Psychosomatic symptoms in Asian populations: more than a headache?

Full text

(1)

Psychosomatic symptoms in

Psychosomatic symptoms in

Asian populations: more than

Asian populations: more than

a headache?

a headache?

Presentation by Presentation by

Dr. Gen Numaguchi, Ph.D. Dr. Gen Numaguchi, Ph.D.

WCMHT – Queenstown WCMHT – Queenstown

(2)
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Who are New Zealand’s Asian

Who are New Zealand’s Asian

People?

People?

Asian people are the New Zealanders who Asian people are the New Zealanders who identify with or feel they belong to one or

identify with or feel they belong to one or

more Asian ethnicities. The largest ethnicity

more Asian ethnicities. The largest ethnicity

among Asian people is Chinese, followed by

among Asian people is Chinese, followed by

Indian, Korean, Filipino, Japanese, Sri

Indian, Korean, Filipino, Japanese, Sri

Lankan, Cambodian, and Thai

(4)

Demographics of Asians in NZ

Demographics of Asians in NZ

4.5 million people live in NZ; up from 4.5 million people live in NZ; up from 4,241,448 in 2013 census.

4,241,448 in 2013 census.

European descent = 70%European descent = 70%Maori = 14.1%Maori = 14.1%

(5)

Demographics of Asians in NZ

Demographics of Asians in NZ

(continued)

(continued)

Assuming a medium level projection, a Assuming a medium level projection, a further 250,000 Asians migrants are

further 250,000 Asians migrants are

expected between 2006 and 2026.

(6)
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Definition

Definition

From the perspective of evolutionary From the perspective of evolutionary psychiatry,

psychiatry, depressiondepression is related to the is related to the response to the loss

response to the loss of significant of significant

interpersonal relationships, social status, or

interpersonal relationships, social status, or

incentives, while

incentives, while anxietyanxiety is related to the is related to the anticipation of threats

anticipation of threats to safety or integrity of to safety or integrity of body or self.

(8)

Mental Health Service Use –

Mental Health Service Use –

General Population

General Population

Individuals with mental illness were Individuals with mental illness were more more likely to experience unmet health care

likely to experience unmet health care

needs

needs and and less likely to receive quality less likely to receive quality medical care

medical care compared to the general compared to the general population.

population.

As well, people in most parts of the world As well, people in most parts of the world do do not view emotional problems as appropriate

not view emotional problems as appropriate

issues

(9)

Fact Regarding Asian Culture

Fact Regarding Asian Culture

Asian American femalesAsian American females have the have the highest highest suicide rate

suicide rate among women 65 years of age among women 65 years of age or older.

(10)

Study in Biological Differences

Study in Biological Differences

Tufts University psychologist Nalini Ambady, Tufts University psychologist Nalini Ambady,

Ph.D., conducted a study on how culture Ph.D., conducted a study on how culture

shapes biology. Ambady’s group based the shapes biology. Ambady’s group based the

study on historical data showing that

study on historical data showing that East- East-Asian cultures value submissiveness

Asian cultures value submissiveness, while , while Western cultures value dominance

Western cultures value dominance. In fact, . In fact, they found, they could see this

they found, they could see this cultural cultural

distinction in the way the brain responds to distinction in the way the brain responds to

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Biological Differences - 1

Biological Differences - 1

When an American thinks about whether he

When an American thinks about whether he

is honest, his brain activity looks very

is honest, his brain activity looks very

different than when he thinks about whether

different than when he thinks about whether

another person is honest, even a close

another person is honest, even a close

relative. That’s not true for Chinese people.

relative. That’s not true for Chinese people.

When a Chinese man evaluates whether he

When a Chinese man evaluates whether he

is honest, his brain activity looks almost

is honest, his brain activity looks almost

identical to when he is thinking about

identical to when he is thinking about

whether his mother is honest.

(13)

Biological Differences - 2

Biological Differences - 2

When Americans viewed dominant

When Americans viewed dominant

silhouettes, but not submissive ones, reward

silhouettes, but not submissive ones, reward

circuitry fired in the brain’s limbic system.

circuitry fired in the brain’s limbic system.

