek professional help through
primary care providers and present their
emotional distress through somatic signs
and symptoms instead of mental/emotional
problems.
 Significantly, they tend to focus only on
somatic suffering when seeking mental
health care. Somatization among APIs has
been well documented.
Expressions of MI (con’t)
 Hsu and Folstein (1997) found that cardiopulmonary and vestibular symptoms are the
predominant physical complaints among
Chinese American people.
 Miller and her colleagues (2003) also found
that cardiovascular disease is the most
common physical condition among
individual with chronic mental disorders.
Expressions of MI (con’t)
 The six leading principal physical diagnoses
among APIs with secondary psychiatric
diagnoses were (1) nonspecific chest pain,
(2) poison with other medicine or drugs, (3)
coronary atherosclerosis and other heart
disease, (4) acute myocardial infarction, (5)
acute cardiovascular disease, and (6)
poison by psychotropic agents.
Expressions of MI (con’t)
 The impression that Asians, Africans, and
others are more prone to somatize than
North Americans has been based largely on
anecdotal observation or on research that
compares people in very different health
care systems (Kirmayer).
Expressions of MI (con’t)
 The most common somatic symptoms of
depression and anxiety are musculoskeletal
pain and fatigue (Kirmayer).
Japanese Specific Concepts
 The culturally distinctive form of social
phobia termed Taijin kyofusho (TKS) in
Japan provides an instructive example of
cultural influences on anxiety.
Taijin kyofusho (TKS)


It is associated with concerns about
upsetting others rather than simply with
one’s own embarrassment.
Awkward social behavior, especially an
inappropriately placed or timed gaze, is
viewed as harming others.
Taijin kyofusho (TKS) (con’t)
 A wide range of types and severity of social
anxiety, including apparently delusional
forms, are grouped together by many
Japanese psychiatrists as forms of TKS that
may be responsive to similar cognitive
interventions.
 Taijinkyofusho predominantly afflicts young
males.
Taijin kyofusho (TKS) (con’t)
 While “pure” taijinkyofusho sufferers
attribute their condition to some kind of
personal or character weakness involving
their inability to cope with interpersonal
situations and eventually seek some form of
psychiatric help, “serious” taijinkyofusho
sufferers lack such insights, perceive their
problems as real, and attempt to deal with
them accordingly.
Taijin kyofusho (TKS) (con’t)
 There is a consensus among Japanese
psychiatrists that taijinkyofusho is a culturebound disorder.
 Western psychiatrists tend to diagnose
Japanese cases of taijinkyofusho as
paranoia and paranoid schizophrenia.
Taijin kyofusho (TKS) (con’t)
 Miyoshi (1970) has suggested that the
disorder is generated by the conflict
between the individual’s strong feelings of
self-conceit, which convince him that he is
essentially different from others, and the
value of Japanese society places on
conformity, which stresses that people are
essentially the same.
Taijin kyofusho (TKS) (con’t)
 Iwai (1982) views the major complaint underlying
taijinkyofusho disorders as less an actual “fear of
strangers” than a state of anxiety aroused by
doubts concerning one’s acceptability to others,
and suggests that a more appropriate term for the
disorder might be “jikitaimenkyofusho” or fear of
self-presentation. According to Iwai, the object of
fear is not the social situation or other people as
much as it is oneself in the context of presenting
that self to others and how that self will be
received by those others.
Japanese Specific Concepts (con’t)
 The greater social acceptability of anxiety
compared with depression may also account for
the low levels of clinical diagnosis and treatment of
depression in Japan until recently.
 The majority of patients with symptoms of
depression in Japan are still treated by internists
primarily with benzodiazepines, although with the
recent introduction of selective serotonin reuptake
inhibitors, antidepressant use is increasing.
Japanese Specific Concepts (con’t)
 Victim-consciousness is embedded in the
Japanese language itself, as is seen in the
so-called suffering passive inflection of
Japanese verbs where something just
happens and one is made to suffer as a
consequence.
Japanese Specific Concepts (con’t)
 Munakata (1986) has argued that Japanese
attitudes toward mental illness also have an
impact on the diagnosis of neurasthenia, which
until recently was diagnosed by Japanese
psychiatrists and doctors to disguise socially
stigmatized mental illnesses such as
schizophrenia in order to spare their patients and
families the psychological shock and ostracism
that would accompany the diagnosis of more
severe mental illnesses.
Japanese Specific Concepts (con’t)
 Shinkeishitsu (constitutional neurasthenia) is
a widely used diagnostic term in Japan
applying to a condition which would be
diagnosed as an anxiety disorder in the
West.
 Somatic rather than dysphoric complaints
are characteristic of both Japanese
depression and shinkeishitsu.
Shinkeishitsu
 Generally, when used popularly,
shinkeishitsu describes a person who is
overly sensitive to certain features of his or
her immediate environment, “nervous,”
“worrisome,” “easily agitated,” and
“anxious.”
Shinkeishitsu (con’t)
 Sufferers are believed to be “nervous” by
temperament, individuals being predisposed
at birth to the disorder (the term
shinkeishitsu itself means ‘of nervous
temperament.”).
 Generally, the disorder is seen as not
particularly serious and as physical rather
than mental in nature.
Shinkeishitsu (con’t)
 In some cases, the diagnosis of
shinkeishitsu is used to disguise depression,
legitimizing the sufferers’ distress by giving it
a physical basis, and thereby circumventing
stigmatization.
DSM-IV-TR:
Outline for Cultural Formulation





