Culture and mental health in Nepal: an interdisciplinary scoping review.

Efforts to address global mental health disparities have given new urgency to longstanding debates on the relevance of cultural variations in the experience and expression of distress for the design and delivery of effective services. This scoping review examines available information on culture and mental health in Nepal, a low-income country with a four-decade history of humanitarian mental health intervention. Structured searches were performed using PsycINFO, Web of Science, Medline, and Proquest Dissertation for relevant book chapters, doctoral theses, and journal articles published up to May 2017. A total of 38 publications met inclusion criteria (nine published since 2015). Publications represented a range of disciplines, including anthropology, sociology, cultural psychiatry, and psychology and explored culture in relation to mental health in four broad areas: (1) cultural determinants of mental illness; (2) beliefs and values that shape illness experience, including symptom experience and expression and help-seeking; (3) cultural knowledge of mental health and healing practices; and (4) culturally informed mental health research and service design. The review identified divergent approaches to understanding and addressing mental health problems. Results can inform the development of mental health systems and services in Nepal as well as international efforts to integrate attention to culture in global mental health.

Cultural logics of emotion: Implications for understanding torture and its sequelae.

This paper explores the significance of cultural variations in emotion for the meaning and impact of torture, focusingon the dynamics of shame, humiliation, and powerlessness. Forms of physical and psychological pain and suffering share some common neurobiological pathways and regulatory systems that are influenced by social and cultural factors. All forms of torture follow an affective logic rooted both in human biology and in local social and cultural meanings of experience. Understanding the impact of specific forms of torture on individuals requires knowledge of their learning histories, and of the personal and cultural meanings of specific kinds of violence. Exploring cultural meanings requires attention to over-arching discourse, embodied practices, and everyday engagements with an ecosocial environment. Restitution, treatment and recovery can then be guided by knowledge of cultural meanings, dynamics, and strategies for coping with catastrophic threats, injury, humiliation, helplessness and loss.

Mental health and psychosocial wellbeing of Syrians affected by armed conflict.

AIMS: This paper is based on a report commissioned by the United Nations High Commissioner for Refugees, which aims to provide information on cultural aspects of mental health and psychosocial wellbeing relevant to care and support for Syrians affected by the crisis. This paper aims to inform mental health and psychosocial support (MHPSS) staff of the mental health and psychosocial wellbeing issues facing Syrians who are internally displaced and Syrian refugees. METHODS: We conducted a systematic literature search designed to capture clinical, social science and general literature examining the mental health of the Syrian population. The main medical, psychological and social sciences databases (e.g. Medline, PubMed, PsycInfo) were searched (until July 2015) in Arabic, English and French language sources. This search was supplemented with web-based searches in Arabic, English and French media, and in assessment reports and evaluations, by nongovernmental organisations, intergovernmental organisations and agencies of the United Nations. This search strategy should not be taken as a comprehensive review of all issues related to MHPSS of Syrians as some unpublished reports and evaluations were not reviewed. RESULTS: Conflict affected Syrians may experience a wide range of mental health problems including (1) exacerbations of pre-existing mental disorders; (2) new problems caused by conflict related violence, displacement and multiple losses; as well as (3) issues related to adaptation to the post-emergency context, for example living conditions in the countries of refuge. Some populations are particularly vulnerable such as men and women survivors of sexual or gender based violence, children who have experienced violence and exploitation and Syrians who are lesbian, gay, bisexual, transgender or intersex. Several factors influence access to MHPSS services including language barriers, stigma associated with seeking mental health care and the power dynamics of the helping relationship. Trust and collaboration can be maximised by ensuring a culturally safe environment, respectful of diversity and based on mutual respect, in which the perspectives of clients and their families can be carefully explored. CONCLUSIONS: Sociocultural knowledge and cultural competency can improve the design and delivery of interventions to promote mental health and psychosocial wellbeing of Syrians affected by armed conflict and displacement, both within Syria and in countries hosting refugees from Syria.

Somatization and depression in fibromyalgia syndrome.

Psychiatric diagnoses, self-reports of symptoms, and illness behavior of 20 fibromyalgia patients and 23 rheumatoid arthritis patients were compared. The fibromyalgia patients were not significantly more likely than the arthritis patients to report depressive symptoms or to receive a lifetime psychiatric diagnosis of major depression. These results do not support the contention that fibromyalgia is a form of somatized depression. Fibromyalgia patients, however, reported significantly more somatic symptoms of obscure origin and exhibited a pattern of reporting more somatic symptoms, multiple surgical procedures, and help seeking that may reflect a process of somatization rather than a discrete psychiatric disorder.

Somatization and the recognition of depression and anxiety in primary care.

