By Shin Ho-chul
A 25-year-old female with symptoms of irritable moods, aggressive behavior, talkativeness, decreased need for sleep, wandering behavior and visual hallucinations was brought to a hospital by her father.
After a thorough interview, my impression was bipolar I disorder, most recent manic episodes, severe with psychotic features and immediate admission to the psychiatric ward was needed for her safety and treatment. Bipolar Ⅰ disorder is a mood disorder with depressive and manic episodes of which intensive and appropriate pharmacotherapy is necessary.
After five days of hospitalization her father strongly insisted on discharge saying she should see a shaman rather than a psychiatrist because an evil spirit was causing all these symptoms. I explained to him that her daughter's moods and psychotic symptoms had nothing to do with that evil spirit but she was having psychiatric problems that can be treated with medication. But he was stubborn and he eventually signed an ``against medical advice” note. He didn't have any insight at all.
I was surprised to discover that some people in this era of science and technology still have blind faith in unscientific approaches when seeking medical help. It is something similar to consulting a fortuneteller at the beginning of the year to find out what their future will be like.
But the consequences are much more serious in the former case since it is directly related to the patient's health and it can be a threat to one's well-being. I'm not trying to devalue or look down on shamanism as it is a part of Korea's folk beliefs that need to be respected in terms of cultural value.
However, the following question came to my mind: Why are some people in Korea more dependent on a shaman than a psychiatrist when psychiatric symptoms occur? There are several reasons for explaining this unscientific behavior.
Firstly, a lack of insight. Insight is defined in psychiatry textbooks as a patient's degree of awareness and understanding about being ill. Patients with psychotic disorders, in particular, have little or no insight at all and do not take their symptoms as medically deviant. This leads to poor compliance making treatment difficult. Therefore it is important to educate patients as well as their families that psychiatric disorders are diseases of the brain that need medical treatment like pneumonia or cancer.
Secondly, psychiatrists’ lack of rapport with the patient acts as a communication barrier and this results in misunderstandings and a lack of confidence. Rapport plays a crucial role in determining the outcome and the prognosis of a disorder. The key in enhancing therapeutic relationships is empathy, that is, sharing the patient's feelings and emotions.
Thirdly, strong rejection of seeking help from a psychiatrist may be due to fear about prejudice and stigma in our society. Seeing a psychiatrist, being diagnosed with a mental disorder and taking antidepressants or antipsychotics are all considered having a scarlet letter.
Patients relieve their feelings of fear and helplessness by denying the fact that they have incapacitating disorders. They attribute their symptoms to external factors instead of admitting the problems arise from within themselves. This attitude drives them to look for nonprofessionals. It is psychiatrists' role to educate the public and give them the right information to weaken prejudice.
As a psychiatrist I've had three of my patients discharged early in the course of treatment for they preferred exorcism performed by a shaman. The first two came back in less than two weeks after financial losses and worsening symptoms. Hopefully my third patient will visit the clinic again before too long and be treated in a proper way.
The writer is a psychiatrist working at a psychiatric clinic in Gunpo, Gyeonggi Province. E-mail him at medics96@naver.com.