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VOL.

14, NO 4, 1988 555


Psychopathology and
Clinical Course of
Schizophrenia: A Cross-
Cultural Perspective

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by Keh-Ming Lin Abstract porary Western and non-Western
and Arthur M. Kleinman urban societies, but also in moun-
The authors critically review the tainous Laotian villages
existing literature on the outcome (Westermeyer 1980), extremely iso-
of schizophrenia in non-Western lated Micronesian islands (Wilson
countries. Compared to studies 1980), and small-scale hunter-
conducted in Europe and North gatherer societies in Papua New
America, the majority of these non- Guinea (Burton-Bradley 1985), sug-
Western longitudinal followup gesting that schizophrenia may be a
studies indicated significantly bet- universal phenomenon.
ter outcome. Such cross-national Concurrently, a number of psy-
variations in the outcome of schizo- chiatrists with extensive clinical
phrenia have been substantiated by experiences in various parts of Asia
two large-scale multicentered stud- and Africa have reported that the
ies sponsored by the World Health majority of psychotic patients they
Organization. Along with this liter- treated in these "Third World"
ature review, the authors also countries tended to suffer from a
discuss potential methodological disease process that was charac-
problems of these studies and terized by acute onset, fulminant
examine in detail several key but typically short clinical course,
hypotheses concerning mediating and, more often than not, complete
factors that could differentially remission (Seligman 1929; Berne
influence the fate of schizophrenic 1949; Smartt 1956; Field 1968; Rin
patients in divergent cultural set- and Lin 1962). These observations
tings. Finally, specific suggestions have led to suggestions that the
are made for future research course of schizophrenia in the so-
directions. called "developing" countries may
not be as malignant as that
Since the late 19th century, the observed in industrialized Western
applicability of the concept of settings (Murphy 1968), and have
"dementia praecox" and later generated useful hypotheses about
"schizophrenia" in non-Western the impact of sociocultural forces on
cultural settings has been repeat- the manifestation and outcome of
edly debated (Leighton et al. 1963; schizophrenia (e.g., Cooper and
Wittkovver and Prince 1974; Leff Sartorius 1977; Waxier 1977).
1981, Murphy 1982). As far back as Despite recent progress in
1904, Kraepelin reported observing cultural psychiatry, there has as yet
typical cases of dementia praecox in been no consensus about the cross-
Java during a trip to the Far East cultural comparability of the clinical
made specifically for such a pur- course of schizophrenia: some
pose. In the subsequent decades, regard it as more benign in
an increasing number of psychia- developing societies; others, as
trists working in non-Western basically similar worldwide. Con-
societies convincingly demonstrated tributing significantly to the
that patients with classic schizo- divergence of opinion is the fact
phrenic symptoms and pro- that proponents on both sides have
gressively deteriorating course exist
in all corners of the earth. Patients
Repnnt requests should be sent to Dr.
with chronic nonorganic psychotic K.-M. Lin, Dept. of Psychiatry, Harbor-
and asocial behavioral patterns have UCLA Medical Center, Rm. D5, 1000 W
not only been identified in contem- Carson St., Torrance, CA 90509.
556 SCHIZOPHRENIA BULLETIN

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based their arguments mostly on discharge. The outcome criteria category had been continuously and
cross-sectional observations rather were similar to those specified by seriously ill for the entire followup
than on longitudinal data (Warner Brown et al. (1966), which took into period. Compared with the out-
1985). Fortunately, in recent years, consideration a variety of factors come of the patients from the
longitudinal followup studies with including rehospitalization, current industrialized countries included in
varying degrees of sophistication in symptoms, employment, financial the IPSS (see below), the clinical
research design and involving status, and level of social function- outcome from this series was sig-
patients from non-Western coun- ing. The study revealed that at the nificantly better.
tries have started to emerge, time of followup, 64 percent of the Around the same time, however,
including the International Pilot subjects had maintained a com- Kulhara and Wig (1978) reported
Study of Schizophrenia (IPSS) plete, symptom-free recovery. Most less favorable results from a retro-
(World Health Organization 1973). of the remaining subjects (32 per- spective cohort study in a rapidly
In this article, we first critically cent), however, had remained industrializing city in the Northwest
review studies conducted separately continuously symptomatic and dis- region of India. One hundred out
in different countries. Because of its abled since discharge. Only 9-11 of 174 schizophrenic patients con-
unique design and its special percent fell in between the two secutively admitted in an inpatient
importance, the IPSS is reviewed in extremes in their outcome status. In ward (1966-67) were identified for
a separate section, as is the more contrast to this, the 5-year followup outcome evaluation 4.5-6 years
recent Determinants of Outcome study conducted by Brown et al. later. All subjects were personally
Study, also conducted by the World (1956-61) in England indicated that interviewed by one of the authors
Health Organization (WHO). We 49 percent of a group of schizo- during the index admissions, and
then examine in detail several key phrenic patients in London were reevaluated by the other author at
hypotheses about mediating factors symptom-free, 28 percent were followup. In 86 percent of the
that could significantly influence severely sick, and 23 percent were cases, other reliable informants
the fate of schizophrenic patients in symptomatic and disabled although were also interviewed in addition to
different cultural settings. Finally, not overtly psychotic. Statistical the patients. Only in 5 percent of
we make specific suggestions for analysis revealed that the dif- cases did the outcome information
future research directions. ferences between the Mauritius and derive solely from the patients, and
the British findings were highly sig- in 9 percent of cases, patients were
nificant at .001 level. not available for interview, but data
Followup Studies From Non-
Western Countries With a prospective design and were provided by relatives. The
