Effects of Culture on Recovery From Transient Psychosis

Psychiatric TimesPsychiatric Times Vol 23 No 14
Volume 23
Issue 14

Analyzing data gathered in a 10-nation study of psychoses by the World Health Organization (WHO), Susser and Wanderling1 found that the incidence of nonaffective psychoses with acute onset and full recovery was about 10 times higher in premodern cultures than in modern cultures. Transient psychoses with full recovery were comparatively rare in modern cultures. Such a dramatic difference begs for explanation.

Analyzing data gathered in a 10-nation study of psychoses by the World Health Organization (WHO), Susser and Wanderling1 found that the incidence of nonaffective psychoses with acute onset and full recovery was about 10 times higher in premodern cultures than in modern cultures. Transient psychoses with full recovery were comparatively rare in modern cultures. Such a dramatic difference begs for explanation.

The WHO studies of psychoses worldwide have made it clear that those with psychoses in general have a better course and outcome in premodern cultures.2-4 Some theorists have speculated that the better course and outcome are due to lesser demands made on patients in the agrarian economies of underdeveloped nations. However, further investigations in Japan, Hong Kong, and Singapore-all societies of advanced economic development--have also demonstrated a better course and outcome for psychoses than in Western cultures.5-8

Hopper and Wanderling9 analyzed the data from the WHO studies, as well as 2 additional samples (from Hong Kong and Madras/Chennai, India), for sources of bias that could account for a differential advantage in course and outcome for persons living in developing countries. They considered several factors: differences in follow-up, arbitrary grouping of research centers, diagnostic ambiguities, selective outcome measures, sex, and age. None of these potential confounders explained the observed differences. They concluded that local cultural practices were probably implicated in this long-standing and provocative finding of a differential advantage in course and outcome in premodern cultures.

Effects of culture
Transient psychoses with full recovery are much more common in premodern cultures that accept the reality of spirits. In premodern cultures, psychoses are usually characterized by paranoid delusions of attack by sorcery, witchcraft, or demonic beings-with accompanying auditory and visual hallucinations.5,10-14 These cultural beliefs structure not only the symptoms of illness but also the indigenous diagnoses, treatments, and outcomes.11,12

Traditional treatment in a premodern society usually consists of a prescribed period of rest; sympathy; heightened social support; alleviation of underlying social stresses; exploration of alternative coping strategies; and various types of traditional healing rituals, sometimes lasting days or weeks, and frequently resulting in the full recovery of the patient.5,11-18

Dutch psychiatrist Marjolein van Duijl,14 who was head of the department of psychiatry at a hospital in southwest Uganda for 6 years, conducted a study there of 120 patients experiencing "spirit possession." Forty-one percent of these patients reported hearing voices, and 65% spoke in a voice different from their own. Of these 120 patients, 45% felt better, and 54% experienced complete recovery after treatment by traditional healers.

Cultural psychiatrists Wolfgang Jilek5 and Beng-Yeong Ng13 concluded that the factor determining course and outcome is not the difference between high and low economic development, but the difference between modern and premodern cultures that have preserved traditional elements in their world views and healing practices. Jilek further suggested that an acute psychotic episode evoked by traumatizing experiences and severe social stress would be of short duration if the society responded with sympathy, social support, and traditional healing practices. However, if there is rejection and social isolation, the traditional extended kinship network is no longer in operation; if there is an expectation of a chronic illness when a patient shows an acute psychotic reaction, transient psychoses could evolve into chronic psychoses, particularly if modernization has become pervasive.

Social stress and trauma
Social stress appears to be a key factor in psychotic symptom onset. In a WHO-sponsored cross-cultural study of life events and schizophrenia, it was found that social stress in the environment precipitated psychotic episodes in patients with schizophrenia. Stressful events tended to cluster in a 2- to 3-week period immediately preceding onset of a psychotic episode.19

Social stress and psychological trauma have also been implicated in numerous studies of psychosis in Western cultures. Holowka and associates20 found that emotional and physical abuse were highly correlated with dissociative symptoms in adult patients with schizophrenia. Kilcommons and Morrison21 found that 94% of psychotic patients reported a history of psychological trauma, and the severity of trauma was associated with the severity of psychotic symptoms. Vogel and colleagues22 reported that 66% of an inpatient sample of patients with schizophrenia had a history of trauma. In a review of 13 studies of women with serious mental illness, Goodman and colleagues23 found that 45% to 92% had experienced childhood sexual or physical abuse.

