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The need for culture sensitive diagnostic procedures

A study among psychotic patients in Morocco

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Social Psychiatry and Psychiatric Epidemiology Aims and scope Submit manuscript

Abstract

Objective

We examine the procedural validity of a standardized instrument for the diagnosis of psychotic disorders in Morocco.

Method

Twenty-nine patients from Casablanca, Morocco, with a psychotic or mood disorder were examined using the Comprehensive Assessment of Symptoms and History (CASH) an adapted version using cultural formulation to make the instrument more culturally sensitive (CASH-CS). Chance corrected agreement was calculated between diagnoses based on these two versions of CASH and independent clinical diagnoses according to local psychiatrists.

Results

Agreement for traditional CASH versus clinical diagnosis and for CASH versus CASH-CS was low (kappa = −0.19; SD 0.16 and kappa = 0.21; SD 0.16, respectively). De CASH-CS, showed good agreement with clinical diagnosis (kappa = 0.79; SD 0.11).

Conclusion

Standardized instruments for the assessment of psychosis such as the CASH may be liable to cultural misinterpretations. This may be relevant to the interpretation of the high incidence rates of schizophrenia among immigrants.

Significant outcomes

Agreement between a culturally naïve version of a standardized diagnostic instrument for the assessment of psychosis and clinical diagnosis by Moroccan psychiatrists is poor. Adding additional probes and decision rules based on cultural formulation improves agreement with clinical diagnosis significantly.

Limitations

The study was conducted in a small sample. Both versions of CASH were administered by the same interviewer in a single interview session.

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Acknowledgements

This study is financially supported by Netherlands Organisation for Health Research Development (Zon-Mw) and Altrecht, Institute for Mental Health Care, Utrecht, The Netherlands. The authors would like to thank Prof. dr. Moussaoui and Prof. dr. Kadri for their comments and support. We gratefully acknowledge the help of the other staff in the hospital Ibn Rochd in Casablanca and my colleague Samira Riane for her cultural advise during interviews and for her translations.

Author information

Authors and Affiliations

  1. Altrecht, Institute for Mental Health Care, Utrecht, The Netherlands

    Tekleh Zandi & Annechien G. Limburg-Okken

  2. Goethelaan 7, 3533VN, Utrecht, The Netherlands

    Tekleh Zandi

  3. Dept. of Psychiatry, VU Medical Centre, Amsterdam, The Netherlands

    Johan M. Havenaar

  4. Malibaan, Centrum of Addiction Psychiatry, Utrecht, The Netherlands

    Hans van Es

  5. Mentrum, Institute for Mental Health Care, Amsterdam, The Netherlands

    Salah Sidali

  6. Centre of Psychiatry, Ibn Rochd, Casablanca, Morocco

    Nadia Kadri

  7. Dept. of Psychiatry, Amsterdam Medical Centre, Amsterdam, The Netherlands

    Wim van den Brink

  8. Dept. of Psychiatry, University Medical Centre, Utrecht, The Netherlands

    Rene S. Kahn

Authors
  1. Tekleh Zandi
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  2. Johan M. Havenaar
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  3. Annechien G. Limburg-Okken
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  4. Hans van Es
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  5. Salah Sidali
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  6. Nadia Kadri
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  7. Wim van den Brink
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  8. Rene S. Kahn
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Corresponding author

Correspondence to Tekleh Zandi.

Appendix

Appendix

General instructions for a diagnostic interview for psychosis among Moroccans

  • Take enough time. If necessary have contact with the family (siblings) to get more information about the patient.

  • Make sure to establish a good rapport. Mostly you get reliable answers only if the patient trusts you. Repeat several times that all reported information is confidential.

  • Before you start with each section, explain to the patient the purpose of that section. Make it clear that if you ask different questions this is because it is a part of the questionnaire and not because you expect him or her to have these symptoms.

