On the expression of psychosis in different cultures: schizophrenia in an Indian and in a Nigerian community

Factor structure and item response of psychosis symptoms among Kenyan adults

BACKGROUND

The aim of this study was to evaluate the construct validity of the psychosis module of the Mini International Neuropsychiatric Interview version 7.0.2 (MINI-7).

METHOD

We utilized data collected from 2738 participants with a primary psychotic or bipolar disorder. Participants were drawn from two Kenyan sites of a large multi-center neuropsychiatric genetic study. The factor structure of the MINI-7 psychosis items were explored using confirmatory factor analyses (CFA) and Item Response Theory approach, for the full sample and by gender.

RESULTS

The CFA revealed that a 1-factor model provided adequate fit for the MINI-7 psychosis items for the full sample (x2 = 397.92, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.92; TLI = 0.90) as well as for the female (x2 = 185.16.92, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.93; TLI = 0.91) and male groups (x2 = 242.09, df = 35, p < .0001; RMSEA = 0.06; CFI = 0.92; TLI = 0.89). Item thresholds for the full sample, and female and male groups were highest for 'odd beliefs' (-1.42, -1.33, and -1.51 respectively) and lowest for 'visual hallucinations' (-0.03, -0.04, and -0.01 respectively).

LIMITATIONS

Our study used a hospital-based population, which may have excluded patients with milder psychotic symptoms. Findings may therefore not be generalizable to the community setting.

CONCLUSIONS

Our findings indicate good construct validity of the MINI-7 psychosis module, and provides support for use of the tool in diagnosing psychotic disorders in clinical settings in Kenya.

Cross-country variations in the reporting of psychotic symptoms among sub-Saharan African adults: A psychometric evaluation of the Psychosis Screening Questionnaire

BACKGROUND

Self-reporting of psychotic symptoms varies significantly between cultures and ethnic groups. Yet, limited validated screening instruments are available to capture such differences in the African continent.

METHODOLOGY

Among 9,059 individuals participating as controls in a multi-country case-control study of the genetic causes of psychosis, we evaluated the psychometric properties of the Psychosis Screening Questionnaire (PSQ). We applied multi-group confirmatory factor analysis and item response theory to assess item parameters.

RESULTS

The overall positive endorsement of at least one item assessing psychotic symptoms on the PSQ was 9.7%, with variability among countries (Uganda 13.7%, South Africa 11%, Kenya 10.2%, and Ethiopia 2.8%). A unidimensional model demonstrated good fit for the PSQ (root mean square error of approximation = 0.009; comparative fit index = 0.997; and Tucker-Lewis Index = 0.995). Hypomania had the weakest association with single latent factor (standardized factor loading 0.62). Sequential multi-group confirmatory factor analysis demonstrated that PSQ items were measured in equivalent ways across the four countries. PSQ items gave more information at higher levels of psychosis, with hypomania giving the least discriminating information.

LIMITATIONS

Participants were recruited from general medical facilities, so findings may not be generalizable to the general population.

CONCLUSION

The PSQ demonstrated a unidimensional factor structure in these samples. Items were measured equivalently across all study settings, suggesting that differences in prevalence of psychotic symptoms between countries were less likely to represent measurement artifact. The PSQ is more reliable in screening for psychosis in individuals with higher degrees of psychotic experiences-hypomania excluded-and might decrease the false-positive rate from mild nonspecific psychotic experiences.

Cultural differences in positive psychotic experiences assessed with the Community Assessment of Psychic Experiences-42 (CAPE-42): a comparison of student populations in the Netherlands, Nigeria and Norway

BACKGROUND

Previous studies have suggested that culture impacts the experience of psychosis. The current study set out to extend these findings by examining cultural variation in subclinical positive psychotic experiences in students from The Netherlands, Nigeria, and Norway. Positive psychotic experiences were hypothesized to (i) be more frequently endorsed by, and (ii) cause less distress in Nigerian vs. Dutch and Norwegian students.

METHODS

Psychology students, aged 18 to 30 years, from universities in the Netherlands (n = 245), Nigeria (n = 478), and Norway (n = 162) were assessed cross-sectionally with regard to the frequency of subclinical positive psychotic experiences and related distress, using the Community Assessment of Psychic Experiences (CAPE-42). Multi-group confirmatory factor analysis and multivariate analysis of covariance were performed to assess measurement invariance of the positive symptom dimension (CAPE-Pos) and compare mean frequency and associated distress of positive psychotic experiences across study samples.

