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Transcultural Psychiatry

Transcultural Psychiatry. Dr. Naresh K. Buttan M.B.B.S., D.P.H.,D.P.M., D.N.B. (Psy), C.C.S.T., Sec 12 (2) Approved Consultant Psychiatrist, PCH-CIC Hon’ Fellow-PCMD, AT & Psychiatry Locality Lead- PMS TPD (CT)- Health Education England South West (HEE-SW)

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Transcultural Psychiatry

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  1. Transcultural Psychiatry Dr. Naresh K. Buttan M.B.B.S., D.P.H.,D.P.M., D.N.B. (Psy), C.C.S.T., Sec 12 (2) Approved Consultant Psychiatrist, PCH-CIC Hon’ Fellow-PCMD, AT & Psychiatry Locality Lead- PMS TPD (CT)- Health Education England South West (HEE-SW) E-mail: N.Buttan@nhs.net, Naresh.Buttan@pcmd.ac.uk

  2. Training Requirement, RCPsych (CT) Intended learning outcome 1 Be able to perform specialist assessment of patients and document relevant history and examination on culturally diverse patients to include: Presenting or main complaint History of present illness Past medical and psychiatric history Systemic review Family history Socio-cultural history Developmental history

  3. Training Requirement, RCPsych (CT)… Intended learning outcome 2 Demonstrate the ability to construct formulations of patients’ problems that include appropriate differential diagnoses Intended learning outcome 3 Demonstrate the ability to recommend relevant investigation and treatment in the context of the clinical management plan. This will include the ability to develop & document an investigation plan… & then to construct a comprehensive treatment plan addressing biological, psychological and socio-cultural domains Intended learning outcome 8 Use effective communication with patients, relatives and colleagues. This includes the ability to conduct interviews in a manner that facilitates information gathering and the formation of therapeutic alliances 18 learning outcomes- importance of communication & cultural awareness !!!

  4. What is Culture ? “Man is an animal suspended in webs of significance that he himself has spun, and the threads of web are but the strands of culture” - Max Webber Culture: Sets of standards for behavior that govern people’s way of life- shared customs & beliefs. Race: Individuals grouped according to shared genetic characteristics- shared genotype Ethnicity: Races or large groups of people classed according to common traits- shared phenotype.

  5. Culture & Values

  6. World- a Global Village

  7. Acculturation

  8. Acculturation…..

  9. Transcultural Psychiatry • Psychiatry- a product of modern Western medicine ? • Emil Kraepelin’s Java visit in 1896. • ‘Civilization & its Discontents’- Freud (1930). • US-UK Project- 60’s • IPSS of WHO in 1973. • ‘Culture Bound Syndromes’-Yap, Hong Kong.

  10. Transcultural Psychiatry…. • Discipline that deals with description, definition, assessment & management of all psychiatric conditions as they reflect and are subjected to influence of cultural factors in a biopsychosocial context while using concepts and instruments from social & biological sciences to advance a full understanding of psychopathology and its treatment. • In order to better evaluate effect that culture has on a patient and their illness-not enough to have factual knowledge about a patient’s culture without having it in context of how people view themselves in it & its role in their lives.

  11. Culture in Diagnostic Systems-ICD-10 Dev. by WHO in consultation with nosologic experts & collaborating centers across world. Used in rest of the world, culture is mentioned least !!! Culture Specific Disorders in “Diagnostic Criteria for Research”. Multiaxial Presentation of ICD-10: Axis I: Clinical Diagnoses Axis II: Disablement Axis III: Contextual Factors

  12. Culture in Diagnostic Systems- DSM IV Axis IV: Psychosocial & Environmental Problems Cultural Formulation Guidelines: 5 Elements of DSM-IV in appendix 9- • Cultural Identity of individual. • Cultural Explanations of individual’s illness. • Cultural factors related to psychosocial environment & level of functioning. • Cultural elements of clinician- patient relationship. • Overall cultural assessment for diagnosis & care.

  13. Cultural Formulation • Cultural Identity. • Preferred language. • Acculturation. • Culturally determined psychosocial factors. • Social stressors. • Community support. • Availability & accessibility of appropriate services.

  14. Cultural Formulation (contd..) • Culturally determined illness beliefs & behaviours. • Insight by illness model. • Expression of symptoms. • Family/ community’s viewpoint. • Cultural meaning of illness/ treatment. • Doctor-patient relationship: • Symptom elicitation & significance. • Therapeutic alliance. • Discussions of treatment options.

  15. Culture Bound Syndromes • Littlewood & Lipsedge (1987) • Young males/ females-’powerless’ & socially neglected. • Dramatic with indiv. unaware /not responsible. • ‘Mystical sanction’- symbolic cultural significance. • Triphasic pattern- dislocation→ exaggerated symptoms →restitution.

