Embed Size (px)
Citation preview
Correspondence: Dinesh Bhugra, Professor of Mental Health and Cultural Diversity, Health Service & Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK. Tel: � 44 20 7848 0500. Fax: � 44 20 7848 5056. E-mail: [email protected]
(Received 16 March 2012; accepted 29 June 2012)
Cultural aspects of schizophrenia
GURVINDER KALRA 1 , DINESH BHUGRA 2 & NILESH SHAH 1
1 Department of Psychiatry, Lokmanya Tilak Medical College and Sion Hospital, Sion, Mumbai, India, and 2 Health Service and Population Research Department, Institute of Psychiatry, King’s College London, UK
Abstract Over the past 50 years, schizophrenia as a disorder has been widely studied across cultures throughout the world. There are differences not only in the symptoms and presentation but also in outcome and prognosis. Various authors have tried to explore and explain such variation but the reasons for this are not always clear. In this paper, we review some of the cultural aspects of schizophrenia.
Introduction
We are born into a culture and not with culture. The core components of culture are diffi cult to defi ne but are often recognized as a collection of beliefs, atti-tudes, shared understanding, knowledge, customs, habits and patterns of behaviour which infl uence cognitions and social development of individuals, and therefore a way of life. There are cultures we are born into and cultures we gather, for example that of the school, university, place of work, etc. So indi-viduals often carry multiple identities related to gen-der, religion, and other factors. On the one hand culture binds individuals together keeping them in a group, while on the other it also sets characteristics related to a distinction from the ‘ other ’ , thus con-fi rming both individual and group identities.
Cultural variations are critical in our under standing of bio-psycho-social models of aetiology and manage-ment of psychiatric conditions. Concerns have been expressed that as medical specialists, psychiatrists see cultures as universalist, whereas anthropologists see cultures as relativist (Skultans, 1993) and this tension can create problems in understanding and interpret-ing differences. Another complicating factor is that when we talk about relationship between culture and mental illness it is not always easy to link particular aspects of culture with specifi c aspects of illness. However, sometimes religious experiences can contribute to contents of delusions and hallucina-tions. In the past three decades, cultural factors and culture have become increasingly important in understanding causative factors and prognosis due to
increased globalization among other factors. Cultural psychiatry is thus primarily concerned with an under-standing of various aspects of normal and abnormal human behaviour, psychopathology and treatment of mentally ill patients in the context of their cultures.
Culture and psychopathology
There is no doubt that culture plays a signifi cant role in our understanding of both normality and deviance through which abnormality is defi ned and identifi ed, which is of signifi cance particularly in psychiatry. Culture defi nes deviance and also how emotional distress is expressed and where help is sought from. Resources for healthcare are allocated according to cultural systems for health-care in place. In addition, cultures determine how sickness and illness are defi ned and that will deter-mine what the fi rst port of call is. This relation between culture and psychopathology has been elaborated by Tseng (2003):
Culturally shared ideas or beliefs directly con-(1) tribute to stress, and this can lead to psychopa-thology (pathogenicity). For instance, culturally shared beliefs over the importance of semen in determining one ’ s vigour and vitality lead to stress over semen-loss and hence dhat syndrome (semen loss anxiety). Culturally sanctioned reaction patterns may be (2) selected by people from a certain culture in times of stress as a means of coping with stress (pathoselec-tivity). For instance, running amok in Malaysian
International Review of Psychiatry, October 2012; 24(5): 441–449
ISSN 0954–0261 print/ISSN 1369–1627 online © 2012 Institute of PsychiatryDOI: 10.3109/09540261.2012.708649
Int R
ev P
sych
iatr
y D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Con
nect
icut
on
08/2
6/13
For
pers
onal
use
onl
y.
442 G. Kalra et al.
culture is a culturally sanctioned reaction pattern in response to stress (Tan & Carr, 1977). How-ever, similar events in the USA such as the Columbine high school attack are not identifi ed as such even though there are clear similarities. Cultural beliefs or ideas infl uence the presenta-(3) tion of symptoms of a psychiatric illness (patho-plasticity). Thus individuals from different cultures may differ in the content of their delusions: an Indian believing that he is a particular famous Bollywood personality, an American believing that he knows President Obama. The two differ-ent cultures that these individuals belong to thus affect the content of their delusions. Even within the same culture the contents vary across times. For example in the UK, delusions related to mustard gas poisoning were very common after the Second World War and then were replaced by science fi ction and now the Internet and terror-ism seem to play a bigger role. Many cultural beliefs may reinforce certain path-(4) ological behaviours making them take extreme forms (pathoelaborative effect). For instance, cultural beliefs that one can be possessed by gods lead to various possession and dissociative states in many individuals in India, states that may not necessarily be considered pathological and in fact may receive social sanction. Cultural factors infl uence the presentation of a (5) psychopathology, especially in terms of its preva-lence (pathofacilitative effect). Thus rates of sub-stance abuse or dependence, suicide and paraphilias (both type and content) can be affected. Cultural beliefs may infl uence people ’ s reaction (6) towards a mental illness (pathoreactivity), thus affe cting the labelling of disorder, and expression of suffering due to the disorder. For instance, research from the 1970s revealed how stigma towards mentally ill people was in part responsi-ble for the unpleasant sight of these patients roaming naked on the streets (Odejide & Olatawura, 1979). Similarly, low levels of stigma attached to mental illness in developing coun-tries may promote greater tolerance and com-munity support for people with serious mental illness (Warner, 2000).
When people express emotional distress it is identifi ed as abnormal according to cultural values. For example, speaking in tongues will not be identi-fi ed as abnormal in certain settings whereas in others it will be seen as clearly abnormal.