RESULTS

Only CAPE-Pos items pertaining to the dimensions 'strange experiences' and 'paranoia' met assumptions for (partial) measurement invariance. Frequencies of these experiences were higher in the Nigerian sample, compared to both the Dutch and Norwegian samples, which were similar. In addition, levels of experience-related distress were similar or higher in the Nigerian sample compared to respectively the Dutch and Norwegian samples.

CONCLUSION

Although positive psychotic experiences may be more commonly endorsed in non-Western societies, our findings do not support the notion that they represent a more benign, and hence less distressing aspect of human experience. Rather, the experience of psychotic phenomena may be just as, if not more, distressing in African than in European culture. However, observed differences in CAPE-Pos frequency and distress between samples from different cultural settings may partly reflect differences in the measure rather than in the latent trait. Future studies may therefore consider further cross-cultural adaptation of CAPE-42, in addition to explicitly examining cultural acceptance of psychotic phenomena, and environmental and other known risk factors for psychosis, when comparing and interpreting subclinical psychotic phenomena across cultural groups.

Impact of distress related to attenuated psychotic symptoms in individuals at ultra high risk of psychosis: Findings from the Longitudinal Youth at Risk Study

AIM

Recent studies have highlighted that attenuated psychotic symptoms (APS) are an important source of distress in ultra high risk (UHR) individuals and that this distress is related to transition to psychosis (TTP). This study examined distress associated with APS in UHR individuals and investigated its association with TTP.

METHODS

The Comprehensive Assessment of At-Risk Mental State (CAARMS) was used to identify 173 UHR individuals, who were included as participants in the study. Distress related to APS was self-reported. Functioning was assessed on the Social and Occupational Functioning Assessment Scale. Associations between each of the 4 APS subscales in the CAARMS-non-bizarre ideas (NBI), perceptual abnormalities (PA), unusual thought content (UTC) and disorganized speech (DS)-with its distress level were examined.

RESULTS

Of the 173 UHR participants, 154 (89%) reported distress related to one or more APS. NBI was rated to be the most distressing out of the 4 APS by the highest number of participants (32.9%) compared to UTC (12.1%), PA (24.9%) and DS (2.9%). Mean distress scores were significantly associated with CAARMS composite scores (P < .001). However, there was no significant relationship between distress scores and functioning. Both mean distress scores (OR = 1.034, P = .029) and functioning (OR = 0.892, P = .022) were significant predictors of transition to psychosis at 1 year of follow-up.

CONCLUSIONS

This study provides additional evidence to link subjective distress experienced by UHR individuals to APS and to their subsequent clinical outcomes and has significant clinical implications.

A Gender and Racial Epidemiological Profile of Public Psychiatric Hospitals in the Western Cape

The aim of this archival epidemiological study was to identify gender and racial patterns of psychiatric diagnosis and management in admissions to mental hospitals. The hospital records of a random, stratified sample ( N =2110) of all patients admitted to the three public psychiatric hospitals in the Western Cape for a calendar year were studied for gender and racial differences regarding demographics, admission-related variables, diagnosis and management, both during hospitalisation and on discharge. Analysis was done for race groups within females and males and differ-ences between groups were tested by chi-square tests. Consistently significant differences in psychiatric diagnosis and management across race and gender were found, many in line with other international and African studies. Anomalies of diagnosis and treatment reflect past inequities of South African society and suggest the role of both social factors and bias in psychiatric hospital practice. Implications for future mental health research, training and practice are raised.

Multicultural Assessment:

Current suggestions for assessing clients across cultures fail to adequately aid the average practitioner This failure arises from unresolved issues and problems, interfering with the ability of most counselors and therapists to render sound clinical judgments. In response to these issues and problems, a procedure is described that sensitizes counselors to cultural data in assessment and case conceptualization. Grounded in a guiding philosophy of assessment, the Multicultural Assessment Procedure (MAP) was developed in consideration of a number of relevant critical issues. The procedure entails identifying cultural data through multiple methods of data collection, interpreting cultural data to formulate a working hypothesis, incorporating cultural data with other relevant clinical information to test the working hypothesis, and arriving at a sound (i.e., comprehensive and accurate) assessment decision. A case illustration demonstrates how to use the proposed procedure.

Ethnic differences in risk of acute compulsory admission in Amsterdam, 1996-2005

PURPOSE

Several European studies have shown that migrants from non-western countries are at increased risk of psychotic disorders. This study examines how this is reflected in the risk of acute compulsory admission (ACA).

