1. No category

Transkulturell Psykiatri:
Innvirkning av kulturell bakgrunn på
psykiske lidelser
Overlege, dr. med. Suraj Thapa
Søndre Oslo DPS
Oslo Universitetssykehus
10.03.2015
Stavanger
Oversikt
n 
n 
n 
n 
n 
n 
Introduksjon
Kultur og sin innvirkning på psykisk helse
Psykisk helse hos innvandrere i Norge
Kasus
Som kliniker
Oppsummering
Oversikt
n 
n 
n 
n 
n 
n 
Introduksjon
Kultur og sin innvirkning i psykisk helse
Psykisk helse hos innvandrere i Norge
Kasus
Som kliniker
Oppsummering
Different terminologies
n 
n 
n 
n 
n 
n 
Transcultural
Cross-cultural
Intercultural
Ecological
Ethocultural
Cultural psychiatry
n 
n 
Section of Transcultural
Psychiatry studies at McGill
University by Eric Wittkower
in 1955
New cross cultural psychiatry
as called by Kleinman in
1977
Emic
vs
Etic approach
n 
Culture-specific
n 
Culture-universal
n 
Cultural relativism
n 
Bio-psychological universalism
How psychiatric disorders
are different across
culture?
- by anthropologists
n 
n 
How psychiatric disorders are
similar across cultures?
- by psychiatrists
Klienman in his book - Rethinking psychiatry (1988)
Dimensions of human existence
Biological
Psychological
Sociocultural
Spiritual
Ponce DE (1998). Cultural epistemology and value orientations; clinical applications in transcultural psychiatry
Oversikt
n 
n 
n 
n 
n 
n 
Introduksjon
Kultur og sin innvirkning i psykisk helse
Psykisk helse hos innvandrere i Norge
Kasus
Som kliniker
Oppsummering
Definitions of culture
n 
Williams (1983)- “One of the two or three most complicated words in
English language”
n 
Kroeber & Kluckhohn (1963)- “Comparable to gravity in physics,
disease in medicine and evolution in biology
n 
“The customs and beliefs, art, way of life and social organization of
particular group or country”, Oxford dictionary.
n 
“A blueprint for living that is nongenetically transmitted from one
generation to the next”, Samuel Okpaku (1998).
Hva er norskkultur?
Norskkultur
n 
”Norsk kultur er det komplekse hele
som inkluderer norske tradisjoner for
kunnskap, tro, kunst, lover, moral,
skikker, ferdigheter og vaner som er
utviklet gjennom vår historie og som vi
har lært i egenskap av å være
medlemmer av det norske samfunn.”
www.norskkultur.com
Innvandrerkultur
n  Heterogent
n  Også heterogent innenfor
eget nasjonalitet
n  Flerkulturell Norge
Importance of culture in mental health
n 
Normality vs. Abnormality
n 
(Sykdom og helse i en kontekst)
n 
Part of the etiology
n 
Clinical presentation and distribution of mental illness
n 
(Forskjellige utrykk og forståelse for følelser og opplevelser)
n 
Recognition and treatment of mental illness
n 
(e.g. culture bound syndromes)
Cecil Helman (2001) in the book “Culture health and illness”
Når to kulturer møter,
Berry og Kim, 1988 (fra Storholt T, 2006)
Psykiatri i Vest og Øst
Møte mellom vest og øst
Hvem behandler psykiske lidelser i Øst?
n 
Familie, naboer, slektninger
n 
Fengselslege/ helsepersonell
n 
Alternative terapeuter: healer, prest, munk, imam,
astrolog, shaman osv
Psykosomatikk?
Fastbundet
Legestudents holdning til
psykiske lidelser i Pakistan
Oversikt
n 
n 
n 
n 
n 
n 
Introduksjon
Kultur og sin innvirkning i psykisk helse
Psykisk helse hos innvandrere i Norge
Kasus
Som kliniker
Oppsummering
Distribution of immigrants according
to the region of their origin
Source: Statistics,
Norway (2012
What we know and donot know about mental
health problem of immigrants in Norway (Abebe D,
Lien L, Hjelde KH 2012
• This review aims to map the available knowledge on immigrants' mental
health status and its associated risk factors in Norway through databases,
such as PUBMED, EMBASE, PsychINFO and MEDLINE.
• About 41 peer-reviewed original articles published since 1990s were
included.
• Adult immigrants from low and middle income countries, have been found
with a higher degree of mental health problems compared to Norwegians
and the general population.
• Increased risk for mental illness is primarily linked to a higher risk for
acculturative stress, poor social support, deprived socioeconomic conditions,
multiple negative life events, experiences of discrimination and traumatic
pre-migration experiences.
Premigration traumatic events and
psychological distress among 5 immigrant
groups
n 
n 
n 
3019 immigrants from Turkey, Iran, Pakisthan, Sri Lnaka and
Vietnam living in Oslo
Highest prevalence of psychological distress among Turkish
immigrants and lowest among Sri Lankans
Experience of torture, imprisonment and unemployment were
associated wit distress.
(Lien et al, 2010)
Other studies from clinical set-ups
n 
n 
80 / 415 admitted in acute psychiatric ward were immigrants ,
whereby there were more men, younger age groups, more with
psychosis diagnosis and with forced admission and less with
substance abuse (Berg & Johansen, 2004).
