The new cross-cultural psychiatry
This new picture emerged from a series of investigations sponsored by the World Health Organization. In the International Pilot Study of Schizophrenia8 and the subsequent International Follow-up Study of Schizophrenia,9 patients in nine countries were examined and were
assigned diagnoses according to local and Schneiderian criteria. It was these studies that confirmed that psychiatrists in the United States and the Soviet Union had very broad conceptions of schizophrenia in comparison with psychiatrists from the other participating countries. This aside, the main finding was that disorders recognizable to Western psychiatrists as ‘schizophrenia’ could be found throughout the world, an observation that was widely interpreted by the psychiatric community as evidence that schizophrenia is a tangible phenomenon that exists independently of the observer. However, as American psychiatrist and anthropologist Arthur Kleinman pointed out, the strategy employed by the WHO investigators was almost bound to filter out cross-cultural differences in psychopathology.10 Indeed, the researchers’ conclusion that schizophrenia is similar the world over was inevitable, as only patients meeting Western criteria for schizophrenia were included in the cross-cultural comparisons.
This criticism applies with even greater force to the more recent WHO study of the Determinants of Outcome of Severe Mental Disorders (DOSMD).11 The researchers who undertook this ambitious project reached the remarkable (and much trumpeted) conclusion that the incidence rate of schizophrenia (the proportion of the population that succumbs to the disease in a given period) does not vary across the world. They therefore inferred that there must be a uniformly distributed liability to schizophrenia and that ‘This liability must have a genetic basis.’
The logic of this argument is baffling. As British psychologist Richard Marshall once remarked before his untimely death, market capitalism is the dominant worldwide economic system but few people believe that there are uniformly distributed genes for capitalism. On the other hand, many diseases of known genetic origin do vary in incidence across the world. (Sickle-cell anaemia, to take but one example, is an inherited blood disorder that is common in African people, or people of African descent, but which rarely affects other ethnic groups.)
In fact, the DOSMD data did not demonstrate that incidence rates for schizophrenia are culturally invariant, as the researchers claimed. The team of over 100 investigators, led by Professors Norman Sartorius and Assen Jablensky, studied people experiencing their first psychotic breakdown at twelve sites (Aarhus in Denmark, Agra and
Chandigarh in India, Cali in Columbia, Dublin in Ireland, Honolulu and Rochester in the USA, Ibadan in Nigeria, Moscow in Russia, Nagasaki in Japan, Nottingham in the UK and Prague in the former Czechoslovakia). To be included in the study, an individual had to be experiencing at least one psychotic symptom, or showing at least two kinds of abnormal behaviour suggestive of psychosis. The researchers made great efforts to find people who were psychotic but who had sought help from non-medical agencies or traditional healers, in this way hoping to catch all new cases who failed to contact local medical services. Whether this strategy was successful is debatable. Occasional ‘leakage’ investigations, in which local informants were asked whether they knew of any psychotic people who had slipped through the net, failed to reveal many previously unidentified cases. However, the evidence we considered in the last chapter suggests that many people experience psychotic symptoms cheerfully and in silence. Certainly, it is difficult to be sure that all new cases have been detected without interviewing a random sample of the population.
In the end, incidence rates were only calculated for seven sites for which adequate data were available, with the Chandigarh site divided into urban and rural subsites. Of course, a further difficulty faced by researchers conducting this kind of study is the choice between the many different definitions of schizophrenia. Rates for both a broad and narrow (Schneiderian) definition of schizophrenia were therefore reported. Not surprisingly, there was considerably more variation in the rates for the broad definition than for the narrow definition (see Figure 6.1). Even for the narrow definition, however, the annual incidence rate reported for Nottingham (1.4 cases aged between 15 and 54 years per 10,000 population) was twice that for Aarhus (0.7 cases). It seems amazing that such a large difference was not considered important by the researchers, but this was because the statistical calculations they carried out on their data suggested that this difference could be due to chance factors (for example, random variations in the numbers of new cases occurring at each site). However, given the relatively small numbers of Schneiderian patients, it seems likely that the study was not large enough to detect reliably even quite big differences between the numbers at each site.12
In fact, statistically significant differences between the sites were observed for the broad definition and, as Kleinman has noted:
Figure 6.1 Incidence rates at seven different sites for two different definitions of schizophrenia detected in the DOSMD study (from A. Jablensky, N. Sartorius, G. Ernberg, M. Anker, A. Korten, J. E. Cooper, R. Day and A. Bertelsen (1992) ‘Schizophrenia: manifestations, incidence and course in different cultures’, Psychological Medicine, Supplement 20: 1-97). Dark columns show data for a broad definition of schizophrenia (S, P or O categories according to the CATEGO system of computerized diagnoses) and light columns show data for a narrow Schneiderian definition (CATEGO S+).
