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Culture Bound Syndromes

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David Shirley

on 14 June 2013

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Transcript of Culture Bound Syndromes

Culture-Bound Syndromes
North American Culture-Bound Syndromes
Latin American Culture-Bound Syndromes
Central American Culture Bound Syndromes
African Culture-Bound Syndromes
Middle Eastern Culture-Bound Syndromes
Eurasian Culture Bound Syndromes
Asian Culture-Bound Syndromes
Australian Culture Bound Syndromes
Cultural Formulation Interview

Cultural Formulation Interview

Cultural Formulation Interview
(CFI) is a set of
fourteen questions
that clinicians may use to obtain information during a
mental health assessment about the impact of a patient’s culture on key aspects of care
. In the CFI, culture refers primarily to the values, orientations, and assumptions that individuals derive from membership in diverse social groups (e.g., ethnic groups, the military, faith communities), which may conform or differ from medical explanations. The term culture also refers to aspects of a person’s background that may affect his or her perspective, such as ethnicity, race, language, or religion.
CFI focuses on
patient's perspectives
on the problem, the
role of others
in influencing the course of the problem, the impact of the
patient’s cultural background
, the
patient’s help-seeking
experiences, and
current expectations about treatment and other forms of care
. The CFI follows a
person-centered approach
to cultural assessment by asking the patient to address these topics based on his or her own views, rather than inquiring about the views of the person’s cultural group(s) of origin. This is intended to
avoid stereotyping
, as
individuals vary substantially in how they combine and interpret cultural information and perspectives
. Since the CFI concerns the patient’s views, there are no right or wrong answers to these questions.
CFI can be used
at the beginning of
an initial assessment
interview with all
adult patients
all clinical settings
regardless of the patient’s background or that of the clinician
Patients and clinicians who appear to share the same cultural background may in fact differ on a number of perspectives relevant to care.
Alternatively, individual questions may be used at any point in the interview, as necessary.
During later stages
in care, the CFI may be particularly helpful
there is difficulty in making a diagnostic judgment, owing to a significant difference in cultural, religious, or socioeconomic background of clinician and patient;
there is uncertainty about the match between culturally expressed symptoms and diagnostic criteria;
it is difficult to make a dimensional judgment of severity;
patients and clinicians disagree on the course of treatment; or
cases of limited engagement and adherence.
The CFI emphasizes four main domains:
Cultural Definition of the Problem:
the presenting issues that led to the current illness episode, cast within the patient’s worldview. In this section, the
patient describes the problem
focuses on its most troubling aspects
. This information starts to address
what is most at stake for the patient
with respect to the current presentation, including non-medical aspects.
Cultural Perceptions of Cause, Context, and Support:
patient’s explanations
for the circumstances of illness, including the cause of the problem. The
patient also clarifies factors
that improve or worsen the problem, with particular attention to the role of family, friends, and cultural background. The clinician seeks to obtain a holistic picture of the patient in his or her social environment with
emphasis on how cultural elements affect the presentation.
Cultural Factors Affecting Self Coping & Past Help Seeking:
strategies employed by the patient
to improve the situation, including those that have been most and least helpful. The
patient also identifies past barriers
to care. This information helps
the patient’s perspective on the nature of the problem, his or her
mental health treatment expectations
as opposed to other forms of help, and current resources to address the situation.
Current Help Seeking:
patient’s perception
of the
relationship with the clinician
, current
potential treatment barriers
, and
preferences for care
. In this section, the patient specifies how the clinician may facilitate current treatment and what may interfere with the clinical relationship. Treatment preferences are elicited that may be incorporated into the treatment plan.
This interview process and the information it elicits are expected to enhance the cultural validity of the diagnostic assessment, facilitate treatment planning, and promote patient engagement and satisfaction.
Hwa-byeong ("fire illness"): Korea
Amok (wild behavior): Malaysia, Indonesia, Philippines, Brunei, Singapore, New Guinea, Laos, Thailand, Polynesia, Navajo Nation
Taijin Kyofusho (interpersonal relations phobia): Japan
Koro (penis shrinkage): Malaysia, Indonesia, China, India, Thailand
Latah (possessed): Malaysia, Japan (Ainu), Thailand, Philippines, Siberia
Qigong Psychotic Reaction: China
Shenjing Shuairuo (nervous breakdown): China
Dhat (insufficient semen): India
Zar (possession): North Africa/Middle East
Bouffee Delirante (brief psychosis): West Africa, Haiti
Brain Fag (brain fatigue): West Africa
Falling-out (blacking out): Southern U.S., Caribbean
Ghost Sickness (from evil forces): American Indian tribes
Pibloktoq ("arctic hysterias"): Inuit
Rootwork/Spells (hexes): Southern U.S.
Ataque de Nervios (attack of nerves): Puerto Rico, Caribbean, Mediterranean
Bilis/Colera (anger and rage)
Locura (chronic psychosis)
Mal de Ojo ("Evil eye" curse)
Nervios (mental stress and nervousness)
Susto ("Soul loss"): Philippines, Papua New Guinea
Sangue Dormido ("Sleeping blood"): Portuguese Cape Verde Islanders
History of Culture-Bound Syndromes
Peculiar, Atypical, or Exotic Psychiatric Disorders: 1890 - 1970
•Twelve cases of non-European distinct mental or behavioral disorders became part of the western classification system, which considered Anglo-Saxon populations “normal” and labeled everything else "peculiar", "atypical", or "exotic"
Culture-Bound Syndromes: 1970 – 1980
•“Culture-bound syndromes” was coined and subgroups formed because fitting these disorders into the existing DSM classification system would classify them as NOS and creating new categories would make them variations of presently recognized disorders. In both instances their cultural meaning would be sacrificed
Evolution: amok originally was the war cry of Malay pirates as an honorable display of their right to plunder. Later, the British colonial government tried these pirates in court which made incidence of amok decline. Amok is now viewed as more of a psychosis or labeled as schizophrenia
Taijin kyofusho:
Found in cultures with emphasis on social etiquette
Evolution: decreased with decrease in family suicide (death is seen as a coping mechanism for difficulties, but leaves care burden on children left behind hence the family suicide); borderline personality disorder is more commonly diagnosed now
In the Japanese Diagnostic System for Mental Disorders
Evolution: epidemics occur only during times of social tension or impending disaster; no episodes reported since 1985; better quality of life may have something to do with this
In Chinese Classification of Mental Disorders
Evolution: was mostly in young women, now only found in older women who have known of the phenomenon since they were young; rarely seen anymore
Brain Fag:
Evolution: restricted to students with responsibility of maintaining family’s prestige with their educational attainment; later experienced by other populations with symptoms closer to anxiety and depression
Culture-Related Specific Syndromes: 1980 – Present
A team of psychiatrists and medical anthropologists (the Culture and Diagnosis Group) gathered information for the DSM-III-R but this was largely ignored and included in the DSM-IV only as a brief appendix in the back because the DSM focuses mainly on categories rather than cross-cultural validation
Currently, managed care culture has forced mental health treatment to time-limited drug-focused outpatient services that are not always applicable to indigenous categories of illness
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.

Faulkner, S.S., Faulkner, C.A, &Hesterberg, L. (2007). Utilizing the cultural formulation model of the DSM-IV-TR with Asian Americans: A Chinese American case application. Psychiatry, Psychology and Mental Health, 1(2), 1-13.

Fields, A.J. (2010). Multicultural research and practice: Theoretical issues and maximizing cultural exchange. Professional Psychology: Research and Practice, 41(3), 196-201. dio: 10.1037/a0017938

Flaskerud, J.H. (2009). What do we need to know about the culture-bound syndromes? Issues in Mental Health Nursing, 30, 406-407. doi: 10.1080/01612840902812947

Hollander, A., Bruce, D., Burstrm, B., & Ekblad, S. (2011). Gender-related mental health differences between refugees and non-refugee immigrants – a cross-sectional register-based study. BMC Public Health, 11. Retrieved from http://www.biomedcentral.com/1471-2458/11/180

Lee, S. (2002). Socio-cultural and global health perspectives for the development of future psychiatric diagnostic systems. Psychopathology, 35, 152-157.

Lewis-Fernandez, R., & Diaz, N. (2002). The cultural formulation: A method for assessing cultural factors affecting the clinical encounter. Psychiatric Quarterly, 73(4), 271-295.

Marsella, A.J. (2010). Ethnocultural aspects of PTSD: An overview of concepts, issues, and treatments. Traumatology, 16(4), 17-26. doi 10.1177/1534765610388062

Miranda, A.O., & Fraser, L.D. (2002). Culture-bound syndromes: Initial perspectives from individual psychology. The Journal of Individual Psychology, 58(4), 422-433.

Paniagua, F.A. (2000). Culture-Bound Syndromes, Cultural Variations, and Psychopathology. In I. Cuellar, & F. A. Paniagua (Eds.), Handbook of Multicultural Mental Health (pp. 142-170). San Diego, CA: Academic Press.