METHODS

Information on all patients with an ACA in Amsterdam from 1996 to 2005 was linked to the Amsterdam municipal register.

RESULTS

The incidence of first ACA in Amsterdam was 4.5 per 10,000 person years. The incidence risk of ACA for any psychiatric disorders and for psychotic disorders in particular showed a 2- to 3-fold increase in almost all migrant groups from non-western countries, and especially for second-generation migrants. In addition, all non-western migrant groups were at increased risk of being assessed as posing a danger to others.

CONCLUSIONS

The relative risk of ACA for psychotic disorders was similar to that for the incidence of psychotic disorders in most ethnic groups from other studies, suggesting that the increased risk of ACA in non-western migrants can mainly be explained by the increased incidence of psychotic disorders in these groups. However, the relative risk of ACA for psychotic disorders among Moroccan migrants was lower than expected on the basis of incidence studies, which suggests that additional factors are relevant, such as illness-related expression and access to and quality of care.

Culture and Psychopathology: Foundations, Issues, Directions

The present article offers an overview of the historical influences, conceptual assumptions, and major findings and issues associated with the study of culture and psychopathology. The article traces continuing reductionistic resistance to the incorporation of cultural considerations in the etiology, expression, and treatment of psychopathology to historical and contemporary forces. These forces include ‘cultural context’ of Western psychiatry and psychology, which choose to locate the determinants of behaviour in the human mind and brain. A definition of culture that acknowledges its internal and external representations is offered, and steps in the cultural construction of reality are proposed. Within this context, the risks of imposing Western cultural views universally are noted, especially attempts to homogenise classification and diagnostic systems across cultures. ‘Culture-bound’ disorders are used as example of Western bias via the assumption that they have ‘real’ disorders, while the other cultures have disorders that are shaped by culture. Cultural considerations in understanding the rate, etiology, and expression are presented, including recommended criteria for conducting epidemiological studies across cultural boundaries, especially ‘schizophrenic’ disorders as this problematic diagnostic category is subject to multiple cultural variations. The article closes with discussions of ‘cultural competence’ and ‘multilevel’ approaches to behaviour.

Transcultural psychiatry: from practice to theory

Psychiatric patients of non-western origin leave treatment against the advice of their clinicians far more often than do their western counterparts. This article presents a theoretical framework for better understanding such clinical cases, developed from examples of psychiatric practice in different cultures. The theory is based on two meanings of the concept of culture, an elaboration of the universality-relativity dichotomy, and a view of the work of mental health care providers as involving three components: (1) building a trusting relationship with the patient; (2) making a diagnosis and treatment plan; and (3) carrying out treatment that is acceptable and meaningful to the patient. The article argues that all psychiatry is transcultural psychiatry, because a cultural gap always exists between the psychiatrist and the patient.

Influence of ethnicity on presentation and outcome of first episode psychosis

We describe a young African male presenting to an Irish psychiatric service with first episode psychosis with an acute onset, no prodromal features and early and complete remission. Migrant and ethnic minority groups may differ in their clinical presentation, course and outcome of psychosis compared with the Caucasian population. This has implications for assessment and treatment of ethnic minority patients in an Irish context given the recent migration into a previously homogeneous population.

A cross-national study of the stigmatization of severe psychiatric illness: historical review, methodological considerations and development of the questionnaire

Despite their potential significance for public policy and health provision in different societies, popular conceptualizations of and social responses to severe psychiatric illness remain relatively unexamined. Two general research procedures may be identified: (1) the anthropological approach uses ethnographic methods to look at explicit categorizations, and (2) the sociological approach employs quantitative survey methods to examine the public ;stigma' of psychiatric illness. This article reviews methodological and conceptual approaches to the study of stigma and describes the development of an ethnographically grounded questionnaire to examine ;stigmatization' from data in different cultures. The difficulties of achieving cross-cultural comparability of meaning are discussed and the psychometric properties of the instrument are presented.

