Clinical Key Question Flashcards
do different socities define mental health disorders differently
Mental disorders are defined with the use of lists of symptoms in, for example, the Diagnostic and Statistical Manual of Mental Disorders (now on its fifth edition) as well as the ICD-10. Definitions of mental health disorders can reflect cultural norms; for example, in the DSM-5 there is now a ‘hoarding disorder’, defined as difficulty in parting with possessions even if they have little or no value. This seems to be a particularly Western disorder perhaps.
Understanding how different cultures define mental health can help to see which aspects of mental health might be innate and which might be culturally acquired, and this can also help when considering treatments
Historically, many cultures have viewed mental illness as a form of religious punishment or demonic possession. In ancient Egyptian, Indian, Greek, and Roman writings, mental illness was categorized as a religious or personal problem. In the 5th century B.C., Hippocrates was a pioneer in treating mentally ill people with techniques not rooted in religion or superstition; instead, he focused on changing a mentally ill patient’s environment or occupation, or administering certain substances as medications. During the Middle Ages, the mentally ill were believed to be possessed or in need of religion. Negative attitudes towards mental illness persisted into the 18th century in the United States, leading to stigmatization of mental illness, and unhygienic (and often degrading) confinement of mentally ill individuals.
Attitudes toward mental illness vary among individuals, families, ethnicities, cultures, and countries. Cultural and religious teachings often influence beliefs about the origins and nature of mental illness, and shape attitudes towards the mentally ill. In addition to influencing whether mentally ill individuals experience social stigma, beliefs about mental illness can affect patients’ readiness and willingness to seek and adhere to treatment. Therefore, understanding individual and cultural beliefs about mental illness is essential for the implementation of effective approaches to mental health.
A review of ethnocultural beliefs and mental illness stigma by Abdullah et al. (2011) highlights the wide range of cultural beliefs surrounding mental health. For instance, while some American Indian tribes do not stigmatise mental illness, others stigmatize only some mental illnesses, and other tribes stigmatize all mental illnesses. In Asia, where many cultures value conformity to norms, emotional self-control, and family recognition through achievement, mental illnesses are often stigmatized and seen as a source of shame.
However, the stigmatization of mental illness can be influenced by other factors, such as the perceived cause of the illness. In a 2003 study, Chinese Americans and European Americans were presented with a scenario in which an individual was diagnosed with schizophrenia or a major depressive disorder. Participants were then told that experts had concluded that the individual’s illness was “genetic”, “partly genetic”, or “not genetic” in origin, and participants were asked to rate how they would feel if one of their children dated, married, or reproduced with the individual. Genetic attribution of mental illness significantly reduced unwillingness to marry and reproduce among Chinese Americans, but it increased unwillingness among European Americans, supporting previous findings of cultural variations in patterns of mental illness stigmatisation.
One way in which culture affects mental illness is through how patients describe (or present) their symptoms to their clinicians. There are some well recognized differences in symptom presentation across cultures. Cultures also vary with respect to the meaning they impart to illness, their way of making sense of the subjective experience of illness and distress.
Cultural meanings of illness have real consequences in terms of whether people are motivated to seek treatment, how they cope with their symptoms, how supportive their families and communities are, where they seek help (mental health specialist, primary care provider, clergy, and/or traditional healer), the pathways they take to get services, and how well they fare in treatment.
The consequences can be grave - extreme distress, disability, and possibly, suicide - when people with severe mental illness do not receive appropriate treatment.
Each culture influences the way people understand mental health and their regard for it. An understanding of and sensitivity to factors valued by different cultures will increase the relevance and success of potential interventions. A Xhosa mother in apartheid era South Africa whose explanation for not comforting her crying son was to ensure he grew up strong enough to leave the country and join the armed struggle exemplifies this. Young soldiers in Angola experienced disruption to their developmental experiences and education (Lavikainen, Lahtinen & Lehtinen 2000; Mendes 2003). Their reports of feeling different and having difficulty relating to others enabled tailored approaches to helping them adjust to peacetime society.
Mental illness is a taboo subject that attracts stigma in much of Africa. Gordon (2013) conducted a study in Uganda revealed that the term ‘depression’ is not culturally acceptable amongst the population, while another study conducted in Nigeria found that people responded with fear, avoidance and anger to those who were observed to have a mental illness.
The stigma linked to mental illness can be attributed to lack of education, fear, religious reasoning and general prejudice. When surveyed by Arboleda-Florez, J. (2002) on their thoughts on the causes of mental illness, over a third of Nigerian respondents (34.3 per cent) cited drug misuse as the main cause. Divine wrath and the will of God were seen as the second most prevalent reason (18.8 per cent), followed by witchcraft/spiritual possession (11.7 per cent). Very few cited genetics, family relationships or socio-economic status as possible triggers.
describe cultural context
Jahoda (1958) elaborated on the 1947 WHO declaration that “health is not merely the absen-
ce of illness but a complete state of physical, psychological and social well-being” by sepa- rating mental health into three domains. First, mental health involves self-realization in that individuals are allowed to fully exploit their potential. Second, mental health includes a sense of mastery by the individual over their environment, and, finally, that positive mental health also means autonomy, as in individuals having the ability to identify, confront, and solve problems. Others, like HB Murphy (1978), argued that these ideas were laden with cultural values considered important by North Americans. The definition of mental health is clearly influenced by the culture that defines it. Mental health has different meanings depending on setting, culture, socioeconomic and political influences.
describe culture bound syndromes
Aspects of culture may also underlie culture-bound syndromes - sets of symptoms much more common in some societies than in others. More often, culture bears on whether people even seek help in the first place, what types of help they seek, what types of coping styles and social supports they have, and how much stigma they attach to mental illness. Culture also influences the meanings that people impart to their illness.