The ‘broad’ sample from the anthropological perspective is the valid one, since it includes all first-contact cases of psychosis meeting the inclusion and exclusion criteria. The ‘restricted’ sample is a ‘constructed’ sample, since it places a template on the heterogeneous population sample and stamps out a homogeneous group of clinical cases. The restricted sample demonstrates to be sure that a core schizophrenic syndrome can be discovered amongst first-contact cases in widely different cultures. This is an important finding, but it is not evidence of a uniform pattern of incidence.13
Other cross-cultural investigators, weighing data from a number of epidemiological studies, have usually concluded that schizophrenia-like psychoses are less common in non-Western societies than in the developed world, and continue to debate the possible causes of these apparent differences.14 For example, New Zealand anthropologist John Allen has recently proposed that schizophrenia occurs less often
in non-Western societies because life is more stressful in those societies than in the industrialized nations.15 (On this view, life close to a state of nature is not so idyllic after all.) Like Paul Meehl, Allen accepts that schizophrenia is a stress-related disorder, but notes that episodes of psychotic illness are associated with reduced reproductive fitness. Therefore, he argues, precipitation of an increased number of schizophrenia episodes in the past will have resulted in a gradual weeding out of schizophrenia genes throughout the undeveloped world, leading to fewer episodes in the present. Ingenious though this argument is, it is, of course, an evolutionary just-so story, and difficult to test scientifically.
Incidence rates of psychosis within one country: the British Afro-Caribbeans
When attempting to make sense of the inconsistent results that have emerged from comparisons between countries it is easy to forget that many modern industrialized nations contain multiracial populations. In fact, some of the clearest evidence of cross-cultural differences in the incidence rates of psychosis has emerged from the comparison of different ethnic groups in Britain.
For many years it has been known that black Afro-Caribbeans are over-represented in British psychiatric hospitals, and are especially likely to be diagnosed as suffering from paranoid schizophrenia16 or mania.17 Not surprisingly, the reasons for this over-representation have been the subject of heated debate. One possible explanation might be that white psychiatrists, ignorant of Afro-Caribbean culture, often misunderstand the experiences of Afro-Caribbean people, and thereby misdiagnose many as schizophrenic.18 To check for this possibility, researchers at the Institute of Psychia
try in London invited a Jamaican psychiatrist, Fred Hickling, to re-evaluate their diagnoses of Afro-Caribbean patients.* Although there was poor agreement between Hickling’s diagnoses of schizophrenia and those made by the white British psychiatrists, the overall rate at which Hickling and the British psychiatrists diagnosed schizophrenia in the patients did not differ much.19 Therefore, it seems unlikely that the high rates of psychosis in British Afro-Caribbeans can entirely be accounted for by misdiagnoses made by culturally insensitive white clinicians.
