The Role of Cultural Factors in Psychiatric Diagnoses

1. The Role of Cultural Factors in Psychiatric Diagnoses Marianne Kastrup Centre Transcultural Psychiatry Copenhagen New Directions in Psychiatry Sorrento May 2012

2. Culture and Diagnosis Faced with patients of your own cultural background, cultural aspects rarely interfere in assessment As a consequence, many tend to underestimate the importance of the cultural dimension Cultural differences may be seen as a hindrance for an understanding and hide the disease process

3. Culture and Diagnosis • Diagnostic considerations: • Do diagnoses and clinical guidelines give meaning in the cultural setting? • Are they compatible with the cultural values of the psychiatrist and those of the patient and the family?

4. Culture and Diagnosis • The similarities across culture are greater the further we move towards biological/organic disorders • The differences from culture to culture increase, the further we move towards personality disorders

5. Culture and Diagnosis Universality contra relativity: Some stress the universality of diagnostic systems independent of cultural context and the need to identify a set of diagnostic categories and guidelines applicable and acceptable around the world Others find cultural adaptations of diagnostic systems useful and necessary

6. Culture and Diagnosis Balance needed: between emphasizing the drawbacks of the prevailing systems and their limitations vis a vis input from other cultural groups and yielding to local and cultural pressure

7. Culture and Diagnosis • We need a common diagnostic system, not diverse cultural adaptations • Such adaptations may lead to local introduction of various disease categories that allow certain groups to be labeled with a psychiatric diagnosis • Ultimately, this may lead to abuse of psychiatry and the use of diagnosis as a mean of social control • Lopez-Ibor 2003

8. Culture and Diagnosis Challenges of intercultural diagnosis Importance of theoretical concepts (cultural relativism vs. universalism) Validity of diagnostic categories Existence of culture dependent syndromes Cultural variability of symptoms

9. Culture and Diagnosis Diagnosing mental disorders in migrants Important aspects Migration specific aspects Culture specific aspects

10. Culture and Diagnosis The diagnostic dimension of migration • Current living conditions • The heterogeneous groups of migrants • The personal history, pre-migratory personalitiy and conditions that caused migration • Consider migration as a long-term process • Consider important psychological variables, such as perceived control over decision to migrate, acculturation strategy and subjective experience of migration (Bhugra 2005)

11. Culture and Diagnosis Methodological considerations Epidemiological approach: Systematic data collection Structured interview /rating scales Statistical analysis High reliability Anthropological approach: Small sample Intensive in-depth interviews High validity Combination of methods welcome

12. International Classifications

13. Culture and Diagnosis • In the development of ICD-10 og DSM-IV attention has been paid to the global use of disease classifications • International and multicultural groups of psychiatrists have been involved in their development

14. Culture and Diagnosis • ICD-10: • International field trials • International expert group • Presumption that diagnoses are universal • Reflecting the universality of conditions • Culture bound aspects not in focus

15. Culture and Diagnosis • In DSM-IV described different information on cultural aspects: • A. Cultural variations in the clinical presentation • B. Description of culture-bound syndromes • C. Suggestion for a cultural formulation

16. Culture and Diagnosis • Ad A. Cultural variation: • Described in line with awareness of age, gender, etc. • Awareness of cultural variations in hallucinations; in using somatic descriptions of emotional problems; distinguish personality traits from acculturation problems

17. Culture and Diagnosis • Ad B. Culture-bound syndromes: • Generally limited to specific societies or culture area • Localized, folk, diagnostic categories that frame coherent meanings for certain patterned, and troubling sets of experiences • Often used to describe phenomena not encountered in Western European countries.

18. Culture and Diagnosis • DSM-IV Cultural formulation: • cultural identity of patient and relation to culture of country of origin and host country • cultural explanation of illness, dominating ways to express illness and local categories explaining the condition • cultural factors related to psychosocial environment and functioning and stressors the individual has been exposed to, and support by family

19. Culture and Diagnosis • DSM-IV Cultural formulation: • cultural elements of relationship between individual and clinician, including the presence of language difficulties • overall cultural assessment for diagnosis and care

20. Cultural FormulationPractical Use

21. Cultural Formulation I want to understand the world from your perspective I want to know what you know in the way you know Spradley 1997

22. Cultural Formulation The use of a Cultural Formulation is aimed to: explore cultural, religious, and social background focus on the significance the patient puts on own background and significant events explore patient’s perception of illness and expectations in relation to treatment in light of cultural context understand patient’s expression of illness optimise diagnostics by including cultural factors and their significance

23. Cultural Formulation The use of a Cultural Formulation is aimed to: improve evaluation of whether a behaviour/symptom is culturally or pathologically based strengthen the basis for therapist’s supportive conversations with patient  develop optimal treatment plan contribute to reflexions on importance of cultural factors for therapeutic relation create a therapeutic alliance based on of trust and recognition

24. Cultural Formulation Cultural identity of patient: How will you describe your childhood? Are there certain groups – religious, cultural, etc – that you feel close to? Do you see yourself as belonging to an ethnic group? Has our perception to belong to a certain group changed over time? Is it problematic to belong to different groups? Or not? Have you experienced misunderstandings/ discrimination due to your group belonging?

25. Cultural Formulation Cultural identity of patient: Which aspects of the life style of your country of origin do you practise? Or miss? Which traditions and rituals mean most to you? Do you use different languages and if so in which situations? Work? Home? Friends? How do you think others see you?

26. Cultural Formulation Cultural explanation of patient’s disease: How serious do you think that your problems are? What kind of help would you like to receive? Had you stayed in your homeland what kind of help had you seeked? What words would you use to describe your problems to your family? How does your family see your problems?

