The International Journal of Psychosocial Rehabilitation

Cultural and Demographic Factors of Schizophrenia

Judy M. Versola-Russo, Psy.D.
Capella University

 Citation:
Versola-Russo, J.  (2006).Cultural and Demographic Factors of Schizophrenia.
   International Journal of Psychosocial Rehabilitation. 
10 (2), 89-103 .






Correspondence:
Judy M. Versola-Russo, Psy.D.
29635 Ferry Point Drive
Trappe, MD 21673
jrusso@dhmh.state.md.us


Abstract
Schizophrenia has been described in all cultures and socioeconomic groups throughout the world. The perception of mental illness within the cultural dynamics may affect the diagnosis, treatment, and reintegration of an individual with schizophrenia. As culture influences the ways individuals communicate and manifest symptoms of mental illness, style of coping, support system, and willingness to seek treatment may be affected as well. The role of folk healing among minority cultures is explored. The purpose of this paper is to review the illness and to examine the cultural and demographic factors for schizophrenia.
Key words: culture, mental health, schizophrenia, treatment


Introduction
Schizophrenia has many effects on a person’s ability to lead a meaningful life.  The disease is found in all cultures throughout the world. Both genders are equally affected. The age of onset of schizophrenia appears to be a factor in the presentation of symptoms. Regardless of its occurrence, whether in Baltimore, Manila, or Rome, the rates remain the same, one percent of the population. According to Kaplan, Sadock, and Grebb (1994), about 0.025 to 0.05 percent of the total population is treated for schizophrenia in any one-year. While most of those treated require inpatient care, only about half of all individuals with schizophrenia obtain treatment, in spite of the severity of the disorder. 

Although the manifestations of schizophrenia are varied, the majority of studies have demonstrated that the symptoms of schizophrenia typically form into three relatively independent complexes: (1) positive symptoms (i.e., hallucinations and delusions); (2) negative symptoms (i.e., blunted affect, anhedonia, poverty of speech, avolition, and diminished social drive); and (3) disorganized behavior, including bizarre behavior, and inappropriate affect (Buchanan et al. 1997). These symptoms are not concrete. Not all individuals will exhibit all or a majority of symptoms.

Perhaps living in a world that is distorted by hallucinations, delusions, and paranoia may cause people living with schizophrenia to appear frightened, anxious or even confused. The preoccupation with hearing voices that others do not may cause an individual to become distant and detached from others.

Differential diagnoses of schizophrenia
There are many disorders that may mimic schizophrenia, and the disease varies so greatly in its clinical presentation for different people and onset. The process of diagnosing schizophrenia is difficult, so several other disorders must be ruled out before the diagnosis can be made with a reasonable amount of confidence (Waldinger, 1990).

Mood disorders may be confused with schizophrenia as symptoms of mania and psychotic depression often present with hallucinations, delusions, and bizarre behavior.  A variety of personality disorders may present with similar features of schizophrenia.  Schizotypal, schizoid, and borderline personality disorders most closely resemble the disease. Personality disorders tend to have mild symptoms that are generally present throughout the person’s life (Kaplan et al. 1994). Organic mental disorders may look exactly like schizophrenia but may be attributed to drugs, metabolic disease, neurological condition, or even infection. A thorough laboratory screening, history, and physical examination should be documented to rule out medical illness (Waldinger, 1990). 

Disorders such as schizophreniform disorder or delusional disorder may present with the same symptoms as schizophrenia, with the exception of duration of symptoms.  The symptoms of schizophreniform disorder have a duration that lasts at least one month but less than six months. Delusional disorder is an appropriate diagnosis if bizarre delusions have been present for at least one month in the absence of the other symptoms of schizophrenia or a mood disorder (Kaplan et al. 1994). Schizoaffective disorder is the appropriate diagnosis when manic symptoms or depressive symptoms develop concurrently with the major symptoms of schizophrenia (Kaplan et al. 1994). 

