Vol 3

Examining Cross-Cultural Differences in Mental Health Diagnoses 

Does Location Matter?   

Why do certain psychiatric conditions share universal diagnosis criteria and treatment while others vary widely, dependent on location and culture? These discrepancies can be attributed to the lack of a gold standard for validating these conditions as well as the lack of biological markers, leading to different clinical interpretations and inconsistency across studies.[1]

Consistency across cultural studies can allow a more general understanding of conditions and how culture affects symptoms’ manifestations and diagnoses differently. By creating a clearer understanding of mental health conditions worldwide, better/more effective treatments and patient outcomes can arise. 

Should Diagnosis be Universal or Relative?   

Within the debate of why these differences occur, two main arguments exist. The first focuses on universality across cultures. The “universalistic viewpoint” emphasizes that all conditions occur equally and have a core set of symptoms - what varies is the manifestations and determination of pathology versus normalcy. “Ethnotypic consistency” was coined by Weisz et al., in 1997 to describe the idea that psychopathology is the same across locations and cultures, but varies in how symptoms are displayed.[2]  

The opposing viewpoint of universality places a larger emphasis on culture. The “relativistic viewpoint” stresses that culture shapes a person’s development and psychopathology. Symptoms and conditions can be unique and particular to specific cultures, as well as affect the magnitude and intensity of the condition.[3] 

From these two viewpoints, a combined conclusion can be established: certain disorders are seen as “universally occurring” due to their neural pathology, while others are shaped by social contexts and cultural norms.[4] 

Examining Cross-Cultural Differences 

One of the most well-researched conditions cross-culturally is attention-deficit/hyperactivity disorder (ADHD). From 1997 to 2016, attention deficit disorders in the United States has fluctuated from 6.1% to 10.2%, with debate ensuing whether the fluctuation arose from over-diagnosis, under-diagnosis and/or diagnostic disparities.[5] When comparing global prevalence, vast differences were found between North America, Africa and the Middle East. However, those differences were not found between North America, Europe, Oceania, Asia or South America. Canino and Alegria (2008) note that these discrepancies were attributed to the differences in instruments, methods, and how these disorders are defined within the different cultural studies compared.[6] 

Professor Mashai Ikeda began to research Bipolar Disorder (BD) after finding most conclusions on major psychiatric disorders were made using European samples. In 2022, Ikeda specifically looked at the genes of patients with BD type I (manic and depressive states) and BD type II (mild mania and depression) between European populations and East Asian populations.[7] He found East Asian populations containing genes of BD I were more correlated with major depression while European populations with BD I were more correlated with schizophrenia, however, no differences were found between the samples when examining BD type II. These differences were attributed to how the disorder is diagnosed in each country; East Asian psychiatrists hold that bipolar disorder is a mood disorder while European psychiatrists tend to diagnose patients with delusion and other psychotic symptoms.[8] These vast differences in definitions can later lead to issues with clinical trials, especially for drug therapy. 

Even the threshold that needed to be met to be considered pathological differs culturally. For example, Hong Kong’s rates of reported hyperactivity are double those of the United States.[9] Additionally, Chinese and Thai cultures place a high value on hiding aggression and overt behaviors, which lowers the threshold of hyperactive behaviors and raises the likelihood that parents would report it. Chinese and Indonesian clinicians also gave higher scores for hyperactive behavior problems when compared to scores given by Japanese and American clinicians.[10] A study conducted by Bird (2002) examined Italy, New Zealand, China, Germany, Brazil and Puerto Rico and found that hyperactive disorders were found in all cultures, but the prevalence and threshold of what was considered pathological is what differed. Therefore, while these conditions happen universally, the way each culture views the symptoms varies widely.[11]

These cultural distinctions of appropriateness not only occur cross-continentally but also within different communities. According to Andrade (2017), African Americans are more likely than White Americans to keep personal distress private and seek spiritual support versus seeking professional mental health treatment.[12] Further, in the United States, most minority groups are less likely than White Americans to seek mental health treatments or delay seeking help until their symptoms are severe. Many of these issues are tied to the discrimination and mistreatment minorities face when seeking help; in fact, 43% of African Americans and 28% of Latinos have felt they were mistreated in clinical settings due to their background.[13] There is also a lack of resources for non-English speakers to gain access to mental health services. These cultural factors tied with affordability and insurance coverage also create a very difficult situation for many people in certain populations to get mental health assistance at all. 

Mental health resources vary widely across the globe, depending on location. Nielsen, et al., (2022) found major differences among countries in the Far East, Middle East, and Southeast Europe, as most countries reported the need for more child psychiatrists and mental health professionals. The researchers note that 10% to 20% of adolescents experience a mental health disorder before they turn 14 years old.[14] Thus, the lack of resources in these countries poses a great risk to the population, as early intervention is key to recovery and well-being.

Future Steps: Integrating Culture and Diagnosis 

These locational and cultural challenges pose a clear threat to the reliability and validity of cross-cultural research; as we discover more about how these factors affect diagnosis and symptoms, it is essential to create instruments keeping these differences in mind. Historically, research has been based on Western diagnosis systems and definitions, but when using those definitions with other populations, concepts can become unclear.[15] Conceptual equivalence ensures the concept is identified uniformly according to the populations being studied.[16] Therefore, these disparities must be emphasized when conducting research. If not, misclassifications and incorrect conclusions about populations can be made. 

Harris (2023) stresses that with the growing importance culture plays on manifestations and diagnosis, it is important clinicians and mental healthcare professionals assess how a person’s background affects their condition. As well, adjust their assessment based on the person’s attitude towards mental health and how they express and cope with their mental health. Different populations may also have stigmas on seeking help or undergoing certain treatments, professionals must be aware of and protect those preferences.[17] 

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has also embraced these strategies and highlights the impact of race and culture on disorders. Clarifications and disclaimers have been added to provide further information when specific communities had higher rates of certain disorders.[18] These considerations are fundamental in improving the disparities in diagnosis found across cultures as it allows psychiatry residents and fellows to see the effects race and culture can have on mental health and diagnosis.  

If you or someone you know is struggling with their mental health, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ryann Thomson

Editor: Jennifer (Ghahari) Smith, Ph.D.

1 Canino, G., & Alegría, M. (2008). Psychiatric diagnosis – is it universal or relative to culture? Journal of Child Psychology & Psychiatry, 49(3), 237–250. https://doi.org/10.1111/j.1469-7610.2007.01854.x

2 Ibid. 

3 Ibid. 

4 Ibid. 

5 Abdelnour, E. (2022, October 1). ADHD diagnostic trends: Increased recognition or overdiagnosis? PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9616454/#:~:text=The%20past%20couple%20of%20decades,the%20causes%20for%20this%20trend 

6 Canino & Alegría (2008)

7 Saito, T., Ikeda, M., Terao, C., Ashizawa, T., Miyata, M., Tanaka, S., Kanazawa, T., Kato, T., Kishi, T., & Iwata, N. (2022). Differential genetic correlations across major psychiatric disorders between Eastern and Western countries. Psychiatry and Clinical Neurosciences, 77(2), 118–119. https://doi.org/10.1111/pcn.13498 

8 Ibid. 

9  Ho, T.P., Leung, P.W., Luk, E.S., Taylor, E., BaconShone, J., & Mak, F.L. (1996). Establishing the constructs of childhood behavioral disturbances in a Chinese population: A questionnaire study. Journal of Abnormal Child Psychology, 24, 417–4314

10 Canino & Alegría (2008)

11 Bird, H. (2002). The diagnostic classification, epidemiology, and cross-cultural validity of ADHD. In P.S. Jensen & J. Cooper (Eds.), Attention deficit hyperactivity disorder: State of the science; best practices (pp. 12-1–12-36). Kingston, NJ: Civic Research Institute. 

12 Andrade, S. (2017). Cultural Influences on Mental Health | The Public Health Advocate. The Public Health Advocate

https://pha.berkeley.edu/2017/04/16/cultural-influences-on-mental-health/

13 Ibid. 

14 Nielsen, M. S., Clausen, C. E., Hirota, T., Kumperscak, H., Guerrero, A., Kaneko, H., & Skokauskas, N. (2022). A comparison of child and adolescent psychiatry in the Far East, the Middle East, and Southeast Europe. Asia-Pacific Psychiatry, 14(2), 1–9. 

https://doi.org/10.1111/appy.12490

15 Canino & Alegría (2008)

16 Ibid. 

17 Harris, J. (2023, January 9). Cultural competency in mental Health Care: Why it matters. NAMI - Dominate Amazing Capabilities. https://nami-dac.org/cultural-competency-in-mental-health-care-why-it-matters/

18 Moran, M. (2022). Impact of Culture, Race, Social Determinants Reflected Throughout New DSM-5-TR. Psychiatric News, 57(3).  https://doi.org/10.1176/appi.pn.2022.03.3.20

Exploring The Psychological Impacts of Pornography

Porn: The Widespread Taboo

Pornography is the most available it has ever been due to online accessibility. Consequently, the more views that pornography accumulates, the increasing amount of societal and psychological consequences people face. This includes, but is not limited to: stereotyping of gender and racial fetishes, sexual violence and misconduct, sex misinformation, content addiction, and sex worker stigmas. Solano et al. (2020) found that among a sample of 1,392 adults in the U.S. (ages 18 to 73), 91.5% of men and 60.2% of women reported that they had engaged in some type of pornography within the past month.[1] Exposure to sexual content seems to be a frequent and inevitable component of being connected to the internet. However, a wave of sexual health research indicates its usage is not inherently negative. Discussions surrounding the psychological impacts of pornography provide insights into how porn can be distributed in healthy ways while also reducing negative consequences. Understanding this research is pivotal in approaching mental health and its relationship with pornography in an exponentially growing online world.

Understanding Pornography

Pornography exists in a variety of forms ranging from written, still imagery, video and auditory content. The Merriam-Webster Dictionary defines pornography as the depiction of erotica for sexual enhancement or excitement.[2] Free online platforms invite higher usage of video content than other forms of porn.[3] Additionally, Solano et al. (2020) found that women are more likely to consume written porn than men.[4] Reasons for pornography usage were researched by Burtăverde et al. (2021), who found that many people seek content for short-term sexual enjoyment and masturbation.[5] Likely due to its increased availability, pornography viewership is also beginning at younger ages; among responses from university students, Biota et al. (2022) found that porn usage began at an average age of 10.4 years, with those partaking primarily out of curiosity.[6] Further, as many students from this study reported feeling that their sex education has been inadequate, this perceived lack of education has likely led to their increased search for sexual information online, through porn.[7] 

Opinions about users of porn, as well as actors, vary by culture and social norms. Societal attitudes about the motivations behind pornographers were studied by Evans-DeCicco & Cowan (2001) in which male performers were perceived as having more positive motivations for partaking in porn production (such as enjoying their work and being at the top of their profession) as opposed to female performers.[8] Female performers were more often than men perceived/stereotyped to come from dysfunctional families, have a lack of employment opportunities and be coerced into the work.[9] Additionally, Perry & Whitehead (2022) point out that in the U.S., the desire for anti-pornography legislation is predicted by Christain nationalism and strict values of sexual order.[10] 

The Neuroscience of Pornography & Addiction

Pornography addiction is not considered a DSM-5 categorized disorder, however, concern exists about the adverse effects of over-watching porn. For instance, Egan & Parmar (2013) note that online porn usage can be reflective of compulsive tendencies in men.[11] Market et al. (2021) also found that for men with higher sexual motivation, attention to pornographic pictures was enhanced but that there were also no connections made with symptoms of cybersex addiction.[12] A study done by Wang et al. (2022) likewise found that people with problematic internet pornography use display higher attention and brain responses to new sexual stimuli, maintaining a cycle of problematic porn consumption when they are presented with more porn.[13] Further, Biota et al. (2022) found that the self-perceived negative effects of pornography use were mainly decreased sexual satisfaction and the need for more stimuli and longer stimulation, suggesting possible reasons for cyclical tendencies.[14]

Behavioral addictions in the brain impair reward systems through the frontal lobes via hyprofrontal syndromes (i.e., cerebral dysfunctions of addiction) leading to compulsivity and flawed judgment;[15] substance abuse, internet gaming disorder, compulsive eating and trauma may change the brain in the same way.[16] More research is warranted for problematic hypersexual tendencies and pornography use, as its general consumption may be completely healthy, while its over-usage may be indicative of compulsive tendencies.