Historical studies
Clinicians recognized that mental illness presents dif-ferently in different cultures as early as the middle of
the 18th century (Tseng, 2001), but it was only around the 1930s that epidemiological surveys were conducted to investigate the pre valence of mental illness in various cultures; for instance, the Thuringia study in Germany (Brugger, 1931), the Baltimore study in the USA (Lemkau et al., 1941), the Formosa study in Taiwan (Lin, 1953), a study by Leighton et al. (1963) in Nigeria, and one by Raman and Murphy (1972) in Mauritius. These initial studies done on census samples indicated general trends and prevalence patterns of different mental illnesses. These pioneering studies also laid the foun-dation for subsequent cross-cultural studies which explored the possible infl uences of culture on mental disorders, especially schizophrenia and other psy-chotic disorders.
In a series of studies on schizophrenia among the Yoruba in Nigeria during this time, the limitations of western diagnostic concepts in African cultural contexts were pointed out by Lambo (1965). This was confi rmed around a decade later in Asia when Yap (1974) conceptualized the so-called ‘ culture-bound syndromes ’ pointing out their differentiation from schizophrenia, again questioning western diag-nostic concepts. These concepts have been chal-lenged recently (Bhugra et al., 2007; Sumathipala et al., 2004).
During the 1960s and 1970s, the World Health Organization (WHO) conducted two major cross-cultural multinational studies to study schizophre-nia in different countries, namely the International Pilot Study of Schizophrenia (IPSS) (Leff et al., 1992; WHO, 1973, 1979) and Determinants of Outcome of Severe Mental Disorders (DOSMeD) (Jablensky et al., 1992) that set the benchmark for comparing illnesses across cultures. These studies, conducted in 16 geographically defi ned areas in 12 different countries across Asia, Africa, America and Europe, were the fi rst of their kind of large-scale studies carried out using standardized diagnostic criteria and assessment methods by locally based mental health professionals trained to use these research tools. While these studies provided a large database allowing direct comparisons of the population rates, psychopathology and outcomes of schizophrenia and other psychoses across various cultures, questions have been raised about their methodology, diagnostic ambiguities and the basic defi nitions of ‘ developed ’ versus ‘ developing ’ nations (Burns, 2009; Cohen et al., 2008; Edgerton & Cohen, 1994; Patel et al., 2006).
There are several problems with these studies including the use of western assessment tools which may not be entirely suitable across cultures. In addi-tion, authors focused on similarities rather than dif-ferences when interpreting their fi ndings. The authors for both studies looked at narrow defi nition
Int R
ev P
sych
iatr
y D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Con
nect
icut
on
08/2
6/13
For
pers
onal
use
onl
y.
Cultural aspects of schizophrenia 443
schizophrenia which in itself also had a two-fold variation across different countries but were ignored in the discussions. The variation across broad defi ni-tion schizophrenia was even greater and may be more likely to be infl uenced by cultural factors.
Kleinman (1988) suggested that the investiga-tors of the DOSMeD study may have placed an overwhelming emphasis on universal aspects of schizophrenia at a syndromal level, while ignoring cultural differences in the subtypes of the disorder that could have led to the signifi cant differences in the outcome of this disorder in the two worlds. A secondary analysis of DOSMeD data showed that Prague and Nottingham from the developed world had schizophrenia outcomes similar to centres from the developing world, while outcomes in Cali from the developing world were similar to those found in the developed world (Craig et al., 1997). Cohen et al. (2008) challenge the assumption of favourable outcomes of schizophrenia in low and middle income countries in the absence of access to healthcare. Studies show that a high percentage of schizophrenia patients from developing coun-tries such as China, India, and Indonesia may never receive biomedical treatments, which means that this section of ‘ severely ill ’ schizophrenics with poor prognosis were never included in the WHO studies (Cohen et al., 2008). It may also be that such comparisons need to take into account details of healthcare systems. Nevertheless, these studies have been highlighted as ‘ arguably the greatest achievements in psychiatric epidemiology provid-ing us with the single most important fi nding in cross-cultural psychiatry ’ (Lin & Kleinman, 1988; McIntosh & Lawrie, 2004). Others have called them one of the best designed and executed out-come studies of psychosis (Alem et al ., 2009). However, the problems in comparing different sites and use of western diagnostic categories can-not be ignored in interpretation of any data.
Incidence and prevalence
As per the WHO IPSS and DOSMeD studies, inci-dence of schizophrenia was found to be 0.7 – 1.4 per 10,000 in the age group of 18 – 44 years, and a life-time prevalence rate of around 1% across national boundaries (Jablensky, 2003; WHO, 1974). Higher rates reported in Washington DC and Moscow were explained by a broader syndrome defi nition in the USA, thus allowing for inclusion of many milder abnormalities as a part of schizophrenia spectrum and in the USSR as a political diagnosis. Again these can be challenged on a number of grounds as the interpretation had ignored the cultural context in both centres.
Cross-national studies have produced point prev-alence rates in the range of 1.4 to 7.1 per 1,000 population at risk (see Jablensky, 2003). Consider-able variation in the rates of schizophrenia across geographical regions may be attributed to method-ological differences between studies, including study design, data collection methods, sample size, and other factors as discussed above.
In the UK, studies have suggested a higher prev-alence of schizophrenia in Afro-Caribbean individu-als for over 50 years. In the 1960s, Hemsi (1967) reported that schizophrenia was 4.5 times higher in Afro-Caribbeans than in Caucasians among patients attending their general practitioner (GP). These fi ndings were replicated by Dean et al. (1981) in South London. Snowden and Cheung (1990) reported that schizophrenia was diagnosed con-sistently more often in black people (56.3%) than in white (31.5%). These higher rates were also mirrored in subsequent studies by Bhugra et al. (1997) and Harrison et al. (1997). A recent study in the UK has reported a 9-fold higher rate of schizophrenia among individuals of Afro-Caribbean ethnicity, and nearly a 6-fold increased risk among black African individuals compared to white Africans (Fearon et al., 2006; Karlsen et al., 2005).