The opposite happened among Japanese

The opposite happened among Japanese

participants;

participants; their reward circuitry fired in their reward circuitry fired in response to submissive, but not dominant,

response to submissive, but not dominant,

silhouettes

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Biological Differences - 3

Biological Differences - 3

Native Chinese, as opposed to Americans,

Native Chinese, as opposed to Americans,

are

are more sensitive to the contextmore sensitive to the context in which an in which an object is embedded, and so focus greater

object is embedded, and so focus greater

attention on that object when it’s in an

attention on that object when it’s in an

inconsistent context

(15)

Biological Differences - 4

Biological Differences - 4

Westerners process human faces more

Westerners process human faces more

actively than East Asians, consistent with

actively than East Asians, consistent with

the

(16)

Biological Differences - 5

Biological Differences - 5

Behavioral work by University of Michigan

Behavioral work by University of Michigan

psychologist Shinobu Kitayama, Ph.D., and his

psychologist Shinobu Kitayama, Ph.D., and his

colleagues showed that people from Japan are far

colleagues showed that people from Japan are far

better at judging the length of a line relative to the

better at judging the length of a line relative to the

size of a box in which it’s drawn, while Americans

size of a box in which it’s drawn, while Americans

are far better at judging the absolute length of the

are far better at judging the absolute length of the

same line. They attribute this difference to

same line. They attribute this difference to

findings from other studies showing that

findings from other studies showing that

Americans pay more attention to details and

Americans pay more attention to details and

Asians pay more attention to context

(17)

Biological Differences - 6

Biological Differences - 6

Northwestern University’s Joan Chiao,

Northwestern University’s Joan Chiao,

Ph.D., for example, has found that

Ph.D., for example, has found that people people who live in collectivist cultures are more

who live in collectivist cultures are more

likely than those in individualistic cultures to

likely than those in individualistic cultures to

have a form of the serotonin transporter

have a form of the serotonin transporter

gene – the S-allele – that correlates with

gene – the S-allele – that correlates with

higher rates of negative affect, anxiety, and

higher rates of negative affect, anxiety, and

depression

(18)

Biological Differences - 7

Biological Differences - 7

I

In contrastn contrast to what you might expect from to what you might expect from the genes alone, she also found that

the genes alone, she also found that people people from collectivist societies are less likely to

from collectivist societies are less likely to

be depressed

be depressed. This suggests that . This suggests that

collectivism, which tends to produce lower

collectivism, which tends to produce lower

levels of negative affect, may have

levels of negative affect, may have

co-evolved with the S-allele

(19)

Biological Differences - 8

Biological Differences - 8

S

Societies of people with the S-allele ocieties of people with the S-allele

developed a collectivist culture that reduced

developed a collectivist culture that reduced

stress

stress and, therefore, risk of depression by and, therefore, risk of depression by emphasizing social harmony and social

emphasizing social harmony and social

support

(20)
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Roles of Culture

Roles of Culture

Culture has Culture has effects on the neural systems, effects on the neural systems, psychological representations, and

psychological representations, and

interactional patterns

interactional patterns that constitute affect that constitute affect throughout the life-span.

throughout the life-span.

Cultural ideologies, institutions, and Cultural ideologies, institutions, and practices provide the

practices provide the context and rules for context and rules for interactional processes

interactional processes that underlie that underlie complex emotions.

(22)

Roles of Culture (con’t)

Roles of Culture (con’t)

Cultural variations in the composition of the Cultural variations in the composition of the family, maternal-infant interactions, and

family, maternal-infant interactions, and

child-rearing practices all prime and shape

child-rearing practices all prime and shape

affect systems.

affect systems.

Emotion ‘display rules’Emotion ‘display rules’ and body practices and body practices regulate socially acceptable and deviant

regulate socially acceptable and deviant

patterns

(23)

Roles of Culture (con’t)

Roles of Culture (con’t)

Culture provides Culture provides categories and a lexicon categories and a lexicon for emotional experience

for emotional experience, making some , making some

feelings salient and others more difficult to

feelings salient and others more difficult to

articulate.

articulate.

