This exercise is designed to test your comprehension of material presented in 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, on the basis of the information provided, making your decisions as you would with a real-life patient.
Questions are presented at "decision 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. On questions that focus on differential diagnoses, bonus points are awarded if you select the most likely diagnosis as your first choice. At the end of the exercise you will add up your points to obtain a total score.
You are the attending psychiatrist in the psychiatric emergency room at a tertiary care medical center on the East Coast of the United States. A woman is brought to the center by ambulance and wheeled in to the psychiatric emergency room strapped to a gurney. She is wrapped in a white linen shawl and is immobile. Although you are unable to see her face, you can see by her hands, which are tightly gripping the rails of the gurney, that she is dark skinned.
The paramedics report that they were dispatched to a private home in a nearby neighborhood after the patient’s daughter called 911 because her mother was "shouting in a strange voice," alternately with garbled speech and with strict demands that she be given specific items of clothing and jewelry. The daughter was reportedly anxious on the telephone and mentioned, "She’s been acting strange lately." The daughter has two children, a 4-year-old boy and a 2-year-old girl; her husband was not at home, so she told the paramedics she was going to take her children to a relative’s house and then come to the emergency department.
The paramedics were unable to communicate with the patient because she spoke a foreign language and seemed unable to understand English. They had to use force to place her on the gurney, but she insisted with body language that her head be covered with the white shawl she had draped around her body. She apparently spat at them and seemed to curse, so they were happy to oblige. One of the paramedics tells you that she "seems possessed." She remained silent for the duration of the short trip to the hospital. She allowed them to take her vital signs and to perform a cursory physical examination; the findings were as follows:
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|Blood pressure:||183/96 mm Hg|
|Head, eyes, ears, tattoo in the nose, throat:||Normocephalic; shape of a cross within a circle on the patient’s forehead, apparently done many years ago given the faded quality of the thick dark inked lines. Unable to assess pupillary reflex or extraocular movements because the patient kept her eyes shut tightly. Unable to thoroughly assess mouth and throat except when the woman was screaming, at which time they noted that her oral mucosa seemed pink and moist and that her teeth had brown streaked discoloration. No thyromegaly, no lymphadenopathy.|
|Chest:||Clear to auscultation bilaterally without wheezes, crackles, or rales|
|Heart:||Regular rate and rhythm, S1 and S2 appreciated, no murmurs, gallops, or rubs|
|Abdomen:||Soft, nontender, no distension; bowel sounds appreciated; not hypo- or hyperactive|
|Extremities:||No clubbing, no wasting|
|Neurological:||Unable to assess as patient was not cooperative. From their struggles with the patient, they estimated that she had full strength in all four extremities and no obvious focal deficits|
As you finish reading the notes on the physical examination, the patient begins to howl from behind her shawl. She struggles to free herself from the restraints and begins speaking loudly in what seems like pressured and hyperverbal speech, although in a language you do not recognize.
Given the above presentation, what should you do? (Multiple answers are possible. Points are taken away for incorrect answers.)
A1. ____ Call for hospital security personnel to take the patient to a seclusion room, where she can be transferred from the ambulance gurney to a hospital gurney and kept in four-point restraints. Her behavior is disruptive, she is not redirectable, and she will likely agitate others in the waiting room. Since you do not speak her language and she is apparently psychotic, she will require medication with haloperidol 5 mg i.m. and lorazepam 2 mg i.m. to keep her calm until her daughter arrives to provide collateral information about her. Once the patient has calmed down, the restraints should be removed in a stepwise fashion, beginning with one wrist and the contralateral ankle. If the patient remains calm and the medications are sufficient, the remaining restraints should then be removed.
A2. ____ Call for hospital security personnel to take the patient to a seclusion room, where she can be transferred from the ambulance gurney to a hospital gurney and kept in four-point restraints. Her behavior is disruptive, she is not redirectable, and she will likely agitate others in the waiting room. Since you do not speak her language, you will wait for her daughter to arrive to provide collateral information about the patient.
A3. ____ Remove the patient’s shawl from her face to examine her and attempt to communicate with her.
A4. ____ Do not remove the patient’s shawl from her face to examine her and attempt to communicate with her.
A5. ____ Attempt to communicate with the patient through her shawl and explain that you understand she is experiencing a lot of frustration right now and you are taking her to a seclusion room until her daughter arrives. Ask if she understands you.