  16. Culture Bound Syndromes- Subtypes • Startle reaction- Latah. • Genital reaction- Koro. • Sudden assault- Amok. • Running- Pibloktoq. • Semen loss- Dhat. • Spirit possession- Spell. • Obsession with dead- Ghost sickness. • Exhaustion- CFS, ME. • Suppressed rage- Bilis.

  17. Culture and Schizophrenia/ Psychoses W.H.O.- IPSS’73, DOSMeD’78, ISOS’90: • Prevalence: 1-2/1000, stable over decades, some pockets of high (Ireland) & low (PNG)→ speculation of western exposure. • Incidence: DOSMeD- 1.5- 4.2/ 10,000 (both genders) of population at risk (15-44 yrs of age). Narrowly defined- 0.7-1.4/10,000.

  18. Culture and Schizophrenia/ Psychoses… Phenomenology: • Symptom Frequencies- IPSS similar symptoms (hallucinations, delusions, social withdrawal & flat affect) common to all cultures, DOSMeD-similar findings except VH more in east & affective Sx more in west. • Delusions & Hallucinations: Content dependent on culture, tolerance, expression and emotional control & reaction as well. • FRSS: Lower rates in developing countries, ?affected by subcultural beliefs. • Subtypes: Catatonia more common in developing world, paranoid and hebephrenia more common in west- ?high lingual competency (Varma et al 1992)

  19. Culture and Schizophrenia & Psychoses... Course & Outcome: • IPSS & DOSMeD gave better outcome in developing world. • Later studies mixed results. • Global Rule of 3rds. • Sociocultural factors- EE & Family support. • Industrialization- by altering familial & social structures & by altering environmental factors. • Higher rates among migrants.

  20. Culture & Affective disorders • US- UK study (1972)- pioneer study. • WHO study (Sartorius et al,1980): Symptoms of depression- variations. • DIS study (1985): Lifetime prevalence- 1.5% (Taiwan)- 11.6% (NZ). • Somatic presentation commoner in primary care • Bipolar: prevalence 0.5-1.5% - no ethnic differences. Mood incongruent psychotic symptoms may mislead to diagnosis of schizophrenia in Afro-Caribbean groups (Strakowski et al, 1993, 1996). • Depression vs. somatization.

  21. Mental Illness & Ethnic Minorities-UK • UK’s Population: 58 m (Census, 2001), BMEs (7.9%) • Non-white groups –younger, 45% live in London, Plymouth (4%), bigger households, majority unemployed, self-reported health-poor. • ‘Count Me In’ Census, 2007- 22% inpatients in MH & 12% LD from BMEs, 1% ↑se /yr., 6-10% -ESL, more referred from legal systems, more detentions, seclusions in BMEs, no difference in rates of physical assault, equal/ lesser incidence of self harms.

  22. Mental Illness & Ethnic Minorities-UK… • Schizophrenia: • Higher rates in Afro-Caribbean people born in UK. • Highest rates in UK born 2nd generation subjects. • No evidence for greater genetic loading. • Suicide: • High rates in young Indian women, low in men. • Low in Caribbean men & women. • Immigrants higher rates of suicide by burning (with 9 X excess among Indian women)-marital/ IPR problems.

  23. So, Where are we now ??? • MHNSF (1999): Services not meeting needs of BMEs and lack of confidence in their use. • Race Relations (Amendment) Act, 2000. • Inside Out (2003)- Improving MHS for BME • Delivering Race Equality (2007), DoH: guidelines for more appropriate & responsive services, community engagement & better information.

  24. So, Where are we now ???... • RCPsych: Position Statement (2007)on Refugees & Asylum seekers, Equality & Diversity in the college, Special Interest Group, Ethnic issues project group. • National BME Mental Health Network • World Association of Cultural Psychiatry (www.wacp2012.org ) Conf. London, March 2012

  25. Exercise: Identify Cultural Barriers in Interviewing Situations with Person from different cultural background

  26. Cultural Communication Barriers

  27. Overcoming Cultural Barriers in Communication

  28. Non- Verbal Technique (SOLER)

  29. Empathy Different from sympathy Core message Feelings- “you feel” to be followed by correct family of emotions & correct intensity Experiences & behaviors- “because” to be followed by Es & Bs Tips to improve quality of empathy:

  30. Further reading • http://www.rcpsych.ac.uk/college/specialinterestgroups/transculturalpsychiatry.aspx • http://www.kingsfund.org.uk/library : Mental Health: Black and minority ethnic communities • www.nimhe.org.uk -Inside Outside – Improving Mental Health Services for Black and Minority Ethnic Communities in England • Delivering Race Equality in Mental Health Care- DH, Jan 2005 • ‘Count Me In’- Commission for Healthcare Audit and Inspection, 2007. • Positive steps – Supporting race equality in mental healthcare: Dept. of Health Feb, 2007

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