Normal or abnormal? 'Normative uncertainty' in psychiatric practice

Examining delusional ideation: Relationships with race and socioeconomic status

Race and socioeconomic status (SES) are commonly cited as risk factors for psychosis and psychotic-like experiences (PLEs). However, few studies have investigated the relationships between race and SES with specific domains of PLEs. Specifically, little work has examined the relationships between race and SES with delusional ideation, severity (preoccupation, conviction, distress), and delusional themes. Using cross-sectional, general population data (N = 727) from the Nathan Kline Institute-Rockland (NKI-Rockland) database, we investigated racial differences in delusional ideation and severity between Black and White participants, including differences in delusional themes. Then, we investigated SES's relationship with delusional thinking and the interaction between race and SES on delusional thinking. Black American participants endorsed higher delusional ideation with stronger severity than White Americans. A significant interaction between race and delusional theme revealed that Black Americans endorse significantly more delusional ideation in themes of grandiosity, religiosity, and referential-guilt. Black Americans endorse greater delusional severity in grandiose and religious ideations. Black Americans endorse stronger preoccupation and conviction - but not distress-in their referential-guilt ideation. SES was not significantly associated with delusional thinking, nor did SES moderate the significant relationships between race and delusional ideation. These results illuminate the clear racial disparity that exist in delusional ideation within a general population, which did not extend to SES in this dataset. Future work should investigate deeper into the contributory factors to these racial disparities, particularly whether they are based in psychological and/or cultural differences or are the result of assessment/measurement bias.

The associations between attenuated psychosis symptoms and functioning in Black and White youth at clinical high-risk for psychosis

Extensive research has demonstrated racial disparities, particularly among Black individuals, in both presentation and course of psychosis spectrum disorders. Few studies, however, have examined racial differences in the clinical high-risk (CHR) phase of illness. It is unclear if functional deficits seen in association with CHR symptoms generalize to marginalized racial groups, or whether race may play a role in the link between symptoms and functioning. In a sample of youth at CHR (N = 46), the present study examined the effect of race (Black and White represented in this sample) on the relation between CHR symptoms and social/role functioning. Race had a moderating effect on the relation between CHR symptoms and social functioning for total positive symptom score (p < .04, f² = 0.10). Although positive symptoms were associated with worse social functioning for White participants, no association was found for Black participants. Follow up analyses indicated suspiciousness was a statistically significant predictor of social functioning for White participants but was unrelated to functioning for Black participants. Results may be indicative of phenomenon experienced by individuals within racial minority groups (e.g., "healthy suspiciousness") or potential measurement validity concerns. Findings further the understanding of racial differences in the CHR phase of illness among White and Black youth and highlight limitations of the existing CHR literature and assessment tools for diverse youth.

Cultural psychiatry: beyond DSM-5

BACKGROUND

Cultural psychiatry evaluates manifestations, symptoms of emotional distress and mental disorders in diverse cultural contexts; it also addresses social problems such as poverty, violence, inequalities between groups or social classes.

OBJECTIVE

To present a narrative review of the most relevant cultural aspects in the context of clinical practice in psychiatry and to suggest some alternatives to improve the cultural competence of health care professionals.

METHOD

A narrative review was carried out of the most relevant articles in the area.

RESULTS

Usually, the cultural argument is used to explain differences in observed prevalences in some mental disorders according to gender and geographical location. Cultural differences modify the expression of emotional distress and this can reduce the accuracy and affect the reliability and validity of the current diagnostic classification used in psychiatry. The American Psychiatric Association, in the most recent classification, revised cultural syndromes but only included a limited number of situations. Consequently, medical education and psychiatry must respond to diverse populations and provide quality care through the development of trans-cultural competence in the curriculum.

CONCLUSIONS

It should be considered that cultural differences modify the expression of distress and thereby undermine the validity and reliability for diagnoses in distinct cultural contexts. In an increasingly globalised world, future classifications may completely omit 'cultural syndromes'.

A Chaplain's View on Religious Delusions (and Other Extraordinary Experiences): Towards a Theological Framework of Understanding

In this article, the author discusses the question of how to evaluate delusions with religious or spiritual content from a theological perspective. How does a spiritual care practitioner listen to such delusions? The author proposes a theory of meaning that can account for both ordinary and extraordinary experiences and discusses a list of theological criteria in terms of which spiritual care practitioners can understand delusional and other extraordinary experiences and beliefs with spiritual content.

Clinician's Subjective Experience in the Cross-Cultural Psychiatric Encounter

INTRODUCTION

The clinical encounter is still at the core of the psychiatric evaluation. Since the diagnostic process remains basically clinical in nature, several authors have addressed the complexity of the clinical reasoning process and highlighted the role played by intersubjective phenomena and clinician's feelings. Some recent studies have supported the view of a significant link between the clinician's subjective experience during the assessment and the diagnosis made. In a globalized world, this issue requires a careful reflection, since cultural differences may affect the intersubjective atmosphere of the encounter, which may indirectly influence the clinician's thinking.