more sophisticated methodology in authors reported that 29 percent
Studies Conducted in South Asia. followup evaluation, including were symptom-free, 16 percent suf-
Murphy and Raman (1971) con- structured interviewing techniques, fered from minor personality and/or
ducted a 12-year (1956-68) followup the use of objective rating scales, neurotic difficulties, 23 percent con-
study of 90 schizophrenic patients and clearer definition of outcome tinued to experience episodes of
on the island of Mauritius in the criteria, Waxier (1979) drew similar relapse along with clear periods of
Indian Ocean (population: 600,000; conclusions from a 5-year followup remission, and 32 percent remained
50 percent Hindu Indians, 17 per- (1970-75) study of 44 consecutively schizophrenic throughout the fol-
cent Moslem Indians, and 33 admitted schizophrenic patients in lowup period. Since these results
percent Creole Africans). These Sri Lanka. Thirty-eight out of the were more similar to those reported
patients represented 98 percent of original 44 patients were suc- from England by Brown et al. (1966)
all first admission schizophrenic cessfully recontacted at the time of than Murphy and Raman's (1971)
patients treated in 1956 in the psy- the followup. Among these, 45 per- data from Mauritius, the authors
chiatric ward of the only hospital cent (17 cases) were completely concluded that the clinical course of
on the island. Supervised by one of functional and symptom-free, 24 schizophrenia in urban Indian set-
the authors, who is a psychiatrist, percent (9 cases) revealed only non- tings may be comparable to that
two psychiatric nurses conducted psychotic symptoms, and the observed in Western societies.
interviews with these patients and/ remaining 31 percent (12 cases)
or their relatives to evaluate their manifested overt psychotic symp- Studies Conducted in Chinese
outcome and clinical course since toms. All of the 12 cases in the last Societies. Lo and Lo (1977) reported
VOL 14, NO. 4, 1988 557

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a retrospective cohort study which outcome rating included symptom same institution, Hsia and Chang
was able to recontact and evaluate severity, personality deterioration, (1978) analyzed the clinical course
82 out of 133 schizophrenic patients need for medication, and employ- of 100 schizophrenic patients with a
10 years after their first admission ment status. The results revealed history of chronic deterioration
to the Hong Kong Psychiatric Cen- that 35 percent were completely (mean duration = 14 years) and
ter. Those patients evaluated and recovered, 28 percent manifested multiple hospitalizations (mean =
those missing to followup did not only minimal illness, 20 percent 5 1 years). They found remarkable
differ significantly in demographic were moderately sick, 9 percent stability in the clinical pictures of
variables and clinical characteristics were severely disabled, and 8 per- these patients between the first and
such as chronicity, type of onset, cent had died (4 percent from the last admissions. This was par-
and symptom patterns. However, natural causes, 4 percent from sui- ticularly true for the prevalence of
the former group had significantly cide). The authors regarded these delusions, hallucinations, and signs
more supportive relatives as com- results as comparable to those of of formal thought disorder.
pared to the latter. The study did Murphy and Raman (1971) and Lo However, agitation and affective
not clearly specify how the clinical and Lo (1977), with outcome better symptoms became less prominent
conditions of the patients were than in the Western studies. over time, and dramatic contrasts
determined at followup and was From Shanghai, China, Hsia et al. existed in manifestations of emo-
similarly vague about outcome clas- (1958) reported their results on an tional blunting (38 percent in the
sification criteria. The results extremely ambitious undertaking, in first admission, 65 percent in the
indicated that 21 percent achieved which attempts were made to last) and personality defects (22 per-
lasting remission, 44 percent had assess the outcome of all the schizo- cent in the first, 70 percent in the
had episodes of relapse but no or phrenic patients hospitalized in last). Paralleling these changes in
only mild personality deterioration, their inpatient wards in the pre- clinical manifestations, significantly
22 percent had had relapses along vious 21 years. Out of a total of more patients were classified as
with moderate deterioration and/or 1,758 such patients, they were able undifferentiated in their last admis-
residual psychotic symptoms, and to evaluate 879 (50 percent) by a sion (64 percent), as compared to
12 percent had had persistent or variety of methods including letter their initial hospitalization (11 per-
incapacitating psychotic symptoms inquiries, home visits, telephone cent). Whereas 75 percent of these
throughout the followup period. In interviews, and information from patients responded to treatment
terms of social functioning at fol- relatives. They reported that 46 per- administered in their first hospital-
lowup, 43 percent were cent were "completely cured," 17 ization, only 30 percent were
independent, 23 percent were percent "significantly improved," 2 responsive to psychiatric interven-
"somewhat dependent" (defined as percent "moderately improved," 29 tion when last evaluated. Since this
requiring supervision), 26 percent percent "still incapacitated," and 6 study deliberately included only
were dependent, and 7 percent percent hospitalized. Despite sig- cases with chronic dysfunction,
were hospitalized. nificant methodological problems, these results are not generalizable
Tsoi et al. (1985) conducted a sim- including the low intensity and to less selected patient groups and
ilar study in Singapore with 557 apparent inconsistency in the cannot be used for cross-cultural
consecutively hospitalized first method of followup and the outcome comparisons. However,
admission patients. All subjects absence of specific criteria for origi- they do convincingly indicate that
were originally diagnosed by the nal diagnosis and outcome chronic deterioration does occur in
first author in 1975 with guidelines assessment, the findings from this a portion of "Third World" schizo-
specified by Slater and Roth, and study should not be neglected. The phrenic patients. Further, when this
were reassessed with various study is important not only because happens, patients may follow simi-
methods including review of rec- of its remarkably large sample size, lar patterns of deterioration to those
ords, reinterview by the treating but also because the researchers in the West.
psychiatrists, and home visits by involved in the project had been
the medical social worker of the responsible for the care of all the
Japanese Studies. Over the last half
hospital. Out of the 557, 424 were patients throughout the two dec-
century, at least a dozen major fol-
successfully rated for their outcome ades of the study period.
lowup studies of schizophrenia
status. Factors considered in the In a more recent study from the outcome have been conducted in
558 SCHIZOPHRENIA BULLETIN

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Japan, virtually the only fully were "seriously disabled"). In con- 3 percent as moderately disabled,
industrialized non-Western society. trast, only 6 percent remained in 12 percent as gravely disabled, and
Unfortunately, the findings of these the gray area 11 percent as having died. These
studies have rarely been reported Ichimiya et al. (1986) reported the findings were quite similar to the
outside of the Japanese psychiatric results of a study of 129 schizo- two studies reviewed above.
literature and have so far remained phrenic patients over a 20- to 44-
unavailable to Western researchers. year period. Among these patients, Critique. Considering the remark-
We review two recent studies. 66 were first seen between 1940 and able differences in the cultural and
Miya et al. (1984) and Ogawa et 1957, and 63 were first evaluated geopolitical milieus in which these
al. (1987) reported a 16- to 21-year between 1957 and 1963. The initial studies took place, the similarities
retrospective followup study of the diagnosis of the patients was made in their methodology and results
clinical course and outcome of 140 according to both Bleuler's and are quite striking. Conducted in the
schizophrenic patients consecutively Schneider's criteria. Outcome rat- last three decades, these studies
hospitalized in a 5-year period ings were also clearly described benefited from experiences of
(1958-62). Out of the 140, only 10 with specific criteria. The method of earlier investigations performed in
(7 percent) were lost to followup. followup was not clearly specified. the Western countries. Their study
Unfortunately, inconsistency in the Although the authors implied that design was either prospective (Wax-
methodology of followup seriously this was a prospective on-going fol- ler's study) or retrospective cohort
limited the robustness of the find- lowup study with a design similar in nature, and included con-
ings: while 46 percent of the to that of Manfred Bleuler (1978), secutively all patients who met the
patients were personally inter- the initial recruitment of subjects diagnostic criteria. With the possi-
viewed, information about the rest was not consecutive, and the drop- ble exception of Kulhara and Wig's
was obtained through review of out rate was quite substantial study, most of the investigators
various records and from patients' between first evaluation and out- recruited patients who were fairly
family members, relatives, and come assessment (e.g., out of 283 acute at the index admission, and
friends. Despite this methodological patients admitted in the period some of the studies limited their
flaw, however, the authors appar- 1957-63, 146 dropped out of treat- research samples to first-admission
ently were able to gather sufficient ment; no attempts were made to patients.
information to reconstruct the clini- contact these patients). This study Compared to the more recent,
cal course of these patients over reported that at the end point of thoroughly designed followup stud-
time. According to them, following the followup, 17 percent were in ies, such as those conducted by
the index admission, most patients' complete remission, 27 percent Tsuang et al. (1979) and McGlashan
conditions were initially unstable, were employed and experienced (1984), some of the limitations of
fluctuating, and unpredictable. As only mild nonpsychotic symptoms, these studies become apparent.
time progressed, the number of 25 percent were symptomatic but These have to do with issues of
patients who remained in such a socially adjusted, 17 percent were diagnosis, criteria of outcome
"transitional" state gradually significantly disturbed, and 14 per- assessment, the method and inten-
decreased. Although a portion of cent remained gravely disabled. sity of followup, and attrition of
these patients progressively deterio- In the discussion section, cases through the followup period.
rated, an increasing number of Ichimiya et al. (1986) also reported Since the psychiatrists involved in
them also entered stable remission. the findings of a 1978 study con- these studies were all influenced by
At followup, this trend resulted in a ducted by Yuasa. This was a 10- to the European—especially British—
large percentage of patients who 14-year followup study which suc- tradition, and subscribed to a more
were essentially symptom-free and cessfully traced 110 of 114 narrowly defined concept of schizo-
socially functional (41 percent were consecutively admitted patients. On phrenia, the discrepancy in
completely independent and 9 per- the basis of information derived diagnosis across these as well as
cent were semi-independent), as from review of records, they rated some of the Western studies with
well as a significant proportion of 52 percent of the patients as com- similar diagnostic practices is proba-
patients who were severely dys- pletely independent, 10 percent as bly not too enormous. However,
functional (26 percent were semi-independent, 10 percent as since acute psychoses with rapid
hospitalized; another 2 percent unemployed but adjusted at home, reconstitution are reported as the
VOL. 14, NO. 4, 1988 559

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commonest psychoses in most non- 17 to 46 percent. Thus, while not psychotic secondary to other
Western societies, there remained a patients in most non-Western stud- reasons (e.g., substance abuse, epi-
possibility that in the above-men- ies did appear to enjoy better lepsy). Among the 1,202 patients,
tioned non-Western studies some of outcome than their counterparts in 811 were diagnosed as schizo-
these presumably more benign con- the Western settings, no definitive phrenic. The rest included 164
ditions were misidentified as core conclusion can yet be drawn from affective psychoses, 29 paranoid
schizophrenic disorders. So long as these findings because, depending psychoses, 73 other psychoses, and
diagnostic criteria are not objec- on the Western studies selected for 125 with other diagnosis.
tively described, the issue of comparison, the results differ. This The results of the initial examina-
whether diagnostic differences con- is especially so for reports of more tion revealed that the diagnostic
tribute to differences in outcome recent Western studies (Bleuler practices leading to the classifica-
remains unsettled. Similarly, the 1978; Bland 1982), which disclose tion, as well as the symptom
absence of more substantial discus- better long-term outcome than pre- manifestations, of the above-men-
sions of operationalized criteria of vious ones from similar cultural tioned psychiatric categories were
various aspects of outcome makes settings. quite similar across all research cen-
comparison of outcome across stud- ters. Such similarities were
ies questionable. The personnel demonstrated in the clinical profiles
International Pilot Study of
involved in followup also varied that were constructed from the item
Schizophrenia (IPPS)
significantly among studies: the scores of the Present State Examina-
outcome evaluators were the treat- Begun in 1968, and carried out tion (PSE) and also from the
ing psychiatrists in four studies, through the early 1970's in nine application of a computerized classi-
research nurses in one, and not countries, the IPSS represented a fication program (CATEGO; Wing
specified in the rest. The intensity ma|or advance in the cross-cultural et al. 1974).
of the followup also differed from research on the phenomenology Followup assessments at 2 and 5
study to study. At one end, Waxier and clinical course of schizophrenia years were carried out in all the
attempted to interview all the (World Health Organization 1973, centers, again with standard instru-
patients as well as their relatives, 1979). Using prospective design, ments including the PSE and other
and also reviewed hospital and identical protocols, standardized followup scales. At the 2-year fol-
clinic records. At the other extreme, interviewing instruments, and rat- lowup, 609 (75 percent) of the 811
some studies attempted to gather ing scales, this study was original schizophrenic patients were
information from any source and performed by researchers in nine successfully reevaluated. However,
rated patients' outcome on such field centers who had been pre- reinterview rates varied markedly
information. Finally, the relatively viously trained and shown to be from center to center, ranging from
higher rates of attrition in some of reliable in their diagnostic and rat- 53 percent in Ibadan to 97 percent
these studies also pose a serious ing practices. All together, 1,202 in Agra.
problem in the interpretation of the patients were admitted to psychi-
data reported (Edgerton 1980). Detailed, objective criteria were
atric centers in Aarhus (Denmark), used to rate the following charac-
In five of these studies, the Agra (India), Cali (Colombia),
authors claimed that their patients teristics: symptomatic outcome,
Ibadan (Nigeria), London (UK), length of episode of inclusion, per-
showed significantly better outcome Moscow (USSR), Prague (Czecho-
than those studied in Western set- cent of time spent in a psychotic
slovakia), Taipei (Taiwan), and episode, pattern of course, type of
tings. As reviewed by Warner Washington, DC (USA). Only
(1985), however, the 30 Western fol- subsequent episodes, degree of
young patients (25-44) with func- social impairment, and length of
lowup studies conducted during a tional psychosis of recent onset
similar time period revealed time out of hospital. In addition, on
who consistently resided in the pre- the basis of information derived
extremely wide variability. For determined catchment areas were
example, those rated as completely from three of these variables (per-
included Various exclusion and centage of followup period spent in
recovered in these Western reports inclusion criteria further ensured
ranged from 9 to 52 percent. In con- a psychotic episode, presence or
that all the patients could be objec- absence of severe social impair-
trast, the non-Western data as tively identified as psychotic, not in
reviewed above showed a range of ment, and type of remission after
a chronic, deteriorated state, and episodes), overall outcome for each
560 SCHIZOPHRENIA BULLETIN

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patient was rated on a 5-point scale. ticularly troublesome. It is not nificantly larger proportion of the
For the whole study, 26 percent inconceivable that, due to geo- non-Western patients initially iden-
belonged to the best outcome graphic or other reasons, tified as schizophrenic may indeed
group, while 18 percent fell into the researchers in Ibadan could have have been misclassified (i.e , the
worst group. These outcome ratings reached proportionally more of the prognosis of the non-Western
were significantly different across better outcome patients, whereas patients appeared to be better
the nine study centers: Agra (India) those patients who had remained because a significant number of
and Ibadan (Nigeria), both repre- dysfunctional could have been kept them actually suffered from affec-
senting developing countries, had in remote villages and become less tive or reactive psychosis and
the highest proportion of best out- accessible to followup. At the same recovered after the index episodes)
come subjects (48 percent and 57 time, patients with poor outcome Some support for this thesis comes
percent, respectively), whereas the were more likely to remain in psy- from the finding that acute onset
study centers located in Western chiatric institutions, and could was characteristic of a higher pro-
industrialized countries uniformly conceivably be overrepresented at portion of patients included in the
manifested a remarkably low per- the 2-year followup in developed nonindustriahzed study centers.
