Inclusion refers to the presence of a comparison group. For the majority of research objectives in cultural epidemiology studies, a comparison group is needed to test inferences. For example, rate of depression among persons without a CCD is important to determine whether a CCD increases depression risk. In a study of a somatic CCD in Nepal, auditory hallucinations were reported by one-fifth of CCD sufferers; however, the control group reported an equally high prevalence of auditory hallucinations.
A total of 36 studies included non-CCD participants. Identifiable refers to use of a strategy to clearly differentiate cases from controls. This is generally straightforward when lifetime prevalence is assessed through self-labelling. However, when assessing current episodes, there should be a clear time period to identify cases and controls.
For example, if 2-week prevalence is used, is a control with no lifetime episodes comparable to a control with an episode that ended 3 weeks ago? All but 1 study including a comparison provided information regarding how the non-CCD group was identified. Source refers to cases and controls drawn from similar populations. If cases are selected from a psychiatric clinic and controls are drawn from other medical clinics, this biases the CCD group to have greater prevalence of psychiatric conditions.
Community representative samples are ideal to assure the same source. Only one study lacked information on source of control participants. Matching and randomization may be used in some studies to optimize similarities between groups. For example, if a researcher is trying to identify family-related protective factors against ataque de nervios, then matching based on economic status, educational status and residential region in recruitment or statistical techniques such as propensity score matching would be helpful.
Matching could be used to control for issues related to language proficiency 55 or years of residence in a new country that may confound endorsement of a CCD. One study employed a matching process. Statistical control refers to using multivariable models to control for issues that may confound relationships between CCD and psychiatric disorders such as socioeconomic status, other psychiatric comorbidities and stressful exposures. A study of dhat found an association with psychological distress General Health Questionnaire caseness when statistically controlling for age, district of residence and marital status, all of which were independently associated with dhat.
A total of 22 studies included some form of multivariable analysis. The remainder used either clinically-assigned labels of a CCD or a proxy measure, such as having somatic complaints.
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CCD label type should describe whether the CCD is attributed according to a single symptom, a constellation of symptoms, a certain type of exposure or being part of a vulnerable group. In many cases, CCD may reflect a combination of the above. In a study of women in Zimbabwe, explanatory models were collected and revealed that kufungisisa was both a symptom of distress and a cause of health problems. CCD severity refers to measurement of the frequency, number of associated symptoms or degree of impairment associated with a CCD.
For example, two individuals may both endorse lifetime ataques de nervios but one individual may have weekly episodes whereas the other has them every few years. This would impact the association with psychiatric categories; 27 studies included severity information. CCD course refers to the age of onset, duration of episodes, timing of episodes and chronicity of experience, with special attention to overlapping periods with psychiatric symptoms. For example, the mean age of onset of dhat in one study was Studying onset of ataque de nervios revealed that the episodes typically preceded depression and anxiety symptoms, 70 which is helpful information for screening and prevention.
Only 14 studies included course information. An additional category for functioning was based on the CCD literature. Exposure is important for CCD because explanatory models typically associate certain types of experiences with invoking CCD. For example, family, financial, health and political stressors are strongly associated with jham-jham paresthesia in rural Nepal.
This contrasts with brain fag in Nigeria, in which academic stress is assumed to be one of the main precipitants. A total of 32 studies included information on exposures. Psychiatric outcome measures require special attention in cross-cultural research. If an instrument has not been validated in the local context, results are difficult to interpret.
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Functional outcome was added as an additional criterion for measurement quality. Early debates in culture-bound syndrome research raised questions about distinguishing between abnormal behaviours related to cultural performance vs abnormal behaviours associated with impairment in multiple domains of life.
A total of 20 studies reported some form of functioning assessment. The Follow-Up category includes percentage lost to follow-up and reasons lost to follow-up. We added change in CCD prevalence. Four studies included a follow-up assessment. Percentage lost to follow-up is standard reporting for longitudinal studies.
Wherever possible, Reasons for loss to follow-up should be elicited and reported to inform interpretation of results, highlight potential biases, and help shape future longitudinal studies of CCD. In a study of dhat, follow-up rates were much lower among patients receiving counselling compared with patients receiving medication; this suggested that participants were dissatisfied with psychotherapeutic interventions and dropped out.
We added CCD change at follow-up as an additional criterion. In treatment studies of dhat and hwa-byung, CCD was not evaluated post treatment. In studies in Nigeria and China, CCD did not resolve after psychotropic medication despite improvement in psychiatric disorders.
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Psychiatric comorbidities : because of the high rate of comorbidity among psychiatric disorders, it is possible that associations between CCD and a target psychiatric disorder are the result of another condition. For example, PTSD and depression are often comorbid. Controlling for comorbidities through selection criteria and analysis is crucial. In a study of social phobia and taijin-kyofu-sho TKS , a CCD in Japan and Korea, the researchers excluded persons with major depressive disorders, bipolar affective disorder, psychosis and substance misuse to assure that associations between TKS and social phobia were not the result of mutual associations with other disorders.
However, when other psychiatric conditions were entered into the analysis, yadargaa associated significantly with depression but the association with chronic fatigue syndrome was no longer significant. Half of the studies include psychiatric comorbidity information.
Physical health comorbidities also impact associations between CCD and psychiatric diagnoses. Investigators of dhat often account for physical comorbidities, especially sexually transmitted infections STIs , in their analyses. Treatment status is a potential confound. If participants are receiving biomedical or traditional treatments, this may influence psychiatric disorders, CCD or both.
Seven studies included information on treatment status. Other confounds include linguistic proficiency differences which may influence endorsement of CCD. One study reported that missing data were significantly more common among persons with low English proficiency. Missing data were repoted by only one study. Clarity and accuracy of data refers to use of confidence intervals, multivariable analyses, and tables and figures that are easily interpreted. A total of 37 studies presented data clearly.
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Other studies inconsistently identified CCD vs non-CCD groups; for example, they did not clarify which participants were included in analyses or included figures that did not clarify CCD association with psychiatric measures in quantitative comparisons. Meta-analyses were conducted with psychiatric conditions as the outcome see Table 4 and Figures 2—6. The results should be interpreted as the odds that an individual has a given psychiatric disorder given endorsement of a CCD. For example, among persons who endorse dhat, ataque de nervios, susto or other CCD, there is an 8-fold greater odds of experiencing bivariate depression compared with persons who do not endorse a CCD.
Meta-analysis for odds of meeting criteria for a psychiatric category among persons endorsing a cultural concept of distress.