Psychosomatic symptoms in Asian populations: more than a headache? Presentation by Dr. Gen Numaguchi, Ph.D. WCMHT – Queenstown Southern DHB. Who are New Zealand’s Asian People?.
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Psychosomatic symptoms in Asian populations: more than a headache?Presentation byDr. Gen Numaguchi, Ph.D.WCMHT – QueenstownSouthern DHB
Who are New Zealand’s Asian People? • Asian people are the New Zealanders who identify with or feel they belong to one or more Asian ethnicities. The largest ethnicity among Asian people is Chinese, followed by Indian, Korean, Filipino, Japanese, Sri Lankan, Cambodian, and Thai.
Demographics of Asians in NZ • 4.5 million people live in NZ; up from 4,241,448 in 2013 census. • European descent = 70% • Maori = 14.1% • Asians = 11% (471,708) • Pacific Islanders = 6.9% • “Other” = 1.6%
Demographics of Asians in NZ (continued) • Assuming a medium level projection, a further 250,000 Asians migrants are expected between 2006 and 2026.
Definition • From the perspective of evolutionary psychiatry, depression is related to the response to the loss of significant interpersonal relationships, social status, or incentives, while anxiety is related to the anticipation of threats to safety or integrity of body or self. (Kirmayer)
Mental Health Service Use – General Population • Individuals with mental illness were more likely to experience unmet health care needs and less likely to receive quality medical care compared to the general population. • As well, people in most parts of the world do not view emotional problems as appropriate issues for health care per se.
Fact Regarding Asian Culture • Asian American females have the highest suicide rate among women 65 years of age or older.
Study in Biological Differences Tufts University psychologist Nalini Ambady, Ph.D., conducted a study on how culture shapes biology. Ambady’s group based the study on historical data showing that East-Asian cultures value submissiveness, while Western cultures value dominance. In fact, they found, they could see this cultural distinction in the way the brain responds to visual input.
Biological Differences - 1 When an American thinks about whether he is honest, his brain activity looks very different than when he thinks about whether another person is honest, even a close relative. That’s not true for Chinese people. When a Chinese man evaluates whether he is honest, his brain activity looks almost identical to when he is thinking about whether his mother is honest.
Biological Differences - 2 When Americans viewed dominant silhouettes, but not submissive ones, reward circuitry fired in the brain’s limbic system. The opposite happened among Japanese participants; their reward circuitry fired in response to submissive, but not dominant, silhouettes.
Biological Differences - 3 Native Chinese, as opposed to Americans, are more sensitive to the context in which an object is embedded, and so focus greater attention on that object when it’s in an inconsistent context.
Biological Differences - 4 Westerners process human faces more actively than East Asians, consistent with the Western focus on individuality.
Biological Differences - 5 Behavioral work by University of Michigan psychologist Shinobu Kitayama, Ph.D., and his colleagues showed that people from Japan are far better at judging the length of a line relative to the size of a box in which it’s drawn, while Americans are far better at judging the absolute length of the same line. They attribute this difference to findings from other studies showing that Americans pay more attention to details and Asians pay more attention to context.
Biological Differences - 6 Northwestern University’s Joan Chiao, Ph.D., for example, has found that people who live in collectivist cultures are more likely than those in individualistic cultures to have a form of the serotonin transporter gene – the S-allele – that correlates with higher rates of negative affect, anxiety, and depression.
Biological Differences - 7 In contrast to what you might expect from the genes alone, she also found that people from collectivist societies are less likely to be depressed. This suggests that collectivism, which tends to produce lower levels of negative affect, may have co-evolved with the S-allele.
Biological Differences - 8 Societies of people with the S-allele developed a collectivist culture that reduced stress and, therefore, risk of depression by emphasizing social harmony and social support.
Roles of Culture • Culture has effects on the neural systems, psychological representations, and interactional patterns that constitute affect throughout the life-span. • Cultural ideologies, institutions, and practices provide the context and rules for interactional processes that underlie complex emotions.
Roles of Culture (con’t) • Cultural variations in the composition of the family, maternal-infant interactions, and child-rearing practices all prime and shape affect systems. • Emotion ‘display rules’ and body practices regulate socially acceptable and deviant patterns of emotional expression.
Roles of Culture (con’t) • Culture provides categories and a lexicon for emotional experience, making some feelings salient and others more difficult to articulate. • Culture sets limits of tolerance for specific emotions and strong affect; it also provides lay theories and strategies for managing dysphoria.
Roles of Culture (con’t) • Culture influences the sources of distress, the form of illness experience, symptomatology, the interpretation of symptoms, modes of coping with distress, help-seeking, and the social response to distress and disability. • Each of these ways in which culture may influence the regulation of emotion has potential implications for the expression of dysphoric affect in clinical settings.
