Cultural psychiatry

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Cultural psychiatry Powered By Docstoc
					 Cultural
psychiatry
                     „Culture‟
• Culture refers to the meanings, values and
  behavioural norms that are learned and
  transmitted in the dominant society and
  within its social groups. Culture powerfully
  influences cognition, feelings, and self
  concept as well as the diagnostic process
  and treatment decisions.
        – The National Institute of Mental Health‟s Culture and
          Diagnosis Group, 1993.
                       Race
• An alternative view is that the number of alleles
  that determine visible differences is such a small
  proportion of the total genetic constitution that the
  term „race‟ is inappropriate.
• When actual allele frequencies are studied in
  „different races‟, allele differences are found more
  often within each group than between groups.
How does ethnicity relate to culture?
• Ethnic groups may approximate sufficiently to
  culture if the sample from which they are drawn
  contains a self selected cultural group.
• If ethnicity is to be used as a key variable in
  research as a class of person its validity as a
  measure of culture, identity,religion and race
  must be fully established for the research to be
  meaningful.
1
                          formulation
          Culturalpatient’s culture, including lan-
    Identification of the
guage and spiritual/religious affiliation, and multi-
cultural identity;
2 Cultural explanations of the illness (i.e. idioms of

distress, explanatory models, experience with popular
and professional sources of care);
3 Factors related to the psychosocial environment and

functioning (e.g. cultural influences on stressors,
social support and stigma);
4 Cultural aspects of the relationship between patient

and clinician.
    College on stolen generation
• May 1997 “Bringing them home” report by
  Human Rights and Equal Opportunity
  Commission
• Removal lead to higher rates of:
   –   Ill health
   –   Arrest
   –   Substance abuse
   –   Premature death
• College apologetic on behalf of profession for not
  having done more to prevent this
What should services aim for?
• Accessible

• Appropriate

• Acceptable
Interpreters: practical considerations
• Time- interviews usually take twice as long.
• Seating- TRIANGULAR is the best
• Take time for introductions
• Define the nature of the interview
• Ensure that the language is correct and
  acceptable
• Political/religious/cultural differences
  should not affect the interview.
        Practical Considerations
• Age/ gender of the interpreter can be very important.
• Confidentiality
• Interruptions and clarifications
• Ensure that the interpreter does not give their own
  technical interpretation
• Ending the interview
• Post interview de-briefing with the interpreter
       Culture bound syndromes*
Whitigo    Syndrome described in native American
           Indians, with fear of being turned into a
           cannibal through possession by a supernatural
           monster.
Koro       Fear that the penis will shrink into the abdomen,
           resulting in death
Amok       Southeast Asian syndrome involving a sudden
           homicidal rampage ending in exhaustion and
           amnesia.
Piblokto   Eskimos: 30 min excitement with bizarre and dangerous
           behaviour preceded by days of withdrawal and irritability
           and followed by seizure and 12 hours of coma. Amnesic
           for event
Neurasthenia    China: fatigue, somatic (dizziness, headache),
     Culture bound syndromes*
Latah       Malaysian word. Syndrome in many parts of
            world: hypersensitivity to sudden fright with
            echolalia, echopraxia, command obedience and
            dissociative or trance-like behaviour
Brain fag West Africa esp.: students having cognitive
            difficulty, “brain fatigue”, somatic head & neck
            sx in response to stresses or study.
Shenkui     Marked anxiety/panic, somatic/vegetative sx
            with sexual dysfunction. Thought to be because
            of excessive semen loss.
Qi gong     Acute, time-limited dissociative, paranoid or other
            psychotic reactions after participating in qi gong (exercise
psychosis   of vital energy).
  Indigenous MI risk contributors
Access       Mistrust of colonisers & their institutions
             Difficulty establishing rapport
             Culturally inappropriate services
             Social/financial disadvantage
Diagnosis    Misdiagnosis <= mis-interpretation of sx
Prevalence Depression esp. <= deculturation/land loss
             SA
             Socioeconomic depravation
             family disintegration
             Abuse
  College ethical guide to ATSI