Psychological Effects of Pornography

The sheer variety of porn produced has resulted in a range of negative and positive psychological effects on viewers, reflected in several conflicting pieces of evidence in the research. Since 2016, 17 states have introduced nonbinding resolutions declaring pornography a public health crisis, with concerns ranging from infidelity, addiction and sex trafficking.[17] Conversely, Nelson & Rothman (2020) report that porn, itself, does not meet the criteria for a public health crisis and that it has also been found to increase feelings of acceptance and health-promoting behaviors such as increased intimacy, communication and safer sexual practice.[18]

However, other researchers have found negative psychological and behavioral associations with pornography. In examining the link between porn and body image, Gewirtz-Meydan & Spivak-Lavi (2023) found that increased porn usage related to more body comparisons being made as well as an increase in eating disorder symptoms in men.[19] Additionally, Rostad et al. found that porn exposure is associated with teen dating violence and aggression (with a higher effect in boys than girls),[20] and Kohut, & Štulhofer (2018) note that porn use is associated with low adult quality of life.[21] 

These associations, however, do not imply a causal relationship with porn. Such consideration may be informative of the demographics of porn users, as porn may be used to improve or satisfy already-impaired psychological states.[22] Kohut, & Štulhofer add that controlling for external factors in an individual’s life (such as family environment and impulsiveness) may help us understand what porn actually does to our mental health.[23] While Mollaioli et al. (2021) found that more sexual activity is generally related to better mental health with lower participant depression and anxiety scores,[24] one must be aware that viewing certain portrayals in porn (e.g., flawless body image, condomless sex and violent fetishization), as well as a user’s dispositions may actually result in adverse effects. 

Relationship Function & Dysfunction

Kohut et al., (2021) investigated the notion that pornography use leads to poor relationship quality and satisfaction and found that differences in partner sex drive is what actually accounts for discrepancies in relationship quality.[25] Differences in sex drive can lead to differences in porn usage among partners, which leads to varied perceptions of the relationship and each person’s sexual satisfaction.[26] Further, when respondents were generally less accepting of porn, more porn usage led to lower perceived relationship satisfaction - but when men were more accepting of porn, they indicated higher relationship satisfaction.[27] These findings provide insight into the effects of the meaning that one places on using pornography, and how the stigmatization of its usage infiltrates itself into relationships.

Addressing The Issues

While the topic of sex and pornography is incredibly taboo in most cultures, increased dialogue surrounding the effects of pornography is important to promote mental health and safe porn use. Porn that portrays harmful aspects of society like nonconsent (i.e., assault) is damaging, such as instances where porn is leaked or promoted without the consent of the people involved.[28] Gius (2022) notes these leaks are societally perceived as extremely negative due to sexism and gender inequality, leading to social pressure on the assaulted/exposed individuals and even suicide.[29] 

Hilton & Watts (2011) add that some people argue for all porn usage to be viewed from a public health lens due to factors ranging from stigmatization of sex to addiction research.[30] Others believe that explicit sexual content is inevitable and that while compulsive use can be targeted with treatment, outlawing porn will not alter its use. Reducing life-impairing over-usage of pornography may be achieved through psychotherapeutic methods and Camilleri et al. (2021) found that morals, faith, and individual motivation were the most effective factors in reducing porn use.[31] Historically, since anti-sex views have not taken away sex from people, approaching porn in an open and informed way may help younger generations form healthy practices. 

For adolescents, sex education regarding healthy, consensual sex may help to reduce the harmful effects of mainstream porn content. Consuming online porn is among the many factors for intimate partner violence among young people.[32] Pathmedra et al. (2023) note that adolescent exposure to sexual content has a large role in establishing healthy sexual and romantic relationships - but acknowledge that it also has a role in establishing unhealthy relationships.[33] A conscientious approach to the way that porn is produced would be beneficial regarding the stereotypes and values it projects to its audiences.[34]

Overall, pornography usage is self-perceived as positive among both adolescents[35] and adults.[36] Additionally, an increased amount of people are participating in generating pornography through online platforms (such as OnlyFans), where they can personally capitalize off of content creation more lucratively than many professional productions and mainstream career paths. Further, Toder & Barak-Brandes (2022) examined homosexual WhatsApp exchanges for profit and discussed how it grants users sexual freedom, escaping from paths of porn careers that promote unethical sex.[37] 

Sexual openness and literacy may help to reduce the negative effects of pornography. Biota et al. (2022) stress that since people tend to consume porn at early ages, sex education needs to be tailored so that people can have a normalized understanding of porn and what is healthy.[38] Further, this education may aid in helping people identify what is unethical and ethical in portrayals of sex so that rape culture and violence are not perpetuated by porn. Regarding problematic or compulsive porn usage, Testa et al. (2023) note that promoting media literacy is an effective strategy to use in order to develop greater critical thinking skills, reduce the shame associated with porn, recognize unrealistic productions of sex and interpret the meaning behind what is being viewed, thereby creating healthier choices. In addition, cognitive behavioral therapy (CBT) and mindfulness-based therapies are evidence-based modalities that can help with compulsive porn usage.[39] Many different factors combine to create the negative mental health and societal effects of porn, and these may be generally addressed through open and updated sex perspectives, in addition to conscientiousness surrounding porn production and distribution. 

If one is experiencing problematic pornography consumption that impairs well-being, relationships and/or daily life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Solano, I., Eaton, N. R., & O'Leary, K. D. (2020). Pornography Consumption, Modality and Function in a Large Internet Sample. Journal of sex research, 57(1), 92–103. https://doi.org/10.1080/00224499.2018.1532488 

2 Merriam-Webster. (n.d.). Pornography. In Merriam-Webster.com dictionary. Retrieved July 3, 2023, from https://www.merriam-webster.com/dictionary/pornography 

3 Ibid.

4 Ibid.

5 Burtăverde, V., Jonason, P. K., Giosan, C., & Ene, C. (2021). Why Do People Watch Porn? An Evolutionary Perspective on the Reasons for Pornography Consumption. Evolutionary Psychology, 19(2). https://doi.org/10.1177/14747049211028798

6 Biota, I., Dosil-Santamaria, M., Mondragon, N.I., Ozamiz-Etxebarria, N. (2022). Analyzing University Students' Perceptions Regarding Mainstream Pornography and Its Link to SDG5. Int J Environ Res Public Health. Jun 30;19(13):8055. doi: 10.3390/ijerph19138055. PMID: 35805712; PMCID: PMC9265877.

7 Ibid. 

8 Evans-DeCicco, Jennee & Cowan, Gloria. (2001). Attitudes Toward Pornography and the Characteristics Attributed to Pornography Actors. Sex Roles. 44. 351-361. 10.1023/A:1010985817751.  

9 Ibid.

10 Perry, S. L., & Whitehead, A. L. (2022). Porn as a threat to the mythic social order: Christian nationalism, anti-pornography legislation, and fear of pornography as a public menace. Sociological Quarterly, 63(2), 316-336. doi:10.1080/00380253.2020.1822220 

11 Egan, V., & Parmar, R. (2013). Dirty habits? Online pornography use, personality, obsessionality, and compulsivity. Journal of sex & marital therapy, 39(5), 394–409. https://doi.org/10.1080/0092623X.2012.710182

12 Markert, C., Baranowski, A. M., Koch, S., Stark, R., & Strahler, J. (2021). The impact of negative mood on event-related potentials when viewing pornographic pictures. Frontiers in Psychology, 12 doi:10.3389/fpsyg.2021.673023

13 Wang, J., Chen, Y., & Zhang, H. (2022). Electrophysiological evidence of enhanced processing of novel pornographic images in individuals with tendencies toward problematic internet pornography use. Frontiers in Human Neuroscience, 16 doi:10.3389/fnhum.2022.897536 

14 Biota et al. (2022)

15 Hilton DL, Watts C. Pornography addiction: A neuroscience perspective. Surg Neurol Int. 2011 Feb 21;2:19. doi: 10.4103/2152-7806.76977. PMID: 21427788; PMCID: PMC3050060.

16 Ibid.

17 Nelson, K. M., & Rothman, E. F. (2020). Should Public Health Professionals Consider Pornography a Public Health Crisis?. American journal of public health, 110(2), 151–153. https://doi.org/10.2105/AJPH.2019.305498

18 Ibid.

19 Gewirtz-Meydan, A., & Spivak-Lavi, Z. (2023). The association between problematic pornography use and eating disorder symptoms among heterosexual and sexual minority men. Body Image, 45, 284-295. doi:10.1016/j.bodyim.2023.03.008

20 Rostad et al. (2019)

21 Kohut, T., & Štulhofer, A. (2018). Is pornography use a risk for adolescent well-being? An examination of temporal relationships in two independent panel samples. PloS one, 13(8), e0202048. https://doi.org/10.1371/journal.pone.0202048 

22 Ibid.

23 Ibid.

24 Mollaioli, D., Sansone, A., Ciocca, G., Limoncin, E., Colonnello, E., Di Lorenzo, G., & Jannini, E. A. (2021). Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout. The journal of sexual medicine, 18(1), 35–49. https://doi.org/10.1016/j.jsxm.2020.10.008

25 Kohut, T., Dobson, K. A., Balzarini, R. N., Rogge, R. D., Shaw, A. M., McNulty, J. K., Russell, V. M., Fisher, W. A., & Campbell, L. (2021). But What's Your Partner Up to? Associations Between Relationship Quality and Pornography Use Depend on Contextual Patterns of Use Within the Couple. Frontiers in psychology, 12, 661347. https://doi.org/10.3389/fpsyg.2021.661347 

26 Ibid.

27 Maas, M. K., Vasilenko, S. A., & Willoughby, B. J. (2018). A Dyadic Approach to Pornography Use and Relationship Satisfaction Among Heterosexual Couples: The Role of Pornography Acceptance and Anxious Attachment. Journal of sex research, 55(6), 772–782. https://doi.org/10.1080/00224499.2018.1440281

28 Gius, C. (2022). Addressing the blurred question of ‘responsibility’: Insights from online news comments on a case of nonconsensual pornography. Journal of Gender Studies, 31(2), 193-203. doi:10.1080/09589236.2021.1892610 

29 Ibid.

30 Hilton & Watts (2011)

31 Camilleri, C., Perry, J. T., & Sammut, S. (2021). Compulsive Internet Pornography Use and Mental Health: A Cross-Sectional Study in a Sample of University Students in the United States. Frontiers in Psychology, 11, Article 613244. https://doi.org/10.3389/fpsyg.2020.613244

32 Barter, C., Lanau, A., Stanley, N., Aghtaie, N., & Överlien, C. (2022). Factors associated with the perpetration of interpersonal violence and abuse in young people’s intimate relationships. Journal of Youth Studies, 25(5), 547-563. doi:10.1080/13676261.2021.1910223

33 Pathmendra, P., Raggatt, M., Lim, M. S. C., Marino, J. L., & Skinner, S. R. (2023). Exposure to pornography and adolescent sexual behavior: Systematic review. Journal of Medical Internet Research, 25 doi:10.2196/43116

34 Ibid. 

35 Dwulit, A. D., & Rzymski, P. (2019). Prevalence, Patterns and Self-Perceived Effects of Pornography Consumption in Polish University Students: A Cross-Sectional Study. International journal of environmental research and public health, 16(10), 1861. https://doi.org/10.3390/ijerph16101861

36 Hald, G.M., Malamuth, N.M. Self-Perceived Effects of Pornography Consumption. Arch Sex Behav 37, 614–625 (2008). https://doi.org/10.1007/s10508-007-9212-1

37 Toder, N., & Barak-Brandes, S. (2022). A booty of booties: Men accumulating capital by homosocial porn exchange on WhatsApp. Porn Studies, 9(2), 145-158. doi:10.1080/23268743.2021.1947880  

38 Biota et al. (2022)

39 Testa, G., Mestre-Bach, G., Chiclana Actis, C., & Potenza, M. N. (2023). Problematic pornography use in adolescents: From prevention to intervention. Current Addiction Reports, 10(2), 210-218. doi:10.1007/s40429-023-00469-4  

Stress Management for Students: Unveiling Coping Strategies & Creative Outlets

Adverse Effects of Stress

Stress is a feeling that most people experience at some point in their life. Students are especially prone to experiencing the negative effects of stress when they feel overworked, sleep deprived and overwhelmed. Symptoms of stress are demonstrated in our bodies, mental state, mood and behavior and have a prominent effect on our day-to-day lives. 

