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Chapter: Essentials of Psychiatry: The Cultural Context of Clinical Assessment

Illness Explanations and Help-seeking

The second major dimension of the cultural formulation concerns cultural explanations of symptoms and illness.

Illness Explanations and Help-seeking


The second major dimension of the cultural formulation concerns cultural explanations of symptoms and illness. Cultures provide systems of diagnosis and treatment of illness and affliction that may influence patients’ experience of illness and help-seeking behavior. People label and interpret their distress based on these systems of knowledge, which they share with others around them. Much


Table 2.2        Explanatory Model Interview

1.      What do you call your problem?

2.      What causes your problem?

3.      Why do you think it started when it did?

4.      How does it work?

5.      What is going on in your body?

6.      What kind of treatment do you think would be best for this problem?

7.      How has this problem affected your life?

8.      What frightens or concerns you most about this problem or treatment?


research in medical anthropology has developed the idea of ex-planatory models, which may include accounts of causality, mecha-nism or process, course, appropriate treatment, expected outcome and consequences. Not all of this knowledge is related directly to personal experience – much of it resides in cultural knowledge and practices carried by others. Hence, understanding the cultural meanings of symptoms and behavior may require interviews with other people in the patient’s family, entourage, or community.


Table 2.2 provides questions for eliciting patients’ explan-atory models. These questions should be modified based on the patient’s responses. For example, the origins of problems may be located not in the body but in the workings of the mind, the family, the community, the realms of ancestors or spirits, or in mythological accounts that explain the social and moral order.


In many cases, particularly with acute illness, patients may not have well-developed explanatory models. Instead, they reason by analogy on the basis of past experiences of their own or other prominent prototypes encountered in family, friends, or mass media. Once an explanatory model is evoked in conver-sation, however, patients may give formulaic accounts that ac-cord with that cultural model or script. Therefore, to obtain more complete information about the cognitive and social factors that are actually influencing the patients’ illness experience and be-havior, it is useful to begin with an open-ended interview that simply aims to reconstruct the events surrounding symptoms and the illness experience. This will reveal idiosyncratic temporal patterns of contiguity and association that may not fit any explicit cultural model. Following this, the clinician can ask about proto-types (Have you ever had anything like this before? Has anyone you know ever had anything like this before?) This will uncover salient models of illness that may shape illness experience and be used to reason analogically about the current episode. Finally, it is important to inquire into explicit cultural models using the sorts of questions devised for the explanatory model interview.


The ethnomedical systems described in anthropological texts often are idealized and complex portraits pieced together by working with cultural experts. In clinical practice, patients usually have only partial or fragmentary knowledge of the tradi-tional explanations and treatment for their problem. Depending on the knowledge and attitudes of family and kin, and on the availability of practitioners of traditional medical systems, pa-tients may be influenced by larger cultural systems to which they themselves do not fully subscribe.



In everyday life, people use culturally prescribed idioms to discuss their problems. These cultural idioms of distress cut across specific diagnostic categories. They may be used to talk about ordinary problems as well as to shape the expression of distress associated with major psychiatric disorders. For exam-ple, many cultures have notions of “nerves” (in Spanish, nervios), which signal emotional distress that may range from mild upset with life events to disabling anxiety or psychosis. Appendix I of DSM-IV-TR provides a list of some common idioms of distress. The same appendix also lists some well-described culture bound syndromes, culturally distinctive clusters of symptoms that may be of pathological significance. Many culture-specific terms, however, do not refer to syndromes or idioms of distress but are actually symptoms or illness attributions that reference folk models of causality. For example, susto, a term used in Central and South America, attributes a wide range of bodily symptoms and diseases (including infectious diseases and congenital mal-formations) to the damaging effects of sudden fright.


Many cultural idioms of distress use bodily metaphors for experience. In seeking medical help, patients usually try to present the sort of problems they believe the clinician is com-petent to treat. Consequently, in biomedical settings patients tend to emphasize physical symptoms. This pattern of clinical presentation combined with the wide currency of somatic idioms of distress has led to a characterization of many ethnocultural groups as prone to somatize their distress (Kirmayer, 2001). The social stigma commonly associated with psychiatric symptoms and disorders, as well as with substance abuse, antisocial behav-ior and various other behaviors also may prevent patients from acknowledging such problems and events. However, with clear communication and a respectful stance, the clinician may be able to build sufficient trust over time for patients to disclose shame-ful or potentially stigmatizing information.


Similarly, people commonly use multiple remedies or con-sult various healers for their symptoms, and may be reluctant to disclose treatments they think the clinician will not understand or accept. They may also omit mention of preparations they view as “natural” or as foods and hence not included under the rubric of medications or drugs. Commonly used remedies like ginseng, St John’s Wort and Gingko biloba have significant effects on pharmacokinetics and drug metabolism and are, therefore, important for their potential impact on physiology as well as their role in patients’ belief systems and sense of control over their illness. A nonjudgmental inquiry by the clinician willenable patients more freely to discuss their use of traditional and alternative treatments.

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