Malingering or factitious disorders may be appropriate diagnoses for those individuals who may be imitating the symptoms of schizophrenia but do not actually have the disease. People who are completely in control of their symptom production maybe given the diagnosis of malingering. These individuals may be motivated by some secondary gain (e.g., financial or legal reasons to gain admission into a psychiatric treatment facility). People who are less in control of their symptoms may be given a factitious disorder (Kaplan et al. 1994).

Culture-bound syndromes
According to Niehas and others (2004), the term cultural bound syndrome, refers to any one of a number of recurrent, locality-specific patterns of aberrant behavior and experiences that appear to fall outside conventional Western psychiatric diagnostic categories. Cultural concepts, values, beliefs, influence health-seeking pathways, and traditional healers play an important role in the management of disease in many cultures where ‘Western’ medicine is unavailable, viewed with skepticism, or used in parallel with traditional treatment methods. Kaplan et al (1994) asserted that Western psychiatrists tend to view mental illness as culture-free, but certain disorders such as bulimia nervosa is as shaped by Western culture as koro is by Asian culture.

Niehas et al. (2004) conducted a study in West Africa and found that individuals with a family history of either schizophrenia or other psychiatric disorders were more likely to receive the diagnosis of ukuthwasa (symptoms include social withdrawal, irritability, restlessness, and appearing to respond to auditory hallucinations) than amafufunyana (described as a hysterical condition characterized by people who speak in a strange muffled voice, cannot be understood, and have unpredictable behavior. This state is believed to be induced by sorcery that led to possession by multiple spirits that may then speak through the individual (‘speaking in tongues’). The authors assert that not all individuals with ukuthwasa and amafufunyana suffer from schizophrenia, but may be used as explanatory models in a subset of schizophrenia sufferers. It may be that families prefer the term amafufunyana, possibly due to fewer stigmas associated than a diagnosis of schizophrenia.

Similarly, among unacculturated Mexican-American families, the term nervios, is used to refer to a wide range of mental illness and psychological distress. With this condition, the patient is not considered blameworthy. However, among Anglo-Americans, schizophrenia is an illness for which the patient’s personal character is implicated. (Lopez et al. 2004).

Asians who are less Westernized exhibit culture-bound syndromes more frequently. Early immigrants (40-60 years ago) are strongest believers in Chinese medicine, newer immigrants (past 20 years) combine both Chinese medicine and Western medicine; and first and second generation Chinese Americans are mostly oriented to Western medicine (Lippson, Dibble, & Minarik, 1996).

However, cultural-bound syndromes occur in European cultures as well. Kaplan and others (1994) note that in France, bouffée délirante, is marked by transient psychosis with elements of trance or dream states. In Spain and Germany, involutional paraphrenia, refers to a paranoid disorder that occurs in midlife and has features of, yet is distinct from schizophrenia, paranoid type. Cultural bound syndromes that share features of schizophrenia include: amok, marked by a sudden rampage, usually including homicide and suicide, ending with exhaustion and amnesia (documented in Southeast Asia and Malaysia); colera, marked by violent outbursts, hallucinations, delusions, and temper tantrums (documented in Guatemala); and latah, marked by automatic obedience reaction with echopraxia and echolalia (documented in Southeast Asia, Malaysia, Bantu of Africa, and Ainu of Japan) (Kaplan et al. 1994).

Explanatory Models of Illness
As culture influences the ways individuals communicate and manifest symptoms of mental illness, their style of coping, their support system, their willingness to seek treatment may be affected as well. Asian Americans and Pacific Islanders have the lowest rates of utilization of mental health services of any ethnic population. This may be attributed to cultural stigmas and financial shortcomings (Sherer, 2002). Patients may be reluctant to discuss emotional problems with strangers. Stoicism is a characteristic that is expected among many Asian Americans. Asian American patients may not express their emotional pain. Somatic complaints may be expressed instead. This somatization may be interpreted as a defense mechanism for the guilt and shame associated with seeking mental health treatment.

