Con \201 dentiality expectations: the reality Despite con \201 dentiality being one of th e main foundations of the \200\230privi- leged \200\231 doctor \200\223patient relationshi p, expectations about where personal information may be reasonably disclosed varies amongst patients and medical professionals at different stages of their training. Table 21.1 Con \201 dentiality expectations House staff (%) Medical students (%) Where information revealed Patients (%) Large professional meeting 69 94 81 To of \201 ce nursing staff 50 69 83 Identi \201 ed by name to other physicians 23 60 55 Told as a story at a party: To other physicians 18 60 57 To non-physicians 9 36 45 Told to spouse or \200\230friend \200\231 17 51 70 Weiss B (1982) Con \201 dentiality expectations of patients, physicians, and medical stude nts. JAMA 247: 2695. 21_Semple_Chap21.indd 899 12/7/2012 4:33:34 PM CHAPTER 21 Legal issues 900 Breaking con \201 dentiality Personal information should not be disclosed to a third party (e.g. relative, partner, solicitor, police of \201 cer, or of \201 cer of a court) witho ut the patient \200\231s express consent, except in the circumstances described here (p. 90 0). If you decide to disclose con \201 dential information against a patient \200\231s wis hes, you must document this decision in the patient \200\231s notes and be prepared to expl ain/justify your decision (and communicate this decision to the patient). Disclosures to protect the patient or others In this case, the risk to third parties is so serious that it outweighs the patient \200\231s privacy interest, and the appropriate perso n or authority should be informed without undue delay. Examples of such circumstances inclu de: \200 Where a colleague, who is also a patient, is placing patients at risk as a result of illnes s or other medical condition. (If you are in doubt about whether disclosure is justi \201 ed, consult an experienced colleague, or seek advice from a professional organization. The safety of patients must come \201 rst.) Where a patient continues to drive, against medic al advice, when un \201 t to do so. In such circumstances you should disclose relevant inf ormation to the medical adviser of the Driver and Vehicle Licensing Agency without delay. F uller guidance is given on b p. 902. To assist in the prevention or detection of a serious crime (i.e. where someone may be at risk of death or serious harm) (e.g. threats of violenc e \200\224see the Box 21.4) or suspected child abuse (b p. 662). Disclosure in connection with judicial or other statutory proceedings Under certain circums tances disclosure of information is required by law: \200 \200 Noti \201 cation of a known or suspected communicable disease. If ordered to do so by a ju dge or presiding of \201 cer of a court (unless the information appears to be irrelevant, e.g. details of relatives or partners of the patient not party to the proceedings). To assi st a Coroner, Procurator Fiscal, or other similar of \201 cer in connection with an inques t or fatal accident inquiry (only relevant information should be provided). An of \201 cia l request from a statutory regulatory body for any of the health care professions, where di sclosure is necessary in the interests of justice and for the safety of other patients. Dif \201 cult situations \200 Children and other patients who may lack competence to give consent (see b p. 870). \200 Always try to persuade them to allow an appropriate person (e.g. individual with parental r esponsibility) to be involved in the consultation. Always inform the patient (and their rel ative or carer) prior to passing on information to another responsible person or statutory agency (e.g. social services). 21_Semple_Chap21.indd 900 12/7/2012 4:33:34 PM BREAKING CONFIDENTIALITY 901 Document in the patient \200\231s record the steps you have taken to obtain consent and the reasons for deciding to disclose information. Where a person lacks capacity, disclosure sh ould be in that person \200\231s best interests and follow the other basic principles regar ding con \201 dentiality. Situations of dual responsibilities (i.e. contractual obligations to third parties, such as companies or organizations) (e.g. occupational health services, insurance companies, bene \201 ts agencies, police forensic medical advisors, armed forces, prison services), as wel l as obligations to patients. Always ensure patients are aware of the purpose of the consul tation, and to whom you are contractually obliged to release information. If in doubt, cons ult (in UK): \200 General Medical Council (GMC): guidance may be found in the document: Con \201 