8. Mental State Examination

Working in remote Aboriginal communities has taught me how much my culture has shaped perception of mental state. Learning about Aboriginal culture, being guided by Aboriginal people together with building on my mental state examination skills has been required, and it is an ongoing process of learning. There are similarities and differences between Aboriginal and nonAboriginal culture in how mental disorders are manifest in the mental state. In a different culture it is sometimes difficult know what is the societal 'norm' for such parameters as appearance, behaviour, expression of certain affects, speech patterns and so on. In a different culture which is changing, these norms also change, making it doubly hard for the clinician. The result is that it was difficult to pick up subtleties of mental state and more difficult to make confident interpretations of the findings. The following discussion focuses mainly on the differences in mental state examination that I encountered.

Appearance:

My white sensibilities and objective neutrality were challenged by the very different interview setting that the households would provide, as described in the chapter on interview setting. It is a setting which could easily create value judgements in the white clinician and taken out of the cultural context a patient from such a community could be labelled 'dishevelled' or 'unkempt'. Misinterpretations could be drawn about poor social function, or the possible presence of chronic mental illness or cognitive decline.

Conversely, it is possible to become totally desensitised, to the extent that any degree of poor hygiene or neglect is dismissed as being non-pathological, and hence signs of mental disorder may be missed. There are some Aboriginal communities which are spotless (one in particular keeps winning the Northern Territory Tidy Town Award) and even within one community there may be tidy homes with well kept litter-free gardens which are side by side with dilapidated premises.

Ultimately the most useful approach is to try to understand the patient's usual level of self care and appearance, so as to detect any changes which may signify a mental disorder. Seeing the family and relatives in their setting is a good yard stick for this, as is the opinion of the Aboriginal health worker.

Another significant cultural difference in appearance is the common occurrence of scars (usually to chest, upper arms and back, more common in men than women). These are mostly from initiation rituals or self-mutilation as part of the normal grieving process (sorry cuts). However there is a grey area between the ritualised grief related self-mutilation and self-mutilation purely born out of a release of frustration. Kidson (10) in his work in the western desert tribes, reported some individuals more prone to selfmutilation than others, and it was occurring not just in grief but after arguments, conflict etc. I can recall one patient who carries out very regular 'sorry cuts' even when there is no sorry business, and occurs in the context of poorly controlled bipolar disorder with co-morbid alcohol abuse. I have also seen several cases of young Aboriginal men in Alice Springs with self-inflicted abdominal knife wounds occurring in the context of pathological extended grief (multiple losses such as separation from spouse, rejection by family) and co-morbid alcohol abuse. Yet other cases resemble borderline personality disorder, but only in Aboriginal people living in the urban environment and a strong Western component in their upbringing.

Behaviour:

Shyness is very common, and can usually be distinguished from guardedness by the extreme avoidance of eye contact and absence of hostility. The people are generally reserved with whites and sometimes have apparent indifference which is actually misleading (appreciation for your help and even excitement at your impending visit is often felt by the patient and family but rarely shown.) Thus if an adult is over-familiar and expansive toward the white clinician, this is likely to be of pathological significance. A fairly traditional Aboriginal woman who was referred for 'talking silly' came straight up to me without any introduction and asked me to take a urine sample. This would be somewhat forward of a non-Aboriginal woman, but for the traditional Aboriginal woman it was highly unusual to behave in such a way toward a male doctor whom she had just met. It transpired that she had mixed mood (elevated) and psychotic features and required admission to the psychiatric ward of Alice Springs hospital.

It is necessary to have a good grounding in the understanding of the Aboriginal culture to judge the inappropriateness of behaviour. For example, somebody singing ceremonial songs outside of the ceremonial setting may be seen by the community as grossly disturbed behaviour because of its breaking of taboos. However the bizarre behaviour that I have witnessed does not appear different from that of Western cultures and has not always occurred in the context of psychosis. One patient with schizophrenia exhibited: strange grimacing, her gait would break into odd skipping movements and in the interview she kept moving objects around the table in a purposeless way. She drew obscure symbols on her arms which did not appear to be motifs of any culture, Aboriginal or non-Aboriginal.