You decide to place the patient in an isolation room but not in restraints. You do not give her any medications. Through your closed-circuit television monitoring system, you see that she is curled into a fetal position, wrapped in her white shawl, lying on the gurney, and quiet. After 20 minutes, the patient’s daughter arrives. You bring her to an interview room, and she begins to sob. "I can’t take this anymore," she says. "I brought her from Ethiopia last year because my father died and she did not have anyone to care for her. She is very traditional, but she has become very demanding lately. All I asked of her is to watch my children while my husband and I are at work during the day." She says that her children love their grandmother but find her strange because she has a tattoo on her forehead and they only understand some of what she says. "We’ve been trying to make the children bilingual by my only speaking to them in Amharic and their father only in English. But they are so young."
You ask her to describe her mother’s behavior and how she thinks it has changed to the point where she required a trip to the psychiatric emergency room. The daughter explains that her mother seemed happy at first, but soon she became easily agitated, did not like to leave the house, hid upstairs when she and her husband had guests, and sometimes mumbled incomprehensibly to herself. About 3 weeks ago she demanded to be taken back to Ethiopia, but the daughter refused because there would not be anywhere for her to go there. "Besides, she was beginning to act more and more strangely, and I could not let her go back like that."
The daughter described her mother’s behavior as increasingly agitated over the past 3 weeks, especially after she learned that she could not return to Ethiopia. She would often stay quiet for days, not uttering a word, and then would burst into screams, making demands in a strange voice, and acting as if she were possessed. The daughter clears her throat and looks around awkwardly. "I know you won’t believe this, but there is a tradition in our culture called the zar," she says. "It is an evil spirit that supposedly takes possession of a person and makes them act somewhat like my mother has been acting. My experience with this is not extensive because I never actually saw someone ‘possessed,’ but I heard from friends and older relatives that the possessed person does not necessarily become violent. My mother started throwing pots in the kitchen; she took some of my children’s toys and hid them under her bed, and when she starts her screaming, she gets right in your face."
You ask if she believes her mother to be possessed by a zar, and if so, what is the remedy? The daughter replies that she does not believe in the zar, but "according to my limited knowledge, you have to have a coffee ceremony, find a zar exorcist, give the possessed person what they want, and if the spirit is satisfied, it leaves." She laughs uncomfortably and says, "I know it sounds crazy to you."
You reassure her that you are interested in the zar, that it is important in psychiatry to understand the person in order to understand the illness, and that you want to help her mother as best you can. The daughter then asks if she can see her mother.
Given the above information, what should you do next? (Multiple answers are possible. Points are taken away for incorrect answers.)
B1. ____ Ask the daughter if she would be willing to translate for you, and bring her to her mother in the isolation room.
B2. ____ Ask the daughter if she would be willing to translate for you, but bring the mother to the interview room if she is cooperative.
B3. ____ Tell the daughter that hospital regulations prohibit her from coming back to the isolation room. Ask if she would be willing to translate for you, but ask her to sit in the waiting room until her mother is calm enough to be brought to an interview room.
B4. ____ Ask for the daughter’s permission to give her mother medications, such as an anxiolytic or an antipsychotic, because of the behavior you have witnessed so far.
B5. ____ Ask the daughter for additional pertinent history, such as whether her mother had ever behaved in a similar way in the past, whether she has a previous diagnosis of mental illness, and about specific symptoms of depression, mania or hypomania, or psychosis.
List definitions for the following terms. (+5 points for correct answers.)
The patient refuses to move. You call the hospital’s translation service and ask for an Amharic translator. (Alternatively, you ask the daughter if she knows of any members of the Ethiopian community who are not related to her family who may be willing to translate, and then ask for assistance.) You bring the daughter to the isolation room. She approaches her mother, strokes her head, and speaks to her in Amharic. The mother does not respond. The daughter continues to speak to her until her mother abruptly speaks in a strange, deep-tenor voice. You ask the daughter to tell you precisely what her mother is saying, word for word. "She’s just saying, ‘I need coffee. I need coffee. I will not release her until you bring me coffee and a new dress.’ See?" She shrugs. "She’s lost it. She’s pretending to be possessed. I’m supposed to go and buy her a dress on a Friday night? Is she crazy?"
The patient begins to rattle the rails of the gurney and starts screaming. The shawl has come off her face, and you see she has her eyes closed. Then she opens them and looks around, but continues screaming. The daughter backs up and leaves the room.
Given everything you have learned to this point, what is your differential diagnosis?
The Outline for Cultural Formulation contained in DSM-IV-TR is "meant to supplement the multiaxial diagnostic assessment and to address difficulties that may be encountered in applying DSM-IV-TR criteria in a multicultural environment." What are the five parts of the cultural formulation?