In studies examining Asians and Caucasians with schizophrenia, it was found that both groups had similar inception rates. Bhugra et al. (1999) found that it there are differences in symptoms manifestations between Asian and Caucasians and in the mode of onset. The London study found that Asians were more likely to commit suicide. Auditory hallucinations were more often reported than in Caucasians. Asians were more likely to show neglect of activities, lose appetite, and be irritable. Caucasians were twice as likely to have somatic complaints and perform violent acts compared to Asians. The study also found that Caucasians were more likely to suggest that others are responsible for the onset of the mental illness of the individual compared to Asians who were more likely to take responsibility for the onset and treatment of the disorder, suggesting higher pre-morbid functioning (Bhugra, et al.1999). These findings may reflect the Western cultural expectations for Asians to be more stoic and controlled than other cultural groups. 

In a longitudinal study by Goater, King, Cole, et al.(1999), it was found that the incidence rates of schizophrenia and non-affective psychosis were higher in all ethnic groups compared with Caucasians in the United Kingdom. The researchers found that members of ethnic minorities tend to see general practitioners that are more likely overlook psychological symptoms. This may not only delay the diagnosis of schizophrenia, but the referral and subsequent treatment (Goater et al. 1999).

Overall, the inception rates of schizophrenia were similar between Asians and Caucasians. This may suggest that ethnicity by itself may not be as strong a factor associated with schizophrenia as previously hypothesized. Bhugra et al. (1999) concluded that other social factors might play a more significant role in the onset, diagnosis, and treatment of schizophrenia in different ethnic groups. The investigators for both studies concluded that further research is needed to study the impact of social support systems and family dynamics on individuals with schizophrenia. Socioeconomic status, perhaps reflected by level of education, may be a more accurate indicator of the recognition, diagnosis, and treatment of schizophrenia in ethnic minorities.

The researchers also noted that among the limitations of their respective studies was the ambiguity in the term “Asian”. Defining who is “Asian” may cause a number of problems in the collection and interpretation of data. Neither study specified if “Asian” referred to immigrants, or if it included children of immigrants who were not born in their families’ country of origin.        
 
Some African Americans may view mental illness has a form of punishment or as "spells" being cast upon wrong doing. The onset and the subsequent treatment may be perceived as a disgrace and may suggest the inability to handle responsibilities and threaten an African American woman’s position/role of mother (Amankwaa, 2003).       McCabe and Priebe (2004) compared explanatory models of illness that may differ among people with schizophrenia from four cultural backgrounds (African-Caribbeans, West Africans, Bangladeshis, and Whites). They found that Whites cited biological causes more frequently than non-White groups, who cited supernatural causes more frequently. African-Caribbeans, West Africans, and Bangladeshis are more likely to have social or supernatural explanatory model. However, the type of explanatory model does not appear to be associated with treatment compliance (McCabe & Priebe, 2004).

Folk Healing
Krajewski-Jaime (1991) asserted that folk medicine and modern scientific practice have coexisted for many years. Folk-healing interventions that have validity and integrity within the client's cultural context may be interpreted as ignorance, superstition, or simply as abuse and/or neglect (Krajewski-Jaime, 1991). Practices and common elements of folk healers may be misinterpreted or even pathologized by members of the majority culture (Dana, 1993). New arrivals are more likely to use indigenous healers. For example, among Southeast Asians, the Vietnamese might seek out Taoist teachers and ethnic health practitioners such as Vietnamese physicians, the Khmer and Lao might use Buddhist monks, and the Hmong might use herbalists and shamans (Kitano, 1989). Curanderismo, or folk healing, is the treatment of a variety of ailments with a combination of psychosocial interventions, mild herbs, and religion (Salimbene, 2000). Some of the ailments that curanderos focus on are thought to be equivalent to those treated by mental health professionals. Bean et al. (2001) urges clinicians to be prepared to collaborate with folk healers when working with Hispanic Americans, as this cultural factor plays a prominent role in the delivery of health care services and treatment compliance.
One implication of folk medicine has to do with the strong ties with the extended family in many minority cultures. It is noted that when a person is ill, many of the family members are involved in deciding if indeed the patient or client is ill in the first place, and the extent of the illness, the treatment to be given, and by whom (Krajewski-Jaime, 1991). Rather than viewing folk healing as a barrier, it should be viewed upon as a strength and resource. Doing so may also help the worker to build rapport with the client. Folk healers may be consulted as a first opinion, because he or she has known the family intimately for many years, speaks their language, and does not dictate orders for care but makes suggestions, leaving the ultimate decision up to the patient and family (Krajewski-Jaime, 1991).

