L8 Psych Med Cultural interpretations of serious mental Illness

Overview

This lecture examines how cultural context shapes the meaning, experience and clinical assessment of symptoms associated with serious mental illness, particularly voice-hearing and psychosis-like experiences. It moves from the general utility and limits of “symptoms” as a concept, through cross-cultural research on voice-hearing, DSM-5 guidance on culture in diagnosis, a detailed Māori case study (George and the Thing) illustrating a Te Ao Māori healing approach alongside Western treatment, DSM-5 cultural concepts of distress, and practical implications for assessing spiritual and cultural experiences in clinical practice.

What is a symptom, and its utility/limitations

A symptom is defined as something unusual or out of the ordinary for the individual, indicating disease, and experienced subjectively by the individual.

Utility of symptoms:

• Shorthand for communication
• Provides a common language
• Useful for research

Limitations of symptoms:

• Transdiagnostic (not specific to one diagnosis)
• Lack of clarity/specificity (e.g., restlessness could indicate many things)
• Descriptive, not explanatory
• Culturally defined (what is normative varies by group)

Key point: knowing symptoms does not necessarily tell you the diagnosis or the treatment needs.

Hallucinations and delusions: definitions

• Hallucination: a perception-like experience that occurs without an external stimulus. Hallucinations can occur in any sensory modality, but auditory hallucinations are the most common in schizophrenia and related disorders.
• Delusion: a fixed false belief held with absolute conviction, despite argument to the contrary.

Voice hearing as a continuum

Voice-hearing exists on a continuum from non-clinical (healthy) to clinical presentations.

Non-clinical voice-hearing features:

• Associated with little distress
• Lifetime prevalence of 5-15% in the general population
• Earlier age of onset
• Many report spiritual beliefs
• Voices are often interpreted as communication from deceased individuals

Clinical vs non-clinical phenomenology (comparative features):

• Perceptual-sensory frequency: higher in clinical, lower in non-clinical
• Perceived control: lower in clinical, higher in non-clinical
• Threat appraisals: higher in clinical, lower in non-clinical
• Content: negative/critical/threatening in clinical vs neutral/mundane in non-clinical
• Emotional distress: higher in clinical, lower in non-clinical
• Functional interference: higher in clinical, lower in non-clinical

Features shared between clinical and non-clinical voice-hearing (do not distinguish the two): volume, clarity, number of voices, localisation, linguistic complexity, form of address, levels of conviction, beliefs regarding origin, interaction/compliance, and personification of identity.

An Aotearoa/NZ case example (NiaNia, Bush & Epston, 2019) describes voice-hearing and communication from ancestors (mate Māori) as part of this non-clinical spectrum.

Cross-cultural differences in the experience of voices

A study compared subjects in San Mateo (California, US), Accra (Ghana), and Chennai (Tamil Nadu, India) (Luhrmann et al., 2015):

• San Mateo subjects: readily use diagnostic labels/criteria; “hearing voices” is equated with being “crazy”; subjects hate their voices; voices often violent in content; voices experienced as a disrupted relationship between thought and mind.
• Accra subjects: almost no diagnosis talk; hearing voices carries a spiritual as well as psychiatric meaning; emphasis on the moral quality of the voice; voices often reported as positive; voices can be physical (can beat the person physically); belief that “the mind should be positive”.
• Chennai subjects: almost no diagnosis talk; voices are often kin; voices can be given a spiritual interpretation; voices can be physical; voices often positive and playful; voices offer guidance, teaching people to “come to know”.

DSM-5: schizophrenia and culture-related diagnostic issues

• Cultural and socioeconomic factors must be considered, particularly when clinician and individual do not share the same cultural/socioeconomic background.
• Ideas that appear delusional in one culture (e.g., witchcraft) may be commonly held in another.
• In some cultures, visual or auditory hallucinations with religious content (e.g., hearing God’s voice) are a normal part of religious experience.
• Assessment of affect requires sensitivity to cultural differences in styles of emotional expression, eye contact, and body language.
• In certain cultures, distress may present as hallucinations or pseudo-hallucinations and overvalued ideas that look clinically like true psychosis but are normative to the patient’s subgroup.

Case study: George and the Thing

• Presentation: 17-year-old Māori male, referred to the Early Intervention Service by his GP.
• Key symptoms: hearing a voice; sense of a bad presence next to him; the voice sometimes associated with seizure-like episodes; sleep disturbance; difficulty concentrating at school; distressed by the voice.
• Relevant history: type 1 diabetes; started using alcohol and cannabis with friends over the previous six months.
• Findings: physical exam did not suggest a neurological problem; urea, electrolytes, CT head scan and EEG all normal.
• Family history: 15-year-old sister with depression and seizure-like episodes.
• Initial management: offered a trial of antipsychotic medication. His presentation was atypical for psychosis (no major mood disturbance, delusions, or disorganised thinking as would be typical). He was referred on to Māori Child, Adolescent, and Family Mental Health Service (Māori CAFS).

