Community Psychiatry &

Transcultural Psychiatry
‘Iffah Maryam binti Azmi Khair (012020040048)
Harith Atiqah Natasya binti Suhaimi (012020040074)
Hemah Banu A/P Kannan (012020040044)
Shahira Adriana Aisya binti Rahizan (012020040011)
Shanthani A/P Ganesan (012019100161)
TOPIC LEARNING OUTCOMES
01 Summarize relevant history of psychiatry and psychiatry
services in Malaysia

02 Describe community psychiatric services and the objectives of

such services

03 Describe the cultural diversity of Malaysian society, and the

mental health implications of this diversity

Differentiate new ways of thinking about concepts of culture,

04 and concept of psychiatric illness across different cultures,
and to apply these concepts in a day-to-day clinical work

05 Demonstrate skills in the integration of cultural competence

into psychiatric assessment, diagnosis and management

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 01
History of Psychiatry
and Psychiatric
Services in Malaysia
Harith Atiqah Natasya binti Suhaimi
(012020040074)

3
History of Psychiatry in Malaysia

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 History of Psychiatry
YEAR EVENTS & DEVELOPMENT

End of 18th century 1st psychiatric facility built for the The East India Company
soldiers in Hospital Pulau Pinang

Early 1900s The establishment of psychiatric hospital in

- Taiping (1910)
- Tanjung Rambutan (1911)
- Tampoi Johor Bahru (1937)
- Penrissen Road in Kuching
- Buli Sim Sim Sandakan Sabah

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YEAR EVENTS & DEVELOPMENT

1958 The revolution of mental health care provision in the country

started when the first mental health ward was opened at the
Penang General Hospital

1962 Dr Cunningham Dex, WHO advisor, suggested improvement in

psychiatric service and decentralization.
- the Mental Disorders Ordinance 1952 was revised
- the quality of mental health delivery in the country was
given an upgrade

1966 First psychiatry department was set up at the country’s first

university, University of Malaya (UM)

1967 First community-based rehabilitation of mentally ill persons was

opened in Ipoh, Perak as a day-care centre

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YEAR EVENTS & DEVELOPMENT

1973 UM started its Postgraduate Master in Psychological Medicine

(MPM)
-2 years programme: course work, a dissertation and the writing
up of six cases treated by the trainee

1975 3 locally trained psychiatrists graduated from UM

1977 Establishment of Malaysian Psychiatric Association (MPA)

1981 Members of MPA assisted their neighbouring countries in the

establishment of ASEAN Psychiatric and Mental Health
Association

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YEAR EVENTS & DEVELOPMENT

1985 Universiti Kebangsaan Malaysia (UKM) started its 4 years Master

Programme in Psychiatry

1995 Universiti Sains Malaysia (USM) started its Master Programme

1998 The country psychiatrists reached a number of 120

2000 Formation of National Conjoint Board for 3 universities

(UM,UKM,USM)
- oversaw the general development of the PG Master Programme
- coordination the academic curriculum
- collate input from various academician psychiatrists

2010 There were a reported 224 psychiatrists in the country

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 Hospital Bahagia Ulu Kinta
● Initially it was known as Federal Lunatic Asylum in 1911 with 4 wards
● Changed to Central Mental Hospital in 1928 with ward capacity reaching 30 males and
14 females respectively
● Finally known as HBUK on 16th December 1971 with 80 wards (the largest psychiatric
hospital in Malaysia)

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 Hospital Permai Johor Bahru
● Was built in Batu Tiga, Johor Bahru in 1916 with 6 wards
● Also known as Hospital Gila Batu Tiga
● The new hospital was built in 1937 by Dr G.H Garlick and
it was called Johore New Mental Hospital with patient
capacity up to 1200
● In 1972, Y.B. Tun Sardon B Hj Jubir, Minister of Health
officially named the hospital with the name "Hospital
Permai”