  • In Moroccan culture shame for forbidden acts (sin) and respect to elders sometimes inhibits people to give a direct answer. This should be taken into account with most of questions related to drugs or alcohol use, sex, physical and mental health.

  • Ask all questions in concrete words (e.g. sad, tired, happy). Avoid abstract words as much as possible (e.g. depression, shame, guilt) and use plain concrete language to explain these conditions. Double-check whether the patient has understood your question correctly.

  • Be alert that some people may try to obtain social facilities with a factitious medical or psychiatric diagnosis.

Instructions for specific symptoms among Moroccans

Depression

Always check for affective symptoms carefully; patient may not report these spontaneously after an initial, straightforward question. For some sub-groups of Moroccans depression is not accepted as a disease. The Berber language, which is one of the major languages in Morocco, does not have a proper word to directly and simply express depression. Only if one has serious somatic disabilities or severe symptoms one is not obliged to fulfil his social obligations. Hearing voices or noises can actually express a distressed situation and is not necessarily a manifestation of psychosis.

Mania

During special days, like in the month of Ramadan and during Offer Ceremony, some Muslims can appear irritable or excited. Do not confuse this with mania or hypomania.

Suicide

Suicide is forbidden in Islam. Muslims will not readily talk about it directly. An alternative question is whether one hopes or prays that God will take him of her sooner to Himself.

Delusions

Make it clear that you are talking about a situation, which is out of the ordinary. Check through the translator if this is fully understood by the patient. Some young Moroccan immigrants feel they are being observed because of recent international events. Consider if the experience of the patient may be understood in terms of a specific Moroccan tradition or religious belief. Some Muslims who have been in Mecca have had a religious experience, which may be mistaken for a delusion. Some people have similar experiences before falling asleep. Ask if somebody believes in evil eye, djunun (spirits) or magical powers, and whether his sickness is related to supernatural powers. On their own such traditional beliefs should not be considered as delusional. Always check with the family whether they consider it abnormal.

Hallucinations

For some Moroccans hearing sounds or noises inside their head is the expression of their thoughts. The sound does not come from outside the head. Some people spontaneously report that they hear their own thoughts. If this is an isolated phenomenon, it is usually not a hallucination. Other people sometimes hear somebody call their name. This is not necessarily hallucination. Feelings of ants under the skin (“nemel”), as isolated sensations, should not be considered as tactile hallucinations. Feelings of being touched on the shoulder by somebody as an isolated sensation should not be considered as hallucinations. Ask if somebody received help from a religious or traditional healer for these symptoms. Ask if these sensations are happening because of a curse on the family. It is very important to distinguish these traditional or religious experiences from hallucinations. The family may help you if you have doubts.

Negative symptoms

Compare the person’s level of functioning with a previous period during which the persons considered himself healthy. In the case of Moroccan, it should be realised that among healthy immigrant youth the percentage of unemployment, and thus inactivity during most of the day, is rather common and occurs more frequently than in the native population.

Dissociation

Dissociative experiences are relatively common and are mostly interpreted as being possessed by Djin. In this state of mind it is accepted to see figures and hear voices of people (e.g. a holy person) or animals. The feeling of being touched is very common in this situation. It is also quite common for people to enter into a state of trance during religious ceremonies. Many people had such an experiences themselves or have observed other people in such a state. In these states, sensations of floating above or outside of the body can occur. If short-lived and not limiting to a persons role functions these experiences are usually a religious phenomenon, rather than a medical condition. The family may help you if you have doubts.

Substance abuse

Be alert that some Moroccans start the use of cannabis at a very young age.

In Islam alcohol is forbidden, but it does not mean that Muslim people do not drink. Take time and explain that the answer is important for a correct diagnosis.

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Zandi, T., Havenaar, J.M., Limburg-Okken, A.G. et al. The need for culture sensitive diagnostic procedures. Soc Psychiat Epidemiol 43, 244–250 (2008). https://doi.org/10.1007/s00127-007-0290-0

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