Toward a more culturally sensitive DSM-IV. Psychoreligious and psychospiritual problems.

In theory, research, and practice, mental health professionals have tended to ignore or pathologize the religious and spiritual dimensions of life. This represents a type of cultural insensitivity toward individuals who have religious and spiritual experiences in both Western and non-Western cultures. After documenting the "religiosity gap" between clinicians and patients, the authors review the role of theory, inadequate training, and biological primacy in fostering psychiatry's insensitivity. A new Z Code (formerly V Code) diagnostic category is proposed for DSM-IV: psychoreligious or psychospiritual problem. Examples of psychoreligious problems include loss or questioning of a firmly held faith, and conversion to a new faith. Examples of psychospiritual problems include near-death experiences and mystical experiences. Both types of problems are defined, and differential diagnostic issues are discussed. This new diagnostic category would: a) improve diagnostic assessments when religious and spiritual issues are involved; b) reduce iatrogenic harm from misdiagnosis of psychoreligious and psychospiritual problems; c) improve treatment of such problems by stimulating clinical research; and d) encourage clinical training centers to address the religious and spiritual dimensions of human existence.     

Review of Religious Variables in Advance Care Planning for End-of-Life Care: Consideration of Faith as a New Construct

Religion and spirituality have long been considered important social determinants of human health, and there exists an extensive body of research to support such. End-of-life (EOL) may raise complex questions for individuals about religious and spiritual (R/S) values guiding advance care planning (ACP) and EOL care decisions, including the provision of spiritual care. This commentary will review the history and current national trends of ACP activities for EOL, principally within the United States. It will describe the relationship of religious variables and the attributes of selected research instruments used to study religious variables on ACP and EOL preferences. The review also summarizes unique ACP challenges for patients with neurocognitive disorders and severe mental illness. Findings disclose that higher levels of religiosity, reliance on religious coping, conservative faith traditions, and “belief in God's control over life's length and divine intervention have lower levels of ACP and more intensive EOL care preferences, although the provision of spiritual spiritual care at EOL mitigates intensive EOL care. Based upon the curated evidence, we propose an epistemological justification to consider “faith” as a separately defined religious variable in future ACP and EOL research. This review is relevant to geriatric psychiatrists and gerontological health care professionals, as they may be part of multidisciplinary palliative care teams; provide longitudinal care to patients with neurocognitive disorders and severe mental illness; and may provide diagnostic, emotional, and therapeutic services for patients and families who may struggle with EOL care decisions.     

A comparative study of opinions of U.S.A. and European professionals on the etiology of infantile autism

The general finding of this cross-national survey is that, contrary to expectation, professionals in the United States, irrespective of discipline, are more convinced that infantile autism is caused primarily by genetic/organic factors when compared to European professionals. Psychiatrists in the U.S.A. give priority to organic factors (97%), followed by constitutional factors (84%), genetic factors (77%), and metabolic disorders (58%). With psychologists and other professionals in the U.S.A. the trend is about the same. An analysis of the differences in responses to items on environmental factors, such as birth complications, viral infection, pollution and receptive language problems, again shows that professionals in the United States tend to attribute more importance to these factors than their European counterparts. In general, half of the Europeans believe in the importance of these factors as compared to professionals in the U.S.A. It is only when we deal with parental psychopathology that we find a reversal in trends. If we combine the "somewhat important" and "highly important," 35% of psychiatrists in the United States and 54% of psychiatrists in Europe indicate that parental psychopathology may be a factor in infantile autism. For psychologists, the percentages were 26% and 50% respectively. No difference was found when "other professionals" in the U.S.A. and Europe were compared. There are some contradictions in the findings. While the responses of 97% of the psychiatrists in the U.S.A. point to organic factors as being "somewhat" and "highly important" in the causation of infantile autism, 36% of them indicate that parental psychopathology might have some influence on the illness. Thus, while almost 100% of psychiatrists subscribe to an organic origin of the illness, about one third of them are still not willing to completely discount parental contribution. The 12th etiology which was added, "cultural factors," was considered to be of least importance. It is assumed that the respondents might have missed the implications of the question. For a discussion of the sociocultural aspects of infantile autism, the reader is referred to a number of papers published in this area (Sanua, 1981, 1982, 1983, 1984, 1985). As an analogy, there is still some controversy about the universality of the existence of schizophrenia. In a review of the literature on the subject, Torrey (1973) concluded that "process" schizophrenia is found in all cultures which have been exposed to Western technology. He points out the need to conduct well-planned field surveys of the prevalence among groups that are in varying stages of exposure to Western technology.(ABSTRACT TRUNCATED AT 400 WORDS)     

Do Canada and the United States differ in prevalence of depression and utilization of services?

