Cultural Psychiatry

Awkward Translation w/ Marcos (1979)

Clinician to Chinese-speaking client: What kind of moods have you been in recently?
Interpreter to client (In chinese): How have you been feeling?
Client (in Chinese): No, I don't have any more pain, my stomach is fine now, and I can
each much better since taking the medication
Interpreter to clinician: She says that she feels fine, no problems
Clinian to client: Do you still feel sad, do you feel that life is not worthwhile sometimes?
Interpret to client (in Chinese): The doctor wants to know if you feel sad and if you like
your life?
Client (in Chinese): No, yes. I know my family need me, so I cannot give up. I try not
to think about it
Interpreter to clinician: She says that no, she says loves her family and that her family
need her
Burden
In latino culture taking care of a close family member is not seen as a burden.
Suggested using the word responsibility
Blue
The lay term blue which is sometimes used as a lay term for depression, means
hope or a state of calmness in Vietnamese.
A cambodian clinician will ask cambodian patients if they feel blue by using
cambodian terms which literally translate as heavy, overcast, gloomy.

Laotian tense/depression
the laotian way of descriving feeling tense is feeling like a balloon blown up until it
is about to burst.
Westmeyer, in a case controlled study in Laos, documented the general inability of
Western psychiatrists to recognize the Laotian sx of depression
Cambodian Depression
Psychiatrists and primary care pyhsicians who search for biological and structural
reasons for complaints (back pain, HA, and dizziness) may miss depression
A Cambodian woman may present with complaints of dizziness, fatigue, and back pain,
while she ignores other neurovegetative sx and is unable to describe feeligns of
dysphoria
Issues with Spanish
Marcos et al (1979) studied 10 inpatients with schizophrenia who were fluent enough in
Spanish and English to respond to items on the Brief Psychiatric Rating Scale. These
subjects seemed more psychotic when they spoke English than when they spoke Spanish
Price and Cuellar (1981) attempted to replicate these findings, subjects seemed more
psychotic when speaking Spanish.
Kline et al (1980) found that patients may feel more understood when interviewed
 through an interpreter than when interviewed in English, even if the patient is capable of
completing the interview in English. In sharp contrast, the clinicians in the Kline et al
study felt that rapport was better when they spoke to the patient directly, without an
interpreter
inability to express themselves
Bilingual patients may most frequently be unable to express themselves in a second
language when acutely psychotic, which may seem withdrawn or have paucity of speech
in the second language but be more forthcoming in their mother tongue. E.g psychosis
in the patient's first language but psychosis w/ negative symptomatology in the 2nd.
AA sx
Compared with their caucasian peers, african americans w/ panic disorder report more
intense fears of dying or going crazy, higher levels of numbing and tingling in their
extremities, and higher rates of co-morbid PTSD and dperession
Avoid using family members, friends, or clerical staff as interpreters.