Affect:

The problem of cross-cultural assessment of affect and mood is that the emotion terms are socio-culturally determined, Goddard (21). The earlier concepts of 'innate emotions' which were said to be anger, joy, surprise, fear and disgust and were said to be universal human emotions based on our shared biology, have been superseded by more recent developments in anthropological psychology' Averill (22), Ortony (23). The work of Morice (2426) has gone part of the way to elucidating cross cultural paraphrases for the meaning of emotional concepts.

Many Aboriginal children are taught from an early age not to cry, as crying is thought to lead to sickness in traditional society (personal communication from staff of Tennant Creek Aboriginal Medical Service). Thus tearfulness is rare in adults with a traditional background. Wailing and self harm are common expressions of grief but seldom crying. (In Western culture, grief counselling may focus on helping the person to cry, which is not appropriate for traditional Aboriginal people).

Seeing the patient in a one to one interview can give a very misleading view of their affect. Shyness, shame and reserve can masquerade as sad or flat affect. Patients with a blank or unreactive facial expression in a one to one interview with myself have come alive when their family join in the interview.

A middle aged Aboriginal woman was referred with possible depression by the DMO who had been seeing her for treatment of diabetes and had noticed a sad and restricted affect. I asked the AHW about this woman, and he was able to say that she 'Is always very ashamed in front of white people - she won't smile or say anything. But in her camp she is laughing and happy'. The exact reason for her 'shame' was not clear but it appeared to be a life long trait.

When a patient with a melancholic major depression is referred, the affect is unmistakable. There is the same empty, nihilistic, totally unreactive qualities that one sees in nonAboriginal cultures. One such young man was slouched on the concrete porch of his family's home, barely moved through the entire interview and seemed oblivious to the swarms of flies on his face. He responded well to tricyclic anti-depressants.

Likewise fatuous and incongruous affect were clearly recognisable and were usually accompanied by psychotic illness.

Strangely I rarely saw elevated or irritable affect, but this may be explained by a relatively low incidence of bipolar disorder in the remote communities (there are several hypotheses outlined in a later chapter).

Anxiety was the most difficult of affects to detect or to even understand its expression in words. The work of Cawte (7) shows how white clinicians can underestimate anxiety and emotional distress in traditional Aboriginal people and the work of Morice (2426) shows that careful study of the Aboriginal languages reveals a surprising array of words and phrases pertaining to different types of anxiety and related somatic phenomena.

Mood:

Reports of 'weak spirit' were a surprisingly reliable indicator of depressed mood and could be used as a synonym for depressed mood for example, 'Do you have weak spirit all of the day/every day?' 'What time of the day does your spirit feel the most weak?'

In contrast Aboriginal English is not adequate to communicate the irritable and elevated mood that one may see in mental disorders. The anthropologist Goddard (21) in his work 'Anger in the western desert a case study in crosscultural semantics of emotion' points out the folly of believing that 'the folk taxonomy provided by English emotion terms provides an objective, culture free analytical framework.' This is especially so with emotions involving anger. He found three expressions in the local language 'pikaringanyi, mirpanarinyi and kuyaringanyi each of which corresponds to some extent to the English concept of anger'. Morice (see appendix 6) was able to find expressions for justified and unjustified anger, which he used clinically with the Pintubi people. Without any linguistic background and having to work with a dozen language groups, my methods have been very crude - relying on the Aboriginal English word of 'cranky' as a synonym of irritability and 'silly' for elevated mood.

Speech and thought form:

Speech would be often difficult to understand because of it being softly spoken, because of broken English or Aboriginal English where word meaning and syntax are different to nonAboriginal English and because the pronunciation of consonants is quite unusual with 'V,' 'F' being pronounced as 'P', for example.

Formal thought disorders (including loose associations, word salad, tangentiality) are easily detected if the patient has good English. But if they do not, and they converse more in their own language, then one is reliant on an Aboriginal health worker/Aboriginal mental health worker acting as interpreter, to report that the patient is not making sense. Self reports of 'thinking backwards' by several young psychotic Arrandamen seemed to be used as a term for thought disorder.