In an inpatient sample of women with schizophrenia, Friedman and Harrison24 found that 60% had suffered childhood sexual abuse. Similarly, Honig and colleagues25 found that 83% of a sample of men and women with schizophrenia had suffered childhood abuse or emotional neglect. They also found that 65% related the initial onset of psychotic symptoms to childhood abuse or other traumatic events. Likewise, in a psychiatric emergency department sample, Briere and colleagues26 found that 53% of women who had suffered childhood sexual abuse were positive for nonmanic psychotic disorders.

Read and colleagues27 suggested that a bias in mainstream psychiatry toward genetic explanations for psychotic symptomatology has led to a neglect of social stress and psychological trauma as factors in models for causation of psychosis. They blame this neglect on an aversion to "family blaming" as a causative factor. Psychiatrists viewed genetic explanations as being more politically acceptable. However, this aversion to psychosocial factors in causation of psychosis is not found in all modern cultures.

In some countries, the concept of "reactive" or "psychogenic" psychoses is widely used in clinical practice. The types of syndromes commonly considered psychogenic psychoses in Scandinavia spread over the general diagnostic categories in DSM-IV. These include schizophreniform disorder, brief psychotic disorder, schizoaffective disorder, delusional disorder, major depression with psychotic features, dissociative trance disorder, dissociative identity disorder, and posttraumatic stress disorder (PTSD).28 Thus, it is possible for all of these disorders to be considered psychogenic psychoses.

Dissociative reactions
The cross-cultural data suggest that the psychological mechanisms of spontaneous trance and dissociation are implicated in causing psychogenic psychoses. Many researchers have come to the conclusion that spontaneous trances occurring during times of extreme stress or trauma can be the cause of many dissociative symptoms associated with psychosis, including hallucinations and delusions.11-14,20-22,27,29-41 These dissociative reactions are thought to recur if the stress or trauma was severe or recurrent because of long-term alterations to the nervous system resulting from the traumatic stress.11,31

Studies have found that 24% to 49% of patients in whom dissociative identity disorder was diagnosed had received previous clinical diagnoses and treatment for schizophrenia.39,40 Ross and Joshi38 concluded that many clinicians are not able to differentiate dissociative symptoms from those of schizophrenia. Haugen and Castillo36 found unrecognized dissociative disorders in 80% of a group of patients given a diagnosis of undifferentiated schizophrenia, in 70% of a paranoid schizophrenia group, and in 33% of a schizoaffective group.

Treatment implications
If spontaneous trances and dissociative reactions structured by local cultural beliefs are at the basis of psychogenic psychoses, then the implications for treatment are that much more emphasis should be placed on rest, counseling, social support and acceptance, alleviating underlying sources of stress, emotional healing for psychological trauma, teaching alternative coping skills, family therapy, expecting a brief duration and full recovery, and the use of traditional healing practices where culturally appropriate.14-16 Also, standards for use of neuroleptic medications for treatment of psychoses should be reevaluated in light of the possible role of trance and dissociation.

Including spontaneous trances and dissociative reactions structured by local cultural beliefs in etiologic models of psychosis, as well as cultural differences in diagnosis and treatment, can help explain several findings concerning transient psychoses.

  • Why psychotic symptoms can be episodic. Symptoms of psychogenic psychoses may be manifestations of spontaneous episodic trances and dissociative reactions.
  • Why psychotic episodes are associated with stressful events. Stressful events can trigger spontaneous trances and dissociative reactions that are the psychological mechanisms underlying psychogenic psychotic symptoms.
  • How spontaneous trances can be responsible for delusions and hallucinations. Highly focused attention in spontaneous trances can block out objective reality and create a subjective reality based on fantasy, imagination, or memory and can include hallucinations and delusions.
  • How dissociation can be responsible for separate streams of thought, auditory hallucinations, and other first-rank symptoms. Spontaneous trances can result in dissociative reactions in which multiple subjectivities can have their own thoughts and voices, which can impact the primary consciousness of the individual, causing auditory hallucinations or other first-rank symptoms, such as thought withdrawal, thoughts ascribed to others, made feelings, made impulses, and made volitional acts.
  • Why there are cultural differences in psychotic symptoms. Modern or premodern meaning systems structure trance experiences in ways consistent with local cultural beliefs. Patients in modern cultures experience dissociation characterized by hearing voices and other first-rank symptoms. Patients in premodern cultures experience spirit attack and possession, which are also characterized by hearing voices, but also by demonic possession.
  • Why psychoses can have a brief or chronic course. Brief course and full recovery become possible when the cause of the symptoms is spontaneous trances and dissociative reactions. Removing the source or motivation for entering spontaneous trances may cause the psychotic symptoms to disappear. If the source of the spontaneous trances is not removed, the trances will recur and psychotic symptoms may become chronic.
  • Why transient psychoses with full recovery are 10 times more common in premodern cultures. Premodern cultures are more likely to ease the effects of stress and trauma-which may be evoking spontaneous trances-by providing social support and acceptance, altering family dynamics, expecting brief duration and full recovery, diagnosing a "spirit possession" illness, and using traditional healing practices.
  • Why chronic psychoses with poor outcomes are associated with modern cultures. A lack of "spirits" to blame for the illness in modern cultures, and a failure to recognize dissociative reactions, results in a bias toward biomedical etiologic models for psychosis. Patients experiencing potentially transient psychogenic psychoses are defined as genetically flawed and incurable. They are treated primarily with neuroleptic medications that dampen symptoms but do not alleviate the effects of stress and trauma, which may be evoking spontaneous trances and dissociation. Therefore, transient psychoses with full recovery are comparatively rare for patients in modern cultures.

