A Young Male With Anxiety: The Interplay of Cultural and Social Factors and Their Impact on Treatment
This exercise is designed to test your comprehension of material relevant to this issue of Focus as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below to the best of your ability with the information provided, making your decisions as if the individual were one of your patients.
Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.
The following vignette is designed to test the reader’s comprehension of the subject of this issue of Focus as well as enhance the reader’s ability to incorporate culturally relevant issues into the diagnostic and treatment plan.
Case Vignette
Dr. M, a Caucasian physician, has been providing mental health services in a small college town for the past 20 years. He leads psychiatric rounds at the local hospital and treats outpatients in the school. Dr. M has been asked to evaluate Anil, an 18-year-old Indian-American college freshman, at an initial visit. Anil was referred to the clinic after an incident in which he appeared to be confused in class. The leading diagnosis was substance intoxication.
During the initial visit, Anil presents as a nervous-looking young man who appears uncomfortable in the clinical setting. He reports that he is unsure why his psychiatric evaluation was recommended. Dr. M notes that Anil is reticent and not forthcoming when talking about himself. Anil reports that he was born in Virginia to first-generation immigrant parents from India. His father is an ophthalmologist and his mother is a homemaker. His parents currently live in his hometown, which is about two hours away from college. The patient is the youngest of three children and was raised in a strict Hindu sect, where indulgence in alcohol or other substances is considered inappropriate and unseemly behavior. Anil describes his parents as supportive and says that he had a good childhood. There is no history of abuse by his family; Anil states he was lucky to be born into such a loving family. He notes with pride that his older sister works as an economist at the World Bank and his brother had recently been accepted into medical school. Anil reports his parents always stressed the value of hard work and the importance of setting career goals. During the interview, Anil becomes tearful and has difficulty speaking. With Dr. M’s encouragement and support, Anil says that unlike other members of his family, he is a failure and has always known that he was not as smart as his siblings. Whereas they have always been straight-A students, he has had to work hard to match their performance. He had to forgo extracurricular activities such as art to focus on grades. He was taking standard, not advanced-level, classes in high school and, ultimately, Anil graduated with “only” a 3.4 grade point average. Unlike his siblings, he was not accepted into an Ivy League college. He feels that he has disappointed his parents, particularly his father. His father expects his sons to join his practice one day. Of note, when Anil was a young child, he secretly nurtured a desire to pursue a career as an interior decorator, but he has never expressed this wish to his family.
Anil reports that for the past two years, he has experienced worry and an inability to relax during stressful situations such as test taking. In addition, he complains of headaches and diarrhea. All of these symptoms have worsened since coming to college seven months ago.
Later in the interview, Anil endorses worries about his grades, difficulty concentrating, restlessness, and low energy. Sometimes, he finds himself worrying about random issues, such as his parents’ health, even when there is no reason for concern. Anil admits to insomnia mostly stemming from racing thoughts. In addition, he describes depressed mood, anhedonia, and low motivation. He has not experienced changes in appetite or weight. Anil denies having any thoughts of self-harm. Although Anil has not had any panic attacks in recent months, he states that he has had them in the past. Anil’s last panic attack occurred a year ago while he was waiting for his college acceptance letters.
Anil reports that in the past month, he started smoking marijuana two to three times a week and in the past week he has used it daily. He also states that he has consumed a few beers occasionally when using marijuana. He reports that marijuana makes him feel less anxious. He denies experiencing blackouts and withdrawal symptoms from alcohol. He feels guilty about using these substances because he thinks he is letting his family down.
At the end of the interview, Dr. M determines Anil is not acutely at risk to himself or others. In addition, Anil has no history of suicide attempts; no family history of suicide or mental illnesses; no access to weapons; and no recent or past risky or dangerous behaviors, threats, or acts. Dr. M also has recent lab work from Anil’s primary care physician (PCP), which is noncontributory to the case.
Consideration Point A.
Initial diagnostic considerations should include which of the following?
| A.1 | Cannabis-induced anxiety disorder | ||||
| A.2 | Generalized anxiety disorder (GAD) | ||||
| A.3 | Major depressive disorder | ||||
| A.4 | Adjustment disorder | ||||
| A.5 | Attention-deficit hyperactivity disorder | ||||
Case Vignette Continues
Upon further evaluation, Dr. M concludes that Anil has GAD comorbid with mild depression. He prescribes escitalopram 10 mg once daily and recommends cognitive-behavioral therapy. In addition, Dr. M engages the patient in motivational interviewing and psychoeducation for cannabis misuse, even though Anil does not meet criteria for a substance use disorder. Two weeks later, Anil returns to report that he is less ruminative, his sleep has improved, and he has abstained from alcohol and marijuana. He continues to feel guilty that he has disappointed his parents and experiences a sense of worthlessness at not having lived up to their expectations. He also reveals that since middle school, he has known that he is not attracted to women. A few months ago, when he first came to college, he had an intimate relationship with another male. He confided in his sister who, although supportive, had expressed fear of their parents’ reaction to the news. Subsequently, Anil broke off the relationship. In addition, he is worried about how his sexual orientation will affect his relationships within the Indian community. In this subsequent appointment, he tearfully asks, “Why am I like this? Am I being punished for what I did?”