centage of best-outcome patients (6- country sites with low rates of There may be other less conspic-
23 percent). Conversely, while very reevaluation (e.g., 58 percent in uous and as yet unidentified
few patients from Agra and Ibadan London and 66 percent in Wash- disparities in the initial sampling
were rated as having the worst out- ington, DC). However, this still that could have contributed to the
come (15 percent and 5 percent, would not explain the sharp con- cross-cultural outcome differences,
respectively), a much larger propor- trast in outcome between Agra (3 since these are not population-
tion of the patients from the percent attrition rate) and Aarhus based samples with local controls.
industrialized societies were (7 percent attrition rate). Also, many previous studies have
assigned to this group (11-31 per- Another major methodological indicated that nonclinical factors
cent). Although the 5-year followup issue has to do with the com- such as premorbid personality
data have not been reported, Sar- parability of patients initially characteristics, as well as premorbid
torius (personal communication, recruited across different study cen- social and occupational adjustment,
April 1986) indicated that the con- ters. The application of specific are more powerful prognostic forces
trast in outcome of schizophrenic inclusion and exclusion criteria than diagnostic and symptomatic
patients between developing and resulted in a high degree of sim- considerations (Strauss and Carpen-
developed countries continued to ilarity in the symptomatology, ter 1979; Bland 1982). It is unclear
exist. Thus, this large-scaled, pro- severity, and chronicity among to what extent these factors are
spective, multinational study patients from different sites. This comparable across the IPSS study
provided strong evidence of cross- should guard against flagrant dis- centers, and to what degree some
cultural variability in the outcome parity in sampling across centers. of these differences may be respon-
of schizophrenia. These data are Nevertheless, at followup, the sible for the outcome differential
congruent with findings from most rediagnosis of 6 of the 21 schizo- between developing and developed
of the earlier reports suggesting phrenic patients (28 percent) at centers (Edgerton 1980).
that schizophrenic patients in Third Agra who suffered from relapses Some of these methodological
World countries tended to enjoy was either affective psychosis or issues, however, have been more
better outcome than those living in reactive psychosis (World Health adequately addressed by a more
industrialized nations. Organization 1979, pp. 153-155). recent World Health Organization
Despite the apparently high level A similarly high proportion of Determinants of Outcome Study
of sophistication in the study changes in diagnosis occurred at (Sartorius et al. 1986). Conducted in
design of the IPSS, unfortunately, Ibadan (3 of 17, or 18 percent), Cali 12 research centers in 10 countries
major methodological problems (7 of 29, or 28 percent), and (Aarhus, Denmark; Agra and Chan-
were not completely avoided. The Moscow (10 of 31, or 39 percent), digarh, India; Cali, Colombia;
wide variation in the attrition rate but not in the other centers (5 of 79, Moscow, USSR; Nagasaki, Japan;
at 2-year followup across centers, or 6 percent). Such a contrast in the Nottingham, UK; Honolulu and
and especially between Ibadan and diagnostic consistency over time Rochester, USA; and Prague,
some of the Western sites, is par- points to the possibility that a sig- Czechoslovakia) over 2 years, this
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newer study used diagnostic and particular type of schizophrenia or a such settings, even those without
outcome assessment criteria com- (nonschizophrenic) psychogenic significant disability may find them-
parable to those used in IPSS. psychosis; and (2) the most recent selves isolated, alienated, and
Unlike the IPSS, this study very long-term outcome studies in alone. It is reasonable to speculate
attempted to identify all patients the West show a more benign out- that there is a relative advantage for
with psychotic symptoms who had come than has heretofore been patients in the less fully indus-
mad<- a first-in-lifetime contact with considered usual for the core trialized societies in regaining
any type of "helping agency," schizophrenia syndromes (Bland adequate social support as com-
either modern or indigenous. The 1982) Nonetheless, an assertion pared to those residing in urban
results indicated that patients in dif- such as this, if proved, would have Western settings (see Lin and Lin
ferent cultures meeting the 1CD a profound impact on the theories [1981] for evidence from Chinese
(World Health Organization 1978) and practices in regard to the treat- society). This, of course, would lead
and CATEGO (Wing et al. 1974) cri- ment and rehabilitation of to better ratings of social function-
teria for schizophrenia had schizophrenic patients throughout ing in the IPSS as well as in other
remarkably similar symptom pro- the world. Moreover, it has similar studies. In addition, lower
files. However, the 2-year illness received more consistent support levels of social isolation would also
course was considerably more than almost any other finding in facilitate patients' recovery in other
favorable in patients in developing cross-cultural psychiatry and indeed aspects of their lives, and thereby
countries compared to patients in constitutes the single most impor- result in a better overall outcome.
developed countries. Furthermore, tant cross-cultural finding. Possible Some indirect evidence for this
this difference could not be fully underlying mechanisms that could comes from the Determinants of
explained by the higher frequency be responsible for such differences Outcome study, where many more
of acute onsets among the former must be examined. In what follows, patients lived alone in several of the
This study thus confirmed the we discuss several plausible industrialized society centers. Thus,
earlier IPSS findings of better prog- hypotheses to explain this datum, it appears reasonable to hypothe-
nosis in less industrialized societies, several of which are based on size that weak or absent social
and also clarified some of the meth- recent findings, others of which are supports are responsible for poor
odological problems clouding the more speculative. outcome.
interpretation of the IPSS data. It is thus plausible that the
Social Isolation and Social Sup- intense individualism characteristic
Speculations on Underlying port. As would have been predicted of modern Western societies is, in
Mechanisms for Better by most psychiatric clinicians, social general, not conducive to the recov-
Prognoses in Non-Western isolation has been identified in the ery of schizophrenic conditions.