A slide describing the cultural therapist (embedded video, referencing a "Frame"/Spinoff documentary segment) could not be transcribed; content beyond a still image and labels was not retrievable from the source PDF.

• Assessment interview: explored cultural/spiritual explanations and previous spiritual experiences (headaches, pain, picking up others’ feelings, seeing someone who had died, a comforting presence).
• Response to medication: voice reduced in intensity and frequency; seizure-like episodes less frequent; continued to be troubled by the bad presence. He was offered consultation with a cultural therapist.
• Māori healing session: explained the concepts of mauri, tapu, and mana, and factors that can weaken mauri and mana (including the role of cannabis and intergenerational conflict). Included whakawetewete, a ritual of forgiveness and releasing past hurts, and karakia (recited with a stated rationale of protection and showing the presence he has mana).
• Two-month follow-up: discontinued risperidone after gaining 5 kg (impacting blood sugar control); accepted a spiritual-origin view of the psychotic-like experiences; one instance of the bad presence but felt less distressed; no longer heard voices or had seizure-like episodes; felt more confident and positive; avoided drugs and alcohol, accepting this was necessary for spiritual wellbeing and diabetes control.
• Long-term follow-up (4.5 years later, age 22): one instance of a seizure-like episode, with a consultation with Wiremu (the cultural healer) at that time; continued spiritual experiences (e.g., feeling upset for no apparent reason); developed awareness of when he is affected and how to manage it.
• Comparison of approaches:
  • Western approach: some relief, but significant side effects.
  • Te Ao Māori approach: an explanation that aligned with the patient’s and whānau’s worldview, greater symptom reduction, and avoiding drugs/alcohol had a wider positive impact on overall health, spiritual wellbeing, and diabetes management.

Cultural concepts of distress

DSM-5 defines three related concepts:

• Cultural syndromes: clusters of symptoms and attributions that tend to co-occur among individuals in specific cultural groups, communities, or contexts, recognised locally as coherent patterns of experience, typically treated by the medicine of that culture.
• Cultural idioms of distress: ways of expressing distress that may not involve specific symptoms or syndromes, but provide collective, shared ways of experiencing and talking about personal or social concerns.
• Cultural explanations or perceived causes: labels, attributions, or features of an explanatory model indicating culturally recognised meaning or etiology for symptoms, illness, or distress.

Māori/Pacific health-model diagrams shown alongside these definitions (Te Whare Tapa Whā, a waka/Hauora diagram, and Te Wheke) had most of their detailed labels illegible at rendered resolution. Legibly captured: Te Whare Tapa Whā's four house-shaped dimensions — Te Taha Wairua (Spiritual), Te Taha Hinengaro (Mental & Emotional), Te Taha Tinana (Physical), Te Taha Whānau (Family & Social) — resting on Whenua (Land, Roots); the Hauora waka diagram (only the caption "Ngā Roma Moana – Ocean Currents" was legible); and Te Wheke, an octopus-based model with tentacles representing dimensions of wellbeing (individual tentacle labels not legible).

DSM-5 catalogues nine detailed cultural concepts of distress. Examples given:

• Kufungisisa (“thinking too much”) - among the Shona of Zimbabwe; both an idiom of distress and a cultural explanation.
• Khyâl attacks / Khyâl cap (“wind attacks”) - among people from Cambodia; a cultural syndrome.

Further examples of culturally specific psychosis-like presentations:

• The Americas: Locura (ataques de locura, “madness attacks”).
• Asia: Qigong-induced mental disorders (Qigong deviation).

Implications for clinical practice

Assessing spirituality and spiritual experiences:

• Use open questions to understand the “symptom” before moving to specific, psychosis-oriented questions (e.g., ask “What was this experience like for you?” rather than going straight to “Is the voice inside or outside your head?” or asking about command hallucinations to harm self/others).
• Normalise spiritual experiences and ask about them within the whānau (e.g., asking whether family members have felt a deceased relative’s presence, or have had dreams that come true).
• Enquire about early experiences (e.g., whether the child seemed to have spiritual experiences when young).

General principles:

• Slow down and take time to understand the patient in their context.
• Be aware of your own “lens” - understand symptoms from the patient’s worldview/lens.
• Be flexible: consider multiple explanations for a “symptom” (normal? sign of mental disorder? spiritual cause? cultural syndrome?), and these can be shared with the patient.
• Keep in mind diagnostic criteria, usual age of onset, and course of symptoms.
• Consult with cultural experts and the team, working in close partnership where possible to build a shared understanding with the whānau.

