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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: 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: Drinking “cold-nature” herbal tea (Note: Such health practice is rare outside Guangdong) “Shenjing shuairuo” (Note: In Mainland China, they have “shenjing ke” in psychiatric OPD and hospital.) “Kidney deficiency” & “tonifying the kidney” Pebble path walking “Frequent sex is harmful to health” Length: 1,000 to 2,000 words Due: Within 2 weeks after Session 8 Group projects Topic: Investigate & report on a prevalent health practice/myth/trend in Hong Kong: Presentation: 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: Submit a group report within 2 weeks after Session 8 Length: about 2,000 words. Teachers Ng, Siu-man Email: [email protected] Fu, Wai 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 Increasingly loose Consultation & treatment compliance Cultural factors Example Chronic tiredness Chinese: Europeans: Kidney deficiency, Qi deficiency Post-viral inflection syndrome USA: 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 Disease as “presence of suffering” Practical value: Defines a group of people likely to seek help Limitations: Insight Variations in tolerance When suffering is normal Disease as “absence of health” But what is health? WHO: “A state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity.” Absence of health “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 BP 145/95 = ill? BP 135/85 = not ill? + cultural beliefs health/illness behaviour Tobacco dependence Diabetes Sick role 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: “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 Schizophrenia Hypertension Gap between onset & 1st psychiatric consultation: Average > 1 year Compliance of drug Tx.: low, esp. stage 1 hypertension Cancer 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: Doctors need to have basic knowledge about common CAMs Be both scientific & open-minded Illness behaviour: Traits vs. State Traits: stable pattern over time Acquired during childhood: family, culture Later life: value as defense mechanism Current social & psychological functioning State: behaviour at a particular time The disease – nature & severity The predicament – psychosocial context Abnormal illness behaviour How to define? Re: the 8 aspects of illness behaviour Can go wrong in 1 or more aspects Related psychiatric diagnoses: Hypochondriasis Hysteria Malingering Factitious illness Munchausen syndrome Meadow’s syndrome Somatization Hypochondriasis Hypochondriacal personality traits Hypochondriacal symptoms Hypochondriacal delusions Forms: Ruminations, over-valued ideas, delusions Can occur in almost any psychotic illness e.g. schizophrenia, dementia When occur in depressive illness Usually secondary to disorder of mood & ideas of pessimism Primary hypochondriasis Characteristic feature: 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” 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 Hysteria Unconscious simulations of the signs of disease Disruption of normal functions (esp. those of CNS) which are usually under voluntary control 2 forms: Conversion: Simulation of physical symptoms e.g. astasia-abasia, fits, tremor, anaesthesia, paralysis Dissociations: Simulation of mental symptoms e.g. amnesia, multiple personalities Hysteria as a defense mechanism Primary gain Relief of difficulties in life Values of hysterical symptom surprising lack of distress on hysterical symptoms “la belle indifference’ Secondary gain Subsequent use of symptom to manipulate others Malingering hysteria Except being CONSCIOUS of simulating the symptoms of disease of the purpose Factitious illness Produce physical signs of disease by selfinjury in order to deceive doctors Examples: 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: Munchausen syndrome & Meadow’ syndrome Munchausen syndrome “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 Meadow’s syndrome “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 How Chinese same/different from the West in: Concepts of disease & health? Socially expected illness behaviour? Desirable health behaviour? Some interesting examples: “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 Delegate a staff member as key worker Rapport building Clear boundaries & baselines Intervention Individual Insight-oriented psychotherapy Suggestive therapy & offer opportunity to “recover”: e.g. hypnosis, acupuncture, short-term inpatient stay Systemic Family Liaison with other agencies consistency Recommended reading Goldberg D, Benjamin S, Creed F (1994). Psychiatry in Medical Practice. London & NY: Routledge.