Download MSBH6002 Culture, Medicine and Behavioral Health

MSBH6002
Culture, Medicine and
Behavioral Health
SESSION ONE
The Disease-health-wellness Framework
&
Illness/Health behaviour
Course orientation
Course objectives

By the end of course, students will:
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Tell the various aspects of illness behaviour
and the roles of cultural factors;
State the common abnormal illness behaviour
and the management principles;
Develop cultural sensitivity in their practice;
Understand how culture become facilitators as
well as barriers to health;
Trace the origins of various health-related
myths; and
Carry out comparative studies in health
practices.
Session-by-session preview
The disease-health-wellness framework
and illness/health behavior
Chinese medicine and health concept &
behavior of Chinese
Critical methodological issues
1.
2.
3.
•
+ Traditional Chinese philosophy & health I:
Daoism
Theories on formation and transmission
of health practices
4.
•
+ Traditional Chinese philosophy & health II:
Zen Buddhism
Cultural sensitive clinical practice
5.
•
6.
7.
8.
Case study: Post-disaster psychosocial
debriefing approaches
Effective wellness promotion
programmes
Group project presentation I
Group project presentation II
Assessment
Individual paper: 50%
 Project presentation: 40%
 Participation: 10%

Individual paper
On any ONE of the following common health
concept or practice of Hong Kong people,
discuss its (possible) sources of origin,
development, influences on the health
behaviour of Chinese people, and implications
for health care professionals:
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Drinking “cold-nature” herbal tea (Note: Such health
practice is rare outside Guangdong)
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“Shenjing shuairuo” (Note: In Mainland China, they
have “shenjing ke” in psychiatric OPD and hospital.)
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“Kidney deficiency” & “tonifying the kidney”
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Pebble path walking
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“Frequent sex is harmful to health”
Length: 1,000 to 2,000 words
Due: Within 2 weeks after Session 8
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Group projects
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Topic: Investigate & report on a prevalent health
practice/myth/trend in Hong Kong:
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Presentation:
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Its history, inception, gathering momentum, and, if
applicable, peaking and fading out
Relationship with cultural issues
Implications for health workers
50 minutes, including 10-15 minutes for discussion
All group members must present
Report:
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Submit a group report within 2 weeks after Session 8
Length: about 2,000 words.
Teachers

Ng, Siu-man
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Email: [email protected]
Fu, Wai
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Email: [email protected]
Session one
The disease-health-wellness framework
&
Illness/health behavior
Individual
factors
Cultural
factors
Illness
behaviour
Health
behaviour
Environmental
factors
Seek
help
Disease
Self
manage
Health
Wellness
The Disease-Health-Wellness Framework of Health/Illness Behaviour
I am sick (healthy)?
Disease
 Illness
 Disorder
 Syndrome
 ….
 (Predicament
 Health
 Wellness)

Ideal disease model
Signs & symptoms
 Pathology
 Aetiology
 Diagnosis
 Treatment
 Prognosis
Expanding the “sick/disease” concept
Pathological process
 Presence of suffering
 Absence of health
 Predictive of ill-health
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Increasingly
loose
Consultation & treatment
compliance 
Cultural factors 
Example

Chronic tiredness
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Chinese:
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Europeans:
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Kidney deficiency,
Qi deficiency
Post-viral inflection syndrome
USA:
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Chronic fatigue syndrome
Disease as “pathological process”
Pathological basis for many “functional
disorders” is still absence
 e.g. functional gastrointestinal disorders
 Traditional clinical diagnosis: exclusive
approach  many unnecessary, fruitless
examinations
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Disease as “presence of suffering”
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Practical value:
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Defines a group of people likely to seek help
Limitations:
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Insight
Variations in tolerance
When suffering is normal
Disease as “absence of health”
But what is health?
 WHO:
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“A state of complete physical, mental and
social well-being, and not merely the absence
of disease or infirmity.”
Absence of health
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“A definition could hardly be more
comprehensive than that, or more
meaningless.”
(Lewis, 1953)
Disease as “predictive of ill-health”
Examples:
 Hypertension  cardio-vascular risk
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BP 145/95 = ill?
BP 135/85 = not ill?
+ cultural beliefs  health/illness behaviour
Tobacco dependence
 Diabetes
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Sick role
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Suggested by Parsons (1951)
A social role that other people bestow on
a person who is ill
4 components:
1.
2.
3.
4.
Exemption from social responsibilities
Right to expect help & care
Obligation to seek & cooperate with Tx.
Desire to recover
Illness behaviour
Suggested by Mechanic (1978)
 Broadly defined as:
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“The ways in which given symptoms may be
differentially perceived, evaluated, and acted
(or not acted) upon.”
Aspects of illness behaviour
Symptom perception
Evaluation of significance (morbid risk)
Communication/complaint behaviour
1.
2.
3.
•
Verbal, non-verbal
Consultation behaviour
Self-treatment
Treatment compliance
Maintenance of customary activities & roles
Mood states
4.
5.
6.
7.
8.
•
e.g. denial, depression, etc.
Ill
Not seeking treatment
(“Abnormal”?)
Ill
Seeking treatment
(“Normal”?)
Not-ill
Not seeking treatment
(“Normal”?)
Not-ill
Seeking treatment
(“Abnormal”?)
Ideal consultation pathway
In-pt.
Tx.

