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Chapter 10

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PSYC14 Notes – Chap 10: Mental and Physical Health Mental Health  What does it mean to say that a psychological disorder is more prevalent in one culture than another? o This disorder is not automatically unfolding from a set of innate biological causes- culture is implicated in the expression and experience of psychopathology.  If normal psychological functioning differs across cultures (as we have seen in past chapters), then it follows that departures from normal behaviour also differ across cultures as well  Disorders are defined with respect to behaviours that are rare and cause some kind of impairment to the individual. This definition is problematic however when considering a rare musical gift that might impair someone’s social life (is this a disorder too?) o Labelling disorders may also be challenging because certain behaviours are considered problematic in one culture but not another (ex: South Asian dhat syndrome)  Culture-bound Syndromes:  Culture bound syndromes are those that appear to be greatly influenced by cultural factors. They either occur with very different frequencies in different cultures or are manifested in highly divergent ways in different cultures. In order to understand them, it is important to understand the cultural values and understandings that go along with them  The 2 most common clinical manifestations of eating disorders are Anorexia Nervosa and Bulimia Nervosa. The symptoms for these two conditions are relatively homogenous across and within cultures. o Anorexia nervosa diagnosis requires: a refusal to maintain a normal body weight, intense fear of gaining weight, denying the seriousness of one’s low body weight, and missing 3 consequtive menstrual cycles o Bulimia nervosa diagnosis requires: recurrent episodes of binge eating (uncontrollably eating large amounts in a 2 hour period), and recurrent inappropriate behaviours to prevent weight gain (vomiting, laxatives, excessive exercise). Both of these must occur at least twice a week for 3 months and the person cannot be concordantly diagnosed with anorexia.  It is thought that these are culture bound syndromes because of the dramatic increase in prevalence over the past 50 years and because it is more prevalent in cultures with Western cultural influences. It seems that changing cultural norms are at least partially responsible (women receive more cultural messages that attractive bodies are thin).  For bulimia, there is a striking absence of documented cases in many parts of the world (Africa, India, and parts of the middle east where there is little Western influence). Also, the historical literature shows little evidence of behaviours that would be characteristic of bulimia.  The evidence for anorexia is more mixed: some studies report an absence of anorexia in some cultures while some studies have found cases of anorexia in diverse cultural contexts with relatively little Western influence.  Documented cases of religiously motivated self-starvation (“holy anorexia”) are seen from the 12 century.  Unlike bulimia, which has all the hallmarks of a culture bound syndrome, anorexia seems to have many symptoms that are universal, although they are still greatly influenced by culture. It may be an existential universal but not a functional universal because self-starvation motivations are present in diverse contexts but for different reasons (concerns about weight vs. being spiritually ascetic)  In South and East Asia the clinical syndrome koro (head of the turtle) is most common among men and manifests as a morbid fear that one’s penis is shrinking into the body. This event can lead to tremendous anxiety, terror, and even death.  Koro meets all the criteria for a culture bound syndrome, as all its symptomology is nearly absent in other cultures.  Amok is a phenomenon in Southeast Asian cultures that has been defined as an acute outburst of unrestrained violence, associated with homicidal attacks, preceded by a period of brooding and ending with exhaustion and amnesia. This occurs primarily among males and is thought to be instigated by stress, lack of sleep, and alcohol.  It is thought that in Malay culture, which values passive and nonconfrontational behaviour, running amok is the result of not being able to find culturally acceptable means of expressing frustration.  While the symptomology and cultural meaning associated with amok seems to be specific to certain Asian cultures, there are similar phenomenon (mass killings in schools) that occur in the USA and other Western cultures. It is unclear whether these similar behaviours are indicative of a common underlying disorder.  Universal Syndromes:  Culture bound syndromes indicate that culturally derived meanings play a large role in the development of psychopathologies; universal syndromes highlight the biological function of mental illness. However, even though some syndromes are universally observed, their manifestation might vary dramatically across cultures.  Depression is a commonly identified psychological disorder in the West. Many people are familiar with it and have event experienced some of the symptoms (sadness, futility, lack of energy). If the symptoms are severe enough the person may be diagnosed with MDD (major depressive disorder)  The lifetime prevalence rate can be as high as 44% in American (it varies depending on the criteria used), but it is less commonly diagnosed in other cultures such as China. However, some studies have found it to be almost 4x more common in other cultures (Nigeria).  There is evidence for the universality of MDD as a diagnostic criteria however: cases that fit the DSM definition of MDD have been found in every culture explored.  However, not all depressed people show the same symptoms. Some key symptoms are psychological whereas some are physiological. o Somatisation is the experience of symptoms primarily in the body o Psychologization is the experience of symptoms primarily in the mind  Kleinman conducted a study in a Chinese psychiatric hospital and assessed a group of patients diagnosed with Neurasthenia: a nervous syndrome that was commonly diagnosed in America in the 19 century. This diagnosis faded in the West however over the 20 century as people found the symptoms less important and began to focus more on the underlying psychopathology.  