Dr Castillo is a medical anthropologist and professor of psychology at the University of Hawaii, West O'ahu, and clinical professor of psychiatry at the John A. Burns School of Medicine, University of Hawaii, Manoa. He reports that he has no conflicts of interest regarding the subject matter of this article.


References1. Susser E, Wanderling J. Epidemiology of nonaffective acute remitting psychosis vs schizophrenia: sex and sociocultural setting. Arch Gen Psychiatry. 1994;51:294-301.
2. Jablensky A, Sartorius N, Ernberg G, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychol Med Monogr Suppl. 1992;20:1-97.
3. Jablensky A, Sartorius N, Cooper JE, et al. A. Culture and schizophrenia: criticisms of WHO studies are answered. Br J Psychiatry. 1994;165:434-436.
4. Sartorius N, Jablensky A, Korten A, et al. Early manifestations and first-contact incidence of schizophrenia in different cultures: a preliminary report on the initial evaluation phase of the WHO Collaborative Study on determinants of outcome of severe mental disorders. Psychol Med. 1986;16:909-928.
5. Jilek WG. Cultural factors in psychiatric disorders. Paper presented at: 26th Congress of the World Federation for Mental Health; July 22-27, 2001; Vancouver, British Columbia.
6. Lee PW, Lieh-Mak F, Yu KK, Spinks JA. Pattern of outcome in schizophrenia in Hong Kong. Acta Psychiat Scand. 1991;84:346-352.
7. Ogawa K, Miya M, Watarai A, et al. A long-term follow-up study of schizophrenia in Japan: with special reference to the course of social adjustment. Br J Psychiatry. 1987;151:758-765.
8. Tsoi WF, Wong KE. A 15-year follow up study of Chinese schizophrenic patients. Acta Psychiatr Scand. 1991;84:217-220.
9. Hopper K, Wanderling J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project: International Study of Schizophrenia. Schizophr Bull. 2000;26:835-846.
10. al-Issa I. The illusion of reality or the reality of an illusion: hallucinations and culture. Br J Psychiatry. 1995;166:368-373.
11. Castillo RJ. Spirit possession in South Asia, dissociation or hysteria? Part 1: theoretical background. Cult Med Psychiatry. 1994;18:1-21.
12. Castillo RJ. Spirit possession in South Asia, dissociation or hysteria? Part 2: case histories. Cult Med Psychiatry. 1994;18:141-162.
13. Ng BY. Phenomenology of trance states seen at a psychiatric hospital in Singapore: a cross-cultural perspective. Transcult Psychiatry. 2000;37:560-579.
14. van Duijl M. Characteristics and help-seeking behavior of spirit possessed patients in SW Uganda. Paper presented at: First World Congress of Cultural Psychiatry, September 24, 2006; Beijing, China.
15. Castillo RJ. Lessons from folk healing practices. In: Tseng WS, Streltzer J, eds. Culture and Psychotherapy: A Guide to Clinical Practice. Washington, DC: American Psychiatric Publishing; 2001:81-101.
16. Jilek WG. Traditional medicine relevant to psychiatry. In: Sartorius N, de Girolamo G, Andrews G, et al, eds. Treatment of Mental Disorders: A Review of Effectiveness. Washington, DC: American Psychiatric Publishing; 1993:341-383.
17. Kleinman A. Patients and Healers in the Context of Culture: An Exploration of the Borderland Between Anthropology, Medicine, and Psychiatry. Berkeley, Calif: University of California Press; 1981.
18. Thong D. A Psychiatrist in Paradise: Treating Mental Illness in Bali. Bangkok, Thailand: White Lotus; 1993.
19. Day R, Nielsen JA, Korten A, et al. Stressful life events preceding the acute onset of schizophrenia: a cross-national study from the World Health Organization. Cult Med Psychiatry. 1987;11:123-205.
20. Holowka DW, King S, Saheb D, et al. Childhood abuse and dissociative symptoms in adult schizophrenia. Schizophr Res. 2003;60:87-90.