Looking at schizophrenia studies from the USA, as noted above, Odegaard in his classic study observed that Norwegian immigrants in the USA were admitted to a psychiatric hospital for schizo-phrenia twice as often as native-born Americans or Norwegians in Norway (Odegaard, 1932). Similar higher fi rst-admission rates for schizophrenia in foreign-born residents of New York State were later reported by Malzberg (1940). The Epidemiologic Catchment Area study also reported a signifi cantly higher prevalence in African Americans than Caucasians (Robins & Regier, 1991), who were about three times more likely than Caucasians in the USA to be diagnosed with schizophrenia in a study by Bresnahan et al. (2007); this risk was maintained at 2-fold after adjusting for indicators of family socio-economic status (SES), thus con-cluding that this association may have been partly but not wholly mediated by an effect of race on family SES. These results were also reproduced in the fi rst National Comorbidity Study which reported a higher prevalence of clinician diagnosed non-affective psychosis in non-white people (Kendler et al., 1996). These fi ndings point to the major health disparities between African Americans and Caucasians that may be present across the life course of indi-viduals (Collins & Hammond, 1996; Geronimus et al., 1996; Polednak, 1991). Higher rates for schizophrenia have also been reported from the Netherlands for Surinamese migrants (Selten et al., 2005) and from Germany for Turkish migrants.
Int R
ev P
sych
iatr
y D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Con
nect
icut
on
08/2
6/13
For
pers
onal
use
onl
y.
444 G. Kalra et al.
Symptoms
Although schizophrenia is universally ubiquitous, its manifestations are not uniform across cultures. As noted above, culture has an important role in the presentation of distress and illness (Bhugra et al., 2011; Kirmayer, 2005) and this in turn affects manifestations of the disorder (Azhar et al., 1995). The content and severity of psychotic symptoms is infl uenced by cultural factors (Al-Issa, 1995; Little-wood & Lipsedge, 1981; Mezzich et al., 1999).
The fi rst cross-cultural surveys on the frequency of different types of hallucinations were carried out by Murphy et al. (1963). These authors showed a difference in the prevalence of types of hallucinations in different cultures and established a relationship between culture and types of hallucinations. The researchers collected data about the local distribu-tion of psychotic features through questionnaires that were sent out to selected psychiatric centres all around the world. The key fi nding of this study was a higher incidence of visual as well as tactile halluci-nations in patients from Africa, a fi nding that was later replicated by Ndetei and Vadher (1984a). They also reported a higher frequency of auditory and visual hallucinations in non-European patients com-pared with Europeans. In fact, literature shows that visual hallucinations are more frequently reported in traditional cultures (Murphy et al., 1963; Pfeiffer, 1994; Suhail & Cochrane, 2002). Culture may have a pathoplastic effect on hallucinations; for instance, a schizophrenic patient from India may hear the voice of Lord Shiva to sacrifi ce his thumb in order to gain Nirvana in life, while a similar patient from the USA or UK may hallucinate with voice of Satan commanding the same. The languages that patients speak also affect auditory hallucinations, as was reported by Wang et al. (1998), wherein patients could hear voices not only in their fi rst language, but also in their second and third languages.
Table 1 highlights a few studies from different countries reporting the prevalence of different types of hallucinations in schizophrenic patients. In all these studies auditory hallucinations were the most
common, followed by visual and kinesthetic halluci-nations. Others such as tactile, olfactory, and gusta-tory hallucinations were infrequently reported by schizophrenia patients. A number of cross-cultural studies have reported persecution as the most preva-lent theme in delusions in schizophrenia in different cultures (Stompe et al., 1999). The prevalence of delusions and hallucinations with religious content varies between cultures and over time (Ndetei & Vadher, 1984b). Religious delusions have been described in schizophrenia in different cultures (Stompe et al., 1999; Tateyama et al., 1993). Although these religious delusions are seen as interesting themes (Stompe et al., 2006), they have also been associated with a poorer prognosis (Mohr et al., 2010). In a cross-sectional study on 193 patients, Siddle et al. (2002) reported religious delusions in 24% of patients, and these patients with religious delusions had higher symptom scores on the Positive And Negative Syndrome Scale (PANSS), lower scores on Global Assessment of Functioning (GAF) indicative of poorer socio-occupational functioning, and were receiving more medications compared to patients of schizophrenia with other types of delu-sions. In religious delusions there is a prevalence rate of 21% in Germany compared to 7% in Japan (Tateyama et al., 1993), 21% in Austria compared to 6% in Pakistan (Stompe et al., 1999), and 36% in the USA (Appelbaum et al., 1999). To differentiate infl uences of culture of native country from the infl u-ence of host nation ’ s culture, Suhail and Cochrane (2002) compared three different groups of Pakistani patients with schizophrenia: (1) Pakistani patients living in Pakistan, (2) Pakistani migrants living in the UK, and (3) patients of white British origin. In their study they found that patients living in Pakistan reported a higher rate of visual hallucinations com-pared to the other two groups, while they reported a lesser rate of auditory hallucinations. This suggests that the infl uence of newer culture on the phenom-enology of hallucinations may be more important than the infl uence of one ’ s native culture. However, this deserves to be explored further.
Table 1. Cross-cultural prevalence of different types of hallucinations.
Study Country Types of hallucinations
Bowman & Raymond (1931) US A (50%); V (18%); T (1%);O (2%); G (0.3%); C (3%)
Ciompi & Muller (1976) Germany A (70.9%); V (28.4%); T (5.9%); O (16.3%); C (22.5%)
Ihezue & Kumaraswamy (1984) Nigeria A (68%)Ndetei & Singh (1983) Kenya A (43%); V (43%)Winokur et al. (1985) Switzerland A (78%); V (32%)Zarroug (1975) Saudi Arabia A (68%); V (62%)
A, auditory; V, visual; T, tactile; O, olfactory; G, gustatory; C, cenesthetic.
Int R
ev P
sych
iatr
y D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Con
nect
icut
on
08/2
6/13
For
pers
onal
use
onl
y.
