cultural psychiatry final powerpoint, cultural influence in psychiatry .pptx

cultural psychiatry

1. Cultural Psychiatry Presenter: Dr Prabidhi Adhikari Moderator: Dr Md Ainuddin Bagban

2. Contents Introduction Culture and psychiatric diagnosis Culture and clinical practice Culture and mental illness Culture and treatment Culture, Immigration and mental illness Culture – Neplease context

3. Introduction Culture is defined as a set of meanings, norms, beliefs, values, and behavior patterns shared by a group of people. - CTP

4. Introduction

5. Introduction Race: Is a concept that entails people being grouped primarily by physiognomy. Its impact is intense, due to its reference to physical, biological, and genetic underpinnings, and because of the intensely emotional meanings and responses it generates. Ethnicity: Refers to the subjective sense of belonging to a group of people with a common national or regional origin and shared beliefs, values, practices and religion. Culture brings together race , ethnicity and other ways of life under one rubric to examine its impact.

6. Introduction Cultural psychiatry is  a branch of psychiatry that focuses on the cultural factors influencing mental health(manifestation, treatment and the delivery of mental health services ) “ T he study of the relations between mental disorders and the psychological characteristics which differentiate nations, peoples or cultures. Its main goals are to identify, verify and explain the links between mental disorders and these broad psychosocial characteristics ” (Prof. Murphy, 1982). Transcultural psychiatry, ethno - psychiatry, cross-cultural psychiatry Clinical level: culturally relevant care Theoretical: cross-culturally valid theories Research: cultural factors affect human behavior, psychopathology and healing

7. History of cultural psychiatry

8. History of cultural psychiatry 1964 APA Committee on transcultural psychiatry by APA 1982 1955 Eric Wittkower & Jacob Fried Established a programme in transcultural psychiatry, McGill University, Canada 1957 Eric Wittkower International conference in Zurich, attended by psychiatrists from twenty different countries The term ‘transcultural’ was adopted by Wittkower implying moving through and beyond cultural barriers Murphy defined the principal objectives of the discipline ; to identify, verify, and explain the links between mental disorders and the broad psychosocial characteristics which differentiates nation, people and cultures 1970 H.B.M. Murphy Founded APA section on Transcultural psychiatry

9. Importance

10. Importance

11. Key elements of transcultural psychiatry

12. Cultural competence Ability of mental health professionals to provide person-centric care by considering individual cultural identity. Components: Cultural sensitivity : recognition that groups of people may tend to experience different types of stress in living and utilize different coping patterns Cultural knowledge : basic knowledge about the habits, customs, beliefs, value systems and illness behaviour of different cultures Cultural empathy : ability to feel and understand on an emotional level about patient’s own cultural perspective Cultural guidance : specific treatment models suited for particular ethnic groups ( Tseng el al., 2003)

13. Culture and psychiatric diagnosis Impacts of culture on psychopathology

14. Culture and psychiatric diagnosis Culture influences what is viewed as a social, moral, spiritual, or a mental health problem. The distinction between mind and body varies across cultures . Hence, the conceptualization and the experiencing of a mental disorder depend on cultural modes of perception, explanation, and causal attributions. Ideas that appear to be delusional in one culture may be commonly held in other. E.g witchcraft In some cultures, visual and auditory hallucinations with religious content ( eg hearing gods voice ) are normal part of religious experiences . Eg in church In certain culture distress may take the form of hallucination, pseudo hallucination or overvalued ideas that may be clinically similar to psychosis but are normative to patients' subgroup.

15. Culture and psychiatric diagnosis The boundaries between normality and pathology vary across cultures for specific types of symptoms and behaviors. Thresholds of tolerance for specific symptoms or behaviors differ also across cultures and social settings. Hence, the level at which an experience becomes problematic or pathological will differ. Judgment about clinical attention depends on cultural norms .

