What a culture considers acceptable strongly influences the expression of anger. The nurse must be aware of cul-tural norms to provide culturally competent care. In the United States, women traditionally were not permitted to express anger openly and directly because doing so would not be “feminine” and would challenge male authority. That cultural norm has changed slowly during the past 25 years. Some cultures, such as Asian and Native American, see expressing anger as rude or disrespectful and avoid it at all costs. In these cultures, trying to help a client express anger verbally to an authority figure would be unacceptable.
Ethnic or minority status can play a role in the diagno-sis and treatment of psychiatric illness. Patients with dark skin, regardless of race, are sometimes perceived as more dangerous than light-skinned patients, and therefore more likely to experience compulsory hospitalizations, increased use of restraints, higher doses of medication, and so forth. One study found that Caucasian children and adolescents were more often diagnosed with depression or substance abuse disorders, while African-American and Hispanic/ Latino patients received psychotic or behavioral disorder diagnoses (Muroff, Edelsohm, Joe, & Ford, 2008). The European Board of Medical Specialists recognizes cultural awareness issues as a core component of psychiatry train-ing, but few medical schools provide training in cultural issues (Qureshi, Collazos, Ramos, & Casas, 2008). These authors propose that education to develop cultural competence is needed to provide quality care to immi-grants and minority group patients.
Hwa-Byung or hwabyeong is a culture-bound syndrome that literally translates as anger syndrome or fire illness, attributed to the suppression of anger (Choi & Lee, 2007). It is seen in Korea, predominately in women, and is char-acterized by sighing, abdominal pain, insomnia, irritabil-ity, anxiety, and depression. Western psychiatrists would be likely to diagnose it as depression or somatization disorder.
Two culture-bound syndromes involve aggressive behav-ior. Bouffée delirante, a condition observed in West Africa and Haiti, is characterized by a sudden outburst of agitated and aggressive behavior, marked confusion, and psychomo-tor excitement. These episodes may include visual and auditory hallucinations and paranoid ideation that resemble brief psychotic episodes. Amok is a dissociative episode characterized by a period of brooding followed by an out-burst of violent, aggressive, or homicidal behavior directed at other people and objects. This behavior is precipitated by a perceived slight or insult and is seen only in men. Origi-nally reported from Malaysia, similar behavior patterns are seen in Laos, the Philippines, Papua New Guinea, Polynesia (cafard), Puerto Rico (mal de pelea), and among the Navajo (iich’aa) (Moitabai, 2005).