Seminar covering trans-cultural aspects of psychiatry and impact of culture on mental health

1. SPEAKER:AMIT CHOUGULE MBBS, DPM
PG REGISTRAR (MD PSYCHIATRY)
CHRISTIAN MEDICAL COLLEGE,VELLORE
TAMIL NADU, INDIA
IMPACT OF CULTURE ON
MENTAL ILLNESS

2. OVERVIEW
1. What Is Culture ?
2. Transcultural Psychiatry
3. Development Of Transcultural Psychiatry
4. Impact Of Culture On Psychopathology
5. Impact Of Culture On Psychodynamics
6. Impact Of Culture On Major Psychiatric Illness
7. Impact Of Culture On Personality
8. Impact Of Culture On Clinical Practice
9. Future Directions And Developments In Transcultural
Psychiatry

3. DEFINITION OF 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
• It is the lens through which a person registers
experiences that shape his/her perceptions,
understanding and reactions to events
(The National Institute of Mental Health’s Culture and Diagnosis Group, 1993)

4. COMPONENETS OF CULTURE
1. Culture is learned
2. Culture can be passed on from one generation to the
next
3. Culture involves a set of meanings in which words,
behaviors have meanings agreed upon by the cultural
group
4. Culture acts as a template to shape and orient future
behaviors
5. Culture exists in a constant state of change
6. Culture includes patterns of both subjective and objective
components of human behavior

5. IMPACT OF CULTURE ON PSYCHIATRY
 Culture shapes how and what psychiatric symptoms are
expressed
 Culture influences the meanings that are given to
symptoms
 Culture also impacts the interaction between the patient
and the health care system

6. TRANSCULTURAL
PSYCHIATRY
“The discipline that deals with the:
description, definition, assessment and
management of all psychiatric conditions
as they reflect and are subjected to the influence
of cultural factors in a biopsychosocial context
while using concepts and instruments from social
and biological sciences
to advance a full understanding of
psychopathology and its treatment”

7. HISTORY OF TRANSCULTURAL PSYCHIATRY

9. DIFFERENT WAYS IN WHICH CULTURE
IMPACTS PSYCHOPATHOLOGY
1. Patho-genic effects
2. Patho-selective effects
3. Patho-plastic effect
4. Patho-elaborative effects
5. Patho-facilitative effects
6. Patho-reactive effects

10. PATHOGENIC EFFECTS
• Pathogenic effects refer to situations in which culture is a
direct causative factor in forming or ‘generating’
psychopathology
• Cultural ideas and beliefs contribute to stress, which in
turn produces psychopathology

11. PATHOGENIC EFFECTS (contd.)
EXAMPLES:
•DHAT SYNDROME
 In INDIA ‘Harmful’ wastage of semen can produce
anxiety , depression and somatic symptoms
•KOROPANIC
 The folk belief that death will result if the penis
shrinks into the abdomen
 Found in Malaysia
•So culture is the direct cause of psychopathology, not of
disease per se

12. PATHOSELECTIVE
EFFECTS
• Tendency of some people in a society, when
encountering stress, to select certain culturally
influenced reaction patterns that result in the
manifestation of certain psychopathologies
• FAMILY SUICIDE’ observed in Japanese society
(Ohara,1963)
• In Japan, cultural influences leads a family to choose,
from among many alternative solutions, to commit
suicide together, forming the unique psychopathology
• Culture selecting certain coping patterns to deal with
stress

13. PATHOPLASTIC EFFECT
• Pathoplastic effects refer to the ways in which culture
contributes to the modeling or ‘plastering’ of the
manifestations of psychopathology
• The content of delusions, auditory hallucinations,
obsessions, or phobias are subject to the cultural
context in which the pathology is manifested

14. PATHOPLASTIC EFFECT(Contd.)
• Religious delusions and delusional guilt are primarily
found in Christian societies than Islamic, Hindus or
Buddhist
• Patients from developing countries reported visual
hallucinations more frequently than those from
developed countries (Varma et al., 1997)
[Kala and Wig (1982), Kim et al., 2001; Murphy (1967), Stompe et al (1999, 2006), Tateyama et al(1998)]

