Culture and Psychopathology

Culture and Psychopathology Overview

• Cultural considerations are important regarding psychopathology.
• It's vital to understand cultural syndromes, idioms, and explanations with relevant examples.
• The impact of culture on psychopathology must be understood.
• Stigma surrounding mental illness needs to be described.
• Various stigma processes have to be explained .
• Trends in stigma, both in Australia and internationally, need to be defined.
• It's important to understand the significance of stigma for individuals with lived experience of mental illness and their support systems.

Cultural Considerations in Clinical Practice

• Psychological symptoms are expressed differently based on the influence of culture, and what is considered a disorder varies.
• Cultural identity influences mental health perceptions.
• Cultural explanations shape reactions to individual experiences with mental health.
• Cultural expectations affect the psychological experience and levels of functioning.
• Cultural elements impact the relationship between the individual and the clinician.

Consequences of Ignoring Cultural Factors

• Failure to consider cultural factors can lead to misdiagnosis.
• This also risks the perpetuation of clinical stereotypes based on race, ethnicity, gender, religion, or sexual orientation, among other factors.

Contemporary Views on Psychopathology

• Concepts of mental health and illness are becoming broader and more benign.
• The increasing use of umbrella terms lacks specificity, like grouping panic disorder under generalized anxiety.
• Over-diagnosis and overtreatment is occurring due to expanding diagnostic ranges in DSM editions, leading to false epidemics.
• Benign experiences that are less serious are creeping in, which marginalizes people who experience severe problems.

Historical Perspectives

• Ancient Mesopotamian cuneiform texts (circa 2000-1500 BCE) described depression and anxiety.
• Ancient Mesopotamian cuneiform texts also described psychosis.
• Supernatural interpretations of possible psychotic experiences were common.
• Hippocrates (c. 460-370 BCE) considered the father of Western empirical medicine, rejected supernatural explanations for psychopathology.
• Hippocrates proposed that biological, psychological, and social/environmental factors were key in the prevention, treatment, and understanding of mental illness.
• Hippocrates' theory centered around the 'humors' or bodily fluids, were imbalances among blood, phlegm, black bile and yellow bile.
• Conditions like mania, melancholy, phrenitis, insanity, paranoia, panic, epilepsy, and hysteria, were described.

Evolution of the Concept of Hysteria

• Hysteria was a 'female condition' used to pathologize and control non-conformity.
• Hippocrates saw 'wandering womb' as the cause, therefore only females could be afflicted and treated with 'scent therapy', sexual activity, and pregnancy.
• The 16th/17th centuries attributed it to sexual deprivation or excess fluid in the uterus, treated by sexual activity and pregnancy.
• In the 19th Century (e.g., Freud), it was a catch-all psychological diagnosis for women defying social norms.
• Symptoms ranged from emotional outbursts to physical issues (conversion) to non-conforming behavior.
• Stereotypes of women as irrational were created.
• The disorder was eventually abandoned due to gender bias and lack of clinical precision, though it still appears in Functional Neurological Symptom Disorder in DSM.

Homosexuality in the Context of Culture and the DSM

• Homosexuality once seen as a pathological sign of biological defect and as a social evil.
• Religious institutions held sway in this view.
• Darwinism and legal systems played a part.
• In 1956, psychiatrist Edmund Bergler held harmful views towards homosexuals.
• Freud in 1935 considered homosexuality not shameful, nor a vice or illness, but a variation of sexual function.

Steps Toward Declassification

• The 'Kinsey Reports' ('Sexual Behaviour in the Human Male'/'Female') were best sellers due to high prevalence of homosexual behavior being demonstrated.
• Evelyn Hooker demonstrated no inherent association between homosexuality and psychological maladjustment.
• LGBT activism emerged, including the Stonewall Riots in 1969, and Christopher St Liberation Day March in 1970.
• A broader cultural challenge to power emerged via the Civil Rights Movement, and the Anti-War Movement.
• On December 15, 1973, Homosexuality was removed from DSM

Understanding Cultural Bound Syndromes

• These are clusters of co-occurring symptoms that are relatively unchanging.
• These symptoms are usually found within a specific cultural group, community, or context.
• Often conceptualized as an illness/affliction within the culture, but that is not always the case.
• They also have a cultural explanation, name, and method of treatment.

Aboriginal Australian Culturally-Bound Syndromes

• They exist in Aboriginal communities: culturally-bound syndromes are perceived as normal in Aboriginal communities but are considered mental illness from a Western perspective, leading to misdiagnoses.
• Examples include spiritual visits from those that have passed on, and sorry cutting during grief.

The Concept of Longing for Country

• Longing for country involves spiritual disconnection from traditional lands in Aboriginal people.
• This leads to physical ill health, such as weakness and nausea, as well as spiritual ill health.
• It also causes cognitive disorientation and cultural "ill health."
• Treatment involves returning to reconnect with the land, culture, and spirit.
• People know they need to return home due to sadness, despondency, moodiness, frequent crying, wanting to be alone and arguing.
• People consider going home to "a rejuvenation".

