Mental and Physical Health

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Mental and Physical Health
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• Psychological processing can vary substantially
  across cultures.
• It follows that departures from normal processing
  will also vary.
• There can be pronounced variation in a number of
  psychopathologies around the world, underscoring
  the role that meaning-making plays in peoples
  psychological realities. There may be biological
  factors underlying most or all of various
  psychopathologies, but how those symptoms are
  interpreted and experienced varies significantly
  across cultures.

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Culture-Bound Syndromes

• Some psychopathologies are far more prevalent, or
  manifest in highly different forms across
  cultures.
• One example is dhat syndrome - men from some
  parts of South Asia become morbidly anxious that
  they are losing semen.
• It is most likely that one could only develop the
  symptoms of dhat syndrome if one had the
  particular set of cultural beliefs about why
  losing semen would be so problematic.
• The challenge for studying mental disorders
  across cultures is that the symptoms that are
  identified for the disorders typically were done
  in Western samples, and its not always clear
  whether Western cultural beliefs are bound to the
  disorders.

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Hikikomori

• Commonly afflicts male (3x more than females)
  adolescents.
• Typical response is to drop out from the social
  world, often barricading oneself up in a room for
  years, and not interacting with anyone, except
  perhaps to make requests/demands to ones
  parents.
• Doesnt map on to any diagnoses in the DSM-IV.
  Some could also be diagnosed as depressed,
  autistic, socially anxious, or schizophrenia, but
  there is no clear match.
• Approximately one child per classroom in junior
  high and high school years in Japan.
• Was largely non-existent in pre-war Japan, and is
  not commonly found in any other culture.
• Appears to be the result of failing to succeed in
  a social world where there are few options for
  those who dont fit in.

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Anorexia/Bulimia Nervosa

• Anorexia involves symptoms where a person refuses
  to maintain a normal body weight because of a
  preoccupation with their body.
• Bulimia involves symptoms where one
  uncontrollably binge eats, and then subsequently
  takes inappropriate measures to prevent weight
  gain.
• Bulimia has all the hallmarks of a culture-bound
  syndrome as it is absent in most cultures of the
  world. It is primarily found in the West.
• Anorexia is more complicated. Rates of anorexia
  have increased over the past several decades, and
  some cultures (non-Western) show far less
  evidence of it than others.
• However, there have also been reports of
  self-starvation in numerous cultural contexts,
  such as in many Italian saints, although the
  reasons for the self-starvation were not about
  bodily preoccupations.

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Koro

• Men develop morbid anxiety that their penis is
  shrinking into their body (or, far less commonly,
  women fear their nipples are shrinking).

• This occurs primarily in South and East Asia,
  especially Southern China and Malaysia.
• There can be epidemics of koro, where hundreds of
  people develop symptoms.
• Some koro-like symptoms have been reported by
  Americans having negative marijuana-induced
  experiences.

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Amok

• A condition where there is an acute outburst of
  unrestrained violent and homicidal attacks,
  preceded by brooding, and followed by exhaustion
  and amnesia.
• Most common in Southeast Asia.
• May be the result of not having culturally
  acceptable means to express frustration.
• Could have parallels with Western mass homicidal
  attacks.

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• Frigophobia - A morbid fear of catching cold.
• It is found largely in China.
• People will avoid cold air, eating cold food, and
  dress with several layers, even in summer.

• Arctic Hysteria - A unique hysterical attack
  observed among Arctic Inuit communities,
  particularly among women.
• People suddenly tear off their clothes, roll in
  the snow, and convulse, with no clear
  precipitating factors.

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• Culture-bound syndromes dramatically reveal the
  cultural basis of some psychopathologies.
• There are, however, many psychopathologies that
  are found universally around the world.
• These universal psychopathologies still do vary
  in prevalence and presentation across cultures.

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Depression

• Depression is probably the most familiar
  psychopathology, and it is found the world over.
• To be diagnosed with a major depressive disorder
  one must have at least five of the following nine
  symptoms and at least one of the first two, for
  two weeks or more
• a) depressed mood, b) an inability to feel
  pleasure
• c) change in weight or appetite, d) sleep
  problems, e) psychomotor change, f) fatigue or
  loss of energy, g) feelings of worthlessness or
  guilt, h) poor concentration or indecisiveness,
  or i) suicidality.