15. PATHOELABORATING EFFECTS
• Certain behaviour reactions (either normal or
pathological) may be universal
• These behaviours may become exaggerated to the
extreme in some cultures through cultural reinforcement
(Simon,1996)
• Phenomenon of “Trance and possession state”
– It is a culturally sanctioned
– This could be described to the religious elaboration
of association with ‘Atman’ and ‘Deities’
• Culture elaborating mental conditions into a unique
nature

16. • In western countries there is increasing
concern with body weight
• Culture-shaped body image belief that
“slim is beautiful" may cause “body
weight anxiety”
• Common reason for eating disorders in
developed countries

17. PATHOFACILITATIVE EFFECTS
• Facilitating effects of culture makes it easier for certain
psychopathologies to develop and increase their
frequency in certain cultures
• A liberal attitude towards weapons control may result in
more weapon-related violence or homicidal behaviour
(Westermeyer,1973)
• Cultural permission to consume alcohol freely may
increase the prevalence of drinking problems

18. PATHOREACTIVE EFFECTS
• Culture influences:
 How people perceive pathologies and label disorders
 How they react to them emotionally
 Guides them in expressing their suffering
• Culture shape folk responses to the clinical condition
• Better prognosis of schizophrenia in developing
countries like India
• Family, social and cultural factors have Pathoreactive
effects on schizophrenia resulting in different
prognosis
(Sartorius et al., 1978)

19. IMPACT OF CULTURE ON
PSYCHODYNAMICS

20. CULTURAL VARIABLES RELATED TO
PSYCHODYNAMICS
1. Dependency versus autonomy
2. Linguistic competence
3. Cognitive style
4. Social support system
5. Material culture
6. Psychological sophistication

21. DEPENDENCY VERSUS AUTONOMY
DEPENDENCE PRONE
SOCIETY
AUTONOMY PRONE
SOCIETY
 Interdependence
 Clearly demarcated ego-
boundaries
 Strong sense of identity with the
primary group
 Control over one’s body,
action, thoughts and
emotions
 Lesser idea of individuality, of
individual rights and
responsibility
 Greater self reliance
 Pity, sacrifice, submission and
gratitude as character traits
An acute sense of one’s
rights , duties and
responsibilities
 “Shame prone society” “Guilt prone society’’

22. INDIAN SOCIETY
• Indian tradition attaches little importance to the
development of a unique, distinctive personality and to
individual self realization
(Hoch,1990)
• Most patient approach the doctor with the expectation of
getting advice and guidance
• This is similar to getting guidance from their parents and
family elders
• Indian patients expect a caring, concerned and nurturing
attitude
(Roland, 1995)

23. LINGUISTIC
COMPETENCE
LANGUAGE:
•Language is itself the shaper of ideas, the programmer
and guide for the individual mental activity
(Whorf 1961)
•Language is a determinant of the conception of reality, a
model shaping the mind as well as a code connecting
minds
(Brown 1965)
•Language and thought develop together
(Brown and Lennenberg 1954)

24. LINGUISTIC COMPETENCE
• Linguistic “competence" is the speaker - hearer's
intrinsic knowledge of his language
• Linguistic “performance" is the actual use of language in
a given situation
• Linguistic competence is an innate attribute of mind
(Chomsky,1965)

25. LINGUISTIC COMPETENCE
AND SCHIZOPHRENIA
1. Mental illness and languages are inter-related
2. Linguistic competence determines the phenomenology
of schizophrenia
3. Language seems to be an essential prerequisite for:
1. Manifestations of schizophrenic symptomatology
2. Outcome of schizophrenia across cultures
(World Health Organization, 1973; 1979) (Varma
(1982)

26. LINGUISTIC COMPETENCE
AND SCHIZOPHRENIA(contd.)
• In Positive Symptom schizophrenia linguistic competence
has:
 Positive correlation with severity of illness
 Negative correlation with outcome
• Greater linguistic competence leads to increased
elaboration of positive symptoms
• The positive symptoms cause further anxiety and
excitement thereby producing more complex and
intractable delusions
• This leads to severe form of illness and has influence on
prognosis
[Giridhar C, Kulhara P, Varma V K (1992) Linguistic competence in positive and negative
subtypes of schizophrenia, Indian journal of psychiatry,34(4),311-320) ]

