CULTURE AND SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

https://doi.org/10.1016/S0193-953X(05)70240-9Get rights and content

Reaction patterns labelled psychopathologic are believed to be universal, indicating their biologic roots. All over the world there are people who express delusions or report hallucinations. Yet, the prevalence and nature of psychopathology also varies, sometimes greatly so, from one culture to another. Differences across cultures underline the impact of cultural processes on mental illness. Cross-cultural psychiatry aspires to investigate both these dimensions, worldwide equivalence and culturally determined variability.

Psychotic illnesses such as schizophrenia extract an enormous price in terms of personal, social, and economic costs, across the world. Research over the decades has been able to establish schizophrenia as a disease of the brain, with multiple clinical manifestations. These manifestations combine in various ways to create considerable diversity among those afflicted. Both its strong genetic-biologic component and its differing presentations, make it ideally suited for the study of interactions between cultural, psychosocial, and biologic influences.

This article attempts to present a brief overview of cultural aspects of schizophrenia and acute psychoses. The major emphasis is on cultural facets of epidemiology, etiology, phenomenology, and the course and outcome of these disorders. The main, and somewhat inevitable focus, is on the distinction between Western (developed) and non-Western (developing) cultures. Although this may not always be the ideal comparison, most research findings on schizophrenia, seemed to have relied on this distinction. Therefore, it is a useful starting point in the process of understanding the cross-cultural complexities of these disorders.

Section snippets

Definitions of Culture

Culture has been defined in many different ways according to preferences of particular authors. Most, however, regard it as some form of shared learned behavior, handed down from one generation to the next, for purposes of individual and societal growth. These definitions also emphasize an objective (external) aspect consisting of artifacts, roles, and institutions, and a subjective (internal) aspect represented by shared beliefs, attitudes, values, and norms1, 62 Even such comprehensive

CONTRIBUTIONS OF THE WORLD HEALTH ORGANIZATION

Since the 1960s the World Health Organization (WHO) has been conducting a series of multinational, multicentric epidemiologic studies of schizophrenia. These began with twin purposes of gathering information about incidence and prevalence, and formulating a model for cross-cultural epidemiologic research. Three such large-scale international collaborative studies have been conducted.83, 84

Prevalence

A striking feature of studies on prevalence of schizophrenia in different cultures is the similarity of their findings. Prevalence rates of the more reliably conducted studies vary between 1 to 2 per 1000 population. Age specific rates above 16 years are of the order of 4 to 5 per thousand.33 Cross-cultural comparisons have also suggested that the rates do not vary greatly between developing and developed countries.57, 69 Studies from different parts of India have also yielded similar rates of

Initial Comparisons

Historically, till the publication of the work of Murphy and Raman69 it was generally accepted that schizophrenia had similar course and outcome across the globe. These authors from Mauritius were the first to demonstrate an improved outcome and favorable course among indigenous Mauritians, than comparable Western populations. Two subsequent studies, one from Hong Kong,59 and the other from Sri Lanka,106 also found good outcomes in a major proportion of their samples. Contrary findings were,

SOCIOCULTURAL FACTORS AND OUTCOME

The exact nature of social, cultural or environmental factors contributing to the better outcome in developing countries has been the subject of much debate. Effects of industrialization, differences in physical environment or family atmosphere, have all been invoked as responsible factors. No definite conclusions have been reached.

CULTURAL ASPECTS OF TREATMENT

This area has been explored in great depth by all manner of professionals. Volumes have written on the role of traditional healers in non-Western cultures. There are also several hypotheses about how therapeutic processes in indigenous treatments work. Research has shown that cultural beliefs and norms also determine the pathways to care.40 In addition, there is growing body of literature that points to the impact of sociocultural factors on treatment with drugs. Ethnic differences in

ACUTE PSYCHOSES

The existence of transient psychoses, which are neither schizophrenic, nor affective, has been long suspected. The concept has survived under several pseudonyms such as hysterical psychosis, bouffee delirante, reactive psychosis, and so forth.113 Clinical experience and research reports have suggested that this entity is much more frequent in non-Western cultures, where it accounts for a large proportion of psychiatric hospitalizations.87, 88 The IPSS111 and the DOSMeD34, 85 studies were able

A METHODOLOGIC DILEMMA

Theoretic and methodologic issues related to cross-cultural psychiatry have been discussed by several authors.19, 41 Only a brief mention of the outstanding problems is made in this article.

The central conflict in comparative psychiatry across cultures seems to be between its two goals: to demonstrate worldwide equivalence and cultural differences. It has been argued that investigators have too often been influenced by Western concepts of normality and abnormality, and the undue reliance of

SUMMARY

The comparative study of schizophrenia and related disorders across cultures has come a long way since Kraepelin advocated its cause, following his trip to Java at the beginning of the last century. The principal development since then has been the burgeoning of interest in the field, culminating in innovative and ambitious international collaborative research by the WHO. Despite reservations about covert ideology or about the more overt methodologic difficulties, the balance of evidence from

References (116)

  • G.W. Brown et al.

    Post-hospital adjustment of chronic mental patients

    Lancet

    (1958)
  • M. Karno et al.

    Cross-cultural issues in the course and treatment of schizophrenia

    Psychiatric Clin North America

    (1993)
  • P. Kulhara et al.

    Positive and negative subtypes of schizophrenia: A follow-up study from India

    Schizophr Res

    (1990)
  • I. Al-Issa

    Does culture make a difference in psychopathology?

  • I. Al-Issa

    Culture and mental illness in an international perspective

  • I. Al-Issa

    Hallucinations and culture

    B J Psychiatry

    (1995)
  • A. Arora et al.

    Subsyndromes of chronic schizophrenia: A phenomenological study

    Acta Psychiatr Scand

    (1997)
  • P.E. Bebbington

    Life events in schizophrenia. The WHO collaborative study

    Soc Psychiatry Psychiatr Epidemiol

    (1987)
  • D. Bhugra et al.

    Factors in onset of schizophrenia: A comparison between London and Trinidad samples

    Acta Psychiatr Scand

    (2000)
  • M. Birchwood et al.

    The influence of ethnicity and family structure on relapse in first-episode schizophrenia. A comparison of Asian, Afro-Caribbean and white patients

    Br J Psychiatry

    (1992)
  • W.T. Carpenter et al.

    Cross-cultural evaluation of Schneider's first-rank symptoms: a report from the international pilot study of schizophrenia

    Am J Psychiatry

    (1974)
  • A. Chakraborty et al.

    Witchcraft beliefs and persecutory ideas in Bengali culture

    Indian J Social Psychiatry

    (1985)
  • R. Chandrasena

    Schneider's first-rank symptoms: An international and interethnic comparative study

    Acta Psychiatr Scand

    (1987)
  • R. Chandrasena et al.

    Schneider's first-rank symptoms: Their prevalence and diagnostic implications in an Asian population

    Br J Psychiatry

    (1979)
  • Y.H. Chen et al.

    Negative symptoms, neurological signs and neurophysiological impairments in 204 Hong Kong Chinese patients with schizophrenia

    Br J Psychiatry

    (1996)
  • J.E. Cooper et al.

    Cultural and temporal variations in schizophrenia: a speculation on the importance of industrialization

    Br J Psychiatry

    (1977)
  • J.E. Cooper et al.

    WHO collaborative studies on acute psychoses using the SCAAPS schedule

  • R. Collignon et al.

    The interface between culture and mental illness in French speaking West Africa

  • P.Y. Collins et al.

    Fever and acute brief psychosis in urban and rural settings in North India

    B J Psychiatry

    (1999)
  • T.J. Craig et al.

    Outcome in schizophrenia and related disorders compared between developing and developed countries. A recursive partitioning re-analysis of the DOSMD data

    B J Psychiatry

    (1997)
  • J.G. Draguns

    Methodology in cross-cultural psychopathology

  • K.C. Dube et al.

    Long term course and outcome of the Agra Cases in the International Pilot Study of Schizophrenia

    Acta Psychiatr Scand

    (1984)
  • J.M. Eagles

    Is schizophrenia disappearing?

    Br J Psychiatry

    (1991)
  • J.M. Eagles

    The relationship between schizophrenia and immigration: Are there alternatives to psychosocial hypotheses?

    Br J Psychiatry

    (1991)
  • R.B. Edgerton et al.

    Culture and schizophrenia: the DOSMD challenge

    B J Psychiatry

    (1994)
  • M.F. El-Islam

    A better outlook for schizophrenics living in extended families

    B J Psychiatry

    (1979)
  • J.B. Enright et al.

    Psychiatric symptoms and diagnosis in two subcultures

    Int J Soc Psychiatry

    (1963)
  • S. Gupta

    Cross-national differences in the frequency and outcome of schizophrenia: a comparison of five hypotheses

    Soc Psychiatry Psychiatr Epidemiol

    (1992)
  • O. Gureje

    Correlates of positive and negative schizophrenic syndromes in Nigerian patients

    B J Psychiatry

    (1989)
  • O. Gureje et al.