Schizophrenic Patients IPSS and the Determinants of Out- Along with their heavy emphasis
come study (Leff et al. 1987) as one on independence, self-reliance, and
In an analysis of the material of the few strong predictors of the personal freedom, individualistic
reviewed in the previous two sec- outcome of schizophrenic patients. value orientations also tend to fos-
tions, it is reasonable to conclude Most developing societies are ter fierce competition, frequent life
that, although none of the studies "sociocentric," with a primary changes, and alienation, and they
are perfect, the more rigorous stud- emphasis on social relations and a do not usually provide the kind of
ies strongly support the hypothesis range of conventions, rules, and structured, stable, and predictable
that schizophrenic patients in non- roles that tend to sustain long-term environments that allow schizo-
industnalized societies enjoy relationships, and make isolation phrenic patients to recuperate at
significantly better prognosis than unusual even for the disabled. In their own pace and to be reinte-
do their Western counterparts. The contrast, Western societies have grated into the society.
issue is not entirely settled, been labeled by anthropologists as
however, for two reasons: (1) "egocentric." In these societies, Family Milieu. Confirming earlier
because acute onset psychoses pre- relationships are more likely to be clinical observations, recent
dominate in the non-Western bilaterally defined, contractual in research has consistently demon-
world, there is still the question of nature, and subject to constant strated that schizophrenic patients
whether better outcome is due to a reevaluation and revocation. In are particularly vulnerable to exces-
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sive emotional demands and/or The Nature of Employment and the are more distant, less "protective,"
criticisms within the family (Brown Sociopolitical Milieu. That "work" and under more bureaucratic regi-
et al. 1972). With the ascendancy of is an important force in facilitating mentation. Again, this is less likely
the nuclear family structure over the recover)' of schizophrenic to be the case for patients returning
the more traditional extended kin- patients is a major thesis which is to traditional communal settings,
ship ties, family members forced to hardly disputed by any students of since their work roles are more inte-
take care of schizophrenic patients schizophrenia. Unfortunately, the grated with other aspects of their
often have to face the task alone resumption of the work role for the lives and are less likely to be taken
with few familial resources to rely recovering schizophrenic patient or away simply because of questions
upon. This frequently results in even the "ex-schizophrenic" patient about their performance. Also, they
unrealistic expectation and height- in modern industrialized societies are more likely to work with friends
ened disappointment, leading to can be quite problematic. A sub- or relatives in a more permissive
excessive demands and criticism. stantial portion of the work force in and protective setting.
Supporting such a hypothesis, El- all capitalistic societies is peren- In a recently published book,
Islam (1979) reported that in Qatar nially unemployed (some social Warner (1985) extensively reviewed
schizophrenic patients with scientists as well as political activ- evidence suggesting that differences
extended families showed better ists argue that it is deliberately kept in the political and domestic econ-
outcome than those who resided in so for the purpose of wage control) omy may significantly affect the
nuclear family households. A more (Warner 1985). The process of seek- course of schizophrenia in different
recent study by Jenkins et al. (in ing reentry into the job market for societies. These bits of evidence
press) quantitatively measured and anyone in the Western societies include: (1) increases in spending
compared the amount of with a substantial disruption in on psychiatric hospital care during
"expressed emotion" (EE) in Mexi- work record is typically frustrating economic depression; (2) lower rate
can-American and Anglo-American and disheartening, and can be of recovery from schizophrenia dur-
families with schizophrenic especially traumatic for recovering ing the Great Depression era, (3)
patients, and demonstrated that schizophrenic patients who, as a better outcome in female schizo-
Mexican-American families were rule, do not take rejection well, do phrenic patients; (4) worse outcome
significantly less likely to be classi- not tolerate high levels of ambigu- in lower social class schizophrenic
fied as belonging to the high EE ity, and are further handicapped by patients; and (5) better schizo-
group. Concurrently, they demon- having a history of mental illness phrenic outcome in societies with
strated that these Mexican- and psychiatric hospitalizations that full employment than in societies
Amencan patients were much less has a negative effect on employers. with perennial unemployment
likely to suffer from a relapse dur- In contrast, in the traditional village problems. Although controversial
ing followup as compared to their or tribal settings, "jobs" are more and at times an inferential leap
Anglo counterparts. Data from the often assigned than sought. When from available data, Warner's
Determinants of Outcome study patients recover from their active review raises important questions
(Leff et al. 1987) show (1) that EE psychotic symptoms, they are far about how social, political, and
can be reliably and validly meas- more likely to find work waiting for economic forces influence psychi-
ured in a non-Western society them and often find it much easier, atric afflictions. This important
(India) and (2) that lower rates of relative to patients living in urban subject deserves more careful scru-
EE (especially negative and critical settings, to reassume the work roles tiny in the future.
affective responses of family mem- they had before the onset of their
bers) were found in one Indian illnesses.
center compared with a Danish cen- Stigma, Self-Attribution, and Sick
Further, in industrialized Role. Several authors (Murphy and
ter and correlated with better
societies, the work environment is Raman 1971; Waxier 1977, 1979;
outcome. EE seems to be a measure
typically impersonal and can be Warner 1985) have argued elo-
closely related to social support.
intensely competitive. Thus, even quently and have substantiated,
Hence, family relations may not be
when a recovering psychiatric with admittedly limited empirical
an alternative hypothesis but a
patient finds a job, the profound data, that the stigma of mental ill-
component of the previous one.
