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Cross-Cultural Medicine Cross-cultural Medicine Psychiatry and Chinese Culture TSUNG-YI LIN, MD, FRCP(C), Vancouver, British Columbia When we examine the cultural characteristics that influence mental disorders and related behavior among the Chinese, no major differences are found between Chinese and other groups in the range of disorders or in overall prevalence. Several cultural factors influence the recognition and treatment of mental illness, among which are attitudes toward emotional display, somatic as opposed to psychogenic disorders and features of the traditional medical belief system in Chinese culture. The Chinese have a relatively favorable prognosis of schizophrenia, low rates of depressive illness, a strong tendency towards somatization and the presence of several unique culture-bound syndromes. From study- ing Chinese in Vancouver, it was found that they have a characteristic way of dealing with mental illness in the family, in that there is first a protracted period of intrafamilial coping with serious psychiatric illness, followed by recourse to friends, elders and neighbors in the community; third, consultation with traditiknal specialists, religious healers or general physicians; fourth, outpatient or inpatient treatment from specialists, and, finally, a pro- cess of rejection and scapegoating of the patient. The efficacy of Western psychiatric treatment of Chinese patients has yet to be objectively assessed. From a growing body of accumulated scientific ob- * Do the Chinese have a system of psychiatric knowl- servations, especially ia the past three decades, edge or theory peculiar to Chinese culture, especially certain differences are becoming apparent in the ways regarding causation, manifestation and evolution of Chinese patients manifest the symptoms and course of mental illness and its intervention? mental disorders and in which the family and society treat and cope with mentally ill persons. This has led to Characteristic Features of Mental Disorders such important questions as the relative vulnerability Among the Chinese and tolerance of the Chinese to specific stresses and the There exist basic similarities in the psychopathology extent to which Chinese culture with its traditional of mental disorders between the Chinese and the people health beliefs and practices influences the perception of Western and other cultures. Two major similarities and management of mental illness and mental health- have been variously reported in the past and substan- related behavior. tiated by the International Pilot Studies of Schizophre- In examining the role Chinese culture plays in shap- nia of the World Health Organization (WHO) and other ing psychiatry and mental health services, I have at- international collaborative studies.1'2 The first important tempted to address four questions: feature is that the entire range of psychopathology to the observed in the West and in other cultures in terms of * Are there psychiatric phenomena peculiar symptoms or syndromes have been observed in the Chinese? Chinese. Second, all types of mental disorders including * Are there psychiatric treatment modalities that are their subtypes, as described in Western literature, have unique to the Chinese? been identified among the Chinese when standard West- * Have the Chinese with their sociocultural traditions ern diagnostic criteria are applied. developed unique coping skills which have expressed The overall prevalence rates of mental disorders and themselves in a pattern of help-seeking and delivery of the rates for psychoses among the Chinese have been mental health services? reported as roughly similar to, or at the lower end of, Refer to Lin T-y: Psychiatry and Chinese culture, In Cross-cultural medicine. West J Med 1983 Dec; 139:862-867. From the Department of Psychiatry, The University of British Columbia Faculty of Medicine, Vancouver. Reprint requests to Tsung-yi Lin, MD, Department of Psychiatry, The University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC, Canada V6T 2A1. 862 THE WESTERN JOURNAL OF MEDICINE PSYCHIATRY AND CHINESE CULTURE the reported rates of those from other cultures.3 Such been a major problem for families, society or psychiatric observations, however, cannot be yet regarded as con- institutions in Chinese society. The prevalence rates of clusive or meaningful. Because epidemiologic studies senile psychoses in a Taiwan survey4 and rates of pa- that have been carried out in Chinese and other cultures tients older than 60 years admitted to hospital with up to the present vary significantly in their scope, psychosis in Hong Kong" are relatively low. These methods of case finding, diagnostic criteria, sociodemo- findings should not be taken to indicate that senile graphic measurements and data