Culture Culture sets limits of tolerance for specific sets limits of tolerance for specific emotions

emotions and strong affect; it also provides and strong affect; it also provides lay theories and strategies for managing

lay theories and strategies for managing

dysphoria.

(24)

Roles of Culture (con’t)

Roles of Culture (con’t)

 Culture Culture influences the sources of distressinfluences the sources of distress, the , the form of illness experience, symptomatology, the

form of illness experience, symptomatology, the

interpretation of symptoms, modes of coping with

interpretation of symptoms, modes of coping with

distress, help-seeking, and the social response

distress, help-seeking, and the social response to to distress and disability.

distress and disability.

 Each of these ways in which culture may influence Each of these ways in which culture may influence

the regulation of emotion has potential implications

the regulation of emotion has potential implications

for the expression of dysphoric affect in clinical

for the expression of dysphoric affect in clinical

settings.

(25)
(26)

Cultural Differences - 1

Cultural Differences - 1

People from collectivist cultures

People from collectivist cultures, such as , such as China, think of themselves as

China, think of themselves as deeply deeply connected to other people in their lives

connected to other people in their lives, , while

while Americans adhere to a strong sense of Americans adhere to a strong sense of individuality

(27)

Cultural Differences - 2

Cultural Differences - 2

Asian Americans and Pacific Islanders Asian Americans and Pacific Islanders

(APIs) generally place less emphasis than

(APIs) generally place less emphasis than

Western cultures place on individualism but

Western cultures place on individualism but

more on a collective corporate identify, such

more on a collective corporate identify, such

as family reputation.

as family reputation.

In API cultures, the In API cultures, the family often is family often is

considered to be more important than the

considered to be more important than the

individual

(28)
(29)

Perceptions of Mental Illness

Perceptions of Mental Illness

 Stigmatization of people with mental illness Stigmatization of people with mental illness

has persisted throughout history and is

has persisted throughout history and is

especially pronounced in Asian

especially pronounced in Asian

communities.

communities.

Family members often try to conceal any Family members often try to conceal any history of mental illness

history of mental illness within the family to within the family to avoid any negative impact on the family and

avoid any negative impact on the family and

potential of the young person to become

potential of the young person to become

married to a suitable mate.

(30)

Perceptions of MI (con’t)

Perceptions of MI (con’t)

In seeking help for mental health needs, In seeking help for mental health needs, APIs

APIs rely first on themselvesrely first on themselves to deal with to deal with any distress, and

any distress, and only secondarily consider only secondarily consider seeking help from friends or family

seeking help from friends or family

members

members..

When these efforts do not work, When these efforts do not work, community community figures

figures such as elders or spiritual healers such as elders or spiritual healers are sometimes consulted.

(31)

Perceptions of MI (con’t)

Perceptions of MI (con’t)

 They They rarely go to mental health rarely go to mental health professionals

professionals for help until they exhaust all for help until they exhaust all other possible resources, often waiting until

other possible resources, often waiting until

their conditions become severe and painful.

their conditions become severe and painful.

Studies have found that Studies have found that primary care is the primary care is the major setting

major setting where APIs seek services for where APIs seek services for psychological distress and disorders.

(32)
(33)

Perceptions of MI (con’t)

Perceptions of MI (con’t)

 Many cultures view nonconfrontation and Many cultures view nonconfrontation and

social harmony as paramount and

social harmony as paramount and

consequently

consequently value the suppression or value the suppression or containment of both interpersonal and

containment of both interpersonal and

internal conflict

internal conflict..

As a result, individuals in these cultures are As a result, individuals in these cultures are less likely to open up to health care

less likely to open up to health care

providers

providers and to provide details of their and to provide details of their

emotional state and social problems.

(34)

Perceptions of MI (con’t)

Perceptions of MI (con’t)

Instead, Instead, emotional difficultiesemotional difficulties, including , including depression and anxiety, are often

depression and anxiety, are often

understood as sociomoral problems

understood as sociomoral problems more more appropriate to bring to a family member,

appropriate to bring to a family member,

elder, spiritual or community leader, or

elder, spiritual or community leader, or

someone else who is familiar with the

someone else who is familiar with the

complex web of social ties, past and

complex web of social ties, past and

present, that define a relational self.