The Mayo Clinic notes that symptoms of stress can manifest in a variety of ways, such as:[1]

It is important to be able to recognize the symptoms of stress in order to effectively manage the cause.[2] 

Common Stressors

Students encounter a number of ongoing stressors, which involve the typical day-to-day challenges they face. Both high school and college students commonly report experiencing continuous stress related to their education, specifically academic-related stress. Pascoe and Parker (2020) found that this stress stems from factors such as the pressure to achieve high grades and concerns about receiving poor marks.[3] A 2017 survey conducted by the Organisation for Economic Co-operation and Development (OECD) across 72 countries involving 540,000 student respondents aged 15-16 revealed that, on average, 66% of students feel stressed about receiving low grades and 59% worry that tests will be difficult. Additionally, the survey found that 55% of students experience high levels of anxiety regarding school testing, even when adequately prepared. Furthermore, 37% of students reported feeling “highly tense” while studying.[4] 

With the prominence of social media in the lives of today’s students, news and world events are more readily available, thus providing additional stress in the lives of students. Information about politics, school shootings, and war are readily available, adding additional stress in their lives as they perceive the world they live in as “unsafe.”[5] Additionally, media can push unhealthy and unrealistic body images as well as idealistic lifestyle expectations on young minds, warping their sense of reality and leaving them feeling inadequate in comparison. While it is important for students to be informed, today’s teens have much more information at their fingertips than ever before, thereby exacerbating their stress. Since the many pressures and events that incite feelings of stress often cannot be avoided, people engage in utilizing coping mechanisms; however, not all coping mechanisms are healthy.[6] 

Unhealthy Coping Methods

As stress levels continue to rise in student populations, a number of unhealthy coping mechanisms have become increasingly popular. Harvard Health (2012) notes that some common methods of dealing with stress involve doing activities that help one put aside their worries for some time (e.g., constantly sleeping, binge-watching television, alcohol consumption and taking illegal drugs.[7] New York University (2015) found that alcohol and marijuana were common relaxers utilized by students for temporary relief from the daily pressures in their lives.[8] Additionally, temporary relief tends to be found through over- or under-eating, smoking, and engaging in a whirlwind of social activities in an attempt to avoid facing their problems. Unfortunately, a buildup of stress can lead to a person lashing out at others and increased violent behavior. On the surface, these coping mechanisms may seem to offer relief; however, many of these actions are not effective at relieving pressure and can actually exacerbate the stress one already feels to a higher degree. Fortunately, there are a number of creative methods of coping with stress that have a positive effect on students.[9]

Effective and Creative Outlets

Art

Art can be used to mitigate feelings of stress and anxiety. Specifically, art therapy is a type of psychological intervention that utilizes various artistic mediums and the individual's creative expression to facilitate the therapeutic exploration and comprehension of emotions – ultimately resulting in the creation of artwork. It is both a natural and enjoyable way for students to manage their stress.[10] Research conducted by Zaidel (2014) on the influence of art and active creativity on the brain indicates that patients who engage in newly discovered creative outlets often experience elevated dopamine levels. Dopamine, a neurotransmitter frequently depleted in individuals suffering from anxiety, depression, and excessive stress, tends to increase through the practice of art therapy. As a result, art therapy emerges as a beneficial option for individuals dealing with high stress levels, as it can effectively raise dopamine levels and promote a sense of happiness and well-being in patients.[11]

Music

Another effective outlet for stress is music. Listening to music offers a stress-reducing effect by influencing both the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. A study published by the Cambridge University Press (2021) indicates that music demonstrated a decrease in cortisol levels (a well-known biomarker of stress) and a reduction in sympathetic activity (reflected in lower heart rate and blood pressure).[12] 

Different compositional elements of music (e.g., melody, rhythm, tonality and frequency) seem to influence individual relaxation responses. While most studies have used classical music, these effects have been observed across various music genres. High-frequency music, particularly at 528 Hz, appears to play a significant role in stress relief. Lata and Kourtesis (2021) note that music with this frequency can lower cortisol levels and increase oxytocin levels, regulating stress response and social bonding.[13] 

Meditation

Meditative practices can also relieve stress experienced by students. The Mayo Clinic describes meditation as a simple and inexpensive method of relaxation that doesn’t involve any materials or equipment to participate. Meditation is classified as a form of complementary medicine that involves the connection between the mind and body. By engaging in meditation, individuals can achieve a profound sense of relaxation and cultivate a calm state of mind.[14] During meditation, one directs their attention to clearing away the influx of chaotic thoughts that often clutter the mind and contribute to stress. This practice has the potential to improve both physical and emotional well-being, fostering a sense of overall balance and tranquility. Meditation can serve as a tool for relaxation and stress management by redirecting one’s focus towards calming elements. Through meditation, one can develop the ability to maintain inner peace and a centered state of mind.[15] 

Furthermore, the benefits of meditation extend beyond the duration of the practice, itself. It can help individuals navigate their daily lives with a greater sense of composure. Yoga is a well known form of meditation utilized to cultivate both physical flexibility and mental tranquility through a sequence of poses and controlled breathing exercises. By engaging in specific postures that demand balance and concentration, attention is redirected away from the demands of a stressful day and towards the present moment.[16]

Exercise

Medical professionals consistently encourage maintaining an active lifestyle as the positive effects of physical exercise have been widely recognized (e.g., improving physical health and combating illness). Exercise is also regarded as essential for preserving mental well-being and can alleviate stress. The Anxiety and Depression Association of America (2022) notes that exercise has significant efficacy in reducing fatigue, enhancing alertness and focus, and improving overall cognitive function.[17] This research is supported by a 2015 study conducted van der Zwan et al., which compared a number of stress intervention methods and indicated physical activity was effective in reducing stress in the sample group.[18] This can be particularly beneficial when stress has depleted one's energy or ability to concentrate. When stress impacts the brain, affecting its numerous neural connections, the rest of the body experiences the repercussions as well. Exercise and other forms of physical activity stimulate the production of endorphins(a natural pain-relieving chemical in the brain) and also contribute to improved sleep, subsequently reducing stress levels.[19]

Psychotherapy

If creative outlets for stress reduction are not enough to mitigate the extreme levels of stress one is experiencing, psychotherapy can be used alongside or in place of creative outlets for stress reduction. Psychotherapy, also known as talk therapy, encompasses a range of therapeutic approaches designed to assist individuals in recognizing and modifying distressing emotions, thoughts and behaviors.[20] People often turn to psychotherapy when coping with intense or prolonged stress caused by work or family circumstances, the bereavement of a loved one, or challenges within relationships or family dynamics. Various forms of psychotherapy and interventions have demonstrated efficacy in addressing mental health disorders. Frequently, the treatment approach is customized to suit the particular case someone is experiencing. This involves identifying techniques for managing stress and formulating targeted problem-solving strategies.[21] 

There are a number of evidence-based approaches in psychotherapy that aid in dealing with stress:

  • Cognitive Behavioral Therapy (CBT)

  • Acceptance and Commitment Therapy (ACT)

  • Mindfulness-Based Stress Reduction (MBSR) 

Both CBT and ACT are evidence-based psychotherapies utilized to help people manage symptoms of stress. CBT places greater emphasis on modifying or rectifying one's negative thoughts in order to relieve distress while ACT focuses more on transforming the way our personal experiences (e.g. thoughts, emotions, memories, and physical reactions) function and increasing our psychological flexibility, so that they no longer have a hold on us.[22,23] MBSR utilizes meditation principles to assist individuals in developing a heightened awareness of the influence negative thoughts have on their physical sensations.[24]

While beneficial for students, any of the afore-mentioned creative outlets and therapies can be useful for the general population experiencing stress, as well.

If you or someone you know is experiencing extreme stress and/or anxiety, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Kumar

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Mayo Foundation for Medical Education and Research. (2021). How Stress Affects Your Body and Behavior. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-symptoms/art-20050987  

2 Ibid.

3 Michaela C. Pascoe, Sarah E. Hetrick & Alexandra G. Parker (2020) The impact of stress on students in secondary school and higher education, International Journal of Adolescence and Youth, 25:1, 104-112, DOI: 10.1080/02673843.2019.1596823

4 Ibid.

5 Simmons, A. (2019). As Teen Stress Increases, Teachers Look for Answers. Edutopia. https://www.edutopia.org/article/teen-stress-increases-teachers-look-answers/ 

6 Columbia University. (2021). Is social media threatening teens’ mental health and well-being? Columbia University Irving Medical Center. https://www.cuimc.columbia.edu/news/social-media-threatening-teens-mental-health-and-well-being 

7 The President and Fellows of Harvard College. (2012, August 4). Watch Out for Unhealthy Responses to Stress. Harvard Health. https://www.health.harvard.edu/healthbeat/watch-out-for-unhealthy-responses-to-stress 

8 New York University. (2015). NYU study examines top high school students’ stress and coping mechanisms. NYU. https://www.nyu.edu/about/news-publications/news/2015/august/nyu-study-examines-top-high-school-students-stress-and-coping-mechanisms.html

9 Harvard Health

10 Sage Neuroscience Center. (2021, July 27). How Art Can Help Relieve Stress. Sage Neuroscience Center. https://sageclinic.org/blog/art-relieve-stress/#:~:text=How%20Can%20Drawing%20and%20Painting,%2C%20depression%2C%20and%20excessive%20stress  

11 Zaidel DW. Creativity, brain, and art: biological and neurological considerations. Front Hum Neurosci. 2014 Jun 2;8:389. doi: 10.3389/fnhum.2014.00389. PMID: 24917807; PMCID: PMC4041074.

12 Lata, F., & Kourtesis, I. (2021). Listening to music as a stress management tool. European Psychiatry, 64(S1), S609-S609. doi:10.1192/j.eurpsy.2021.1621

13 Ibid.

14 Mayo Clinic. (2022). Meditation: A simple, fast way to reduce stress. Mayo Foundation for Medical Education and Research (MFMER). 

https://www.mayoclinic.org/tests-procedures/meditation/in-depth/meditation/art-20045858

15 Ibid.

16 Ibid.

17 Anxiety and Depression Association of America. (2022). Physical Activity Reduces Stress. ADAA. https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/stress/physical-activity-reduces-st#:~:text=Exercise%20and%20other%20physical%20activity,your%20body%20to%20produce%20endorphins.

18 van der Zwan, J.E., de Vente, W., Huizink, A.C. et al. Physical Activity, Mindfulness Meditation, or Heart Rate Variability Biofeedback for Stress Reduction: A Randomized Controlled Trial. Appl Psychophysiol Biofeedback 40, 257–268 (2015). https://doi.org/10.1007/s10484-015-9293-x

19 Anxiety and Depression Association of America

20 U.S. Department of Health and Human Services. (2023). Psychotherapies. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/psychotherapies  

21 Ibid.

22 Guarna, J. (n.d.). Comparing ACT and CBT. Association for Contextual Behavioral Science. https://contextualscience.org/comparing_act_and_cbt#

23 Wersebe H, Lieb R, Meyer AH, Hofer P, Gloster AT. The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention. Int J Clin Health Psychol. 2018 Jan-Apr;18(1):60-68. doi: 10.1016/j.ijchp.2017.09.002. Epub 2017 Oct 17. PMID: 30487911; PMCID: PMC6220909.

24 Johns Hopkins Medicine. (2023) Stress Busters: 4 Integrative Treatments. The Johns Hopkins University. https://www.hopkinsmedicine.org/health/wellness-and-prevention/stress-busters-4-integrative-treatments

How Mortality Changes Our Behaviors: Insights from Death Anxiety Research

Reminders of Death

Everyone eventually dies. Despite this commonality, psychologists like Gordillo et al., (2007) have found that being reminded of our own demise (i.e., mortality salience) can change several of our thoughts and behaviors due to the emergence of imminent death anxiety.[1] Whether we are aware of it or not, we typically become more fearful and sad following death reminders, and our behavior is subsequently impacted[2] as we work towards protecting ourselves through self-preservation. Fritsche et al. (2007) found an increase in reproductive behaviors and desire for offspring and Rosenblatt et al. (1989) found an increase in the defensiveness of culturally-upheld values after mortality becomes salient.[3,4] These findings relate to the evidence-based Terror Management Theory (TMT), which states that death anxiety is a primary motivator for all human behaviors.[5] TMT adds that every culture preserves ideas of immortality to reduce the feelings of this “terror” or anxiety such as memorials, symbolic afterlives and statues. Death anxiety and its impacts on people provide insight into several processes of the human condition as well as mental health treatment and practice.

