Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0116aProblems of AssessingPsychiatric Symptoms and Illnessin Different CulturesMelanie AbasUniversity of Auckland, New ZealandIncreasingly, psychiatrists must have the skills to assess anddeliver care for people from different cultures. Many areas canonly be touched on here, and several of the references stem fromthe cross-cultural literature in younger adults. The context is verybroad, covering industrialized countries with multicultural populationsand less-industrialized countries. It is worth noting that,due to a range of barriers, many people from different cultureshave, of course, very poor access to psychiatric assessment andcare 1–4 .COMMUNICATION AND CULTURAL AWARENESSWhile health staff often come from different cultures than theirpatients 5 , they are usually working within at least a familiarframework and landscape. With someone from a very differentculture, the ability to assess appearance, behaviour andsymptoms will be limited. The practitioner must work harderto gather the information to make an accurate assessment and todevelop rapport and trust. Awareness of one’s lack ofinformation of one’s own cultural ‘‘encumbrances’’ and ofpotential strong feelings about each other’s cultures is crucial 6 .Training and consultation with a wide circle of people from therelevant culture is needed. Ask the patient early on about his/herbackground and, for migrants, his/her place of origin andexperience in the new setting. Listening, asking open questions,acknowledging family expectations and a willingness to discussissues such as racism and social needs are all vital. Withinreasonable professional boundaries, the psychiatrist should bewilling to respond to some questions about him/herself. Forexample, with older Jamaican migrants, culture-specific careproviders stressed that making ‘‘a connection’’ with the doctorwould facilitate the assessment and acceptance of care 7 . Showsensitivity but do not neglect important areas on ‘‘cultural’’grounds, such as alcohol intake in Muslims. Apparent persecutoryideas must be explored and may reflect an appropriateresponse to injustice.Language barriers should be addressed through the employmentof ethnically close bilingual workers, otherwise use acompetent interpreting and advocacy service 8 . Using relatives orother staff to interpret should be limited to emergencies.Requiring patients to speak in their second language can distortthe clinical picture 6 . Aspects of non-verbal communication mayalso differ, such as avoidance of direct eye-to-eye contact in someAsian and Pacific cultures.DIFFERENT PRESENTATIONS OF EMOTIONALDISTRESSPeople from all cultures experience both somatic and psychologicalsymptoms when emotionally distressed 9 . One reason for a moresomatic presentation may be that this is seen as a more appropriatefocus for medical consultation by some cultures. Second, theremay be a continuum of experience and interpretation, with themore ‘‘somatizing’’ cultures at one end and the more ‘‘psychologizing’’10,11 at the other. Thirdly, a large number of ‘‘somatic’’complaints are actually metaphors for mental distress. Many ofthese relate to heart discomfort (e.g. a heart that is ‘‘sinking’’ or‘‘uncomfortable’’) 12–14 and to abdominal sensation 15,16 .Culture-bound syndromes usually represent cultural explanationsfor recognizable psychoses or neuroses 13 . For example,Dhat, a belief that semen is leaking from the body in urine, is acomplaint in India. It may be a presenting feature, and is used asan explanation for weakness due to depression or organic disease.DEPRESSIONThere has been much debate about the existence of depression as auniversal cross-cultural category 10,17 . It is reasonably establishedthat depressive disorders exist across cultures and are stronglyrelated to local constructs 15,18,19 . However, symptoms vary (e.g.depressed older Jamaicans and African-Americans describe feeling‘‘low’’, ‘‘bad’’ or ‘‘fed-up’’) 20,21 ; multiple somatic symptoms ormetaphors may be presented; and some cultures may emphasizetheir explanation (e.g. social or spiritual) for their symptoms 22 .The validity of screening scales may vary, e.g. a lower cut-off pointfor the Geriatric Depression Scale has been recommended forolder African-Caribbeans, African-Americans and Mexican-Americans 23,24 . Symptom profiles in depressed cases may alsodiffer considerably across cultures, as shown even across Europeancentres in older people 34 . Depression at community level alsoappears to be highly correlated with anxiety 25 . The implicationsare that: (a) it is important to enquire about the full range ofaffective and neurotic symptoms; and (b) a wide definition ofmood disorders is likely to be most useful in the clinical setting.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd