Culture and Mental Illness

What is Mental Illness?  Actually, the preferred term is Psychological Disorder. The problem with using Mental illness is that it implies a medical disorder which is not the case.  A Psychological Disorder is defined as any psychological dysfunction associated with distress or impairment in functioning that is not typical or culturally expected.

What Constitutes Abnormality?  Defining Abnormality  Statistical approach-define behavior as abnormal because its occurrence is rare or infrequent.  Problem: Not all rare behavior is abnormal.  Whether an individual’s behavior is associated with impairment or inefficiency, deviance, or subjective distress.  Problem: Using Social Norms.

Most Common Types of Psychological Disorders Depression  Depression is a mood disorder characterized by feelings of extreme sadness and dejection – more than just the feeling of sadness; we all experience at times!  Depression is one of the most common mental disorders. Roughly from 15% to 25% will experience depression at some time in their life.

Psychological Disorders (cont.) Bipolar Disorder  Bipolar disorder, like depression, is a mood disorder. It is a new name for what used to be called manic depression. Bipolar disorder affects the functioning of the brain, causing exaggerated swings of mood from being high, over-excited and self-important to feeling extremely low and helpless, and having difficulty in making decisions.

Psychological Disorders (cont.) Anxiety  Anxiety disorders, of which there are several types, have in common an intense and paralyzing sense of fear or a sustained pattern of worrying when there is no real danger or threat.

Psychological Disorders (cont.)  Anxiety disorders include: 1) panic disorders 2) phobias 3) obsessive-compulsive disorder (OCD) 4) post traumatic stress disorder PTSD)

Psychological Disorders (cont.) Schizophrenia  Schizophrenia interferes with the mental functioning of a person and limits our ability to think, feel and act.  Symptoms include: - delusions, - phobias, - hallucinations and - confused thinking.

Psychological Disorders (cont.) An alarming fact: Approximately one in a hundred people (1%) will develop schizophrenia. Some may experience only one or more brief episodes, while for others, it remains a life-long condition.

Psychological Disorders (cont.) Eating Disorder  Anorexia and bulimia are the two most recognized and serious eating disorders. Each involves having a preoccupation with control over eating, body weight and food. People with anorexia are determined to control the amount of food they eat, while people with bulimia tend to feel out of control where food is concerned.

What’s the Role of Culture?  Two points of view: 1. Culture and psycho-pathology are inseparable— abnormal behaviors can only be understood within the cultural context in which they occur.  This perspective is called CULTURAL RELATIVISM

Culture’s Role? 2. Basic psychological disorders are present in all cultures. (universality argument) Culture, however, plays a role in determining the exact behavioral and contextual manifestation

 International Pilot Study of Schizophrenia  Discovered set of symptoms across cultures: lack of insight, auditory and verbal hallucinations, ideas of reference (assuming one is center of attention).  Also discovered course of illness easier for patients in developing countries (i.e. Colombia, India, and Nigeria vs. England, Soviet Union, and U.S.).  Differences in symptom expression: Patients in U.S., less likely to demonstrate lack of insight and auditory hallucinations than Danish or Nigerian patients. Cross-Cultural Research

Cross-Cultural Research (cont.)  Cross-cultural studies of depression  World Health Organization Study  Investigated Depression in Canada, Switzerland, Iran, and Japan  76% reported cross-culturally constant symptoms-sadness, joylessness, anxiety, tension, lack of energy, loss of interest, loss of ability to concentrate, and ideas of insufficiency.  More than half reported suicide ideation.

Cross-Cultural Research (cont.)  Other studies report differences in expression of symptoms  Some cultural groups less likely to report extreme feelings of worthlessness and guilt- related symptoms.  Others are more likely to report somatic complaints.  Cultures vary in communication of emotional terminology and hence, how they experience and express depression (Leff, 1977).

Cross Cultural Research (cont.)  Somatization  Bodily symptoms/complaints as expression of psychological distress.  Some studies indicate, certain cultural groups (Hispanics, Japanese, Arabs) somaticize more than Europeans or Americans.  However recent studies, indicate that there is not much support that somatization varies across cultures (Kirmayer, 2001).  Although previously considered culture specific, it is a universal phenomenon with culture specific meanings and expressions.