(35)
(36)

Expressions of Mental Illness

Expressions of Mental Illness

 APIs tend to seek professional help through APIs tend to seek professional help through

primary care providers and present their

primary care providers and present their

emotional distress through

emotional distress through somatic signs somatic signs and symptoms instead of mental/emotional

and symptoms instead of mental/emotional

problems

problems..

Significantly, they tend to Significantly, they tend to focus only on focus only on somatic suffering when seeking mental

somatic suffering when seeking mental

health care

health care. Somatization among APIs has . Somatization among APIs has

been well documented.

(37)

Expressions of MI (con’t)

Expressions of MI (con’t)

Hsu and Folstein (1997) found that Hsu and Folstein (1997) found that cardio- cardio-pulmonary and vestibular symptoms are the

pulmonary and vestibular symptoms are the

predominant physical complaints

predominant physical complaints among among Chinese American people.

Chinese American people.

Miller and her colleagues (2003) also found Miller and her colleagues (2003) also found that

that cardiovascular disease is the most cardiovascular disease is the most common physical condition among

common physical condition among

individual with chronic mental disorders

(38)

Expressions of MI (con’t)

Expressions of MI (con’t)

The six leading principal physical diagnoses The six leading principal physical diagnoses among APIs with secondary psychiatric

among APIs with secondary psychiatric

diagnoses were (

diagnoses were (1) nonspecific chest pain, 1) nonspecific chest pain, (2) poison with other medicine or drugs, (3)

(2) poison with other medicine or drugs, (3)

coronary atherosclerosis and other heart

coronary atherosclerosis and other heart

disease, (4) acute myocardial infarction, (5)

disease, (4) acute myocardial infarction, (5)

acute cardiovascular disease, and (6)

acute cardiovascular disease, and (6)

poison by psychotropic agents

(39)

Expressions of MI (con’t)

Expressions of MI (con’t)

The impression that Asians, Africans, and The impression that Asians, Africans, and others are more prone to somatize than

others are more prone to somatize than

North Americans has been based largely on

North Americans has been based largely on

anecdotal observation

anecdotal observation or on research that or on research that compares people in very different health

compares people in very different health

care systems

(40)

Expressions of MI (con’t)

Expressions of MI (con’t)

The most common somatic symptoms of The most common somatic symptoms of

depression and anxiety are musculoskeletal

depression and anxiety are musculoskeletal

pain and fatigue

(41)
(42)

Japanese Specific Concepts

Japanese Specific Concepts

The culturally distinctive form of social The culturally distinctive form of social phobia termed

phobia termed Taijin kyofusho (TKS)Taijin kyofusho (TKS) in in Japan provides an instructive example of

Japan provides an instructive example of

cultural influences on anxiety.

(43)

Taijin kyofusho (TKS)

Taijin kyofusho (TKS)

It is associated with It is associated with concerns about concerns about upsetting others

upsetting others rather than simply with rather than simply with one’s own embarrassment.

one’s own embarrassment.

Awkward social behaviorAwkward social behavior, especially an , especially an inappropriately placed or timed gaze, is

inappropriately placed or timed gaze, is

viewed as harming others

(44)

Taijin kyofusho (TKS) (con’t)

Taijin kyofusho (TKS) (con’t)

A wide range of types and severity of social A wide range of types and severity of social anxiety, including apparently delusional

anxiety, including apparently delusional

forms, are grouped together by many

forms, are grouped together by many

Japanese psychiatrists as forms of TKS that

Japanese psychiatrists as forms of TKS that

may be responsive to similar cognitive

may be responsive to similar cognitive

interventions.

interventions.