Cultural Differences - 1 People from collectivist cultures, such as China, think of themselves as deeply connected to other people in their lives, while Americans adhere to a strong sense of individuality.
Cultural Differences - 2 • Asian Americans and Pacific Islanders (APIs) generally place less emphasis than Western cultures place on individualism but more on a collective corporate identify, such as family reputation. • In API cultures, the family often is considered to be more important than the individual.
Perceptions of Mental Illness • Stigmatization of people with mental illness has persisted throughout history and is especially pronounced in Asian communities. • Family members often try to conceal any history of mental illness within the family to avoid any negative impact on the family and potential of the young person to become married to a suitable mate.
Perceptions of MI (con’t) • In seeking help for mental health needs, APIs rely first on themselves to deal with any distress, and only secondarily consider seeking help from friends or family members. • When these efforts do not work, community figures such as elders or spiritual healers are sometimes consulted.
Perceptions of MI (con’t) • They rarely go to mental health professionals for help until they exhaust all other possible resources, often waiting until their conditions become severe and painful. • Studies have found that primary care is the major setting where APIs seek services for psychological distress and disorders.
Perceptions of MI (con’t) • Many cultures view nonconfrontation and social harmony as paramount and consequently value the suppression or containment of both interpersonal and internal conflict. • As a result, individuals in these cultures are less likely to open up to health care providers and to provide details of their emotional state and social problems.
Perceptions of MI (con’t) • Instead, emotional difficulties, including depression and anxiety, are often understood as sociomoral problems more appropriate to bring to a family member, elder, spiritual or community leader, or someone else who is familiar with the complex web of social ties, past and present, that define a relational self.
Expressions of Mental Illness • APIs tend to seek professional help through primary care providers and present their emotional distress through somatic signs and symptoms instead of mental/emotional problems. • Significantly, they tend to focus only on somatic suffering when seeking mental health care. Somatization among APIs has been well documented.
Expressions of MI (con’t) • Hsu and Folstein (1997) found that cardio-pulmonary and vestibular symptoms are the predominant physical complaints among Chinese American people. • Miller and her colleagues (2003) also found that cardiovascular disease is the most common physical condition among individual with chronic mental disorders.
Expressions of MI (con’t) • The six leading principal physical diagnoses among APIs with secondary psychiatric diagnoses were (1) nonspecific chest pain, (2) poison with other medicine or drugs, (3) coronary atherosclerosis and other heart disease, (4) acute myocardial infarction, (5) acute cardiovascular disease, and (6) poison by psychotropic agents.
Expressions of MI (con’t) • The impression that Asians, Africans, and others are more prone to somatize than North Americans has been based largely on anecdotal observation or on research that compares people in very different health care systems (Kirmayer).
Expressions of MI (con’t) • The most common somatic symptoms of depression and anxiety are musculoskeletal pain and fatigue(Kirmayer).
Japanese Specific Concepts • The culturally distinctive form of social phobia termed Taijin kyofusho (TKS) in Japan provides an instructive example of cultural influences on anxiety.
Taijin kyofusho (TKS) • It is associated with concerns about upsetting others rather than simply with one’s own embarrassment. • Awkward social behavior, especially an inappropriately placed or timed gaze, is viewed as harming others.
Taijin kyofusho (TKS) (con’t) • A wide range of types and severity of social anxiety, including apparently delusional forms, are grouped together by many Japanese psychiatrists as forms of TKS that may be responsive to similar cognitive interventions. • Taijinkyofusho predominantly afflicts young males.
Taijin kyofusho (TKS) (con’t) • While “pure” taijinkyofusho sufferers attribute their condition to some kind of personal or character weakness involving their inability to cope with interpersonal situations and eventually seek some form of psychiatric help, “serious” taijinkyofusho sufferers lack such insights, perceive their problems as real, and attempt to deal with them accordingly.
Taijin kyofusho (TKS) (con’t) • There is a consensus among Japanese psychiatrists that taijinkyofusho is a culture-bound disorder. • Western psychiatrists tend to diagnose Japanese cases of taijinkyofusho as paranoia and paranoid schizophrenia.
Taijin kyofusho (TKS) (con’t) • Miyoshi (1970) has suggested that the disorder is generated by the conflict between the individual’s strong feelings of self-conceit, which convince him that he is essentially different from others, and the value of Japanese society places on conformity, which stresses that people are essentially the same.
Taijin kyofusho (TKS) (con’t) • Iwai (1982) views the major complaint underlying taijinkyofusho disorders as less an actual “fear of strangers” than a state of anxiety aroused by doubts concerning one’s acceptability to others, and suggests that a more appropriate term for the disorder might be “jikitaimenkyofusho” or fear of self-presentation. According to Iwai, the object of fear is not the social situation or other people as much as it is oneself in the context of presenting that self to others and how that self will be received by those others.