Mortality Salience in Everyday Life

Presentations of mortality salience (MS) may appear as: viewing a cemetery on the way to work, witnessing constant sickness and death as a healthcare worker, viewing violence and danger on television, seeing an ambulance on the freeway, or anything that may remind someone of their own danger. By fMRI (functional magnetic resonance imaging), the parts of the brain that can be activated after MS include the prefrontal cortex (involved in self-regulation), to regulate and motivate defense of concerns of death.[6] The right amygdala (important for emotional processing), and the behavioral inhibition system (BIS) as well as general anxiety systems, are also involved.[7] Xu et al. (2022) found that MS also increases activation in areas of the brain regarding guilt and shame as one experiences death anxiety.[8]

Changed Behaviors

Cultural Values 

A person’s thoughts and behaviors typically change after they are reminded of their mortality. When self-esteem (i.e., a person's sense of their worth) is high, it is found to be a protective buffer against fears surrounding death.[9,10] Furthermore, Basset & Bussard (2021) found that the strength of one’s religious beliefs and actions increases as fears of death conversely decrease, suggesting that religion can help protect oneself from death anxiety and boost self-esteem.[11,12] 

The impact of the perceived mortality reminder also depends on whether it was felt individually or collectively. Utilizing data across 79 countries, Fog (2023) found that mortality salience of individual danger (danger to oneself) reveals increased religious behavior but no effect on religious beliefs, less regard toward authorities and less nationalism.[13] On the contrary, perceived collective danger (danger to a group of people including oneself) tends to result in increased nationalism, traditionalism, security, religiosity and strict sexual morals.[14] Additionally, Rosenblatt et al. (1989) found that after mortality salience, judges fined prostitutes more and declared harsher punishments, upholding negative views toward prostitution while promoting culturally conservative values.[15] Rosenblatt et al. also found that people promote “heroism” following MS. They found that college students that were primed with a death reminder (when compared with a control group) gave three times as large of a reward to a fictional hero as well as a more severe punishment to a fictional non-violent criminal.[16] 

Decreased Altruism

Possibly in an effort to maintain self-preservation, reminders of death tend to lessen a person’s altruism (i.e., behavior that is unselfishly beneficial to others).[17] Kheibari et al. (2023) found that those with low self-esteem, tend to develop increased stigma about suicide once they face MS.[18] In addition, respondents reported a lower likelihood to intervene and try to prevent another’s suicide, and they responded that they would allocate less money to suicide prevention organizations.[19] 

Risk-Taking and Safety Behavior

Being reminded of death has risk-taking implications. Weng et al. (2023) found that among publicly traded firms in the United States, MS inflicted on the director or CEO led to decreased long-term investment by firms.[20] Bessarabora & Massey (2023) also found that MS produced adaptive opinions towards texting and driving, resulting in greater attempts at safe driving and self-preservation.[21] Li et al. (2023) note that people were impacted by the death anxiety caused by negative media exposure during the COVID-19 pandemic.[22] As a result, employees were shown to follow increased human resources practices (e.g., workplace safety behaviors) during the pandemic.[23] In an effort of self-preservation, death anxiety also enhances consumer purchasing desires, alluding to practical applications regarding marketing and advertising.[24] Emergency-related death anxiety from the COVID-19 pandemic additionally led to studies involving panic shopping (i.e., “consumer misbehavior”) as people feverishly sought to stock up on perceived essentials necessary for survival.[25] By collecting responses from 400 consumers that shopped during the pandemic, Scarpi et al. (2023) found that death anxiety impacted customers’ awareness of their shopping misbehavior and individual responsibility.[26] 

Relationships and Attachment

Following a death reminder, Plusnin et al. (2018) note that close relationships were found to be a way of reducing death anxiety similar to self-esteem’s buffer function.[27] Mental accessibility of words related to attachment is also increased after MS, in addition to commitment to a partner and the desire for psychological intimacy.[28] 

Death Anxiety’s Purpose and Relevance

Many elements of an individual’s life are impacted by a reminder of death, yet how this actually functions is less known. Many models are proposed based on sociological, anthropological, philosophical, and neurological evidence (including TMT) making this field extremely interdisciplinary. 

Reasons why death anxiety affects so many human behaviors may relate to legacy motivations[29] and the desire for one’s legacy to last through familial and generational knowledge (akin to symbolic immortality). This perceived immortality through remembrance may act as a coping mechanism to overcome death anxiety and[30] many cultures seek symbolic immortality by preserving life as never-ending through modes such as religion, art and rituals. 

Psychopathology and Death Anxiety

Death anxiety creates a sense of powerlessness and meaninglessness in life and coping mechanisms to combat these sensibilities can sometimes be more hurtful than helpful (such as avoidance) and are correlated with many psychiatric disorders.[31] For instance, existential anxiety may help drive, cause, or sustain many anxiety disorders including:[32]

Research with anxiety disorders will typically prime individuals with a death reminder and observe an increased perceived threat and maladaptive behaviors within individuals when presented with anxiety-provoking stimuli, as opposed to when presented with no death reminder.[33] In addition to promoting a range of anxiety disorders, death anxiety can be a factor in:[34]

The frequency of death-related thoughts is typically increased for individuals with such disorders. Additionally, those with substance abuse disorders may engage in self-medication as a form of maladaptive coping with death anxiety, as Menzies & Menzies (2023) note that among people with substance abuse disorders, increased symptom severity correlates with higher existential anxiety.[35] 

Treating Death Anxiety

While death anxiety seems to be an inevitable and even unconscious element of being human, an exceeding amount of it may factor into impairment in life. Death anxiety was found to predict psychosis[36] among many mental disorders and targeting death anxiety, itself, may be a way to prevent and treat subsequent life impairments. 

Menzies & Menzies (2023) note that Cognitive Behavioral Therapy (CBT) has been useful in reducing death-related anxiety through methods such as Exposure Therapy that allow patients to confront their fears surrounding death.[37] Death “thought-reframing” has also been employed to encourage positive adaptive coping with death anxiety.[38] Acceptance and Commitment Therapy (ACT), a modality used to focus on awareness of mental states and thoughts, may also be a way for clients to reflect on the meaning of their lives and restore this from what was lost in experiences of death anxiety.[39,40] Relating to Buddhist thought and practice, Anālayo et al. (2022) found that mindfulness also reduces death anxiety through facing mortality, which simultaneously increases self-compassion.[41] 

Death anxiety takes implicit and explicit forms that range from completely expected to life-impairing. Its empirical insights may lead to a holistic perspective of human behavior. Being mindful of these findings may include applying them to practical situations such as justice systems and hospital employees. Aldiabat et al. (2023) note that consideration for perceptions of death and death reminders is relevant to nurses and other healthcare workers for how MS may impact their actions in practice.[42] Further research in the field, including death anxiety and psychiatric disorders, may also open doors for clinical treatment to target existential anxiety, particularly for middle-aged adults, seniors and those with chronic or terminal illnesses. 

If one is experiencing death anxiety that is impacting daily life and overall well-being, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Gordillo, F., Mestas, L., Arana, J. M., Pérez, M. Á., & Escotto, E. A. (2017). The Effect of Mortality Salience and Type of Life on Personality Evaluation. Europe's journal of psychology, 13(2), 286–299. https://doi.org/10.5964/ejop.v13i2.1149

2 Huang, C., & Hu, C. (2023). The terror management and sorrow management of death consciousness. Acta Psychologica Sinica, 55(2), 318-335. doi:10.3724/SP.J.1041.2023.00318

3 Fritsche I, Jonas E, Fischer P, Koranyi N, Berger N, Fleischmann B. Mortality salience and the desire for offspring. Journal of Experimental Social Psychology. 2007;43:753–62. https://scholar.google.com/scholar_lookup?journal=Journal+of+Experimental+Social+Psychology&title=Mortality+salience+and+the+desire+for+offspring&author=I+Fritsche&author=E+Jonas&author=P+Fischer&author=N+Koranyi&author=N+Berger&volume=43&publication_year=2007&pages=753-62&

4 Rosenblatt, A., Greenberg, J., Solomon, S., Pyszczynski, T., & Lyon, D. (1989). Evidence for terror management theory: I. The effects of mortality salience on reactions to those who violate or uphold cultural values. Journal of personality and social psychology, 57(4), 681–690. https://doi.org/10.1037//0022-3514.57.4.681

5 Greenberg, J., Solomon, S., Pyszczynski, T., Rosenblatt, A., Burling, J., Lyon, D., Simon, L., & Pinel, E. (1992). Why do people need self-esteem? Converging evidence that self-esteem serves an anxiety-buffering function. Journal of personality and social psychology, 63(6), 913–922. https://doi.org/10.1037//0022-3514.63.6.913

6 Silveira, S., Graupmann, V., Agthe, M., Gutyrchik, E., Blautzik, J., Demirçapa, I., Berndt, A., Pöppel, E., Frey, D., Reiser, M., & Hennig-Fast, K. (2014). Existential neuroscience: effects of mortality salience on the neurocognitive processing of attractive opposite-sex faces. Social cognitive and affective neuroscience, 9(10), 1601–1607. https://doi.org/10.1093/scan/nst157

7 Ibid.

8 Xu, Z., Zhu, R., Zhang, S., Zhang, S., Liang, Z., Mai, X., & Liu, C. (2022). Mortality salience enhances neural activities related to guilt and shame when recalling the past. Cerebral Cortex (New York, N.Y.: 1991), 32(22), 5145-5162. doi:10.1093/cercor/bhac004   

9 Greenberg et al. (1992)

10 E.G. Hepper, Self-Esteem, Editor(s): Howard S. Friedman, Encyclopedia of Mental Health (Second Edition), Academic Press, 2016, Pages 80-91, ISBN 9780123977533, https://doi.org/10.1016/B978-0-12-397045-9.00076-8

11 Bassett, J. F., & Bussard, M. L. (2021). Examining the Complex Relation Among Religion, Morality, and Death Anxiety: Religion Can Be a Source of Comfort and Concern Regarding Fears of Death. OMEGA - Journal of Death and Dying, 82(3), 467–487. https://doi.org/10.1177/0030222818819343 

12 Szcześniak, M., & Timoszyk-Tomczak, C. (2020). Religious Struggle and Life Satisfaction Among Adult Christians: Self-esteem as a Mediator. Journal of religion and health, 59(6), 2833–2856. https://doi.org/10.1007/s10943-020-01082-9

13 Fog, A. (2023). Psychological and cultural effects of different kinds of danger. An exploration based on survey data from 79 countries, Culture and Evolution (published online ahead of print 2023). doi: https://doi.org/10.1556/2055.2023.00029

14 Ibid.

15 Rosenblatt et al. (1989)

16 Ibid.

17 Kheibari, A., & Cerel, J. (2023). The Role of Death Anxiety and Self-Esteem in Suicide Attitudes. OMEGA - Journal of Death and Dying, 86(3), 1069–1088. https://doi-org.colby.idm.oclc.org/10.1177/00302228211000935 

18 Ibid.

19 Ibid. 

20 Weng, D. H., & Kim, K. H. (2023). Letting go or pushing forward: Director death and firm risk-taking. Long Range Planning, 56(3), 102322. ISSN 0024-6301. https://doi.org/10.1016/j.lrp.2023.102322.