Taijinkyofusho predominantly Taijinkyofusho predominantly afflicts young afflicts young males

(45)
(46)

Taijin kyofusho (TKS) (con’t)

Taijin kyofusho (TKS) (con’t)

While While “pure”“pure” taijinkyofusho sufferers attribute taijinkyofusho sufferers attribute

their condition to some kind of

their condition to some kind of personal or personal or character weakness

character weakness involving their involving their inability to inability to cope with interpersonal situations

cope with interpersonal situations and and

eventually seek some form of psychiatric eventually seek some form of psychiatric

help,

help, “serious”“serious” taijinkyofusho sufferers lack taijinkyofusho sufferers lack such insights,

such insights, perceive their problems as perceive their problems as real

real, and attempt to deal with them , and attempt to deal with them accordingly.

(47)

Taijin kyofusho (TKS) (con’t)

Taijin kyofusho (TKS) (con’t)

There is a consensus among Japanese There is a consensus among Japanese psychiatrists that taijinkyofusho is a

psychiatrists that taijinkyofusho is a culture- culture-bound disorder

bound disorder..

Western psychiatrists tend to diagnose Western psychiatrists tend to diagnose Japanese cases of taijinkyofusho as

Japanese cases of taijinkyofusho as

paranoia and paranoid schizophrenia

(48)

Taijin kyofusho (TKS) (con’t)

Taijin kyofusho (TKS) (con’t)

Miyoshi (1970) has suggested that the Miyoshi (1970) has suggested that the disorder is generated by the

disorder is generated by the conflict conflict

between the individual’s strong feelings of

between the individual’s strong feelings of

self-conceit

self-conceit, which convince him that he is , which convince him that he is essentially different from others, and the

essentially different from others, and the

value of Japanese society places on

value of Japanese society places on

conformity

conformity, which stresses that people are , which stresses that people are essentially the same.

(49)

Taijin kyofusho (TKS) (con’t)

Taijin kyofusho (TKS) (con’t)

 Iwai (1982) views the major complaint underlying Iwai (1982) views the major complaint underlying

taijinkyofusho disorders as less an actual “fear of

taijinkyofusho disorders as less an actual “fear of

strangers” than a

strangers” than a state of anxiety aroused by state of anxiety aroused by doubts concerning one’s acceptability to others

doubts concerning one’s acceptability to others, , and suggests that a more appropriate term for the

and suggests that a more appropriate term for the

disorder might be “jikitaimenkyofusho” or

disorder might be “jikitaimenkyofusho” or fear of fear of self-presentation

self-presentation. According to Iwai, the object of . According to Iwai, the object of fear is not the social situation or other people as

fear is not the social situation or other people as

much as it is oneself in the context of presenting

much as it is oneself in the context of presenting

that self to others and how that self will be

that self to others and how that self will be

received by those others.

(50)
(51)

Japanese Specific Concepts (con’t)

Japanese Specific Concepts (con’t)

 The The greater social acceptability of anxiety greater social acceptability of anxiety compared with depression

compared with depression may also account for may also account for

the low levels of clinical diagnosis and treatment of

the low levels of clinical diagnosis and treatment of

depression in Japan until recently

depression in Japan until recently..

 The majority of patients with symptoms of The majority of patients with symptoms of

depression in Japan are still

depression in Japan are still treated by internists treated by internists primarily with benzodiazepines

primarily with benzodiazepines, although with the , although with the recent introduction of selective serotonin reuptake

recent introduction of selective serotonin reuptake

inhibitors, antidepressant use is increasing.

(52)

Japanese Specific Concepts (con’t)

Japanese Specific Concepts (con’t)

Victim-consciousness is embedded in the Victim-consciousness is embedded in the Japanese language itself, as is seen in the

Japanese language itself, as is seen in the

so-called suffering passive inflection of

so-called suffering passive inflection of

Japanese verbs where

Japanese verbs where something just something just happens and one is made to suffer as a

happens and one is made to suffer as a

consequence

(53)

Japanese Specific Concepts (con’t)

Japanese Specific Concepts (con’t)

 Munakata (1986) has argued that Japanese Munakata (1986) has argued that Japanese

attitudes toward mental illness also have an

attitudes toward mental illness also have an

impact on the diagnosis of neurasthenia, which

impact on the diagnosis of neurasthenia, which

until recently was diagnosed by Japanese

until recently was diagnosed by Japanese

psychiatrists and doctors to

psychiatrists and doctors to disguise socially disguise socially stigmatized mental illnesses

stigmatized mental illnesses such as such as

schizophrenia in order to spare their patients and

schizophrenia in order to spare their patients and

families the psychological shock and ostracism

families the psychological shock and ostracism

that would accompany the diagnosis of more

that would accompany the diagnosis of more

severe mental illnesses.