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Hospital Sentosa, Hospital Mesra
Kuching, Sarawak Bukit Padang, Sabah

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Psychiatric Services in Malaysia

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 Scope of Services
1) Primary care
- Promotion of mental health
- Early detection and prompt treatment
- Follow up of stable cases and defaulter tracing
- Psychosocial rehabilitation
3) Hospital with resident psychiatrist
- Promotion of mental health
- Early detection and prompt treatment
- Specialist outpatient care
- Inpatient care
- Hospital based community psychiatry
- Psychosocial interventions
- Consultation services
- Sub Specialised services
- Research
- Training
2) Hospital with no resident psychiatrist
- Promotion of mental health
- Early detection and prompt treatment
- Follow up of stable cases and defaulter tracing
- Inpatient care
4) Mental institution
- Promotion of mental health
- Early detection and prompt treatment
- Specialist outpatient care
- Inpatient care
- Hospital based community psychiatry
- Psychosocial interventions
- Forensic psychiatry
- Residential care for hard to place patients
and long stay patients
- Research
- Training
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 Outpatient Services
Promotion of Mental ● Promote mental health policy
Health ● Promote an acceptance and valuing cultural diversity

Prevention ● Prevention of specific illness, specific risk groups

● Early intervention of disease

Diagnosis ● Uncertain diagnosis from primary health care and non specialist hospital should
be referred to psychiatrist

Treatment ● Pharmacological treatment

● Psychosocial treatment
● Patients who are being stated on treatment which are not responding to
treatment should be referred to psychiatrist

Rehabilitation ● Patient required special rehabilitation services need to be referred to rehabilitation

services at specialist or psychiatric hospital

Training ● Training of allied health staffs

● Training of health professionals
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 Inpatient Services
Day Care Center/ Rehabilitation:
Promotion of Mental Health - Ensuring continuity of care
- Psychosocial rehabilitation

Prevention Care of forensic patient

(only in psychiatric hospital)

Assessment & Diagnosis

Training: Comprises of CMEs and
Postgraduate psychiatry training
Treatment:
- Inpatient stay is short encouraging early
discharge
- Optimize treatment Research

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 Components of Services
Outpatient Services Neuropsychiatry

Inpatient Services Psychiatric Hospitals

Child and Adolescent Services Psychiatric Nursing Homes

Hospital-based Community Psychiatry Community Mental Health Center

Addiction Psychiatry Clinical Psychology

Geriatric Psychiatry Training and Research

Forensic Psychiatry Promotion of Mental Health

Rehabilitation and Recovery Oriented Services

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17
 02
Types of Community
Psychiatric Services
and their Objectives
‘Iffah Maryam binti Azmi Khair
(012020040048)

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“A facility providing services for the prevention or
diagnosis of all types of mental disorders or care
and treatment or rehabilitation of mentally ill
patients; and the services are principally for
persons residing in a particular community or
communities in or near which the facility is
situated.”

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MENTARI
Derived from Kesihatan
Mental dan Psikiatri
‘The Sun’

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DEFINITION
A community mental health centre (CMHC)
is a centre for community care treatment
which includes the screening, diagnosis,
treatment and rehabilitation of any person
suffering from any mental disorder.

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 OBJECTIVES OF CMHC

To promote mental health, To provide continuing

provide screening of mental treatment in an accessible
illness and ensure early manner in the community
treatment

To provide rehabilitation &

psychosocial interventions
To reduce stigma and
including counselling,
discrimination
psychotherapies, patient & family
education

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 RANGE OF SERVICES
Psychosocial Interventions &
Promotion of Mental Health
Daycare Services

Rehabilitation, focused on
Screening & Early Detection
supported employment

Prompt Assessment &

Quality initiatives & research
Intervention

Community mental health Training with emphasis on

teams community based treatment

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 INPUTS

Human Ways of Obtaining

Location
Resources Premises

Maintenance
Design Equipment
of Premises

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 OPERATIONS

MENTARIs will operate during office hours from 8AM to 5PM

In places where flexi-hours are practiced, the operation hours may be adjusted
accordingly

