"Ghost on the Coast": Persistent hallucinations through the prism of cultural concepts of distress.

There is minimal literature and case reports on cultural concepts of distress, especially on ghost sickness. The aim of this article is to educate clinicians to culture-bound syndromes/cultural concepts of distress when assessing people from culturally and linguistically diverse backgrounds. This case report describes an elderly male of Papua New Guinea who presented with psychotic symptoms, shaped by the cultural concept of distress from experiencing loss. This paper describes the importance of utilizing of cultural liaison officers to provide culturally-informed care and before diagnosing a patient with the culture concept of distress, every effort should be made to thoroughly investigate to exclude an organic cause for the presentation. Copyright:

Ghost sickness is a cultural belief most commonly seen in Native American peoples (Navajo, Muscogee) and peoples of the Polynesian islands.[1] The “sickness” often begins following the passing of a loved one and includes symptoms of lethargy, nightmares, and feelings of dread and impending doom. The visual phenomenon of ghost sightings and the occurrence of possession have also been described.[2] These are culturally attributed to ghosts, malevolent spirits, witchcraft, and/or sorcery.[3] This case report aims to explore the symptomatology of Ghost Sickness, which includes hallucinations and other perceptual disturbances experienced by an elderly male originating from Papua New Guinea (PNG), shaped by cultural concepts of distress from experiencing loss.

CASE REPORT

Mr. X was a 60-year-old, single male of PNG heritage was referred to a public tertiary hospital by the General Practitioner (GP) for diagnostic clarification and ongoing management of psychosis. He was interviewed by the authors at the initial assessment and was subsequently accepted for a short voluntary admission to the inpatient adult mental health unit for investigations, diagnostic clarification as well as psychotropic and psychological interventions.

He was admitted to the hospital suffering from visual and auditory hallucinations, which had gradually developed over 5 weeks following the demise of a close friend. He denied any prior mental health history. He reported experiencing visual symptoms whereby he was able to see various human figures, with increasing clarity within his visual sensorium. These figures would appear to him throughout the day, more noticeably at night and when the patient closed his eyes. These were understood to be 'not real' by him and his explanatory model was that they were most likely apparitions.

According to the patient, one of these figures was that of his late friend who was Caucasian. He described his friend to be standing approximately 10 maway from him, behind which were a group of other individuals. The friend would tell the patient, “Be strong” and would not interact with him by any other means. The group, in contrast, was identified as being made up of people of New Guinean origin. They would often speak amongst themselves in Pigin, a local dialect, but never directly with the patient. The men were collectively described as “Chem-bu.” a tribe belonging to the highlands of New Guinea who were known for their formidable stature and propensity for violence. The patient described these figures as being “ghosts” or “spirits,” their presence caused him considerable anxiety.

He presented with dysphoric mood and sleep disturbance with initial, middle, and terminal insomnia, though his energy levels were normal, there was no anhedonia and he denied suicidal ideation. Besides these he did not voice any other persecutory beliefs, ideas of reference nor first-rank symptoms. Mr. X did not have symptoms suggestive of posttraumatic stress disorder as per the Diagnostic and Statistical Manual of Mental Disorders (DSM V) criteria. He did not have any significant medical history nor any allergies to medications. The patient denied alcohol or illicit substance abuse.

Routine physical examination revealed normal neurological examination, with no visual field deficits or ocular pathology (with corrected vision). Standard hematology revealed his electrolytes, full blood count and thyroid function were all within the normal range. In addition to these, the following serum antibody testing was performed, none were positive [Table 1].

Table 1

Antibody screening (indirect immunofluorescence)

Test	Associated receptor/syndrome
NMDA-R	NMDA-R
Anti-VGKC	VGKC
Anti-Hu	Neuronal nucleus (paraneoplastic encephalomyelitis)
Anti-Ri	Paraneoplastic encephalomyelitis
Anti-Yo	Purkinje cell antibody
Anti-PCA-2	PCA-2
Anti-CV2/CRMP5	CRMP5
Anti-Ma/Ta	Limbic encephalitis
Anti-GAD	Anti- GAD
Anti-amphiphysin	Paraneoplastic/stiff person syndromes

NMDA-R – N-methyl-D-aspartate receptor; VGKCL – Voltage-gated potassium channel; PCA-2 – Purkinje cell cytoplasmic autoantibody Type 2; CRMP5 – Collapsin response-mediator protein-5; GAD – Glutamic acid decarboxylase

Following assessment, the patient was linked in with the hospital cultural liaison officers (CLO) to further understand the patient's presenting symptomatology in the context of his cultural beliefs. The CLO indicated that the presentation could be considered culturally appropriate for an individual from PNG, and not necessarily considered secondary to an acute mental illness. With the aim of short-term distress control for his symptoms, he was commenced on diazepam 5 mg twice daily and when required up to a maximum of 10 mg/day. We considered psychological treatment as the first-line therapy; however, the patient was distressed with his symptoms and was not psychologically minded during the initial presentation. He showed a good response to the above treatment, and he was discharged 4 days later to the care of his GP once the psychotic symptoms settled, following thorough medical workup. His GP was also advised to refer the patient to a psychologist for grief counseling.

DISCUSSION

For the modern psychiatrist understanding the cultural context of illness is essential for reaching an accurate diagnosis, with a comprehensive formulation informing evidence-based clinical practice. Culture refers to systems of knowledge, concepts, rules, and practices that are learned and transmitted across generations.[4] To improve diagnosis and care to people of all backgrounds, the fifth edition of the DSM-V incorporates a greater cultural sensitivity throughout the manual. Rather than a simple list of culture-bound syndromes which were referred to in DSM IV, DSM-V updates criteria to reflect cross-cultural variations in presentations provides more detailed and structured information about cultural concepts of distress and includes a clinical interview tool to facilitate comprehensive, person-centered assessments. Different cultures and communities exhibit and explain symptoms in various ways. As such, it is important for clinicians to be aware of relevant contextual information stemming from a patient's culture. What might be considered within the realms of normal human experience in one culture or belief system, might be considered pathological in another. Understanding such distinctions will help clinicians to more accurately diagnose problems as well as to treat them more effectively.[5] Historical and anthropological reports indicate that a person's individual beliefs concerning the origin of their psychological or physical disease can vary vastly across different cultures.[6] In particular, early agrarian and hunter-gatherer societies commonly believed that supernatural entities and beings were often responsible for causing bad-luck and illnesses.[7]

Modern psychiatrists should consider cultural aspects of the patients when assessing and to be mindful not to medicalize patients presenting with symptoms explainable by the cultural context of distress. A thorough culturally informed history that screens for social/familial precipitants, use of traditional medicine, individual religious or tribal beliefs should be utilized. A multi-disciplinary team approach, utilizing a cultural liaison officer is key for the treating psychiatrist to overcome trans-cultural barriers in cases with atypical presentations such as ours.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.