A culture bound syndrome (CBS) refers to a pattern of symptoms that:
- do not easily fit into the categories and classifications of supposedly universal disorders identified by the ICD-10 and DSM-1V diagnostic manuals
- occur almost exclusively in specific geographical locations or cultural populations
- are regarded to be illnesses or afflictions and thus have local names
The above points raise the possibility that diagnostic manuals and systems may be culturally biased by the society that created them. Thus the ICD-10 and DSM-IV may only categorise disorders that are familiar, local and of concern to those living in Western cultures. They are therefore interpreted differently in certain cultures and it is this reason as to why culture-bound syndromes have occurred.
describe dhat culture bound syndromes
Dhat is found in men from the Indian subcontinent, its main symptoms are severe anxiety and an obsessive concern over the discharge of semen which is accompanied by weakness and fatigue.
CHADDA (1995) supported Dhat in which 50 patients reporting Dhat were found to meet the criteria for emotional disorder (unspecific) on the DSM-111-R (the fore runner of DSM-IV). The fact that the patients appeared to be suffering sufficiently severe symptoms to warrant a psychiatric diagnosis yet did not meet the criteria for any existing DSM categories suggests that Dhat is a disorder in its own right.
On the other hand it may be that Dhat is merely a more standard condition accompanied by the cultural belief that symptoms are associated with a loss of semen. Many cultures, including those in India and neighbouring countries, share the belief in an association between semen, blood and energy. So Dhat may simply be a product of cultural association that when men discharge semen through ejaculation or urine they expect to be weakened.
MUMFORD (1996) found that Pakistani men suffering Dhat had key depressive symptoms including depressed mood and fatigue. He suggested that we think of Dhat as depression expressed in a culturally specific manner rather than as a distinct mental disorder.
describe koro culture bound syndromes
Koro is most commonly found in South Chinese men of Han origin although there are cases throughout South-East Asia and other areas but only a minority. Sufferers of Koro are plagued by the belief that their sex organs are shrinking and will disappear inside their abdomen, leading to death. The term “genital retraction syndrome” is thus also used to describe this syndrome.
CHOWDHURY (1996) looked at a range of circumstances in which Koro has been reported and concluded that men who feel their penis has shrunk due to cold, wet or following ejaculation are likely to interpret this as genital retraction if Koro is part of their cultural belief system. Cultural beliefs about Koro thus prime people to panic if they feel the very normal sensation of their penis is shrinking as its blood supply is reduced.
BARTHOLOMEW (1998) has attacked the diagnosis of Koro as a metal disorder on the basis that, given the cultural beliefs of sufferers, their response to the sensation of a shrinking penis is quite rational. He maintains that there is little evidence to suggest that Koro is associated with any other symptoms and therefore we should think of it as a social phenomenon, not a problem of individual psychology. He suggests that Koro is only classified as a disorder because its symptoms appear so bizarre from the perspective of European and American culture.
how do we overcome cultural bias when defining mental health in society
In order to get greater reliability and validity, less emphasis must be placed on symptoms that show cultural differences and more emphasis on symptoms and features that seem to be universal. For example, something bizarre in one culture might not be bizarre in another culture (ie, hearing voices), so “bizarreness” might be a symptom that has less emphasis placed on it when making a diagnosis using the DSM. The review of the DSM-IV to create the DSM-IV-TR looked at removing “bizarre” from the list of symptoms, but it was so central that it was not felt this could be done. Instead, a warning of the need to the mindful of the cultural differences the judgement “bizarre” can entail was added.
One of the problems with diagnosing schizophrenia is the importance of fist rank symptoms e.g., hearing voices, delusions and other features of distortion. These symptoms are also more open to interpretation which means there could be cultural issues. FLAUM ET AL (1991) found a lack of reliability when using the DSM with regard to first-rank symptoms and that was with a similar sample from one culture. Therefore it is likely that such unreliability would be increased if using first-rank symptoms across different cultures. Decreasing the importance of first rank symptoms and taking care with “bizarre” features would mean less unreliability with regard to diagnosis across cultures.
There should be greater emphasis on symptoms that are objectively measured, FLAUM suggests that negative symptoms e.g. poverty of speech etc. are more objectively assessed and measured than positive symptoms like hallucinations.
It is worth noting that how societies define, thus view and diagnose mental health is not a distinct difference between the western society culture and other culture. There are differences within cultures as well as between them.
describe the conclusion
So overall, there are diverse effects of culture and society on mental health, mental illness, and mental health services. Understanding is key to developing mental health services that are more responsive to the cultural and social contexts of racial and ethnic minorities.
With a seemingly endless range of subgroups and individual variations, culture is important because it bears upon what all people bring to the clinical setting (patients and practitioners). It can account for minor variations in how people communicate their symptoms and which ones they report.
Some aspects of culture may also underlie culture-bound syndromes - sets of symptoms much more common in some societies than in others. More often, culture bears on whether people even seek help in the first place, what types of help they seek, what types of coping styles and social supports they have, and how much stigma they attach to mental illness.
Culture also influences the meanings that people impart to their illness. Consumers of mental health services, whose cultures vary both between and within groups, naturally carry this diversity directly to the service setting.