dentiality: Protecting and Providing Information. Royal College of Psychiatrists (RCP): guidance may b e found at http://www.rcpsych.ac.uk/ \201 les/pdfversion/cr133.pdf Consider seeking the ad vice of your Medical Defense body. M Box 21.4 The Tarasoff case On 27 October 1969, Prosenjit Poddar killed his ex-girlfriend, Tatiana Tarasoff. Two months earlier, Poddar had declared his intentions dur- ing an outpatient appointment with his ps ychotherapist, Dr Lawrence Moore, at the University of California at Berkeley \200\231s Cow ell Memorial Hospital. Dr Moore tried to have Poddar con \201 ned to a mental institu- tio n for observation (including asking the university police for assist- ance). When law enfor cement agents decided that Poddar was harmless and released him, Moore \200\231s director, Dr Harvey Powelson, requested that all evidence of contact between Moore and the police dep artment be destroyed. No one, including Dr Moore, pursued the case further. After the murder, Tatiana \200\231s parents became aware of this prior knowl- edge and sued the university regents, hospital, and police department, claiming that, at least, a warnin g should have been issued to her. On 1 July 1976 (more than six-and-a-half years after the murder), the Supreme Court of California found that the defendants had breached their duty to exercise reasonable care. In other words, physicians and therapists have a duty to warn third parties of threatened danger arising from a patient \200\231s violent intentions. As a \201 nal statement, the Court stated that \200\230protective privilege ends where publ ic peril begins \200\231. Note: although often quoted when discussing issues of con \201 dentiality, this case has n o legal bearing in the UK. Even in the USA the impact of the Tarasoff case has been less dr amatic and intrusive than one might expect. 21_Semple_Chap21.indd 901 12/7/2012 4:33:35 PM CHAPTER 21 Legal issues 902 Fitness to drive Principles and legal de \201 nitions \200 The Driver and Vehicle Licensing Agency (DVLA) in the UK sets out minimum medical standards of \201 tness to drive and the requirements for mental health in broad terms. A clear di stinction is made between the standards needed for Group 1 (cars and motorcycles) and Group 2 (lorries and busses) licenses, the latter being more stringent due to the size of vehicl e and the greater time spent at the wheel. \200\230Severe mental disorder \200\231 is de \201 ned by section 92 of the Road Traf \201 c Act 1988 as \200\230mental illness, arrest ed or incomplete development of the mind, psychopathic disorder or severe impairment of int elligence or social functioning \200\231. The standards set re \202 ect not only the need for an improvement in the mental state but also a period of stability, such that the risk o f relapse can be assessed should the patient fail to recognize any deterioration. The stand ards for patients with misuse of or dependency on alcohol or drugs are detailed on b p. 606 . Notes on medication \200 Section 4 of the Road Traf \201 c Act 1988 states that \200\230any person who is driving or attempting to drive on the public highway, or other public place whilst un \201 t due t o any drug, is liable to prosecution \200\231. All drugs acting on the central nervous syst em can impair alertness, concentration, and driving performance. This is particularly so at initiation of treatment or soon after and when dosage is being increased. Driving must cea se if adversely affected. When planning the treatment of any patient (particularly professi onal drivers, e.g. of taxis, lorries, busses, or construction vehicles), always consider ad verse side-effect pro \201 les which may impair driving ability: \200 Antidepressants \200\224anticholinergic/antihistaminic effects (sedation). \200 Antipsychotics \200\224bo th sedation and EPSEs (assess regularly). BDZs \200\224the most likely psychotropic medicat ion to impair driving \200 performance; avoid long-acting compounds. For all psychotropic s \200\224consider the epileptogenic potential. Duties and other considerations \200 Duty of care potential dangers of adverse effects from medication and interactions with oth er substances, especially alcohol. Con \201 dentiality unsafe and the patient is either un able to appreciate this or refuses to cease driving, GMC guidelines advise breaking con \201 dentiality and informing the DVLA (see Box 21.5). Patients detained under the MHA pati ents (i.e. drivers must be able to satisfy the standards of \201 tness for their respecti ve conditions and be free from any effects of medication which will affect driving adversel y). Doctors have a duty