OBJECTIVE: The authors examined the effect of patients' style of clinical presentation on primary care physicians' recognition of depression and anxiety. METHOD: The subjects were 685 patients attending family medicine clinics on self-initiated visits. They completed structured interviews assessing presenting complaints, self-report measures of symptoms and hypochondriacal worry, the Diagnostic Interview Schedule (DIS), and the Center for Epidemiologic Studies Depression Scale (CES-D). Physician recognition was determined by notation of any psychiatric condition in the medical chart over the ensuing 12 months. RESULTS: The authors identified three progressively more persistent forms of somatic presentations, labeled "initial," "facultative," and "true" somatization. Of 215 patients with CES-D scores of 16 or higher, 80% made somatized presentations; of 75 patients with DIS-diagnosed major depression or anxiety disorder, 76% made somatic presentations. Among patients with DIS major depression or anxiety disorder, somatization reduced physician recognition from 77%, for psychosocial presenters, to 22%, for true somatizers. The same pattern was found for patients with high CES-D scores. In logistic regression models education, seriousness of concurrent medical illness, hypochondriacal worry, and number of lifetime medically unexplained symptoms each increased the likelihood of recognition, while somatized presentations decreased the rate of recognition. CONCLUSIONS: While physician recognition of psychiatric distress in primary care varied widely with different criteria for recognition, the same pattern of reduction of recognition with increasing level of somatization was found for all criteria. In contrast, hypochondriacal worry and medically unexplained somatic symptoms increased the rate of recognition.

Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment.

This article reviews cultural variations in the clinical presentation of depression and anxiety. Culture-specific symptoms may lead to underrecognition or misidentification of psychological distress. Contrary to the claim that non-Westerners are prone to somatize their distress, recent research confirms that somatization is ubiquitous. Somatic symptoms serve as cultural idioms of distress in many ethnocultural groups and, if misinterpreted by the clinician, may lead to unnecessary diagnostic procedures or inappropriate treatment. Clinicians must learn to decode the meaning of somatic and dissociative symptoms, which are not simply indices of disease or disorder but part of a language of distress with interpersonal and wider social meanings. Implications of these findings for the recognition and treatment of depressive disorders among culturally diverse populations in primary care and mental health settings are discussed.

Consensus statement on transcultural issues in depression and anxiety from the International Consensus Group on Depression and Anxiety.

OBJECTIVE: To provide primary care physicians with a better understanding of transcultural issues in depression and anxiety. PARTICIPANTS: The 4 members of the International Consensus Group on Depression and Anxiety were James C. Ballenger (chair), Jonathan R. T. Davidson, Yves Lecrubier, and David J. Nutt. Five faculty invited by the chair also participated: Laurence J. Kirmayer, Jean-Pierre Lepine, Keh-Ming Lin, Osamu Tajima, and Yutaka Ono. EVIDENCE: The consensus statement is based on the 5 review articles that are published in this supplement and the scientific literature relevant to the issues reviewed in these articles. CONSENSUS PROCESS: Group meetings were held over a 2-day period. On day 1, the group discussed the review articles, and the chair identified key issues for further debate. On day 2, the group discussed these issues to arrive at a consensus view. After the group meetings, the consensus statement was drafted by the chair and approved by all attendees. CONCLUSION: The consensus statement underlines the prevalence of depression and anxiety disorders across all cultures and nations while recognizing that cultural differences exist in symptom presentation and prevalence estimates. In all countries, the recognition of depression by clinicians in the primary care setting is low (generally less than 50%), and the consensus group recommends a 2-step process to aid the recognition and diagnosis of depression. In line with the low recognition of depression and anxiety disorders is the finding that only a small proportion of patients with depression or anxiety are receiving appropriate treatments for their condition. Biological diversity across ethnic groups may account for the differential sensitivity of some groups to psychotropic medication, but this area requires further investigation.

Culture and context in the evolutionary concept of mental disorder.

The evolutionary theory of the concept of mental disorder as harmful dysfunction that J. C. Wakefield (1999) proposed (a) does not correspond to how the term disorder is used in psychiatric nosology or in clinicians' everyday practice; (b) does not cover the territory to which the term reasonably could be applied; and (c) is not especially useful for research, clinical, or social purposes. The broad concept of disorder is a polythetic, not a monothetic, concept. As such, there need be no essential characteristic, criterion, or single prototype of disorder. Instead, multiple prototypes with varying features are used to group together a wide range of disparate phenomena by analogy. Useful refinements of our concepts of disorder have come from analyses of the nature of action and intentionality. What are most needed now are careful analyses of the social embedding of our concepts in cultural knowledge and practice.

Somatoform disorders: personality and the social matrix of somatic distress.

