Cultural Assessment And Treatment Of Psychiatric Patients

Function

With rapid changes in the ethnic diversities and multicultural and linguistic groups in the population, clinicians need to develop awareness and knowledge about different attitudes and beliefs that can influence their psychological thought processes. In assessing a patient who speaks a different language other than English and may hold beliefs that are different from the mainstream culture, every clinician has to be knowledgeable about the complex processes that facilitate adjustment and conflict resolution among members of that culture. Every cultural group defines what they consider a spectrum of "normal behaviors" within their ethnic or cultural group. They also have various thresholds of tolerance for "abnormal behaviors." Behavior that may be unacceptable in Western society can lead to a diagnosis of a psychiatric disorder for a clinician who is raised and trained in the same society. However, the same behavior in other subcultures or ethnic groups can be indicative of a normal adaptive response to a stressful situation. In understanding a patient's cultural identity, the clinician should make a note of the patient's age, gender, race, ethnicity, language, sexual orientation, socioeconomic class, education level, and religious and spiritual beliefs. For immigrants and ethnic minorities, it is crucial to understand the degree of acculturation and capacity to adapt to the host culture.[5][6][7]

Issues of Concern

Some of the psychopharmacological considerations for patients of varying backgrounds are listed below.

African Americans tend to receive more diagnoses of schizophrenia compared to other populations. When presenting with affective disorder, clinicians often misdiagnose them as having schizophrenia. African American clients also receive higher doses of antipsychotic medications and can be more sensitive to the effects of these medications. They are also less likely to receive second-generation antipsychotics and have twice the likelihood of tardive dyskinesia compared to Caucasians.

Hispanic Americans tend to focus more on somatic complaints when depressed compared to other populations. They also require half of the dose of anti-depressants compared to Caucasians in treatment. The Hispanic population is also more prone to experience anticholinergic side effects of psychopharmacological agents. 

Like Hispanics, Asians will often deny depressed mood but present with more somatic rather than psychological complaints. Asians are also at higher risk of extrapyramidal side effects of psychotropic medications. Research has shown plasma haloperidol levels to be 52% higher in the Chinese than in other populations.

Caucasians have lower serum haloperidol and prolactin levels than Asians (both American and foreign-born). Studies have found a  correlation between a genetic marker, the human leukocyte antigen HLA-B*1502, and Stevens-Johnson syndrome induced by carbamazepine in certain groups of the Chinese population.

Alcohol metabolism differs in cultures. Eighty percent of Asians, particularly women, and 50% of native Americans exhibited the flushing response to alcohol which is explained by the genetic polymorphism of the isoenzymes alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ADHD), enzymes that are critical for the metabolism of alcohol.

The cytochrome P450 enzyme system plays a key role in the metabolism of psychotropic and non-psychotropic drugs. Genetic defects in the isoenzymes of this system are present in certain ethnic groups that can put them at risk of being poor metabolizers and thus make them more vulnerable to the toxic effects of drugs.

Clinical Significance

The notion of “cultural syndromes” was first introduced by Lewis-Fernandez in the latest published Diagnostic and Statistical Manual of Mental Disorders as 1 of 3 concepts that replaced the concept of “culture-bound syndromes.” Lewis-Fernandez wrote that cultural syndromes are “clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts.” He led the development of DSM-V Cultural Formulation Interview, a standardized method for cultural assessment in mental health practice.

The following are a few cultural syndromes to be aware of in practice.[8][9][10]

An example of a cultural syndrome specific to Koreans and Korean immigrants is Hwa-Byung, and what follows here is a summary of symptoms and possible treatments for this condition.

The incidence of comorbid depression, anxiety, and conversion disorder are high in middle-class, middle-aged Korean women. The prevalence of these symptoms among Korean women is high, as Koreans customarily internalize their emotions. The symptoms of Hwa-Byung are mostly physical, presenting with palpitations, insomnia, and headaches. Psychological symptoms may include but are not limited to, heightened startle response, sad or depressed mood, and guilt or hopelessness. The syndrome is translated into English as "anger syndrome" and explained as suppression of anger.

Treatments for Hwa-Byung vary widely. While some Korean families may be open to the concept of family therapy to benefit the family as a whole, other families may decline family therapy as they identify women to be the primary source of the problem in the family. Korean women often have difficulties verbalizing their distress and directly confronting their spouse and children in therapy. Family therapy in the United States commonly engages families in discussing their interpersonal conflicts and family dynamics in session. But this is often not acceptable to the Korean culture. A family therapist working with this culture needs to be aware that when there are significant tension and stress among family members in a session, it may be necessary to incorporate individual sessions into the treatment. The wife may feel more comfortable discussing personal issues about relationships in a non-threatening and confidential environment of an individual session. In joint sessions, the therapist has to focus on teaching concrete skills rather than discuss the wife's specific concerns. The development of Hwa-Byung may be related to the chronic stress involved with interpersonal family conflicts, however other social issues like poverty, lack of trust in relationships, discrimination of women and other weaker individuals in the family can be an added source of stress. It also merits noting that the syndrome often manifests with physical symptoms rather than psychological symptoms. Thus a clinician should integrate psychotherapy in treatment early on and not just depend on medications to treat the physical symptoms.