Instructions for interpreter

Ask questions when not sure of a term, phrase, concept, acronym, etc.
never answer questions
Make sure the interpreter is clear that they are never to answer questions on
your behalf.
No changing or altering
Ask interpreters not to change or alter what you say even if they think it may
cause offense. If you plan to talk about a controversial issue let the interpreter
know.
Commentary
The sophisticated translator may be able to offer insightful commentary about
the patient's language usage, including overinclusiveness, rapidity of speech,
and other qualities
Be sure to ask translator about nonverbal information including patient's attire
and meaning of hand or facial gestures
positions
triangle formation
horse shoe formation for more than 2, e.g. family, with interpreter next to
provider
circle formation for large groups
ground rules
For example, try and communicate how you want a meeting run, the number of
sentences to be translated at a time, the confirmation of jargon or idioms before
they are translated, when breaks will be taken and seemingly trivial matters like
seating arrangements.
 Introduce subject matter
Always prepare the interpreter (in person) on the subject matter to be
presented/discussed
Instructions for Provider
Maintain eye contact with your audience/interlocutor(s) at all times
Try to speak in short thought groups, and pause for your interpreter to catch up.
If you do not, you may force the interpreter to omit some of your words, but you
wont know which ones! Be concise and deliberate in your speech pattern,
enunciate clearly, and agree in advance with the interpreter on the pace and pause
intervals you will use. On the other hand, there is no need to use Me Tarzan, You
Jane style sentences. Just be aware and allow time for the interpreting process.
Beware of telling jokes.
Plan your time carefully. Conversing through an interpreter makes conversations
twice as long.
Overall
If the speaker is annoyed this will be obvious in their body language and tone.
Never involve the interpreter at a personal level in any discussions and if you see
an interpreter translating your emotions, ask them to stop. The interpreter is there
to purely translate what is being said.
Cultural
Ataque De Nervios
Hikikomori
Amok (Berserker)
Southeast Asia, Scandinavia
Loosely translated as "rampage" in Malay, amok is a dissociative condition
characterized by a non-premeditated violent, disorderly, or homicidal rage
directed against other objects or persons. The condition, which is often
accompanied by amnesia and exhaustion, is typically incited by a perceived or
actual insult and can occur as part of a brief psychotic episode or as an
exacerbation of a chronic psychotic illness. A similar state, berserker, is used in
Old Norse literature to describe a frenzied rage in Viking warriors. [1,3,4]
Conditions such as intermittent explosive disorder; catatonic excitement;
agitation and aggression under the influence of substances; and aggression
associated with psychotic, mood, or personality disorders share features with
amok.
Khyal Cap (Wind Attacks)
Cambodia and Cambodian immigrant communities
Found in Cambodians and Cambodian immigrants, and new to DSM-5, is khyl
cap -- or, "wind attacks" -- characterized by dizziness, shortness of breath,
palpitations, and other symptoms of anxiety and autonomic arousal. The
episodes often meet the criteria for panic attacks and can be related to other
 anxiety or trauma-related disorders. The name comes from the theory that
symptoms are due to a wind-like substance rising up in the body. Clinicians
should rule out physical causes of anxiety symptoms and explore potential
trauma etiology. Treatment approaches should focus on anxiety symptoms and,
if present, trauma.[2]
Latah/Imu/Jumping Frenchmen of Maine
Southeast Asia, Japan
Latah describes an exaggerated startle response to frightening stimuli. Patients
can experience a trance-like dissociation as well as echolalia and echopraxia. A
similar condition, termed "jumping Frenchmen of Maine" syndrome, has been
described in Franco-Canadian lumberjack communities. [1,4] This condition has
features of dissociative or conversion disorders or catatonia, or could also be a
severe form of shock in response to a sudden or severe traumatic event.
Kufungisisa (Thinking Too Much)
Zimbabwe
Also new to DSM-5 is kufungisisa, or "thinking too much," a disorder of distress
reported by the Shona people of Zimbabwe. The term represents both a cause
of conditions akin to anxiety and depression (eg, "my heart is painful because I
think too much") as well as an idiom of psychosocial stressors, such as financial
or marital problems. Symptoms can overlap with several DSM diagnoses,
including anxiety, panic disorders, and depression. Ruminations and somatic
symptoms may be addressed with cognitive-behavioral psychotherapeutic
approaches; otherwise, standard treatments for anxiety or depression can be
tried.[2]
Cultural Bound Syndromes
Piblokto/Pibloktoq
Arctic and Subarctic Eskimos
Piblokto, also known as "arctic hysteria," describes a dissociative episode
in which patients experience prolonged, extreme excitement sometimes
followed by seizures and coma. A prodrome of irritability can occur, and
during the episode patients frequently exhibit dangerous, irrational behavior (ie,
property destruction, stripping naked). It has been hypothesized by at least one
researcher that the condition could result from vitamin A toxicity; organ meat
from Arctic food sources such as polar bears, seals, and walruses contains
extremely high levels of the vitamin.[1,5,6] Other potential causes of this
syndrome include forms of malnutrition (eg, vitamin D or calcium deficiency) and
the conditions associated with amok, including delirium and severe psychotic,
mood, or personality disorders.
Maladi Moun (Humanly Caused Illness)
Haiti and Haitian communities
Maladi moun ("humanly caused illness"), found in Haitian communities, is seen
as an explanation for a number of medical and psychiatric symptoms. It is
thought that illness is literally "sent" by others out of envy and hatred and
 can describe psychosis, depressive symptoms, and even academic or
social problems. The condition often overlaps with delusional disorder and
schizophrenia with paranoid features. In approaching this condition, it is
important to differentiate extreme forms of rationalization mixed with magical
beliefs, overvalued ideas, and explanations shared by a cultural subgroup from
emerging or manifest psychotic symptoms. Potentially emerging psychosis may
require close observation and treatment of frequently present comorbid
conditions, including depression and substance use disorders, whereas
manifest psychotic disorders probably require antipsychotic treatment. [2]
Taijin Kyofusho
Japan
Patients with taijin kyofusho (literally "the disorder of fear") experience
extreme self-consciousness regarding their appearance. Patients suffer
from intense, disabling fear that their bodies are embarrassing or
offensive to others.[1,9] This culture-bound condition has overlapping features
with social phobia and body dysmorphic disorder.
Saora
Southeastern India
Young men and women in India's Saora tribe will occasionally exhibit
memory loss, fainting, and inappropriate crying or laughing. Sufferers often
claim to experience the sensation of being repeatedly bitten by insects when
none are present. This behavior has been claimed to occur in response to social
pressure to lead a certain way of life expected by one's family and/or community
(ie, farming), while tribe members often attribute the behavior to the actions of
supernatural beings who want to marry the afflicted persons. [10] This syndrome
has features of a dissociative or conversion disorder.
Koro
Asia, Southeast Asia
Koro is intense anxiety related to the belief that one's own genitalia are shrinking
or receding, resulting in possible death. Localized epidemics have been
reported. Koro, rooted in Chinese metaphysics and cultural practices, is
included in the Chinese Classification of Mental Disorders, Second Edition.[1,11]
The disorder has also been associated with the belief that perceived
inappropriate sexual acts (eg, extramarital sex, sex with prostitutes, or
masturbation) disrupt the yin/yang equilibrium, thought to be achieved during
marital sex. Koro has also been thought to be transmitted through food. One
could also hypothesize that excessive guilt and shame about fantasized or
executed sexual acts might play a role in the delusional belief.
Dhat Syndrome / Shenkui India/CHina
Dhat derives from the Sanskrit for "elixir that constitutes the body." Dhat is an
Indian folk diagnosis in which patients suffer from severe anxiety and
hypochondria related to the loss of semen through urine, nocturnal
emission, or masturbation. A similar condition, shenkui, has been described in
China.[1,12] In shenkui, marked anxiety or panic symptoms are accompanied by
 somatic complaints, such as dizziness, backache, fatigue, and complaints of
sexual dysfunction. The excessive loss of semen is feared because it is seen as
the loss of one's vital essence. Similar to koro, one could hypothesize that the
intense fear present in dhat and shenkui could be related to fantasized or
performed sexual acts that the person feels are forbidden or unacceptable
to the self or others. However, the description could also be related to an
unrecognized depressive disorder or somatization disorder.
Zar
Region/Culture: Northern Africa, Middle East
Attributed to spirit possession -- and not considered a pathology locally -- people
experiencing zar undergo dissociative episodes, including fits of excessive
laughing, yelling, crying, and hitting their head against a wall. Patients are
often apathetic and report developing long-term relationships with their possessor.
[1] On the basis of its phenomenology, zar could be conceptualized as a recurrent
brief psychotic episode, delusional disorder, dissociative condition, or potentially a
substance-induced event. Zar is an important example of how certain culture-bound
syndromes can be seen as normal, or as a sign of being "selected," where other
cultures would consider such symptoms pathologic. [1]