27. LINGUISTIC COMPETENCE
AND SCHIZOPHRENIA(contd.)
In patients with negative symptoms of schizophrenia:
1. Positive correlation was observed between outcome
and linguistic competence
2. High linguistic competence was associated with:
 Low degree of negative symptoms
 Increased chances of recovery
1. Low linguistic competence produces high degree of
negative symptoms which are not easily amenable to
therapeutic change

28. COGNITIVE STYLES
• Cognitive styles represent the ways in which the mind:
 Perceives the environment
 Interprets it
 Draws conclusions about it
• Individuals and cultures differ from each other in
cognitive styles
• The cognitive style can be characterized as "analytical"
at one extreme and "synthetic " at the other

29. ANALYTICAL STYLE SYNTHETIC STYLE
Understand a thing or a
phenomenon by breaking it
into parts
Tries to see things or
phenomena in the totality
The Western mind is
classically analytical
The Indian mind is synthetic
in its cognitive style
Prevail in autonomous
oriented society
More conducive to the
development of a unitary,
holistic concept
Consistent with the
dependence and loose ego-
boundaries in the
relationship of individual with
society

30. SOCIAL SUPPORT SYSTEMM
• Differences across cultures in the social support system
has impact on course and outcome of mental illness
• The traditional and developing societies which are richer
in social support network have shown to have a better
prognosis of severe mental illnesses (WHO 1973, 1979)
• A very fruitful area of research in this area is expressed
emotions
• Expressed emotions like critical comments and hostility
have been correlated with adverse prognosis

31. MATERIAL CULTURE
• Culture consists of:
 Beliefs, values, norms and myths
 Physical environment which is comprised of artifacts like
roads, bridges, buildings, etc.
• The nature of material culture has influence on
psychopathology
• The same malevolent force is perceived as a:
 Spirit of a ghost in a developing society
 X-rays and radio waves in a technologically advanced
society
(Varma V K. Cultural psychodynamics in health and illness. Indian J Psychiatry 1986;
28:177-186)

32. PSYCHOLOGICAL SOPHISTICATION
• Psychological sophistication is the ability to see conflicts
in intrapsychic terms
• Conflict is perceived as within the mind or between the
components of the psychic structure
• Psychological sophistication may be related to coping
mechanisms and certain types of neuroses like hysteria
• It may also give rise to high introspection as a mental
attribute to understand and resolve conflicts

33. IMPACT OF CULTURE ON
MAJOR PSYCHIATRIC
DISORDERS
1. Schizophrenia
2. Bipolar affective disorder
3. Depressive disorder
4. Anxiety disorder
5. Somatoform and dissociative disorders

34. IMPACT OF CULTURE ON SCHIZOPHRENIA
• Landmark research projects by the Mental Health Division
of WHO:
1. International Pilot Study of Schizophrenia (IPSS)
2. Study of the Determinants of Outcome of Severe
Mental Disorders (DOSMED)
• These studies confirmed that:
1. The syndrome originally described by Emil Kraepelin
and Eugen Bleuler exists in very diverse ethnic and
cultural groups
2. Pathoplastic effects of socio-cultural factors shape
the symptom profiles differently in developed and
developing countries

35. IMPACT OF CULTURE ON SCHIZOPHRENIA
Western developed countries showed a higher frequency
of:
1. Depressive symptoms
2. Primary delusions
3. Thought insertion
4. Thought broadcasting
Non-Western developing countries showed a higher
frequency of:
1. Visual hallucination
2. Auditory hallucinations
[SARTORIUS et al. 1986; JABLENSKY et al 1992]