16. Culture and psychiatric diagnosis Culture influences the process of diagnosis in many ways: Experience/expression of symptoms/signs, and behaviors; Configuration of symptoms into culturally distinctive syndromes; Stigma attached may prevent their clinical reporting. As a result, cultural context and differences between the clinician and patient have implications in accuracy of diagnosis ,treatment decisions, prognosis, compliance, and clinical outcomes. Diagnostic assessment must consider: social and cultural contexts of the patient and the clinician The degree to which the patient’s experience and behavior differ from relevant social and cultural norms and generate conflict or difficulties in adaptation within his/her culture of origin and the current social context.

17. Psychopathology - transcultural differences Social and cultural factors may be partly or wholly responsible for the causation of disease and modify its nature and course psychodynamic factors leading to psychopathology ; Dependence vs autonomy Linguistic competence Cognitive style Social support system Material culture Psychological sophistication Nature of guilt vs shame ( Varma et al., 1986 )

18. Psychopathology - transcultural differences 1. Dependence versus Autonomy An autonomous individual resist mental breakdown to larger extent. But such a breakdown results in greater psychopathology and less favorable course and outcome. 2. Linguistic Competence- more competence, more elaborate symptomatology H igh level of linguistic competence leads to binding of intense psychic anxiety in of schizophrenia to elaborate delusions that are less amenable to treatment. A low level of competence leaves the anxiety unbound and results in catatonic and somatic symptoms . Varma (1981) schizophrenic patients in developing countries more often develop catatonic symptoms and make greater use of body language ; developed countries - highly systematized delusions. (Hoch 1959, 1961).

19. Psychopathology - transcultural differences 3. Cognitive style It represents ways on which mind perceives the environment, interprets and draws conclusions about it. Can be and synthetic or analytical 4. Material Culture E.g. T here is possession of ghost, evil spirit in developing culture, technologically advanced society, the same is attributed to UFO, Martians.

20. Psychopathology - transcultural differences 5. Social support and Expressed Emotions Traditional societies are richer in social networks - better course and outcome. Patients living in homes characterized by high levels of expressed emotion are significantly more likely to relapse. (Vaughn C, leff J 1976; karno et al 1987) 6. Psychological Sophistication Can be perceived as ability to see conflicts in the intra-psychic terms. It involves introspection and ability to translate one’s emotions into words. These factors are more important in psychotherapy.

21. Impacts of culture on psychopathology Patho- genic effects Patho- selective effects Patho- plastic effect Patho- elaborative effects Patho- facilitative effects Patho- reactive effects

22. Pathogenic effects Culture is a direct causative factor in forming or ‘generating’ psychopathology Cultural ideas and beliefs contribute to stress, which in turn produces psychopathology, not of disease per se Dhat syndrome Koropanic Culture STRESS PSYCHO PATHOLOGY

23. Patho selective effects Through enculturation & socialization some individual members of a given society select culturally influenced reaction patterns, which may be pathological. Amok, family suicide. In Japan, cultural influences leads a family to choose, from among many alternative solutions, to commit suicide together, forming the unique psychopathology Culture STRESS PSYCHO PATHOLOGY * ******* * * ***** * * * ** ** * ** Selected people in society

24. Patho plastic effect The ways in which culture contributes to the modeling or ‘ plastering ’ of the manifestations of psychopathology The content of delusions, auditory hallucinations, obsessions, or phobias are subject to the cultural context in which the pathology is manifested CULTURE content DELUSION ADUITORY HALLUCINATION OBSESSION PHOBIAS President of US is more popular Eg . Donald trump Delusion of grandiosity I am President of US. Or I am more influential than Donald trump

25. Patho elaborating effects Situations where the cultural context exaggerates behaviours which otherwise are normal through cultural reinforcement E.g., Latah- exaggerated startle reflex Phenomenon of “ Trance and possession state ” This could be described to the religious elaboration of association with ‘Atman’ and ‘Deities’ CULTURE Behavior Reinforcement Behavior Response to Startle Cultural acceptance