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• Depression is found everywhere, however rates of
  depression vary across cultures.
• In particular, much research has identified how
  depression rates in China are only about 1/5 that
  observed in the West.
• However, a challenge in comparing rates of
  depression across cultures arises because the
  presentation of depression also appears to vary.
• Some symptoms of depression are primarily
  physiological, such as appetite and sleep
  disorders. When peoples symptoms are primarily
  physiological we say they are experiencing
  somatization.
• Other symptoms of primarily psychological, such
  as mood or feelings of guilt. When symptoms are
  primarily in the mind we can say that people are
  experiencing psychologization.

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• Many Chinese psychiatric patients have been
  diagnosed with neurasthenia.
• Neurasthenia has symptoms of poor appetite,
  headaches, insomnia, and an inability to
  concentrate.
• Neurasthenia has been dropped from the DSM
  because it seemed to be more of a collection of
  physiological symptoms rather than a
  psychopathology.
• Arthur Kleinman, an anthropologist and
  psychiatrist, conducted extensive interviews with
  Chinese neurasthenia patients and concluded that
  a majority (87) could be diagnosed as having
  depression, even though only 9 of them reported
  depressed mood as a chief complaint. That is, he
  argued that depression manifests itself among
  Chinese chiefly through somatization rather than
  psychologization.

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• Why do these different presentations of
  depression exist?
• One possibility is that Chinese people with
  depression are worried about the public stigma of
  having a mental disorder, and thus conceal it
  with somatic symptom reporting.
• Another possibility is that Westerners are more
  attentive than Chinese to their emotional states.
  Western psychological symptoms might thus be
  more accessible to them than they are for
  Chinese.
• One recent study investigated this question by
  comparing psychiatric outpatients in China and
  Canada (Ryder et al., 2008).

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• All patients had to report at least one of the
  nine diagnostic markers of depression. Patients
  reporting any kind of psychotic symptoms were
  excluded.
• Patients symptoms were assessed with three
  different methods.
• A spontaneous problem report, where they
  described their concerns with little prompting
  from the interviewer.
• A standard clinical interview, in which the
  patients responded to specific questions about
  symptoms from an interviewer.
• A standard questionnaire, which was completed in
  private, in which patients gave answers to
  specific symptom questions.
• Patients also completed measures of stigma and
  attention to emotional states.

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SPR - Spontaneous Problem Report
SCI - Structured Clinical Interview
SxQ - Symptom Questionnaire

• Chinese expressed greater somatic symptoms than
  Canadians with all measures except the private
  questionnaire.
• Canadians expressed greater psychological
  symptoms with all measures.

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• Chinese scored higher than Canadians on a concern
  for stigma.
• However, concerns with stigma correlated with the
  severity of all symptoms, both psychological and
  somatic - it does not seem to be the case that
  Chinese somatize because they have greater stigma
  concerns.
• Chinese also scored lower than Canadians on a
  measure of their attentiveness to emotional
  states.
• This measure was shown to mediate the cultural
  differences in somatic symptom reporting. That
  is, a key reason that Chinese somatize depression
  symptoms more than Westerners is that they are
  less attentive to their emotional states in
  general.

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• One common finding from Western research on
  depression is that depressed people show
  diminished emotional reactivity to both positive
  and negative emotion-eliciting stimuli. They
  often seem emotionally numb.
• The cross-cultural generalizability of this was
  explored in one study comparing both
  non-depressed and depressed people of
  European-American and Asian-American backgrounds
  (Chentsova-Dutton et al., 2008).
• Participants were shown a neutral film, a sad
  film, and an amusing film, and their emotions
  were assessed by examining their on-line reports
  during the films, by physiological measures, and
  by observers assessing presence of crying.
• There were no differences across cultures in the
  neutral and amusing film conditions. In the sad
  film conditions, there were cultural differences.