METHODS

We used a previously validated instrument, named Assessment of Clinician's Subjective Experience (ACSE), to compare the clinician's subjective experience during the evaluation of Italian patients with the subjective experience of the same clinician during the assessment of foreign patients. The 2 patient groups (n = 42 each) were individually matched for known potential confounders (age, sex, categorical diagnosis, and clinical severity).

RESULTS

We found no significant differences in mean scores on all ACSE dimensions (tension, difficulty in attune-ment, engagement, disconfirmation, and impotence), which suggests that cultural diversity did not substantially affect the clinician's subjective experience. However, the lack of information about the native country and linguistic proficiency of about a quarter of foreign patients may have limited the possibility to detect subtle or specific differences, especially with regard to the clinician's empathic attunement.

CONCLUSIONS

Although further investigation is needed, our preliminary findings may have significant implications for the reflection upon the clinician's empathic experience as well as pragmatic consequences for the act of psychiatric diagnosis in the cross-cultural encounter.

Culture and Context in Mental Health Diagnosing: Scrutinizing the DSM-5 Revision

This article examines the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and its claim of incorporating a "greater cultural sensitivity." The analysis reveals that the manual conveys mixed messages as it explicitly addresses the critique of being ethnocentric and having a static notion of culture yet continues in a similar fashion when culture is applied in diagnostic criteria. The analysis also relates to current trends in psychiatric nosology that emphasize neurobiology and decontextualize distress and points to how the DSM-5 risks serving as an ethnic dividing line in psychiatry by making sociocultural context relevant only for some patients.

Making the subjects of mental health care: a cross-cultural comparison of mental health policy in Hong Kong, China and New South Wales, Australia

Constituting 'social problems' in particular ways has a range of effects, including for how subjects are positioned within policy and discourse. Employing an approach grounded in poststructuralist and social constructionist thinking, this analysis interrogates how the subjects of mental health care were constituted and problematised in mental health policies in two distinctive contexts, unsettling the taken-for granted assumptions which underpin these problematisations. Two policies were selected for analysis as exemplar pieces of mental health policy reform in Hong Kong and New South Wales (NSW). Subjects were constituted as 'patientised' individuals (in Hong Kong) encouraged to depend on professionals who help them reintegrate into the 'normal' community, and as 'traumatised' individuals (in NSW) expected to take responsibility to guide the delivery of mental health care and respected as a part of diversity in community settings. While both policies constituted subjects as 'unwell individuals' and enacted 'dividing practices', subjectivities were shaped by distinctive cultural and socio-political contexts. This analysis shifts our attention away from a focus on the effectiveness of policy solutions to the heterogeneity and contingency of policy 'problems' and 'subjects', opening up new possibilities for 'out-of-the-box' policy responses to mental health.

Religion, assessment and the problem of 'normative uncertainty' for mental health student nurses: a critical incident-informed qualitative interview study

There is limited research around how mental health (MH) student nurses interpret and differentiate between people's religious and cultural beliefs and the existence of psychopathological symptomatology and experiences. Here we focus on one cultural issue that arose from research exploring how MH student nurses approach and interpret religion and culture in their practice - that is, the difficulties in determining the clinical significance of the religious beliefs and experiences expressed by the people they care for. While problems with establishing the cultural boundaries of normality in clinical assessments are an important area of debate in cultural psychiatry, it remains a peripheral issue in MH nurse education. An anthropologically informed qualitative research design underpinned 'critical incident' (CI)-focused ethnographic interviews with 36 second and third-year MH nursing field students and seven undergraduate MH branch lecturers. Follow up focus groups were also carried out. Interview transcripts were subject to thematic analysis. Four subthemes were identified under the broad theme of the clinical significance of religious-type expression and experience: (1) identifying the difference between delusions and religious belief; (2) identifying whether an experience was hallucination or religious experience; (3) the clinical implications of such challenges; and (4) applying religion-specific knowledge. There are clinical implications that may result from the difficulties with assessing the clinical significance of religious beliefs and experiences, identified in both our research and within international cultural psychiatry literature and research. Misinterpretation and therefore wrongly assessing someone's experience as pathological is a significant concern. It is suggested that CI analysis could be adapted to help nurses, nursing students and nurse educators recognize the religious dimensions of mental distress, particularly those that then potentially impact upon the accuracy and person centeredness of clinical assessment. Further research is proposed to investigate the clinical assessment and training needs of nurses in the area of religion and mental distress.