to advise their patients of the When a patient has a condition which makes driving Similar rules as for informal 21_Semple_Chap21.indd 902 12/7/2012 4:33:35 PM FITNESS TO DRIVE 903 Further advice on \201 tness to drive \200 Doctors may write to the DVLA or may speak to one of the medical advisors during of \201 c e hours to seek advice about a particular driver (identi \201 ed by an M number), or about \201 tness to drive in general. All of the DVLA advice is available online at: (includin g an email facility for use by medical professionals only). M http://www.dvla.gov.uk Box 21.5 GMC guidelines for informing the DVLA \200 The DVLA is legally responsible for deciding if a person is medically un \201 t to drive. They need to know when driving license holders have a condition which may, now or in the fu ture, affect their safety as a driver. Therefore, where patients have such conditions, you should: Make sure that the patients understand that the condition \200 may impair their a bility to drive. If a patient is incapable of understanding this advice (e.g. because of de mentia), you should inform the DVLA immediately. Explain to patients that they have a legal duty to inform the DVLA about the condition. If the patient refuses to accept the diagnosis or the effect of the condition on their abil ity to drive, you can suggest that the patient seeks a second opinion, and make appropriate arrangements for the patient to do so. You should advise patients not to drive until the s econd opinion has been obtained. If patients continue to drive when they are not \201 t t o do so, you should make every reasonable effort to persuade them to stop. This may include telling their next of kin. If you do not manage to persuade patients to stop driving, or y ou are given or \201 nd evidence that a patient is continuing to drive contrary to advice , you should disclose relevant medical information immediately, in con \201 dence, to the medical advisor at the DVLA. Before giving information to the DVLA you should inform the pa tient of your decision to do so. Once the DVLA has been informed, you should also write to the patient, to con \201 rm that a disclosure has been made. 21_Semple_Chap21.indd 903 12/7/2012 4:33:35 PM CHAPTER 21 Legal issues 904 DVLA requirements for speci \201 c psychiatric conditions Anxiety or depression without si gni \201 cant memory or concentration problems, agitation, behavioral disturbance, or suic idal thoughts. Group 1 drivers: DVLA need not be noti \201 ed and driving may continue. Gr oup 2 drivers: Very minor short-lived illnesses need not be noti \201 ed. Severe anxiety or depression with signi \201 cant memory or concentra- tion problems, agit ation, behavioral disturbance or suicidal thoughts. Group 1 drivers: Driving should cease p ending the outcome of medical enquiry. A period of stability depending upon the circumstanc es will be required before driving can be resumed. Particularly dangerous are those who may attempt suicide at the wheel. Group 2 drivers: Driving may be permitted when the person is well and stable for a period of 6mths. Medication must not cause side-effects which would interfere with alertness or concentration. Driving is usually permit- ted if the anxiety or depression is long-standing, but maintained symptom- free on doses of psychotropic medicat ion which do not impair. DVLA may require psychiatric reports. Acute psychosis (any cause) Group 1 drivers: Driving must cease during the acute illness. Re-licensing can be considere d when all of the following conditions can be satis \201 ed: \200 \200 \200 \200 Has remained well and stable for at least 3mths. Is compliant with treatment. Is free from adverse effects of medication which would impair driving. Subject to a favorable specialist report. Note: drivers who have a history of instability and/or poor compliance will require a longe r period off driving. Group 2 drivers: Driving should cease pending the outcome of medical enquiry. The person mu st be well and stable for a minimum of 3yrs with insight into their condition before drivin g can be resumed. At that time, the DVLA will usually require a consultant examination. Any psychotropic medication should be of minimum effective dosage and not interfere with alert ness, concentration, or in any other way impair driving performance. There should be no sig ni \201 cant likelihood of recurrence. Hypomania/mania Group 1 drivers: Driving must cease during the acute illness. Following an isolated episode, re-licensing can be reconsidered when all the following conditions can be satis \201 ed: \200 \200 \200 \200 \200 Well and stable for at least 3mths. Compliant with treatment. Insight has been regained. Fr ee from adverse effects of medication which would impair driving. Subject to a favorable sp ecialist report. 