Personality traits that may contribute to somatization are reviewed. Negative affectivity is associated with high levels of both somatic and emotional distress. Agreeableness and conscientiousness may influence interactions with health care providers that lead to the failure of medical reassurance to reduce distress. Absorption may make individuals more liable to focus attention on symptoms and more vulnerable to suggestions that induce illness anxiety. More proximate influences on the selective amplification of somatic symptoms include repressive style, somatic attributional style, and alexithymia; however, data in support of these factors are scant. Most research on somatoform disorders confounds mechanisms of symptom production with factors that influence help seeking. Longitudinal community studies are needed to explore the interactions of personality with illness experience and the stigmatization of medically unexplained symptoms.

Affective disorders in cultural context.

This article reviews epidemiologic and ethnographic evidence for the cultural shaping of the causes, symptomatology, and course of affective disorders. Cross-cultural research demonstrates much overlap of depression with anxiety, somatoform, and dissociative disorders, raising questions about the universality of the prototypical representation of depression in North American psychiatry. Culture-specific symptoms may lead to under-recognition or misidentification of syndromes of mania and depression in many ethnocultural groups. Cultural idioms of distress may employ symptoms related to affective disorders to express sentiments and perceptions that do not in themselves indicate psychopathology. Socially mediated cognition about the self and specific modes of interpersonal interaction influence the course of depression. This article discusses some implications of these findings for the recognition and treatment of affective disorders among culturally diverse populations in primary care and mental health care settings.

The cultural context of anxiety disorders.

About a century ago, George Crile, a surgeon and experimental physiologist, suggested that the meaning of pain could be discovered in the context of evolution. Pain is a signal of a physical injury that would be otherwise ignored by the individual, a form of ignorance that would ultimately have mortal consequences. Crile believed that pain has a second purpose, that has important implications for how psychiatry now understands the emotions, specifically fear and anxiety. In essence, he suggested that fear is the memory of pain, and its adaptive advantage is that it enables individuals to anticipate and avoid injury. Fear-as-memory could be acquired either through individual experience (learned fear) or through species experience (instinctive fear). Among other things, this conception of pain and fear explained why surgical shock (from physical injury) and nervous shock (induced by fear or fright) appeared, at times, to provoke a similar physiologic response--a phenomenon first commented on by the British surgeon, Herbert Page. With this simple grammar, injury-pain-fear, Page and Crile laid the foundations for the modern concept of psychogenic trauma, extending the old idea of "trauma," meaning a wound or physical injury, to include psychological experiences and processes. The modern conception was completed by Freud, by connecting one more emotional state, anxiety. If fear is not simply a memory of pain but a memory that is bound to stimuli in the here-and-now, then anxiety is memory set loose. Put in other words, anxiety is the capacity to imagine pain and not merely to recollect pain. From the time of Beyond the Pleasure Principle (1919), anxiety took on a life of its own, so to speak, no longer part of the constellation of emotions and experiences identified by Page and Crile. Without an external object toward which to direct itself, fear becomes anxiety--a state of nervous anticipation of the unknown, of what is hidden in the shadows or penumbra of awareness. Anxiety is not a vector directed toward a threatening object or event in the environment but is situated in the person's own bodily experience, the workings of the mind, the Cartesian theater of self-representation. As an experience and event located entirely within the psyche, to be mastered by asserting a strong ego, reflections on anxiety became one of the self-constituting experiences of the Western concept of the person. In contemporary psychiatry, the constellation of injury, pain, fear, anxiety, memory, and imagination would seem to live on mainly in the context of traumatogenic anxiety and PTSD.(ABSTRACT TRUNCATED AT 400 WORDS)

Cultural variations in the response to psychiatric disorders and emotional distress.

Culture influences the experience and expression of distress from its inception. While Western psychiatry has identified several universal patterns of distress, there are significant geographical variations in the prevalence, symptomatology, course and outcome of psychiatric illness. Indirect evidence suggests that cultural differences in the recognition, labelling and interpretation of deviant behaviour affect the outcome of major psychiatric disorders as well as milder forms of distress. Emotion theory and the cultural concept of the person provide links between social and cognitive processes that contribute to the natural history of emotional distress. However, many current studies of ethnopsychology confound psychology (mechanisms of behaviour) and meta-psychology (theories of the self). Further advances in understanding the impact of culture on distress depend on the development of psychological and social theory that is neither ethnocentric nor naive about the wellsprings of action. Three arenas for further study are identified: (1) the handling of the gap between experience and expression; (2) the labelling of deviant behaviour and distress as voluntary or accidental; and, (3) the interpretation of symptoms as symbols or as meaningless events. Attention to these themes can guide re-thinking the assumptions of Western psychological and social theory.