26. Patho elaborating effects In western countries there is increasing concern with body weight Culture-shaped body image belief that “slim is beautiful" may cause “body weight anxiety” Common reason for eating disorders in developed countries

27. Patho facilitative effects Facilitating effects of culture makes it easier for certain psychopathologies to develop and increase their frequency in certain cultures e.g., AUD #$%^&*@+- $#@%^*+$ ^&*U#@*+% Cultural facilitation for ‘+’ Global prevalence #$%^&*@ + - $#@%^* + $ ^&*U#@* + % +++++++++ +++++++++ +++++++++ Prevalence in facilitated society Media facilitation

28. Patho reactive effects Culture influences: How people perceive pathologies and label disorders How they react to them emotionally Guides them in expressing their suffering Family, social and cultural factors have Pathoreactive effects on schizophrenia resulting in different prognosis Better prognosis of schizophrenia in developing countries like India (Sartorius et al., 1978 ) Culture Psychopathology Course & Outcome

29. CULTURE & CLINICAL PRACTICE Culture bound syndromes (CBS) and Cultural formulation interview (CFI)

30. Culture in DSM-5 To give the context of culture a more prominent position, the following additions were made in DSM 5 Description of basic cultural concepts and culture-related diagnostic issues for each diagnostic category. specific diagnostic criteria were changed to better apply across diverse cultures. For example, the criteria for social anxiety disorder now include the fear of “offending others” to reflect the Japanese concept in which avoiding harm to others is emphasized rather than harm to oneself.) DSM-5 (2013)

31. Culture in DSM-5 Data in DSM-5 criteria includes information on cultural variations in prevalence, symptomatology, associated cultural concepts and other clinical aspects Revision of the Outline for Cultural Formulation and Culture Formulation Interview (Section III) Clinical conceptualizations of distress (Section III and appendix) provides examples of well-studied cultural concepts of distress DSM-5 (2013)

32. Outline for culture formulation (OFC) R evised in DSM-5 Calls for assessment of following categories Cultural identity of the individual Cultural explanation of individual’s distress Interpretation of cultural factors related to psychosocial vulnerabilities and resilience (e.g. social support, environmental stressors) Cultural aspects of relationship between individuals and clinician Overall assessment of how cultural context influences the diagnosis and management plan DSM-5 (2013)

33. Culture formulation interview (CFI) Objective : To explore the significance of culture in psychiatric assessments in an individualized, non-stereotyping way Developed and field tested in 6 countries including India (>300 patients) Brief semi structured interview. Recommended for all patients irrespective of cultural background 12 supplementary modules for in depth exploration of initial 16 questions and for use in other groups (children, elders, migrants, refugees) Supplementary modules for informants/care givers E mphasizes shared decision regarding diagnosis and treatment between patients, families, community members, and clinicians DSM-5 (2013)

34. CFI Consists of 16 questions divided into 4 sections: DSM-5 (2013)

35. Cultural concepts of distress Represent ways in which the individual patient “ experiences, understands, and communicates his or her symptoms to others.” The cultural explanations of illness also may help define the sick role or behavior the patient assumes. The explanatory model of illness includes the patient’s beliefs about their prognosis and the treatment options they would regard as being helpful ( moral model, religious model, magical or supernatural explanatory model, medical model, and psychosocial stress model ) Difficulties may arise when there are conceptual differences in the explanatory model of illness between clinician, patient, family, and community.

