TAN Issue: January/February 1998: Features: Mental disorders and culture-bound syndromes

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by Michael Stewart, MA

Examples of culture-bound syndromes

Diversity and Mental Health

On a patient's first presentation in a health care facility, it can be difficult for even a skilled clinician to determine the nature of a patient's signs and symptoms when a mental disorder might be involved. Signs and symptoms may be the result of a general medical condition, a mental disorder or substance abuse, a medication problem, or they may be the result of several of these causes working in combination.

Further complicating accurate diagnosis and treatment is a subtype of conditions known as culture-bound syndromes. These have received little attention even among mental health professionals.

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the term "culture-bound syndromes" denotes "recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be illnesses' or at least afflictions, and most have local names." DSM-IV notes that culture-bound syndromes are "generally limited to specific societies or culture areas and are localized, folk, diagnostic categories." (See "Examples of Culture-Bound Syndromes.")

It is useful in any initial encounter with a patient to note the cultural identity of the individual and the individual's (or family member's) own cultural explanations of the person's illness. Nurses may wish to be particularly attuned to cultural factors related to the patient's psychosocial environment and levels of functioning and to the cultural elements of the relationship between the nurse and the patient.

According to DSM-IV, examples of these factors include "culturally relevant interpretations of social stressors, available social supports and levels of functioning and disability. This would include stresses in the local social environment and the role of religion and kin networks in providing emotional, instrumental and informational support."

DSM-IV notes the importance of acknowledging and working within the "differences in culture and social status between the individual and the clinician and [the] problems these differences may cause in diagnosis and treatment (e.g., difficulty in communicating in the individual's first language, in eliciting symptoms or understanding their cultural significance, in negotiating an appropriate relationship or level of intimacy [and] in determining whether a behavior is culturally normative or pathological.)"

Examples of culture-bound syndromes

Ataque de nervios: Primarily reported by Latinos from the Caribbean. Symptoms may include uncontrollable shouting, attacks of crying, trembling, heat in the chest rising to the head and verbal or physical aggression. Dissociative experiences, seizure-like or fainting experiences and suicidal gestures are prominent in some attacks. People may experience amnesia for what occurred during the attack.

Falling-out or blacking-out: These episodes occur primarily in southern United States and Caribbean groups. They are characterized by a sudden collapse, which sometimes occurs without warning, but sometimes is preceded by feelings of dizziness or "swimming" in the head. The individual's eyes are usually open, but the person claims an inability to see. The person usually hears and understands what is occurring around him or her but feels powerless to move.

Hwa-byung (also known as wool-hwa byung): A Korean folk syndrome literally translated into English as "anger syndrome" and attributed to the suppression of anger. The symptoms include insomnia, fatigue, panic, fear of impending death, dysphoric affect, indigestion, anorexia, dyspnea, palpitations, generalized aches and pains and a feeling of a mass in the epigastrium.

Those three examples are abbreviated and adapted from a listing of more than 20 culture-bound syndromes that appears in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), published by the American Psychiatric Association, 1994.

Michael Stewart, MA, is senior public relations specialist at the American Nurses Association.

Diversity and Mental Health

Nurses also are referred to the Statement on Psychiatric-Mental Health Clinical Practice and Standards of Psychiatric-Mental Health Clinical Nursing Practice (1994) for further information on nursing and psychiatric illness. To order ($9.50 for SNA members; $13.95 for nonmembers), call ANA Publications at (800) 637-0323. ANA also is finalizing a new document, Components of Psychiatric Mental Health & Addictions Nursing Workforce, which will include sections dealing directly with cultural competence. This document will be completed in 1998 and will be available through ANA's Department of Nursing Practice.