Smart, D.W., & Smart, J.F. (1997). DSM-IV and cultural sensitivity diagnosis: Some observations for counselors. Journal of Counseling and Development, 75, 392-398.

Trimble, J.E. (2010). Bear spends time in our dreams now: Magical thinking and cultural empathy in multicultural counseling theory and practice. Counseling Psychology Quarterly, 23(3), 241-253 doi: 10.1080/09515070.2010.505735

Tseng, W. (2006). From peculiar psychiatric disorders through culture-bound syndromes to culture-related specific syndromes. Transcultural Psychiatry, 43(4), 554-576. doi: 10.1177/1363461506070781
The Five Components of Cultural Formulation
Cultural Identity...
Cultural Explanations...
Cultural Factors...
Cultural Elements...
Overall Culture...
Considers subgroup characteristics:
-sexual orientation

How the individual fits against a specific cultural background.
Predominant idioms of distress through which symptoms
or the need for social support are communicated.

"kill two birds with one stone"

"going postal"
"freaking/flipping out"
"having a cow"
Meaning and perceived severity of the individual's symptoms in relation to norms of the cultural reference groups.
Current preferences for and past experiences with professional and popular sources of care.
Ways in which members of sociocultural groups convey, express, experience, and cope with feelings of distress or affliction.

"Ataques de Nervios": an idiom of distress describing an episode of uncontrollable shouting, crying, trembling, and aggression typically triggered by a stressful event involving family and followed by amnesia.

"Nervios": a state of vulnerability to stress, marked by headaches, irritability, stomach problems, inability to concentrate, and dizziness.
Over-pathologizing what could be normal or Normalizing what is pathological in the client's culture.
Relates to treatment engagement...

treatments that are counter to the primary etiological understanding are likely to be ineffective.

Clients help seeking pathways are best served through methods that match their explanatory models.

"Culture Matters" (7:38-14:01)
1-Interpretation of of social stressors
2-available social supports
3-levels of functioning and disability
4-stresses in local social environment
5-role of religion and kin networks that provide emotional support
1-Individual differences in culture and social status between individual and clinician.
2-Problems that these differences may cause in diagnosis and treatment.
*difficulty in communicating
*difficulty in eliciting symptoms and understanding cultural significance
*negotiating an appropriate relationship or level of intimacy
*determining whether a behavior is normal or pathological
A concluding discussion of how cultural considerations specifically influence comprehensive diagnosis and care.
of the individual.
1. Note the individual's ethnic or cultural reference groups.
2. Note immigrants and ethnic minorities degree of involvement with host culture and culture of origin.
3. Note language abilities, use, and preference
of the individual's illness.
1. Symptoms and social support can be communicated through idioms of distress.
2. Meaning and perceived severity of symptoms in relation to cultural norms of the cultural reference group.
3. Any local illness category used by individual's family and community to identify the condition.
4. The perceived causes or explanatory models that the individual and the reference group use to explain the illness.
5. Current preferences for and past experiences with professional and popular sources of care.
related to psychosocial environment and levels of functioning.
of the relationship between the individual and the clinician.
assessment for diagnosis and care.
-current diagnostic standards rely on an exaggerated interpretation of neurophysiological findings and understate the scientific importance of social-psychological variables.

-cultural and ethnic diversity of individuals is often discounted by researchers and service providers.

-current diagnostic guidelines have been criticized as having a fundamentally Euro-American outlook.

-even when a diagnostic criteria set is accepted across different cultures, it does not necessarily indicate that the underlying constructs have any validity within those cultures; even reliable application can only demonstrate consistency, not legitimacy.

-Western bias is ironically illustrated in the introduction of cultural factors to the DSM-IV: the fact that disorders or concepts from non-Western or non-mainstream cultures are described as "culture-bound", whereas standard psychiatric diagnoses are given no cultural qualification whatsoever, is revelatory of an underlying assumption that Western cultural phenomena are universal.

-large number of documented non-Western mental disorders are still left out, and those included are often misinterpreted or misrepresented.

-addition of cultural formulations was an attempt to placate cultural critics, and that they lack any scientific motivation or support.

-culture-bound diagnoses are rarely used in practice, maintaining that the standard diagnoses apply regardless of the culture involved.

-the mainstream psychiatric opinion: if a diagnostic category is valid, cross-cultural factors are either irrelevant or are only significant to specific symptom presentations.
What is Culture?
Values & Beliefs
Social Life
Sex Life
Gender Roles
Artistic Expression
Mental Illness Expression
Educational Goals/Attainment
Emotional Expression
Full transcript