36. IMPACT OF CULTURE ON SCHIZOPHRENIA
• According to IPSS Study:
1. India had highest percentage with best outcome
(66%)
2. Nigeria had the lowest percentage with worst
outcome (10%)
3. The major limitation of the study was that the
sample was not an epidemiological sample
• Schizophrenic psychoses have a better prognosis in
Asian and African than in comparable British patient
populations
[JABLENSKY et al 1992, OGAWA et al. 1987; LEE et al. l991; TSOI & WONG l991]

37. IMPACT OF CULTURE ON SCHIZOPHRENIA
• Two thirds of schizophrenia patients in India have partial‑
to full remission of symptoms
• Demonstrated by:
1. The Madras longitudinal study
2. The study of factors associated with course and
outcome of schizophrenia (SOFACOS)
• The DOSMED study used an epidemiological sample
from 12 centers in 10 countries

38. CONCLUSIONS OF DOSMED STUDY
1. The content of psychotic symptoms tends to identify
critical problems existing in a particular culture
2. Persecutory delusions and auditory hallucinations are
not necessarily indicative of schizophrenia in persons of
African cultural background
3. Influence of ethnicity and culture on psychopathology
weighs more than geographic proximity, historical
relations and racial similarity
4. Ethnic and cultural differences are reflected in the
schizophrenic symptom profiles even if the populations
adhere to the same religion
[KATZ et al. 1988] [NDETEI & VADHER1984; NDETEI 1988]

39. 5. Studies in Japan, Hong Kong and Singapore
demonstrated a more favourable course and outcome
than in Europe and North America
6. These findings from are of special interest as:
 They are derived from countries of advanced
technological development
 But from cultures that are still quite different from
those of modern Western societies

40. What are the specific aspects of
modern Western societies that may
exert effects conducive to a chronic
course and poor final outcome of
mental disorders??

41. Factors Leading To Chronic Course
And Poor Outcome
1. The crucial difference leading to different outcome is not
the difference between societies of high or low
technological development but between modern
Western societies and non-Western societies that were
able to preserve important elements of their traditional
culture
2. Extreme nuclearization of the family leading to lack of
support for mentally ill members
3. Covert rejection and social isolation of the mentally ill in
spite of public assertions to the contrary

42. 4.Immediate sick role typing
5.General expectation of a chronic mental illness if a person
shows an acute psychotic reaction
6.Assumption that a person is insane if beliefs or behaviour
appear somewhat strange or "irrational“
7.Unclear and uncertain role expectation of the youth in
Western societies

43. CULTURE AND ACUTE TRANSIENT
PSYCHOSIS
• Acute transient psychotic reactions are known to be
more common than schizophrenia in developing
countries
• French term bouffée délirante introduced by Magnan in
1886
• Bouffée délirante is reminiscent of the transient
psychotic reactions occuring in the early phases of
industrialization and mass-urbanization in 19th century
Europe
[MOREL 1860; MEYNERT 1889]

44. CULTURE AND ACUTE TRANSIENT
PSYCHOSIS
• Transient psychotic reactions are of particular interest to
comparative cultural psychiatry because:
 They are interwoven with culturally validated beliefs in
sorcery and witchcraft
 These beliefs persist even after the traditional
resources of protection or assumed persecution by
magical or supernatural powers are no longer valid as
a consequence of Westernization and urbanization

45. CULTURAL ASPECTS OF ACUTE TRANSIENT
PSYCHOSIS
• Number of individuals experiencing the pressures of
rapid social change is steadily increasing
• Many feel unprotected against magical forces in which
they still firmly believe
• The individual reacts with an acute psychotic episode to
react to emotional trauma and to severe social stress
• The human environment responds with sympathy,
support, and traditional therapeutic resources and not
with rejection and isolation
[SIZARET et al. 1987]

46. • This applies as long as the extended primary social
support is still operational in a traditional non-Western
society
• Transient psychotic reactions will evolve into chronic
psychoses once the process of Westernizing acculturation
becomes completely irreversible
[SIZARET et al. 1987]

47. AFFECTIVE DISORDERS- DEPRESSION
• Culture greatly influences the way in which depressive
symptoms are expressed
• In the WHO collaborative study assessed depressive
disorder in 583 patients at five centers (Basel, Montreal,
Tehran, Nagasaki, and Tokyo)
• Most of them had common features of sadness,
anhedonia, lack of interest and energy, impaired
concentration, and ideas of worthlessness
• Feelings of guilt and suicidal ideations were least
common in Tehran