As far as possible, MENTARI services should be made available on all working

days

Services can be outpatient and daycare; on-site and off-site; for individual and
groups

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 OPERATIONS

Referrals must be to the medical officer incharge of the MENTARI

All MENTARIs must have a multidisciplinary community psychiatry team

All patients referred for MENTARI services would be assessed by a

multidisciplinary team headed by a psychiatrist

Less hour 24-hour loading may be considered where adequate resources are
available

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 CRITERIA
Inclusion Exclusion
Anyone who requires ● High risk of danger to
● Screening self or to others:
● Diagnosis brought to emergency
● Continuous psychiatric services
treatment ● Clients from specific
● Psychosocial groups; substance
interventions dependence, learning
● Rehabilitation, disabilities
work-based

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 SERVICE COMPONENTS
SCREENING, DIAGNOSIS & TREATMENT
CONSULTATION CLINIC
● New cases – accepts self referrals apart from referrals
● Follow up management
○ Medication, psychosocial intervention; counseling, family session,
rehabilitation

COMMUNITY MENTAL HEALTH TEAM (CMHT)

● Run by multidisciplinary team
● Facilitate discharge from ward, acute illness recovery, relapse prevention
● Home visits by case managers
● Symptom/illness management, medication use training, side effect handling,
psychoeducation

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 SERVICE COMPONENTS
REHABILITATION
SUPPORTED EMPLOYMENT PROGRAM
● Competitive employment for clients with mental illness who want to work
● Job matching, job search, job placement, job analysis, intensive job coaching
● Personalised benefits counselling & facilitate benefit application
● Continuous support for working clients and employers

EMPLOYMENT TRANSITION PROGRAM

● Train clients based on actual business concepts based on real work tasks
● To improve working skills and cultivate good work habits
● Provide income & client empowerment via social enterprise models

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 SERVICE COMPONENTS
REHABILITATION
JOB CLUB & RECREATIONAL THERAPY
● Promote positive interactions with other clients by effective use of leisure time
● Promote patient empowerment through patient-led activities
● Provide an environment for low key activities and drop-in approach for existing
clients
● Help patients to be maintained at home/work and reduce contact time with
families
● Provide training in social skills, ADL, grooming, dining etc to prepare client before or
during employment and to optimize client’s function in community
● May be expanded to other specialized populations such as geriatric and youth
populations

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 SERVICE COMPONENTS
OUTREACHING, NETWORKING AND COLLABORATIONS

A MENTARI may
● collaborate with other government sector, non-governmental organisation
(NGO), the academia or private companies
● to create partnerships in promoting mental health, service provision and
community empowerment
○ providing jobs for patients with moderate and severe mental illness.
● Established NGOs in community psychiatry
○ MIASA
○ MINDs
○ MMHA

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MENTARI GALLERY

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 03
Cultural Diversity in
Malaysian Society
and their Mental
Health Implications
Shahira Adriana Aisya binti Rahizan
(012020040011)

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 CULTURAL DIVERSITY
0.7% 69.9%
OTHERS BUMIPUTERA
Those who do not fall Malays and
under the 3 categories indigenous people

6.6% 22.8%
INDIANS CHINESE
Ethnic Indian citizens Ethnic Chinese citizens

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 CULTURAL BACKGROUND

MALAYS CHINESE INDIANS

Islam, Black Magic Buddhism, Yin & Yang Hindu, Social Hierarchy

ORANG ASLI DAYAKS ANAK NEGERI

Animism, 3 Worlds Christianity, Shamanism Islam, Christianity

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IMPACT OF CULTURE

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 MENTAL HEALTH IMPLICATIONS
MALAYS
● Most Malays often attribute mental health disorders to the use of black magic,
violation of taboos, punishment from God and spiritual possessions
● Other than that, modern medicine for the treatment of mental health disorders
are often underutilised (especially in rural areas) as they often opt for traditional
healers such as a ‘bomoh’ or a shaman
● Religious coping: visiting religious figures and using specific tools that are
thought to contain “spiritual power” to heal their mental disorders (e.g. “air
penawar”) as well as “spiritual healing” (praying, duas)
● Malays like to somaticize their symptoms rather than accepting them as
psychological symptoms (e.g. “susah hati”, “kurang semangat”, “angin”)
● Suppression of emotional expression: use of idioms or proverbs