Cultural aspects of schizophrenia 445
Course and prognosis
Jablensky (2007) points out that the course and prognosis of schizophrenia shows greatest extent of variation across different cultures. Although doubted, early reports did suggest a better course and prognosis of schizophrenia in developing countries such as Mauritius (Raman & Murphy, 1972) and Sri Lanka (Waxler, 1979). Findings reported in these studies were confi rmed by the WHO multi-centre studies which employed standardized asse ssment measures of course and outcome in schizophrenia. The IPSS study reported better outcome of schizophrenia at 2- and 5-year follow-up assessments (Table 2) in countries such as India, Colombia, and Nigeria as compared to outcomes in developed countries (WHO, 1973; 1979). These results were replicated by other investigators (Kulhara & Chandiramani, 1988; Ohaeri, 1993; Thara, 2004). Patients with schizophrenia in ‘ developing ’ countries (excluding India, Nigeria, Columbia, Mauritius) experience more short- and long-term recovery outcomes than people in Europe and the USA (Bhugra, 2006; Cohen et al., 2008; Kulhara & Chakrabarti, 2001). Various bio-psychosocial factors may give rise to these differences in outcome of schizophrenia from developing countries (Jablensky, 2007).
Stigma
A signifi cant number of patients with schizoph-renia face discrimination by others due to stigma (Loganathan & Murthy, 2008; Poulton et al., 2000; Wig, 1997); stigma is universal but its nature, source and impact is known to vary across cultures and regions (Shrivastava et al., 2011). It is often argued that stigma is a major determinant of outcome of severe mental illness across cultures (Littlewood,
1998). In a study comparing experiences of stigma and discrimination in rural and urban patients of schizophrenia in India, Loganathan and Murthy (2008) found signifi cant differences. Patients from rural backgrounds experienced more ridicule, shame and discrimination compared to the urban sample. These factors can act as important barriers to healthcare access by such patients, delaying their fi rst and even subsequent contacts with the health-care system (Sartorius, 2002). In the long run this often leads to negative stereotyping (Davidson et al., 1998; Link et al., 1997), loss of self-esteem (Wahl & Harman, 1989), depression and demoral-ization (Link et al., 1991, 1997; Markowitz, 1998).
Critique
Some of the points that deserve further exploration have already been mentioned. There are major challenges in understanding the epidemiological differences not only according to the method and assessment tools, but how the data are interpreted. Some of these observations have been described earlier.
The higher rates of schizophrenia seen in migrant and ethnic minority groups raise a number of issues. Odegaard (1932) found that a peak of cases occurred 10 – 12 years after migration. This excess morbidity is not restricted to only the recent immigrants, but is higher in the British-born second generation migrants (Hutchinson et al., 1996). This observation does not fi t into the previously described patterns and hence warrants alternative explanations and hypotheses (Bhugra et al., 1999). Explanations such as a bio-logical predisposition to schizophrenia in immigrants due to increased incidence of obstetric complications or maternal infl uenza have been tested but did not
Table 2. Two-year course and outcome in the WHO ten-country study: Developed versus developing countries.
Course and outcome measuresPatients in developing
countries (%)Patients in developed
countries (%)
Remitting, complete remissions 62.7 36.8Continuous or episodic, no complete remission 35.7 60.9Psychotic � 5% of follow-up 18.4 18.7Psychotic � 75% of follow-up 15.1 20.2No complete remission during follow-up 24.1 57.2Complete remission for � 75% of follow-up 38.3 22.3On antipsychotic medication � 75% of follow-up 15.9 60.8No antipsychotic medication during follow-up 5.9 2.5Hospitalized for � 75% of follow-up 0.3 2.3Never hospitalized 55.5 8.1Impaired social functioning throughout follow-up 15.7 41.6Unimpaired social functioning � 75% of follow-up 42.9 31.6
Reproduced with permission from the Textbook of Cultural Psychiatry , by Dinesh Bhugra & Kamaldeep Bhui (2007).
Int R
ev P
sych
iatr
y D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Con
nect
icut
on
08/2
6/13
For
pers
onal
use
onl
y.
446 G. Kalra et al.
fi nd any support. Later studies in the Caribbean (Bhugra et al., 1996, 1999; Hickling & Rodgers-Johnson, 1995; Mahy et al., 1999; Selten et al., 2005) failed to report a higher incidence of schizophrenia in countries of origin from which various migrants were recruited. In this context, the high risk of schizo-phrenia in such disadvantaged groups as migrants suggests that social factors may be more important in the etiology of this disorder. Migrants are exposed to the experience of ‘ social defeat ’ , that is defi ned as a subordinate position or an outsider status (Selten & Cantor-Graae, 2005); a chronic experience of social defeat may later on lead to sensitization of the meso-limbic dopamine system, thus increasing overall risk for schizophrenia.
Another possibility of fi nding higher schizophrenia risk in migrants is a tendency in psychiatrists trained in western diagnostic systems to more readily assign severe diagnosis such as schizophrenia to migrant than to non-migrant patients. There is also a higher likelihood of clinicians and researchers to misinter-pret psychotic symptoms in some patients, especially if they are not familiar with the culture of immigrant patients, thus resulting in overestimation of rates of schizophrenia (Littlewood & Lipsedge, 1981). How-ever, several other researchers reported otherwise (Hickling et al., 1999; Lewis et al., 1990). Hickling et al. (1999) reported a negligible difference between diagnoses given by British psychiatrists to patients of schizophrenia who were later diagnosed by Jamaican psychiatrists. Nevertheless, this study also does not answer the queries satisfactorily (Sharpley et al., 2001). This may refl ect the fact that all psychiatrists were trained in western models of psychiatry, hence the differentials may be less acute.