36. Cultural concepts of distress Formulation of a collaborative model that is acceptable to both the clinician and the patient which would include an agreed upon set of symptoms to be treated and an outline of treatment procedures should be sought for, Culture affects the patient’s expectations of treatment, such as whether the clinician should assume an authoritarian, paternalistic, egalitarian, or nondirective demeanor in the treatment process . Conflicts between explanatory models Results Between the patient’s and the clinician Diminished rapport or treatment, noncompliance Between the patient’s and the family Lack of support from the family and family discord Patient’s and the community Lead to social isolation and stigmatization

37. Cultural concepts of distress-DSM 5 Cultural syndromes Cultural idioms of distress Causal attribution Defined as a cluster/group of cooccurring symptoms found in a specific cultural group, community, or context. The syndrome may or may not be recognized as an illness within the culture but may be recognized by an outside observer. Eg : Ataque de nervios , dhat , syndrome, khyâl cap, kufungisisa , maladi moun , nervios , shenjing shuairuo , susto and tajin kyofusho Is a linguistic term, phrase or way of talking about suffering, shared with other people from the same culture and used to express, communicate, or comment on distress in general. It need not be associated with specific symptoms, syndromes, It may be used to convey a wide range of uncomfortable, emotional pain or social shakiness including subclinical conditions or everyday experiences that do not necessarily constitute mental disorders. Eg : physical symptoms (somatization) Causal attribution is a label, an attempt at explaining or ascertaining the causes of the symptoms, illness, or distress. Causal explanations may be part of folk classifications of disease used by lay people or healers, which may provide temporary relief. E.g : attribution to ancistral spirits; karmako phal

38. Culture bound syndromes Yap (1962) first gave the term ‘Atypical Culture-Bound Psychogenic Psychosis’ currently known as Culture bound syndromes (CBS) The DSM-5 discarded the concept of culture bound syndromes - cultural concepts of distress Defined as ‘ ways cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions .’ Called culture bound due to the overriding influence of specific cultural traits in the formation of these conditions CBS occur with much greater frequency in some societies than in others

39. syndrome Clinical features Related syndromes Dsm 5 correlation Ataque de nervios A syndrome among individuals of latino descent, characterized by symptoms of: Intense emotional upset, including acute anxiety, anger, or grief Screaming and shouting uncontrollably, attack of crying, trembling, becoming verbally and physically aggressive C/o heat in the chest rising into the head Dissociative experiences (depersonalization, derealization, amnesia), seizure-like or fainting episodes, and suicidal gestures (infrequent) Indisposition in Haiti Blacking out in the Southern United States Falling out in the West Indies Panic attack/ panic disorder Other anxiety disorders Dissociative disorder Conversion (functional neurological symptom) disorder Intermittent explosive disorder Trauma and stressor-related disorder Dhat syndrome Seen in young male patients who attributed their various symptoms to semen loss: Anxiety, depression, fatigue, weakness, c/o weight loss, impotence, multiple somatic complaints The cardinal feature is anxiety and distress about the loss of dhat / semen in th absence of any identifiable physiological dysfunction Koro in Southeast Asia, particularly Singapore Shen- k'uei ("kidney deficiency") in China Major depressive disorder/ persistent depressive disorder (dysthymia) Generalized anxiety disorder Somatic symptom disorder Illness anxiety disorder Erectile disorder/ early (premature) ejaculation/ other sexual dysfunctions

40. Syndrome Characteristics Amok Amok is a Malaysian term used to describe a syndrome characterized by: homicidal frenzy, preceded by brooding and followed by amnesia. the predominant and most dramatic aspect of the syndrome is mass assault, Latah Described among the Malaysians, is marked by hypersensitivity to sudden fright or startle, often with echopraxia, echolalia, command obedience, and dissociative or trancelike behavior . koro Koro occurs when extreme anxiety is evoked in response to a somatic preoccupation. Afflicted individual is seized with terror when he believes that his penis is retracting into his body, and complete retraction will eventuate in death. Desperate measures are taken to prevent retraction, including applying clamps or strings and summoning friends and family to assist. Less commonly, koro is found in women who fear labial and breast involution Taijin Kyofusho Prevalent among the Japanese, is similar to social phobia. The afflicted are intensely anxious that their bodies, their body parts, or body functions may offend, embarrass, or displease others. Typical concerns include embarrassing others by blushing, or causing discomfort by one's gaze, facial expression, or body odor. Especially prevalent among youth,