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• Replicating other research, non-depressed
  European-Americans showed more crying and
  reported sadness to the sad film than did
  depressed participants. The depressed
  individuals showed signs of emotional numbness.
• In contrast, the depressed Asian-Americans showed
  more emotional reactivity - they cried more and
  reported more sadness than the non-depressed
  people.
• One possibility is that depression disassociates
  people from cultural norms. Normally expressive
  European-Americans become less expressive, and
  normally less expressive Asian-Americans become
  more expressive.

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Social Anxiety

• Social anxiety is a disorder that is found
  universally across cultures.
• The diagnostic criteria include
• a marked fear of social situations in which the
  person is exposed to unfamiliar people.
• exposure to the feared social situation
  invariable provokes anxiety.
• the person recognizes that the fear is excessive.
• the feared social situation is avoided, and
  interferes with a persons normal routine.

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• There are two key ways that social anxiety has
  been studied endorsing symptoms on self-report
  surveys and diagnoses by clinicians through
  interviews.
• Interdependence strongly correlates with people
  endorsing symptoms of social anxiety.
• Self-report surveys find that East Asians have
  more social anxiety symptoms than do Westerners.
• At the same time, clinical diagnoses of of social
  anxiety disorders are far lower among East Asians
  (about 0.5 lifetime prevalence) than among North
  Americans (about 7).
• One possibility for this discrepancy is that in
  interdependent contexts social approval is valued
  more, so it is viewed as natural that one
  experiences distress in social situations.

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• There is a related culture-bound syndrome,
  largely limited to East Asia, known as
  taijinkyoufushou (TKS), which translates to the
  fears of confronting others.
• Similar to social anxiety, this fear is elicited
  by social situations.
• However, unlike social anxiety, the primary
  symptoms are a preoccupation with physical
  symptoms, many imaginary, that the person may
  have excessive body odor, blushing, sweating, and
  a penetrating gaze.
• People with severe TKS are primarily afraid of
  the discomfort that others will feel because of
  their physical symptoms - it has been referred to
  as the altruistic phobia.
• People are often most fearful around
  acquaintances, rather than around strangers.

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Suicide

• Suicide rates vary quite dramatically around the
  world. At the extreme ends various Eastern
  European nations have especially high suicide
  rates (e.g., Hungary, Lithuania), whereas Muslim
  nations have especially low suicide rates (e.g.,
  Egypt, Saudi Arabia).
• In Canada, some of the highest suicide rates that
  are found are among Aboriginal youth, where the
  rates are several times higher than the national
  rates (see Chandler Lalonde, 1998).
• However, there is tremendous variability in
  suicide rates among Native bands from different
  tribal councils in Canada. The suicide rates for
  one five year period ranged from a low of
  0/100,000 people to a high of 633/100,000 people.
• What factors predict the likelihood that a bands
  associated with a given tribal council will have
  a high suicide rate?

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• In general, people who feel a lack of continuity
  within their selves are more vulnerable to
  suicide. People at risk for suicide often dont
  have a clear narrative about how their life fits
  together.
• A sense of cultural continuity, that is, a clear
  narrative about what your culture is and how it
  fits together, can be related to a sense of
  self-continuity.
• Many First Nations bands do not have a strong
  sense of cultural continuity as a result of
  Western colonization. Their present culture can
  be in many ways quite divorced from what the past
  culture was like.
• Chandler and Lalonde (1998) assessed various
  markers of cultural continuity among 196 Native
  bands in BC, and compared these with the suicide
  rates for those bands.

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• The markers that they identified were whether
  the band was negotiating a land claim with the
  government, whether the bands had
  self-government, whether the bands had control
  over their educational services, whether the
  bands controlled their police and fire services,
  whether the bands managed their own health
  services, and whether the bands had their own
  cultural facilities.

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Schizophrenia

• Schizophrenia is one of the most debilitating
  mental disorders, and it is universally found
  around the world.
• To be diagnosed, one must have two or more of the
  following symptoms, each present for a
  significant period of time.
• delusions, hallucinations, disorganized speech,
  grossly disorganized or catatonic behavior, or
  negative symptoms (e.g., a loss of speech, or
  flattening of mood).
• There are genetic factors associated with
  schizophrenia, as well as identified prenatal
  experiences, and neuroanatomical features. The
  biological basis of schizophrenia is better
  understood than other mental disorders.
• Rates of schizophrenia range from 0.7 to 1.4
  annual incidents per 10,000 across diverse
  cultures. This is considerably less cultural
  variation than for most other mental disorders.