Other factors that have been shown to be impor-tant in understanding different rates of schizophrenia in migrant groups are those of ethnic density and cultural congruity (Bhugra, 2005; Boydell et al., 2001; Faris & Denham, 1960). The former refers to the size of a particular ethnic group relative to the total population in a specifi ed area; the latter refers to similarity of cultural values of people living close to one another, or, simply said, the congruence in cultural values of people living together. These fac-tors give rise to a sense of belonging or alienation, depending on whether sociocultural characteristics of an individual match or differ from those of the population that resides in that area. The cultural con-gruity model focuses on cultural factors and qualities rather than simply on numbers of people living in a specifi c geographical area.
Conclusion
We thus see how schizophrenia, though a single dis-order, varies in different cultures. These differences
are obvious from the explanatory models used by patients and their families in understanding the pathways into care and help-seeking where the patients go fi rst and where they go next and so on. Culture determines where the individual presents as fi rst port of call. It is likely that globalization and urbanization may lead to changes in traditional societies that may in turn affect various aspects of schizophrenia including social support and path-ways into care and after care. These changes as a result of globalization may also produce some homogenization of cultures and cultural values. It is also possible that the combined forces of urban-ization, globalization and increased education will alter explanatory models that people use in under-standing their symptoms and illnesses and hence affect help-seeking behaviour of mentally ill indi-viduals. Through increased use of the Internet as is beginning to be noticed in western clinical settings, patients and their families often present with a lot of information off the net. It will also be interesting to see how different cultural aspects of this disorder change in our societies that are increasingly becom-ing multi-cultural.
Declaration of interest: The authors report no confl icts of interest. The authors alone are respon-sible for the content and writing of the paper.
References
Alem , A. , Kebede , D. , Fekadu , A. , Shibre , T. , Fekadu , D. , Beyero , T. , … Kullgren , G . (2009) . Clinical course and outcome of schizophrenia in a predominantly treatment-na ï ve cohort in rural Ethiopia . Schizophrenia Bulletin , 35 , 646 – 654 .
Al-Issa , I . (1995) . The illusion of reality or the reality of illusion: Hallucinations and culture . British Journal of Psychiatry , 166 , 368 – 373 .
Appelbaum , P.S. , Robbins , P.C. & Roth , L.H . (1999) . Dimen-sional approach to delusions: Comparison across types and diagnoses . American Journal of Psychiatry , 156 , 1938 – 1943 .
Azhar , M.Z. , Varma , S.L. & Hakim , H.R . (1995) . Phenomeno-logical differences of delusions between schizophrenic patients of two cultures of Malaysia . Singapore Medical Journal , 36 , 273 – 275 .
Bhugra , D . (2005) . Cultural identities and cultural congruency: A new model for evaluating mental distress in immigrants . Acta Psychiatrica Scandinavica , 111 , 84 – 93 .
Bhugra , D . (2006) . Severe mental illness across cultures . Acta Psychiatrica Scandinavica Supplementum , 429 , 17 – 23 .
Bhugra , D. & Bhui , K. (2007) . Textbook of Cultural Psychiatry . Cambridge: Cambridge University Press .
Bhugra , D. , Gupta , S. , Bhui , K. , Craig , T. , Dogra , N. , Ingleby , J.D. , … Tribe , R . (2011) . WPA Guidance on mental health and mental health care in migrants . World Psychiatry , 10 , 2 – 10 .
Bhugra , D. , Hilwig , M. , Hossein , B. , Marceau , H. , Neehall , J. , Leff , J. , … Der , G . (1996) . First-contact incidence rates of schizophrenia in Trinidad and one-year follow-up . British Jour-nal of Psychiatry , 169 , 587 – 592 .
Bhugra , D. , Leff , J. , Mallett , R. , Der , G. , Corridan , B. & Rudge , S . (1997) . Incidence and outcome of schizophrenia in
Int R
ev P
sych
iatr
y D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Con
nect
icut
on
08/2
6/13
For
pers
onal
use
onl
y.
Cultural aspects of schizophrenia 447
whites, African-Caribbeans and Asians in London . Psychological Medicine , 27 , 791 – 798 .
Bhugra , D. , Mallett , R. & Leff , J . (1999) . Schizophrenia and African-Caribbeans: A conceptual model of aetiology . Interna-tional Review of Psychiatry , 11 , 145 – 152 .
Bhugra , D. , Sumathipala , A. & Siribaddana , S . (2007) . Culture-bound syndromes: A re-evaluation . In D. Bhugra & K. Bhui (Eds) , Textbook of Cultural Psychiatry . (pp. 141 – 156) . New York: Cambridge University Press .
Bowman , K.M. & Raymond , A.F . (1931) . A statistical study of hallucinations in the manic-depressive psychoses . American Journal of Psychiatry , 11 , 299 – 309 .
Boydell , J. , van Os , J. , McKenzie , K. , Allardyce , J. , Goel , R. , McCreadie , R.G. & Murray , R.M . (2001) . Incidence of schizophrenia in ethnic minorities in London: Ecological study into interactions with environment . British Medical Journal , 323 , 1336 – 1338 .
Bresnahan , M. , Begg , M.D. , Brown , A. , Schaefer , C. , Sohler , N. , Insel , B. , … Susser , E . (2007) . Race and risk of schizophrenia in a US birth cohort: Another example of health disparity? International Journal of Epidemiology , 36 , 751 – 758 .
Brugger , C . (1931) . Versuch einer Geisteskrankenzahlung in Turingen . Zeitschrift fner Neurologie und Psychiatrie [Journal of Neurology and Psychiatry] , 133 , 252 – 390 .
Burns , J . (2009) . Dispelling a myth: Developing world poverty, inequality, violence and social fragmentation are not good for outcome in schizophrenia . African Journal of Psychiatry (Johannesberg) , 12 , 200 – 205 .
Ciompi , L. & M ü ller , C . (1976) . Lebensweg und Alter der Schizo-phrenen [Life course and age of schizophenics], Berlin: Springer .
Cohen , A. , Patel , V. , Thara , R. & Gureje , O . (2008) . Questioning an axiom: Better prognosis for schizophrenia in the developing world? Schizophrenia Bulletin , 34 , 229 – 244 .