41. Syndrome Characteristics Brain fag The predominant complaint is fatigue. The term originated in West Africa and is used to refer to a condition experienced by students, primarily male, in response to the stress of their schooling. Symptoms include pain, pressure or tightness in the head and neck, difficulty concentrating, Agnosia; Anxiety, visual complaints Victims complain of "brain tiredness" from "too much thinking," and might also have problems with reading, remembering, and understanding Susto Seen throughout Latin America, It is believed that sudden fright will cause the soul to leave the body, making the individual vulnerable to a variety of ills, even for many years following the fright. Numerous physical and emotional symptoms have been attributed to susto . Possession Syndrome Diagnosable under Dissociative disorders. Patient is possessed usually by ‘spirit/soul’ of deceased relative or a local deity. Speaks in changed tone, even gender changes at times if the possessing soul is of opposite sex. Usually seen in rural areas or in migrants from rural areas . Majority of these patients are females who otherwise don’t have any outlet to express their emotions. Found in India Jhin Jhinia ; Suudu ; Gilhari Syndrome

42. CULTURE AND SPECIFIC MENTAL ILLNESSES

43. Impact of culture on schizophrenia Landmark research projects by the Mental Health Division of WHO: International Pilot Study of Schizophrenia (IPSS) Study of the Determinants of Outcome of Severe Mental Disorders (DOSMED) These studies confirmed that: The syndrome originally described by Emil Kraepelin and Eugen Bleuler exists in very diverse ethnic and cultural groups Pathoplastic effects of socio-cultural factors shape the symptom profiles differently in developed and developing countries

44. Impact of culture on schizophrenia Western developed countries showed a higher frequency of: Depressive symptoms Primary delusions Thought insertion Thought broadcasting Non-Western developing countries showed a higher frequency of: Visual hallucination Auditory hallucinations [SARTORIUS et al. 1986; JABLENSKY et al 1992]

45. Impact of culture on schizophrenia According to IPSS Study: India had highest percentage with best outcome (66%) Nigeria had the lowest percentage with worst outcome (10%) The major limitation of the study was that the sample was not an epidemiological sample Schizophrenic psychoses have a better prognosis in Asian and African than in comparable British patient populations Two‑thirds of schizophrenia patients in India have partial to full remission of symptoms Demonstrated by: The Madras longitudinal study The study of factors associated with course and outcome of schizophrenia (SOFACOS) [JABLENSKY et al 1992, OGAWA et al. 1987; LEE et al. l991; TSOI & WONG l991]

46. Impact of culture on schizophrenia The DOSMED study used an epidemiological sample from 12 centers in 10 countries ; Conclusions: The content of psychotic symptoms tends to identify critical problems existing in a particular culture Persecutory delusions and auditory hallucinations are not necessarily indicative of schizophrenia in persons of African cultural background Influence of ethnicity and culture on psychopathology weighs more than geographic proximity, historical relations and racial similarity Ethnic and cultural differences are reflected in the schizophrenic symptom profiles even if the populations adhere to the same religion Studies in Japan, Hong Kong and Singapore demonstrated a more favorable course and outcome than in Europe and North America [KATZ et al. 1988] [NDETEI & VADHER1984; NDETEI 1988 ]

47. Affective disorders- depression Culture greatly influences the way in which depressive symptoms are expressed In the WHO collaborative study assessed depressive disorder in 583 patients at five centers (Basel, Montreal, Tehran, Nagasaki, and Tokyo) Most of them had common features of sadness, anhedonia, lack of interest and energy, impaired concentration, and ideas of worthlessness Feelings of guilt and suicidal ideations were least common in Tehran