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 MENTAL HEALTH IMPLICATIONS
CHINESE
● Chinese citizens often view mental health disorders as a lack of spirit or the
weakness of ‘Yin and Yang’, spiritual possessions as well as problems related to
self-worth, which is measured by material achievement, including education,
occupation and monetary gain that brings the expected honour to the family
● Religious coping: some people believe that mental health disorders are due to
impurities of the soul so Buddhists often go to temples to worship Buddha and
Christians often go to church to socialise with others
● Traditional chinese medicine or sinseh are also often utilised for the treatment of
mental health disorders

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 MENTAL HEALTH IMPLICATIONS
INDIANS
● Indians, like Malays, derive mental health disorders from spirit possessions or
social punishment
● ‘Karma’: God’s punishment due to leading an unrighteous life
● Religious coping: visiting a Hindu temple for spiritual healing
● Some indians also often use Ayurvedic medicine as a traditional method for
healing mental health disorders, “Vaidya”

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 04
Concepts of Culture
& Psychiatric Illness
in Different Cultures
& Its Application
Shanthani A/P Ganesan
(012019100161)

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 WHAT IS CULTURE?

● Systems of knowledge, concepts,rules and

practices that are learned and transmitted
across generations.

● Includes language, religion, spirituality, moral

and legal systems.

● Changes over the time

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 CULTURE AND PSYCHOPATHOLOGY
● Culture contributes to psychopathology in different ways.

● Psychopathology is predominantly determined by biological factors is less influenced by cultural factors and
any such influence is secondary.

● In contrast, psychopathology that is predominantly determined by psychological factors is attributed more to

cultural factors.

● This basic distinction is necessary in discussing different levels of cultural impact on various types of
psychopathologies.

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 CULTURE CAN CONTRIBUTE TO
PSYCHOPATHOLOGY IN SIX DIFFERENT
WAYS
Pathogenic effects

Pathoselective effect

Pathoplastic effects

Pathoelaborative effects

Pathofacilitative effects

Pathoreactive effects

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 PATHOGENIC EFFECTS
● Pathogenic effects refer to situations in which culture is a direct causative factor in
forming or ‘generating’ psychopathology.
● Cultural ideas and beliefs contribute to stress, which in turn produces psychopathology.
● Stress can be created by culturally formed anxiety/culturally demanded performance.

Examples:
● Dhat Syndrome- In India, ‘Harmful’ leaking of semen can produce anxiety, depression and
somatic symptoms
● Koropanic- The folk belief that death will result if the penis shrinks into the abdomen;
also found in Malaysia

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 PATHOSELECTIVE EFFECTS
● It is the tendency of some people in a society, when encountering stress, to select certain
culturally influenced reaction patterns that result in the manifestation of certain
psychopathologies.

Examples:

● Family suicide - Observed in Japanese society (Ohara,1960)

In Japan, cultural influences lead a family encountering serious stress or a hopeless
situation to choose, from among many alternative solutions, to commit suicide together,
forming the unique psychopathology.

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 PATHOSELECTIVE EFFECTS
● AMOK ATTACK

● Culture has a powerful influence on the choices people make in reaction to stressful
situations and shapes the nature of the psychopathology that occurs as a result of those
choices.

● This only applies to minor psychiatric disorders, particularly of culture-related specific

syndromes, not to major psychiatric disorders.

