Culture and Psychiatry

Overview

Race, ethnicity, and culture may all exert a tremendous impact on medical diagnosis, treatment, and outcomes. This is especially true in psychiatry, given the prominent role that culture plays in patients' interpretation and management of symptoms that fall within the affective, behavioral, and cognitive domains. Behaviors that appear bizarre in one cultural context may be perfectly acceptable in another. Although an in-depth understanding of every culture is impossible, familiarity with some basic principles will help minimize cultural clashes and reduce the risk of compromised medical care.

Understanding a patient's culture will aid in the delivery of high-quality care. However, a little knowledge can also be a dangerous thing. Variability among individuals is inevitable; a particular patient may not fit into a clinician's preconceived notion of his or her culture. Thus, the clinician must probe for clues regarding the patient's background, while remaining flexible enough to recognize when a patient's behaviors and clinical presentation do not necessarily match what is expected. The clinician should be aware of his or her own feelings, biases, and preconceptions about other cultures. In addition, the consulting psychiatrist must assess the impact of the hospital environment, the attitudes of the medical and ancillary care teams, and the patient's experience within the healthcare system. Mistrust of the healthcare system is common and may influence a patient's behavior, level of cooperation, and adherence to treatment. Furthermore, disparities in healthcare delivery have been well documented and are influenced by factors such as gender, race, ethnicity, and culture.

The role of culture in health care has become a topic of increasing importance due to rapid demographic changes in the United States. Although the US population already exhibits tremendous racial and ethnic diversity, projections expect this pattern to become further magnified in the coming decades. By 2044, non-Hispanic whites will be the minority race in the United States, and by 2060, nearly one in five of the nation's total population is projected to be foreign-born. Most racial and ethnic groups are projected to experience growth between 2014 and 2060, with the largest rates of growth projected for Hispanics, Asians, and non-Hispanics of two or more races.

Culture is the collected body of beliefs, customs, and behaviors that a group (or people) acquire socially and transmit from one generation to another through symbols, shared meanings, teachings, and life experiences. It provides the tools by which members of a given society adapt to their physical environment, their social environment, and one another. It organizes groups with ready-made solutions to common problems and challenges.

Physical culture—as exemplified by art, literature, architecture, tools, machines, food, clothing, and means of transportation—can be observed directly through the five senses, and through items collected in a museum or recorded on film. Ideological culture refers to aspects of culture that must be observed indirectly, usually through specific behaviors and customs. These include beliefs and values, the reasons for considering some things sacred and other things ordinary, the characteristics and events of which a society is proud or ashamed, and the sentiments that underlie patriotism or chauvinism. Religion, philosophy, psychology, literature, and the meanings that people give to symbols are all part of the ideological aspect of culture. The physical level of culture yields more easily to change and to adaptation than does the ideological level, but without some understanding of the ideological aspect of culture, it is difficult to understand the meaning of a group purely at the physical level.

Each society establishes its own criteria regarding which forms of behavior are acceptable or abnormal, and which represent a medical problem. Learning more about an individual's culture and/or working with bilingual and bicultural interpreters can help to clarify normal and abnormal behaviors. It is also important to recognize that an individual may be influenced by multiple cultures or subcultures. The consulting psychiatrist must often employ the skills of a detective to verify whether a patient's statements or beliefs are appropriate to his or her environment, heritage, and culture.

Cultural Differences in Illness Presentation

Cultural differences in the presentation of psychiatric illnesses abound. For example, a woman originally from South Korea may present with chief complaints of dizziness, fatigue, and back pain, while she ignores other neurovegetative symptoms of depression, and is unable to describe feelings of dysphoria. American mental healthcare providers are generally unfamiliar with various Indo-Chinese cultural syndromes and culturally specific meanings attributed to certain symptoms. For example, the Laotian way of describing feeling “tense” is feeling “like a balloon blown up until it is about to burst.” Westermeyer, in a case–controlled study in Laos, documented the general inability of Western psychiatrists to recognize the Laotian symptoms of depression. On the other hand, common American expressions, such as “feeling blue,” cannot be readily translated into many other languages. A Cambodian clinician will ask Cambodian patients if they “feel blue” by using Khmer terms, which literally translate as “heavy, overcast, gloomy.”

Similarly, the phenomenology of panic disorder may vary among minority groups within the United States. Compared with their Caucasian peers, for example, African Americans with panic disorder report more intense fears of dying or going crazy, as well as higher levels of numbing and tingling in their extremities, and exhibit higher rates of co-morbid post-traumatic stress disorder (PTSD) and depression. African Americans also use somewhat different coping strategies (e.g., religious practice and “counting one's blessings”), and endorse less self-blame. Cambodian populations may understand panic-like symptoms as khyâl cap (literally, “wind attacks”) caused by khyâl , a wind-like substance, rising up in the body and causing a range of serious effects, including compressing the lungs or entering the cranium.