48. Depression Indian studies have found guilt to be less common among Indian patients than those in the West Indian patients reported guilt of an impersonal nature. The present suffering is attributed to possible bad deeds of previous life (consequence of “Karma”) rather than due to self‑failure as in the West Physical symptoms are common presenting symptoms in depression

49. Anxiety disorders Results of a study assessing the prevalence rates of anxiety disorders in U.S population: Asian Americans had symptoms of all four major anxiety disorders less frequently than other racial groups White Americans reported symptoms of social anxiety disorder, generalized anxiety disorder and panic disorder more frequently than other racial groups African Americans more frequently met criteria for post-traumatic stress disorder (PTSD) as compared to other racial groups

50. Transcultural aspects of dissociative and somatoform disorders Transformation of personal or social distress into somatic complaints is a norm in most cultures. ( Fabrega , 1991) (Kleinman, 1987) Patients tend to develop symptoms that are "medically correct “ Somatic symptoms tend to be less stigmatizing than psychological symptoms Worldwide most common medically unexplained symptoms are Gastrointestinal complaints Abnormal skin sensations (World Health Organization, 1992) Most common medically unexplained somatic symptoms in the United States were gynecological complaints, followed by gastrointestinal and cardiovascular symptoms (Epidemiologic Catchment Area study ,Escobar et al., 1987)

51. Transcultural aspects of dissociative and somatoform disorders Nigeria and India common somatic symptoms are: Feeling of heat Peppery and crawling sensations Numbness Burning hands and feet Hot, peppery sensations in head These symptoms are extremely rare in Western countries Indian study observed that most patients with dissociation presented with a "brief dissociative stupor" that coexisted with anxiety and panic symptoms Multiple Personality Disorder (MPD) is an iatrogenic disorder largely confined to North America MPD is rare or nonexistent in other western and non western countries

52. Culture & psychopharmacology Affect levels of expectation for optimum treatment response Affect expected rate of treatment recovery Affect threshold and tolerance for side effects Influence the target symptoms Ethnopharmacology - Use of substances medicinally by different ethnic or cultural groups. Example - St John Wart - used traditionally in Germany and Northwestern Europe Pharmacogenetics - Differences in response to or handing of drugs based on ethnicity Example - Asian patients require lower dose of dopamine receptor antagonist, tricyclic antidepressants, benzodiazepines and lithium to achieve same clinical response compared to white population with more predisposition to side effects at higher doses

53. Culture & psychotherapy Ethnopsychology - study of how individuals within a cultural group conceptualize the self, emotions, human nature, motivation, personality, and the interpretation of experience ( Kirmayer , 1989) There is a lack of of perceived cultural relevance of Western psychotherapeutic techniques Need to modify the existing psychotherapeutic techniques according to culture and to integrate existing traditional forms of support Example - In Asian population there is need to involve family members during therapy sessions, involving religious concepts, introduce the concept of “mind control” or Sattvavajaya(Trance therapy)

54. IMMIGRATION & MENTAL ILLNESS Migration and accultration

55. Culture, immigration and mental illness When a person shifts his residence from one political or administrative boundary to another, it is known a migration Three principal hypothesis explain the relationship between immigration and mental illness: Certain mental disorders incite their victims to migrate. The process of migration creates mental stress, which may precipitate mental illness in susceptible individuals There is a non-essential association between migration and other variables, such as age, social class and culture conflict ( Murphy et el.,1973) Obtaining a thorough migration history will assist in understanding background and precipitating stressors and help guide development of an appropriate treatment plan.