General    Recognise MI/SA/physical
           Recog. Dispossession/hx
           Recog. Ongoing racism/disadvantage
           Recog. May need special expertise
           Learn about culture
           Respect patients & ATSI colleagues
           Western health model not necessarily applicable
Clinical   Use understandable language/interpreters
           Use safe/culturally appropriate environment
           Use ATSI health workers
           Respect/use traditional healers/methods
           NB land, spitirual/cultural influence
       College on ATSI MHPs
• Paid adequately e.g. because of varied work hours
• Gender issues addressed
• Respected as part of multidisciplinary team
• Research
• Lack of formal qualifications should not be a
  barrier
• Should be able to review own budget allocation
          Cultural depression
Synonyms Cultural grief
           Collective PTSD
           Acculturative stress
Clin       Culture-wide
              mood, worth, self-esteem, hope
              self-destruction: self-harm, SA
Aet        Individual beh. not enough to explain  MI/SA
           Explanatory model of  MI/SA:
           Probably <=
              cultural genocide,
              loss of control,
              tension in trying to live in both cultures at once
Odds and
  ends
         Vicarious Traumatisation

• Distress associated with working with
  victims of extreme trauma
  –   Preoccupation and rumination
  –   Intrusive imagery
  –   Mood disturbance
  –   insomnia
  –   Changed world view, paranoid perception
                       Terminology
Prosopagnosia       Dys-recognising faces

 Palinopsia      Recurring visual hallucinations

Aesterognosis    Dys-recognising by touch

Autotopagnosia   Dys-recognising own body parts

Pareidolia       the erroneous or fanciful perception of a pattern or meaning in
                 something that is actually ambiguous or random.*

Anosognosia      Denial of an illness or defect
Finger agnosia          Terminology
                 Dys-recognising which finger was touched

                 Impairment of perversion of sense of taste
   Dysgeusia

                 = catalogia. Senseless repetition of stereotyped words and phrases
Verbigeration

                 Seeing an image of oneself/part thereof, recognised as oneself,
Austoscopy       often tranparent or colourless. Often mimics patient.  in
                 stress. Rarely progresses to schizophrenia.
Capgras vs       Seeing the familiar as identical imposters
Fergoli          Seeing the unfamiliar as familiar
                 Nihilistic delusions about having being dead!, havingı lost
Cotard sdm       finances, loved ones or even organs. In SCZ or elderly
                 psychotic MDE.
De            Erotomanic delusion esp. regarding someone of higher status
Clerambault’s
Ganser syndrome           Terminology
                  Pretending psychosis

                  Originally Florence Goodenough‟s 1926 Draw-a-man test of
Draw-a-person
                  intelligence for children. Revised by Harris (63) and Machover
    test
                  (46) to include aspects of personality. Culture free.
Gegenhalten       Involuntary resistance to having limbs moved by examiner

                  Involuntary, sudden loss of tone e.g. following laughing,
Cataplexy         anxiety or anger

Catalepsy         Waxy flexibility

                  Non-volitional, stereotyped movements that are more complex
Stereotypy        than tics and occur while fully conscious

                   consistent, characteristic, distinctive, apparently purposeful and highly stylised
                  ways of doing things, that may seem very exaggerated or bizarre ( eg spinning b/f
Mannerisms        sits )
                  - under voluntary control ( unlike complex tics, automatisms and stereotypies )
                  - not accompanied by altered consciousness ( unlike automatisms )
Cluttering
                        Terminology acts
                  Dropping ends of words etc. while talking very rapidly
                  •Loss of the ability to perform purposive
 Parapraxia vs
                  •Unintentional words/behaviours that are clues to the person‟s
  Parapraxis
                  wishes, attitudes, impulses i.e. the Freudian slip
                  Blocq‟s disease. Conversion disorder with inability to stand
Atasia abasia     (atasia) or walk (abasia) despite normal lying muscle tone and
                  power. Patient staggers or falls if it is attempted to walk her.
                  Diminished sensitivity to pain
Dysesthesia

                  Able to see parts but not integrate into a whole or understand
Simultanagnosia   what is happening in a scene although different elements are
                  recognised. ? Left anterior occipital lobe lesion
                  Inability to express affect through tone of speech: dominant
Dysprosody        lobe disorders

Gestalt           Fredrick Perls. Emphasis on here & now.
therapy
                             Definitions
 Elementary Noises rather than formed words
hallucination
                    Hallucinations that required a triggering sensory stimulus e.g.
 Functional
               hearing a bark leads to hearing a voice. Within one sensory
hallucinations modality.

    Mass       Hearing a whole crowd of voices
hallucinations
    Silent          Common visual hallucination in the elderly: full-sized figures
   boarders         in the house who do not speak.