analysis, they have dementia does not develop in Chinese or that they do yielded no data for meaningful comparisons, especially not suffer from senile psychoses. The age-specific rates where the overall rates of mental disorders are con- of senile dementia and psychoses in the Taiwan study cerned. are found to be comparable with those reported from Bavaria and Thuringia. It is conceivable that the low Major Psychoses hospital admission rates of senile psychiatric patients Observations on certain specific types of mental dis- reflect the protective attitude of the Chinese toward old orders are amenable for comparison with other studies people, sick or well. It is postulated that the Chinese by virtue of the use of better defined diagnostic criteria. community has a higher tolerance for old people, mak- Schizophrenia. The prevalence rates of schizophrenia ing them feel loved, wanted, respected and useful, which in various studies range from 1.1 to 4.0 per 1,000, which gives them a sense of self-respect and belonging. How are in the lower range of rates reported from other much such traditional attitudes help retard the aging cultures.3-6 It should be noted, however, that the above process or influence onset and course of senile psychoses findings require further confirmation through systematic is a subject for future medicosocial inquiry. epidemiologic studies using standardized research meth- odology and well-defined criteria. Minor Mental Disorders and Culture-Bound Syndromes Two significant features among Chinese who have In the case of minor mental disorders and culture- schizophrenia seem to stand out from the reported find- bound syndromes, three elements seem to predominate ings. First, a large percentage of schizophrenic patients in most studies regardless of whether they are based on in Taiwan are diagnosed as paranoid both in clinical hospital statistics or community surveys: (1) the very and systematic comparative studies.2- Second, the data low prevalence rates of depressive illness, especially obtained from Taiwan and Hong Kong seem to indicate neurotic depression, (2) the large number of patients a considerably favorable prognosis for schizophrenic diagnosed as "neurasthenic" and (3) the relatively few Chinese. The Chinese schizophrenic patients in WHO's cases of obsessive-compulsive neurosis among Chinese. pilot study showed better prognoses than those from Western countries after two years and five years.' In Depressive illness. It is fair to state that depressive Hong Kong two thirds of schizophrenic patients were illnesses among the Chinese have so far received little found to have a lasting remission or showed only mild attention largely due to their perceived low prevalence deterioration at a ten-year follow-up.8 The hospital rates. Findings from hospitals and outpatient clinics in statistics I obtained during my visits in 1981 and 1982 the People's Republic of China confirm the generally also suggested a benign prognosis for schizophrenic held view that depressive illnesses are rarely diagnosed. patients in China. For example, less than 3% of outpatient-clinic patients and about 1 % of inpatients are diagnosed as having In addition, to investigate the role biogenetic factors depression. might possibly have in the favorable outcome of schizo- phrenia, the contribution of psychosocial factors pecu- Several reasons have been suggested to account for liar to Chinese culture should be explored. It is con- the rarity of reported cases of depressive illness among ceivable that the strong supportive network traditionally the Chinese: embodied in Chinese families and the community may (1) The characteristics of depression, consisting play a key role. It is also possible that the preindustrial mainly of dysphoric mood change, self-depreciation Chinese societal structure, with its well-defined roles and guilt feelings, do not fit in with the traditional and functions for each person, might place fewer de- concept of "madness" in Chinese society, which em- mands on sick persons and thus make it easier for them phasizes outward antisocial or bizarre behavior as the to regain their prescribed roles and functions. pathognomonic features. Therefore, persons with dys- Affective psychoses. Prevalence rates of affective phoric conditions neither seek psychiatric help nor get psychoses in Taiwan and Hong Kong are lower than reported in epidemiologic surveys. generally assumed rates in other cultures.4'5'9"0 Manic (2) A Chinese reluctance to express or discuss one's disorders are in the majority in most studies. Whether own feelings, especially to anyone outside of the family, this finding is due to underreporting of cases of depres- may also play a part in inhibiting the expression of sion or to overreporting of cases of mania
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