The contributions of Sam Greenhouse to research on psychiatric diagnosis and psychopharmacology

Sam Greenhouse began his involvement in mental disorders research in 1954 when appointed chief of the Theoretical Statistics and Mathematics section at the National Institute of Mental Health. He remained with the NIMH until 1966. Despite moving on to several other positions at the NIH and at the university during the ensuing years, he continued as a consultant to NIMH investigators. He also participated actively as an advisor and co-investigator on a number of important collaborative research programmes launched by the Institute in the 1970s and 1980s. His contributions to the design and methodology of the first clinical trials of drugs for the treatment of schizophrenia, to research aimed at revising the national and international classification systems for the mental disorders, and his participation in the planning of the first attempt to use the collaborative research model to test hypotheses about the genesis of a specific mental disorder (depression), are described. Finally, the signal importance of the 'profile analysis of variance' method that he and Seymour Geisser developed, to research on personality and mental disorders, is examined in detail. The authors describe applications of the method in their own research on the classification of the mental disorders, predicting response to drug treatment and the variations in the expression of mental illness across different cultures. Sam worked in mental health during an era of revolutionary changes in the diagnosis and treatment of mental disorders. The field was acutely aware of his many contributions to the progress of research and his colleagues are very grateful to have had the opportunity to work with him.

Improving community-based care for the treatment of schizophrenia: lessons from native Africa

Recent innovations in the treatment of schizophrenia reflect a growing trend towards community-based care, such as Assertive Community Treatment (ACT). These programs reduce psychiatric hospitalization rates, improve residential stability, and result in improved satisfaction with care; however, they fail to show any consistent reduction in psychiatric symptoms or long-term improvement in social adjustment. As growing evidence suggests that the course and outcome of schizophrenia is significantly more favorable in undeveloped countries where community interventions are primary, this paper is an attempt to identify key factors in native African healing practices and their potential application to community-based treatment in the West.

Long-term follow-up of schizophrenia in 16 countries. A description of the International Study of Schizophrenia conducted by the World Health Organization

An unexpected finding of the International Pilot Study of Schizophrenia, launched by the World Health Organization (WHO) in 1967, was that patients in countries outside Europe and the United States have a more favourable short- and medium-term course of the disease than those seen in developed countries. Since then, WHO has intensified its schizophrenia research programme and has initiated a set of international studies that have confirmed these initial findings and explored possible reasons for such differences in the course and outcome of schizophrenia. While such work has provided important findings and has generated additional pertinent hypotheses, it did not explain the differences in outcome. The present paper describes a new initiative in which approximately 2500 subjects involved in previous WHO multicentre schizophrenia studies are being followed up for between 15 and 25 years after initial examination. Nineteen research centres in 16 countries are taking part in this work. The research methodology is described.

Culture and schizophrenia: the DOSMD challenge

The World Health Organization's International Pilot Study on Schizophrenia (IPSS) and subsequent Determinants of Outcomes of Severe Mental Disorder (DOSMD) studies have reported that the course of schizophrenia is more favourable in 'developing' than 'developed' societies. The 1992 DOSMD study attributes this difference to culture. We review studies concerning the course of schizophrenia and conclude that the evidence for a more favourable course in developing societies is not conclusive. Indeed, a favourable course has also been reported in various industrialised societies. We also raise questions about the findings reported in the recent DOSMD study, including the conclusion that the putatively more favourable course is a product of culture. Finally, we argue that longitudinal, direct observation of patients in their natural environments must be carried out before variations in the course of schizophrenia can be adequately understood.

Movement disorder in never and minimally treated Nigerian schizophrenic patients

Two hundred and forty-two Nigerian schizophrenic patients (63% male, 37% female), whose mean age was 42 years and length of illness 12 years, were examined for movement disorders using the Abnormal Involuntary Movements Scale, the Simpson and Angus Parkinsonism Scale and the Barnes Akathisia Scale. Twelve patients had never received antipsychotic medication; and none of these had dyskinesia. Dyskinesia was found in 5 of 49 patients (10%) who had taken medication throughout the course of their illness for a total of up to 3 months, 13 of 74 (18%) who had taken medication for 4-12 months, 14 of 41 (34%) for 1-5 years, and 29 of 66 (45%) who had taken medication for more than 5 years. Of 77 patients who were receiving antipsychotic medication at the time of examination, 9 (12%) had Parkinsonism and 12 (15%) akathisia. Examination of the patients' mental state by the Positive and Negative Syndrome Scale showed an association between dyskinesia and positive, but not negative, schizophrenic symptoms. Nigerian patients showed a low level of negative symptoms.