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• Despite the strong biological basis, and the
  similar incidence rates across cultures, there is
  still some noteworthy cultural variation.
• First, it should be noted that in cross-cultural
  studies of schizophrenia incidence, a very narrow
  definition of the disorder is used. The majority
  of people with psychotic conditions were not
  included in the study. It is possible that there
  is more cultural variation in these more atypical
  kinds of psychoses.
• The subtype of schizophrenia did vary
  substantially. The most common subtype among
  Westerners is paranoid schizophrenia
  (characterized by paranoid delusions) with rates
  as high as 75 of schizophrenics in the UK, but
  only 15 in India.
• In contrast, catatonic schizophrenia
  (characterized by a near absence of motor
  activity) accounts for only 1-3 of
  schizophrenics in the UK, but 20 in India.

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• The most striking pattern of cultural variation
  is that patients in less-developed societies have
  a far greater rate of recovery than in more
  industrialized societies.
• This pattern is opposite to that for most kinds
  of pathologies, either for physical or mental
  health.
• The cause of this cultural difference remains
  unknown. It may be that schizophrenics are more
  likely to remain members of a community in
  less-developed societies, rather than becoming
  homeless in industrial societies, and this
  community integration aids them in the course of
  their disease.

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Physical Health

• The cultural variation in the presentation of
  such a biologically-based disease as
  schizophrenia raises a question of the degree to
  which physical health varies across cultures.
• In what ways does the biology of humans vary
  around the world?
• Some biological variation is due to differences
  in inherited genes. The most salient example of
  biological variation is skin color.

• Skin color is strongly correlated with the amount
  of ultraviolet radiation (UVR) that reaches the
  surface in different parts of the globe. People
  need light enough skin to allow sufficient UVR be
  able to synthesize Vitamin D, but dark enough
  skin to prevent the breakdown of folic acid.

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• Skin color is an example of how geographic
  factors have influenced population variation in
  the human genome.
• There are also some cases where cultural factors
  have influenced the genome.
• For example, people from cultures in which cows
  have been domesticated for a longer period of
  time are more likely to have a mutation that
  allows them to digest lactose into adulthood.

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• Thus far, the majority of adaptive gene
  variations have been associated with thermal
  regulation, resistance to pathogens, and enduring
  dietary practices. There is much variation
  associated with non-adaptive genetic drift.
• There is scant known variation in genes
  associated with clear psychological outcomes, but
  surely this will increase as research in genetic
  population variation progresses.
• In addition to genetic variation across
  populations, there is also some acquired physical
  variation. That is, various aspects of peoples
  bodies may change because of cultural experiences.

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• One example of acquired physical variation is
  that the Moken, sea gypsies from Southeast Asia,
  have twice the underwater visual acuity as
  Europeans.

• From a young age Moken children swim underwater
  to retrieve seafood.
• Their enhanced underwater visual acuity appears
  to be the result of experience rather than a
  genetic adaptation.

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Obesity and Diet

• Obesity rates vary dramatically across countries,
  from a low of 1.5 of Chinese women to a high of
  55 for Samoan women.
• These differences across countries are most
  likely cultural as opposed to genetic.
• One source of evidence for the role of culture is
  that obesity rates have been growing remarkably
  across many countries - there have not been
  parallel changes in gene prevalence. Americans
  have gained about 1.5 lbs. a year over past 20
  years.

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• Within the West itself, there is considerable
  variation in obesity rates.
• France, for example, has about one fifth the
  obesity rate of the US.
• This is despite the fact that French food is rich
  in fat. Some evidence of this is that the French
  have higher blood cholesterol levels than
  Americans, yet they have lower heart disease
  rates than Americans. This is known as the
  French Paradox.
• One account for this is that the French live in a
  culture where food comes in smaller portions than
  it does in North America.
• Paul Rozin and colleagues set about measuring
  food serving sizes in the US and France. There
  were some striking differences.