21_Semple_Chap21.indd 904 12/7/2012 4:33:35 PM DVLA REQUIREMENTS FOR SPECIFIC PSYCHIATRIC CONDITIONS 905 Note: hypomania or mania are particularly dangerous to driving when there are repeated chan ges of mood. Therefore, when there have been 4 or more episodes of mood swing within the pr evious 12mths, at least 6mths \200\231 stability will be required, with evidence of treatme nt compliance and a favorable specialist report. Group 2 drivers: Driving must cease pending the outcome of medical enquiry. The person must be well and stable for a minimum of 3yrs with insight into their condition before driving can be resumed. At that time, the DVLA will usually require a consultant examination. Any p sychotropic medication should be of minimum effective dosage and not interfere with alertne ss, concentration, or in any other way impair driving performance. There should be no signi \201 cant likelihood of recurrence. Schizophrenia or other chronic psychoses Group 1 drivers: The driver must satisfy all the f ollowing conditions: \200 \200 \200 \200 Stable behavior for at least 3mths. Adequately compliant with treatment. Free from adverse effects of medication which would impair driving. Subject to a favorable specialist report. Note: for patients with continuing symptoms, even with limited insight, these do not necess arily preclude licensing. Symptoms should be unlikely to cause signi \201 cant concentrati on problems, memory impairment, or dis- traction whilst driving. Particularly dangerous are those drivers whose psychotic symptoms relate to other road users. Group 2 drivers: Driving must cease pending the outcome of medical enquiry. The person must be well and stable for a minimum of 3yrs with insight into their condition before driving can be resumed. At that time, the DVLA will usually require a consultant examination. Any p sychotropic medication should be of minimum effective dosage and not interfere with alertne ss, concentration, or in any other way impair driving performance. There should be no signi \201 cant likelihood of recurrence. Dementia or any organic brain syndrome It is extremely dif \201 cult to assess driving abi lity in those with dementia. Those who have poor short-term memory, disorientation, lack of insight and judgment are almost certainly not \201 t to drive. The variable presenta- ti ons and rates of progression are acknowledged. Disorders of attention will also cause impai rment. A decision regarding \201 tness to drive is usually based on medical reports. Group 1 drivers: In early dementia when suf \201 cient skills are retained and progression is slow, a license may be issued subject to annual review. A formal driving assessment may be necessary. Group 2 drivers: Refuse or revoke license. Learning disability Group 1 drivers: Severe learning disability is not compatible with driv ing and the license application must be refused. In milder forms, provided there are no oth er relevant problems, it may be possible to hold a license, 21_Semple_Chap21.indd 905 12/7/2012 4:33:35 PM CHAPTER 21 Legal issues 906 but it will be necessary to demonstrate adequate functional ability at the wheel. Group 2 drivers: Recommended permanent refusal or revocation if severe. Minor degrees of le arning disability when the condition is stable with no medical or psychiatric complications may be compatible with the holding of a license. Persistent behavior disorder Includes post-head injury syndrome, psychopathic disorders, and non- epileptic seizure diso rder. Group 1 drivers: If seriously disturbed (e.g. violent behavior or alcohol abuse) and likely to be a source of danger at the wheel, license should be revoked or the application refuse d. License will be issued after medi- cal reports con \201 rm that behavioral disturbances have been satisfactorily controlled. Group 2 drivers: Recommended refusal or revocation if associated with serious behavior dist urbance likely to make the individual a source of danger at the wheel. If the person mature s and psychiatric reports con \201 rm stability a consideration would be given to restorat ion of the license but a consultant psychiatrist report would be required. 