    Thirteen-year social outcome among Nigerian outpatients with schizophrenia

    Soc Psychiatry Psychiatr Epidemiol

    (1999)
  • O. Gureje et al.

    Three syndromes in schizophrenia: validity in young patients with recent onset of illness

    Psychological Medicine

    (1995)
  • G. Harrison et al.

    Schizophrenia—falling incidence and better outcome?

    Br J Psychiatry

    (1995)
  • H.G. Hwu et al.

    Negative symptoms at discharge predict poor outcome in schizophrenia

    Br J Psychiatry

    (1987)
  • A. Jablensky

    Is schizophrenia universal?

    Acta Psychiatr Scand

    (1988)
  • A. Jablensky et al.

    Culture and schizophrenia

    Psychological Medicine

    (1975)
  • A. Jablensky et al.

    Schizophrenia; manifestations incidence and course in different cultures. A World Health Organization ten-country study

    Psychol Med

    (1992)
  • A. Jablensky et al.

    Culture and schizophrenia

    Br J Psychiatry

    (1994)
  • J.H. Jenkins

    Anthropology, expressed emotion and schizophrenia

    Ethos

    (1991)
  • J.H. Jenkins et al.

    The meaning of expressed emotion: theoretical issues raised by cross-cultural research

    Am J Psychiatry

    (1992)
  • P. John-Mathai et al.

    Deficits of chronic schizophrenia in relation to long-term hospitalization

    Br J Psychiatry

    (1986)
  • P. Jorgensen et al.

    Acute and transient psychotic disorder: a 1-year follow-up study

    Acta Psychiatr Scand

    (1997)
  • A. Kleinman

    Anthropology and psychiatry. The role of culture in cross-cultural research on illness

    Br J Psychiatry

    (1987)
  • P. Kulhara et al.

    The chronicity of schizophrenia in North-West India: results of a follow-up study

    Br J Psychiatry

    (1978)
  • P. Kulhara et al.

    Phenomenology of schizophrenic and affective disorders in India—a review

    Indian J Social Psychiatry

    (1985)
  • P. Kulhara et al.

    Positive and negative subtypes of schizophrenia

    Acta Psychiatr Scand

    (1986)
  • P. Kulhara et al.

    Psychiatric manifestations of CATEGO S + schizophrenia

    Indian J Psychiatry

    (1987)
  • P. Kulhara et al.

    Magico-religious beliefs in schizophrenia: A study from India

    Psychopathology

    (2000)
  • T. Kurihara et al.

    Outcome of schizophrenia in a non-industrialized society: comparative study between Bali and Tokyo

    Acta Psychiatr Scand

    (2000)
  • K. Kuruvilla

    Society, culture and psychopharmacology

    Indian J Psychiatry

    (1996)
  • P.W.H. Lee et al.

    Patterns of outcome in schizophrenia in Hong Kong

    Acta Psychiatr Scand

    (1991)
  • Cited by (57)

    • Regional differences in treatment response and three year course of schizophrenia across the world

      2012, Journal of Psychiatric Research
      Citation Excerpt :

      The three WHO studies – The International Pilot Study of Schizophrenia (IPSS) (WHO, 1979), the Determinants of Outcome of Severe Mental Disorders (DOSMeD) (Jablensky et al., 1992) and their successor, the long-term (15- and 25-year) International Study of Schizophrenia (ISoS) (Harrison et al., 2001) – all confirmed that patients living in less economically developed regions have better outcomes than those living in more industrialized regions. While the exact nature of socio-cultural factors contributing to this observation has been the subject of much debate (Kulhara and Chakrabarti, 2001), close family support, greater opportunities for social reintegration, and more positive attitude towards mental illness in less developed countries have been offered as possible explanations (Birchwood et al., 1992). Given that most of these studies were conducted 2–3 decades ago, the present study aimed to revisit this issue to investigate whether the geographical differences in the prognosis of schizophrenia are still present today, using the large naturalistic 3-year W-SOHO (Worldwide-Schizophrenia Outpatient Health Outcomes) study conducted in 37 countries across six regions (Northern Europe, Southern Europe, Central and Eastern Europe, East Asia, North Africa and Middle East, Latin America).

    • The usefulness of a self-report questionnaire measuring auditory verbal hallucinations

      2010, Progress in Neuro-Psychopharmacology and Biological Psychiatry
    • Stress management in family environment

      2024, Indian Journal of Psychiatry
    View all citing articles on Scopus

    Address reprint requests to Parmanand Kulhara, MD, FRCPsych, FAMS, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh -160012, India

    *

    Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

    View full text