Accurate evaluation of the meaning and significance of seemingly bizarre beliefs, hallucinations, and psychotic-like symptoms among diverse populations remains a clinical challenge. For example, a Puerto Rican woman who acknowledges hearing the voices of her ancestors may not be psychotic, as this phenomenon is relatively common among Caribbean Latinos in the absence of a thought disorder. In many traditional, non-Western societies, spirits of the deceased are regarded as capable of interacting with, and possessing, those still alive. It may be difficult for the clinician to determine whether symptoms are bizarre enough to yield a diagnosis of a primary psychotic disorder without an adequate understanding of a patient's sociocultural and religious background. On the other hand, caution must be taken not to assume that bizarre symptoms are culturally appropriate when in fact they are a manifestation of psychiatric illness. A culture may interpret abnormal behavior as relating to some kind of voodoo or anger and therefore regard the symptoms as normal even though they are in fact consistent with a primary psychotic disorder. The use of bilingual and bicultural interpreters, along with the search for information from other sources (e.g., family, community leaders, religious officials) and attention to other more objective features of psychiatric illness (e.g., poor self-care, deterioration of personal and professional relationships) may help determine whether an individual's behavior is culturally acceptable or evidence of a psychiatric illness.

Western clinicians who search only for physiologic explanations for somatic complaints such as back pain, tinnitus, headaches, palpitations, and dizziness may miss depression or anxiety. Afflicted patients are often prescribed meclizine for dizziness and analgesics for pain by their primary care providers, when an antidepressant or anxiolytic would have been most appropriate. The appropriate diagnosis and treatment will only be elucidated if sufficient time and attention are spent understanding the cultural factors affecting an individual's distress, a process that is described further in the following section.

Cultural Assessment for Clinicians

The Diagnostic and Statistical Manual of Mental Disorders , 5th edition (DSM-5) introduced a number of conceptual innovations with regard to the role of culture in psychiatric diagnosis and treatment. These included direct cross-referencing of multicultural explanations for clusters of symptoms within the descriptions of each DSM-5 disorder, more detailed and structured information about cultural concepts of distress, and expanded clinical interviewing tools to facilitate person-centered and culturally focused assessments. In addition, DSM-5 went further than any previous versions of the manual in its explicit assertion that “all forms of distress are locally shaped, including the DSM disorders.”

DSM-5 provides clinicians with two practical tools to help clinicians produce a nuanced cultural assessment: the Outline for Cultural Formulation (OCF), and the Cultural Formulation Interview (CFI), both of which bear further description here, given this chapter's focus on the role of culture in psychiatry.

The Outline for Cultural Formulation describes five distinct domains, as shown below, that can be used to describe an individual's ethnic and cultural context as related to psychiatric illness.

Cultural Identity of the Individual

Ethnic or cultural references and the degree to which an individual is involved with his or her culture of origin versus the host culture are all critical to understanding that individual's identity. Clinicians should delve into this topic using open-ended questions with reference to cultural and social context, recognition of the hybrid nature of cultures, and the possibility of change over time. For instance, an Asian American man who grew up in the Southern United States may exhibit patterns, behaviors, and views of the world that are more consistent with those of a Caucasian Southerner. Attention to language abilities and preferences must also be addressed. Other important aspects of cultural identity may include religious affiliation, socioeconomic background, sexual orientation, gender identity, country of origin, and migration history.

Cultural Conceptualizations of Distress

How an individual understands and experiences his or her symptoms is often communicated through cultural syndromes and idioms of distress (e.g., nervios /“nerves,” possession by spirits, somatic complaints, misfortune). Individuals may also make sense of their experience in terms of a specific sequence of events or prior episodes of illness. Thus, the meaning and severity of an illness in relation to one's culture, family, community, and personal history should be elicited. The resultant explanatory model, in conjunction with past and current expectations of care, may prove extraordinarily helpful when developing an interpretation of symptoms, a diagnosis, and a treatment plan.

Psychosocial Stressors and Cultural Features of Vulnerability and Resilience

Culture exerts significant impacts at the level of the psychosocial environment—e.g., religion, family, social circle—and also significantly influences interpretations of stress, social support, and level of disability versus function. It is the physician's responsibility to determine a patient's level of functioning, resilience, and disability in the context of his or her cultural reference groups.

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Overview