21. Kilcommons AM, Morrison AP. Relationships bet-ween trauma and psychosis: an exploration of cognitive and dissociative factors. Acta Psychiatr Scand. 2005;112:351-359.
22. Vogel M, Spitzer C, Barnow S, et al. The role of trauma and PTSD-related symptoms for dissociation and psychopathological distress in inpatients with schizophrenia. Psychopathology. 2006;39:236-242.
23. Goodman LA, Rosenberg SO, Mueser KT, Drake RE. Physical and sexual assault history in women with serious mental illness: prevalence, correlates, treatment, and future research directions. Schizophr Bull. 1997;23:685-696.
24. Friedman S, Harrison G. Sexual histories, attitudes, and behavior of schizophrenic and “normal” women. Arch Sex Behav. 1984;13:555-567.
25. Honig A, Romme MA, Ensink BJ, et al. Auditory hallucinations: a comparison between patients and nonpatients. J Nerv Ment Dis. 1998;186:646-651.
26. Briere J, Woo R, McRae B, et al. Lifetime victimization history, demographics, and clinical status in female psychiatric emergency room patients. J Nerv Ment Dis. 1997;185:95-101.
27. Read J, Perry BD, Moskowitz A, Connolly J. The contribution of early traumatic events to schizophrenia in some patients: a traumagenic neurodevelopmental model. Psychiatry. 2001;64:319-345.
28. Stromgren E. Scandinavian contributions to psychiatric nosology. In: Mezzich JE, Honda Y, Kastrup MC, eds. Psychiatric Diagnosis: A World Perspective. New York: Springer-Verlag; 1994:33-38.
29. Kleinman A, Kleinman J. Remembering the cultural revolution: alienating pains and the pain of alienation/transformation. In: Lin TY, Tseng WS, Yeh EK, eds. Chinese Societies and Mental Health. New York: Oxford University Press; 1995:141-155.
30. Price R. Dissociative disorders of the self: a continuum extending into multiple personality. Psychotherapy. 1987;24:387-391.
31. van der Kolk BA, van der Hart O. Pierre Janet and the breakdown of adaptation in psychological trauma. Am J Psychiatry. 1989;146:1530-1540.
32. Bentall, RP. Hallucinatory experiences. In: Cardena E, Lynn SJ, Krippner SC, eds. Varieties of Anomalous Experience: Examining the Scientific Evidence. Washington, DC: American Psychological Association; 2000:85-120.
33. Ellason JW, Ross CA. Positive and negative symptoms in dissociative identity disorder and schizophrenia: a comparative analysis. J Nerv Ment Dis. 1995;183:236-241.
34. Ellason JW, Ross CA. Childhood trauma and psychiatric symptoms. Psychol Rep. 1997;80:447-450.
35. Giese AA, Thomas MR, Dubovsky SL. Dissociative symptoms in psychotic mood disorders: an example of symptom nonspecificity. Psychiatry. 1997;60:60-66.
36. Haugen MC, Castillo RJ. Unrecognized dissociation in psychotic outpatients and implications of ethnicity. J Nerv Ment Dis. 1999;187:751-754.
37. Ross CA, Keyes B. Dissociation and schizophrenia. J Trauma Dissociation. 2004;5:69-83.
38. Ross CA, Joshi S. Schneiderian symptoms and childhood trauma in the general population. Compr Psychiatry. 1992;33:269-273.
39. Ross CA, Miller SD, Reagor P, et al. Schneiderian symptoms in multiple personality disorder and schizophrenia. Compr Psychiatry. 1990;31:111-118.
40. Ross CA, Norton GR. Multiple personality disorder patients with a prior diagnosis of schizophrenia. Dissociation. 1988;1:39-42.
41. Castillo RJ. Trance, functional psychosis, and culture. Psychiatry. 2003;66:9-21.

Related Videos
Video 6 - "Future Perspectives on Schizophrenia Care"
Erin Crown, PA-C, CAQ-Psychiatry, and John M. Kane, MD, experts on schizophrenia
Video 4 - "Physician Awareness of Cognitive Dysfunction in Schizophrenia"
Video 3 - "Insights on the Pathophysiology of Schizophrenia"
Video 2 - "Exploration into the Management of the Three Symptom Domains of Schizophrenia"
brain depression
nicotine use
brain schizophrenia
© 2024 MJH Life Sciences

All rights reserved.