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1. SOCIAL AND
TRANSCULTURAL
PSYCHIATRY
Presenter:- Dr. D. Raj Kiran
Chairperson:- Ms. Mariella D’ Souza

2. First Note…
• “ Eve ry c ulture e njo y s
s o m e fo rm o f hum o ur.
But, hum o ur ha s
d iffic ulty c ro s s ing
c ultura l bo und a rie s
be c a us e wha t is
hum o ro us in o ne
c o untry is o fte n no t
hum o ro us in a no the r”
- Ro g e r A te ll.
x

3. Definitions
• Social psychiatry- It is a branch of
Psychiatry that focuses on the
interpersonal and cultural context of
mental disorder and mental wellbeing.
• Stigma- Undesirable ‘deeply discrediting’
attributes that ‘ disqualify one from full
social acceptance’ and motivate efforts by
the stigmatised individual to hide the mark
when possible (Goffman 1963).

4. Definitions
• Culture:- It is defined as a set of
meanings, norms, beliefs, values, and
behaviour patterns shared by a group of
people.
• Transcultural Psychiatry:- It is a branch
of psychiatry concerned with the cultural
context of mental disorders and the
challenges of addressing ethnic diversity
in psychiatric services.

5. Definitions
• Synonyms - Cross-Cultural psychiatry, Ethnopsychiatry,
Comparative & Cultural psychiatry.
• Emic – Etic:- Terms used by anthropologists to refer to
different kinds of data concerning human behaviour.
– Emic / Inside view: - Behaviour described as seen
from the perspective of cultural insiders, in constructs
drawn from their self-understanding.
– Etic / Outside view: - Behaviour described from a
vantage external to the culture, in constructs that
apply equally well to other cultures.

6. Definitions
• Culture Bound Syndromes:- forms of
psychopathology produced by certain
systems of implicit values, social
structures and obviously shared beliefs
indigenous to certain areas (Yap 1985).
• e.g., dhat syndrome, koro, latah,
pibloktoq, witiko psychosis, voodoo etc,

7. Why Transcultural psychiatry
important???
• Boundaries between normality and pathology vary
across cultures.
• Thresholds of tolerance for specific symptoms or
behaviours differ across cultures.
• A given behaviour is abnormal or not and whether
it requires clinical attention depends on cultural
norms.
• Awareness of the significance of culture may
correct mistaken interpretations of
psychopathology.
• Culture contributes to vulnerability and
suffering.

8. Why Transcultural psychiatry
important???
• Cultural meanings, habits, and traditions
contribute to either stigma or support.
• It provides coping strategies and suggest help
seeking options.
• Influences acceptance or rejection of a diagnosis
and adherence to treatments.
• Cultural differences between the clinician and
patient have implications for the accuracy and
acceptance of diagnosis as well as for treatment
decisions and clinical outcomes.

9. History
• 19th century- alienists believed that
insanity is rare among ‘primitive’ people
and more prevalent as civilization
evolves.
• Alienists also believed that insanity
could be reaching alarming levels in
large European cities.

10. History
He thought that high
frequency of insanity could
be due to– disordered life,
– abuse of alcoholic
beverages,
– consanguine marriages,
– social disturbances,
– revolutions,
– abrupt changes of habits,
– customs and values.
Esquirol

11. History
• Believed that railways and
modern ships help man to deal
with difficulties of life →thus
protect from the risk of
becoming insane.
• Hard life, excessive labour,
discipline, and rigid and
authoritarian education →
shield from mental illness.
• Attributed the increase in
insanity to self-indulgence,
sexual excesses and the lack
of sacrifice.
Maudslay

12. History
• In 1843, published
first study on mental
illnesses among
‘exotic people’ based
on visits to eastern
Mediterranean area.
Moreau de Tours

13. History
• Winslow was the
superintendent of a
psychiatric
sanatorium in Bengal.
• In 1853, he
summarized the
ethno psychiatric
observations.
Winslow

14. History
• Colonialism was
accompanied by the growing
interest in special mental
illnesses among the native
people.
• Alienists noticed contrasts
b/w patients seen there
and those previously seen in
Europe.
• Lead to identification of
Culture bound syndromes.