21_Semple_Chap21.indd 906 12/7/2012 4:33:35 PM 907 Chapter 22 Transcultural psychiatry Introduction 908 Cultural context and the presentation of psychiatric disorders 910 Cultural formulation of psychiatric disorders 912 Culture-bound syndromes 914 Glossary of c ulture-bound syndromes 916 22_Semple_Chap22.indd 907 12/7/2012 4:34:37 PM CHAPTER 22 Transcultural psychiatry 908 Introduction Psychiatry is undeniably a branch of Western medicine and our concep- tion of psychiatric illness (and how best to treat it) is undoubtedly heavily in \202 uenced by We stern social and cultural factors. However, the scienti \201 c validity of these concepts can be readily tested if they can be shown to cross cultural boundaries. Emil Kraepelin recognized this argument when he visited Java in 1896, and found that the cl inical symptoms of dementia praecox could be seen in patients he met there, just as they we re manifest in his own patients in Germany. It was not until the WHO International Pilot St udy of Schizophrenia in 1973 that the incidence of schizophrenia (de \201 ned by narrow cr iteria) was found to be 0.7 \200\2231.4 per 10 000 aged 15 \200\22354 across all nine count ries studied worldwide. Despite variations in the content of delusions and hallucinations ( which were culturally derived), the form was found to be the same. These conclusions have b een supported by a large number of epidemiological studies and similar results have been fo und for bipolar affective disorder. The manifestations of depressive, stress-related, and anxiety disorders show the greatest c ultural variations (see b p. 910). The myth that these are predominantly Western diseases h eld sway for a long time (based on views of Western civilization articulated most eloquentl y by Freud in Civilization and its discontents in 1930). Certain manifestations of emotional distress, termed \200\230culture-bound syndromes \200 \231 by P.M. Yap, a former professor of psychiatry in Hong Kong, are particular to differen t cultures. These present as mixed disorders of behavior, emotions, and beliefs and many ha ve local names (see b p. 916). Some are clear symptom-correlates of disorders found in ICD- 10 and DSM-IV; others have no Western equivalent but appear to be varia- tions of somatofor m, conversion, or dissociative disorders. Some Western disorders (e.g. anorexia nervosa, de liberate self-harm) are rarely seen in non-Western countries. However, as we move towards a more global society, \200\230Western in \202 uences \200\231 appear to be making these t ypes of disorder increasingly frequent in non-Western societies. Debate continues as to whether Western diagnostic categories are uni- versally valid. Under standing the biological underpinnings of the common disease entities (e.g. schizophrenia, b ipolar affective disorder, depression, anxiety) and the development of treatments based upo n our understand- ing of neurophysiological and neuropharmacological mechanisms will inform this debate. However, awareness of cultural issues as they impact upon an individual, thei r illness (and illness beliefs), and the relationship between psychiatrist and patient, is critical if we are to provide appropri- ate interventions successfully. 22_Semple_Chap22.indd 908 12/7/2012 4:34:37 PM This page intentionally left blank CHAPTER 22 Transcultural psychiatry 910 Cultural context and the presentation of psychiatric disorders Schizophrenia Some apparentl y psychotic experiences may be normal when viewed within a cultural context. This applies t o delusions (e.g. belief in magic, spirits, or demons) and hallucinations (e.g. seeing \200\230auras \200\231, the appearance of divine entities, hearing God \200\231s voice). Ot her evidence of apparent psychosis, such as disorganized speech, may actually re \202 ect local variations in language syntax, or the fact that the person is not completely \202 u ent in the language used by the interviewer. Differences in non-verbal communication (e.g. eye contact, facial expression, body language) may also be misinterpreted. Historically the re has been a tendency in the UK and US to diagnose schizophrenia more readily in certain c ultural groups (e.g. Afro-Caribbeans). This probably does not re \202 ect differences in t he incidence of schizophrenia, but rather a lack of understanding of cultural differences. Some symptoms of schizophrenia (e.g. catatonia) are more common in non-Western countries, a nd even between Western countries the diagnosis of brief psychoses (e.g. bouf e deliriante ) varies. Interestingly the course of schizophrenia appears to be more acute and have bette r long-term outcome in some developing countries. Mania Often used colloquially to mean \200\230changes in normal behavior \200\231, rather than its strict de \201 nition. It may be dif \201 cult to distinguish periods of frenzied activity (e.g. in amok \200\224see b p. 916) from increased activity, energy, and reduced need for sleep in a manic