56. Culture shock Psychological adjustment to an abrupt transition from one culture to another Phase 1/ Honeymoon phase - new environment is regarded as exciting and new opportunities for work, pleasure and social activities are welcomed Phase 2/ Disenchantment phase - fatigue of not understanding gestures, signs and language sets in; and miscommunications may happen frequently Phase 3/ Beginning resolution phase - the individual seeks patterns of behaviour appropriate to the new setting leads directly to the Phase 4/ Effective function phase - the individual has worked through his loss and re-established his self-esteem, and may experience reverse culture shock on returning home (Brink and Saunders,1976)

57. Culture, immigration and mental health Acculturation : the process by which members of one cultural group adopts the cultural traits and social patterns of another cultural group Integration Assimilation Marginalization Separation/segregation Acculturative stress : refers to the psychological, somatic and social difficulties that may accompany acculturation. The intensity of acculturative stress experienced by immigrant is directly proportional to the openness of the host government and population

58. Cultural Perspective in Nepal 63 Concept of the self (Person) -dfG5]_ Complex divisions: mind, body, spirit –Heart mind -dg_ : organ of emotion & memory -Brain mind - lbdfu _ : cognition & social behavior -Physical body - lhp ÷z/L/_ -Spirit -; ftf ]_ -Soul - cfTdf _ -Social status - OHht _ -Family -kl/ jf /_ -Ancestral deities - s'nb ] jtf _ -Society -; dfh _ Traumatic/ Intrusive memories - dgsf ] 3fp_ considered acceptable Brain mind problems - dfgl;s /f]u_ stigmatizing Treatment by faith-healers/ shamans - wfdLemfFs|L Kohrt et al, 2012; IASC, 2015

59. Nepali idioms of distress 64 Nepali terms do not directly translate to the psychiatric diagnoses vocabulary of terms for emotions, thoughts, & behaviors Dfgl:ylt ljrf / Jojxf / Nepali idioms of distress relate to Nepali conceptions of the self Dfgl;s /f]u÷; d:of Dfgdf s'/f v]Ng]÷ kL / kg]{ Nepalese with psychological distress commonly express somatically lhp÷uf ]8f Efmdemdfpg ] k]6 b'Vg] -Uofli6«s_ 6fpsf] b'Vg]÷ skfn kf ]Ng] Kohrt et al, 2012; IASC, 2015

60. 65

61. Explanatory models of Illness 66 Mental health and psychosocial problems attributed to impacts on the heart-mind ( dg ) and brain-mind ( lbdfu ) Etiological factors: Life stress, physical illness, religious infractions, bad karma - sd {_, being born with an inauspicious astrological forecast -g/ fd|f ] u|xgIfqsf ] k|efj _ Traumatic life events and mass disasters (e.g. earthquake) also may cause psychosocial problems though soul loss -; ftf ] uP /_, loss of love ones, constant fear, worries, and economic stress IASC, 2015; Chase et al, 2018

62. Traditional modes of treatment 67 Traditional healers ( wfdLemfFs|L,nfdf,u'? jf ): psychological distress results from being struck by ghosts ( e"t ) or witches ( af ]S;L ), offended ancestors - lkt [_ or from curses sent by others -> fk _ -healing requires appeasing those spirits Sudden fright or trauma: soul loss ( ; ftf ] hfg ] ) -treated by traditional healers calling the soul back Tibetan Medicine: a formal system of training with an extensive psychiatric/psychological practice Informal sector: family, friends, neighbors, local community organizations, religious/ cultural assemblies -common source of help-seeking Kohrt et al, 2012; IASC, 2015

63. Conclusion Culture is a common heritage; set of beliefs, norms, and values, having a meaning shared by a group of people Cultural factors have huge influence on mental health Failure to adequately address social and cultural contexts limits the effectiveness in management of psychosocial problems Understanding the cultural perspective locally, not only globally, is vital for adequate mental health care 68

64. References Comprehensive textbook of psychiatry 10 th edition Oxford textbook of psychiatry Diagnostic and statistical manual – 5;2013;APA Cultural Bound Syndromes in India Vishal Chhabra, M.S. Bhatia, Ravi Gupta Nepali Concepts of Psychological Trauma: The Role of Idioms of Distress, Ethnopsychology, and Ethnophysiology in Alleviating Suffering and Preventing Stigma; Cult Med Psychiatry. 2010 June