(54)

Japanese Specific Concepts (con’t)

Japanese Specific Concepts (con’t)

ShinkeishitsuShinkeishitsu (constitutional neurasthenia) is (constitutional neurasthenia) is a widely used diagnostic term in Japan

a widely used diagnostic term in Japan

applying to a condition which would be

applying to a condition which would be

diagnosed as an anxiety disorder in the

diagnosed as an anxiety disorder in the

West

West..

Somatic rather than dysphoric complaintsSomatic rather than dysphoric complaints are characteristic of both Japanese

are characteristic of both Japanese

depression and shinkeishitsu.

(55)
(56)

Shinkeishitsu

Shinkeishitsu

Generally, when used popularly, Generally, when used popularly,

shinkeishitsu describes a person who is

shinkeishitsu describes a person who is

overly sensitive

overly sensitive to certain features of his or to certain features of his or her immediate environment, “nervous,”

her immediate environment, “nervous,”

“worrisome,” “easily agitated,” and

“worrisome,” “easily agitated,” and

“anxious.

(57)

Shinkeishitsu (con’t)

Shinkeishitsu (con’t)

Sufferers are believed to be Sufferers are believed to be “nervous” by “nervous” by temperament

temperament, individuals being , individuals being predisposed predisposed at birth

at birth to the disorder (the term to the disorder (the term

shinkeishitsu itself means ‘of nervous

shinkeishitsu itself means ‘of nervous

temperament.”).

temperament.”).

Generally, the disorder is seen as not Generally, the disorder is seen as not particularly serious and as

particularly serious and as physical rather physical rather than mental in nature

(58)

Shinkeishitsu (con’t)

Shinkeishitsu (con’t)

In some cases, the diagnosis of In some cases, the diagnosis of shinkeishitsu is

shinkeishitsu is used to disguise depressionused to disguise depression, , legitimizing the sufferers’ distress by giving it

legitimizing the sufferers’ distress by giving it

a

a physical basisphysical basis, and thereby , and thereby circumventing circumventing stigmatization

(59)

DSM-IV-TR:

DSM-IV-TR:

Outline for Cultural Formulation

Outline for Cultural Formulation

 Cultural identity of the individual.Cultural identity of the individual.

 Cultural explanations of the individual’s Cultural explanations of the individual’s illness.

illness.

 Cultural factors related to psychosocial Cultural factors related to psychosocial environment and levels of functioning. environment and levels of functioning.

 Cultural elements of the relationship Cultural elements of the relationship

between the individual and the clinician. between the individual and the clinician.

 Overall cultural assessment for diagnosis Overall cultural assessment for diagnosis and care.

(60)
(61)

Practical Guidelines

Practical Guidelines

 1) The basis of any general ability to work 1) The basis of any general ability to work

with people from diverse cultural

with people from diverse cultural

backgrounds begins with the

backgrounds begins with the clinician’s clinician’s knowledge of their own ethnocultural

knowledge of their own ethnocultural

identity

identity and the implicit biases this brings. and the implicit biases this brings.  2) A second step involves 2) A second step involves careful careful

consideration of the cultural bases and

consideration of the cultural bases and

biases

biases of contemporary psychiatric of contemporary psychiatric

practice.

(62)

Practical Guidelines (con’t)

Practical Guidelines (con’t)

 3) A third skill concerns working with interpreters 3) A third skill concerns working with interpreters

and culture-brokers able to

and culture-brokers able to provide the missing provide the missing social and cultural context

social and cultural context..