48. INDIAN SCENARIO – DEPRESSION
• Indian studies have found guilt to be less common
among Indian patients than those in the West
• Indian patients reported guilt of an impersonal nature
• The present suffering is attributed to possible bad deeds
of previous life (consequence of “Karma”) rather than
due to self failure as in the West‑
• Physical symptoms are common presenting symptoms
in depression

49. BIPOLAR AFFECTIVE DISORDER
INDIA VS WESTERN COUNTRIES
• Indian bipolar patients have preponderance of mania in
contrast to patients in Western countries
• Higher prevalence of grandiose delusions, delusions of
persecution and reference and those related to sexual
and religious themes than in the West
• Hostile irritability is the predominant affect in Indian
manic subjects
• There are reports of seasonal occurrence of mania in
summer season which is not reported in the west
• Recurrent unipolar mania is commoner in India and
tropical countries

50. OUTCOME OF AFFECTIVE DISORDERS
• The outcome of affective disorders has been found to be
favorable in India than in developed countries
• In a 4 year follow up of first episode manic patients from‑ ‑ ‑
Ranchi:
 40% of the patients did not have any recurrences
 25% had one recurrence

51. CONCLUSIONS FROM INTERNATIONAL
STUDIES
1. Current psychiatric classification schemes adopted
regarding the transcultural variations of BPAD seem to
be inadequate
2. There is no evidence that individuals belonging to
certain ethnic groups present a greater risk of acquiring
BPAD
3. Ethnocultural aspects seem to influence the clinical
presentation, diagnosis and treatment of BPAD

52. ANXIETY DISORDERS
Results of a study assessing the prevalence rates of
anxiety disorders in U.S population:
1.Asian Americans had symptoms of all four major anxiety
disorders less frequently than other racial groups
2.White Americans reported symptoms of social anxiety
disorder, generalized anxiety disorder and panic disorder
more frequently than other racial groups
3.African Americans more frequently met criteria for post-
traumatic stress disorder (PTSD) as compared to other
racial groups

53. CULTURAL IMPACT
• These results reflect the sociopolitical history of ethnic
groups in the United States:
1. African American community has shared a
longstanding battle with racism with significant
change in this experience over several centuries
2. Hispanic and Asian Americans have immigrated
relatively recently but have faced their own
individual challenges with integrating into
mainstream society

54. TRANSCULTURAL ASPECTS OF DISSOCIATIVE
AND SOMATOFORM DISORDERS
• Concept of somatization may have arisen from the
Cartesian dualism prevalent in Western societies
• Cartesian Dichotomy may have led to the cleavage of
mental health care from "medical care"
• Transformation of personal or social distress into
somatic complaints is a norm in most cultures
• Patients tend to develop symptoms that are "medically
correct “
• Somatic symptoms tend to be less stigmatizing than
psychological symptoms
(Fabrega, 1991) (Kleinman, 1987)

55. • Worldwide most common medically unexplained
symptoms are
1. Gastrointestinal complaints
2. Abnormal skin sensations
(World Health Organization,
1992)
• Most common medically unexplained somatic symptoms
in the United States were gynecological complaints,
followed by gastrointestinal and cardiovascular
symptoms (Epidemiologic Catchment Area study ,Escobar et al.,
1987)

56. • Nigeria and India common somatic symptoms are:
 Feeling of heat
 Peppery and crawling sensations
 Numbness
 Burning hands and feet
 Hot, peppery sensations in head
• These symptoms are extremely rare in Western
countries
• Indian study observed that most patients with
dissociation presented with a "brief dissociative stupor"
that coexisted with anxiety and panic symptoms
• Multiple Personality Disorder (MPD) is an iatrogenic
disorder largely confined to North America
• MPD is rare or nonexistent in other western and non
western countries