15. Nosology- ICD 10
• Culture bound syndromes included under
“Other Specified Neurotic Disorders”
(F48.8) in “Neurotic, Stress related and
Somatoform Disorders” (F40 – F48).
• This label lacks descriptive and
explanatory power.
• It does not make differences related to
the characterization and diagnosis in
different cultures or ethnic groups.

16. Nosology- DSM IV TR
• Culture Bound Syndromes are mentioned in
a glossary in Appendix I.
• It provides a cultural formulation to
supplement the multi axial diagnostic
assessment.
• Cultural formulation provides an
opportunity to describe the individual’s
cultural and social reference group and
ways in which the cultural context is
relevant to clinical care.

17. Nosology- DSM 5
• Assessment by using the Cultural Formulation
Interview (CFI)- gives impact of culture.
• Includes– Cultural identity of the individual,
– Cultural conceptualization of distress,
– Psychosocial stressors and cultural features of
vulnerability and resilience,
– Cultural relationship between the individual and
the clinician and
– Overall cultural assessment.

18. Social factors and mental
illness
•
•
•
•
•
•
•
•
Social class
Sex
Domicile
Marriage
Family
Religion
Age
Migration

19. Social class
• Various studies find a definite inverse relation
between social class and psychiatric patient.
• Numerous explanations have been
postulated like
–
–
–
–
–
Greater genetic predisposition.
Social stress hypothesis.
Social selection hypothesis.
Differential tolerance hypothesis.
Small city hypothesis.

20. Social class
• Social class hypothesis- there is a greater
stress as a result of living in poverty.
• Social selection hypothesis- has “drift” &
“residue” hypothesis
– Drift hypothesis- mentally ill person tend to drift
downwards in society where social demands ae
less.
– Residue hypothesis- mentally healthy individuals
in lower class tend to move upward in class,
leaving behind residue of mentally ill persons.

21. Social class
• Differential tolerance hypothesis- various
communities have different levels of
tolerance for schizophrenia. Many pts
therefore move into areas that are more
tolerant towards behaviour.
• Small city hypothesis- In small cities there
is less social isolation & everybody knows
everybody.

22. Social class
• In India, Nandi et al found results
contrasting to west.
• They found people in higher class had the
highest risk of developing mental illness.
• Thus our social class is not strictly
comparable with the west.
• In absence of suitable system to classify
class, relation between Social class and
mental illness cannot be established.

23. Sex
• No consistent sex difference in
schizophrenia.
• Affective disorders, anxiety disorders and
primary degenerative dementia is mc in
females.
• Personality disorders and substance abuse
disorders mc in males.
• Younger boys have higher morbidity than
girls until they reach puberty, after
adolescence girls show higher rates of
morbidity.

24. Sex
• Research shows that adult women are more
predisposed to anxiety and depression
whether at home or at work.
• As house wife, women are isolated from
outside and exposed to unstructured
household work.
• As working women, they are faced with
disadvantage of salaries, promotions and
family aspirations v/s professional interests.

25. Sex
• In India, again morbidity is higher in
women.
• Reasons could be due to
– Lack of education,
– Superstitious beliefs,
– Social stigma,
– Matrimonial placement,
– Inequality with males,
– Orthodox families.

26. Domicile
• Urban areas have higher morbidity.
• Schizophrenia, anxiety and personality
disorders are mc in urban areas.
• Manic depressive mc in rural areas.
• In India, Nandi et al found that mental
illness is unrelated to urban or rural areas.
• They postulated that community having
high level of aspiration show higher stress
dependent mental disorders.

27. Marriage
• Married persons have better mental health
than unmarried people.
• But some contrasting studies in India,
where higher morbidity in married when
compared to single.
• Reasons could be early pregnancy,
responsibility of rearing children and
multiple chorus.

28. Family
• Families are the primary transmitters of
the cultural patterns from one generation
to the other.
• Greater vulnerability is observed in
nuclear family than joint family.
• Elder sibling is more privileged in regard to
inheritance, but at the same time has to
go through stress due to responsibilities of
the family.

