- Email: [email protected]
Cultural considerations in the diagnosis and treatment of schizophrenia: A case example from India
Accepted Manuscript Title: Cultural considerations in the diagnosis and treatment of schizophrenia: A Case example from India Author: Saranya Dhanasekaran Santosh Loganathan Ajit Dahale Mathew Varghese PII: DOI: Reference:
S1876-2018(16)30562-7 http://dx.doi.org/doi:10.1016/j.ajp.2017.02.019 AJP 1069
To appear in: Received date: Revised date: Accepted date:
10-12-2016 19-2-2017 19-2-2017
Please cite this article as: Cultural considerations in the diagnosis and treatment of schizophrenia: A Case example from India, Asian Journal of Psychiatry (2017), http://dx.doi.org/10.1016/j.ajp.2017.02.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title Page
an
us
2. Santosh Loganathan Associate Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email:
cr
Author names and affiliations: 1. Saranya Dhanasekaran Senior Resident Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email: [email protected]
ip t
Title: Cultural considerations in the diagnosis and treatment of schizophrenia: A Case example from India
d
M
3. Ajit Dahale Assistant Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email:
Ac ce pt e
4. Mathew Varghese Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email: Corresponding author: Saranya Dhanasekaran Senior Resident Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email: [email protected]
Page 1 of 5
Key words: cultural considerations; schizophrenia; India
Sociocultural factors influence symptom presentation and outcomes in
cr
•
ip t
Highlights:
schizophrenia
The cultural formulation helps explore cultural identity and explanatory models
•
Culture sensitive interventions ensure amenability to treatment
an
us
•
Abstract
M
Culture plays an important role in the presentation, help seeking, treatment and outcomes of psychiatric illnesses like Schizophrenia. We report a case of Paranoid
d
schizophrenia in a 35-year-old lady, from South India, whose clinical presentation
Ac ce pt e
was influenced by various sociocultural factors. These cultural constructs were taken into consideration to formulate an acceptable and effective management plan. A detailed case description using a cultural formulation to highlight the etic and emic perspectives and challenges in treatment and management are discussed.
Page 2 of 5
Cultural considerations in the diagnosis and management of schizophrenia: A Case example from India Dear Sir, Cultural factors influence symptom presentation, help seeking, acceptance of the
ip t
diagnosis, and outcomes in psychiatric illnesses (Bhikha, Farooq, Chaudhry, & Husain, 2012; Lewis-Fernández & Aggarwal, 2013 ; Vega & Lewis-Fernández,
cr
2008). This report is indicative of the relevance of considering cultural contexts even while diagnosing and treating severe psychiatric conditions such as schizophrenia.
us
Case description:
A 35 year old married Hindu lady, from a village in Southern India, presented with a
an
continuous illness of 2 years duration characterised by delusions of persecution and control, third person auditory hallucinations and by episodes of trance and possession. She had no significant past or family history of psychiatric illness. On
M
mental status examination, she appeared fearful and her thought content comprised themes of religion, of somatic control (of Hindu Goddesses controlling her body) and
d
of persecution. She also reported of auditory hallucinations (voices of Hindu
Ac ce pt e
Goddesses chastising her and discussing about her amongst themselves). After admission, she insisted on being discharged from the hospital and be taken to the temple. She was often found praying and chanting in the ward. The treating team made a diagnosis of Paranoid Schizophrenia (as per the DSM-5 criteria)(American Psychiatric Association, 2013) and started on Tab Risperidone which was gradually increased to 8 mg. Initial clinical history revealed presence of socio-cultural factors influencing the symptoms, and as a result the treating team decided to apply the DSM-5 cultural formulation interview (American Psychiatric Association, 2013) to gather information on the patient’s cultural identity, illness explanations and to formulate a patient-centred treatment plan. Role of Cultural Identity: The cultural formulation revealed that the patient belonged to a traditional Hindu household, but she had considered converting to Christianity a few months prior to the onset of her illness. This was met with severe opposition from her family and her husband in particular. On their insistence, she had continued to be a Hindu while covertly attending masses and sermons at churches. She expressed conflict
Page 3 of 5
regarding her religious views, wanting to follow both religions while at the same time fearing repercussions for doing so. Cultural Perceptions of Cause, Context, and Support: After the onset of her illness, her family believed that her possession attacks were a sign that her illness was a result of her being punished by Hindu Gods for considering conversion to another religion.
ip t
Past Help Seeking ,Barriers and Preferences:
She had been taken to multiple faith healers by her family. During the process of
cr
faith healing, she was beaten, starved and burnt to appease the Gods. This had also led to a delay of two years in seeking medical treatment for her illness and
us
considerable distress to the patient. The patient also attributed her abnormal experiences to supernatural possession and revealed that she asked to be
an
discharged so that she could visit temples to appease the angry Gods and Goddesses who were punishing her.
