culture and the individual schizophrenia. symptoms delusions hallucinations thought confusion...

Culture and the Individual

Schizophrenia

Schizophrenia

SymptomsDelusionsHallucinationsThought confusionFlattened or inappropriate affectWithdrawal into fantasy worldPurposeless excited motor behavior not explained by external stimuli

Not reported in ancient or medieval literatureMay be chronic and long termMay occur in a single or in repeated episodes

Delusional Content

• Delusions affected significantly by culture, with familiar items, people, beliefs and events part of delusions

• Must know about cars, electricity, robots for them to be part of delusions

International Study

• Cross-cultural study of nine countries

Colombia, Czechoslovakia, Denvark, India, Nigeria, Taiwan, United Kingdom, US, USSR

Found relatively consistent symptoms of schizophrenia across patients

Symptoms were evaluated using etic criteria.

Barrett

• The Iban, Sarawak, Borneo, Malaysia• A comparison of First Rank Symptoms

(FRS) between the Iban and Australians• An analysis of the effect of cultural models

on symptoms• Issues of

– Translation– Language– Culture

BarrettFirst Rank Symptoms of Schizophrenia

*Audible thoughts

Voices arguing

Voices commenting on one’s actions

*Thought insertion or thoughts ascribed to others

*Thought withdrawal

*Diffusion or broadcasting of thoughts

Impulses

Volutional acts experienced as controlled by others

Delusional Perception

Subjective thought disorder vs Auditory Hallucinations

Barrett

Iban concept of thinking arises from the heart-liver region of the body

Personhood is defined not as a matter of thought and mental privacy, but as an aspect of verbal interaction

Correspondence between concepts of thinking and talking in Iban cosmology

Contrast between auditory hallucinations and thought disorder based on cultural concepts

Barrett

Auditory hallucinations ever experienced

- 48 of 50 Iban patients

- 40 of 50 Australian patients

Subjective Thought Disorder ever experienced - 3 of 50 Iban patients - 39 of 50 Australian patients

Barrett

• Translation of thought disorder questions did not make sense to participants

• Disturbances in speech are interpreted as disturbances in thought in Australians

• Disturbances in speech are interpreted as disturbances in auditory reception by Ibanese

Barrett

• Conclusion– It is necessary to understand the meaning

systems of the culture in order to frame diagnostic questions

– Cultural systems determine how symptoms are experienced by patients

– Cultural systems affect the kinds of symptoms that are reported by patients

Corin, Thara & Padmavati

Chennai/Madras, India, South Asia• Study of the subjective experiences of

individuals with schizophrenia• Use of narratives to study individuals and

families• Three patient themes identified

– A quest for significance– An appeal to religious referents– The construction of a withdrawal space

Quest for Significance

Traditional Etiologies Used by Families

Malevolent humans

Malevolent spirits

Karma

Astrology

All were used to place disordered behavior into a normal worldview

Corin, Thara & PadmavatiWithdrawal into Religious Ideology

Patients withdrew from family and other social contact perhaps to reduce stress

Withdrawal was seen as creating a boundary dividing the confused self from intrusion.

Withdrawal created “inner spaces” that the patient occupied.

“Inner spaces” were labeled with marginal religious or personal religious terminology

Withdrawal associated with pilgrimage, temples, mosques

Withdrawal based on the Indian ideals of renunciation and austerity

Corin, Thara & Padmavati

• Participants developed strategies for dealing with suffering and fear

• Participants used cultural themes to interpret their experiences

• South Asian culture is tolerant of psychosis and deals with it within the family context.

Good and Subandi

• Yogyakarta, Java, Indonesia• Brief, acute, episodic psychosis (less than the 6-

month requirement for DSM-IV diagnosis)• Non-affective, Acute, Remitting Psychosis (NARP)• 10 times higher incidence in developing countries

than in industrialized nations• Twice as many women as men• Duration usually 4-6 months• Studied in terms of ideas pertaining to the self

rather than as psychophysiological state

Good and Subandi

The Javanese World View as ContextSelf as a form of potencySelf developed through a variety of spiritual practices and self restraintThe ability to maintain a refined, controlled self

is central to normal behaviorThe powerful self can relate to and interact with

the unseen spirit world without being harmedPurity of body and spirit is essentialPurity is attained through ritual practices.

Good and Subandi

• Case Study: Yani• Episodes of illness from college on• Symptoms: “irritated, frustrated, disappointed”,

fearful, disoriented, withdrawn• Leaving home and wandering aimlessly• Illness framed as a desire/need to find pure

Islam• Yani withdrew into her room and into religious

ritual to cope with her illness

WilceBangladesh, South AsiaMental illness is shaped by

Metacommunicative abilityGender rolesAesthetics of behavior and use of language

Concept of “pagalami” Described as being like the behavior of goats =Out of control, oral, intrusive, embarrassing

Wilce

CausesCan be divinely inspired ecstacy or insanityCan be “spiritually caused” (then ritually treated) by a “wild spirit” or “jinn”Can be caused by the patient (breaking taboo, etc.)Can be intrinsic to the person- mathakharap = bad head

Wilce

Symptoms

Speaking in ways that violate the protocols of polite conversation

Speaking in ways that are not gender appropriate

Eating or any other behavior that is done excessively

Family members try to shape and correct speech acts so that they will be appropriate

Diaz, Fergusson & Strauss

• Bogota, Colombia

• Spanish, Indian, African Cultural Mix

• Spanish Language

• Study of homeless, poor, schizophrenic individuals through FUNGRATA

• 6 Ethnographic interviews

Diaz, Fergusson & Strauss

• Symptoms were seen as protecting the participants from factors in everyday life

• Explanations of illness were central to improvement and participation in the program

• As explanations aligned with the ideals and practical aspects of the program, it was more likely that individuals would join the program and show improvement.

Diaz, Fergusson & Strauss

• Work was a key factor in improvement

• Learning and the acquisition of skills were important in improvement

• Medication was important, but second to work

• Religious concepts and meanings were used to explain symptoms by many

Diaz, Fergusson & Strauss

• The goal of FUNGRATA was:

“the construction of personal meaning within an organized community setting”

Sadowsky

• Yoruba Ethnic Group, Nigeria• Historical study of diagnosis in colonial

period• Use of historical records from

asylums/hospitals between late 1800’s and 1960.

• Opening two asylums to deal with homeless mentally ill

• Focus on context and content

Sadowsky

Yoruba Traditional

• Madness in Yoruba culture– “were” and is translated as “foolish or silly person”

• Causes include organic and physical problems, bewitchment, actions by deities

• Breach of taboo causes spirit (orisa) to impose madness

Sadowsky

• Records show diagnoses that include political content

• Political content includes rage and paranoia about colonial government and its treatment of indigenous people

• Does this mean that some diagnoses were politically based or that the content of delusions were focused on problems of oppression that permeated the society?