sense of marginality and insecurity ness is much less prominent in
lingers on. Also, work relationships manv of the less industrialized cul-
563
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tures. In traditional societies, as well as the West's adversarial Conclusions and Future
psychiatric problems are often con- legal system involved in the deter- Research Directions
veyed through physical (medical) mination of the disability of and
and/or supernatural idioms of dis- benefits for the patients, retards Despite the caveats indicated earlier
tress, patterns of help seeking, and giving up sick role behavior, quit- in this article, the literature does
interpretations. Patients suffering ting passive dependency on the provide fairly convincing evidence
from these conditions are thus not disability system, and normalizing in support ot the assertion that
regarded as personally responsible one's behavioral aberrations. This is schizophrenic patients in develop-
for their predicament. In contrast, not to say that modern psychiatric ing societies often have better
modern psychiatric theories tend to care necessarily fosters chronicity or outcome as compared to those
equate mental illness with person- to agree with the politically residing in industrialized countries.
ality and psychodynamic defects conservative in their reactionary This hypothesis is further sup-
that are integral parts of the position about welfare. Well-orches- ported by as yet unpublished data
patients and hence may not be trated mental health and social from the Determinants of Outcome
easily remediable. This sets the services systems are certainly essen- study (Sartorius et al. 1986) that
stage for stigmatizahon and rejec- tial in the care of a large number of finds outcome remains better in
tion from the outside, and self- psychiatric patients in the indus- developing societies even when
attribution and self-blame from the trialized societies. However, the acute onset is controlled in statisti-
inside The expectation of others role of these institutions in exag- cal analysis. On the surface, it may
and self is more pessimistic. Waxier gerating and perpetuating the sick appear preposterous that patients
(1977, 1979) argues that expecta- role behavior of at least some living in economically disadvan-
tions of schizophrenia in Sri Lanka schizophrenic patients in urban taged parts of the world and with
are that it is like any other acute ill- societies still awaits further less mental health resources should
ness, and the societal reaction is in clarification. experience better outcome. Nev-
keeping with this view. In contrast, ertheless, on closer scrutiny, one
the societal expectancies of many in finds sociocultural forces charac-
Western society are that insanity is Differential Survival of Vulnerable teristic of the technologically
a hopeless, incurable, and lifelong Individuals. Recent research find- advanced societies that could possi-
affliction, and the response of care ings derived from several areas bly complicate or retard the
givers and laity is to treat the men- have converged to suggest that a recovery of schizophrenic patients.
tally ill as lifelong deviants. In a high proportion of schizophrenic Thus, clinical observations, research
comparison between German and patients may have suffered from findings, and theoretical considera-
American patients and providers, perinatal and/or neonatal brain tions converge to indicate that
Townsend (1978) showed that a damage. Although no objective data sociocultural factors exert significant
major difference in attitudes can be are yet available, it is plausible to influences on the clinical course of
shown even in two Western speculate that in nonindustrial cul- schizophrenia. Indeed, we would
societies, with German patients and tures most of these "vulnerable" argue that this finding of better out-
psychiatrists being more pessimistic individuals fail to survive into their come in less developed societies,
about the outcome of schizophrenia second or third decades to experi- though a very crude measure of
than their American counterparts. ence schizophrenic breaks (Cooper societal difference, is arguably the
(Alternatively, Chinese society is an and Sartorius 1977). In contrast, single most important finding of
example of at least one non-West- these "biologically disadvantaged" cultural differences in cross-cultural
ern society with very strong stigma children in the modern urban research on mental illness. It is as
attached to the mentally ill and societies would be more likely to important as the finding that the
their families.) survive into maturity. Such biolog- core schizophrenic syndrome can be
ical vulnerability may be associated diagnosed in patients from virtually
While the "chronic" psychiatric
with signs (e.g., enlarged ventri- every society in which researchers
sick role has not been systematically
cles, negative symptoms) that are have looked for it.
investigated, there can be little
doubt that the extensive bureau- associated with chronicity in schizo- However, much remains to be
cratization of the modern mental phrenia (Andreasen et al. 1982; clarified for an issue with so many
health and social welfare systems, Pogue-Geile and Harrow 1985). profound theoretical as well as
564 SCHIZOPHRENIA BULLETIN

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practical implications. In fact, we Western countries. Uncertainty in levels of industrialization7 Or is it
believe that the understanding of diagnostic equivalence across cul- determined by variations in
this finding should head the agenda tures has been one of the most sociopolitical structures (Livingston
of future cross-cultural research of difficult issues confronting cross- and Lowinger 1983)? Supporting
schizophrenia. The following list of cultural comparative studies. the thesis that industrialization is
suggestions, we believe, will be Whereas the definition and the the key issue, the World Health
particularly useful for future diagnosis of schizophrenia remain Organization data from urban and
research efforts. problematic for the psychiatric pro- rural India showed some important
fession, recent development of differences in schizophrenic out-
• Much more information needs operationalized criteria for psychi- come. However, much more needs
to be accumulated on the clinical atric diagnostic criteria (e.g., to be done to clarify this issue.