The use of the DSM-5 cultural formulation interview helped in the understanding of
M
patient’s cultural and religious identity, the possible influence of culture on the symptom presentation of her symptoms and reasons behind the delay in help-
d
seeking. This information helped in the negotiation of a treatment plan that
Ac ce pt e
advocated continued hospitalisation while at the same time allowed the patient and her family to visit a temple nearby to daily to offer their prayers. The patient’s psychotic
symptoms
gradually
improved
over
a
period
of
three
weeks.
Psychoeducation and supportive therapy helped the patient better understand her illness, the need for continued treatment and enabled her to have a dialogue with her family about her religious choices. At the time of discharge, she reached her premorbid level of functioning. She decided to continue practising both Hinduism and Christianity and agreed on the need for continued medications and regular follow ups. An integration of etic and emic perspectives enabled the treating team to better understand the patient’s perception of her illness and the roles that both faith and medications had in her recovery. Often, the cultural assessment is restricted to mention of the patient’s religion, race and language. An in-depth exploration of the patient’s cultural and religious identity and illness explanatory models enabled the planning of individual tailor made interventions that ensured amenability to treatment, mutual participation and cooperation with the treating team and thus facilitated recovery.
Page 4 of 5
References: Bhikha, A. G., Farooq, S., Chaudhry, N., & Husain, N. (2012). A systematic review of explanatory models of illness for psychosis in developing countries. International Review of Psychiatry (Abingdon, England), 24(5), 450–62. http://doi.org/10.3109/09540261.2012.711746 mental disorders (5th ed.). Washington, DC: Author.
ip t
American Psychiatric Association. (2013). Diagnostic and statistical manual of
Disorders. CHAP, American Psychiatric Association.
cr
Cultural Formulation. (2013). In Diagnostic and Statistical Manual of Mental
http://doi.org/doi:10.1176/appi.books.9780890425596.CulturalFormulation
us
Lewis-Fernández, R., & Aggarwal, N. K. (2013). Culture and psychiatric diagnosis. Advances in Psychosomatic Medicine, 33, 15–30.
an
http://doi.org/10.1159/000348725
Vega, W. A., & Lewis-Fernández, R. (2008). Ethnicity and variability of psychotic symptoms. Current Psychiatry Reports, 10(3), 223–8. Retrieved from
Ac ce pt e
d
M
http://www.ncbi.nlm.nih.gov/pubmed/18652790
Page 5 of 5
S1876-2018(16)30562-7 http://dx.doi.org/doi:10.1016/j.ajp.2017.02.019 AJP 1069
To appear in: Received date: Revised date: Accepted date:
10-12-2016 19-2-2017 19-2-2017
Please cite this article as: Cultural considerations in the diagnosis and treatment of schizophrenia: A Case example from India, Asian Journal of Psychiatry (2017), http://dx.doi.org/10.1016/j.ajp.2017.02.019 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title Page
an
us
2. Santosh Loganathan Associate Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email:
cr
Author names and affiliations: 1. Saranya Dhanasekaran Senior Resident Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email: [email protected]
ip t
Title: Cultural considerations in the diagnosis and treatment of schizophrenia: A Case example from India
d
M
3. Ajit Dahale Assistant Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email:
Ac ce pt e
4. Mathew Varghese Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email: Corresponding author: Saranya Dhanasekaran Senior Resident Department of Psychiatry National Institute of Mental Health and Neurosciences Bangalore-29 Email: [email protected]
Page 1 of 5
Key words: cultural considerations; schizophrenia; India
Sociocultural factors influence symptom presentation and outcomes in
cr
•
ip t
Highlights:
schizophrenia
The cultural formulation helps explore cultural identity and explanatory models
•
Culture sensitive interventions ensure amenability to treatment
an
us
•
Abstract
M
Culture plays an important role in the presentation, help seeking, treatment and outcomes of psychiatric illnesses like Schizophrenia. We report a case of Paranoid
d
schizophrenia in a 35-year-old lady, from South India, whose clinical presentation
Ac ce pt e
was influenced by various sociocultural factors. These cultural constructs were taken into consideration to formulate an acceptable and effective management plan. A detailed case description using a cultural formulation to highlight the etic and emic perspectives and challenges in treatment and management are discussed.
