Schizophrenia – how far are presentation and management determined by culture?

Psychiatrists wishing to better manage their patients need to take cross-cultural differences into account, Cyril Höschl, director of the National Institute of Mental Health in Klecany, Czech Republic, told a Lundbeck Institute seminar in Copenhagen.¹

Socio-cultural factors relate to psychiatry by influencing the pathogenesis and symptomatology of psychiatric illness, by influencing our response to it, and by underpinning and legitimising psychiatric and other interventions.

A study of 1080 schizophrenia patients from Austria, Poland, Lithuania, Georgia, Pakistan, Nigeria and Ghana found pronounced differences between countries in the overall incidence and nature of hallucinations. For example, patients in developing countries experienced more visual and acoustic hallucinations than their Western peers. The authors concluded that this was probably due to cultural differences, particularly in perceptual and attentional processing.

Culturally sensitive diagnosis

Clearly, schizophrenia manifests itself in different ways throughout the world. This suggests that over-reliance on tools such as DSM-5 risks pathologising normality and medicalising reactions to adverse experiences which – given their cultural context – are understandable.

Indeed, cross-cultural differences don’t relate solely to symptoms but can influence the diagnostic process. In the USA, African Americans are five times more likely to be diagnosed with schizophrenia rather than a less severe mood disorder than Caucasian Americans. Thus, race itself plays a role in diagnosis.

Markers of vulnerability and resistance

Considering vulnerable populations, a meta-analysis investigated the unequal distribution of schizophrenia between the general population and first- and second-generation migrants. The increased risk of schizophrenia among immigrants persisted into the second generation, suggesting that post-migration factors were more important than pre-migration factors or migration per se. Others have suggested that these findings might arise from biases introduced by the use of culturally insensitive diagnostic procedures and/or confounding environmental factors.

Language can help or hinder accurate diagnosis. In Japan, changing the term for schizophrenia from ‘mind split disorder’ to ‘integration disorder’ aided diagnosis considerably both because physicians no longer used euphemisms to describe schizoid symptoms and because society was more accepting of the new terminology.

Sociocentricity is another important concept in understanding cultural variance in schizophrenia. In a study relating schizophrenia to socioeconomic and minority status in the USA, Caucasian Americans were found – against expectations -- to be more symptomatic than Black American and Latino groups. The greater sociocentricity of the minority groups was held to be the ‘protective’ effect at work.

There also appear to be marked cultural differences in response to negative emotion: in a study of three groups’ ability to empathise with sad faces, Indian patients and controls responded less negatively than German or American patients and controls. It was suggested that the collective nature of Indian culture, unlike the individualistic nature of American and German societies, suppresses negative emotional experiences.

Reactions to mental disorders

Socio-cultural reactions can have profound consequences for those with mental disorders, with stigma and discrimination undermining the prospect, for example, of employment. While the majority of those with mental disorders want to work, and despite the policies of institutions such as the European Union and International Labour Organisation, unemployment among those with mental disorders remains unacceptably high.

Culture can also have an impact on prognosis. A WHO collaborative study showed that newly-diagnosed patients from different cultural backgrounds were similar in their symptom profile, but the course of the disease was more favourable in those from developing rather than developed countries. This may be because family and social support are greater, and the stigma of mental illness, stress and the pressure to achieve are less in the developing than in the developed world.

Coercive strategies vary

The EUNOMIA project studied the use of coercive measures in involuntarily admitted patients in twelve countries. Overall, 1284 patients with psychotic illness were included, 41% of whom experienced some coercive measure, presumably to mitigate acute psychotic agitation and/or self-harm and aggression.

All the countries studied used coercive measures, but these differed in nature. Involuntary medication was the most frequent (used in seven countries) but was not found in the UK, Germany and Greece. Seclusion rooms were available in only five countries and were most commonly used in the UK. Some kind of mechanical restraint was used in all centres. But, even across Europe, there is cultural variation in the coercive means thought legitimate in patient management.

For detail on this topic please go to the feature on Lundbeck Institute Campus http://institute.progress.im/en/content/schizophrenia-across-cultures