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 PATHOPLASTIC EFFECTS
● Pathoplastic effects refer to the ways in which culture contributes to the modeling or
‘plastering’ of the manifestations of psychopathology.
● The content of delusions, auditory hallucinations, obsessions, or phobias are subject to
the cultural context in which the pathology is manifested.

Examples:
● Religious delusions and delusional guilt are primarily found in Christian societies than
Islamic, Hindus or Buddhist.
● Patients from developing countries reported visual hallucinations more frequently than
those from developed countries.

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 PATHOELABORATIVE EFFECTS
● Certain behaviour reactions (either normal or pathological) may be universal.
● These behaviours may become exaggerated to the extreme in some cultures through
cultural reinforcement.
● Phenomenon of “Trance and possession state”
-It is a culturally sanctioned .
-This could be described to the religious elaboration of association with ‘Atman’—self
/ breath—reincarnation and ‘Deities’—god / goddess
● In western countries there is increasing concern with body weight.
● Culture-shaped body image belief that “slim is beautiful" may cause “body weight
anxiety”.
-Common reason for eating disorders in developed countries.

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 PATHOFACILITATIVE EFFECTS
● Cultural factors do contribute significantly to the frequent occurrence of certain mental
disorders in a society.

● The disorder potentially exists and is recognized globally, yet, due to cultural factors, it
becomes prevalent in certain cultures at particular times. Thus, ‘facilitating’ effects make
it easier for certain psychopathologies to develop and increase their frequency.

● A liberal attitude towards weapons control may result in more weapon-related violence or
homicidal behaviour.

● Cultural permission to consume alcohol freely may increase the prevalence of drinking
problems.

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 PATHOREACTIVE EFFECTS
● Culture influences how people perceive pathologies and label disorders, and how they
react to them emotionally, and then guide them in expressing their suffering.

● Faith healing practices in India in cases of major psychiatric disorders like schizophrenia,
bipolar disorders or in OCDS . People attribute illness as results of “Black magic”.

● Another prevalent misconception in India is that mental illness is due to the patient ‘not
getting married at proper age’, and that marriage will cure his/her sexual frustration or
problem and there by cure his/her mental illness.
●
● Better prognosis of schizophrenia in developing countries like Indonesia. Although the
factors underlying this result remain insufficiently understood, it has been speculated that
family, social and cultural factors may have some Pathoreactive effects on schizophrenia
resulting in different prognosis.
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 05
Integration of Cultural
Competence into
Psychiatric Assessment,
Diagnosis & Management
Hemah Banu A/P Kannan
(012020040044)

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 DEFINITION

● Transcultural psychiatry focuses on understanding and managing

psychiatric conditions that are influenced by cultural factors.

● By recognizing and addressing the cultural factors that may contribute to

mental health issues, transcultural psychiatry can help improve the
effectiveness of psychiatric care and treatment outcomes for individuals
from diverse cultural backgrounds.

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 CULTURE BOUND SYNDROME
● Also known as culture-specific syndrome, is a term used to
describe a set of psychiatric and somatic symptoms that are
prevalent only within a specific society or culture.

● Cultural and religious beliefs often shape our understanding

of health, illness, and wellbeing, as well as our beliefs about
the causes and appropriate treatments for mental health
conditions.

● These syndromes may be characterized by episodic and

dramatic reactions that are specific to a particular
community, and may not be easily classified within
traditional psychiatric diagnostic categories, such as those
outlined in the DSM-IV.
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54
 AMOK
● Amok, or running amok, is derived from the Malay word ‘mengamok’, which means to make
a furious and desperate charge.It is a common usage which refers to an irrational-acting
individual who causes havoc.
● A specific type of violent behavior that is characterized by a sudden outburst of aggression
or rage, often resulting in a killing spree or other violent acts.
● In malaysia, man humiliated in public, following culture custom, lead to take weapon and kill
people indiscriminately to show his manhood.
● Malaysians traditionally believe that amok is caused by the hantu belian, which is an evil tiger
spirit that enters one's body and compelling him or her to behave violently without
conscious awareness.
● Early recognition of the risk factors for amok and prompt treatment of the underlying
psychiatric condition or personality disorder offer the best chance of preventing it.