Shin-byung (Spirit Sickness)

Region/Culture: Korea
This folk diagnosis is characterized by anxiety and numerous somatic
complaints, such as weakness, dizziness, and gastrointestinal symptoms.
Patients often dissociate and attribute their state to possession by ancestral
spirits.[1] The condition can also be viewed as somatization of an underlying
major depressive or anxiety disorder -- or as an adjustment disorder -- which is
destigmatized by attributing this mental state to possession by a spirit. Shin-
byung shares features of somatoform or dissociative disorders.
Ghost Sickness
Region/Culture: Native Americans, Hispanics
Ghost sickness is characterized by a preoccupation with death and the
deceased and is frequently seen in Native Americans but has also been
described in Hispanic cultures. Symptoms are broad and can include weakness,
dizziness, loss of appetite, feelings of danger, dizziness, fear, anxiety,
hallucinations, and a sense of suffocation.[1] As evidenced by this symptom
constellation, ghost sickness could also be conceptualized as protracted or
pathological grief or depression, which is expressed predominantly somatically
and may increase the acceptability of the disturbed mental state to afflicted
people and those who know them.
Susto

Region/Culture: United States, Latin America, South America

From the Spanish for "fright," and common in certain Latino populations, susto
 refers to the soul leaving the body in response to a frightening experience.
Symptoms can recur for years and are consistent with multiple DSM-5
diagnoses, including major depressive disorder, posttraumatic stress disorder,
and somatic symptom and related disorders.[1]

Falling Out

Region/Culture: Southern United States, Caribbean

Falling-out episodes are characterized by a sudden collapse, sometimes
preceded by dizziness, in which patients often report temporary blindness
despite their eyes remaining open. Patients are generally aware of their
environment but report being unable to move.[1] This set of symptoms has
overlapping features with cataplexy, a rare condition in which patients have a
sudden and transient loss of muscle tone (usually in response to strong
emotions) and fall to the ground. They also may experience vasovagal syncope,
due to a strong physical or psychological event, as well as catatonia, conversion
disorder, or dissociative disorder.
Grisi Siknis

Region/Culture: Central and South America

Grisi siknis is a hysterical condition reported in Nicaragua. In English, the term
translates to "crazy sickness." It is highly contagious and affects mainly young
girls and women, especially those 15-18 years old. The attacks start with
headaches, dizziness, anxiety, nausea, irrational anger, and/or fear. During the
attack, the victim "loses consciousness," falls to the ground, and subsequently
runs away. Afflicted persons may view others as devils, feel no pain from bodily
injuries, and have absolute amnesia regarding their physical circumstances.
Some shadow-fight with unseen opponents, while others have been reported to
have performed superhuman acts and spoken in tongues. This condition has
features of dissociative or conversion disorders.[1]

Gururumba

Region/Culture: New Guinea

Gururumba describes an episode in which the afflicted person (usually a
married man) begins burglarizing neighboring homes, taking objects that he
considers valuable but which seldom are. He then runs away, often for days,
returning without the objects and amnestic about the episode. Sufferers have
been described as hyperactive, clumsy, and with slurred speech. This syndrome
has features of a dissociative or conversion disorder but also could be a
 substance intoxication-related condition.[8]