Another example of a culture-bound syndrome is Amok. This condition is a dissociative episode characterized by depression followed by outbursts of violence, aggression, and homicidal behavior. This syndrome tends to be caused by a perceived threat to the individual and is accompanied by persecutory ideas. After a stressful stimulus occurs, there is a period of social withdrawal and brooding followed by aimless wandering; this can then transition to a sudden and extremely violent homicidal tendency. Verbalizations may be frenzied and may represent internal conflict. Cessation may occur spontaneously but usually results from being overpowered or killed. Psychosis or depression may occur after the episode. Amok is prevalent only among males from Malaysia, Laos, Philippines, and Polynesia.

Ataque de nervios is a condition reported primarily among Latinos from the Caribbean and Latin America. The most common symptoms include uncontrollable shouting, crying, and verbal or physical aggression. Dissociative experiences, in addition to seizure-like or fainting episodes, can be present. A general feature of ataque de nervios is a feeling of being out of control. It most commonly occurs as a response to a stressful event related to the family. The initiation of the episode is immediate upon exposure to the stimulus. An intense affective storm is followed by bodily sensations (trembling, chest tightness) as well as swearing, yelling, and possible attempts to harm self or others. Partial or total amnesia frequently follows the attack and may include alterations of consciousness. Psychotherapy has proven to be useful, and medication can be indicated to address underlying symptoms of anxiety or depression.

Dhat is a folk term used to describe severe anxiety and hypochondriacal concerns with the discharge of semen that contributes to feelings of weakness and exhaustion in the male population in rural India.

Koro is a syndrome that exists in some East Asian cultures; this presents with intense anxiety related to fears that the genitalia will recede into the body and cause death.

Susto is an illness prevalent among Latinos in the United States that correlates with a scary event that causes the soul to leave the body and leads to unhappiness and sickness. Patients may often present with neuro-vegetative symptoms of disturbances in sleep, appetite, and multiple somatic complaints.

Other Issues

In conclusion, to develop a better understanding of the treatment of cultural issues, four principles should be considered.

1. The importance of avoiding stereotypes about individuals and groups
2. Learning how to ask the right questions-that is, improving the clinician’s skills for active listening and eliciting culturally relevant information
3. Improving cultural competence in a way that is coextensive with the trainee’s emerging clinical skills in other areas
4. Improving the clinician’s insight and acceptance of cultural competence as integral to the assessment and clinical care of every patient

Cultural sensitivity remains vital in the accurate diagnosis and treatment of patients from different backgrounds and ethnicities. The treatment of Hwa-Byung, for example, shows the finesse needed by the diligent physician to ensure proper management of this condition. Cultural influences carry links with healthcare disparities and the providers’ attitudes in the clinical encounter. The entire health care team must learn the importance of appropriate response to a patient’s concerns that involve cultural differences. Studying one’s implicit assumptions regarding reactions towards a patient’s culture can help eliminate bias and improve the deliverance of healthcare. Delicately eliciting cultural information is also necessary to help enhance rapport with the patient and family.

Enhancing Healthcare Team Outcomes

Treatment of a cultural syndrome is a diagnostic challenge for any clinician. Gathering a detailed history and understanding the patient and the family's views and opinions about the presenting problems assists in developing insight into the dynamics of the patient's world and helps the clinician in developing a treatment plan that is acceptable and conducive to the patient's well being. This approach also facilitates better communication between patient and clinician and leads to improved outcomes in treatment.

Irrespective of their particular role in the health care team, each member must be aware of these cultural differences when dealing with patients and report to the team leader as concerns arise. As one member of the team learns about a cultural norm that applies to a patient, they should document it for the benefit of other members; this prevents wasted time for each team member to have to find out the same information, and also can avoid indelicate situations that may occur as each provider interacts with the patient for the first time. Physicians (MDs, DOs, NPs, PAs), nurses, pharmacists, and other healthcare team personnel all bear a responsibility to not only understand and respect these cultural differences but also to share them with other providers. This type of collaborative communication will streamline the healthcare delivery process and better drive optimal outcomes for patients with cultural diversity concerns. [Level V]