Specialists

Family doctor

Sick
Consultation pathway in reality
In-pt.
Tx.

Specialists

Family doctor

Sick
Complementary
& alternative
medicines
Examples
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Schizophrenia
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Hypertension
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Gap between onset & 1st psychiatric
consultation: Average > 1 year
Compliance of drug Tx.: low, esp. stage 1
hypertension
Cancer
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Most patients uses CAMs in parallel to
conventional tx. (also true in Western
countries)
What are these CAMs?
Fact: Many patients use CAMs while still
seeking conventional tx.
 Patients often don’t tell their doctor
 Important to have better doctor-patient
communication:
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Doctors need to have basic knowledge about
common CAMs
Be both scientific & open-minded
Illness behaviour: Traits vs. State
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Traits: stable pattern over time
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Acquired during childhood: family, culture
Later life: value as defense mechanism
Current social & psychological functioning
State: behaviour at a particular time
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The disease – nature & severity
The predicament – psychosocial context
Abnormal illness behaviour
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How to define?
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Re: the 8 aspects of illness behaviour
Can go wrong in 1 or more aspects
Related psychiatric diagnoses:
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Hypochondriasis
Hysteria
Malingering
Factitious illness
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Munchausen syndrome
Meadow’s syndrome
Somatization
Hypochondriasis
Hypochondriacal personality traits
 Hypochondriacal symptoms
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Hypochondriacal delusions
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Forms: Ruminations, over-valued ideas,
delusions
Can occur in almost any psychotic illness
e.g. schizophrenia, dementia
When occur in depressive illness
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Usually secondary to disorder of mood & ideas
of pessimism
Primary hypochondriasis
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Characteristic feature:
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Over-valued ideas about illness (usually
physical)
Vague but pervasive & persistent belief
Likely have been intensively investigated by
many physicians & surgeons with –ive results
Depressive symptoms – absent or inconsistent
Reluctant to see psychiatrists
 “chronic somatization”
 USA: “Briquet’s syndrome”
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Dysmorphophobia
Believe that the body is deformed in some
way, e.g. nose, face, hair, breasts, or
genitalia
 Can be over-valued idea or delusion
 Repeatedly consult plastic surgeons
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Hysteria
Unconscious simulations of the signs of
disease
 Disruption of normal functions (esp. those
of CNS) which are usually under voluntary
control
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2 forms:
 Conversion:
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Simulation of physical symptoms
e.g. astasia-abasia, fits, tremor, anaesthesia,
paralysis
Dissociations:
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Simulation of mental symptoms
e.g. amnesia, multiple personalities
Hysteria as a defense mechanism
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Primary gain
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Relief of difficulties in life
Values of hysterical symptom  surprising lack
of distress on hysterical symptoms  “la belle
indifference’
Secondary gain
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Subsequent use of symptom to manipulate
others
Malingering
 hysteria
 Except being CONSCIOUS of
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simulating the symptoms of disease
of the purpose
Factitious illness
Produce physical signs of disease by selfinjury in order to deceive doctors
 Examples:
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Rashes, infections (e.g. urinary tract, septic
arthrities, “pyrexia of unknown origin”, lapses
of consciousness due to injection of insulin
Well aware of the deception
 Little/no insight into motives
 Special forms:
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Munchausen syndrome & Meadow’ syndrome
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Munchausen syndrome
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“Hospital addiction”
Tend to present A&E with “acute abdomen”,
haemtemesis, blood-stained vomitus, etc. 
surgery  scars of many previous episodes
May use false name & give a polished history
If staff suspect & check record  patient left
mysteriously
In ward, rarely wait to be seen by psychiatrists
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Meadow’s syndrome
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“Munchausen syndrome by proxy”
Factitious illness in children (almost always by
mother)
e.g. hypoxia  to induce fits
 serious physical & psychological abuse
Comparison of Abnormal Illness Behaviour
Hypochondriasis
Hysteria
Conscious
of
simulation
of disease
Communic
ation/
complaint
Self-injury
Verbal
mainly
Non-verbal
mainly
Malingering
Factitious
illness


both
both

In the Chinese culture context
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How Chinese same/different from the
West in:
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Concepts of disease & health?
Socially expected illness behaviour?
Desirable health behaviour?
Some interesting examples:
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“Dizziness”
“Kidney deficiency”
“Stagnation”
Management of
abnormal illness behaviour
Can’t totally preclude the existence of
physical disorders
 But important to avoid unnecessary
physical examinations  need to work
closely with all professionals involved!
 Though physical disorders may be present
(e.g. IBS) the whole issue is primarily
psychosocial
 Take detailed psychosocial history
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Delegate a staff member as key worker
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Rapport building
Clear boundaries & baselines
Intervention
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Individual
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Insight-oriented psychotherapy
Suggestive therapy & offer opportunity to “recover”:
e.g. hypnosis, acupuncture, short-term inpatient stay
Systemic
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Family
Liaison with other agencies  consistency
Recommended reading

Goldberg D, Benjamin S, Creed F (1994).
Psychiatry in Medical Practice. London &
NY: Routledge.