OBJECTIVE: This study compared the prevalence of depression and the determinants of mental health service use in Canada and the United States. METHODS: The study used data from preliminary analyses of the 2003 Joint Canada/United States Survey of Health, which measured Canadian (N=3,505) and United States (N=5,183) resident ratings of health and health care services. Cross-national comparisons were made for the 12-month prevalence of DSM-IV major depression, 12-month service use for mental health reasons according to the type of professional seen, and determinants of service use. RESULTS: The rates of depression were similar in Canada (8.2%) and the United States (8.7%). However, U.S. respondents without medical insurance were twice as likely as Canadian respondents and U.S. respondents with medical insurance to meet the criteria for depression. Rates of mental health service use did not differ between Canada (10.1%) and the United States (10.6%). In the United States, medical insurance was not a determinant factor of service use. However, U.S. respondents with no medical insurance were more likely than the other two groups to report an unmet need. Also, among those with depression, U.S. respondents with no medical insurance were less likely to use any type of mental health service (36.5%) than U.S. respondents with medical insurance (55.7%) and Canadians (55.7%). Further, a positive correlation between a mental health need and service use was observed in Canada but not for those without medical insurance in the United States. CONCLUSIONS: There was no difference in the prevalence of depression and mental health service use between Canada and the United States. Among those with depression, however, disparities in treatment seeking were found to be associated with medical insurance in the United States. Both Canada and the United States need to improve access to health services for those with mental disorders, and special attention is needed for those without medical insurance in the United States.     

Ergot, the "jerks," and revivals

Epidemics of epilepsy, a form of mass hysteria, were known in Eastern and Western cultures in the 17th and 18th centuries. A unique situation in the United States during the 19th centurey was the frontier religious movement, the setting in which the "jerks" occurred. The "falling exercise," "dancing exercise," "barking exercise," "laughing exercise," and the "running exercise" centered around the excitement involved in the religious revival. During some exercises, people saw "visions," and exhibited bizarre behavior and sudden jerking motions. During the summers of 1801-1803 on the Kentucky frontier, some pioneers who attended the religious revival camp meetings had convulsions, hallucinations, tremors, jerks, compulsive dancing and "epileptic trances." Although these have been assumed to be psychological in origin, the epidemiology of the symptoms may correlate with the diagnosis of ergotism. Those affected were usually children and young adults. Symptoms of ergotism include giddiness, fatigue, depression, formications, muscle twitching, tonic spasms, convulsions, delirium, and loss of speech.     

Assessing problems with religious content: a comparison of rabbis and psychologists

This study measured distinctions made by a sample of clergy and mental health professionals in response to three categories of presenting problems with religious content: mental disorder, religious or spiritual problem, and "pure" religious problem. A national, random sample of rabbis (N = 111) and clinical psychologists (N = 90) provided evaluations of three vignettes: schizophrenia, mystical experience, and mourning. The participants evaluated the religious etiology, helpfulness of psychiatric medication, and seriousness of the presenting problems. The rabbis and psychologists distinguished between the three diverse categories of presenting problems and concurred in their distinctions. The results provide empirical evidence for the construct validity of the new DSM-IV category religious or spiritual problem (V62.89). Use of the V code allows for more subtle distinctions among the variety of problems that persons bring to clergy and mental health professionals. These distinctions may also provide a foundation for the initiation of co-professional consultation.     