The patient is given haloperidol 2 mg i.m. and lorazepam 2 mg i.m. After an hour she is calm but alert. Her daughter continues to translate. You learn that the patient is oriented to person, place, and time, but she still lapses into a strange-sounding voice, which the daughter refers to as her mother’s zar. When speaking in this voice, the patient is demanding a coffee ceremony, a dress, and to be taken back to Ethiopia. Your assessment is that the patient is acutely psychotic, and you admit her to the inpatient psychiatry unit for safety and further evaluation. She is started on risperidone, which is titrated to 3 mg daily. She is also started on sertraline, which is titrated to 150 mg daily for mood symptoms. After 1 week, the patient is no longer agitated and she sleeps well, but she still lapses into her "possessed voice" several times each day.
You are now the treating psychiatrist on the inpatient floor. You do not find an available Amharic-speaking translator, so you depend on the daughter for communication with the patient and for collateral information. You use the Internet to learn about the zar, which is described as a culturally based syndrome common to certain countries in Africa, including Ethiopia. The zar functions in a wide range of crisis-oriented contexts, including infertility, role clashes, marriage difficulties, and intense social and cultural change. Zar illness and therapy, therefore, can represent a method of coping with a disruptive condition, whether it is physiological, psychological, or social. When an individual is afflicted with a zar, he or she attends a zar ceremony with others who have experienced similar illness. A trance is induced, and the zar spirit then enters the person’s body and reveals its identity and wishes through movement and speech. The spirit is not exorcised; rather, the individual forms a relationship with it to prevent future episodes of illness. This typically requires that the individual accept "to undertake certain activities, which may include performing certain rituals, attending regular zar ceremonies, wearing special clothing or jewelry, ingesting specific foods or other substances such as tobacco, or altering his or her marital status to appease the spirit" (Edelstein 2002).
After 10 days, the daughter tells you that she is willing to take her mother home but believes she needs outpatient psychiatric care.
Given what you know about the patient’s progress on the inpatient unit and what you learned by developing a cultural formulation of the case, what are the most appropriate steps for you to take to help this patient? (Multiple answers are possible. Points are taken away for incorrect answers.)
F1. ____ The patient is likely depressed and anxious. She may be using the zar to express her mental distress. Continue her antidepressant medication, but wean her from the antipsychotic before discharge, as she probably does not need it. Hold the patient in the inpatient unit until you are able to find an Amharic-speaking therapist in the community for outpatient psychotherapy.
F2. ____ Discharge the patient to her daughter’s care, since she has agreed to take her mother home. Continue the risperidone and sertraline at the dosages prescribed in the hospital, since she is tolerating them well.
F3. ____ The patient is suffering from a culturally based syndrome, and medications are useless. Discontinue the risperidone and sertraline. Discharge the patient to her daughter’s care, since she has agreed to take her mother home.
F4. ____ Arrange to have a person from the Ethiopian community visit the hospital and perform a zar ceremony to help the patient through her crisis according to the tradition. Then discharge her to her daughter’s care if she improves.
F5. ____ Arrange a zar ceremony yourself on the basis of what you learn about the tradition, with help from the daughter’s family. If the ceremony works and the patient improves, discharge her to her daughter’s care.
High positive scores (+3 and above) indicate a decision that would be effective, would be required for diagnosis, and without which management would be negligent. Lower positive scores (+2) indicate a decision that is important but not immediately necessary. The lowest positive score (+1) indicates a decision that is potentially useful for diagnosis and treatment. A neutral score (0) indicates a decision that is neither clearly helpful nor harmful under the given circumstances. High negative scores (−5) indicate a decision that is inappropriate and potentially harmful or possibly life-threatening. Lower negative scores (−2 and above) indicate a decision that is nonproductive and potentially harmful.
A1. +2 While this exercise is designed to explore how a clinician should approach a patient whose cultural expression of illness may be in question or whose language the clinician does not understand, the first rule in the emergency department regarding a patient who is agitated and not redirectable is to stabilize the patient and the situation. According to the narrative, the patient is so agitated that there should be concern about placing her with other patients in the waiting room. It is important to control the acuity level in the waiting room, so removing the patient to a seclusion room in this instance makes sense. Giving the patient haloperidol 5 mg i.m. and lorazepam 2 mg i.m. represents the standard of care in treating a patient who is agitated and not redirectable. However, since you do not understand her, a diagnosis of psychosis may or may not be appropriate. Behavioral dyscontrol seems more apparent. In this case, the restraints were necessary to transfer the patient to the hospital and then to the seclusion room.