 4) Finally, the clinician must consider his or her 4) Finally, the clinician must consider his or her

own position in the health care system, as well as

own position in the health care system, as well as

that of the clinical or institutional setting, vis-à-vis

that of the clinical or institutional setting, vis-à-vis

the specific ethnocultural community to

the specific ethnocultural community to consider consider problems of power, racism, and accessibility

problems of power, racism, and accessibility that that may impede forming a therapeutic alliance and

may impede forming a therapeutic alliance and

negotiating effective care.

(63)

Working with Asian Clients

Working with Asian Clients

Explain and reframe the roleExplain and reframe the role of the therapist of the therapist and the client in the beginning of therapy

and the client in the beginning of therapy..

Therapists emphasize their role is an Therapists emphasize their role is an ‘expert ‘expert in therapy’

in therapy’ and the client is the and the client is the ‘expert in his ‘expert in his or her life.’

or her life.’

Don’t discount physical complaintsDon’t discount physical complaints..

Avoid asking too many personal questionsAvoid asking too many personal questions during initial sessions.

(64)

References

References

 American Psychiatric Association (2000). American Psychiatric Association (2000).

Diagnostic and Statistical Manual of Mental

Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition – Text Revision (TR).

Disorders, Fourth Edition – Text Revision (TR).

Washington, DC: American Psychiatric

Washington, DC: American Psychiatric

Association, 897-903.

Association, 897-903.

 Azar, B. (2010). Your brain on culture. Azar, B. (2010). Your brain on culture. American American Psychological Association Monitor, 41

Psychological Association Monitor, 41 (10). (10). Available:

Available:

(65)

References (continued)

References (continued)

Chen, H. J. (2005). Mental illness and Chen, H. J. (2005). Mental illness and

principal physical diagnoses among Asian

principal physical diagnoses among Asian

American and Pacific Islander users of

American and Pacific Islander users of

emergency services.

emergency services. Issues in Mental Issues in Mental Health Nursing, 26

Health Nursing, 26, 1061-1079., 1061-1079.

(66)

References (continued)

References (continued)

 Kirmayer, L. J. (2001). Cultural variations in the Kirmayer, L. J. (2001). Cultural variations in the

clinical presentation of depression and anxiety:

clinical presentation of depression and anxiety:

Implications for diagnosis and treatment.

Implications for diagnosis and treatment. Journal Journal of Clinical Psychiatry, 62

of Clinical Psychiatry, 62 (13), 22-30. (13), 22-30.

 Oshima, A., Higuchi, T., Fujiwara, Y., Iida, M., Oshima, A., Higuchi, T., Fujiwara, Y., Iida, M.,

Iwanami, A., Kanba, S., Motohashi, N., Uchitomi,

Iwanami, A., Kanba, S., Motohashi, N., Uchitomi,

Y., Yamada, K., & Yamawaki, S. (1999).

Y., Yamada, K., & Yamawaki, S. (1999).

Questionnaire survey on the prescribing practice

Questionnaire survey on the prescribing practice

of Japanese psychiatrists for mood disorders.

of Japanese psychiatrists for mood disorders.

Psychiatry and Clinical Neurosciences, 53

Psychiatry and Clinical Neurosciences, 53

(Suppl.)

(67)

References (continued)

References (continued)

 Population and Sustainable Development. Population and Sustainable Development.

Available:

Available:

http://www.population.govt.nz/information-by -subject/population-groups/asian-people.asp x

Russell, J. G. (1989). Anxiety disorders in Russell, J. G. (1989). Anxiety disorders in Japan: A review of the Japanese literature

Japan: A review of the Japanese literature

on shinkeishitsu and taijinkyofusho.

on shinkeishitsu and taijinkyofusho. Culture, Culture, Medicine and Psychiatry, 13

(68)

References (continued)

References (continued)

 Southern District Health Board Website. Southern District Health Board Website.

Available:

Available: http://www.southerndhb.govt.nz/  Statistics New Zealand. Available: Statistics New Zealand. Available:

http://www.stats.govt.nz/infoshare/

Tracey, M. D. (2006). Cultural worlds Tracey, M. D. (2006). Cultural worlds intersect.

intersect. American Psychological American Psychological Association Monitor, 37

Association Monitor, 37 (2). Available: (2). Available:

(69)

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