On the expression of psychosis in different cultures: Schizophrenia in an indian and in a Nigerian community

Abstract

This sub-study of the WHO Determinants of Outcome of Severe Mental Disorders research project was aimed at characterizing the behavioral and expressive qualities of schizophrenia in two highly diverse cultures. Early research has indicated that the core elements involving affect, perceptual and cognitive dysfunction in schizophrenia are highly similar in form in most cultures of the world. Much of the cross-cultural literature emphasizes, however, strong differences in the ways in which schizophrenia is actually expressed and manifested in different settings. The basic methodology for psychiatric description and diagnosis in the WHO program was the Present State Examination. In five of the field centers a method for investigating the expressive quality and the social behavior of patients in their own communities through the eyes of significant others was applied. This method was then subjected to psychometric tests of cross-cultural applicability and found to be valid for comparing behavior across settings. The expressive patterns of the Indian and Nigerian patients were studied from two perspectives. Indian schizophrenics were described by family members as manifesting a more affective and "self-centered" orientation; the Nigerian patients presented with a highly suspicious, bizarre, anxious quality to the basic behavioral pattern. The main features of pathology were in general accord with the descriptions of indigenous psychiatrists. The special qualities of the psychosis in the two cultures were interpreted against the background of traditional psychopathological and anthropologic theories concerning the psychodynamics and the influence of differing social conflictual themes in the two cultures. Analysis of psychopathology in this manner was found to enhance understanding of underlying mechanisms and the role of cultural conflicts in its expression.

Subtypes and Factors of Schizophrenia in an Acutely Ill Nigerian Sample

“…One interesting result of adding ICD-10 DCR symptoms to the analysis was the emergence of what appears to be a catatonic syndrome (table 3). While catatonia appears to be uncommon in developed countries from the last decades of the 20th century [36,37] -with the possible exception of rural Spain [38] -it is quite a common clinical experience in developing countries [16,31]. To our knowledge, previous factor analysis reports did not include a catatonic syndrome.…”

“…The robustness of the negative syndromes is an indication that they transcend cultural barriers [17]; but their instability during treatment implies that the concept of deficit schizophrenia does not apply for this group of acutely ill and noninstitutionalized patients. Coupled with the results of good short-term clinical outcome in other reports from Nigeria, it is possible that negative symptoms are a characteristic of the untreated acute state only, among noninstitutionalized Nigerian patients, and hence the rarity of deficit schizophrenia among treated Nigerian patients is one further expression of the heterogeneity of schizophrenia across cultures [31].…”

“…It is possible that the nonenduring nature of negative syndromes among our patients is based on the fact that none of them met criteria for residual schizophrenia. Perhaps the nonenduring nature of negative syndromes in treated schizophrenia in our setting is one expression of the cross-cultural heterogeneity of the disease [9,31].…”

“…One possible reason for this shortterm clinical outcome is the rather frequent use of electroconvulsive therapy, especially for patients who show no significant response to medication by the fourth week of treatment [42]. The controversy in Nigeria [43] about the well publicized good outcome of schizophrenia in developing countries [31] is mainly concerned with long-term social outcome in a country which has been in severe economic depression for at least two decades. The nonenduring nature of the negative syndromes in this Nigerian study is in marked contrast to reports from North America and western Europe, where attempts have been made to categorize schizophrenia as deficit/nondeficit, largely based on the enduring nature of negative symptoms, in spite of adequate treatment [44,45].…”

Culture and Psychopathology: Foundations, Issues, Directions

“…Results form these studies all point to international variations in these areas, bewildering as this may be for many affiliated with the WHO projects because of their professional beliefs in biological positions and their support for DSM and ICD classification systems (e.g., Day, Nielsen, Korten, Ernberg, et al, 1987;Hooper, Harrison, Janca, & Sartorius, 2007;Katz, Marsella, Dube, Olatawura, et al, 1988). …”