A2. −3 Removing the patient to a quiet area and awaiting her daughter’s arrival are appropriate steps, but use of physical restraints alone is not. Standard of care is to avoid the use of physical restraints when possible and to use chemical restraints first. Medications should be the first-line option for controlling this patient’s agitation, even if she is already in physical restraints for the transfer to the seclusion room.
A3. +5 You must perform at least a cursory physical examination of this patient to rule out any obvious signs of trauma or potentially reversible causes of her dyscontrol. Now that you are the physician responsible for her care, you cannot rely on the report from the paramedics’ examination. You may be concerned about offending the patient by removing her shawl, looking into her eyes, and touching her in any way or offending her in some other unintended way. For this reason (especially if you are a male physician), it is a good idea to have a female nurse or other clinician with you while you perform the examination.
A4. −5 As stated above, you must perform at least a cursory physical examination of the patient. While it is possible that you will offend her by removing the shawl, you are a medical professional with a duty to care for this patient. The paramedics told you that the patient’s daughter expects to arrive at the hospital soon, but you have no way of knowing when she will arrive. Since the patient is acting in a way that suggests a need for emergent treatment, you must evaluate her immediately.
A5. +3 Attempting to communicate, explaining your actions despite your uncertainty about whether the patient understands you or not, and taking her to a seclusion room because of her dyscontrol are all appropriate actions.
B1. +5 You must make every attempt to communicate with your patient. The daughter represents your best opportunity to learn both from the patient and about the patient from a collateral source. If your hospital lacks an appropriate translator or is unable to find one who can help at this instant, you must use the resources available—in this case, the daughter. Keep in mind that she will likely interpret more than translate, since she is the patient’s daughter, lives with the patient, and was the source of the 911 call that brought the patient to the emergency department. You should interview the daughter separately, just as you would with any family members who come in with a patient, especially since the patient is unable or unwilling to respond.
B2. +3 It would be more comfortable for the patient if she could move from the isolation room to an interview room. However, this would require that you be able to communicate with the patient in some fashion to ascertain whether she understands you. Given the patient’s acute presentation and the circumstances in the emergency room, this might not yet be possible.
B3. −5 If the daughter is your sole means of communicating with this patient, she should be brought to the isolation room if necessary. You should find the most effective means to evaluate the patient emergently.
B4. +3 Since your patient is unable to communicate directly with you, you require the daughter’s help to evaluate the patient. If the daughter is able to translate and the patient is responding appropriately to your questions and it is apparent that she understands you, you can ask her permission to provide treatment if you deem it necessary. If the patient remains unable to communicate and you conclude that it is necessary to medicate her, you can give emergent medications without consent.
B5. +5 As stated in B1, you need collateral information about the patient. Since the daughter is there, you should see what you can learn from her about your patient, keeping in mind that she is a biased source. You can research cultural differences or expressions of illness unique to your patient later, once the patient is stabilized.
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|C1. Ethnicity||(+5) Identification with, and feeling part of, an ethnic group, and exclusion from certain other groups because of this affiliationEthnic group: Group distinguished by cultural similarities (shared among members of that group) and differences between that group and others; ethnic group members share beliefs, values, habits, customs, and norms and a common language, religion, history, geography, kinship, and/or race.|
|C2. Culture||(+5) Distinctly human; transmitted through learning; traditions and customs that govern behavior and beliefs|
|C3. Race||(+5) Can be broken down into biological and social race. This question is about social race: a group assumed to have a biological basis but actually perceived and defined in a social context, by a particular culture rather than by scientific criteria|
|a From Conrad, 2006|
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|Axis I:||Psychotic disorder not otherwise specified (+2); rule out malingering (+2); rule out dissociative trance disorder (+2)|
|Axis II:||Deferred (+2)|
The patient is displaying psychotic symptoms in the form of disorganized speech, behavior, and possible delusions or hallucinations. While it may be possible to explain her behavior and speech from a cultural perspective, at the moment it is not possible to independently validate the daughter’s translation or accept her interpretations. Moreover, the patient may be psychotic and expressing her symptoms in a way that is culturally familiar to her. For now, without further evidence or information to make a specific diagnosis, the more nonspecific diagnosis of psychotic disorder not otherwise specified is appropriate.