57. CONCLUSIONS
• Somatoform and dissociative syndromes are:
 Heterogeneous
 Core of the stress reactive syndromes
 Present in all cultures as the most typical sequelae of
trauma
 More frequently reported from non-western,
developing societies
 Generally framed as exotic culture-bound syndromes

58. CULTURE AND PERSONALITY
• Culturally determined personality attributes influence
coping mechanisms and mental illness
• When faced with emotional conflict a passive-dependent
person may:
 More likely to easily "give up”
 More prone to break with reality
 Develop psychotic coping behaviour
 More likely to turn to society for care
 Develop hysterical and somatoform disorders so as
to involve other members of the society in its
resolution

59. CULTURE AND PERSONALITY
• When faced with emotional conflict an autonomous
individual:
 May resist his loss of control
 May reject his dependency needs
 May try to resolve his conflicts himself at the intrapsychic
level
 May keep on battling with the anxiety
 May convert anxiety into development of neurotic-type
distress
• Personality configuration either individually or culturally
influence the choice made
• The subsequent elaboration and proliferation of the
symptomatology depends upon the various socio-
cultural factors

60. CULTURAL ASPECTS OF INSIGHT
• The traditional uni-dimensional view of insight has been
replaced with recent multi-dimensional perspectives
• Three dimensions of insight are:
– Awareness of mental illness
– Ability to re-label psychotic experience as abnormal
– Seeking medical treatment
Multi-dimensional perspectives of insight is criticized for:
(i) Employing western concepts of disease
(ii) All mental illnesses are considered medical
diseases
(iii) Failure to recognize as “Medical Disease” is
considered absence of insight
(iv) Alternative local and culture explanations for mental
illness are not considered
[The assessment of insight across cultures, K. S. Jacob. Indian Journal of Psychiatry
52(4), Oct-Dec 2010]

61. PROPOSED CHANGES TO DIMENSIONS OF
INSIGHT
Current dimensions of
insight
Proposed dimensions of
insight
Awareness of mental illness Awareness of non-visible
change in body or mind and
its relation to their illness
Re-label experience Re-label experience
Seek medical treatment Need for restitution
Seeks any forms of available
treatment

62. NEED OF CULTURAL STANDARD TO ASSESS
INSIGHT
 If a person acknowledges some kind of non-visible
change in his or her body or mind that affects the ability
to function socially
and
 If he or she feels the need for restitution/ restoration
then
 Irrespective of the attribution and the pathways of care
that the person seeks
 We could call this as presence of “insight”
• The awareness of changes in body or mind has to have
a non-delusional explanation
• Diagnosing the non-delusional nature of the explanation
requires an understanding of the local culture
• Need to use local and cultural standards rather than
universal yardsticks to assess insight in people with
psychosis

63. CULTURAL
CONSIDERATION IN
CLINICAL PRACTICE

64. CULTURAL FORMULATION
• DSM-5 includes an updated version of the cultural
formulation outline
• Presents an approach to assessment using the Cultural
Formulation Interview (CFI)
• Systematic assessment of the following categories:
– Cultural identity of the individual
– Cultural conceptualizations of distress
– Psychosocial stressors and cultural features of
vulnerability and resilience
– Cultural features of the relationship between the
individual and the clinician
– Overall cultural assessment

65. CULTURAL IDENTITY OF THE INDIVIDUAL
• Describe the individual's racial, ethnic, or cultural
reference groups
• Language abilities, preferences and patterns of use,
identify difficulties with access to care, social integration
and the need for an interpreter
• Religious affiliation, socioeconomic background, personal
and family places of birth and growing up, migrant status,
and sexual orientation

66. Cultural conceptualizations of distress
• Describe the cultural constructs that influence how the
individual experiences, understands, and communicates
his or her symptoms or problems to others
• These constructs may include cultural syndromes,
idioms of distress and explanatory models or perceived
causes
• Assessment of coping and help-seeking patterns should
consider the use of professional as well as traditional,
alternative or complementary sources of care

67. Psychosocial stressors and cultural features
of vulnerability and resilience
• Identify key stressors and supports in the individual's
social environment
• Identify the role of religion, family, and other social
networks in providing emotional, instrumental, and
informational support
• Levels of functioning, disability and resilience should be
assessed in light of the individual's cultural reference
groups