Collins , J.W. & Hammond , N.A . (1996) . Relation of maternal race to the risk of preterm, non-low birth weight infants: A popula-tion study . American Journal of Epidemiology , 143 , 333 – 337 .
Craig , T.J. , Siegel , C. , Hopper , K. , Lin , S. & Sartorius , N . (1997) . Outcome in schizophrenia and related disorders compared between developing and developed countries. A recursive par-titioning re-analysis of the WHO DOSMeD data. [Comment] . British Journal of Psychiatry, 170 , 229 – 233 .
Davidson , L. , Stayner , D. & Haglund , K.E . (1998) . Phenom-enological perspectives on the social functioning of people with schizophrenia . In K.T. Mueser & N. Tarrier (Eds), Handbook of Social Functioning . (pp. 97 – 120 ). Boston, MA: Allyn & Bacon .
Dean , G. , Walsh , D. , Downing , H. & Shelley , E . (1981) . First admissions of native-born and immigrants to psychiatric hospi-tals in south-east England 1976 . British Journal of Psychiatry , 139 , 506 – 512 .
Edgerton , R.B. & Cohen , A . (1994) . Culture and schizophrenia: The DOSMD challenge . British Journal of Psychiatry , 164 , 222 – 231 .
Faris , R. & Denham , W . (1960) . Mental Disorders in Urban Areas . New York: Hafner .
Fearon , P. , Kirkbride , J.B. , Morgan , C. , Dazzan , P. , Morgan , K. , Lloyd , T. , … Murray , R.M . (2006) . Incidence of schizophrenia and other psychoses in ethnic minority groups: Results from the MRC AESOP study . Psychological Medicine , 36 , 1541 – 1550 .
Geronimus , A.T. , Bound , J. , Waidmann , T. , Hillemeir , M. & Burns , P . (1996) . Excess mortality among blacks and whites in the United States . New England Journal of Medicine , 335 , 1552 – 1628 .
Harrison , G. , Glazebrook , C. , Brewin , J. , Cantwell , R. , Dalkin , T. , Fox , R. , … Medley , I . (1997) . Increased incidence of psychotic disorders in migrants from the Caribbean to the United Kingdom . Psychological Medicine , 27 , 799 – 806 .
Hemsi , L.K . (1967) . Psychiatric morbidity of West Indian immi-grants . Social Psychiatry , 2 , 95 – 100 .
Hickling , F.W. , McKenzie , K. , Mullen , R. & Murray , R . (1999) . A Jamaican psychiatrist evaluates diagnoses at a London psychiatric hospital . British Journal of Psychiatry , 175 , 283 – 285 .
Hickling , F.W. & Rodgers-Johnson , P . (1995) . The incidence of fi rst contact schizophrenia in Jamaica . British Journal of Psychiatry , 167 , 193 – 196 .
Hutchinson , G. , Takei , N. , Fahy , T.A. , Bhugra , D. , Gilvarry , C. , Moran , P. , … Murray , R.M . (1996) . Morbid risk of schizo-phrenia in fi rst-degree relatives of white and African-Caribbean patients with psychosis . British Journal of Psychiatry , 169 , 776 – 780 .
Ihezue , U.H. & Kumaraswamy , N . (1984) . A psychosocial study of Igbo schizophrenic patients treated at a Nigerian psychiatric hospital . Acta Psychiatrica Scandinavica , 70 , 310 – 315 .
Jablensky , A . (2003) . The epidemiological horizon . In S.R. Hirsch & D.R. Weinberger (Eds) , Schizophrenia (2nd ed . ) . (pp. 203 – 231 ). Oxford: Blackwell Science .
Jablensky , A . (2007) . Schizophrenia and related psychoses . In D. Bhugra & K. Bhui (Eds) , Textbook of Cultural Psychiatry. ( pp. 207 – 223 ). New York: Cambridge University Press .
Jablensky , A. , Sartorius , N. , Ernberg , G. , Anker , M. , Korten , A. , Cooper , J.E. , … Bertelsen , A . (1992) . Schizophrenia: Manifesta-tions, incidence and course in different cultures. A World Health Organization 10-country study . Psychological Medicine, Mon-ograph Supplement , 20 , 1 – 97 .
Karlsen , S. , Nazroo , J.Y. , McKenzie , K. , Bhui , K. & Weich , S . (2005) . Racism, psychosis and common mental disorder among ethnic minority groups in England . Psychological Medicine , 35 , 1795 – 1803 .
Kendler , K.S. , Gallagher , T.J. , Abelson , J.M. & Kessler , R.C . (1996) . Lifetime prevalence, demographic risk factors, and diagnostic validity of nonaffective psychosis as assessed in a US community sample . Archives of General Psychiatry , 53 , 1022 – 1031 .
Kirmayer , L.J . (2005) . Culture, context and experience in psychi-atric diagnosis . Psychopathology , 38 , 192 – 196 .
Kleinman , A . (1988) . Rethinking Psychiatry: Cultural Category to Personal Experience . New York: Free Press .
Kulhara , P. & Chakrabarti , S . (2001) . Culture and schizophrenia and other psychotic disorders . Psychiatric Clinics of North America , 24 , 449 – 464 .
Kulhara , P. & Chandiramani , K . (1988) . Outcome of schizophre-nia in India using various diagnostic systems . Schizophrenia Research , 1 , 339 – 349 .
Lambo , T.A . (1965) . Schizophrenia and borderline states . In A.V. De Reuck & S.R. Porter (Eds) , Transcultural Psychiatry . CIBA Foundation Symposium. London: Churchill.
Leff , J. , Sartorius , N. , Jablensky , A. , Korten , A. & Ernberg , G . (1992) . The International Pilot Study of schizophrenia: Five-year follow-up fi ndings . Psychological Medicine , 22 , 131 – 145 .
