Culture and Psychopathology
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Culture and Psychopathology

A Guide To Clinical Assessment

Jon Streltzer, Jon Streltzer

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eBook - ePub

Culture and Psychopathology

A Guide To Clinical Assessment

Jon Streltzer, Jon Streltzer

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About This Book

Since the first edition of Culture and Psychopathology was published, a growing national and international interest in how culture impacts mental disorders and how psychopathology is influenced by culture has become a rising field of focus. In this extensive revision, chapters have been updated with new material and now incorporate the DSM-5's classification system of mental disorders. This book is international in scope, not focusing on specific cultural groups, but rather how the cultural context affects the presentation and the process of assessment of different types of psychopathology. This edition highlights case studies and practical guidelines to support clinicians who assess patients of any cultural background.

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Culture and Psychopathology
Wen-Shing Tseng, M.D.

Case Vignettes

Mental health clinicians frequently encounter cases with unusual clinical pictures that are different from textbook or standard classification categories and are puzzling to the clinicians in making their assessments. For instance, when an Asian patient complained of an “empty heart,” the doctor needed to clarify whether the patient was suffering from the medical problem of a weak heart, with other cardiac-related somatic symptoms such as palpitations or shortness of breath, or from a low spirit, with feelings of emptiness and depression. ·
In a hospital setting, a Latino man shouted very loudly while dramatically and emotionally striking his own body with his fists when he learned of his spouse’s death. The doctor was uncertain whether this was a usual acute grief reaction for a man of Latin background, or if the behavior was an excessively emotional and dramatic hysterical reaction that required psychiatric attention.
A Caucasian medical doctor was confused by a Polynesian woman patient, who, after being told by the doctor that she would not be discharged from the hospital, tied the cord to the light switch around her neck and refused to talk to the doctor. Suspecting that the patient might be suicidal, a psychiatric consultation was requested.
Most experienced clinicians are aware that the clinical picture of a patient is influenced by many factors, such as the patient’s age, gender, and socioeconomic and educational backgrounds, as well as ethnic-cultural factors. Furthermore, the process of psychiatric evaluation itself is influenced by such factors in both the patient and the clinician, as is the interaction that takes place between them (Figure 1.1). The case vignettes described above illustrate that the clinical picture is colored by the cultural background of the patient, and the process of mental assessment is influenced by the cultural backgrounds of both the patient and the clinician to the extent that it may confuse or bias the clinician’s assessment.
It is the intention of this book to explore how cultural factors may alter the presentation of mental symptoms, how cultural variables may influence the process of assessment, and how culturally relevant clinical evaluation is needed to make appropriate clinical assessments—an important task that is required of all psychiatrists and mental health professionals working in our increasingly polyethnic and multicultural society.

Introduction: Understanding Culture

Anthropological Definition of Culture

In order to discuss cultural influences on psychopathology, let us first clarify the term culture. Scholars of behavioral science define culture in various ways. According to anthropologists Kroeber and Kluckhohn [1],
Culture consists of patterns, explicit and implicit, of and for behavior acquired and transmitted by symbols, constituting the distinctive achievement of human groups, including their embodiments in artifacts; the essential core of culture consists of traditional ideas and especially their attached values; culture systems may, on the one hand, be considered as products of action, on the other as conditioning elements of further action.
Another anthropologist, Keesing [2], emphasized that culture exists at two levels. The first is the realm of observable phenomena—the patterns of life within a community; and the second is the realm of ideas—the organized system of knowledge and beliefs that allows a group to structure its experiences and choose among alternatives.
The most current concept of culture includes the effects of “enculturation” on the mind-brain [3]. As a result of enculturation, every individual learns a language, a religion, or other meaning system specifying the operation of forces of nature in the world, as well as norms of behavior and patterns of experiencing the environment. All of these are structured in neural networks in the mind-brain. It has been found that the strengths of synaptic connections between individual neurons are determined by use patterns [4]. By the habitual act of thinking in a particular language, or believing in the forms of a particular religion, those forms of thought assume a type of physical reality in the organization of neural networks in the brain. In a very real sense, the social-cultural environment becomes physically structured in the brain of the individual. This process has frequently been referred to as “downward causation” [5]. That is, thinking as an activity pattern is causal in that it alters the brain at the level of dendritic branching, and the strengths of neurotransmitter properties in the individual synapse. This means the organization of culture has its psychobiological correlates in the organization of the mind-brain—in the microanatomy of the individual neuron and in the organizational formation of neural networks [3]. (Editor’s note: This is consistent with the evolutionary theory of memes [6]).
As pointed out by Castillo [3] (p. 23),
For example, in order to speak Chinese one must have the neural networks for speaking Chinese structured in the brain—no Chinese neural networks, no speaking Chinese. The presence of Chinese neural networks, of course, results from enculturation. Someone who is genetically Chinese, but born and raised in the United States and fully assimilated into American culture, will have American neural networks—an American mind-brain.
It is these culture-specific neural organizations that in turn influence most aspects of cognitive processing by individuals in the form of cognitive schemas [5]. These cognitive schemas structure experience of the world, and thus influence the development of psychopathology.
Two frequently used terms closely related to culture are race and ethnicity. The term race refers to a group of people that is characterized by certain physical features, such as color of skin, eyes, and hair, or physical size, that distinguish it from other groups. Modern anthropologists refer to race as geographic race. Geographic race is a human population that has inhabited a continental land mass or an island chain sufficiently long enough to have developed its own distinctive genetic composition, as compared with that of other geographic populations [7]. African (Black), American (Native American), Asian (Yellow), Australian, European (White), Indian, and Polynesian are some of the major geographic races recognized around the world. Thus, race refers to a biological group that may or may not coincide with a culture system shared by the group. Although it may be possible to define races by biological or genetic factors, it must be pointed out that races, by definition, are largely social. Essentially, when an ethnic group is assumed to have a biological basis, it is called a race.
The term ethnicity refers to social groups that distinguish themselves from other groups by a common historical path, behavior norms, and their own group identity. Thus, culture refers to behavior patterns and value systems, while ethnicity refers to a group of people that share a common culture.
As culture is an abstract term, relatively difficult to identify and distinguish, reference is customarily made to ethnicity or country. For example, Japanese culture refers to the culture system that is shared by the people of Japan; and Jewish culture to the culture system shared by the Jewish ethnic group. However, caution is necessary in such use, as the unit of culture does not necessarily tie in with the unit of ethnicity or country. For instance, there have been a substantial number of Koreans living in Japan for nearly a century, but, after three or four generations, due to differences in the historical backgrounds of Japan and Korea, they still identify themselves as Korean, and are not accepted by other Japanese nationals as Japanese. Thus Japanese culture is not necessarily shared by “all” of the people of Japan; and Korean culture is shared by people not only living in Korea proper, but also by this group of people that is, in reality, Korean-Japanese.