21 Bessarabova, E., & Massey, Z. B. (2023). The effects of death awareness and reactance on texting-and-driving prevention. Risk Analysis, 00, 1– 13. https://doi-org.colby.idm.oclc.org/10.1111/risa.14107 

22 Li, S., Young, H.R., Ghorbani, M. et al. Keeping Employees Safe During Health Crises: The Effects of Media Exposure, HR Practices, and Age. J Bus Psychol 38, 457–472 (2023). https://doi.org/10.1007/s10869-022-09837-9

23 Ibid.

24 Menzies, R. E., & Menzies, R. G. (2023). Death anxiety and mental health: Requiem for a dreamer. Journal of Behavior Therapy and Experimental Psychiatry, 78, 101807. ISSN 0005-7916. https://doi.org/10.1016/j.jbtep.2022.101807

25 Scarpi, D., Pantano, E. and Marikyan, D. (2023), "Consumers' (ir)responsible shopping during emergencies: drivers and concerns", International Journal of Retail & Distribution Management, Vol. 51 No. 6, pp. 791-806. https://doi.org/10.1108/IJRDM-08-2022-0300 

26 Ibid. 

27 Plusnin, N., Pepping, C. A., & Kashima, E. S. (2018). The Role of Close Relationships in Terror Management: A Systematic Review and Research Agenda. Personality and Social Psychology Review, 22(4), 307–346. https://doi.org/10.1177/1088868317753505

28 Ibid.

29 Waggoner, B., Bering, J. M., & Halberstadt, J. (2023). The desire to be remembered: A review and analysis of legacy motivations and behaviors. New Ideas in Psychology, 69, 101005. ISSN 0732-118X. https://doi.org/10.1016/j.newideapsych.2022.101005

30 Ibid.

31 Menzies, R. E., & Menzies, R. G. (2023). Death anxiety and mental health: Requiem for a dreamer. Journal of Behavior Therapy and Experimental Psychiatry, 78, 101807. ISSN 0005-7916. https://doi.org/10.1016/j.jbtep.2022.101807

32 Ibid.

33 Ibid.

34 Ibid.

35 Ibid.

36 Easden, D., Gurvich, C., Kaplan, R. A., & Rossell, S. L. (2023). Exploring fear of death and psychosis proneness: Positive schizotypy as a function of death anxiety and maladaptive coping. Clinical Psychologist, 27(1), 35-44. DOI:10.1080/13284207.2022.2070426. 

37 Menzies & Menzies (2023)

38 Ibid. 

39 Wersebe, H., Lieb, R., Meyer, A. H., Hofer, P., & Gloster, A. T. (2018). The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention. International journal of clinical and health psychology : IJCHP, 18(1), 60–68. https://doi.org/10.1016/j.ijchp.2017.09.002 

40 Ibid.

41 Anālayo, B., Medvedev, O.N., Singh, N.N. et al. Effects of Mindful Practices on Terror of Mortality: A Randomized Controlled Trial. Mindfulness 13, 3043–3057 (2022). https://doi.org/10.1007/s12671-022-01967-8 

42 Aldiabat, K., Alsrayheen, E. A., & Le Navenec, C. -. (2023). Death anxiety among older adults during the COVID-19 pandemic: Implications for nursing practice. Universal Journal of Public Health, 11(1), 89-96. doi:10.13189/ujph.2023.110110  

Autism Diagnosis & Treatment: Understanding Racial Disparities

Diagnostic Symptoms & Patterns 

Autism Spectrum Disorder (ASD) is a neurological developmental disability that causes individuals to have lifelong difficulties in communication, interpretation and behavior. ASD is most commonly referred to as a developmental disorder because symptoms first appear within the first two years of a person’s life.[1] Commonly observed ASD symptoms within a child’s first 24 months include:[2]

- Limited social interaction (avoiding eye contact, disinterest in interactive games)

- Repetitive behaviors (playing with the same toy, having obsessive interests) 

-Delayed language and/mobility 

-Mood or emotional reactions that deviate from the norm

-High comorbidity with anxiety, depression, and attention-deficit hyperactivity disorder (ADHD)

As a spectrum disorder, it is common to see different combinations and severities of ASD symptoms in each diagnosed person. Regardless of which symptoms manifest in a person, treatment typically still has the potential to effectively mitigate some of ASD’s long-term challenges. With proper intervention and therapy, adults with ASD are often capable of achieving significant autonomy and social integration.[3] But, early detection is crucial. The American Academy of Pediatrics recommends that all children receive “well-child visits” (including screening for autism) at 18 and 24 month appointments; the sooner a child with symptoms receives an accurate screening, the sooner they are able to begin effective intervention and treatment.[4] Through assessment methods such as observation, blood tests and interactive tests, the accuracy of ASD assessments continues to improve - thus improving the odds of developmental and social progress in children with ASD.[5] 

In 2023, there was a groundbreaking shift in autism diagnosis statistics: for the first year in U.S. history, Black and Hispanic youth were diagnosed at a higher rate than their White counterparts.[6] This comes after decades of underrepresentation of autism in minority populations. However, understanding racial differences in access, culture and environment among marginalized communities provides insight into the progress required to see continual improvements in ASD disparities.

Early Assumptions 

When Leo Kanner first published his observations in 1943, he referred to this condition as “early infantile autism” and asserted that it occurred most often in children belonging to White middle and upper-class families.[7] Unfortunately, Kanner overlooked the reality that the parents who could typically seek help regarding their child’s developmental problems were likely those with resources, privilege and access to appropriate healthcare. In the 1940s those parents were almost exclusively White, and decades later White children continue to have disproportionate access to autism treatment and resources.[8,9] Research from the Center for Disease Control (CDC) has since established that ASD has no disposition toward a particular ethnic group, so factors other than biological differences contribute to White American children receiving the quickest and most frequent ASD diagnosis of all socioeconomic groups.[10] 

ASD in Black Children

According to a 2017 study conducted by the American Journal of Public Health, Black children are 19 percent less likely than their White counterparts to receive an autism diagnosis.[11] Similarly to other health disparities in America, high poverty rates and limited access to treatment facilities contribute to autism’s underdiagnosis in Black Americans. Research continues to identify racism as one of the greatest determinants in a person’s long-term health.[12] It is estimated that Black Americans live four years less than their White counterparts from compounding issues that contribute to a poorer quality of life (e.g., Black Americans are under-represented in higher income jobs and have a disproportionately high rate of chronic diseases in comparison to their White counterparts).[13] 

Addressing this socioeconomic gap is crucial to improving Black Americans’ ASD diagnosis. Research conducted between 2002 and 2010 on the prevalence of autism in White, Black and Hispanic children found autism diagnosis was higher in high socioeconomic Black Americans than their counterparts. Therefore, diminishing socioeconomic differences is key to improving ASD diagnosis for all Black Americans, who remain the demographic with the lowest average annual income in America.[14,15] 

Diagnosis issues also tend to arise when Black families seek autism treatment facilities with concerns. The majority of school documentation of ASD children identifies the child’s history as “bad behavior” instead of a developmental disorder.[16] A 2007 study conducted at the University of Pennsylvania found that Black children with ASD are 5.1 times more likely to be misdiagnosed with behavior disorders before they are correctly diagnosed with autism.[17] Another 2007 study found that African-American children were 5.1 times more likely than White children to receive a diagnosis of adjustment disorder, and 2.4 times more likely to receive a diagnosis of conduct disorder.[18] 

Racist stigmas labeling Black children as rude, unruly, and aggressive also extends to teachers. A 2020 American Psychological Association study on 178 prospective teachers across universities in southeastern states revealed that the majority of teachers within the study inaccurately observed anger in both genders of Black children at higher rates than of White children. The implications of this study extend to autism: teachers and other school administrators (e.g., school psychologists) play an instrumental role in referring children for further behavioral assessments.[19]

ASD in Hispanic Children

In past decades, Hispanic children were diagnosed at an average 65% lower rate than their White counterparts.[20] Recent strides in autism awareness within the Hispanic community have contributed to their improvements in ASD diagnosis, but there are still improvements to make in resources, treatment accessibility and awareness. Similarly to Black children, Latino children often have delayed diagnoses caused by low socioeconomic standings and limited accessibility to treatment and resources.

Spanish is also the second highest primary language spoken in the U.S, and is a factor that has been identified as both a barrier to identifying ASD and a communication challenge between parents and healthcare providers. In a 2004 study by Shapiro et al. 16 young, low-income Hispanic mothers described feelings of “alienation” in their interactions with healthcare providers.[21] The mothers described how information was not always explained enough and if a translator is not present, they felt as though they missed a lot of information.[22] Another study conducted in 2016 by Steinberg et al. found that Spanish-speaking parents are often asked less about their developmental concerns even if their child is known to be at risk, and have reported trouble connecting with providers because they are treated as though they lack knowledge.[23] These experiences not only dissuade parents from asking questions, but also intensify a caregiver’s skepticism, as families with limited English proficiency report less trust in providers compared to English proficient families.[24]

Emerging solutions to disparities in ASD diagnosis/treatment

There are growing resources available to help families from underrepresented communities better understand and identify ASD in their children, aiding in diagnosis and treatment and help close these racial disparities. 

  • The Autism Society of Los Angeles (ASLA) runs a hotline at (424) 299-1531 to help parents navigate the diagnosis and healthcare landscape. This organization also offers services in English and Spanish, providing families the resources they need without a financial burden.[25]

  • The Children's Hospital, Los Angeles employs liaisons to connect families to further assessment, locate other treatment facilities and gain general support. This hospital is physically located in Los Angeles, and it also provides a virtual autism assessment that can be accessed at: https://chla.purview.net/patient/start.

  • “Autism in Black” is a non-profit that aims to provide support to black parents who have a child on the spectrum, through educational and advocacy services like podcasts, free consultations and  hosting outreach events to better educate local communities. Managed by licensed mental health providers, “Autism in Black” is grounded in a mission to improve awareness of and reduce the stigma associated with ASD in the Black community.[26]

  • The Center for Disease Control (CDC) has a “Learn the Signs. Act Early.” program that provides free resources in English and Spanish to monitor children’s development starting at 2 months of age. Additionally, by downloading the CDC’s free Milestone Tracker mobile app, caregivers can log and monitor their child’s behavior to later share with healthcare providers.[27]

Community-based Intervention for ASD

JAMA Pediatrics (2022) conducted analysis of decades of autism studies and found that compounding factors increase the likelihood of early morbidity for individuals with autism in comparison to the general population as well as for minorities in comparison to their White counterparts.[28] Under this consideration, marginalized individuals with ASD are uniquely vulnerable to compounding issues related to how they must navigate the world due to their racial identity and neurodivergence (e.g., non-verbal communication, self-harming, and dependence on a caretaker).[29]

 People of color have a higher likelihood of limited availability of treatment centers, fewer services provided by Medicare providers, and of belonging to a lower socioeconomic group.[30] Equal access to healthcare is the foundation for children with mental disabilities to find the resources and treatment plans that will enable them to not only survive but also reach their full. With Hispanic people comprising both the largest minority population in the United States and the majority of the 25 million people in the United States with limited English proficiency, healthcare must continue to make adjustments in order to ensure that ASD is not only diagnosed accurately for this population, but healthcare providers also need to ensure that this demographic continues to feel supported as they navigate this complex condition.[31] Similarly, Black Americans continue to face the greatest discrimination of any group in America, and improving access to timely quality ASD treatment is crucial.[32]

As a growing pediatric concern, ASD was found to occur in 1-in-125 children in 2018 only to triple to 1-in-36 in 2023.[33] As the ASD population increases and the conversation shifts towards finding the resources to assist individuals on the spectrum better integrate into their communities, understanding the health disparities that affect progress is paramount. By diminishing the barriers to affordable and accessible care for marginalized communities, autism advocates will continue to become better equipped to serve the diverse population of individuals with ASD.

Help and support are available: If you or someone you know is struggling to obtain an ASD diagnosis and/or treatment, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Kate Campbell

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 National Institutes of Health. Autism Spectrum Disorder. National Institute of Health Website. Updated 2023. Accessed June 12, 2023.  https://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd

2 Centers for Disease Control and Prevention. Signs and Symptoms of Autism of Spectrum Disorder. Centers for Disease Control and Prevention Website. Updated March 28, 2022. Accessed June 12, 2023. https://www.cdc.gov/ncbddd/autism/signs.html

3 Whiteley, P., Carr, K., & Shattock, P. (2019). Is Autism Inborn And Lifelong For Everyone?. Neuropsychiatric disease and treatment, 15, 2885–2891. https://doi.org/10.2147/NDT.S221901

4 Durkin, M. S., Maenner, M. J., Baio, J., Christensen, D., Daniels, J., Fitzgerald, R., Imm, P., Lee, L. C., Schieve, L. A., Van Naarden Braun, K., Wingate, M. S., & Yeargin-Allsopp, M. (2017). Autism Spectrum Disorder Among US Children (2002-2010): Socioeconomic, Racial, and Ethnic Disparities. American journal of public health, 107(11), 1818–1826. https://doi.org/10.2105/AJPH.2017.304032

5 Ibid.

6 Centers for Disease Control and Prevention. Autism Prevalence Higher, According to Data from 11 ADDM Communities. Centers for Disease Control and Prevention Website Updated March 23, 2023. Accessed June 10, 2023. 