29. Religion
• Different religions again cause barriers,
with non integration of people with
different faiths.
• In India, kapur et al did a study in kota
which found
– Brahmins with lower case rates than bants
and mogers.
• However there were other factors like
socioeconomic and educational status.

30. Age
• In west, age does not show consistent
relationship morbidity.
• In India, there is increase in morbidity after 30
and decrease after 50yrs.
• Various reasons implicated are–
–
–
–
Shorter life span,
Physical problems are more common,
Joint family and
Old age symptoms may be considered as normal
for the age.

31. Migration
• Mental health of immigrants has been a
concern to governments.
• Previously when no legal restriction was
there on migration in US, ratio of mental
illness was higher in immigrants than the
natives.
• Kaila et al concluded that overseas
migration is associated with greater risk of
mental illness than internal migration.

32. Migration
• Srole et al concluded that low status and
poverty are responsible for poor mental
health of immigrants.
• Murphy postulated reasons for relation
between migration and mental illness
– Persons with incipient mental illness, unable to
cope in their homeland migrate.
– Hardships of migration precipitate mental illness.
– Contributes with other factors to the increase.

33. Culture & Psychopathology
•
•
•
•
•
•
Patho-genic effects
Patho-selective effects
Patho-plastic effects
Patho-elaborating effects
Patho-facilitative effects
Patho-reactive effects

34. Patho-genic effects
Cultural beliefs, values, traditions and
norms are seen to have direct effect.
– e.g., dhat syndrome, koro, frigophobia.
Culture
STRESS
PSYCHO
PATHOLOGY

35. Patho-selective effects
Through enculturation & socialization some
individual members of a given society select
culturally influenced reaction patterns, which
may be pathological.
– amok, family suicide.
********
Culture
STRESS
* *
********
* ***** *
Selected people in society
PSYCHO
PATHOLOGY

36. Patho-plastic effect
Manifestations of symptoms are highly
influenced by the culture settings of the
society in question.
– pibloktoq, brain fag
DELUSION
ADUITORY HALLUCINATION
OBSESSION
PHOBIAS
CULTURE
President of US
is more popular
Delusion of grandiosity
I am President of US

37. Patho-elaborating effects
Situations where the cultural context
exaggerates behaviours which otherwise
are normal.
– e.g., latah.
CULTURE
Behavior Reinforcement
Response to Startle
Cultural acceptance
Behavior

38. Patho-facilitative effects
Culture influences the frequency at which
a particular problem occurs.
– e.g., drunkenness, anorexia.
#$%^&*@+$#@%^*+$
^&*U#@*+%
Cultural facilitation for ‘+’
#$%^&*@+$#@%^*+$
^&*U#@*+%
+++++++++
+++++++++
Media facilitation
Global prevalence
Prevalence in facilitated society

39. Patho-reactive effects
How society and individuals react to
psychopathology, and thereby affect the
expression, course and outcome of
psychopathology.
Culture
Psychopathology
Course & Outcome

40. Transcultural….???

41. Alcoholism
• Drinking practices and the definition of what
constitutes normal drinking vary.
• Substantial differences in these definitions
and practices exist within country based on
ethnic & culture.
• Clinicians & Public health officials attempting
to develop effective prevention and
treatment approaches must consider the
population’s attitudes and expectations.

42. Alcoholism- India
• Differ considerably b/n southern &
northern areas, of different castes.
• Not considered as central to normal
social life.
• In certain tribal groups considered as a
gift to mankind.
• Religion also plays an important role, like
Muslims, Buddhists and Jains are
strictly prohibited.

43. Alcoholism- India
• Among Hindus, Brahmins and other Upper
caste are forbidden from drinking.
• Caste groups who are meat eaters are
permitted to drink.
• Drinking among females is infrequent in
India, except in particular festival seasons.
• But trend is changing with urbanization &
globalization.

44. Schizophrenia
• Epidemiological studies show more
prevalence in societies that had greater
exposure to western influences.
• This suggests that “as civilisation makes
in roads, schizophrenia follows in its
footsteps”.
• Lowest rates:- Taiwanese (0.9/1000).
• Highest rates:- developed country
Sweden (9.5/1000).