After interviews with the patients, Kleinman found that 87% of them could be described as having some form of clinical depression however, only 9% of them had depressed mood as a chief complaint. o Somatisation is most common among Chinese presentations of depression than it is among Westerners. Chinese patients experience more somatic symptoms and less psychological ones compared to Canadian patients  What might cause these cultural differences in the presentation of depression?  1) It might be due to social stigma, and Chinese people may have greater social costs in acknowledging a psychological disorder opposed to a physiological one. The experience of depression may be the same, but Chinese are less willing to discuss the psychological difficulties. However, this might not be the case because even in private, confidential responses, Chinese do not report many psychologization  2) The symptoms experienced by people may be the same, but people from different cultures may focus on certain symptoms more. Westerns may attend more to their psychological/emotional symptoms because these are more meaningful to them.  3) The symptoms are actually experienced differently across cultures. This may be because, since the time of Descartes, Westerners view a clear distinction between the mind and body while the Chinese do not.  Social anxiety disorder (previously known as social phobia) is the fear that one is in danger of acting in an inept and unacceptable manner, and that such poor performance will result in disastrous social consequences.  Social anxiety is well documented around the world- reflecting the universal concerns that people share as a social species. It would seem then that social anxiety concerns should be especially prevalent in cultural contexts where there is more emphasis on the value of fitting in with others (East Asian cultures).  It has been found that East Asian Americans are more likely to endorse social anxiety symptoms on questionnaires. Interdependence has also been found to have a very strong correlation with social anxiety.  This raises that possibility that people may view social anxiety disorder as less of a problem in Asian than in the West. o Although east Asians score higher than Westerners on measures of social anxiety, surveys have found that there are less people who meet clinical criteria of social anxiety disorder in East Asian than in the West.  When people’s social anxieties do become problematic however, they are presented differently across cultures.  TKS (taijin kyoufushou) is a Japanese diagnosis that, similar to social anxiety disorder, is elicited but social situations, but has quite distinct symptoms. TKS involves several physical symptoms (blushing, body odour, sweating, etc.) that the person is preoccupied with, but they are also preoccupied with how uncomfortable and tense they are making Others feel around them because of the repulsiveness of their physical faults.  TKS is more prevalent in Japan than social anxiety disorder is in the West. TKS is also the most common phobia in Japan. Whereas social anxiety disorder is more common among women, TKS is more common among men. TKS is considered a culture bound syndrome.  Suicides represent a category of mental illness that is easily compared across cultures because the outcome of the behaviour is well defined.  Although suicide is recognized quite similarly around the world, its frequency varies enormously- suicide is a more significant part of some cultures than others. Furthermore, people in different cultures commit suicide at different points in their lives.  As seen in Fig 10.1, in all cultures (except Egypt and Mirconesia) suicide rates tend to increase among the elderly and be quite similar to the adolescent years.  The pattern of suicides in Micronesia is unique and warrants some discussion. It did not always have a high suicide rate, but it began to increase dramatically in the 1970’s. The majority of suicides occurred among adolescent males living at home and typically, they did not show any outward signs of psychological disorder. They tended to be sparked by trivial matters (have an argument with a brother) and the suicides involved people asphyxiating themselves. It is not clear what has caused this cultural change, but in other places too, there is an increase in suicide rates as traditional cultures become more Westernized (losing traditional roles in the society).  People’s motivations for suicide can vary considerably across cultures. In the West, suicide is seem as stemming from depression, substance abuse, health problems, life tragedies, etc. While suicides around the world may share some of these motivating factors, some motivations are less familiar in the West. An example would be the idea of committing suicide to accept responsibility and preserve one’s honour in Japan.  To be diagnosed with schizophrenia, one must have 2 or more of the following symptoms present for a significant period of time: delusions, hallucinations, disorganized speech, disorganized or catatonic behaviour, or negative symptoms (flattening affect).  Given the clear biological foundation of schizophrenia, it is not surprising that it emerges quite regularly across cultures. Longitudinal studies have found that, while neurotic disorders are on the rise, schizophrenia rates have remained constant overtime across cultures. o The uniformity of the symptoms and the narrow range of prevalence speaks to the cultural similarity of the manifestations of this disorder.  At the same time, there is still striking evidence of cultural variability in schizophrenia. While the paranoid subtype was the most common in most locations, the proportions varied considerably across locations. 75% of schizophrenics in the UK were diagnosed as paranoid while only 15% were in India. There was a 1-3% diagnosis of the catatonic subtype in the West, while a 20% prevalence in India.  A striking find
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