Delayed answers to questions and a small amount of speech, for reasons already outlined, should not be considered in themselves as psycho-motor retardation or poverty of speech.

Thought content:

This proved to be a rich and absorbing area of the mental state examination. If rapport could be developed then often a large amount of material would be forthcoming. Interpreting any clinical significance was more difficult and once again reliance on family, and AHWs was crucial. Some beliefs expressed by patients were clearly delusional: ideas of reference from television or radio, grandiose delusions for example, 'I am Slim Dusty's sister' and well systematized persecutory delusions (the latter occurring in Aboriginals who had lived much of their life in more Westernised settings).

Of more difficulty were beliefs involving Aboriginal spirituality and customs, passivity phenomena and possession by outside forces. There are widespread cultural beliefs still prominent in remote areas that thoughts and feelings can be shared between closely related individuals in a telepathic way, that magical spells can be cast causing ill heath or even death, and that the Ngungkari can cure illness through removal of objects such as bone from the individual's body. If a patient expresses such beliefs, some of the beliefs may be delusional (not accepted by their community), some may be culturally accepted explanations of a primary psychotic phenomena and yet others may be culturally accepted beliefs occurring in the absence of any mental disorder.

Attempts to establish what is a culturally accepted belief can be frustrating as families seem to adopt the delusional beliefs, as per the process of association described by Eastwell (14). A young woman with depressive symptoms and suicidal thoughts was convinced that her ex-husband had put a spell on her 'to make my life a misery'. She believed that the reason that he had done this was because he was jealous, as she had remarried. She had remarried three years previously, her first husband had been living in a different community and there was no recent contact between the patient and the first husband, and no identifiable psychosocial stressors. It was unclear whether the depressive symptoms predated her belief in the spell and unclear about how she became aware of the spell. Circular logic was used to explain the cause and effect: 'I know the spell was put on me because my first husband is jealous.' 'I know my first husband is jealous, putting a spell on me was a very bad thing to do'. 'I want to die because the spell has made my life a misery.' Interviewing the family only added to the confusion. The mother told me that the patient is 'a mad one, just like her aunty who had the same problem', but that the spell was real and that if the ex-husband had not cast the spell the patient would have been alright.

There are various ways of interpreting the above information:

  1. That she developed a psychotic illness which manifested itself through depressed mood and delusions of persecutory control, and that the mother recognised her daughter was mentally ill but through the associative processes (documented by Eastwell) had adopted the daughter's psychotic beliefs. There is family history of mental illness (maternal aunt).
  2. That she developed a depressive illness, and that she adopted a culturally accepted explanation for the aetiology (a spell). There is family history of mental illness (maternal aunt).
  3. That there is no mental illness, but that through some mechanism unknown, but culturally accepted, she developed her belief in the spell, and then developed secondary depressed mood in response to this.

A day after the assessment the patient travelled several hundred kilometres to see a highly regarded Ngungkari. Some weeks later she was noted by clinic staff to be well and she had had no antipsychotic medication.

Usually most cases are less perplexing than this. The primary symptoms can usually be seen to pre-date the culturally based retrospective attributions, the retrospective attributions tend to be multiple different explanations of the primary symptoms, and the family will express concern if there are psychotic symptoms even if they may not be able to label some symptoms as delusional. (Note that one is conscious in these situations of asking the family to think in a very Western way regarding cause and effect).

As a reflection of the fact that Aboriginal cultures are in constant state of flux, many psychotic patients have expressed delusions with very Aboriginal content together with very Western/European content all in the same episode, for example, a young man with schizophrenia who believed he was being called to become a Ngungkari to save his grandfather from an evil spell, and at the same time believed that Jesus Christ was interfering with his brain.

There are often phenomena that remain puzzling, and it is a danger that the non-Aboriginal clinician may attempt to put a familiar label to it more to decrease his or her own anxieties than to enhance understanding. One young man was referred by family for becoming withdrawn, odd and uncharacteristically aggressive towards his parents. In the interview he was perplexed and preoccupied by internal phenomena and said that he had struck his parents 'because they made my memories go away'. Was this thought withdrawal? Whatever phenomena it was, it responded to neuroleptics. The overall picture (an impressionistic one rather than of photographic quality) was of an acute psychosis, so I treated it but my diagnostic doubts were compelling me to label his symptom as thought withdrawal.