The relationship between psychiatry and religion among U.S. physicians

OBJECTIVE: This study compared the religious characteristics of psychiatrists with those of other physicians and explored whether nonpsychiatrist physicians who are religious are less willing than their colleagues to refer patients to psychiatrists and psychologists. METHODS: Surveys were mailed to a stratified random sample of 2,000 practicing U.S. physicians, with an oversampling of psychiatrists. Physicians were queried about their religious characteristics. They also read a brief vignette about a patient with ambiguous psychiatric symptoms and were asked whether they would refer the patient to a clergy member or religious counselor, or to a psychiatrist or a psychologist. RESULTS: A total of 1,144 physicians completed the survey, including 100 psychiatrists. Compared with other physicians, psychiatrists were more likely to be Jewish (29% versus 13%) or without a religious affiliation (17% versus 10%), less likely to be Protestant (27% versus 39%) or Catholic (10% versus 22%), less likely to be religious in general, and more likely to consider themselves spiritual but not religious (33% versus 19%). Nonpsychiatrist physicians who were religious were more willing to refer patients to clergy members or religious counselors (multivariate odds ratios from 2.9 to 5.7) and less willing to refer patients to psychiatrists or psychologists (multivariate odds ratios from .4 to .6). CONCLUSIONS: Psychiatrists are less religious than other physicians, and religious physicians are less willing than nonreligious physicians to refer patients to psychiatrists. These findings suggest that historic tensions between religion and psychiatry continue to shape the care that patients receive for mental health concerns.     

Psychotherapists' spiritual,religious, atheist or agnostic identity and their practice of psychotherapy: A grounded theory study

Abstract

In this present grounded theory study, 16 experienced psychologists, who practiced from varied theoretical orientations and came from diverse religious/spiritual/nonreligious backgrounds, explored their personal religious/spiritual/nonreligious identity development journeys, their experiences with clients' religious/spiritual content in psychotherapy sessions, and how their identity may have influenced the way they interacted with religious/spiritual material during sessions. Results revealed that psychologists' spiritual/religious/nonreligious identity is conflicted and complex and that their academic and clinical training did not provide sufficient opportunity to examine how this may affect their therapeutic work. A tentative grounded theory emerged suggesting that psychologists both identified with and were activated by clients' spiritual/religious conflicts and their internal experiences about the spiritual/religious content, both of which presented significant challenges to therapeutic work.     

Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication

CONTEXT: There is growing recognition that bipolar disorder (BPD) has a spectrum of expression that is substantially more common than the 1% BP-I prevalence traditionally found in population surveys. OBJECTIVE: To estimate the prevalence, correlates, and treatment patterns of bipolar spectrum disorder in the US population. DESIGN: Direct interviews. SETTING: Households in the continental United States. PARTICIPANTS: A nationally representative sample of 9282 English-speaking adults (aged >or=18 years). MAIN OUTCOME MEASURES: Version 3.0 of the World Health Organization's Composite International Diagnostic Interview, a fully structured lay-administered diagnostic interview, was used to assess DSM-IV lifetime and 12-month Axis I disorders. Subthreshold BPD was defined as recurrent hypomania without a major depressive episode or with fewer symptoms than required for threshold hypomania. Indicators of clinical severity included age at onset, chronicity, symptom severity, role impairment, comorbidity, and treatment. RESULTS: Lifetime (and 12-month) prevalence estimates are 1.0% (0.6%) for BP-I, 1.1% (0.8%) for BP-II, and 2.4% (1.4%) for subthreshold BPD. Most respondents with threshold and subthreshold BPD had lifetime comorbidity with other Axis I disorders, particularly anxiety disorders. Clinical severity and role impairment are greater for threshold than for subthreshold BPD and for BP-II than for BP-I episodes of major depression, but subthreshold cases still have moderate to severe clinical severity and role impairment. Although most people with BPD receive lifetime professional treatment for emotional problems, use of antimanic medication is uncommon, especially in general medical settings. CONCLUSIONS: This study presents the first prevalence estimates of the BPD spectrum in a probability sample of the United States. Subthreshold BPD is common, clinically significant, and underdetected in treatment settings. Inappropriate treatment of BPD is a serious problem in the US population. Explicit criteria are needed to define subthreshold BPD for future clinical and research purposes.     