7 Rosen, N. E., Lord, C., & Volkmar, F. R. (2021). The Diagnosis of Autism: From Kanner to DSM-III to DSM-5 and Beyond. Journal of autism and developmental disorders, 51(12), 4253–4270. https://doi.org/10.1007/s10803-021-04904-1

8 American Psychiatric Association. (2023). New Research Points to Disparities in Autism Prevalence and Access to Care. Last updated April 23, 2023. Accessed June 20, 2023. https://www.psychiatry.org/news-room/apa-blogs/disparities-in-autism-prevalence-and-access

9 Mandell, D.S., Listerud, J., Levy, S.E., Pinto-Martin, J.A. (2002). Race Differences in the Age at Diagnosis Among Medicaid-Eligible Children with Autism. Journal of Child & Adolescent Psychiatry, 41(12), 1447-1453. https://doi.org/10.1097/00004583-200212000-00016.

10 Centers for Disease Control and Prevention. Spotlight on Closing the Racial and Ethnic Gaps in the Identification of Autism Spectrum Disorder among 8-year-old-Children. Centers for Disease Control and Prevention Website. Last updated March 23, 2023. Accessed June 23, 2023. https://www.cdc.gov/ncbddd/autism/addm-community-report/spotlight-on-closing-racial-gaps.html

11 Ibid.

12 Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. PloS one, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511

13 Price, J. H., Khubchandani, J., McKinney, M., & Braun, R. (2013). Racial/ethnic disparities in chronic diseases of youths and access to healthcare in the United States. BioMed research international, 2013, 787616. https://doi.org/10.1155/2013/787616

14 Mehta, N. K., Lee, H., & Ylitalo, K. R. (2013). Child health in the United States: recent trends in racial/ethnic disparities. Social science & medicine (1982), 95, 6–15. https://doi.org/10.1016/j.socscimed.2012.09.011

15 The Urban Institute.(2009). Racial and Ethnic Disparities among Low-Income Families [Fact sheet]. https://www.urban.org/sites/default/files/publication/32976/411936-racial-and-ethnic-disparities-among-low-income-families.pdf

16 Mandell, D. S., Ittenbach, R. F., Levy, S. E., & Pinto-Martin, J. A. (2007). Disparities in diagnoses received prior to a diagnosis of autism spectrum disorder. Journal of autism and developmental disorders, 37(9), 1795–1802. https://doi.org/10.1007/s10803-006-0314-8

17 Halberstadt, A. G., Cooke, A. N., Garner, P. W., Hughes, S. A., Oertwig, D., & Neupert, S. D. (2022). Racialized emotion recognition accuracy and anger bias of children’s faces. Emotion, 22(3), 403–417. https://doi.org/10.1037/emo0000756

18 Ibid.

19 Centers for Disease Control and Prevention. Spotlight on Closing the Racial and Ethnic Gaps in the Identification of Autism Spectrum Disorder among 8-year-old-Children. Centers for Disease Control and Prevention Website. Last updated March 23, 2023. Accessed June 23, 2023. https://www.cdc.gov/ncbddd/autism/addm-community-report/spotlight-on-closing-racial-gaps.html

20 Shapiro, J., Monzó, L. D., Rueda, R., Gomez, J. A., & Blacher, J. (2004). Alienated advocacy: perspectives of Latina mothers of young adults with developmental disabilities on service systems. Mental retardation, 42(1), 37–54. https://doi.org/10.1352/0047-6765(2004)42<37:AAPOLM>2.0.CO;2

21 Ibid.

22 Steinberg, E. M., Valenzuela-Araujo, D., Zickafoose, J. S., Kieffer, E., & DeCamp, L. R. (2016). The "Battle" of Managing Language Barriers in Health Care. Clinical pediatrics, 55(14), 1318–1327. https://doi.org/10.1177/0009922816629760

23 Ibid.

24 Warm Line. (2021). Autism Society of Los Angeles. https://www.autismla.org/1/program/speaker-series/

25 Advocacy, Education, and Support. (2023). Autism in Black. https://www.autisminblack.org/

26 About CDC’s Learn the Signs. Act Early. Program. (2023). Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/wicguide/about-cdcs-learn-the-signs-act-early-program.html

27 Ferrán, C. L., Hutton, B., Page, M.L., Driver, J.A., Ridao, M., Arroyo, A.A., Valencia, A., Saint-Gerons, D.M.,Tabarés-Seisdedos, R. (2022). Mortality in Persons With Autism Spectrum Disorder or Attention-Deficit/Hyperactivity Disorder. JAMA Pediatr, 176(4), e216401. https://doi.org/10.1001/jamapediatrics.2021.6401

28 Ibid.

29 Ibid.

30 Steinberg, E. M., Valenzuela-Araujo, D., Zickafoose, J. S., Kieffer, E., & DeCamp, L. R. (2016). The "Battle" of Managing Language Barriers in Health Care. Clinical pediatrics, 55(14), 1318–1327. https://doi.org/10.1177/0009922816629760

31 Dietrich, S., Hernandez, E. (2022). What Languages Do We Speak in the United States? United States Census Bureau Website. Last updated December 06, 2022. Accessed June 27, 2023.

32 The Texas Politics Project. Most Discriminated Group (April 2022). The Texas Politics Project at the University of Texas at Austin Website. https://texaspolitics.utexas.edu/set/most-discriminated-group-april-2022

33 Centers for Disease Control and Prevention. Data and Statistics on Autism Spectrum Disorder, Centers for Disease Control and Prevention Website. Last updated April 4, 2023. Accessed June 25, 2023.

Exploring the Mechanisms, Popularity & Health Implications of Vaping

How Does Vaping Work?

Vaping imitates the act of smoking by utilizing battery-powered devices that produce an aerosol resembling water vapor. However, this aerosol contains not only nicotine but also flavorings and over 30 additional chemicals. When inhaled, the aerosol enters the lungs, allowing the nicotine and chemicals to enter the bloodstream. A single vape pod contains the same amount of addictive nicotine as 20 cigarettes. Vaping conditions the brain to anticipate higher nicotine levels, leading to a stronger desire to vape.[1]

Initially, vape devices resembled traditional cigarettes, but more recent models have taken on different forms, such as resembling a USB flash drive or a compact pod. Vaping devices vary in their appearances, yet they share fundamental components, including a battery, sensor and atomizer/flavor cartridge.[2]

Targeted Age Group

As numbers for cigarette smoking have been on the decline for the past year, the popularity of vapes, a type of e-cigarette, has exploded in the United States, especially in younger generations. Johns Hopkins Medicine conveyed that over two million middle and high school students admitted to the use of vapes in 2022, with 80% of them using flavored e-cigarettes.[3] The Texas Health and Human Services notes that the teenage brain is particularly vulnerable to the impact of nicotine, making it more challenging to quit vaping and raising the likelihood of teens transitioning to smoking tobacco cigarettes due to nicotine addiction.[4]

Vaping devices have gained immense popularity among teenagers, becoming the most prevalent form of nicotine used among youth in the United States. A 2020 report from the National Institute on Drug Abuse indicates that many teens are unaware that vaping cartridges contain nicotine and mistakenly believe they only contain flavoring.[5] The widespread availability of these devices, captivating advertisements, a wide range of e-liquid flavors, and the perception that they are safer than traditional cigarettes contribute to their appeal among this age group. Moreover, their concealable nature, lacking the distinct odor of tobacco cigarettes, and their ability to be disguised as flash drives make them easier for teens to hide from teachers and parents.[6]

Why do People Vape?

The idea that vaping is less harmful than smoking has made it especially popular to young audiences, who do not see negative repercussions from the devices and often do not even know they contain nicotine.[7] According to the CDC, some vaping devices advertise themselves as not even containing any nicotine despite being found to have it.[8] The popularity of vaping makes it extremely accessible to young people, and teenagers are especially susceptible to the idea of doing something because those around them choose to participate. The CDC adds that one of the most common reasons provided for beginning to vape by middle and high school students in the United States was that they had a friend who used vapes. Further, most participants added they continued to vape due to feelings of stress, depression and anxiety.[9]

Negative Health Effects

While there is a belief that vaping is significantly better for health than smoking cigarettes, this is not necessarily true. Vaping can be linked to a number of lung injuries and even deaths as a large number of harmful chemicals have been identified in these devices. Nicotine, found in both traditional cigarettes and e-cigarettes, serves as the main active component and possesses a strong addictive nature. It generates a desire for smoking and can lead to withdrawal symptoms if the craving is ignored. Johns Hopkins Medicine notes that nicotine is considered a toxic substance, capable of elevating blood pressure, triggering a surge in adrenaline levels, accelerating heart rate, and augmenting the risk of experiencing a heart attack.[10]

effects on the brain

Additionally, the use of nicotine during adolescence can pose risks to the developing brain, which continues to mature until approximately the age of 25. Nicotine consumption during this stage can potentially harm the regions of the brain responsible for attention, learning, mood regulation and impulse control.[11] In the process of forming memories or acquiring new skills, the brain establishes stronger connections (synapses) between its cells, and the adolescent brain constructs synapses at a faster rate compared to adult brains. However, nicotine alters the normal formation of these synapses. Furthermore, the use of nicotine during adolescence may also heighten the likelihood of future addiction to other substances.[12]

easing Anxiety?

The CDC found that when asked why they vape, one of the most common responses youth will provide is that it, “helps ease their feelings of stress, anxiety or depression”. However, continuous use of an e-cigarette can actually exacerbate these feelings.[13] Nicotine-containing e-cigarettes exert an impact on various major systems within the body. For instance, vaping stimulates increased dopamine activity in the brain's reward pathway, elevates heart rate and blood pressure, and potentially disrupts the functioning of the hypothalamic-pituitary-adrenal (HPA) axis. These physiological changes, in turn, have psychological implications for addiction, cognition, mood and anxiety.[14]

The use of nicotine salts in e-cigarettes enhances the efficiency of nicotine delivery, potentially increasing their addictive nature. Vaping may also result in short-term enhancements in cognitive performance, as nicotine has the ability to improve memory and attention. Users of e-cigarettes often report mood-enhancing and anxiety-reducing effects, although Tattan-Birch & Shahab (2020) note these may be actually attributed to the relief of withdrawal symptoms.[15] Symptoms of nicotine withdrawal encompass irritability, restlessness, feelings of anxiety or depression, sleep difficulties, impaired concentration, and intense cravings for nicotine. In an attempt to alleviate these symptoms, individuals may continue using tobacco products and associate their feelings of relief with the act of vaping rather than withdrawal. Teenagers may resort to vaping as a means to cope with stress or anxiety, inadvertently perpetuating a cycle of nicotine dependency.[16]

If you or someone you know is struggling with anxiety and/or nicotine addiction, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support. Click here to see our interview on the role of social anxiety in addiction as well as how Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) can be effective methods at overcoming substance abuse.

Contributed by: Ananya Kumar

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Texas Health and Human Services. (2023). What is Vaping? Texas Department of State Health Services. https://www.dshs.texas.gov/vaping/what-is-vaping#:~:text=Vaping%20simulates%20smoking.,cross%20over%20into%20the%20bloodstream.

2 Ibid.

3 Blaha, M. J. (2022). 5 Vaping Facts You Need to Know. Johns Hopkins Medicine.  https://www.hopkinsmedicine.org/health/wellness-and-prevention/5-truths-you-need-to-know-about-vaping

4 Texas Health and Human Services

5 NIDA. 2020, January 8. Vaping Devices (Electronic Cigarettes) DrugFacts. Retrieved from https://nida.nih.gov/publications/drugfacts/vaping-devices-electronic-cigarettes

6 Ibid.

7 Johns Hopkins Medicine

8 Centers for Disease Control and Prevention. (2022). Quick Facts on the Risks of E-cigarettes for Kids, Teens, and Young Adults. CDC. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html

9 Ibid.

10 Johns Hopkins Medicine

11 CDC

12 Ibid.

13 Ibid.

14 Tattan-Birch, H., & Shahab, L. (2020). The Psychobiology of Nicotine Vaping. In Psychobiological Issues in Substance Use and Misuse (1st Edition). Routledge. 