episode. Thi s may be par- ticularly dif \201 cult when such episodes are preceded by apparent depressi ve symptoms. Depression Cultural expressions of depressive symptoms vary across populations . In some cultures there is greater emphasis on somatic terms, e.g. \200\230nerves \200 \231 or \200\230headaches \200\231 (Mediterranean cultures); \200\230problems of the hear t \200\231 (Middle East); \200\230imbalance \200\231, \200\230weakness \200\231, or \200 \230tiredness \200\231 (China and Asia). This often makes the use of Western diagnostic cla ssi \201 cations dif- \201 cult, as symptoms may cross diagnostic boundaries (e.g. mood, anxiety, somatoform disorders). Equally dif \201 cult may be the interpretation of cul- t urally normal explanations for symptom causation \200\224which may appear delusional (e.g. spirit possession), or associated somatic symptoms (see b p. 802) \200\224that need to be d istinguished from actual hallucinations. Anxiety and stress-related disorders Agoraphobia Social sanctions against members of certai n populations (e.g. women) appearing in public may sometimes be confused with agoraphobic s ymptoms. Panic attacks In some cultures these may be interpreted as evidence of magic or witchcraft (particularly when they come \200\230out of the blue \200\231). OCD Religious and cultural beliefs strongly in \202 uence the content of obsessions and na ture of compulsions. It may often be dif \201 cult to assess the signi \201 cance of ritu alistic behaviors unless the clinician has a knowl- edge of local customs. 22_Semple_Chap22.indd 910 12/7/2012 4:34:37 PM CULTURAL CONTEXT AND PRESENTATION OF PSYCHIATRIC DISORDERS 911 PTSD Immigrants may have emigrated to escape military con \202 ict or par- ticularly harsh regimes. They may have had experience of signi \201 cant trau- matic events, but may be u nwilling (or unable) to discuss them because of language problems or fears of being sent ba ck. Somatization disorder Common types of somatic symptoms vary across cultures (and gender s within cultures). These re \202 ect the princi- pal concerns of the population (or indiv idual), e.g. worms/insects in the scalp/under the skin \200\224seen in South East Asia and Africa; concern about semen loss \200\224seen in India (see Dhat b p. 917) and China (see S henk-k \200\231ui b p. 920). Conversion and dissociative disorders More common in rural pop ulations, in \200\230less educated \200\231 societies, and may be culturally normal. Certa in religious rituals involve alteration in consciousness (including trance states), beliefs in spirit possession, and varieties of socially sanc- tioned behaviors that could be viewe d as conversion or dissociative dis- orders (e.g. falling out b p. 917, spell b p. 920, zar b p. 921). \200\230Running \200\231 subtypes of culture-bound syndromes have symptoms tha t would meet criteria for dissociative fugue (b p. 806). Anorexia nervosa More prevalent in Western societies, with an abun- dance of food, and where there are strong cultural in \202 uences promoting thinness as the ideal of body shape. Immigrants from other cultural b ack- grounds may assimilate this ideal, or may present with primary symptoms other than dis turbed body image and fear of weight gain (e.g. stomach pains, lack of enjoyment of food). Alcohol and substance misuse Cultural factors heavily in \202 uence the availability, patt erns of use, attitudes about, and even the physiological or behavioral effects of alcohol a nd other substances. Alcohol Social, family, and religious attitudes towards the use of alcohol may all in \202 uence patterns of use and the likelihood of developing alcohol- related problems. Although it is dif \201 cult to separate cause from effect, low levels of education, unemployment, and low social status are all associated with increased misuse of alcohol. In some populat ions (e.g. Japanese and Chinese) up to 50% may have a de \201 ciency of aldehyde dehydroge nase (complete absence in 10%), with low rates of alcohol problems in these populations bec ause the physiological effects of consuming alcohol may be extremely unpleasant (e.g. \202 ushing and palpitations due to accumulation of acetylaldehyde). How individuals behave when intoxicated may also be culturally determined, with aggressive and antisocial behavio r (typi \201 ed by \200\230football hooligans \200\231) not seen to the same extent in cu ltures where alcohol is more of a \200\230social lubricant \200\231, despite levels of alc ohol consump- tion being similar. Other substances Use of hallucinogens and other drugs may be cultur- ally acceptable when p art of religious rituals (e.g. peyote in the Native American Church, cannabis in Rastafaria nism). Equally, secular move- ments, typi \201 ed by the hippie movements of the 1960s and \200\23170s, or more recently the \200\230dance culture \200\231, provide a context in w hich psychedelic expe- riences (e.g. induced by LSD or MDMA) may be experienced without any adverse social sanctions. 