Psychological aspects of fibromyalgia: research vs. clinician impressions

OBJECTIVE: This study was designed to compare the psychological features of patients with fibromyalgia, as described in the research literature, with physicians' clinical impressions. METHOD: Using a survey method, physicians (n=44) and physicians-in-training (n=54) were polled regarding their clinical impressions of 18 psychological features, culled from the research literature, which are attributed to fibromyalgia patients. RESULTS: Over 90% of respondents reported that fatigue, muscle tension, pain proneness, depression and anxiety were clinically associated with fibromyalgia patients "frequently" or "very frequently." The majority of respondents (52%) endorsed 10 of 18 items as occurring "frequently" or "very frequently." CONCLUSIONS: Physicians and physicians-in-training appear to observe in fibromyalgia patients over half of the psychological features identified in the research literature. For the remainder of items, we discuss possible explanations for the disparity.     

Associations of self-reported past "psychotic" phenomena with features of personality disorders

Patients with borderline personality disorder (BPD) may present with "psychotic" phenomena, which can be defined as a range of specified "altered experiences of reality." This study investigated the associations between self-reported past psychotic phenomena and features of DSM-III-R personality disorders (PDs) in 57 inpatients without a previous diagnosis of the main disorders that involve delusions and hallucinations. The present findings include associations between past psychotic phenomena and features of BPD, between repeated self-harm and a report that "thoughts seemed put into head," and between psychotic phenomena and features of other PDs, particularly schizotypal PD. There was a high prevalence of BPD in the present sample. Dissociation, in the context of the features of BPD, may be a causal factor for the development of some of the psychotic phenomena presented by patients with PD.     

Explanatory model of psychosis: impact on perception of self-stigma by patients in three sub-saharan African cities

Background

Most cultures in sub-Saharan Africa subscribe to the belief that the root cause of psychosis is supernatural. Individuals in the community who hold a religiomagical explanatory model of causation have been shown to exhibit more stigmatizing attitudes towards people with psychosis. Self-stigma among individuals with psychosis is less frequently studied.

Method

We used a mixed-method approach, consisting of key informant’s interviews to elicit information on explanatory models of causation of psychosis and questionnaire assessment of internalized stigma with an adapted version of the Scale for Internalized Stigma of Mental Illness. Twenty-four, 31, and 30 subjects with recent experience of utilizing the service of traditional or faith healers for severe mental disorders in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya), respectively, were interviewed.

Results

About 44 % (42.1 %) of the Nigerian respondents had a high (severe) level of self-stigma with the respective proportions among Ghanaian and Kenyan respondents being 20.7 and 37.5 %. Compared with 4 out of a total of 12 respondents (33.3 %) who reported low self-stigma reported supernatural attribution, 14 out of 20 respondents (70 %) with the highest level of self-stigma reported supernatural attribution across the three sites. When low scorers ascribed supernatural causation, it was often with a religious focus.

Conclusion

There is a greater tendency for persons with high levels of self-stigma than those with low levels to ascribe supernatural attribution to their experience of a severe mental health condition.

     

Effects of faith and secular factors on locus of control in middle-aged and older cardiac patients

The complex relationships between faith factors and health locus of control were explored. Different from general expectancy, internal control was conceptualized as event-specific self-efficacy. Both control and faith are multidimensional phenomena and affect an individual's health and wellbeing. Yet, how faith and secular factors (e.g., demographic variables) are jointly related to personal control of patients in the face of medical crises remains empirically under-examined. Based on a comprehensive review of different aspects of perceived personal control, spiritual surrender, and faith factors, we presumed a multivariate association among them. Using data from two sequential interviews and the Society of Thoracic Surgeons' Adult Cardiac Database, the study examined the association between these faith factors and different health loci of control among 224 middle-aged and older patients 1 day prior to major cardiac surgery. Primary findings from multiple regression analyses generally supported our hypotheses. Greater internal control was positively related to using private prayer for coping, an event-specific "vicarious" control strategy, but negatively related to subjective religiosity, a general faith measure, after controlling for effects of other secular factors, especially cardiac-significant ones. Several factors in the medical history affected different loci of control. Older age and minority status were associated with greater external control.     

Working with an interpreter in psychiatric assessment and treatment

Cross-cultural assessment and care frequently involve cross-language communication via a translator, interpreter, or bilingual worker. A resurgence of immigration, legalization of former illegal migrants, and refugee flight to the United States has increased the need for such special means of communication. Psychiatrists and other mental health professionals should develop conceptual models, skills, and experience for conducting cross-language interviews. This article provides information, terminology, and models for one aspect of this special clinical task, i.e., working with translators.     

