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A DSM home for cultural syndromes.

SANTA ANA PUEBLO, N.M. -- After being told of a traumatic family event, a Puerto Rican woman screams, cries, and trembles uncontrollably in a trancelike state--which she later does not remember although her reaction seems to have relieved her distress.

A Cambodian man presents at an emergency room with dizziness and a sore neck. He is extremely worried that these symptoms signal what he calls a khyal, a life-threatening surge of blood from his body to his head.

Despite aspects of commonly recognized anxiety disorders, in particular panic attacks, these presentations do not quite fit criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) They represent cultural syndromes that overlap but do not correlate on a one-to-one basis with major diagnoses, Dr. Roberto Lewis-Fernandez explained at the annual conference of the Anxiety Disorders Association of America.

Cultural syndromes constitute an "alternate nosology, not alien but organized differently," he said at a plenary session on cultural considerations in anxiety disorders. A glossary describes them in the DSM-IV--separately in an appendix at "the very back of the book."

The phenotypes should be brought up front and incorporated into the common nosology of anxiety disorders, advocated Dr. Lewis-Fernandez, director of the New York State Center of Excellence for Cultural Competence and Hispanic Treatment Program at the New York State Psychiatric Institute. He urged that the next edition, the DSM-V, be more universal and more heterogenous, so that it can be used by clinicians anywhere in the world.

"Make sure all the phenotypes that you need are included in DSM-V," said Dr. Lewis-Fernandez, also a clinical psychiatrist at Columbia University, New York.

Among the benefits would be broader recognition that these patients are likely to have co-morbid mental disorders. Dr. Lewis-Fernandez said. Greater awareness would reduce misdiagnosis. The psychiatric nosology would be more comprehensive, and treatment outcomes more effective.

A prime example, the ataque de nervios, as sketched in the first paragraph of this article, was described at the meeting by Peter J. Guarnaccia, Ph.D., of the department of human ecology, Rutgers University, New Brunswick, NJ.

An ataque would be recognized by people from the Caribbean and other Hispanic populations but can mislead a Western clinician confronting it for the first time, he explained. Sometimes, family members will say the patient is having a seizure, assuming the doctor will not understand the phenomena.

Almost always triggered by a stressful event, an ataque does not present with the acute fear or apprehension that is a hallmark of panic episodes, Dr. Guarnaccia noted. Moreover, patients can return to normal function rapidly and often feel better afterward, "which is very unlike a panic attack." But studies have shown that a person who has had an ataque is much more likely to have symptoms of anxiety, depression, and suicidal ideation, dissociation, and trauma, he said.

Susto, another cultural syndrome, is seen in Hispanic people from Mexico, Central America, and South America, Dr. Guarnaccia added. It results from a frightening event, but may occur any time from days to years afterward. He described the core signs as lack of appetite, sleeping too much or too little, troubled sleep or dreams, and not being able to do much of anything. These symptoms relate to depression, he noted, "but the trigger is a fright--not a loss.

"Most cultural syndromes mix aspects of anxiety and depression," Dr. Guarnaccia said, suggesting they support a mixed anxiety-depression diagnosis. "They really challenge us to think about the boundary [by which] we separate disorders that are really much more complicated."

In the case of the Cambodian gentleman presenting with neck pain, Dr. Devon E. Hinton described a mechanism in which physical and psychological symptoms feed each other in a form of posttraumatic stress disorder.

"Neck tension in general encodes all the traumas of the Pol Pot period," said Dr. Hinton of Harvard Medical School, Boston.

Under the Pol Pot regime, Cambodians were forced to do slave labor carrying heavy burdens on their shoulders. Their necks often became callused, and a common way of killing people was to bludgeon them on the neck, he explained.

As a result, many Cambodians associate neck discomfort with distress and worry that khyal, sometimes described as wind, is rising up from the body and forcing blood to the head.

Dr. Hinton and his associates developed a culturally based treatment that he called "flexibility and somatic-focused therapy." This incorporates muscle relaxation, applied stretching and breathing, mindfulness exercises, and talk about the traumas associated with neck tension -- "a lot of somatic and emotional regulation techniques," he said.

Vietnamese patients do not present with neck tension, Dr. Hinton added, but are more focused on headaches. Patients with cultural syndromes "have a different set of stories from what we are used to hearing in patients with anxiety disorders," he said.
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Author:MacNeil, Jane Salodof
Publication:Clinical Psychiatry News
Date:May 1, 2009
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