Another possibility is that Afro-Caribbean people express distress in a culturally idiosyncratic way that often culminates in violence, leading to especially prompt intervention by psychiatric services. It is certainly true that Afro-Caribbean people are more likely to be compulsorily admitted to psychiatric hospitals in the UK than other ethnic groups.20 However, as early as 1988, Glyn Harrison and his colleagues found a higher than expected rate of psychosis in a community sample of Afro-Caribbeans living in Nottingham, assessed using standardized criteria.21 This finding has been replicated several times, notably by psychiatrists Dinesh Bhugra, Julian Leff and their colleagues in London.22
Studies conducted in the Caribbean have found lower incidence rates for psychosis in Trinidad23 and Barbados24 than in the British Afro-Caribbean community. Therefore, the Afro-Caribbean population as a whole does not appear to be especially vulnerable to psychosis, and a racially specific genetic sensitivity to madness can be ruled out. More intriguingly, several studies in Britain have found that the excess rates of psychosis are most evident in the children of Afro-Caribbeans who have moved to Britain, rather than in the generation that migrated.25
In a later chapter, we will see that this over-representation of psychosis in the British Afro-Caribbean community has provided important clues about environmental determinants of madness. For the present, however, we can note that this finding convincingly establishes that the incidence of psychosis is not identical in all ethnic groups in all regions of the world.
Cross-cultural differences in the outcome of psychosis
Ironically, although the DOSMD study obscured differences in incidence rates, it succeeded in its main purpose, which was to confirm a suspicion that cross-cultural differences exist in the course and
outcome of psychosis. This suspicion arose in earlier research, in particular the five-year follow-up of patients recruited to the International Pilot Study of Schizophrenia.26 In that study, it was reported that 27 per cent of patients in the developing nations experienced only one psychotic episode, followed by complete recovery, compared to only 7 per cent of patients from industrialized nations. Nor was this difference in outcome confined to symptoms; 65 per cent of patients in the developing countries compared to 56 per cent of patients in the industrialized countries were judged to have no or only mild social impairment at the end of the follow-up period. Arthur Kleinman described these observations as ‘arguably the single most important finding of cultural differences in cross-cultural research on mental illness’.27
The DOSMD data broadly replicated these observations. In the two-year follow-up data from the study, 37 per cent of patients from the developing countries suffered one episode, followed by complete recovery, compared to only 16 per cent of patients from the developed world. Nearly 16 per cent of patients in the developing countries showed impaired social functioning throughout the follow-up period, whereas the corresponding figure for the developed countries was nearly 42 per cent. Despite the undoubted limitations of the WHO programme of cross-cultural research, the evidence that madness is more benign outside the industrialized world is quite compelling. On the basis of these findings, Ezra Susser and Joseph Wanderling of Columbia University in New York proposed the term non-affective acute remitting psychosis (NARP) to describe a clinical picture in which there is a rapid onset of symptoms followed by complete recovery. True to the spirit of the DSM, they argued that it should be considered a diagnostic entity distinct from schizophrenia. They calculated the incidence of this type of clinical presentation to be ten times greater in the developing world than in industrialized nations.28
Unfortunately, as critics of the WHO studies have pointed out, the researchers who designed the studies defined culture simply in terms of geography, and almost completely neglected to measure cultural factors that might be responsible for the observed differences.29 The reasons people who experience psychosis in the developing world do so much better than those in the West must therefore remain a matter of speculation. It has been pointed out that developing societies
have many positive characteristics in comparison with developed countries.30 These include families who are more supportive and less critical; greater opportunities for employment; less competitiveness and impersonality in the workplace; and lower levels of stigma associated with psychiatric disorder. In later chapters we will encounter evidence that some of these factors really do help to determine the long-term prospects of psychiatric patients.