Consideration Point B.
What is the most important next step that should be considered in the treatment formulation at this point?
| B.1 | Asking culturally sensitive questions | ||||
| B.2 | Increasing the dose of escitalopram | ||||
| B.3 | Acknowledging cultural differences between the psychiatrist and the patient | ||||
Case Vignette Continues
Anil returns to Dr. M’s office. He is struggling to explain his current situation to his family. He feels that he can no longer handle their questions about his health and school difficulties and fears that he will have a panic attack if he tries to explain. Anil would like to address his lack of interest in his current college courses and ongoing need for medications and treatment. Anil and Dr. M decide that engaging his family may be a productive treatment strategy.
In the family meeting, Anil’s parents express surprise that their son is in psychiatric treatment. His parents are concerned that their son has been prescribed antidepressants and ask Dr. M about how this would affect his career as a physician later on. Anil’s father states that no one in his or his wife’s family has ever been mentally ill and asks how Anil could feel depressed and anxious when he came from a “good family.” Anil’s mother is more supportive than his father is and reports that she wants her son to feel better. Both parents express shock that their son had been using alcohol and drugs. They are quite unprepared when Anil tells them that he would like to switch his major to fine arts.
Consideration Point C.
What culturally appropriate concerns should be discussed in the family sessions?
| C.1 | Addressing stigma. | ||||
| C.2 | Recognizing family dynamics and structure. | ||||
| C.3 | Disclosing sexual orientation to the parents. | ||||
| C.4 | No focus on cultural issues is needed. | ||||
Answers: Scoring, Relative Weights, and Comments
Consideration Point A
| A.1 | (+2) Cannabis-induced anxiety disorder. The patient’s symptoms are consistent with DSM-5 definitions of an anxiety disorder and a substance use disorder (1). There are strong lifetime associations between anxiety disorders and drug use (2). However, although the symptoms are likely worsened by substances, the symptoms of anxiety precede the use of alcohol and substances. It is also known that patients with anxiety attempt to self-medicate, or mitigate their symptoms with alcohol and substances such as cannabis. Life transitions, anxiety, mood symptoms, gender, sense of isolation from family, and sexual identity are some risk factors for substance use in this case. | ||||
| A.2 | (+3) Generalized anxiety disorder (GAD). DSM-5 criteria for GAD include a 6-month period of excessive anxiety and worrying and difficulty controlling the worry, along with symptoms such as restlessness, fatigue, impaired concentration, irritability, muscle tension, and sleep disturbances. The patient in this vignette endorses several of these symptoms, along with impairment in functioning. His symptoms have been present for approximately 2 years and have worsened in the past 7 months. The symptoms predate the use of substances. | ||||
| A.3 | (+1) Major depressive disorder. The patient endorses several symptoms: depressed mood, anhedonia, low energy, guilt feelings, and insomnia. An evaluation for major depressive disorder includes an assessment of suicidal risk, although this patient has denied any thoughts of suicide. Anxiety disorders and major depressive disorder are highly comorbid conditions, with some studies showing rates as high as 50%−60% (3, 4). | ||||
| A.4 | (+2) Adjustment disorder. DSM-5 states that adjustment disorder is characterized by emotional behavioral symptoms experienced in response to an identifiable stressor or stressors that occur within 3 months of stressor onset. These symptoms are clinically significant but do not meet criteria for other mental disorders. The beginning of college can be viewed as an adjustment period; in this case, though, the patient symptoms go beyond 3 months. | ||||
| A.5 | (0) Attention-deficit hyperactivity disorder. Falling grades and poor concentration at this age require this diagnosis to be evaluated. In this patient, however, these findings occur in the context of a symptom complex that is consistent with anxiety and depressive spectrum disorders. | ||||
Consideration Point B
| B.1 | (+3) Asking culturally sensitive questions. Authors such as Roberto Lewis-Fernández and colleagues (5) have discussed how culture shapes patients’ perceptions of care, including type and duration of treatment. Cultural conceptualizations of distress have been highlighted in the DSM-5. The Outline for Cultural Formulation from DSM-IV was revised to create the DSM-5 Cultural Formulation Interview, a cross-cultural assessment tool that consists of a 16-item semistructured questionnaire (6). To treat emotional distress, it is necessary to develop a narrative that incorporates the patient’s psychosocial stressors, religious beliefs, individual beliefs, and morality. All these factors must be taken into consideration for effective treatment. | ||||
Explanatory models, as described by Kleinman and colleagues (7), are useful in eliciting patients’ views and explanations of their illness and can help inform the course of treatment. Ton (8) described some common explanatory models. For example, a patient who subscribes only to the medical model may consider his or her distress to be secondary to biological factors and view medications alone as the answer (both Western allopathy and alternate schools such as Ayurveda and homeopathy are included in this description). In the moral model, the patient or family members may attribute the illness to a moral defect such as laziness or selfishness. Under the spiritual or religious model, patients may believe that their illnesses are punishments for religious transgressions. A patient subscribing to the psychosocial stress model may reject necessary medications. In this vignette, it is evident that Anil is using multiple models, as is common. He believes his religion and family are in direct opposition to his perceived sexual identity, and he believes his symptoms could be a form of punishment. He is, however, receptive to education from Dr. M and recognizes that medications can be beneficial to him. Developing a collaborative explanatory model between the patient and Dr. M is likely to achieve future adherence to treatment.
