Patients are less homogeneous than they were, say, 20 years ago. As a result, today's psychiatrists practicing in America must be able to treat people of many different cultures. Given these changing demographics, should we adjust our treatment of patients who have anxiety disorders--or any mental illness, for that matter--depending on the patient's cultural orientation? What responsibilities do we have to learn about different cultures and address our biases?
Advice From the DSM-IV
I served as the executive scientific advisor for a 60-minute video program called "The Culture of Emotions," in which 23 multicultural experts spoke about five sections in appendix I of the DSM-IV. The sections serve as a clinical tool to assess culture.
The first section asks us to state the cultural identity of the patient, which includes important variables such as gender, sexual orientation, religious beliefs, language, socioeconomic status, and cultural migration into a foreign country. According to the second section, we must understand the cultural expressions and explanations of illness that are particular to a patient's culture. In this section, the DSM-IV lists different idioms of distress of various disorders, such as somatic complaints, that don't meet diagnostic criteria but are often ways that the disorder is experienced. It's also important to understand that a patient is not being resistant to treatment when he asks for a pathway that is consistent with what he would expect from his background.
In the third section, we learn that patients may have specific cultural stressors and supports for dealing with stress. We ought to think about the possibility of traumatic stress coming from areas such as Cambodia or Kosovo, even if the patient does not want to discuss it.
In the fourth section, we must understand the difficulties that may arise because of the cultural differences between the clinician and the patient.
The fifth section pulls together the implications we have deduced from the patient's culture to figure out how they may affect the differential diagnosis and treatment plan. With the Cambodian patient, we may want to keep posttraumatic stress disorder in mind even if the patient doesn't come in with flashbacks and nightmares. He could have concomitant depression and might not be able to verbalize his experiences.
In 2002, the Group for the Advancement of Psychiatry, of which I am a member, put out the book "Cultural Assessment in Clinical Psychiatry." This book is a valuable resource because it examines seven case studies using the five-section outline.
Francis G. Lu, M.D.
Isolated Sleep Paralysis
In 1983, my agency surveyed African Americans about some of the unique features of their lives. In our survey, we found that 40% of 108 African Americans had had at least one episode of isolated sleep paralysis. During an episode of sleep paralysis, people cannot move and feel a sensation similar to someone sitting on their chest, which causes panic. When we went to the literature, we found that only 19% of Americans of European descent experience the condition. That 40% was the highest rate of sleep paralysis that has been recorded since 1846, when records were first kept.
When we did a follow-up study and looked at the issue of anxiety disorders, we found a relationship between isolated sleep paralysis and panic disorder (J. Natl. Med. Assoc. 78:649-59, 1986). Some African Americans had an episode of isolated sleep paralysis once every year or every 6 years. Those levels of frequency of did not affect their risk for panic disorder, but those who had sleep paralysis disorder once or more a month were at greater risk for panic disorder. Interestingly, the neurology of panic disorder and sleep paralysis appear to overlap as well.
One of the major problems in psychiatry is that we haven't been able to tease out the culturally specific and the universal aspects of mental health. …