Ataque de Nervios

• This syndrome is diagnosed among individuals of Latino descent.
• Symptoms include intense emotional upset, acute anxiety, terror, or grief, uncontrollable screaming, attacks of crying, trembling, heat in the chest rising into the head.
• It can also involve the subject becoming verbally and physically aggressive.
• Dissociative and seizure-like experiences are also associated.

Khyâl Cap

• This syndrome is found among Cambodian people both in Cambodia and internationally.
• There exists common symptoms similar to those of panic attacks, such as dizziness, palpitations, shortness of breath, and cold extremities.
• Other symptoms include anxiety and autonomic arousal, which present themselves as tinnitus and neck soreness.
• Attacks include catastrophic cognitions centered on the concern that khy'l (a windlike substance) may rise in the body-along with blood and cause a range of serious effects.

Cultural Idioms of Distress

• Cultural idioms of distress are linguistic terms or phrases.
• Describe suffering within a cultural group, like similar ethnicity or religion.
• The idioms refer to shared concepts of pathology, methods of expression, communication, or essential features of distress.

Kufungisisa

• 'Thinking too much' in Shona culture (Zimbabwe) presents as an idiom of spiritual, mental, and social distress.
• It is considered by the culture to be a causative agent.
• It commonly causes symptoms of anxiety, depression, stress more broadly, and somatic problems.
• This also causes interpersonal and social difficulties.

Cultural Explanations

• A label, attribution, or feature of an explanatory model provides a culturally conceived etiology or cause.
• Examples include 'maladi moun' in Haiti or being sung/pointing the bone in Australian Aboriginal culture, for symptoms, illness, or distress
• Causal explanations are features of folk classifications of disease.

Maladi Moun

• Translated, this means "humanly caused illness" and it is sometimes referred to as "sent sickness."
• Interpersonal envy and malice cause people to harm one another illnesses such as psychosis, as well as depression, social or academic failure.

Culture and Symptom Expression

• Visual hallucinations are more common in developed than developing cultures.
• Hallucinations and delusions involving paranoid themes are more common now.
• Hallucinations involving themes of wealth and grandeur were more common during the 1930s in the US.
• Auditory verbal hallucinations: phenomenology and cultural responses vary considerably.
• USA vs Africa/Asia: differences in explanations of voices.
• USA vs India/Ghana: differences in distress and Command-Order AVH.
• Kenya - Masai: culturally endorsed AVH vs not.

Stigma

• Originated with the ancient Greeks, who branded criminals, slaves, or traitors to mark them as undesirable.

Mental Illness Stigma Framework (Fox et al., 2017)

• Stigma can be broken down as stereotypes, prejudice, and discrimination.
• These are intersected with various factors in the stigmatized individual.
• These could include mental illness type, gender or ethnic background .
• Internalized, anticipated, and experienced stigmas all shape public perception.
• The end result is that help-seeking is reduced.
• Participation and mental health outcomes are made more difficult.
• Opportunities become more scarce, and self-esteem is diminished.

Types of Stigma

• Self-stigma (internalized stigma) occurs when people with mental health conditions are aware of and agree with negative stereotypes.
• Stigma by association (affiliate/courtesy stigma) are negative stereotypes and discrimination directed at family members or staff.
• Public stigma covers knowledge, stereotypes, negative attitudes (prejudice), and discrimination by society.
• Structural stigma covers policies and practices that disadvantage those with mental health conditions.

Australians affected by Stigma

• Australian context: greater stigma exists about common disorders like depression and anxiety.
• Stigma exists to a less extent about poorly understood disorders.

National Stigma Report Card

• This survey aimed to understand how Australians living with severe and complex mental illnesses experience stigma and discrimination.
• It hoped to advocate for action to address its findings.
• The survey’s participants included those aged 18 and over, living in Australia and diagnosed with one or more severe and complex issues over the 12 months prior to the survey being conducted .
• It comprised 1912 Australians, averaging 39 years old.
• It covered 14 Life Domains - Relationships, Employment, Healthcare services, Social media, Mental healthcare services, Mass media, Welfare and social services, Education and training, Housing and homelessness services, Cultural, faith or spiritual practices and communities, Sports, community groups and volunteering.

Key Findings From the National Stigma Report Card

• Respondents reported experiencing stigma and discrimination mostly in relationships with friends and family and in social media.
• A common negative experience among the respondents was that their illness was dismissed and that they were ignored.
• Another common negative experience reported involved being isolated or estranged by potential friends.

Positive treatment in Relationships

• Some respondents stated that "being in a relationship allows me to talk more that I ever have about how I feel. On my own, I never spoke to anyone about the things which consumed me”.

Stigma by Association in Australia

• Support persons reported discriminatory experiences.
• Some had been shunned or avoided by people who found out about their support role.
• Many had avoided telling others for fear of being judged.

How to Reduce Stigma and Discrimination

• Positive contact should be made with people with lived experience.
• Psychoeducation: It helps to improve understanding and dispel myths.
• Family capacity building can help reduce Stigma and discrimination.
• Skills training can help those affected to cope with this issue.
• Connection with community.
• Individual and group psychological therapies including cognitive, acceptance-based, narrative enhancement, and self-compassion approaches are useful to address the problems.