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Cultural Presentations of Distress

CALD Child and Adolescent Mental Health Resource

eCALD Supplementary Resources

Asian youth with depression or anxiety may focus on physical symptoms or use culture-specific bodily idioms to express distress (Groleau & Kirmayer, 2004; Kirmayer, 2001). Medically unexplained symptoms, particularly pain, fatigue, and gastrointestinal and genitourinary symptoms, are common in primary care presentations (Kirmayer et al., 2004). CALD young people are reluctant to reveal psychological and emotional distress to general practitioners because they think such stressors are inappropriate topics for medical attention or they believe that their situation will not be understood (Hollifield et al., 2002). There is limited but emerging evidence that information about associated psychological distress and social predicaments can be elicited by enquiring about the effect of the physical symptoms or other presenting concerns on activities of daily living, stressors, social supports, functioning in work and family, or community contexts (de Ridder et al., 2007; Kirmayer et al., 2004; Peters et al., 2009; Salmon et al., 2004; Salmon et al., 2009). The following table shows that culturally patterned idioms of distress and culture-bound syndromes are linguistic and bodily styles of expressing and experiencing illness, ie cultural ways of talking about distress (Ahmed & Bhugra, 2007). In the case of depression, these often take the form of somatic metaphors as shown in the next section. Knowledge of these cultural idioms can facilitate diagnosis of depression, establish rapport, and minimise the risk of misdiagnosis. 

Idioms of Distress and Culture-Bound Syndromes

(Office of the Surgeon General (US), Center for Mental Health Services (US), National Institute of Mental Health (US), 2001).

Idioms of distress are ways in which different cultures express, experience, and cope with feelings of distress. One example is somatisation, or the expression of distress through physical symptoms (Kirmayer & Young, 1998). For example, the following are common somatic idioms of distress for depression in Indian, Chinese, Middle Eastern and African groups (Bhugra & Mastrogianni, 2004):

Somatic Idioms of distress for depression

India

Sinking heart, feeling hot, gas (Bhugra, et al., 1997a; 1997b)

Nigeria

Heat in the head, biting sensation all over the body, heaviness sensation in the head (Ebigbo, 1982)

Chinese

‘Shenjing shuairuo’, neurasthenia (Parker et al., 2001)

Arab cultures

Breathlessness is one of the common somatic complaints in depressed Arab patients. Breathlessness is often attributed to the experience of the tightening up of the chest. Repeated sighing, which assures the patient of his/her ability to take in enough air by deep inspiration now and again has a temporary comforting effect.

“Sadri dayeq alayya’, my chest feels tight, ‘Tobana’, I am tired, fatigued’ ‘Jesmi metkasser’, broken body (Sulaiman et al., 2001)
  • Cardiopulmonary and vestibular symptoms, such as dizziness, vertigo, and blurred vision are common forms of somatisation in Chinese people (Hsu & Folstein, 1997).
  • In African and South Asian populations, somatisation sometimes takes the form of burning hands and feet, or the experience of worms in the head or ants crawling under the skin (APA, 1994).
  • Culture-bound syndromes are clusters of symptoms much more common in some cultures than in others. For example, some Chinese clients display Shenjing shuairuo – a condition characterised by physical and mental fatigue, headaches, difficulty concentrating, dizziness, sleep disturbance, and memory loss. Other symptoms include gastrointestinal problems, sexual dysfunction, irritability, excitability, and autonomic nervous system disturbances.
  • A culture-bound syndrome from Japan is taijin kyofusho. This syndrome refers to an individual’s intense fear that his or her body, its parts, or its functions displease, embarrass, or are offensive to other people in appearance, odour, facial expressions, or movement.
  • Zar is a term used in a number of countries in North Africa and the Middle East to describe the experience of spirit possession. Possession by spirits is often used in these cultures to explain dissociative episodes (sudden changes in consciousness or identity) that may be characterised by periods of shouting, banging of the head against the wall, laughing, singing, or crying. Affected people may seem apathetic or withdrawn or refuse to eat or carry out their usual responsibilities.
  • Brain fag is a term used in Nigeria and in East and Southern African countries in reference to mental exhaustion in students (Ayonride et al., 2015). The distinctive symptoms of the syndrome are: intellectual impairment; sensory impairment (chiefly visual); somatic complaints, most commonly of pain or burning in the head and neck; other complaints affecting the student’s ability to study; an unhappy, tense facial expression; and a characteristic gesture of passing the hand over the surface of the scalp or rubbing the vertex of the skull. The symptoms most often present during periods of intensive reading and study prior to examinations or sometimes just following periods of intensive study. The client generally attributes their illness to fatigue of the brain due to excessive ‘‘brain work’’ (Prince, 1960).
  • Numerous other culture-bound syndromes are given in the DSM-V “Glossary of Culture-Bound Syndromes”.
  • The DSM-V offers an adaptive interview technique, the Cultural Formulation of Diagnosis (APA, 2013a) to compensate for the cultural insensitivity of diagnostic instruments. Cultural interviews provide additional information on the client’s life context and perceptual meanings and can ultimately facilitate comprehensive care (Marsella & Kaplan, 2002). Assessing a client’s cultural and religious perspectives, health beliefs and practices, and perceptions of health and illness is important to make a comprehensive, culturally sensitive assessment (Lonner & Ibrahim, 2002). See the Assessing Migrant and Refugee Children and Adolescents section for further information.

The Cultural Formulation of Diagnosis (APA, 2013b) can be downloaded from: http://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.CulturalFormulation.

Further information on cultural presentations of distress and culture-bound syndromes can be accessed on the following links:

Waitemata DHB eCALD® Services (2016b). CALD 9: Working in a mental health context with CALD clients. Auckland: WDHB eCALD® services. Retrieved from: https://www.ecald.com/courses/cald-cultural-competency-courses-for-working-with-patients/cald-9-working-in-a-mental-health-context-with-cald-clients/.

Waitemata DHB eCALD® Services (2010).  Working with Asian mental health clients. Auckland: WDHB eCALD® services. Retrieved from: https://www.ecald.com/resources/cross-cultural-resources/working-with-asian-mental-health-clients/.

Waitemata DHB eCALD® Services (2013).  Working with Middle Eastern and African Mental health clients. Auckland: WDHB eCALD® services. Retrieved from: https://www.ecald.com/resources/cross-cultural-resources/working-with-middle-eastern-and-african-mental-health-clients/.