Psychologists as Expert Witnesses in Australian Courtrooms

Mental health professionals assist Australian courts and tribunals with explanations about human behaviour and mental processes related to offending behaviour. Contrary to other witnesses who are only allowed to give evidence in relation to what they directly heard or saw, mental health professionals are allowed to express opinions because they are recognised as expert witnesses with specialised knowledge. However, in Australia at least, little is known about how these expert witnesses are chosen and how they meet the requirements of possessing “specialised knowledge”. In this article, we provide a brief history of expert witnesses in the courtroom, including the use of psychologists as expert witnesses. We then highlight some of the concerns that legal professionals have raised about psychologists as expert witnesses in the limited number of studies that have been conducted in Australia, the United States, and the United Kingdom. Finally, we raise questions about how psychologists are chosen to be expert witnesses in Australia and introduce directions for future research.     

The use of complementary and alternative therapies to treat anxiety and depression in the United States

OBJECTIVE: This study presents data on the use of complementary and alternative therapies to treat anxiety and depression in the United States. METHOD: The data came from a nationally representative survey of 2,055 respondents (1997-1998) that obtained information on the use of 24 complementary and alternative therapies for the treatment of specific chronic conditions. RESULTS: A total of 9.4% of the respondents reported suffering from "anxiety attacks" in the past 12 months; 7.2% reported "severe depression." A total of 56.7% of those with anxiety attacks and 53.6% of those with severe depression reported using complementary and alternative therapies to treat these conditions during the past 12 months. Only 20.0% of those with anxiety attacks and 19.3% of those with severe depression visited a complementary or alternative therapist. A total of 65.9% of the respondents seen by a conventional provider for anxiety attacks and 66.7% of those seen by a conventional provider for severe depression also used complementary and alternative therapies to treat these conditions. The perceived helpfulness of these therapies in treating anxiety and depression was similar to that of conventional therapies. CONCLUSIONS: Complementary and alternative therapies are used more than conventional therapies by people with self-defined anxiety attacks and severe depression. Most patients visiting conventional mental health providers for these problems also use complementary and alternative therapies. Use of these therapies will likely increase as insurance coverage expands. Asking patients about their use could prevent adverse effects and maximize the usefulness of therapies subsequently proven to be effective.     

Psychotherapy and religion: a survey of Northern Bavarian psychotherapists

By taking a survey of physicians and psychologists accredited as psychotherapists in Franconia (northern Bavaria), we attempted to draw conclusions about the importance of religion for the therapists themselves and for their therapeutic settings. 253 physicians and 78 psychologists returned usable questionnaires (a return rate of 70% for each group). 30% of each group were non-denominational, significantly more men than women were not religious or considered themselves "agnostic/atheistic." Catholic therapists appeared to be more loyal toward their church and more open-minded toward religion in general than protestants and non-denominationals, respectively. Around 1/5 of the psychologists had prayed for their patients. Among the psychoanalysts there were no fewer non-denominationals or agnostics/atheists than among physician/psychotherapists or behavioural therapists. The physician/psychoanalysts classified the role of religion as less important than physician/psychotherapists; however, there were marked differences between the psychoanalytic schools. Many therapists could imagine consulting a spiritual counselor in appropriate cases. The results indicate a correlation between the subjective attitude of therapists toward religion and their handling of this topic in therapeutic practice.     

Coping over time: the parents of children with autism

Background Although coping with autism has been examined in a number of papers, virtually no research exists on how families cope over time. This paper reports the results of a longitudinal study of parents coping with autism over a period of approximately a decade. Methods The research method for the study was based on ethnographic methods that emphasized in‐depth interviews and participant observation. The sample for this study consisted of 28 parents (19 mothers and nine fathers) of children with autism. The instrument for the interviews consisted of questions concerning: the child’s medical history and referral experience, the child’s present symptomatology, the effects of the child’s problems on the parent’s well‐being, the effects of autism on the family’s social life, parental coping strategies, illness conceptualization and the parents’ expectations for the future. Results and conclusions Coping strategies changed from the time of the initial study, as fewer parents coped through reliance on service providers, family support, social withdrawal and individualism and relatively more parents coped through their religious faith and other emotion‐focused strategies. The results tentatively support previous research on coping that indicates that aging is linked to the use of more emotion‐focused coping strategies.