Perception:

As Hunter (17) points out, in all cultures hallucinations may be pathological or 'culturally based' for example, it is normal for Pentecostalists to receive messages from God. In Aboriginal cultures an AHW can be useful in exploring whether the hallucinations make sense in a cultural way.

Most of the hallucinations that seemed culturally based in my work were fleeting visual hallucinations occurring in the absence of organic mental disorder for example, glimpses of spirits, or the feared Kudaicha man, or during intense ceremonies.

The Kudaicha man is a real man, especially assigned to creep up on people and either scare them or to in fact kill them as a form of punishment for previous misdemeanours. The Kudaicha man is said to move around at night on the quarter moon and to walk with the specially made emu feather shoes to disguise his tracks.

Because of the intense fear surrounding the Kudaicha man one could speculate that many of the sightings may be caused by suggestion.

In some of the ceremonies there is very intense suggestion mediated by charismatic elders. Even the few non-Aboriginal people allowed in such a setting may develop visual hallucinations or illusions. A colleague of mine, who attended such a ceremony, was convinced he saw a man turn into a black kangaroo and was quite distressed by the experience. The other men at the ceremony saw the same vision, while the man who had transformed himself to the kangaroo was a charismatic elder revered for his magical skills.

Auditory hallucinations, especially if they persist for any length of time were seldom seen as culturally based by Aboriginal people and almost always there was other evidence of serious mental illness.

Cognition:

My ability to assess cognition was hampered by the lack of culturally sensitive assessment tools. The challenge to come up with more culturally appropriate measures was greater in the cognitive assessment than any other component of the mental state examination. The Folstein Mini Mental State Examination and most other modes of assessment that I had gained in my training were virtually useless. Traditional Aboriginal people had no written tradition, individual numbering went up to the number three, general knowledge is vastly different and the concept of a Prime Minister is alien let alone the name of the Prime Minister. And in the area of orientation, the concept of time and place is very different. The people of the remote communities would find standard tests of cognition silly and they would be unable to understand their purpose thereby making their motivation poor. Furthermore, standard assessments of function and activities of daily living (ADLs) are not appropriate in remote communities where living is more communal. Diagnostic classification of dementia such as in DSM IV require criteria about impaired function, but how does one measure that in a remote community when the individual does not have to catch public transport, memorise a PIN number or carry out any of the other familiar tasks of daily living that are familiar to us in Western society?

Zann (31) has come up with culturally appropriate cognitive assessment scales for dementia screening in the ATSI people of North Queensland, but even this was not applicable to Central Australia for example, one question asks the subject to state why the following names are famous: Neville Bonner, Albert Namatjira, Charlie Pride and Slim Dusty. Many people in the remote communities, especially the elderly, have never heard of these names.

Mahajani et al (36) attempted to modify the Folstein MMSE for Aborigines in the Top End, but found technical problems (poor eyesight and hearing in subjects limited alternative tests for cognition, for example they tried sequencing with coloured sticks instead of numbers or with notes on xylophone instead of numbers). Collecting 'informant history' has been focused on, though with some problems with family not wanting to give embarrassing details of their elder relative's behaviour, Pollitt (30).

There is a high incidence of cognitive decline in remote Aboriginal communities because of multiple risk factors: alcohol abuse, petrol sniffing, high incidence of head trauma, CNS infections, and poor nutrition. But the families of sufferers do not seek help until very late, Pollitt (30). Several cases of undiagnosed moderate to severe dementia were referred to me because of extreme disruptive behaviour, while their declining abilities had been quietly managed by the family for the preceding several years.

The following measures for cognitive assessment were ones which I developed through necessity. They are coarse and not validated, but more useful than the usual measures:

Information from family:

Orientation:

Concentration:

Short term memory:

Long term memory:

Cortical Function:

Figure 15. Talking to an Aboriginal elder on the concrete verandah
 
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Figure 16. Some emergencies can require calling on the services of the Royal Flying Doctor Service.
 
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