Use of forced medication /treatment was higher among
immigrant patients admitted to acute psychiatric departments
in Oslo (34.3% vs 12.0% in age groups 18-29 (Knutzen et al, 2007)
Psykiskhelse hos innvandrere fra
HUBRO studien
Prevalence of distress (%) according
to gender
30
25
20
Immigrants from
high-income
countries
Immigrants from lowincome countries
15
10
5
0
Male
Female
Total
Prevalence of distress (%) by job status
40
35
30
Immigrants from
high-income
countries
Immigrants from lowincome countries
25
20
15
10
5
0
Employment
No employment
Prevalence of distress according to gender
and regions
50
45
40
35
East Europe
Africa
Soth Asia
South/East Asia
South America
Middle East
30
25
20
15
10
5
0
Male
Female
Total
Prevalence of distress (%) according to
annual family incomes (x100 NOK)
40
35
30
25
Immigrants from
high-income
countries
Immigrants from lowincome countries
20
15
10
5
0
<200
200300
300400
400500
>500
Rates of traumatic & negative life events
(NLE)
70
60
50
Immigrants from
high-income
countries
Immigrants from lowincome countries
40
30
20
10
0
War
Impris
Tort
NLE
OR of distress among immigrants from LI
countries compared to HI countries
2.5
2
1.5
Odds of
distress
1
0.5
0
Crude Model Model Model
OR
1
2
3
Model 1: adjusted for sociodemograpfic chracteristics
Model 2: model 1 + pre-migration experiences
Model 3: model 2 + post-migration experiences
Odds of distress (95% CI)
from multivariate models (n=1265)
___________________________________________________________________
Immigrants
Unadjusted
Model 1
Model 2
Model 3
from
OR
OR
OR
OR
________________________________________________________________________
High-income countries (Reference)
Low-income countries 2.79 (2.16-3.60)
2.59 (1.60-3.13)
1.99 (1.25-2.55) 1.33 (.88-1.93)
p value
.001
.002
.001
.176
__________________________________________________________________________________
Model 1: adjusted for gender, age, religion, marital status and education
Model 2: adjusted for gender, age, religion, marital status, education, and pre-migration risk factors (traumatic
experiences)
Model 3: adjusted for gender, age, religion, marital status, education, pre-migration risk factors, and postmigration risk factors (negative life events, lack of job, annual family income
Distress in different groups
30
25
20
15
Distress %
10
5
0
Norwegian born
Imm LI
Imm HI
Imm LI: Immigrants form low-income countries
Imm HI: Immigrrants from high-income countries
Gender differences in factors associated
with distress
Risk factors for male
immigrants
n 
n 
n 
Lack of paid job
Denial of job
Negative life events
Risk factors for female
immigrants
n 
n 
n 
n 
n 
n 
n 
Lack of paid job
Higher age
Negative life events
Living alone
Denial of housing
Middle East background
Visit by Norwegians as a
protective factor
(Thapa & Hauff, 2005)
Factors that can affect mental health of
migrants
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
n 
Age
Pre-migration
Gender
Education
Ethnicity
Trauma
Type of migration
--------------------------------------------------------------------------Loss of family member
Migration
Mental
Time for preparation for migration
Availability of social supports
-------------------------------------------------------------------------------Sosial supports
Post-migration
Economical problems
Job
Integration
Sociocultural factors
Negative life events
Discrimination
Self efficacy
Acculturation
health
Oversikt
n 
n 
n 
n 
n 
n 
Introduksjon
Kultur og sin innvirkning i psykisk helse
Psykisk helse hos innvandrere i Norge
Kasus
Som kliniker
Oppsummering
Kasus
n 
En kvinne fra Thailand på 35 år, kom til Norge for 4 år siden,
gift med en Nordmann på 60 år, har to barn, kan litt norsk, mor
og søstere prostituerte i Thailand, HIV smittet, alkohliserte
brødre
n 
Henvist fra fastlege med mistanke om bipolar lidelse
n 
Ble søkt innlagt på akuttpsykiatrisk avd. til tvungen observasjon
Hva sier pasienten selv?
n 
n 
n 
n 
Jeg er en frisk person og hadde det bra før jeg kom til Norge.
Mine største problemer er søvnvansker, smerter og mistrivsel i
Norge.
Har nesten ingen nettverk her og savner mitt nettverk i Thailand
100% sikker på at jeg blir helt frisk når jeg flytter tilbake til
Thailand.
Oversikt
n 
n 
n 
n 
n 
n 
Introduksjon
Kultur og sin innvirkning i psykisk helse
Psykisk helse hos innvandrere i Norge
Kasus
Som kliniker
Oppsummering
Hva kan vi gjøre som kliniker?
n 
n 
n 
n 
Være nysgjerrig for pasientens kulturell bakgrunn som kan være
forklaring til pasientens symptomer / lidelser
Kulturformulering av pasientens psykiske vansker, ta hensyn til
det før man stiller en diagnose eller planlegger behandling
Spør pas om det finnes noen behandlings metoder i deres kultur
for slike symptomer
Bruk redskaper /veiledninger som finnes
Retninslinjer/veiledninger
Kulturformulering i DSM IV
n 
n 
n 
n 
n 
n 
n 
Personens kulturelle identitet
Kulturelle forklaring på sykdom
Kulturelle faktorer relatert til psykososialt miljø og
funksjonsnivå
Kulturelle faktorer i relasjon mellom pasient og
kliniker
------En generell kulturell vurdering med henblikk på
diagnostisering og behandling
Migrasjon ok akulturasjon
Oppsummering
n 
n 
n 
n 
n 
Viktig å huske på kulturforskjeller og likheter når det
oppstår kontakt mellom to forskjellige kulturer.
Innvandrere har som regel høyre prevalens av
psykiske lidelser.
Kultursensitive utredningsmetoder
Bruk av tolk, kulturekspert osv.
Bruk av redskaper som finnes
.......
Thanks for your attention!