Culturally Bound Syndromes Culturally Specific Syndromes  Forms of abnormal behavior found only in certain cultures  AMOK – sudden rage and homicidal aggression - Found: Parts of Asia (Malaysia, Philippines, Thailand)  WITIKO (OR WINDIGO) – possession by an evil spirit (witiko, a man-eating monster) - Can produce cannibalistic behavior - Found: Algonquin Indians in Canada

Culturally Bound Syndromes (cont.)  ANOREXIA NERVOSA – distorted body image, fear of getting fat, a serious loss of weight from food restraining or purging - Found: Although at first limited to Western Europe and North America, the disorder is spreading to other cultures.  ZAR – involuntary movements, mutism, incomprehensible language - Found: Africa (possession by Zar)

Culture and Psychiatric Assessment  The DSN (Diagnostic and Statistical Manual of Mental Disorders)  First published in 1952, it is currently in its fifth edition, DSN-V  This latest version, DSM-V-TR, claims to acknowledge the influence of culture. Culture and Psychiatric Diagnoses

Developing Diagnostic Systems Across Cultures  Diagnostic and Statistical Manual of Mental Disorders  Adjustments were made to most recent version to include:  Incorporating information on how manifestations of symptoms can vary across cultures  Including 24 culture bound syndromes in the appendix  Adding in depth guidelines for including cultural backgrounds  However, Even the most recent DSM Edition does not require an assessment of cultural elements.

Developing Diagnostic Systems Across Cultures (cont.)  International Classification of Diseases  100 major diagnostic categories encompassing 329 individual clinical classifications.  Fails to incorporate culture.  Chinese Classification of Mental Disorders  Has culture specific features that do not exist in international systems

Cross Cultural Assessment  Traditional tools are based on a standard definition of abnormality and standard set of classification.  Therefore having little meaning in cultures with varying definitions.  The American Indian Depression Schedule  Developed to assess depressive illness.  Includes items not found in the Diagnostic Interview Schedule and the Schedule for Affective Disorders and Schizophrenia.  Researchers have offered guidelines for developing measures.  Examine socio-cultural norms of healthy adjustment and culturally based definitions of abnormality.

Cross Cultural Assessment (cont.)  Cultural backgrounds of therapist and client contribute to perception and assessment of mental health.  2 types of errors in making assessments (Lopez, 1989)  Overpathologizing-clinician incorrectly judges the client’s behavior as pathological when in fact they are normal in that individual’s culture.  Underpathologizing-a clinician explains the client’s behavior as cultural when in fact it is an abnormal symptom.

 African Americans  Reiger et al (1993)  Studied over 18,000 adults from five US cities on the prevalence of a variety of disorders.  Found that prevalence of mental illness was higher among African American than European American  Lindsey and Paul (1989)  African American more often diagnosed with schizophrenia than European Americans.  Differences may be due to SES disparities  When Regier controlled for SES, the prevalence difference disappeared.  Differences in misdiagnosis may be due to biases Mental Health of Ethnic Minorities

 Asian Americans  Some studies indicate a higher prevalence of mental disorders among Asian than European Americans  However, other studies indicate a variation within Asian Americans depending on Ethnic Background, Generational Status, and Immigrant or Refugee Status  I.e. Kuo’s study (1984) found that Korean Americans had higher rates of depression followed by Fillipino Americans, Japanese Americans, and Chinese Americans. Mental Health of Ethnic Minorities

 Latino Americans  Fewer differences have been found between Latino Americans and European Americans in rates of psychiatric disorders.  Canino et al. (1987) study of Puerto Ricans  Reported similar lifetime and 6-month prevalence rates of disorders compared with there US communities. Mental Health of Ethnic Minorities

Mental Health of Ethnic Minorities (cont.)  Also significant within group differences depending on specific Latino group.  I.e. one study found Puerto Ricans have higher rates of major depression than Cubans and Mexican Americans. (Cho, 1993)  US born Mexican Americans in California showed rates of mental disorders similar to US nationals, whereas Mexican-born showed lower rates. (Alderete et al. 2000)

 Native Americans  Few studies have included this group, but those that have suggest that Depression is a significant problem.  Alcohol abuse, and rates of suicide significantly higher than US nationals.  Migrants  Experiencing stresses associated with acculturation may lead to poorer mental health (Berry and Sam, 1997)  Findings are inconsistent  Refugees  Migrants forced to flee from their countries because of political violence, social unrest, war, etc.  They report higher rates of PTSD, depression and anxiety. Mental Health of Ethnic Minorities