| B.2 | (−2) Increasing the dose of escitalopram. There is growing awareness of the correlation between racial and ethnic variation and medication response. Studies have demonstrated that Asian Americans require lower doses of antidepressants because of the strength of their response to low amounts of isoenzymes CYP2D6 and CYP2C19 (9, 10). This would have been an important consideration for Dr. M at the previous visit when escitalopram was prescribed. Because it has been only 2 weeks and the patient has had a partial response to treatment with no side effects, adjusting the dose is not warranted at this time. | ||||
| B.3 | (+2) Acknowledging cultural differences between the psychiatrist and the patient. The United States is becoming far more diverse, with Hispanic and Asian populations on the rise. Through the use of motivational interviewing, Dr. M has already established rapport and is helping his patient’s ambivalence to facilitate change. Anil appears to be comfortable discussing intimate issues with Dr. M; however, because Dr. M and Anil are from different cultures, interethnic transference (11) must be kept in mind. For example, interethnic transference can be seen as the patient’s response to a clinician from a different ethnocultural background and can create treatment challenges. These challenges can manifest in many ways: overcompliance, where the patient may agree to treatment in the clinical setting but may be nonadherent at home; denial of culture and ethnicity, where the patient avoids discussing cultural issues; or mistrust, hostility, and ambivalence. Comas-Díaz and Jacobsen also described interethnic countertransference, which may be experienced by the clinician in various forms (11). Dr. M’s approach, therefore, must integrate a sensitivity to and awareness of cultural differences while maintaining objectivity. All of these cultural components need to be integrated into a comprehensive treatment approach. | ||||
Consideration Point C
| C.1 | (+3) Addressing stigma. Anil’s father’s questions bring up the issue of stigma and misperceptions surrounding mental illness, which are significant obstacles in Asian Indian and Indian-American communities. It is anecdotally noted that Asian Indians may commit to initial appointments but not follow through with the treatment and subsequent appointments. Therefore, the practitioner must endeavor to engage the patient and his or her family in an ongoing discussion of stigma, as this may be crucial to treatment success. Explanations from the clinician about the biological nature of mental illness may resonate with family members, especially in this case, where the patient’s father is a physician. Conversely, somatization of psychiatric symptoms is well-known in Asian American communities (12, 13). In addition, referral to family support groups is recommended, which can help lead to a gradual acceptance of illness. | ||||
| C.2 | (+3) Recognizing family dynamics and structure. Respect and deference to parents or elders through one’s lifespan are important in Asian Indian cultures. This applies in this vignette even though Anil is legally an adult. Du and Lim (14) stressed that to conduct family or group therapy with Asian American patients, it is crucial for the therapist to identify and to show respect to the head of the family. In this case, Dr. M may have to help Anil’s father to understand his intergenerational conflicts with Anil, such as his expectation that both of his sons will join his practice as physicians. | ||||
| C.3 | (−3) Disclosing sexual orientation to the parents. The patient clearly expressed that he does not want to address this issue at this time. The physician should respect his wishes and not disclose it to his family. Although Anil’s sexual orientation is a source of emotional distress and likely is contributing to the symptomatology, individual therapy is recommended for distress. Homosexuality may be a risk factor for suicide among Asian American youths who lack support (15). | ||||
| C.4 | (0) No focus on cultural issues is needed. This approach would clearly impede treatment because of the reasons noted above. | ||||
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