68. Cultural features of the relationship between
the individual and the clinician
• Identify differences in culture, language and social status
between an individual and clinician that may cause:
1. Difficulties in communication
2. May influence diagnosis and treatment
• Effects may include:
– Problems eliciting symptoms
– Misunderstanding of the cultural and clinical
significance of symptoms and behaviors
– Difficulty establishing or maintaining the rapport

69. Overall cultural assessment
• Summarize the implications of the components of the
cultural formulation identified in earlier sections of the
Outline
• This will help in diagnosis and appropriate management

70. Cultural Formulation Interview (CFI)
1. The CFI is a set of 16 questions
2. CFI is used to assess impact of culture on key aspects
of an individual's clinical presentation and care
3. CFI is a brief semi structured interview for
systematically assessing cultural factors in the clinical
encounter

71. FOUR DOMAINS OF (CFI)
1. Cultural Definition of the Problem (questions 1-3)
2. Cultural Perceptions of Cause, Context, and Support
(questions 4-10)
3. Cultural factors affecting Self-Coping and Past Help
Seeking (questions 11-13)
4. Cultural Factors Affecting Current Help Seeking
(questions 14-16)

72. Future Directions and
Research in Transcultural
Psychiatry

73. FUTURE PERSPECTIVES
1. Identification of specific fields in general psychiatry that
could be the subject of focused research from a cultural
perspective
2. A number of cultural variables should be considered in
conducting cultural psychiatry research like:
 Language
 Religion
 Traditions
 Beliefs
 Ethics
 Gender orientation

74. Concepts And Instruments For Research In
Cultural Psychiatry
• Exploration of key concepts and/or instruments in
culturally relevant clinical research
• There are four key concepts:
1. Idioms of distress
2. Social desirability
3. Ethnographic data
4. Explanatory models

75. 1. Idioms of distress:
•Specific ways in which different cultures or societies report:
1. Ailments
2. Behavioral responses to threatening or pathogenic
factors
3. Unique style of description, nomenclature, and
assessment of stress
2. Social desirability:
– Similarities or differences among cultures in actual
experiencing of stressful events
– Members show different levels of vulnerability or
resignation, resilience or acceptance

76. 3. Ethnographic data:
1. Should be included together with clinical data and
laboratory analyses or tests
2. Narratives of life that enrich the descriptive aspects
of the condition
4. Explanatory models:
1. Each culture explains pathology of any kind in its
own distinctive way
2. This lead to the culturally accepted clinical
diagnosis

77. CRITICAL ISSUES IN
RESEARCH IN CULTURAL
PSYCHIATRY

78. CONCEPTUAL ISSUES IN CULTURAL PSYCHIATRY
• One of the primary issues is the conceptual differentiation
between culture and environment
• Environment represents a broad and polymorphic concept
and considered opposite of genetics
• Culture and cultural factors in health and disease though
part of environment are unique
• Culture plays a role in both normality and psychopathology
• The role of culture in psychiatric diagnosis is an excellent
example of this conceptual issue
• Culture has an impact on treatment approaches based on
both conventional medical and psychiatric knowledge and
on the explanatory models

79. Evidence based approach vs Value based
approach
• A conceptual debate:
 Evidence-based approach to research and practice
versus
 Value-based view to clinical presentations which are
influenced by cultural factors
• The value-based approach considers moral issues such
as poverty, unemployment, internal and external
migration, and natural and man-made disasters
• Evidence may be found to support both positions in
scientific research

80. OPERATIONAL ISSUES IN CULTURAL
PSYCHIATRY
• The dichotomy of normality and abnormality in human
behavior is a crucial operational issue
• Relativism is a strong conceptual pillar in cultural
psychiatry
• Normality is a relative idea as it varies in different
cultural contexts
• Research needs to take into account representativeness
of the study populations and generalizability of the
findings
• Research data needs to be collected in a culturally
specific constructs