34

• Yogurt containers are about 80 bigger in the US
  than they are in France.

35

• McDonalds french fries are about 70 bigger in
  the US than in France.
• A meal at a Chinese restaurant in France is less
  than 60 the size of a meal at a Chinese
  restaurant in the US.
• Recipes in the US call for larger portions of
  ingredients than they do in France.
• Even fruit is bigger in the US! About 28 larger
  for the same fruit.
• Curiously, cat food cans are slightly larger in
  France than in the US.

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• Large American portion sizes are the result of
  fairly recent cultural change. Here are some
  examples of changes since the 1950s.

37

• Aside from portion sizes, French have different
  attitudes towards food compared with Americans.
• French savor their food more, and take more time
  eating it. It takes them 50 longer to finish a
  McDonalds meal, despite the fact that it is a
  smaller meal.
• A far smaller proportion of French food products
  have been altered to make them healthier, such as
  being low salt, low fat, or sugar-free.
• Americans are more likely to associate food with
  fat.
• People were asked to choose which of the
  following options is the best metaphor for the
  human body in relation to its diet a tree, a
  car, or a temple.
• The most common answer, by far, for French was a
  tree - this was the least common for Americans,
  who preferred a car metaphor.

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• People from France, Belgium, Japan, and the US
  completed several questions about their attitudes
  towards various food products (Rozin et al.,
  1999).
• Their attitudes are summarized with Chernoff
  figures, where the size of each feature of the
  face is linked to peoples responses. Positive
  attitudes towards food are associated with large
  and happy features.

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Socioeconomic Status (SES) and Health

• One of the strongest predictors of health within
  a given country is ones SES.
• The higher ones SES, the longer one lives, on
  average. Even relatively small increments are
  associated with longer life outcomes.

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• Evidence or an SES gradient in health has been
  found in every industrialized country
  investigated.
• There is also evidence from non-industrialized
  countries. For example, in north east Burkina
  Faso there are three ethnic groups that coreside
  - the Fulani, Mossi, and Rimaibe.
• A major cause of death in the region is malaria,
  and the Mossi and Rimaibe have evolved much
  genetic resistance to malaria over thousands of
  years.
• The Fulani moved to the region less than 200
  years ago, and lack most of the genetic
  resistance to malaria.
• However, the Fulani have higher SES, and when
  they first arrived they conquered, enslaved, and
  decultured the Mossi and Rimaibe.
• Despite that they have less genetic resistance to
  malaria, the Fulani contract malaria less often
  than do either the Mossi or the Rimaibe.

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What Causes the Lower Health Risks for Higher SES
People?

• No simple single answer.
• Access to health care cannot explain all of this
  relation. The relation is similar for people
  with the same health care access, and the
  relation is at least as pronounced for conditions
  that are the least amenable to treatment.
• Lower SES people are more likely to engage in
  unhealthy habits, such as smoking, eating fast
  food, and are less likely to exercise. However,
  the SES differences still remain if you control
  for health habits.
• One mediating role between status and health
  outcomes is stress.

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Stress and Health

• Stress affects health in at least two ways.
• First, when people are stressed theyre more
  likely to engage in health-compromising behaviors
  like smoking and drinking.
• Second, stress directly weakens the immune
  systems ability to fight off infections.
• Some cultural environments produce more stress.
  For example, being in New York City makes most
  people feel more stressed, and they are more
  likely to suffer a heart attack while there.
• People also feel stress when they feel a lack of
  control over their lives. One situation that
  creates this is being lower in a hierarchy.
• Lower-SES people feel less in control of their
  lives than higher-SES people, and lower-SES
  people show less vulnerability to illness when
  they are provided with control (Chen, 2007).

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• Primates lower in the hierarchy show greater
  stress hormone levels when they belong to a
  social system where
• the hierarchy is stable,
• is maintained through intimidation rather than
  direct physical attacks,
• the subordinates cannot avoid dominant
  individuals, and
• they have low availability for social support.
• There are many similarities to these societal
  features and those experienced by low-SES people
  in modernized industrialized societies (see
  Sapolsky, 2005).