   Somatic     Haptic: touch                          Kinaesthetic: joint mvt/pos
hallucinations Hygric: wetness                        Thermic: cold/hot

   Perceptual       The label used for illusions that occur in organic states e.g.
misinterpretation   delirium

   Extra-     Hallucinations beyond the sensory field e.g. hearing someone
campine Hall. speak in Italy
                            Definitions
               an action where the person                        Insane: due to a mental disorder
               committing is not in control of                   (inc.TLE)
Automatism     his/her behaviour.                                Sane: not due to a mental disorder


               Experiencing a stimulus in one modality (e.g. a bark) as a
Synasthesia    sensation in another (e.g. the colour red)

               Inability to write (complete or being limited to letters and
 Agraphia
               unable to write words/phrases). Broca‟s or Dominant parietal.
               (= visual aphasia) Inability to understand written words
   Alexia
               Wernicke‟s or Dominant parietal lobe lesion
               = False memory: “remembering” something not experienced
Paramnesia
               e.g. jamais vu, or believing a story you‟ve heard is actually real
               The slowing of mind seen in patients with Parkinson‟s disease
Bradyphrenia
               that parallel‟s their slowed movements
               [L.parents of the country] The state or other authority regarded as legally responsible to protect
  Parens       citizens who can not protect themselves, or the principle of such responsibility e.g. the
               constitutional right of the state to involuntarily commit the mentally ill
  patriae
                  Definitions
               an abnormally increased distance
Hyperterlorism between two organs or parts.Usually it
               is used to refer to widely spaced eyes
             that persons with more than one disorder
 Berkson’s
             have an increased chance of being treated
   Bias
             for either disorder
                  Odds and ends
Charles         Persistent, complex, stereotyped visual hallucinations with
                insight without other psychotic phenomena, usu. In the
Bonnet          elderly and usu. With visual impairment.
Phonemic        Use of incorrect words approximating to the correct one in
                sound e.g. in Broca‟s area pathology: frouch instead of couch
paraphasia      vs Semantic (which involves approximations in meaning)
Gerstmann’s     Dominant parietal lobe lesion:
syndrome        Dyscalculia, dysgraphia, finger agnosia, L/R disorientation
Gait apraxia    Difficulty in initiating and maintaining gait despite intact
                motor function: bilateral medial frontal lobe pathology e.g. in
                hydrocephalus
Hyper-          Increased response and attention to visual stimuli e.g. in
metamorphosis   Kluver-Bucy syndrome
Paraphrenia     Either: paranoid schizophrenia OR scz with progressive
                deteriorating course OR well-systematized delusions
Cotard’s        Intermittent nihilistic delusions associated with mood,
                psychotic or organic disorders: that the person is dead, or
                                              ends
                     Odds and speech which is thus
                   Disjointed or disorganised
Incoherence
                   incomprehensible




Jargon             Incoherent speech due to aphasia. Sounds like word salad
apahasia
Wilson-Patterson GD Wilson and CH Patterson: social attitude scale used to
Attitude         assess conservatism-liberalism, realism-idealism, militarism,
Inventory        antihedonism, ethnocentrism and puritanism
Counter            Extinction of a particular response e.g. fear by conditioning
                   an acceptable response to the stimulus ≈ systematic
conditioning       desensitisation
Shaping            (Skinner) operant conditioning behaviour therapy by step-by-
                   step reinforcement of closer and closer approximations to the
                   desired response.
                Bits and bobs
45 X         Turner‟s
47 XXY       Kleinfelter
47 XXX       Triple-X
Palilalia    Repetition of words and phrases with increasing speed and
             diminishing meaning: Parkinson‟s, Alzheimer‟s, CO poison.
             The systematic desensitization achieved by having someone
Reciprocal   engage in progressive relaxation activities while reviewing
inhibition   segments of a trauma may inhibit anxiety*
Names and concepts in psychiatry
Malarial treatment of neurosyphilis (NobelPrize)Wagner von
Jauregg
Moral treatment; breaking chains in Saltpetriere Pinel (1745-
1826)
Primal therapy A. Janov
Psychobiology Adolf Meyer (1866-1950)
Psychodrama J. Moreno
Reciprocal Inhibition Joseph Wolpe
Self-instructional training Meichenbaum
Social Learning Albert Bandura
Sociological theory of suicide Durkheim
Suicide Thomas Browne
The Sick Role Parsons
Therapeutic Community Maxwell Jones
Transactional analysis F. Berne
Names and concepts in psychiatry
Abnormal Illness Behaviour Pilowsky
Advocated treatment without mechanical
restraints Conolly (1794-1866)
Aggressive and Creative Psychopaths Henderson
Agnosia Term coined by Freud
Alexithymia Nemiah & Sifneos
Anxiety Lewis
Crisis Intervention Linderman (1944), Caplan (1961)
Development of Clozapine Kane
Development of Imipramine Kuhn
Ecological theory of suicide Sainsbury
Gestalt Therapy F. Perls
Hypnotherapy Milton Erikson
Illness Behaviour Mechanic
Interpersonal therapy Sullivan
Names and concepts in psychiatry
Client-centred therapy: Carl Rogers
Inferiority complex: Alfred Adler
Novelty seeking: Cloninger
Good enough mothering: Donald Winnicot