81. OPERATIONAL ISSUES
• Many tests and questionnaires used in clinical settings
and research have been developed on English-speaking
Western subjects
• They may not be appropriate for use among ethnic
minority patients or non–English-speaking individuals
due to lack of cultural equivalence
• Translating items is insufficient to achieve linguistic
equivalence
• Norms also may differ between ethnic groups and tests
need to be standardized with representative patients

82. Topical Issues in Cultural Psychiatry
• Five dimensions are relevant to research in cultural
psychiatry
• These includes consideration of culture as an:
1. Interpretive or explanatory tool of human behavior
2. Pathogenic or Pathoplastic agent
3. Diagnostic and nosological instrument
4. Therapeutic or protective factor
5. Service or management element
• Culture impacts each of these areas
• They are relevant at different stages of the clinical
encounter between patient and clinician

83. FIVE DIMENSIONS
1. Culture as an Interpretive or Explanatory Tool:
Explanatory models are the ways in which individuals in
different cultures see the core reasons of their suffering
2. Culture as a Pathogenic or Pathoplastic Agent:
Culture may be a pathogenic agent in the construction
of a clinical picture
It may contribute to the production of symptoms
3. Culture as a Diagnostic or Nosological Tool:
The DSM-5 cultural formulation is developed to be used
as clinical instrument and valuable tool for research

84. 4. Culture as a Therapeutic or Protective Factor:
1. Culture can be considered as a healing force
2. A great variety of cultural psychotherapies have
emerged
3. The use of religion and spirituality as clinical
instruments is of great importance
5. Culture as a Service or Management Element:
– The use of providers who belong to the same ethnic
group as the patient is a matter of continuous
debate
– The setting in which the clinical encounter occurs
deserves more research

85. SUMMARY
1. Definition and components of culture
2. History and evolution of Transcultural Psychiatry
3. Impact of culture on psychopathology:
(Patho-genic/selective/plastic/elaborative/facilitative/
reactive effects)
1. Cultural variables related to Psychodynamics:
(Dependency versus autonomy, Linguistic competence, Cognitive
style, Social support system, Material culture, Psychological
sophistication)
1. Impact of culture on major Psychiatric disorders:
(IPSS, DOSMED, Madras longitudinal study, SOFACOS)
1. Cultural aspects of Insight
2. Cultural Formulation and CFI
(Cultural identity, Cultural conceptualizations of distress,
Psychosocial stressors and cultural features of vulnerability and
resilience, Cultural features of the relationship between individual
and the clinician, Overall cultural assessment)
1. Future directions and research in transcultural psychiatry
(Idioms of distress, social desirability, ethnographic data ,explanatory
models) (conceptual issues, operational issues, topical issues)

86. REFERENCES
1. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th
Edition. Sadock, Benjamin J.; Sadock, Virginia A.; Ruiz, Pedro
2. Cross-Cultural Aspects of Anxiety Disorders. Stefan G. Hofmann1 and
Devon E. Hinton. Curr Psychiatry Rep. 2014 June ; 16(6): 450.
doi:10.1007/s11920-014-0450-3.
3. Cultural Aspects of Major Mental Disorders: A Critical Review from an
Indian Perspective. Biju Viswanath, Santosh K. Chaturvedi. Indian
Journal of Psychological Medicine | Oct - Dec 2012 | Vol 34 | Issue 4
4. Indian culture and psychiatry. Shiv Gautam, Nikhil Jain. Indian J
Psychiatry 52, Supplement, January 2010 S309
5. Transcultural aspects of bipolar disorder. Marsal Sanchesa,b and
Miguel Roberto Jorgea. Rev Bras Psiquiatr 2004;26(Supl III):54-6

87. INDIAN CULTURE
Dr. Radhakrishnan:
“India has seen empires come and go, has watched
economic and political systems flourish and fade. It has
seen these happen more than once. Recent events have
ruffled but not diverted the march of India’s History. The
culture of India has changed a great deal and yet has
remained the same over three millennia. Fresh springs
bubble up, fresh streams cut their own channels through
the landscape, but sooner or later each rivulet, each stream
merges into one of the great rivers which has been
nourishing the Indian soil for centuries.”