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• Objective levels of wealth in many ways are less
  relevant than subjective experiences of SES in
  terms of peoples health outcomes. Feeling poor
  can matter as much as being poor.
• For example, at the national level, there is
  only a relation between GDP and longevity up
  until a GDP of about 10,000.

45

• Poor African-Americans suffer considerably more
  health problems than do Indians living in the
  poor province of Kerala, despite the fact that in
  absolute dollar terms, the African-Americans as a
  group are better off.
• The more income inequality in a country, on
  average, the lower is that countrys longevity.
• The more income inequality in a country also the
  stronger the relation between SES and health
  outcomes. Greater income inequality is
  associated with stronger feelings of relative
  deprivation for those lower in the hierarchy.
• Even among Hollywood actors and actresses, there
  appears to be a relation between relative status
  and health. Oscar winners live longer than Oscar
  nominees, who live longer than those who have
  never been nominated.

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• Various disadvantaged minority groups tend to be
  lower in SES than majority members, and they also
  tend to suffer from worse health outcomes.
• For example, for the 15 leading causes of death
  in the United States, African-Americans had
  higher death rates than European-Americans for
  all of these except respiratory diseases,
  Alzheimers disease, and suicide.
• However, even when SES is controlled for,
  African-Americans suffer some worse health
  outcomes than European-Americans, in particular,
  infant mortality rates and hypertension.
• There is a link between these conditions with
  stress, and stress is also clearly linked with
  being discriminated against. Racial
  discrimination also appears to be implicated in
  worse health outcomes.

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• Conversely, Hispanic Americans, who are also, on
  average, of considerably lower SES than
  European-Americans, tend to show better health
  outcomes than European-Americans.
• Of the leading 15 causes of death in the US,
  Hispanics had higher death rates than
  European-Americans only for diabetes, cirrhosis
  of the liver, hypertension, and homicide.
• The surprisingly positive health outcomes of
  Hispanic-Americans has been labeled the
  epidemiological paradox.
• This remains largely unresolved, and some argue
  that it is due to a higher value placed on
  child-bearing, enhanced emotional support from
  the community, or the benefits of higher levels
  of positive affect.

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Medicine and Culture

• Much medical knowledge derives from cultural
  learning.
• Modern medicine finds that the three leading
  causes of illness are deteriorating organ
  systems, stress, or infections. In contrast,
  among 186 traditional non-Western societies, none
  viewed organ deterioration as a cause of disease,
  only 3 viewed stress as a cause, and only 1
  viewed infection as a cause.
• In traditional societies, beliefs in supernatural
  causes of illness are the most common. The
  single most common account for disease in
  traditional societies is ghosts.
• Even among Western industrialized societies there
  is considerable variation in medical attitudes.

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• In France, the metaphor of the body is the
  terrain,which emphasizes a sense of balance.
• French doctors prescribe antibiotics less, and
  long rests and spa visits more.
• Dirt and germs are seen as something that can
  strengthen ones terrain, and as a consequence,
  there is relatively less emphasis placed on daily
  bathing (see Payer, 1996).
• In contrast, in the US, the metaphor of the body
  is a machine. American doctors are far more
  likely to treat the body with surgery, to fix
  malfunctioning parts.
• Also, American doctors view germs to be a key
  threat to health, and they prescribe more
  antibiotics than anywhere else.

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Doctors Have Culture Too.

• Study by Leeman, Fischler, Rozin (2008).
• 50-70 doctors and 50-70 lay people were asked 20
  questions regarding diet, eating, and health in
  five Western countries France, Germany, Italy,
  UK, and USA.
• Sample questions included the value of vitamin
  pills, the healthiness of dairy products, wine,
  meat, the importnace of food, exercise, and
  moderation for health.
• The participants answers to the 20 questions
  were correlated with other participants answers
  to the same questions.

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• Physicians show much agreement with lay people
  from their own culture.
• However, physicians show rather poor agreement
  with physicians or lay people from other
  cultures, underscoring the cultural foundation of
  their views on health and diet.