15 Ibid.

16 CDC

Anxious Attachment: Self-Sabotaging Romance

Growing the Roots of Attachment 

A child hides behind his mother’s leg, crying and tugging on her jeans, begging her to stay with him. She gently pulls him off of her, and guides him into the classroom with all of the other students who are now in the caring hands of the teacher. The child is clearly in distress, now wailing and screaming loudly as his mother walks away. The teacher tries to calm him down by rubbing his back and offering him toys, but it seems as if nothing will soothe this anxious child. This is a common experience for many young children when they are first separated from their parents and sent off to school - and most children grow out of this issue. However, if this display of extreme anxiety persists as the child grows older, it can be a telltale sign of having anxious attachment.[1]

Anxious attachment is one of the four attachment styles: secure, avoidant, ambivalent, and disorganized. Developing at a young age, anxious attachment style can carry on into adulthood, at various degrees. A few important signs/symptoms in a child include:[2] 

  • Severe distress when separated from caregivers

  • Fear of strangers

  • Extreme clinginess to caregivers

  • Little desire for exploration for the environment around them

  • Behaviors of aggression

Although the anxious attachment style is more easily visible in infants and children (due to their higher likelihood of displaying adverse reactions) it exists in adults, as well. Adult attachment is important to investigate in romantic relationships, as one’s attachment style  impacts how they think, act and feel.[3]

Forming Attachment: Nature vs. Nurture? 

Attachment forms regardless of one’s gender.[4] To understand the basis of anxious attachment, the evolutionary perspective can be applied; the instinctive reason why children feel an intense desire to stay close to their parents is because children are vulnerable and seek protection, especially when distressed. Protection by their caregiver increases chances of survival (which is the fundamental basis of natural selection) causing the genes coding for this anxious attachment style to be passed onto future generations.[5]

However, anxious attachment is not solely a product of genetics and evolutionary patterns - it is also affected by environment and interpersonal relationships in an individual’s life. For example, a caregiver who is consistently neglectful towards a child will likely induce feelings of stress in the child. This neglect may be displayed by the caregiver as turning away and ignoring the child when he/she cries for comfort or attention. If the child’s emotional needs are persistently failing to be met, it may cause them to develop an anxious attachment style; this can continue later into life and project on their romantic relationships, as well.[6]

How an individual is treated by others, especially in a time of stress, has a serious impact on the attitudes and expectations they carry into the rest of their lives. If a child has been conditioned to learn that when they are upset, they cannot count on their caregiver for support, they may develop an anxious attachment style. This type of insecure attachment style could have been avoided if the caregiver had more quickly and reliably attended to the crying child. Being able to count on their caregiver for assurance and comfort allows for the formation of a secure attachment style. 

In these examples, the caregiver serves as a working model for the child. A “working model” is a significant person (e.g., a parent, friend or romantic partner) who shows various levels of responsiveness to an individual’s extreme desire for comfort and support in interactions. The working model also includes one’s self, and how they themselves respond themselves to others when they desire closeness. Working models guide an individual's future attitudes and expectations towards relationships (especially during stressful times) based on how they have been responded to in the past. Thus, working models shape an individual’s type of attachment style.[7]

Attachment in Romantic Relationships

As we grow into adults, insecure attachment styles can divide into one of two main categories in a romantic relationship: avoidant and anxious. Avoidant adults tend to hold more negative views of their romantic partners, and value the maintenance of independence and autonomy in their relationships. They generally act this way because they have internally decided that seeking further proximity/closeness to their romantic partner is not possible or not desirable.[8] They are overall less interested in their relationships, and maintain psychological and emotional independence from their partners. They do not feel as comfortable with having closeness and emotional intimacy.[9]

Conversely, anxious adults tend to be very invested in their romantic relationships, and want to be emotionally and physically close to their partner to avoid worry and feel more secure. Anxious individuals tend to worry that their partner will reject or abandon them. Due to the deep-rooted distress from childhood, causing them to question the availability of their caregivers, highly anxious individuals strongly question whether they can count on their partner’s presence. For this reason, they often heavily crave a lot of support, emotional intimacy, and reassurance.[10] 

Anxious adults will hold more negative views of themselves, and more positive views of their partner. They tend to feel underappreciated or highly distressed and worry that they cannot depend on their partner or that their partner will leave them. Their partner leaving would lead them to question their own worth. Anxious individuals will also use unfavorable coping strategies to react to chronic distress they feel regarding the security in their romantic relationships; this ironically can lead to a less stable and less satisfying relationship. Gender differences do not necessarily impact whether an individual will display more avoidant or anxious attachment styles, and their potential relationship outcomes.[11] 

Signs of anxious attachment style in adults that reflect in their romantic relationships include:[12]

  • Constant worry that their partner will leave them

  • Extreme distress when separated from their partner

  • Needing constant reassurance 

  • Hypersensitive to rejection 

  • High sensitivity and emotional reactivity to partner’s actions 

  • Negative self-view compared to a much more positive view of partner

  • Very afraid of being alone 

  • Overanalyzing minor events/words/actions

  • Intensifying degree of relationship-threatening cues

 

Ending the Cycle of Self-Sabotage

If you are experiencing anxious attachment, and it is negatively affecting your relationships by causing high levels of distress and worry, there are many ways you can learn to self-soothe and heal, to develop a more secure attachment style. It is important to recognize that distance/separation from your partner, or the uncertainty of the future, is not actually a reason to be emotionally distressed. It is important to start perceiving yourself, your partner and your relationship more positively, rather than negatively, and actmore constructively. To help learn these steps, a licensed mental health provider (e.g., psychotherapist) can guide someone through cognitive behavioral therapy (CBT) which teaches these evidence-based methods.

This control of emotions and thoughts is known as self-regulation. Calming oneself during moments of internal distress can be achieved by activities such as exercise, walks, taking deep breaths, journaling and meditation. In the long run, however, anxious individuals must work on creating a better self-image and creating healthy boundaries for themselves. Finding hobbies and things you enjoy doing, pursuing them, and building a positive self-image though that can be extremely beneficial to healing your anxious attachment and overbearing need for external support from a partner. It is vital to learn to be content with yourself, and only pursue healthy relationships to avoid the internal stressors associated with an anxious attachment style.[13] 

To reduce the distress one may experience when they desire greater intense proximity to a romantic partner, one must actively use coping strategies to avoid needing constant reassurance and support. This is because if this constant intense desire for proximity and support is met by a romantic partner, the anxious attachment system stays activated, continuing the cycle of distress and fear of rejection in a relationship. Actively breaking away from the cycle and deactivating the anxious attachment system requires one to tire of needing constant physical and emotional proximity. It is also crucial for one to actively begin viewing their partner’s actions and words in a more positive light during stressful times. This will help avoid the anxious anticipation of the worst-case outcome in every situation.[14]

Negative views and attributions towards a romantic partner due to the anxious attachment style decreases relationship satisfaction. These negative perceptions also feed into the cycle of anxious attachment. The only way to overcome this is to self regulate and manage internal stressors to cope with stressful events within one’s relationship. These pessimistic attributions may also be linked to higher cortisol levels in the anxious partner, especially after discussing a conflict. This physiological stress is not only detrimental to one’s health, but can also reflect in the overall relationship satisfaction of both individuals. This is because the attachment behaviors of one partner will affect the other as well, in terms of their behavior and level of relationship satisfaction.[15]

The actor-partner interdependence model (APIM) was implemented by Kimmes et al. (2015) to understand the relationship between one partner’s attributions and the other partner’s relationship satisfaction over time. The results of this study showed a significant negative association between pessimistic attributions of one partner and the relationship satisfaction level of the other. This data indicates that the attributions which stem from anxious attachment from one partner negatively affects relationship satisfaction in the other, emphasizing the importance of overcoming anxious attachment to achieve a more stable and satisfactory romantic relationship.[16]

If you feel you are suffering from an anxious attachment style and it is negatively impacting your relationships, a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) can offer guidance and support.

Contributed by: Ananya Udyaver

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Evans, O. G. (2023, June 8). Anxious attachment style: Signs in adults, how it develops & How to Cope. Simply Psychology. https://www.simplypsychology.org/anxious-attachment-style.html#Signs-in-Children 

2 Ibid. 

3 Simpson, J. A., & Steven Rholes, W. (2017, February). Adult attachment, stress, and romantic relationships. Current opinion in psychology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4845754/ 

4 Ibid.

5 Ibid.

6 Ibid.

7 Ibid.

8 Evans, O. G. (2023, June 8)

9 Campbell, L., & Marshall, T. (2011, February 7). Anxious attachment and relationship processes: An Interactionist Perspective. Journal of Personality. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1467-6494.2011.00723.x  

10 Ibid

11 Ibid.

12 Simpson, J. A., & Steven Rholes, W. (2017, February).

13 Campbell, L., & Marshall, T. (2011, February 7)

14 Kimmes, J. G., Durtschi, J. A., Clifford, C. E., Knapp, D. J., & Fincham, F. D. (2015). The role of pessimistic attributions in the association between anxious attachment and relationship satisfaction. Family Relations, 64(4), 547–562. https://doi.org/10.1111/fare.12130  

15 Ibid.

16 Ibid.

Schizophrenia:  Cross-Cultural Comparisons of Case Management & Research Progress

A Global Enigma

While our understanding of the human brain is constantly advancing, one of the least understood psychological disorders with the most ubiquitous global impact, is schizophrenia. Schizophrenia is a chronic mental illness characterized by symptoms generally falling into three categories:[1,2] 

  • Psychotic Symptoms: Hallucinations, delusions, disorganized speech and behaviors

  • Negative Symptoms: Withdrawal from aspects of life, difficulty functioning normally, affective flattening, lack of motivations

  • Cognitive Impairment: Problems in attention, concentration and memory. 

The prevalence of the disease is approximately 1% worldwide and accounts for a large healthcare burden. It is highly heritable (e.g., the likelihood of the disorder to aggregate among family members), estimated at around 80%.[3] Further, Degnan et al. (2018) note that the incidence rate of schizophrenia in ethnic minority populations are triple that of major White populations.[4] 

In itself, the definition and categorization throughout the history of schizophrenia has differentiated across countries. Schizophrenia was first described by Emil Kraepelin (1899), a German psychiatrist, as “attentional impairments”.[5] Eugen Bleuler (1911) later famously coined it as a disorder which originates from the splitting of different psychic functions leading to loss of unity within the personality (hence the name “schizophrenia”) from the Greek roots “split-mind.”[6] Our foundational understanding of the disease is still limited, and this article aims to review some current cross-cultural perspectives on the research and management of the disease.

The diverse faces of psychosis in schizophrenia  

Recent research has consolidated the literature on the effects of cultural and social perspectives on the framing of schizophrenic/psychotic symptoms. While psychosis is present globally as a symptom for schizophrenia, the actual content of the psychotic symptom is culturally determined.[7] For example, research conducted in India, Nigeria and Trinidad in 2016  concluded that “disruptive behaviors, wandering and decline in functioning” are more commonly thought of as psychosis rather than the “distorted perceptions and beliefs” emphasized in Western understanding of the condition.[8] 

Additionally, the interpretations of psychiatrists determine what behaviors constitute psychosis; this, too, will vary based on one’s training, education, upbringing and life experiences, which differ across cultures.[9] In a case study in 2008, a NHS psychiatric nurse in a London hospital recounted his conflict for a Nigerian patient diagnosed with schizophrenia under his care. While in Nigeria, the patient’s “psychotic symptom” of religious delusions would have been considered gifted, the patient was coerced into taking medication in the UK.[10] Therefore, it is important to consider cultural backgrounds as a crucial factor in determining the symptoms of the disease. 