Symptoms and social adjustment of schizophrenic patients as evaluated by family members

The purpose of this study is to reveal the relationship between family expressed emotion (EE) and family evaluation for symptoms and social adjustment of schizophrenic patients. Chronic schizophrenic outpatients in offshore islands under stationary therapeutic conditions were studied. For evaluation, the Five Minute Speech Sample (FMSS) for EE and the Katz Adjustment Scale (KAS) for family evaluation of patients were used. EE level was high among relatives who thought the patient was belligerent, negativistic, unstable or helpless. High-EE relatives tended to evaluate their patients' performance of social activities rather low and showed strong dissatisfaction with the patient's leisure activities. Moreover, a high emotional overinvolvement (EOI) value is more common in Japan than in other countries. A subgroup of the FMSS-EOI, the emotional display, was seen where many mothers began to cry while speaking.

Language content and schizophrenia in acute phase Turkish patients

The purpose of this study was to replicate and extend, in a Turkish sample, previous investigations of speech content in English-speaking schizophrenics. Computer content analytic procedures, which quantify thematic emphases in the subjects' free speech, have been shown to differentiate schizophrenic patients from other acutely ill psychiatric patients and from normal controls. We repeated the speech sampling procedure with hospitalized psychiatric patients in Turkey, and analyzed their responses using content analysis procedures with a translation of the dictionary or language classification system used in the original studies of English-speaking patients in the United States. Eighty subjects were included in the study: 20 schizophrenics, 20 depressives, 20 manics and 20 healthy controls. There were ten females and ten males in each group. After being diagnosed separately by two clinicians using the Turkish version of the Structured Clinical Interview for DSM-III-R (SCID), each subject's free speech was tape-recorded in a standardized session. The speech content of Turkish patients with schizophrenia exhibited considerable similarity to that previously observed in American subjects, but there were certain dissimilarities that appeared to reflect the impact of culture on the manifestations of the schizophrenic disorder. The phenomenological differences between the three psychiatric syndromes compared were also reflected in the results of the content analysis. The most dissimilar syndromes were mania and depression whereas the most similar were mania and schizophrenia. The particular word categories emphasized by specific groups also appeared to be consistent with the effects of their psychiatric disorders.(ABSTRACT TRUNCATED AT 250 WORDS)

WHO's work on the epidemiology of mental disorders

The WHO programme on epidemiology of mental disorders started in the early 1960's with a series of reviews of knowledge. These were followed by activities aiming at four main goals: the standardization of psychiatric diagnosis, classification and statistics; the development of standardized internationally applicable instruments for the assessment of mental patients and of variables relevant to the assessment of mental illness; the conduct of epidemiological studies of mental disorders; and the training relevant to the above goals. The paper provides a description of the activities undertaken to achieve these goals and stresses the importance and usefulness of the collaboration of individuals, experts and institutions all over the world in this effort.

Symptoms and social adjustment of schizophrenic patients as evaluated by their family members: a cross-cultural psychiatric study between offshore islands and an urban city

We conducted a comparative study of symptoms and social adjustment of schizophrenic patients on offshore islands and one urban region in Japan. In the evaluation of symptoms and social behavior by family members, no differences were observed between the two regions. Looking at social adjustment in the two regions, no differences were observed by family members either in the performance level or in the expectation level of socially expected activities. However, on the offshore islands, the expectation level of socially expected activities by family members was significantly higher than the level of self-accomplishment set by schizophrenic patients themselves. As for leisure activities, both family members and patients on the islands evaluated the level of performance to be significantly higher than in the urban region, and the level of satisfaction of the patients themselves was also higher on the islands. Considering both these findings and Japanese traditional views of work and leisure, it is believed that on the islands patients are required to engage in more productive activities and less leisure activities than in the urban region. Further it seems that patients on the islands compared to patients in the urban region may have greater difficulty in social adjustment.

Features of schizophrenic patients and patients with depression as observed by family members--symptoms, social activities and social performance

We carried out a comparative study of a group of schizophrenic patients and a group of patients with depression, looking at 1) symptoms and social behaviors, 2) the performance level of socially expected activities and free-time activities, and 3) the level of expectations of family members with respect to patients' activities according to the results of a KAS evaluation by the family members of the two groups. The evaluation of symptoms and social behaviors by the family members clearly reflected the clinical features of schizophrenia and depression. In respect to the performance level of socially expected activities, depressive patients were evaluated significantly higher than schizophrenic patients. As for free-time activities, there were no differences between the two groups in the evaluation of levels of performance, but the family members of the depressive group expected a significantly higher level of free-time activities than was achieved, while such a significant discrepancy between expectation and performance was not observed for the schizophrenic group.