manifestations, longitudinal course, Feighner's criteria [Feighner et al. It is also important to expand our
and prognostic indicators in non- 1972], DSM-llI [American Psychi- knowledge of the clinical course of
Western countries. Compared to atric Association 1980], Research schizophrenia in various cultural
the more than 100 followup studies Diagnostic Criteria [Spitzer et al. settings. We need to know, for
that have been conducted in Europe 1978*7]) and structured interviewing example, whether there are dif-
and North America, the followup instruments (e.g., Schedule for ferences between Western societies,
projects focusing on cultures out- Affective Disorders and Schizo- and whether these differences cor-
side of the Western World are few phrenia [Spitzer et al. 1978/;], relate with economic or cultural
and far between. These kinds of Diagnostic Interview Schedule indices. Conversely, there may be
studies are needed not only for the [Robins et al. 1981], Structured societies which are less indus-
purpose of cross-cultural com- Clinical Interview for DSM-III trialized where schizophrenic
parison but, more important, [Spitzer et al. 1985]) have provided patients suffer from poor outcome.
because they provide the most basic reliable mechanisms for ensuring If this is true, then we need to look
material for the establishment of that patients being studied are com- into specific parameters beyond
culturally appropriate psychiatric parable to one another Similar economic issues which determine
practices. Multicenter designs evi- criteria and instruments should be the poor outcome in these commu-
dently are advantageous for many used in future cross-cultural studies nities. For future investigations, we
reasons as discussed above, but to achieve a higher level of com- suggest that attention should be
they are expensive. Thus, not many parability among patients belonging focused on specific aspects of
such comparisons are likely to be to divergent cultural groups. societal differences in social organi-
funded. Bilateral and trilateral com- • Future studies should go zations, universe of symbolic
parisons and intracountry long-term beyond simply contrasting "West- meanings, and behavioral norms
outcome data based on population ern" with "non-Western" cultures, that may profoundly influence the
surveys may be more feasible. It is or "industrialized" with "nonin- response to the mentally ill.
not the outcome data, per se, but dustrialized" societies, and be more
• A substantial proportion of
the examination of hypotheses on specific about the sociocultural
schizophrenic patients studied
sources of presumed better outcome characteristics of the groups being
recently in the Western countries
that should distinguish this next investigated. Communities influ-
demonstrated soft neurological
generation of studies. enced by the same cultural tradition
signs, enlarged cerebral ventricles,
often vary greatly in their degree of
• The methodology of followup predominantly "negative" schizo-
urbanization and industnalization.
studies has gone through vast phrenic symptoms (withdrawal,
The contrast between Taiwan and
improvement in the past several apathy, blunted affect, and person-
China provides an interesting exam-
decades. Instead of "reinventing ality defects) and possibly a more
ple. The clinical course of Chinese
the wheel," future studies con- chronic clinical course. It would be
schizophrenic patients in Taiwan
ducted in developing countries important to find out whether such
seems to be as unfavorable as of
should capitalize on such advances patients are less often seen in non-
those residing in Western countries,
in research methodology to ensure Western settings, as would have
yet Chinese patients in mainland
that they will be as meth- been predicted by the theory link-
China tend to enjoy better outcome.
odologically rigorous as studies ing better schizophrenic prognosis
Is the difference related to different
currently being conducted in the with lower perinatal survival rates.
VOL. 14, NO. 4, 1988 565

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On the other hand, the presence of rehabilitation and secondary/tertiary in schizophrenia. Canadian journal of
concurrent tropical disease could prevention are crucial additions to Psychiatry, 27:52-62, 1982.
make rates comparable or even the still dominant curative model. Bleuler, M. The Schizophrenic Disor-
greater in the non-Western world. Perhaps with all the attention to der: Long-term Patient and Family
We simply do not know the answer what differentiates schizophrenia Studies New Haven, CT: Yale Uni-
to this question. from other chronic disorders (e.g., versity Press, 1978.
• To answer not only the ques- heart disease, diabetes, arthritis,
and chronic pain syndrome), we Brown, G.W.; Bone, M.; Dalison,
tion of whether there are cross-
also need to look at those more B.; and Wing, J.K. Schizophrenia and
cultural differences in recovery from
generalizable factors that contribute Stx'ial Care. Maudsley Monograph
schizophrenia, but also why, out-
to disability and retard normaliza- No. 17. London: Oxford University
come studies should be conducted
tion in all disorders. Finally, the Press, 1966.
simultaneously with studies inves-
tigating various specific socio- findings reviewed here point to Brown, G.W.; Birley, J.L.T.; and
cultural hypotheses that have been some problems in the systems of Wing, J.K. Influence of family life
modeled as underlying reasons for care and of societal response to on the course of schizophrenic dis-
the cross-cultural differences. These patients in our own society and that orders: A replication. British journal
should include detailed, quantita- of other industrialized societies of Psychiatry, 121:241-258, 1972.
tive, and ethnographic information which may be more important to Burton-Bradley, B.C. Transcultural
about employment, job perform- identify and change than any spe- psychiatry in Papua New Guinea.
ance, work relationships, social cific individual treatment Transcultural Psychiatric Research
support, alienation, family struc- intervention. It will be a great mis- Rei'iexo, 22:5-36', 1985.
ture, family interactions (e.g., EE), take if future research on
schizophrenic disorder does not pay Cooper, ) . , and Sartorius, N.
stigma, and illness behavior. Opera-
at least as much attention to Cultural and temporal variations in
tionalized definitions and clinically
sociocultural factors as it does to schizophrenia: A speculation on the
meaningful instruments for the
the biological dimensions of the importance of industrialization. Brit-
measurements of some of these
condition. Cross-cultural settings ish journal of Psychiatry, 130:50-55,
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would seem to provide a crucial 1977.
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