Leighton , A.H. , Lambo , T.A. , Hughes , H.H. , Leighton , D.C. , Murphy , J.M. & Macklin , D.B . (1963) . Psychiatric Disorder Among the Yoruba . Ithaca, NY: Cornell University Press .
Lemkau , P. , Tietze , C. & Cooper , M . (1941) . Mental hygiene problems in an urban district . Mental Hygiene , 25 , 624 – 646 .
Lewis , G. , Croft-Jeffreys , C. & David , A . (1990) . Are British psychiatrists racist? British Journal of Psychiatry , 157 , 410 – 415 .
Lin , K.-M. & Kleinman , A.M . (1988) . Psychopathology and clinical course of schizophrenia: A cross-cultural perspective . Schizophrenia Bulletin , 14 , 555 – 567 .
Lin , T.Y . (1953) . An epidemiological study of the incidence of mental disorder in Chinese and other cultures . Psychiatry , 16 , 313 – 336 .
Link , B.G. , Mirotznik , J. & Cullen , F.T . (1991) . The effectiveness of stigma coping orientation: Can negative consequences of
Int R
ev P
sych
iatr
y D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Con
nect
icut
on
08/2
6/13
For
pers
onal
use
onl
y.
448 G. Kalra et al.
mental illness labeling be avoided? Journal of Health and Social Behavior , 32 , 302 – 320 .
Link , B.G. , Struening , E.L. , Rahav , M. , Phelan , J. & Nuttbrock , L . (1997) . On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnosis of mental illness and substance abuse . Journal of Health and Social Behavior , 38 , 177 – 190 .
Littlewood , R . (1998) . Cultural variation in the stigmatization of mental illness . Lancet , 352 , 1056 – 1057 .
Littlewood , R. & Lipsedge , M . (1981) . Some social and phenom-enological characteristics of psychotic immigrants . Psychological Medicine , 11 , 289 – 302 .
Loganathan , S. & Murthy , S.R. , (2008) . Experiences of stigma and discrimination endured by people suffering from schizo-phrenia . Indian Journal of Psychiatry , 50 , 39 – 46 .
Mahy , G.E. , Mallett , R. , Leff , J. & Bhugra , D . (1999) . First-contact incidence rate of schizophrenia on Barbados . British Journal of Psychiatry , 175 , 28 – 33 .
Malzberg , B . (1940) . Social and Biological Aspects of Mental Disease . Utica, NY: New York State Hospital Press .
Markowitz , F.E . (1998) . The effects of stigma on the psycholo gical well-being and life satisfaction of persons with mental illness . Journal of Health and Social Behavior , 34 , 335 – 347 .
McIntosh , A. & Lawrie , S . (2004) . Cross-national differences in diet, the outcome of schizophrenia and the prevalence of depression: You are (associated with) what you eat . British Journal of Psychiatry , 184 , 381 – 382 .
Mezzich , J.E. , Kirmayer , L.J. , Kleinman , A. , Fabrega , H. Jr., Parron , D.L. , Good , B.J. , … Manson , S.M . (1999) . The place of culture in DSM-IV . Journal of Nervous and Mental Disease , 187 , 457 – 464 .
Mohr , S. , Borras , L. , Betrisey , C. , Pierre-Yves , B. , Gilli é ron , C. & Huguelet , P . (2010) . Delusions with religious content in patients with psychosis: How they interact with spiritual coping . Psychiatry: Interpersonal and Biological Processes , 73 , 158 – 172 .
Murphy , H.B. , Wittkower , E.D. , Fried , J. & Ellenberger , H.A . (1963) . Cross-cultural survey of schizophrenic symptomatol-ogy . International Journal of Social Psychiatry , 10 , 237 – 249 .
Ndetei , D.M. & Singh , A . (1983) . Schneider ’ s fi rst rank symptoms of schizophrenia in Kenyan patients . Acta Psychiatrica Scandi-navica , 67 , 148 – 153 .
Ndetei , D.M. & Vadher , A . (1984a) . A comparative cross-cultural study of the frequencies of hallucinations in schizophrenia . Acta Psychiatrica Scandinavica , 70 , 545 – 549 .
Ndetei , D.M. & Vadher , A . (1984b) . Frequency and clinical signifi cance of delusions across cultures . Acta Psychiatrica Scandinavica , 70 , 73 – 76 .
Odegaard , O . (1932) . Emigration and insanity: A study of mental disease among the Norwegian born population of Minnesota . Acta Psychiatrica et Neurologica Supplement , 4 , 1 – 206 .
Odejide , A.O. & Olatawura , M.O . (1979) . A survey of community attitudes to the concept and treatment of mental illness in Ibadan, Nigeria . Nigerian Medical Journal , 9 , 343 – 347 .
Ohaeri , J.U . (1993) . Long-term outcome of treated schizophrenia in a Nigerian cohort. Retrospective analysis of 7-year follow-ups . Journal of Nervous Mental Diseases , 181, 514 – 516 .
Patel , V. , Cohen , A. , Thara , R. & Gureje , O . (2006) . Is the outcome of schizophrenia really better in developing countries? Revista Brasileira de Psiquiatria , 28 , 149 – 152 .
Pfeiffer , W.M . (1994) . Transkulturelle Psychiatrie [Transcultural Psychiatry] . New York, Stuttgart: Thieme .
Polednak , A . (1991) . Black – white differences in infant mortality in 38 standard metropolitan statistical areas . American Journal of Public Health , 81 , 1480 – 1482 .
Poulton , R. , Caspi , A. & Moffi tt , T.E . (2000) . Children ’ s self-reported psychotic symptoms and adult schizophreniform disorder: A 15-year longitudinal study . Archives of General Psychiatry , 57 , 1053 – 1058 .
Raman , A.C. & Murphy , H.B.M . (1972) . Failure of traditional prognostic indicators in Afro-Asian psychotics: Results from a long-term follow-up study . Journal of Nervous and Mental Diseases , 154 , 238 – 247 .