Cultural identity of the individual.
Cultural explanations of the individual’s
illness.
Cultural factors related to psychosocial
environment and levels of functioning.
Cultural elements of the relationship
between the individual and the clinician.
Overall cultural assessment for diagnosis
and care.
Practical Guidelines


1) The basis of any general ability to work
with people from diverse cultural
backgrounds begins with the clinician’s
knowledge of their own ethnocultural
identity and the implicit biases this brings.
2) A second step involves careful
consideration of the cultural bases and
biases of contemporary psychiatric
practice.
Practical Guidelines (con’t)
 3) A third skill concerns working with interpreters
and culture-brokers able to provide the missing
social and cultural context.
 4) Finally, the clinician must consider his or her
own position in the health care system, as well as
that of the clinical or institutional setting, vis-à-vis
the specific ethnocultural community to consider
problems of power, racism, and accessibility that
may impede forming a therapeutic alliance and
negotiating effective care.
Working with Asian Clients
 Explain and reframe the role of the therapist
and the client in the beginning of therapy.
 Therapists emphasize their role is an ‘expert
in therapy’ and the client is the ‘expert in his
or her life.’
 Don’t discount physical complaints.
 Avoid asking too many personal questions
during initial sessions.
References
 American Psychiatric Association (2000).
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition – Text Revision (TR).
Washington, DC: American Psychiatric
Association, 897-903.
 Azar, B. (2010). Your brain on culture. American
Psychological Association Monitor, 41 (10).
Available:
http://www.apa.org/monitor/2010/neuroscience.as
px
References (continued)
 Chen, H. J. (2005). Mental illness and
principal physical diagnoses among Asian
American and Pacific Islander users of
emergency services. Issues in Mental
Health Nursing, 26, 1061-1079.
 Demographics of New Zealand.Available:
http://en.wikipedia.org/wiki/Demographics of
New_Zealand
References (continued)
 Kirmayer, L. J. (2001). Cultural variations in the
clinical presentation of depression and anxiety:
Implications for diagnosis and treatment. Journal
of Clinical Psychiatry, 62 (13), 22-30.
 Oshima, A., Higuchi, T., Fujiwara, Y., Iida, M.,
Iwanami, A., Kanba, S., Motohashi, N., Uchitomi,
Y., Yamada, K., & Yamawaki, S. (1999).
Questionnaire survey on the prescribing practice
of Japanese psychiatrists for mood disorders.
Psychiatry and Clinical Neurosciences, 53
(Suppl.), S67-S72.
References (continued)
 Population and Sustainable Development.
Available:
http://www.population.govt.nz/informationby-subject/population-groups/asianpeople.aspx
 Russell, J. G. (1989). Anxiety disorders in
Japan: A review of the Japanese literature
on shinkeishitsu and taijinkyofusho. Culture,
Medicine and Psychiatry, 13, 391-403.
References (continued)
 Southern District Health Board Website.
Available: http://www.southerndhb.govt.nz/
 Statistics New Zealand. Available:
http://www.stats.govt.nz/infoshare/
 Tracey, M. D. (2006). Cultural worlds
intersect. American Psychological
Association Monitor, 37 (2). Available:
http://www.apa.org/monitor/feb06/intersect.a
spx