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56
 KORO SYNDROME
● Koro is a culture-bound syndrome that is believed to originate from Southeast Asia, and is
characterized by the sudden and intense fear that the genitals (penis, vulva, or nipples) will
retract into the body and cause death.
● The term "koro" is derived from a Malay word that refers to the head of a turtle, which
resembles the retracted genitals during an episode of koro.
● More common in males compared to female
● Individuals with koro may also experience:
○ Delusions of genitalia shrinkage
○ Acute anxiety
○ Psychosomatic complaints
○ The conviction among some individuals that death will occur once the genitalia fully
retract.
○ They anticipate not only impotence or sterility but also death.
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TREATMENT
•Anti-psychotics
•Antidepressants
•Anxiolytics

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 LATAH
● The condition that also known as "Jumping Disease". Latah is
characterized by an exaggerated startle reflex, which can cause the
affected person to jump, yell, hit, or obey sudden commands without
conscious control.
● More common in middle-aged women, but it can affect people of any
age or gender.
● The onset of Latah is usually after a period of anxious or traumatic
experience, such as the loss of a child.
● Experienced as sudden reaction to fear with symptoms of
○ Echolalia (meaningless repetition of someone’s else words)
○ Echopraxia (involuntary repetition or imitation of someone else's
actions)
○ Coprolalia (involuntary and repetitive use of obscene language)
○ Dissociative behavior (jumping, raising arms, yelling, hitting)
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 DHAT SYNDROME
● Dhat syndrome is a term that was coined in South Asia(especially
India, Pakistan, Bangladesh, Nepal, Sri Lanka) little more than half a
century ago
● Disorder found in men where they experience anxiety to semen loss.
● Defined as vague somatic symptoms of fatigue, weakness, anxiety,
guilt and sexual dysfunction experienced by the pt due to loss of
semen in nocturnal emission through urine and masturbation.
● Dhat was identified by patients as a white discharge that was noted
on defecation or urination.

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 TREATMENT
● Resolving sexual myths
● Relaxation exercise
● Reassurance
● Supportive psychotherapy
● Anxiolytics, and antidepressants
● Cognitive behavioral
intervention

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 CULTURE-BOUND PHENOMENON
● Pibloktoq: abrupt dissociative episodes outburst of cries and screams
● Wendigo: delusions of being possessed by a flesh eating monster
(east coast forest Canada)
● Susto: lost of a soul (Mexican)
● Palen: pathological fear of cold, giving fatigue impotence and death
(China)

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 REFERENCES
● DHAT syndrome - DMS-5th Edition (page 833-834),
https://www.healthtipsever.com/dhat-syndrome-treatment/
● Koro syndrome -
https://www.freemalaysiatoday.com/category/leisure/2019/03/01/koro-the-genital-shrinking-di
sease-with-a-malaysian-origin/
● http://factsanddetails.com/southeast-asia/Malaysia/sub5_4b/entry-3638.html
● https://prezi.com/ghfjoa7zypgg/culture-bound-syndromes-malaysia/
● Sarkar, Siddharth; Punnoose, Varghese P.1. Cultural Diversity and Mental Health. Indian Journal of
Social Psychiatry 33(4):p 285-287, Oct–Dec 2017. | DOI: 10.4103/ijsp.ijsp_94_17
● Mohamad, Mohd Suhaimi & Subhi, Nasrudin & Zakaria, Ezarina & mohamad aun, Nur. (2014).
Cultural Influences in Mental Health Help-seeking among Malaysian Family Caregivers. Pertanika
Journal of Social Science and Humanities. 22. 1-16.
● Community Mental Health Implementation Guideline, 2020

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THANK YOU
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