Page 2 of 5
Cultural considerations in the diagnosis and management of schizophrenia: A Case example from India Dear Sir, Cultural factors influence symptom presentation, help seeking, acceptance of the
ip t
diagnosis, and outcomes in psychiatric illnesses (Bhikha, Farooq, Chaudhry, & Husain, 2012; Lewis-Fernández & Aggarwal, 2013 ; Vega & Lewis-Fernández,
cr
2008). This report is indicative of the relevance of considering cultural contexts even while diagnosing and treating severe psychiatric conditions such as schizophrenia.
us
Case description:
A 35 year old married Hindu lady, from a village in Southern India, presented with a
an
continuous illness of 2 years duration characterised by delusions of persecution and control, third person auditory hallucinations and by episodes of trance and possession. She had no significant past or family history of psychiatric illness. On
M
mental status examination, she appeared fearful and her thought content comprised themes of religion, of somatic control (of Hindu Goddesses controlling her body) and
d
of persecution. She also reported of auditory hallucinations (voices of Hindu
Ac ce pt e
Goddesses chastising her and discussing about her amongst themselves). After admission, she insisted on being discharged from the hospital and be taken to the temple. She was often found praying and chanting in the ward. The treating team made a diagnosis of Paranoid Schizophrenia (as per the DSM-5 criteria)(American Psychiatric Association, 2013) and started on Tab Risperidone which was gradually increased to 8 mg. Initial clinical history revealed presence of socio-cultural factors influencing the symptoms, and as a result the treating team decided to apply the DSM-5 cultural formulation interview (American Psychiatric Association, 2013) to gather information on the patient’s cultural identity, illness explanations and to formulate a patient-centred treatment plan. Role of Cultural Identity: The cultural formulation revealed that the patient belonged to a traditional Hindu household, but she had considered converting to Christianity a few months prior to the onset of her illness. This was met with severe opposition from her family and her husband in particular. On their insistence, she had continued to be a Hindu while covertly attending masses and sermons at churches. She expressed conflict
Page 3 of 5
regarding her religious views, wanting to follow both religions while at the same time fearing repercussions for doing so. Cultural Perceptions of Cause, Context, and Support: After the onset of her illness, her family believed that her possession attacks were a sign that her illness was a result of her being punished by Hindu Gods for considering conversion to another religion.
ip t
Past Help Seeking ,Barriers and Preferences:
She had been taken to multiple faith healers by her family. During the process of
cr
faith healing, she was beaten, starved and burnt to appease the Gods. This had also led to a delay of two years in seeking medical treatment for her illness and
us
considerable distress to the patient. The patient also attributed her abnormal experiences to supernatural possession and revealed that she asked to be
an
discharged so that she could visit temples to appease the angry Gods and Goddesses who were punishing her.
The use of the DSM-5 cultural formulation interview helped in the understanding of
M
patient’s cultural and religious identity, the possible influence of culture on the symptom presentation of her symptoms and reasons behind the delay in help-
d
seeking. This information helped in the negotiation of a treatment plan that
Ac ce pt e
advocated continued hospitalisation while at the same time allowed the patient and her family to visit a temple nearby to daily to offer their prayers. The patient’s psychotic
symptoms
gradually
improved
over
a
period
of
three
weeks.
Psychoeducation and supportive therapy helped the patient better understand her illness, the need for continued treatment and enabled her to have a dialogue with her family about her religious choices. At the time of discharge, she reached her premorbid level of functioning. She decided to continue practising both Hinduism and Christianity and agreed on the need for continued medications and regular follow ups. An integration of etic and emic perspectives enabled the treating team to better understand the patient’s perception of her illness and the roles that both faith and medications had in her recovery. Often, the cultural assessment is restricted to mention of the patient’s religion, race and language. An in-depth exploration of the patient’s cultural and religious identity and illness explanatory models enabled the planning of individual tailor made interventions that ensured amenability to treatment, mutual participation and cooperation with the treating team and thus facilitated recovery.
Page 4 of 5
References: Bhikha, A. G., Farooq, S., Chaudhry, N., & Husain, N. (2012). A systematic review of explanatory models of illness for psychosis in developing countries. International Review of Psychiatry (Abingdon, England), 24(5), 450–62. http://doi.org/10.3109/09540261.2012.711746 mental disorders (5th ed.). Washington, DC: Author.
ip t
American Psychiatric Association. (2013). Diagnostic and statistical manual of
Disorders. CHAP, American Psychiatric Association.
cr
Cultural Formulation. (2013). In Diagnostic and Statistical Manual of Mental
http://doi.org/doi:10.1176/appi.books.9780890425596.CulturalFormulation
us
Lewis-Fernández, R., & Aggarwal, N. K. (2013). Culture and psychiatric diagnosis. Advances in Psychosomatic Medicine, 33, 15–30.
an
http://doi.org/10.1159/000348725
Vega, W. A., & Lewis-Fernández, R. (2008). Ethnicity and variability of psychotic symptoms. Current Psychiatry Reports, 10(3), 223–8. Retrieved from
Ac ce pt e
d
M
http://www.ncbi.nlm.nih.gov/pubmed/18652790
Page 5 of 5