Self-test

1. Define a symptom as used in this lecture, and give two of its limitations.
2. Distinguish a hallucination from a delusion.
3. List the features that differ between clinical and non-clinical voice-hearing, and name three features that are shared between the two.
4. Describe how the meaning and experience of voice-hearing differed between subjects in San Mateo, Accra, and Chennai in the Luhrmann et al. study.
5. According to DSM-5, why must cultural and socioeconomic factors be considered when assessing possible delusions or hallucinations?
6. In the George case, what was atypical about his presentation compared with typical psychosis, and why was this significant for his management?
7. Describe the steps and rationale of the Māori healing session George received.
8. Why did George discontinue risperidone, and what happened to his symptoms and functioning over the following follow-up periods?
9. Distinguish a cultural syndrome, a cultural idiom of distress, and a cultural explanation/perceived cause, giving the example given for each.
10. A patient from an unfamiliar cultural background reports hearing a deceased relative’s voice with no distress. Using the principles from this lecture, describe how you would approach assessing this experience.

Answers

Reveal answers

1. A symptom is something unusual or out of the ordinary for the individual, indicating disease, and experienced subjectively. Limitations include: transdiagnostic (not disease-specific), lack of clarity/specificity, descriptive rather than explanatory, and culturally defined.
2. A hallucination is a perception-like experience occurring without an external stimulus (can occur in any sensory modality, most commonly auditory in schizophrenia). A delusion is a fixed false belief held with absolute conviction despite argument to the contrary.
3. Clinical voice-hearing shows higher perceptual-sensory frequency, lower perceived control, higher threat appraisals, negative/threatening content, higher emotional distress, and higher functional interference than non-clinical voice-hearing. Shared features (not distinguishing) include volume, clarity, number of voices, localisation, linguistic complexity, form of address, levels of conviction, beliefs regarding origin, interaction/compliance, and personification of identity (any three).
4. San Mateo subjects readily used diagnostic language, hated their voices, experienced them as violent and as a disrupted relationship between thought and mind. Accra subjects rarely used diagnostic language, gave voices spiritual as well as psychiatric meaning, focused on moral quality, often found voices positive, and could experience them as physical. Chennai subjects also avoided diagnostic language, often experienced voices as kin offering guidance, gave them spiritual interpretation, could be physical, and were often positive/playful.
5. Because ideas that appear delusional in one culture (e.g., witchcraft) may be normative in another, and hallucinations with religious content can be a normal part of religious experience in some cultures; assessment must also account for cultural variation in emotional expression, eye contact and body language, so as not to misclassify normative cultural experience as psychopathology.
6. George lacked the major mood disturbance, delusions, and disorganised thinking typical of psychosis (atypical symptoms). This meant the clinical team looked beyond a standard psychiatric framework, leading to referral to Māori CAFS and consultation with a cultural therapist rather than relying solely on antipsychotic treatment.
7. The healing session explained the concepts of mauri, tapu and mana, and the factors that can weaken mauri and mana (including cannabis use and intergenerational conflict). It included whakawetewete, a ritual of forgiveness and releasing past hurts, and the recitation of karakia, given for the rationale of protection and to show the presence that George has mana.
8. He discontinued risperidone because he had gained 5 kg, which was impacting his blood sugar control (relevant given his type 1 diabetes). At two-month follow-up he no longer heard voices or had seizure-like episodes, felt more confident and positive, and avoided drugs/alcohol. At 4.5-year follow-up (age 22) he had one seizure-like episode and consulted the cultural healer again, continued to have spiritual experiences, but had developed awareness of when he is affected and how to manage it.
9. A cultural syndrome is a cluster of symptoms/attributions recognised locally as a coherent pattern, typically treated by that culture’s medicine (e.g., Khyâl attacks/wind attacks among Cambodians). A cultural idiom of distress is a shared way of expressing distress without a specific symptom/syndrome (e.g., Kufungisisa, “thinking too much,” among the Shona, which is also a cultural explanation). A cultural explanation/perceived cause is a label or attribution giving culturally recognised meaning or etiology to symptoms (Kufungisisa also serves as an example here).
10. Use open questions first (e.g., “What was this experience like for you?”) rather than jumping to psychosis-oriented questions; normalise spiritual experiences and ask about them within the whānau; slow down and take time to understand the patient’s context; be aware of your own lens and view the experience from the patient’s worldview; remain flexible and consider multiple explanations (normal, spiritual, cultural syndrome, or mental disorder), sharing these with the patient; keep diagnostic criteria, typical age of onset, and course of symptoms in mind; and consult with cultural experts/the team to build a shared understanding with the whānau.