45. IPSS
• In this 9 field centers in 9 countries
were selected.
• Mc- paranoid > schizoaffective subtype.
• WHO researchers concluded from
study that there were “clear
differences in the course and outcome
of schizophrenia, with pts in developing
countries having better outcomes than
those in the developed countries”.

46. Schizophrenia
• Social and emotional withdrawal, auditory
hallucinations, general delusions and
flatness of affect- in all samples.
• Delusions of destructiveness and religious
nature- frequent among Christians and
Muslims.
• Delusions of jealousy- mc Asians.
• Social hallucinations- mc in africans and
north east.

47. Schizophrenia
• Depersonalisation- mc in urban patients.
• Delusions of Grandeur- mc in rural
patients.
• FTD and flatness of affect- higher in
illiterates.
• Paranoid delusions- mc in literate.
• Hebephrenic / Catatonic types- mc in
non western countries.

48. Schizophrenia
• Paranoid type- mc in Western countries.
• In India, Catatonic rigidity, Negativism
and stereotypy are more common.
• In Africa, patients are quieter,
displaying deterioration such as blunting
of affect/ bizarreness of behaviour.
• In Japan, more ideas of reference,
disturbance of thinking, apathy, social
isolation and loss of interest.

49. Schizophrenia
• In America- greater disruption of reality
testing, hallucinations and bizarre ideas.
• In Italy- more hostile, acting out, elation
and bizarre mannerisms. No feelings of
sin/ guilt.
• In Irish- more preoccupation with guilt
concerning sexuality.
• Variations in symptomatology are
attributed to various factors.

50. Mood Disorders
• US Epidemiological Catchment Area
(ECA) study- BPAD equally prevalent
among different ethno racial groups in
US when other demographic
differences were controlled.
• WHO Collaborative study- found
Sadness, Joylessness, Anxiety, Tension
and Lack of energy were the most
common symptoms.

51. Mood Disorders
• In Eastern culture- higher frequency of
Somatic symptoms.
• In India, the symptoms which are
prominent are Chest, Musculo Skeletal,
GIT and Sexual symptoms.
• In Asian countries, guilt feelings are
less when compared to in many Western
countries.

52. Mood Disorders
• In Africa, frequent clinical
presentations of mania than depression.
• In Afro-Caribbean, more of mood
incongruent symptoms → over diagnosis
of schizophrenia.
• Psychomotor agitation and decreased
need for sleep could be considered free
from any cultural influence.

53. Mood Disorders
• Grandiosity and excessive involvement in
activities- masked/superimposed on
certain cultural behaviours.
• Chinese Classification of Mental
Disorders opted for maintaining the
diagnostic category “unipolar mania”,
considering it valid in Chinese patients.
• Similar picture was found in patients
belonging to the Yoruba tribe in Nigeria.

54. Somatoform disorders
• Previously, somatization was believed to
be more common among patients nonWestern cultures.
• WHO collaborative study- similar
pattern of association between Western
and non-Western countries
• This indicates that cultural factors
influence subsequent illness behaviour.

55. Culture Bound Syndromes
• Def- These are mental conditions or
psychiatric syndromes whose
occurrence or manifestations are
closely related to cultural factors and
which thus warrant understanding and
management from a cultural
perspective.
• Recent suggestions to rename it as
“Culture Related Specific Syndromes”.

56. Culture Bound Syndromes
• Earliest described in journal was “amok”
by W. Gilmore Ellis in 1893.
• Later latah (1897), pibloktoq (1913),
witiko psychosis (1933), koro (1934), imu
syndrome (1938), dhat syndrome (1940)
etc.
• In 1969, Yap coined the term CBS.

57. Culture Bound Syndromes
• Both ICD 10 and DSM 5 do not include a
diagnostic section, but CCMD 2 R includes
Koro, Qigong induced mental disorder and
Superstition & Witchcraft induced mental
disorder.
• Different categorizes for classification
proposed are– cardinal symptoms (Yap),
– taxons (Charles C Hughes)
– relationship to culture (Tseng & McDermott).