22_Semple_Chap22.indd 911 12/7/2012 4:34:37 PM CHAPTER 22 Transcultural psychiatry 912 Cultural formulation of psychiatric disorders When there are clear cultural issues impactin g upon the presentation of a psychiatric disorder it is important to have a systematic way of describing the nature and form these take. This may help by engaging the patient more di rectly in the assessment process; identifying other predisposing, precipitating, or perpetu ating factors; and allowing any proposed manage- ment plans to be more tailored to the indi vidual patient. Issues that ought to be considered include: \200 Cultural identity \200\224how the person regards themselves; af \201 liations with ethnic or religious subgroups. Preferred language. If an immigrant \200\224integration into host s ociety and culture. Speci \201 c psychosocial factors that may be culturally determined. P articular social stressors. Support within the community (including the role of religious i nstitutions) and from family and friends. Availability and access to appropriate services. Culturally determined illness beliefs and behavior. What the patient believes to be wrong w ith them (the particular illness model used to explain perceived causation and nature of th e condition). How the patient expresses their symptoms (language used, local idioms, behavi oral manifestations). How the local community and family view their problems. The doctor \200\223patient relationship \200\224differences in culture, perceived social status, commu nication dif \201 culties (due to language) and how they impact on: \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 Eliciting symptoms and understanding their signi \201 cance. Forming a \200\230therapeuti c alliance \200\231. Discussing the possible treatment options (when \200\230disease model s \200\231 may be at odds with each other). The attitude of their culture towards mental illness and the implications of a psychiatric diagnosis (e.g. will preclude marriage in some cultures). 22_Semple_Chap22.indd 912 12/7/2012 4:34:37 PM This page intentionally left blank CHAPTER 22 Transcultural psychiatry 914 Culture-bound syndromes Culture-bound or culture-speci \201 c syndromes comprise a wide ra nge of disorders occurring in particular localities or ethnic groups. The behav- ioural man ifestations or subjective experiences particular to these disor- ders may or may not corres pond to diagnostic categories in DSM-IV or ICD-10. They are usually considered to be illnes ses and generally have local names. They also include culturally accepted idioms or explana tory mechanisms of illness that differ from Western idioms and outside of their cultural se tting may be mistaken for psychosis. Awareness of culture- bound syndromes is important to allow psychiatrists and physicians to make culturally appropriate diagnoses. According to Littlewood and Lipsedge (1987),1 these disorders share a number of common general characteristics: \200 Occur in young men or women who are \200\230powerless \200\231 and socially neglected. Usu ally dramatic with the individual unaware or not responsible. The disorder has symbolic cul tural signi \201 cance ( \200\230mystical sanction \200\231) and show a typical triphasic pattern: \200 \200 \200 \200 Dislocation of an individual as representative of a particular group. Emergence of symptoms as exaggerated form of this extrusion. Restitution into normal relationships. In fact, these features could also be applied to many of the Western neuroses (where \200 \230mystical sanction \200\231 is provided by the medical model). Although controversial, s ome commentators regard the neuroses (includ- ing dissociative states, somatoform, and conv ersion disorders) as exam- ples of Western culture-speci \201 c syndromes.2 This would inc lude a range of speci \201 c syndromes such as neurasthenia, fugue, and trance states, as well as the more modern neuroses: multiple personality disorder, ano- rexia nervosa, chroni c fatigue syndrome, alien abduction syndrome, recov- ered memory syndrome, ritual or satani c abuse, Gulf War syndrome, and even shoplifting and overdosing(!). If culture-bound syndromes are categorized according to primary phe- nomenology, a number o f common subtypes emerge (see Box 22.1). Descriptions of speci \201 c