Cross-national context and culturally-adapted interventions of schizophrenia

Schizophrenia has been identified as a globally-prioritized mental health problem with the magnitude of its impact on individuals’ health, economic and social hardships, increased mortality rates and human rights violation (e.g., involuntary hospitalization or imprisonment with inadequate mental health care).[11,12] Recommendations from the World Health Organization (WHO) guidelines and the Disease Control Priorities (DCP3)  have shown that there are two kinds of intervention for schizophrenia that have strong enough evidence to deem them significant: antipsychotic drugs and psychosocial treatments.[13] However, one important limitation is that there is little evidence supporting these interventions in low and middle income countries (LMIC), and few of them have been actually implemented in high income countries.[14]

 

Psychosocial Interventions:

The psychosocial treatments of schizophrenia with strongest empirical support are: social skills training; family psychoeducation; cognitive behavioral therapy (CBT) and cognitive rehabilitation.[15,16] 

In 2012, Lora et al. noted that among 50 LMICs, around 69% of those diagnosed with schizophrenic disorders do not have access to specialized care despite evidence that psychosocial interventions alone can alleviate symptoms of the disorder, and not all patients may require treatment with antipsychotics.[17,18] In 2018, Degnan et al. published a review on adaptations of Western psychosocial interventions to specific ethnic groups or subculture studying these adaptations in 13 different countries.[19] It was found that all cultural adaptations included language, a majority adapted to concepts and illness models, cultural norms and practices, and family. Noticeably, there were modifications to include spiritual/religious activities, adjustments to communication styles and family dynamics. The analysis demonstrated significant outcomes in support of adapted interventions, however only two studies out of 43 compared the effectiveness of adapted and non-adapted interventions, and neither found significant differences in outcomes.[20] Overall, while the study indicates positive results for culturally-adapted psychosocial interventions, the limited studies providing support for adapted over non-adapted treatments is not enough evidence of a significant increase in effectiveness.

 

Antipsychotic Interventions: 

While psychosocial interventions have been increasingly researched and recognized as effective care for schizophrenia, antipsychotics have long been the popular measure of intervention for medical professionals.[21] Common antipsychotic agents are classified as first-generation (chlorpromazine, haloperidol) or second-generation (clozapine), which work by blocking dopamine receptors.[22] According to Wood et al. (2003), first-generation drugs are more-likely to induce parkinsonian side effects and second-generation drugs are thought to have enhanced therapeutic efficacy.[23] However, research by Agid et al. (2006) questions if the side effects of first-generation schizophrenia drugs may actually be from unintentionally overdosing patients while searching for optimal drug efficacy (hence, inadvertently causing more-pronounced side effects).[24] 

Recent research on culturally-adapted antipsychotics and alternative drug treatments for schizophrenia has been scarce. However, a study done by Chong et al. (2004) on differences in antipsychotics usage in East Asian countries revealed that prescription patterns of antipsychotic drugs vary greatly between countries.[25] This can be explained by the differences in respective healthcare policies, preferred treatment modality, availability and cost of the drugs.[26]

For example, Japan has a long history of national health insurance and a preference for treating patients with mental health issues in psychiatric hospitals over community care. Therefore, a higher prevalence of antipsychotics is prescribed due to the longer hospitalization period for schizophrenia in the country.[27] Meanwhile, Xiang et al. (2017) also found that while community-based services are increasingly encouraged, a large number of patients in China end up receiving hospital-based services.[28] Additionally, as clozapine is the most effective and affordable antipsychotic medication in China, over one-third of schizophrenia patients have been prescribed the drug.[29] This is not the case for all countries in the surrounding regions, as the cost of second-generation antipsychotic is considerably higher, thus is often restricted and difficult to prescribe.[30] However, as first-generation antipsychotics for schizophrenia are known as “major tranquilizers” with more serious side effects, this may create a disparity in treatment of the disorder in different countries.[31] 

Alternative treatments may also prove valuable. In 2017, a study conducted by Deng et al. on Wendan decoction (WDD), a traditional Chinese medicine for schizophrenia, discovered that WDD demonstrated some short-term positive effects on its own. Further, when WDD was used alongside an antipsychotic, positive outcomes were observed with fewer adverse effects.[32] 

Future directions: beyond the “one-size-fits-all” treatment framework

While there is still more research to be done, this brings the question to whether popular antipsychotics are the ultimate pharmacological treatment for schizophrenia, or if there are alternative options we need to take into consideration. Specialists have long called for the facilitation of mental health care by traditional practitioners due to lack of resources in LMICs; research has echoed the sentiment that traditional healers are generally more accessible and affordable, and patients benefit from sharing cultural beliefs and world views with them.[33] 

Traditional healers have often been more open to collaborating with primary health care than vice versa.[34] Watt et al. (2017) studied this issue qualitatively with populations in Ghana, Kenya and Nigeria. They found that many patients and caregivers still distrust non-medical treatments; despite some medical practitioners advocating for their validity, traditional care is often met with ridicule and doubt. The study further found that there appear to be suggestions to “convert” non-medical healers to a medical paradigm, and that rivalry and perceived superiority seem to be the underlying cause of this attitude.[35] 

However, it is also important to note that patients who implore both methods of care seem to reap more benefits, overall.[36,37] Watt et al. note that non-medical healers also desire to be recognized in their validity and not be exoticized simply due to their non-Western practices and beliefs.[38] Many studies have supported that labeling these practices as “witchcraft” or “inferior” is failing to understand indigenous knowledge and meaningful perspectives, and thus a missed opportunity to improve population health.[39,40]

Social and cultural perspectives continue to inform the characteristics and future directions of both the research and treatment of schizophrenia. Yet, as we have seen, the current landscape of what we know about the disorder in a cross-cultural context is lacking. As we expand on this field of research in a broader context, it is important to note the potentials of alternative medicine, culturally-adapted measures and how they can benefit the accessibility of health care for ethnic minorities, non-Western or low/middle-income patients. Acknowledgement and deeper insight into culturally-appropriate diagnosis and care for patients with schizophrenia is crucial to shift the evolution of global mental health into a truly global discipline. 

If you or someone you know are experiencing any signs of schizophrenia, it’s best to speak with a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) to discuss your concerns and determine the underlying cause of symptoms.

Contributed by: Mai Tran

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

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2 NHS. (2023, April 13). Symptoms - Schizophrenia. NHS. https://www.nhs.uk/mental-health/conditions/schizophrenia/symptoms/ 

3 McCutcheon RA, Reis Marques T, Howes OD. Schizophrenia—An Overview. JAMA Psychiatry. 2020;77(2):201–210. doi:10.1001/jamapsychiatry.2019.3360  

4 Degnan, A., Baker, S., Edge, D., Nottidge, W., Noke, M., Press, C. J., Husain, N., Rathod, S., & Drake, R. J. (2018). The nature and efficacy of culturally-adapted psychosocial interventions for schizophrenia: a systematic review and meta-analysis. Psychological Medicine, 48(5), 714–727. https://doi.org/10.1017/S0033291717002264

5 Kraeplin, E. (1950). Dementia praecox and paraphrenia (J. Zinkin, Trans.).

6 Bleuler, E. (1950). Dementia praecox or the group of schizophrenias. International Universities Press. 

7 Shalhoub, H. (2012). Decoding schizophrenia across cultures: Clinical, epidemiological and aetiological issues (Doctoral dissertation, School of Social Sciences Theses).

8 Cohen, Alex; Padmavati, Ramachandran; Hibben, Maia; Oyewusi, Samuel; John, Sujit; Esan, Oluyomi; Patel, Vikram; Weiss, Helen; Murray, Robin; Hutchinson, Gerard; Gureje, Oye; Thara, Rangaswamy; Morgan, Craig (2016). Concepts of madness in diverse settings: a qualitative study from the INTREPID project. BMC Psychiatry, 16(1), 388–. doi:10.1186/s12888-016-1090-4

9 Shalhoub (2012)

10 Ibid.

11 Wigand, M. E., Orzechowski, M., Nowak, M., Becker, T., & Steger, F. (2021). Schizophrenia, human rights and access to health care: A systematic search and review of judgements by the European Court of Human Rights. The International Journal of Social Psychiatry, 67(2), 168–174. https://doi.org/10.1177/0020764020942797

12 Patel V. (2016). Universal Health Coverage for Schizophrenia: A Global Mental Health Priority. Schizophrenia Bulletin, 42(4), 885–890. https://doi.org/10.1093/schbul/sbv107

13 Ibid. 

14 Ibid.

15 Alan. S. Bellack (2001) Psychosocial treatment in schizophrenia, Dialogues in Clinical Neuroscience, 3:2, 136-137, DOI: 10.31887/DCNS.2001.3.2/asbellack

16 Cooper, R. E., Laxhman, N., Crellin, N., Moncrieff, J., & Priebe, S. (2020). Psychosocial interventions for people with schizophrenia or psychosis on minimal or no antipsychotic medication: A systematic review. Schizophrenia Research, 225, 15–30. https://doi.org/10.1016/j.schres.2019.05.020

17 Ibid.

18 Lora, Antonio; Kohn, Robert; Levav, Itzhak; McBain, Ryan; Morris, Jodi; Saxena, Shekhar (2012). Service availability and utilization and treatment gap for schizophrenic disorders: a survey in 50 low- and middle-income countries. Bulletin of the World Health Organization, 90(1), 47–54B. doi:10.2471/BLT.11.089284  

19 Degnan et al. (2018)

20 Ibid. 

21 Guo, Xiaofeng; Zhai, Jinguo; Liu, Zhening; Fang, Maosheng; Wang, Bo; Wang, Chuanyue; Hu, Bin; Sun, Xueli; Lv, Luxian; Lu, Zheng; Ma, Cui; He, Xiaolin; Guo, Tiansheng; Xie, Shiping; Wu, Renrong; Xue, Zhimin; Chen, Jindong; Twamley, Elizabeth W.; Jin, Hua; Zhao, Jingping (2010). Effect of Antipsychotic Medication Alone vs Combined With Psychosocial Intervention on Outcomes of Early-Stage Schizophrenia. Archives of General Psychiatry, 67(9), 895–. doi:10.1001/archgenpsychiatry.2010.105 

22 Wood, Alastair J.J.; Freedman, Robert (2003). Schizophrenia. New England Journal of Medicine, 349(18), 1738–1749. doi:10.1056/NEJMra035458  

23 Ibid. 

24 Agid, O., Seeman, P., & Kapur, S. (2006). The “delayed onset” of antipsychotic action—An idea whose time has come and gone. Journal of Psychiatry & Neuroscience, 31(2), 93–100.

25 Chong, M. Y., Tan, C. H., Fujii, S., Yang, S. Y., Ungvari, G. S., Si, T., Chung, E. K., Sim, K., Tsang, H. Y., & Shinfuku, N. (2004). Antipsychotic drug prescription for schizophrenia in East Asia: rationale for change. Psychiatry and Clinical Neurosciences, 58(1), 61–67. https://doi.org/10.1111/j.1440-1819.2004.01194.x

26 Ibid.

27 Ibid.

28 Xiang, Y. T., Kato, T. A., Kishimoto, T., Ungvari, G. S., Chiu, H. F. K., Si, T. M., Yang, S. Y., Fujii, S., Ng, C. H., & Shinfuku, N. (2017). Comparison of treatment patterns in schizophrenia between China and Japan (2001-2009). Asia-Pacific Psychiatry: official journal of the Pacific Rim College of Psychiatrists, 9(4), 10.1111/appy.12277. https://doi.org/10.1111/appy.12277

29 Ibid.

30 Chong et al. (2004)

31 Ibid.

32 Deng H, Xu J. Wendan decoction (Traditional Chinese medicine) for schizophrenia. Cochrane Database Syst Rev. 2017 Jun 28;6(6):CD012217. doi: 10.1002/14651858.CD012217.pub2. PMID: 28657646; PMCID: PMC6481906.

33 van der Watt, A. S. J., Nortje, G., Kola, L., Appiah-Poku, J., Othieno, C., Harris, B., Oladeji, B. D., Esan, O., Makanjuola, V., Price, L. N., Seedat, S., & Gureje, O. (2017). Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways. Qualitative Health Research, 27(14), 2177–2188. https://doi.org/10.1177/1049732317729342

34 Ibid.

35 Ibid.

36 Abbo C. (2011). Profiles and outcome of traditional healing practices for severe mental illnesses in two districts of Eastern Uganda. Global health action, 4, 10.3402/gha.v4i0.7117. https://doi.org/10.3402/gha.v4i0.7117

37 Nortje, G., Oladeji, B., Gureje, O., & Seedat, S. (2016). Effectiveness of traditional healers in treating mental disorders: a systematic review. The Lancet Psychiatry, 3(2), 154–170. https://doi.org/10.1016/S2215-0366(15)00515-5

38 Watt et al. (2017)

39 Konadu, K. (2008) Medicine and Anthropology in Twentieth Century Africa: Akan Medicine and Encounters with (Medical) Anthropology. African Studies Quarterly, Vol. 10 (2&3).

40 Shaw, I., & Middleton, H. (2013). Approaches to “mental health” in low-income countries: A case study of Uganda. Mental Health Review Journal, 18, 204–213. doi:10.1108/MHRJ-07-2013-0025