Case Scenario

A 24-year-old graduate student from Japan visited our university student health clinic with concerns about body odor. He reported having an offensive body odor for the past several months, and told me that he bathed daily and had tried countless deodorants without successfully eliminating the odor. His dental hygiene was also excellent. Despite living in the United States for the past year, he had made few real friends. Although none of his fellow students commented about it, he felt increasingly ashamed about his problem and seldom left his apartment except to attend classes. Now he felt others were starting to avoid him, and he sought medical help out of desperation.

A review of systems was remarkable for difficulty falling asleep and a poor appetite, but no weight loss. He had no previous health problems and did not take medications. He denied any history of depression, substance abuse, or academic problems. He also denied having hallucinations or thoughts of self-harm, and adamantly denied being depressed. However, he asserted that he needed to rid himself of his terrible body odor.

Despite limited English fluency, the patient was a good historian with good grooming. He appeared withdrawn and had a depressed, anxious affect. No body or breath odor was noted, and his physical examination was unremarkable.

My impression was that the patient was clearly depressed, and his mood was probably complicated by social phobia and an adjustment disorder (culture shock). The offensive body odor did not appear to be grounded in reality, and likely represented a manifestation of a mood disorder.

Unfortunately, the patient became very distressed when his problem was attributed to mental health issues rather than a physical cause. It became clear that he did not want to try antidepressant medications or attend counseling sessions. He did agree to make a follow-up appointment for a second opinion. How do I help a foreign patient manage his mental illness, especially when his culture stigmatizes the disease?

Commentary

Somatic symptoms often replace emotional complaints in foreign-born students from cultures where mental illness is stigmatized. After excluding physical disorders and confirming the diagnosis of underlying depression, the next step is even more challenging: getting the patient to accept treatment. In the case of this patient, truthfully reframing the diagnosis as culture shock or perhaps as a chemical imbalance could make starting a selective serotonin reuptake inhibitor (SSRI) more acceptable. Counseling could also be reframed as a less threatening orientation to American college life. A direct introduction to the counselor at the time of the visit will help establish a personal connection and will make the patient more likely to keep future appointments.

Many Asian immigrants come from cultures that stigmatize mental illness more than American culture does.¹ Mental illness is often thought of as incurable, and counseling is considered only for those with incurable mental illness. Being labeled as mentally ill brings shame on the person and his or her family. This can explain the reluctance of some patients to keep counseling appointments, although many patients may be too polite to decline outright.

Because of the stigma associated with mental illness, such problems usually present as somatic complaints rather than mood disorders.² This is usually not a conscious deception on the part of the patient. In many cultures, there are typical somatic symptoms (culture-bound syndromes) that suggest psychiatric distress to the culture-savvy physician.

In Japan, taijin-kyofusho is defined as a fear of offending others because of socially awkward behavior or an imagined physical offense (e.g., body odor).³ Translated literally, the disorder (sho) of fear (kyofu) of interpersonal relations (taijin), subtype offensive, refers to the patient's perception of offending others. Taijin-kyofusho may be considered a pathologic exaggeration of avoiding giving offense in social settings, which is an important custom in Japanese culture. Emotional distress appears to magnify this feature into a disabling social phobia that may respond to SSRIs.^4,5

Another example of a culture-bound syndrome is hwa-byung in Korean women. In this syndrome, depression or suppressed anger may lead to complaints of an uncomfortable, yet nonpalpable, abdominal mass.^6,7 Although emotional distress may metaphorically and physically induce “heartache” in the West, it is more likely to cause abdominal pain in the East, where the gut is the presumed “seat of the soul.” Many fruitless gastrointestinal work-ups have failed to recognize and address underlying emotional distress.

First-generation immigrants are most likely to adhere to these cultural generalizations. As a person becomes more acculturated, there is less difficulty accepting the approaches of American health care. Therefore, the son or daughter of an Asian immigrant might have less difficulty seeking mental health care when needed. It helps to remember that American culture stigmatized mental illness until not so long ago, and that somatic presentations of psychiatric disease are not uncommon in our own culture.

Culture-bound syndromes include a broad array of psychological, somatic, and behavioral symptoms that present in certain cultural contexts, and are readily recognized as illness behavior by most participants in that culture.⁸ The Cultural Formulation model in appendix I of the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision, consists of a five-component, case-based narrative with a cultural identity assessment, explanations of illness, factors related to the psychosocial environment, cultural elements of the physician-patient relationship, and the overall impact of culture on diagnosis and care.⁹ This information can help physicians explore a patient's cultural identity, the illness's explanatory models, and cultural barriers to treatment.¹⁰