Effects of Culture on Recovery From Transient Psychosis

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.

Conclusion
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.

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