58. Culture Bound Syndromes
• In India–
–
–
–
–
–
–
–
–
Dhat Syndrome,
Possession Syndrome,
Koro,
Bhanmati sorcery,
Suudu,
Gilhari syndrome,
Ascetic syndrome,
Mass hysteria
culture-bound suicide (sati, santhra).

59. Dhat syndrome
• ‘Dhat’ gets its origin from the Sanskrit
word ‘Dhatus’.
• In Susruta Samhita, it means “elixir that
constitutes the body”.
• In Charaka samhita, disorder of Dhatus
have been described as “Shukrameha” in
which there is a passage of semen in the
urine.
• First described in western literature by
NN Wig.

60. Dhat syndrome
• It is more prevalent in the India.
• It showed global presence
– China (Shen K'uei),
– Sri Lanka (Prameha) and
– other parts of South East Asia (Jiryan)
• Malhotra and Wig called ‘Dhat’ ‘a sexual
neurosis of the Orient’.
• In China, Shen-K'uei has been associated with
epidemics of Koro.

61. Dhat syndrome
Notion of semen loss
Frightens the individual
Series of somatic symptoms

62. Symptoms
• Vague somatic symptoms due to semen
loss.
• Semen loss via nocturnal emissions,
urine and masturbation.
• Weakness (70.8%), fatigue (68.7%),
palpitations (68.7%), sleeplessness
(62.4%), anxiety, loss of appetite and
guilt.

63. Clinical profile
•
•
•
•
•
Age range - 20-38 years.
Age of onset- 16-24 years.
Marital status- unmarried (54.2%).
Education- 5th class or above (79.1%).
Patients divided into three categories– Dhat alone.
– Dhat with comorbid depression & anxiety.
– Dhat with sexual dysfunction.

64. Co-morbid illness
• Psychiatric disorders associated are
– Depressive neurosis (40-42%),
– Anxiety neurosis (21-38%),
– Somatoform/ Hypochondriasis (32-40%).
• Psychosexual dysfunctions associated
are
– Erectile dysfunction (22-62%)
– Premature ejaculation (22-44%).

65. Treatment
• Wig suggested
–
–
–
–
–
Emphathetic listening,
Non-confrontational approach,
Reassurance,
Correction of erroneous beliefs,
Use of placebo, anti-anxiety and
antidepressant drugs, wherever required.
• Good response- anti-anxiety and
antidepressant drugs as compared to
psychotherapy.

66. Possession Syndrome
• Diagnosable under Dissociative
disorders.
• Person is possessed usually by
‘spirit/soul’ of deceased relative or a
local deity.
• Speaks in changed tone, sometimes in
opposite sex tone.
• Usually seen in rural areas or in
migrants from rural areas.

67. Possession Syndrome
• In religious shrines during special annual
festivals where people get possessed
simultaneously.
• Majority are females who otherwise
don’t have any outlet to express their
emotions.
• Treatment- careful exploration of
underlying stress which precipitated
the possession attack.

68. Koro
• Koro- Malay word meaning “the head of
a turtle”.
• Reported primarily among the Chinese
of southern coastal china.
• In India it is seen in Northeast states
like Assam.
• There is fear of retraction of genital
organs.

69. Koro
psychosexual problems
•lack of masculine relations,
•lack of heterosexual relations,
•misconceptions about sexual practices
•existence of castration anxiety
Sudden & intense anxiety that penis or vulva or nipples will retract into body
This belief will lead to panic reaction

70. koro
• Sociocultural and community factors >
Individual psychopathology.
• It occurs as an epidemic in a particular
group.
• Strong belief that ghosts are involved
and driving away of ghosts would lead to
removal of the disease.

71. Secondary Koro…!!!
• Emergence of cases in association with
drugs.
• Common drug associated is Cannabis.
• Precipitated by withdrawal from drugs
like Heroin, Buprenorphine.
• Amphetamine, Imipramine, Ludiomil and
l-dopa consumption have preceded
symptoms.

