Schizophrenia and Related Psychotic Disorders
The cross-cultural presentation and course of schizophrenia are among the best-studied aspects of cultural psychiatry. Research has revealed both cross-cultural similarities and differences, both of which are important for elucidating the biological and en-vironmental bases of the disease. A “spectrum’’ of schizophrenic syndromes – consisting of a combination of certain positive and negative psychotic symptoms – has been found nearly every-where, although the specific content of hallucinations and delu-sions as well as the prevalence of visual and other nonauditory hallucinations varies (Krassoievitch et al., 1982; Ndetei and Vad-her, 1984). Significant cross-cultural variation has been found, however, in several features of the syndrome. Its distribution is not uniform, ranging from 1 in a 1000 in the nonWestern societies to more than 1% in the West; its highest prevalence is displayed in economically and technologically advanced, urbanized and bureaucratized societies (Kleinman, 1988; Warner, 1985). Its phenomenology varies with cultural setting, with much higher rates of catatonia in India and of hebephrenia in Japan than in the West. Most important, the course and outcome of schizophrenia are markedly better in nonindustrialized countries, even when cultural differences in outcome assessment and in acuteness of presentation are taken into account (Sartorius et al., 1986; Lin and Kleinman, 1988; Kulhara and Chakrabarti, 2001). Varia-tions in outcome are thought to be related in part to different attitudes toward persons with the disorder, a set of culturally pat-terned interactions studied under the rubric of expressed emotion (Jenkins and Karno, 1992) (Table 21.2). Other cross-cultural vari-ations with regard to schizophrenia include higher misdiagnosis among patients from devalued and ethnic minority groups (Good, 1992/93), differences in cultural and gender-related conceptions
regarding the expression of emotion that complicate the assess-ment of flat affect (Karno and Jenkins, 1997), and culturally syntonic experiences that may be mistaken for schizophrenic symptoms. The latter include the accepted appearance of hal-lucinations among the bereaved Native Americans (Hultkrantz, 1979) or reports of perceptual alterations among the distressed Puerto Ricans (Guarnaccia et al., 1992).
Cross-cultural differences have also been detected in emotional processing among the German, American and Indian subjects with schizophrenia. Face discrimination performance was most impaired in the Indian subgroup (Habel et al., 2000). Another study comparing the German natives and the Turkish immigrants with schizophrenia also found cross-cultural differ-ences, this time in higher indices of hostile excitement and de-pression among the immigrant group (Haasen et al., 2001).