1969 Attachment theory                  John Bowlby
1970s Biofeedback                       Birk
1971   Classification of phobias        Marks
1974   Structural Family Therapy        Salvador Minuchin
1974   The „Milan School‟ of Systemic   Palazzoli et al.
       family therapy
1976   Alcohol Dependency Syndrome       G. Edwards & M.
                                         M. Gross
1976   Cognitive Treatment of Depression A. Beck
1681 Hysteria – a disease of the mind
1800s
                       Names & concepts                                  Thomas Sydenham
          Removal of post-central, temporal, and frontal cortices from patients     Burckhardt
1843 Hypnotism                          James Braid; based on work by Anton Mesmer
1886 Dysmorphophobia                                                     Morselli
1893 Dementia Praecox                                                    Emil Kraepelin
1903 Barbiturates introduced
1905 Spirochaete isolated in GPI – the beginnings of biological          Schaudinn
     psychiatry
1911    The Four A‟s of Schizophrenia                                    Eugene Bleuler
1913 Behaviourism; stressed the observable rather than the unconscious            John Watson


1923           Capgras delusion                                  Raboul-Lachouz
1927           Fregoli delusion                                  Courbon & Frail
1930s          “Bell and Pad” treatment of enuresis              Mowrer & Mowrer
1933           Schizoaffective Disorder                          Kasanin
1935           Autism described                                  Leo Kanner
  Names & concepts in psychiatry
1949   Beneficial response of a manic patient to Lithium     J. F. J. Cade
1950   Alcoholics Anonymous; „12-step programme‟             Bill
1950   Psychosomatic medicine                                F. Alexander
1950   Synthesis of Chlorpromazine – attempting to synthesize       Charpentier
       an antihistaminergic agent for anaesthetic use
1952   DSM I published                   Influenced by the ideas of Adolf Meyer
1954 Chlorpromazine introduced to the USA; Delay &           Delay & Deniker
     Deniker published the first favourable responses        1952
1955   Psycholinguistics                                     Naom Chomsky
1955-1958    Development of MAOIs                            Kline


1958   „Social Class and Mental Health‟ – demonstrated          Hollingshead &
       strong inverse association between social class and      Redlich
       mental health
1958   „The Psychodynamics of Family Life‟; development of Nathan
       Family Therapy                                      Ackermann
  Names & concepts in psychiatry
1959   First Rank Symptoms of Schizophrenia     Kurt Schneider
1960s Aversion Therapy, Covert Sensitization    Rachman & Teasdale
1960s-70   Exposure Therapy               Marks, Gelder, and Mathews

1962       Five factor model of Personality     Types and Christal
1963       Cognitive Theory of Depression       Aaron Beck


1965    „Transitional object‟, „primary        Donald Winnicott
        object‟, „good-enough mother‟;
1965    Gate Control Theory of Pain            Melzack and Wall
1966    Anti-manic properties of Valproate     Lambert
1967    Borderline Personality                 Otto Kernberg
1967    Learned Helplessness                   Seligman & Maier
1967    Marital Therapy                        Henry Dicks
                       Resource
•    World's Neurochemistry Portal
    <http://www.neurochem.org/pages/links_index.htm> -
    from the International Society for Neurochemistry
    http://www.neurochem.org/pages/links_index.htmWeb
    Textbook on Nerve Impulses
    <http://pb010.anes.ucla.edu/> - with interactive
    simulations of ions channels (this is an awesome web
    site)http://pb010.anes.ucla.edu/*Introduction to
    Neurobiology
    <http://instruct1.cit.cornell.edu/courses/bionb222/links.htm
    >
    http://instruct1.cit.cornell.edu/courses/bionb222/links.htm
    US National drug abuse
    websitehttp://www.drugabuse.gov/NIDAHome.html

				
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