Once the patient is stabilized, you should find an objective translator and conduct research on the zar. If you consider the patient’s alleged possession by a zar a cultural expression of illness, to label her symptoms as malingering would be the same as denouncing the zar as intentional. If the patient is using the zar intentionally, then malingering is appropriate. Otherwise, the zar can be considered a dissociative disorder, specifically a dissociative trance disorder, which is defined as single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular locations and cultures. According to DSM-IV-TR, dissociative trance involves narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one’s control. Possession trance involves replacement of the customary sense of personal identity by a new identity, attributed to the influence of a spirit, power, deity, or other person and associated with stereotyped "involuntary" movements or amnesia.
Because you are a Western doctor in a Western hospital, it is appropriate to use psychotic disorder not otherwise specified as the primary diagnosis and dissociative trance disorder as the rule-out.
E1. +2 Cultural identity of the individual. This patient is an Amharic-speaking Ethiopian. She is unable to speak English. She recently immigrated to the United States. The tattoo on her forehead suggests that she is or was significantly involved with her culture of origin. Additional information about the patient’s religion, her culture of origin, her level of participation in her religion or culture, and the context of this level of participation would help in the evaluation.
E2. +2 Cultural explanations of the individual’s illness. This patient presents as possibly being possessed by a zar, which is described in the DSM-IV-TR Glossary of Culture-Bound Syndromes (in the same appendix as the Outline for Cultural Formulation). It is important to obtain information about the patient’s preferences for and past experiences with professional and popular sources of care.
E3. +2 Cultural factors related to psychosocial environment and levels of functioning. This patient is unable to communicate outside her home, has no significant social supports other than her daughter and immediate family, and is living in a country with which she is unfamiliar, far from the comfort of her culture of origin. It is important to understand how the patient and her family experience death and bereavement, given that the patient lost her husband within the past year.
E4. +2 Cultural elements of the relationship between the individual and the clinician. You do not speak Amharic, so direct oral or written communication is impossible. She is not responding to you, possibly because she is frightened, unfamiliar with the environment of your emergency room, and/or shaken by having been brought here forcibly—all of which are added on top of the issues that elicited the 911 call in the first place. She does respond to her daughter, although it seems apparent that there are some interpersonal difficulties between them, so accurate evaluation without the help of an impartial translator is problematic. Her behavior is possibly within the realm of a cultural syndrome. There may be social norms for interaction between unmarried members of the opposite sex about which you are unaware. Until you learn enough about how your patient would expect you to behave in a similar context based in her culture of origin, you will not know if you are unintentionally creating barriers between you and the patient.
E5. +2 Overall cultural assessment for diagnosis and care. Whether or not this patient’s symptoms are related directly to her possession by a zar, she meets the diagnostic criteria for being psychotic, her behavior is unpredictable, erratic, and violent, and you cannot determine with any certainty whether she is a risk to herself or to others. If she is not able to calm down even with the help of her daughter, she should be given an antipsychotic and an anxiolytic, either orally or, if she does not cooperate, by injection. Given the severity of her symptoms, you would admit her to a psychiatric inpatient facility. You will need an Amharic translator if available.
F1. +3 There are many psychosocial stressors that may have caused this patient to become depressed and anxious. She may be expressing her mental distress according to an acceptable culturally based syndrome and not actually be psychotic. While she is in the safe environment of the inpatient unit, an attempt to wean her from the antipsychotic may be appropriate, especially given the physiological risk and the cost of these medications. However, waiting for an Amharic-speaking therapist before discharging the patient is not practical. This patient, if your assessment is correct, would benefit from individual psychotherapy to cope with her many psychosocial stressors. However, finding an Amharic-speaking therapist may be difficult or impossible. Arranging follow-up at an outpatient psychiatric clinic with the daughter present may be the best you can do. It may not be possible to accommodate the most culturally appropriate treatment.
F2. +3 As stated above, you may not be able to accommodate the most culturally appropriate treatment for the zar, so you continue to treat the patient according to your working differential, which includes psychosis. You may wish therefore to keep this patient on risperidone for now and consider weaning her from it during outpatient treatment after she is discharged. If the patient is not truly psychotic, you will want to minimize the use of the antipsychotic because of the physiological risk and the cost.
F3. −3 Although this may be true, you are responsible for the patient, and until it is possible to better evaluate her, simply stopping the medications and sending her home may cause a relapse of the more violent and unpredictable symptoms and put the patient and her family in danger.
F4. +3 This is ideal, although given the information you have, it seems unlikely that it will occur.
F5. −3 This is probably not feasible or advisable.
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|Decision Point||Your Score||Ideal Best Score|