Robins , L.N. & Regier , D.A . (1991) . Psychiatric Disorders in America: The Epidemiologic Catchment Area Study . New York: Free Press .
Sartorius , N . (2002) . Iatrogenic stigma of mental illness . British Medical Journal , 324 , 1470 – 1471 .
Selten , J.P. & Cantor-Graae , E . (2005) . Social defeat: Risk factor for schizophrenia? British Journal of Psychiatry , 187 , 101 – 102 .
Selten , J.P. , Zeyl , C. , Dwarkasing , R. , Lumsden , V. , Kahn , R.S. & van Harten , P.N . (2005) . First-contact incidence of schizophre-nia in Surinam . British Journal of Psychiatry , 186 , 74 – 75 .
Sharpley , M.S. , Hutchinson , G. , Murray , R.M. & McKenzie , K . (2001) . Understanding the excess of psychosis among the African-Caribbean population in England: Review of current hypotheses . British Journal of Psychiatry , 178 , S60 – 68 .
Siddle , R. , Haddock , G. , Tarrier , N. & Faragher , E.B . (2002) . Reli-gious delusions in patients admitted to hospital with schizophrenia . Social Psychiatry and Psychiatric Epidemiology , 37 , 130 – 138 .
Skultans , V . (1993) . The case of cross-cultural psychiatry: Squaring the circle? International Review of Psychiatry , 5 , 125 – 128 .
Snowden , L. & Cheung , F . (1990) . Use of inpatient mental health services by members of ethnic minority groups . American Psychologist , 45 , 347 – 355 .
Shrivastava , A. , Johnston , M.E. , Thakar , M. , Shrivastava S , Sarkhel G , Sunita I ., Parkar , S . (2011) . Origin and impact of stigma and discrimination in schizophrenia – patients ’ percep-tion: Mumbai study . Stigma Research and Action , 1 , 67 – 72 .
Stompe , T. , Friedmann , A. , Ortwein , G. , Strobl , R. , Chaudhry , H.R. , Najam , N. & Chaudhry , M.R . (1999) . Comparison of delusions among schizophrenics in Austria and Pakistan . Psychopathology , 32 , 225 – 234 .
Stompe , T. , Karakula , H. , Rudaleviciene , P. , Okribelashvili , N. , Chaudhry , H.R. , Idemudia , E.E. & Gscheider , S . (2006) . The pathoplastic effect of culture on psychotic symptoms in schizo-phrenia . World Cultural Psychiatry Research Review , 1 , 157 – 163 .
Suhail , K. & Cochrane , R . (2002) . Effect of culture and environ-ment on the phenomenology of delusions and hallucinations . International Journal of Social Psychiatry , 48 , 126 – 138 .
Sumathipala , A. , Siribaddana , S.H. & Bhugra , D . (2004) . Culture-bound syndromes: The story of dhat syndrome . British Journal of Psychiatry , 184 , 200 – 209 .
Tan , E.K. & Carr , J.E . (1977) . Psychiatric sequelae of amok . Culture, Medicine and Psychiatry , 1 , 59 – 67 .
Tateyama , M. , Asai , M. , Kamisada , M. , Hashimoto , M. , Bartels , M. & Heimann , H . (1993) . Comparison of schizo-phrenic delusions between Japan and Germany . Psychopathology , 26 , 151 – 158 .
Thara , R . (2004) . Twenty-year course of schizophrenia: The Madras Longitudinal Study . Canadian Journal of Psychiatry , 49 , 564 – 569 .
Tseng , W.S . (2001) . Handbook of Cultural Psychiatry . San Diego, CA: Academic Press .
Tseng , W.S . (2003) . Clinician ’ s Guide to Cultural Psychiatry . San Diego, CA: Academic Press .
Wahl , O.F. & Harman , C.R . (1989) . Family views of stigma . Schizophrenia Bulletin , 15 , 131 – 139 .
Wang , J.H. , Morales , O. & Hsu , L.K.G . (1998) . Auditory hallucinations in bilingual immigrants . Journal of Nervous and Mental Disease , 186 , 501 – 503 .
Warner , R . (2000) . Community attitudes towards mental disorder . In G. Thornicroft & G. Szmuckler (Eds) , Textbook of Community Psychiatry . ( pp. 453 – 464 ). Cambridge: Cambridge University Press .
Waxler , N.E . (1979) . Is outcome for schizophrenia better in non-industrial societies? The case of Sri Lanka . Journal of Nervous and Mental Disorders , 176 , 144 – 158 .
Int R
ev P
sych
iatr
y D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Con
nect
icut
on
08/2
6/13
For
pers
onal
use
onl
y.
Cultural aspects of schizophrenia 449
WHO (1973) . Report of the International Pilot Study of Schizophrenia. Vol. 1. Results of the Initial Evaluation Phase . Geneva: World Health Organization .
WHO (1974) . International Pilot Study of Schizophrenia, Vol 1. WHO Offset Publication No. 2. Geneva : World Health Organization .
WHO (1979) . Schizophrenia. An International Follow-up Study . Chichester: Wiley .
Wig , N.N . (1997) . Stigma against mental illness . Indian Journal of Psychiatry , 39 , 187 – 189 .
Winokur , G. , Scharfetter , C. & Angst , J . (1985) . The diagnostic value in assessing mood congruence in delusions and hallucina-tions and their relationship to the affective state . European Archives of Psychiatry and Neurological Sciences , 234 , 299 – 302 .
Yap , P.M . (1974) . Comparative Psychiatry. A Theoretical Framework . Toronto: University of Toronto Press .
Zarroug , E.A . (1975) . The frequency of visual hallucinations in schizophrenic patients in Saudi Arabia . British Journal of Psychiatry , 127 , 553 – 555 .
Int R
ev P
sych
iatr
y D
ownl
oade
d fr
om in
form
ahea
lthca
re.c
om b
y U
nive
rsity
of
Con
nect
icut
on
08/2
6/13
For
pers
onal
use
onl
y.