27. Cultural Formulation Cultural explanations of patient’s disease: What do they think may be the reason behind? Have you looked for alternative kínds of help? How would your problems be seen in your homeland? What do you see as the greatest stress factor for you right now? How do others react to that you have psychological problems?

28. Cultural Formulation Cultural factors related to level of functioning and psychosocial milieu: How do your problems influence your daily life? How do your problems affect your contact with friends/ relatives? How do your problems influence your ability to take care of your home? Or manage your work? Do you have any confident with whom yyou may talk about your problems?

29. Cultural Formulation Cultural factors related to level of functioning and psychosocial milieu: Is it possible to talk about your problems with your family? What kind of help is needed for you to carry out daily activities? How do you express nedd for help for your daily activities? Do you have a belief (e.g. religious) that helps you in your daily life?

30. Cultural Formulation Cultural factors related to the relation between patient and therapist: ”Sorry doctor. I do not understand. I went to the G.P. and told him about my bachache. He did not believe in there was a bachache and referred me to the psychiatrist. Now I am here and you start talking about my bachache”

31. Cultural Formulation Cultural factors related to the relation between patient and therapist: Did you succeed in explaining your problems? What were your reactions to the questions I asked? How was it not to be able to speak your mothertongue during the interview? How well do you think I understand your problems?

32. Cultural Formulation Cultural aspects of migration and acculturation: What made to you move to this …country? How has your life changed following migration? Do you visit your homeland? What new relations have you developed in …? What did you leave behind when migrating?

33. Cultural Formulation Reflections on overall cultural assessment of diagnostics and therapy: How has the communication with the patient been? How do you judge your ability to understand the patient’s problem? What kinds of reaction has the patient created in you? How do you judge you are able to understand the lifesituation of the patient? How have you dealt with your reactions and emotions?

34. Cultural Formulation Reflections on overall cultural assessment of diagnostics and therapy: How do you evaluate the level of emotional interaction with the patient? How do you evaluate your ability to assess what is psychopathology and what is normal? How reliable to you think that your diagnosis is? How do you evaluate your ability to suggest a treatment plan? Do you think you will be able to explain the diagnostic evaluation to the patient and family?

35. Summary

36. Culture and Diagnosis • Assessment and diagnosis: • Conceptual issues relating to assessment • distinction between illness and disease • range of the phenomology of psychopathology variations are reflected in use of language • the ”netting effect” in assessment, i.e. fishing with a net depends on size of mesh and where net is set • Tseng 2003

37. Culture and Diagnosis • Assessment and diagnosis: • Practical considerations in clinical assessment and diagnosis • overcoming language barrier • obtaining cultural background information • becoming culturally sensitive and empathetic • dealing carefully with certain diagnostic dilemmas • Tseng 2003

38. One World – One Language • Theme for the World Congress of Psychiatry • Madrid 1996

40. Cultural variations • Cultural variations: • Concepts regarding medical and health care • In stressors and responses to change • Patterns in deviance and dysfunction • In stressors associated with needs and values • In stressors related to sociopolitical factors • In coping patterns • Marsella Cultural aspects of depressive experience and disorders 2003

41. Culture and Diagnosis • Assessment and diagnosis: • Definition of normality • By professional definition - normality and deviation can be distinguished by nature of phenomenon • By deviation from the mean - uses deviation from mean to distinguish normal/abnormal • By assessment of function - consider effect of behaviour or feeling on function • By social definition - using social and cultural judgment to decide if behaviour is deviant • Tseng 2003

42. Culture and Diagnosis • Assessment and diagnosis: • Different classification systems used in different societies • Cross-cultural investigation of diagnosing - conditions may be categorized differently in different settings • Tseng 2003

43. ICD Marianne Kastrup Centre Transcultural Psychiatry Copenhagen

44. Personality Change after Catastrophic Experience (F62.0) • Persistent personality change min 2 years The stress must be so extreme that personal vulnerability cannot explain its profound effect on the personality. B. (2 or more of): • Hostile attitude • Social isolation • Hopelessness • Chronic tense or hypervigiliance • Feeling of alienation C. Impact on daily functioning D. Duration more than 2 years E. No previous personality traits or other mental disorder Marianne Kastrup Centre Transcultural Psychiatry Copenhagen

45. Diagnostic Considerations Towards DSM-V for PTSD: The 3 cluster model reexperiencing, avoidance/numbing, hyperarousal may be changed to A 4 cluster model separating avoidance and numbing and including “negative alterations in cognitions and mood” Friedman 2011

46. Diagnostic Considerations Towards DSM-V: Criterion A1/A2 Is exposure aetiological or temporally significant? Can we distinguish traumatic from non-traumatic stressors? Necessary to experience “fear, helplessness or horror”? Maximise sensitivity or specificity? Friedman M. 2011

47. Diagnostic Considerations Towards DSM-V: Criterion B Traumatic nightmares (B2), flashbacks (B3) are most recognisable Recollections (B1) may change to involuntary and intrusive recollections (to exclude ruminations) Emotional & physiological arousal (B4, B5) are retained

48. Diagnostic Considerations Towards DSM-V: Criterion C Avoidance of reminders (C1 –C2) are preserved Numbing symptoms (C3-C7) will be redefined in a new D cluster Propose a new symptom of self-blame

49. Diagnostic Considerations Towards DSM-V: Criterion D Symptoms: insomnia, concentration problems, hypervigilance and startle reaction retained Suggestion that aggressive behaviour and reckless behaviour added

50. Diagnostic Considerations Towards DSM-V: Criterion E The 1 month duration retained Delayed-onset PTSD also retained (is primarily seen after man-made trauma) Eliminate 3 month distinction between acute and chronic PTSD