Sapir's vision of culture and personality.

For Edward Sapir the concept of culture was a reification of processes that were rooted in individuals' personality and psychology. Sapir suggested that psychiatry's focus on individual biography and pathology gives it unique relevance for social science efforts to understand the mechanisms of cultural transmission and transformation. As a discipline that must integrate culture and biology in theory and practice, psychiatry can provide a corrective to the extremes of biological or cultural reductionism. Although mainstream psychiatry has largely abdicated the role it once had in the social sciences, the interdisciplinary field of cultural psychiatry may meet some of Sapir's hopes. Recent work in cultural psychiatry is centrally concerned with illness narratives that arise from the interaction of personal and collective meaning. Illness narratives may serve individual defensive functions, position individuals in a social world, and help to maintain overarching cultural formations. They also may challenge or subvert existing cultural meanings and create new forms of discourse. The close analysis of how cultural and individual meanings interact that is provided by cultural psychiatry has much to offer the wider field of cultural anthropology.

Social constructions of hypnosis.

Both clinical and experimental views of hypnosis are social constructions that reflect the biases and interests of practitioners and scientists. Each perspective offers useful metaphors for hypnosis. Underlying clinical uses of the term hypnosis are states of mind associated with imaginative reverie and automatic behavior based on procedural knowledge. Social discourse and narratives shape hypnotic experience, but they are themselves influenced by mechanisms of attention and automaticity. Study of hypnosis must proceed on both social and psychological fronts to account for the experience and clinical efficacy of hypnosis.

[Culture and mental illness among the Inuit of Nunavik]. / Culture et maladie mentale chez les Inuit du Nunavik.

While the major psychiatric disorders described in current nosology can be found among the Inuit of Northern Québec (Nunavik), there are important cultural influences on the symptomatology, social response and course of these disorders. A literature review, consideration of experiences with psychiatric consultation among the Inuit and the preliminary results of ongoing ethnographic research underscore the importance of the study of Inuit ethnopsychology and current attitudes toward the mentally ill in developing culturally sensitive psychiatric care.

Healing and the invention of metaphor: the effectiveness of symbols revisited.

In this essay, I argue that a theory of meaning adequate to account for the effectiveness of symbolic healing and psychotherapy requires some variant of the three concepts of myth, metaphor and archetype. Myth stands for the overarching narrative structures of the self produced and lent authority by cultural tradition. Archetype stands not for performed ideas or images, but for the bodily-given in meaning. Metaphor occupies an intermediate realm, linking narrative and bodily-given experience through imaginative constructions and enactments that allow movement in sensory-affective quality space. This pluralistic perspective itself constitutes a middle-ground between constructivist and realist approaches to meaning that can integrate causal and interpretive models of symbolic healing.

Improvisation and authority in illness meaning.

Using the example of psychosomatic diagnosis, I argue that the clinical context has unique epistemological constraints that limit the certainty of diagnosis and so make meaning indeterminate for sufferer and healer. As a result, forms of clinical truth are borrowed from the therapeutic context to create and authorize meanings for ambiguous or ill-defined conditions and inchoate suffering. Diagnostic interpretation is concerned with classification and legitimation through the production of authoritative truth. In contrast, therapeutic interpretation is fundamentally concerned with the pragmatic problem of "how to continue" and hence, with the improvisation of meaning. These different ends give rise to tensions and contradictions in psychosomatic theory and practice. While authority is necessary to provide a structure on which variations of meaning can be improvised, authoritative meanings may also restrict the possibilities for invention by clinician and patient. The goal of patient and physician is to create enough certainty to diminish the threat of the inchoate while preserving enough ambiguity to allow for fresh improvisation. Accounts of illness meaning must recognize the interdependence of normative rigidity and metaphoric invention.

The place of culture in psychiatric nosology: Taijin kyofusho and DSM-III-R.

The place of culture in psychiatric nosology is explored through the example of taijin kyofusho (TKS), a common Japanese psychiatric disorder characterized by a fear of offending or hurting others through one's awkward social behavior or an imagined physical defect. Although variants of this disorder have been described in other cultures (e.g., dysmorphobia), the full spectrum appears to be confined to Japan. TKS can be understood as a pathological amplification of culture-specific concerns about the social presentation of self and the impact of improper conduct on the well-being of others. Both social interaction and constitutional vulnerability may contribute to the cognitive processes that underlie TKS. The salience of cultural differences for psychiatric nosology then depends on whether the clinical focus is on disordered biology, individual psychology and experience, or the social context of behavior. Any attempt to include cultural variation in psychiatric diagnoses must begin by making explicit the intended use of the classification because different social contexts and clinical goals demand alternative diagnostic schemes.