syndromes are outlin ed in the following glossary (b p. 916), illustrating the vast range of manifestations.3 22_Semple_Chap22.indd 914 12/7/2012 4:34:37 PM CULTURE-BOUND SYNDROMES 915 Box 22.1 Subtypes of culture-bound syndromes \200 Startle reaction menkeiti, bah-tschi, bah-tsi, baah-ji, imu, mali-mali, silok. Genital retr action Sudden assault sickness, juramentado, Puerto Rican syndrome, iich \200\230aa, going postal. Running Semen loss Food restriction mirabilis/holy anorexia. Spirit possession Obs ession with the deceased shin-byung. Exhaustion fag/brain fog, shenjian shuairuo, nervios. Suppressed rage e.g. latah, amurakh, irkunii, ikota, olan miryachit, \200 e.g. koro, suo yang, jinjinia bemar, rok-joo. e.g. amok, cafard/cathard, mal de pelea, \201 ghting \200 \200 e.g. pibloktoq/arctic hysteria, grisi siknis. e.g. dhat, jiryan, sukra prameha, shenkui. e.g. anorexia nervosa, bulimia nervosa, anorexia \200 e.g. bebainan, spell, zar. e.g. ghost sickness, hsieh-ping, e.g. neuraesthenia, chronic fatigue syndrome/ME, brain e.g. hwa-byung/wool-hwa-bung, bilis, colera. 1 Littlewood R and Lipsedge M (1987) The butter \202 y and the serpent: culture, psychopat hology and biomedicine. Cult Med Psychiat 11: 289 \200\223335. 2 Showalter E (1998) Hystori es. London: Picador Press. 3 For further reading see: Simons RC and Hughes CC (eds) (1985) The culture-bound syndromes: folk illnesses of psychiatric and anthropological interest. Do rdrecht: D. Reidel Publishing Company. 22_Semple_Chap22.indd 915 12/7/2012 4:34:38 PM CHAPTER 22 Transcultural psychiatry 916 Glossary of culture-bound syndromes Amok, Amuck (Malayan males) Literally \200\230battling furiously \200\231: sudden, unprovoked, random acts of violence, for which the subject is amnesic, and after which they may commit suicide. May be preceded by a period of depression or brooding, anxiety, or feelings of hostility following perceived loss of face or being i nsulted. Also called Matal/Mata Elap ( \200\230darkened eye \200\231). Similar syndromes ar e reported in other countries of South East Asia, the Philippines, Polynesia (cafard or cat hard), New Guinea (ahade idzi be), Puerto Rico (mal de pelea; \201 ghting sickness; Puert o Rican syndrome), the Andes of Bolivia, Columbia, Ecuador, and Peru (colerina), and the US (going postal; iich \200\231aa in Navajo Native Americans). Amurakh (Siberian women) \200 \230Copying mania \200\231 characterized by echo- praxia. (See Lata.) Arctic hysteria (See Piblokco.) Ashanti (West African women, e.g. Ghana) Consists of two subtypes: frenzied guil t and fear (FGF) where, sometimes following physical illness and fever, the person believes they are being punished for some offense, becomes frightened, and then frenzied, followed by a period of with- drawal, hallucinations, hebephrenic behavior, dancing, singing, tearin g off clothes, and eating feces; and depressive (DP) where those affected accuse themselves of being witches and harming someone else without conscious intent. In younger women this often follows a dif \201 cult childbirth and subsequent illness, or the death of an infant . Ataque de nervios (Puerto Ricans and other Hispanics) Dissociative trance disorder, usual ly following an acute stressful event (e.g. death or con \202 ict) with brief symptoms inc luding: a trance-like state (with narrowing of awareness, perceptual distortions, depersona lization, loss of conscious- ness, and partial or global amnesia), anxiety, somatic complai nts, impulsive behavior, and depression. Bangungut (young male Filipinos) \200\230Oriental nightmare-death syndrome \200\231 where a series of terrifying dreams culminate in death f rom presumed cardiac arrhythmia. (See also Hmong sudden death syndrome.) Bebainan (Indonesi a) Possession state, believed to be caused by a spirit power, deity, or other person, in wh ich the subject assumes a new iden- tity, associated with stereotyped involuntary movements and amnesia. Beserk, Berserk, Beserkergang (Northern Europe) \200\230Fighting fever \200 \231, very similar to amok. Bilis and colera (Latin America) An idiom of distress in which physical or mental illness is explained as due to extreme emotion (anger) that upsets the h umors (described in terms of hot and cold). Brain fag, brain fog syndrome (West African stu dents) \200\230Brain fatigue \200\231, an idiom of distress with symptoms attributed to ov er-work, tiredness, and \200\230too much thinking \200\231. The subject complains of reduc ed concentra- tion, poor memory, blurred vision, and head/neck pain (often described as 22_Semple_Chap22.indd 916 12/7/2012 4:34:38 PM GLOSSARY OF CULTURE-BOUND SYNDROMES 917