Cross-cultural differences in symptoms
So far, we have seen that there is evidence of cross-cultural differences in both the incidence and outcome of psychosis. However, all the studies we have so far considered have taken the Kraepelinian paradigm for granted. Further evidence of cross-cultural differences comes to light when we consider symptoms, rather than broad and scientifically questionable diagnostic concepts such as ‘schizophrenia’. For example, the DOSMD researchers found that visual hallucinations were much more frequently reported in the developing than in the developed countries. This observation received little attention compared with the researchers’ more contentious claims about incidence rates, but has been repeated by other investigators.31 Studies of delusions also point to cross-cultural and historical differences. For example, although the most common type of delusion reported by modern patients is persecutory,32 patients admitted to US hospitals during the Great Depression of the 1930s more commonly suffered from delusions of wealth and special powers.33
To these observations must be added the so-called culture-bound syndromes – disorders that are apparently restricted to particular societies.34 Examples include koro (an illness suffered by Chinese people, usually males, who believe that their sexual organs are shrinking), latah (experienced by Indonesians, who develop an exaggerated startle response, which includes shouting rude words and mimicking the behaviour of those nearby) and witiko psychosis (a rare disorder in which Algonquian-speaking Indians of Canada believe themselves to be possessed by vampires). Western psychiatrists have sometimes attempted to account for these syndromes by arguing that the form of mental disorder remains constant across cultures but that the content varies, so that the culture-bound syndromes are locally shaped
expressions of disorders that are universal (for example, witiko psychosis might be seen as an unusual variant of schizophrenia).35 When doing so, they have typically ignored culture-specific factors that have shaped the observed behaviour (for example, there is evidence that latah evolved as a way of mimicking the unintelligible demands of European colonialists).36 A further problem with this approach is that it assumes that Western psychiatry somehow ‘knows best’, and has discovered an accurate taxonomy of abnormal behaviours that can be applied without difficulty to non-Western cultures. The research we have reviewed in previous chapters suggests that this kind of psychiatric imperialism has no merit. Given the paucity of evidence supporting the Kraepelinian paradigm, it is not obvious why we should regard it as superior to that of the Baganda.
Are Psychotic Experiences Normal in Some Cultures?
Extract from my field diary:
Dorze, Southern Ethiopia, Sunday 24 viii 69
Saturday morning old Filate came to see me in a state of great excitement: ‘Three times I came to see you, and you weren’t there!’
‘I was away in Konso.’
‘I know. I was angry. I was glad. Do you want to do something?’
‘What?’
‘Keep quiet! If you do it, God wil
l be pleased, the Government will be pleased. So?’
‘Well, if it is a good thing and I can do it, I shall do it.’
‘I have talked to no one about it: will you kill it?’
‘Kill? Kill what?’
‘Its heart is made of gold, it has one horn on the nape of its neck. It is golden all over. It does not live far, two days’ walk at most. If you kill it, you will become a great man!’
And so on… It turns out Filate wants me to kill a dragon. He is to come back this afternoon with someone who has seen it, and they will tell me more…
Dan Sperber37
We must now turn to the second of our two questions. Because different cultures embrace starkly different taxonomies of mental disorder, there is clearly a possibility that the boundaries drawn between madness and normal functioning vary with geography. It just might be possible to be mad in one culture but at the same time sane in another.
Roland Littlewood, one of the few British psychiatrists with an interest in anthropology, has lamented that the most common question he is asked by his medical colleagues is, ‘Is this a delusion?’38 Certainly, as the above excerpt from anthropologist Dan Sperber’s field diary demonstrates, the apparently irrational beliefs of other cultures present a challenge to those who seek a clear dividing line between normal and abnormal beliefs. What, for example, is the psychiatrist to make of the Fataleka of the Solomon Islands, who maintain that the Earth occupies the fifth of nine parallel strata, that reflections are in stratum three, flutes are in stratum four, crocodiles are in stratum seven, and stratum eight is empty? In a thoughtful discussion of these kinds of beliefs, Sperber has noted that they can sometimes be understood as proto-scientific theories.39 For example, the West African notion that the mind is the meeting place of multiple souls is similar to Freud’s theory of psychoanalysis. At other times the beliefs seem to be metaphors. The assertion by Bororo males that they are red macaws can be understood when it is known that red macaws are taken as pets by Bororo women, who play a dominant role in Bororo society. Sperber goes on to argue that much of the remaining puzzlement experienced by Westerners when encountering the beliefs of other cultures can be resolved by recognizing that often they are not literal statements of observed facts. When people are asked about these kinds of beliefs, they often justify them in terms of tradition or knowledge passed to them by others, much as a modern-day Christian might justify belief in the resurrection by referring to the Bible.
Madness Explained Page 16