Different Levels of Culture Addressed

In everyday life, culture may be perceived at different levels or in different dimensions. From the standpoint of behavior analysis, it is important to be aware of the different ways of grasping culture. They are as follows.

Ideal Cultural Behavior

A desirable pattern of life prescribed by a certain group of people. This ideal does not necessarily match the actual behavior observed in the society. Ideal norms are generally selected and described by the members of a society in terms of group well-being; and they are often violated when individual self-interest induces another course of action [7].

Actual Cultural Behavior

A norm of behavior actually observed in life. The real culture is what the members of a society do and think in all their activities in fact [7]. The gap between the ideal culture and the real culture may be great or small, depending on the societies in question.

Stereotyped Cultural Behavior

This refers to a certain behavior pattern that is described by an outsider to the group as if it represents the total behavior pattern of the group. The described behavior pattern is usually fragmented, exaggerated, or distorted. It may be merely a product of the outsider’s own projection and not reflect the actual culture at all.

Deviated Cultural Behavior

The behavior pattern observed within a group is not necessarily homogeneous. Some of the members may manifest behavior patterns that are idiosyncratic and deviate from the pattern of the majority. Such deviated behavior may or may not be pathological.

Different Natures of Cultures Compared

When comparison is made between different cultural systems, it is necessary to understand the kind of cultural systems that are being compared. Otherwise, the comparison may be inappropriate and misleading.

Homogeneous Versus Heterogeneous

The degree of variation within a cultural system may be minimal, and the culture homogeneous; or the differences may be so great that the nature of the culture is heterogeneous. If a culture is relatively homogeneous, any portion of the group will well represent the total of the society, and generalizations may be fairly inferred. In a heterogeneous culture, on the other hand, no one fragment of the society may be taken as a reflection of the totality. When a comparison is made between cultures, the degree of variation that exists within each culture is an important consideration.

Traditional Versus Contemporary

Also deserving attention is the matter of cultural patterns that have existed in the past versus those that are observed at present within a society. Although, by definition, it is the nature of culture to maintain its characteristics, cultures also have a tendency to evolve over the course of time. What has been described as traditional may or may not be practiced anymore, or may continue to exist in a modified form. A time reference may be needed in referring to particular value systems or unique behavior patterns held by a society, to avoid confusing the present situation with the past.

Similar Versus Dissimilar

It is important to examine the relative similarities and differences that may exist between the cultures being compared (the extent of cultural difference). For instance, a comparison made between a Caucasian American and an African American may not reveal obvious differences that can be attributed to culture. Because they are living in the same host society, the United States, any differences that may exist are minimized. However, a comparison of a Caucasian American and an African living in a traditional part of Africa may demonstrate great differences between them. The wider the culture gap, the easier it is to demonstrate the impact of cultural factors.

Culture and Psychopathology

Type of Psychopathology

In order to discuss culture and psychopathology, it is first necessary to clarify the term psychopathology. In particular, it is helpful to distinguish different groups of psychopathology, which have varying cultural implications.

Major Versus Minor Psychiatric Disorders

Mental disorders may be divided into major and minor disorders. Major psychiatric disorders are relatively severe, with gross impairment, including psychoses of various kinds, both functional and organic. Minor psychiatric disorders are usually less severe, allowing a person to maintain a reasonable connection to reality. Minor psychiatric illness includes adjustment disorders and a group of disorders formerly categorized as neuroses.
Major psychiatric disorders have prominent biological determinants and are less likely to be caused by psychological and sociocultural factors. The influence of cultural factors is secondary. Thus, culture may affect the phenomenology of, reaction to, and management and outcome of the disorder. On the other hand, the origin of minor psychiatric disorders is more intimately tied to psychological and contextual factors, and therefore sociocultural factors are more critical in their etiology.

Definitions of Normality and Pathology

To assess cultural influence on psychopathology, one must take into account the operating definitions of normality versus pathology. There are four ways to distinguish normality from pathology [8].

By Agreement of Experts

This first approach takes the view that normality or pathology can be distinguished clearly by the nature of the phenomenon itself, and can be judged by experts. In medicine, the occurrence of bleeding or a bone fracture, by the nature of the condition, is judged without doubt to be pathological and needing medical care. In psychiatry, if a person talks to nonexistent people, claims to be hearing the voice of a spaceman, or eats his or her own feces, he or she will be professionally considered ...

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