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: N.Buttan@nhs.net, Naresh.Buttan@pcmd.ac.uk
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 &
beliefs.
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
Individualism
Familism
Independence
Interdependence
Emphasis on Science &
Technology
Emphasis on Nature &
Acausal Principles
Endeavor towards Material
Progress
Present & Future Orientation
Endeavor towards Spiritual
Progress
Past, Present & Future
Orientation
Emphasis on Respecting
Past
Emphasis on Newness
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 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
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
patterndislocation→
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 (1544 yrs of age). Narrowly defined- 0.71.4/10,000.
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 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
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
History Taking
Mental State Examination
Explanations
Cultural Communication Barriers
Verbal:
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
class/education
4. Body Language
5. Facial Expressions
Overcoming Cultural Barriers in Communication
Acceptance
& respect
Training
&
Docume
ntation
Patient
&
carers
Interpr
eters
Empowe
rment/
discrimi
nation
Non- Verbal Technique (SOLER)
Sit
Open
Lean
• Facing patient squarely
• Posture indicating involvement
• Friendly posture
• Non- threatening
• Towards patient- “being with patient”
• Encourages communication
• Regular but not constant (staring!)
Eye
Contact • Beware of Cultural meaning
Relax
• Beware of your own body language
• Beware of Cultural meaning of nonverbal gestures
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’t
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
• 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