Neuro4: Social And Cultural Context Of Mental Illness

Front 1

Is it ok for a physician to have biases or make stereotypes

Back 1

Yes, but NOT ok to not be aware of

Front 2

Culture and Society def

Back 2

Society - system of social relationships

Culture - shared patterns of belief, feeling and knowledge that guide behavior and individuals' def of reality

Culture is transmitted from one generation to the next via symbols, shared meanings, teachings and life experiences

Includes tools by which a society adapt to their physical environment, organized groups with ready made solutions to problems faced

Can be observed directly through five senses (art, food, tools) and indirectly through behavior (holding something sacred, patriotism, chauvinism)

Front 3

Definitions Ethnicity, Race, Environment, Cultural Difference

Back 3

Ethnicity - sense of shared heritage
Race - taxonomic schema based on superficial difference, erroneously implying shared genetic heritage
Environment - Physical surroundings, resources and stressors, climate
Cultural Difference - Belief that problems between cultures must be approached by looking at both cultures involved thus avoiding ethnocentric bias

Front 4

Definitions Emic, Etic

Back 4

Emic - View of a phenomenon in terms of the culture where it occurs
Emit - Universal approach to psychological or social phenomena

Front 5

Cultural identity of an individual, how to discover

Back 5

Degree of involvement in culture of origin and host culture

Listen for clues and ask q's about identity, pay attention to language abilities and preferences. (ie an Asian-American growing up in south may align with south more)

Front 6

Cultural explanations of an individuals illness

Back 6

How an individual understands distress or the need for support communicated through SYMPTOMS ("nerves", spirit possession, somatic)

Meaning and severity of an illness in relation to culture (ex. stigmatizing)

Both help to determine an interpretation, diagnosis and Tx plan

Front 7

Cultural factors related to psychosocial environment

Back 7

Cultural interpretations of social stress, support and level of disability must be assessed

Physician must determine level of disability to help PT and FAMILY adjust to new roles

Front 8

Cultural aspect of relationship between individual and clinician

Back 8

Difficulties in:

Language
Eliciting symptoms or understanding significance
Negotiating appropriate relationship
Determining if a behavior is normal or pathologic
Determining the environment the pt is receiving treatment

Front 9

General Trends in cross-cultural diagnosis

Back 9

PATIENT reports MOST RELIABLE info about symptoms

Diagnostic information / History gathered as a SYNTHESIS of cross-cultural exchange (ex. through FAMILY) is the LEAST reliable

Physician observation is MORE acceptable than cross cultural synthesis but still LESS reliable than Pt report of symptoms



So be careful about information gathered cross culturally, can be reliable though but just be aware

Front 10

Race vs Culture, Reasons for misdiagnosis

Back 10

Race is outwardly evident and FIRST thing a physician knows about a pt and vice versa. Can be complicated if individual resides in a setting with racial disparities

African American pts OVERDIAGNOSED with psychotic disorders and UNDERDIAGNOSED with mood disorders. Can lead to undue longterm exposure to antipsychotics,

Reasons for misdiagnosis:
Mistrust of healthcare system and physician bias

Front 11

Difficulty in Presentation of Illness

Back 11

Pt culturally may not be able to express symptoms (ex "feeling blue"), may have cultural beliefs that fit a psychotic like symptom (ex. speaking to ancestors, spirit possession, etc)

Depression is particularly hard to dx

Front 12

Acculturation

Back 12

Acculturation - when two cultures meet

Must make effort to understand background (ex. political prisoner, victims of trauma, separation from family)

Front 13

Acculturative stresses mental disorders

Back 13

Can contribute to

"culture shock"
Depression
Anxiety
PTSD

Front 14

Psychopharmacology Ethnic Biologic and Nonbiologic issues

Back 14

Biologic - MOST anti-psychotics are LIVER metabolized. Ethnicities have different pharmacokinetics (poor and extensive metabolizers with CYPp2D6 exmample, risk factors, environmental influence [ex return to old habits])

Nonbiologic - Concern about western meds, herbal medicine use, etc

Front 15

Culture Bound Syndrome

Back 15

Collection of signs and symptoms that is restricted to a limited number of cultures by reason of certain psychosocial features

Setting restricted b/c of special relationship
Classified by etiology (magic, angry ancestors, etc)
Hallucinations may be normal variants
Ex. schizophrena behavior may be interpreted as voodoo or anger

Front 16

Culture-Specific Syndromes, Distribution, Presentation: Antaques de nervios

Back 16

Distribution: Americas, people of Hispanic heritage

Presentation: socially sanctioned display of grief or conflict characterized by agitation, unfocused aggression, lability of mood, fluctuating consciousness, hyperventilation and difficulty moving limbs

Front 17

Culture-Specific Syndromes, Distribution, Presentation: Amok

Back 17

Distribution: Various including Asia, Africa, New Guinea

Presentation: Following personal HUMILIATION characterized by prodromal brooding, followed by sudden, uncontrollable homicidal rage then full or partial amnesia of the episode

Front 18

Culture-Specific Syndromes, Distribution, Presentation: "falling out", "blacking out", indisposition

Back 18

Distribution: African American, Bahamians, Haitians

Presentation: After EMOTIONAL EXCITEMENT, collapes, inability to move, loss of volitional movement without loss of sensory consciousness or bowel or bladder control

Front 19

Culture-Specific Syndromes, Distribution, Presentation: Pibloktog, Chakore, Grisis siknis, "frenzy" witchcraft

Back 19

Distribution: Artic natives, Nicaragua, Navajos

Presentation: Prodromal lethargy, depressed, anxious state followed by agitation, seemingly purposeless running ending in exhausting, sleep and amnesia for episode

Front 20

Culture-Specific Syndromes, Distribution, Presentation: Koro

Back 20

Distribution: Asia

Presentation: PANIC feelings brought on by conviction that ones genitals are retracting into abdomen and that will lead to death

Front 21

Culture-Specific Syndromes, Distribution, Presentation: Anorexia, bulemia

Back 21

Distribution: North America

Presentation: Bizzare eating patterns from distorted body image, restriction or binging or purging

Front 22

Culture-Specific Syndromes, Distribution, Presentation: Hwa-byung

Back 22

Distribution: Korean

Presentation: Ascribed to "excess anger", CHRONIC frustration, adversity, characterized by sensation of an epigastric mass, anorexia, anxiety, dyspnea and epigastric pain

Front 23

Interpreters problems, issues

Back 23

Misdiagnosis
Unnecessary or inappropriate treatment
May lead to refusal or termination of treatment

Issues:
Clinician may feel less control or uncertainty, opposing views on pt diagnosis or plan, interpreters uncomfortable about sensitive issues.

Front 24

Guidelines for working with interpreters

Back 24

Know qualifications
AVOID family members, friends or staff that are not certified
USE professionals
MEET before with interpreter
INTRODUCE interpreter to pt
SPEAK TO PT not interpreter
Encourage feedback after each session

Front 25

How to minimize cultural clashes

Back 25

First moments crucial
Be respectful to all patients
Will take TIME to develop trust and alliance
If Dx is unclear consider structured Dx interview to reduce possiblity of misdiagnosis
SPEND more TIME w/ pts from different culture esp. if session with interpreter

Front 26

Cultural areas that impact treatment course and efficacy

Back 26

Symptom expression, diagnosis, presentation, acculturation, and pharmacokinetics