72. Bhanmati Sorcery
• Seen in South India.
• It is believed to be due to psychiatric
illness i.e. conversion disorders,
somatization disorders, anxiety
disorder, dysthymia, schizophrenia etc.
• Nosological status unclear.

73. Suudu
• Syndrome of painful urination and pelvic
“heat” familiar in south India.
• Occurs both in males and females.
• Attributed to an increase in the “inner
heat” of the body often due to
dehydration.
• Treated by local practices like applying
sesame oil, having oil massage and intake
of fenugreek.

74. Gilhari Syndrome
• Characterised by patient complaining of
small swelling on the body changing its
position from time to time as if a gilhari
(squirrel) is travelling in the body.
• Not much literature available.
• Nosological status is not clear.

75. Ascetic Syndrome
• First described by Neki (1972).
• Appears in adolescents and young
adults.
• Characterised by social withdrawal,
severe sexual abstinence, practice of
religious austerities, lack of concern
with physical appearance and
considerable loss of weight.

76. Mass Hysteria
• Short lasting epidemics where hundreds
to thousands of people believe and
behave in a manner in which ordinarily
they won’t.
• Choudhary et al (1993) reported an
epidemic of atypical hysteria in a tribal
village of the State of Tripura India.
• Twelve persons were affected in a chain
reaction within a span of ten days.

77. Mass Hysteria
• Cardinal feature was an episodic trance
state of 5 to 15 min.
• It was associated with restlessness,
attempts at self-injury, running away,
inappropriate behaviour, inability to
identify family members, refusal of food
and intermittent mimicking of animal
sounds.
• Self-limiting and showed an individual
course of one to three days duration.

78. Culture bound suicide
• Sati: self-immolation by a widow on her
husband’s pyre.
• Named based on Hindu mythology.
• Seen mostly in Upper Castes notably
Brahmins and Kshatriyas.
• Banned in India since 19th century by
Raja Ram Mohan Roy.

79. Culture bound suicide
• Jouhar: Suicide committed by a woman
even before the death of her Husband
when faced by prospect of dishonour
from another man.
• Santhara/Sallekhana: Voluntarily giving
up life by fasting unto death over a
period of time for religious reasons to
attain God/ Moksha.

80. Honour Killings
• It is murder of a member of a family or
social group by other members, due to
the belief that the victim has brought
dishonour upon the family or community.
• Seen in Muslims, Sikhs, and Hindus.
• Rights are collective, not individual.
• Family, clan, and tribal rights supplant
individual human rights.

81. Why Culture Bound
Syndromes difficult to
classify?
• Classification of CBS into diagnostic
categories is based on a perception of
their predominant symptoms.
• But identifying predominance of
symptoms itself is problematic.
• For e.g., koro, Initially as a somatoform
disorder on the basis of the perception .
Recently as an anxiety disorder.

82. Food for thought…
• How do we characterize the culture bound
syndrome within its cultural context?
• What are the defining features of the
phenomenon?
• Who are the people who experience
culture-bound syndromes and what is their
social structural location?
• What situational factors provoke these
syndromes?
• So on…???

83. References
•
•
•
•
•
•
•
•
•
•
Robert Kohn, Ronald M, Wintrob, Renato, Alarcon. Chapter 4.4. Transcultural Psychiatry. Kaplan &
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Morris MW, Leung K, Ames D, Lickel B. Views From Inside And Outside: Integrating Emic & Etic
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Mandelbaum DG. Alcohol and Culture. Current Anthropology. Vol. 6. No. J Jun 1965. Pg 281 -293.
Torrey EF, Torey BB, Burton Bradley BG. The Epidemiology Of Schizophrenia In New Guinea. Ajp
1974; 131; 576-578.

84. References
•
•
•
•
•
•
•
•
•
•
Dunham HW. Community And Schizophrenia: An Epidemiological Analysis. Detroit. Wayne state
university press, 1965.
WHO. Schizophrenia: An International Follow Up Study. Chicester: Wiley 1979.
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Tseng WS. From Peculiar Psychiatric Disorders Through Culture-Bound Syndromes To CultureRelated Specific Syndromes. Transcultural psychiatry 2006; 43; 554.
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