Use of herbs common may be a common practice among Asian American patients. However, this practice may interfere with the efficacy of psychotropic medications. Fundamental Asian health beliefs that may impact mental health treatment include imbalance of the yin and yang, and the corresponding conditions of “hot” and “cold”. Illness may be attributed to an upset in this balance of forces (Salimbene, 2000).        Braswell and Wong (1994) notes that Native American healing practices are those which may involve traditional medicine practitioners, such as medicine men and women, herbalists, and shamen, to restore an individual to a healthy state using traditional medicines, such as healing and purification ceremonies, teas, herbs, special foods, and special activities such as therapeutic sings, prayers, chants, dancing, and sand painting. Traditional healers may be combined with use of Western medicine. As many as two-thirds of this population continue to use traditional healers, sometimes in combination with mental health care providers (Galanti, 2004).

Native American beliefs hold that the individual is ultimately responsible for his own wellness (Dana, 1993). Wellness implies harmony in spirit, mind, and body, while unwellness, comes from natural causes of violations of taboos. This is supported by the Trimble and Hayes (1984) who stated that mental illness is the result of living beyond the rules of right living in which a shaman can be helpful. This is contrary to the mainstream White population in the United States, which views mental illness as the result of trauma and external stressors, a chemical imbalance, or a pathological process within the individual that can be relieved through medication and personal efforts toward behavior change (Trimble & Hayes, 1984).

Onset of schizophrenia
For many people, the symptoms of schizophrenia can be frightening and tragic.  Confusing changes in behavior, complex delusional belief systems, and cold detachment from otherwise engaging members of families may tragically withdraw from society, unable to cope with the manifestations of a chronic and persistent debilitating illness.  Individuals who are just entering adulthood are often struck down by the symptoms of schizophrenia. While it is generally regarded that this illness has an onset in late adolescence, a significant amount of people first manifest symptoms of schizophrenia in middle or even old age. 

The type of onset is significant in the analysis of an individual with schizophrenia.  Adolescent onset may be considered the age range from 10 to 17 years.  Early-adult onset may be considered from 18 to 30 years of age.  Middle-age onset may occur between the ages of 30 to 45 years.  Late-onset may be considered after 45 years of age (Hollis, 2000).  But the exact determination of the onset can be very difficult, as the illness does not suddenly “strike”.  More obvious psychotic symptoms are preceded by more ambiguous behaviors. Misdiagnosis may often occur as the symptoms of other disorders overlap with schizophrenia. 

According to a study by Howard et al. (2000), it was found that categorization by specific age at onset ranges is relatively arbitrary. The peak period of onset seems to be from 15 years up to 30 years. They found that early and late onset cases are more similar than different in terms of positive symptoms. Furthermore, no difference in type of cognitive deficits appears in early versus late onset cases. The researchers did note, however, that among cases involving later onset of schizophrenia, somewhat milder cognitive deficits might exist, especially in the areas of learning and abstraction. 

Studies of the childhood histories of adult schizophrenic patients have suggested that some early patterns of developmental difference from children who did not become schizophrenic in their adulthood (Lewis, 1996). Children who subsequently develop the disorders have been noted to demonstrate premorbid patterns of behavior such as conduct problems, attentional deficits, or avoidant behaviors. Lewis (1996) reports that onset of disturbance appears to follow at least three general patterns: insidious onset, with a gradual deterioration in functioning; acute, without premorbid signs of disturbance; and insidious onset with acute exacerbation of disturbance.  It is further reported that, as in adults, males appear to have an earlier onset of the disorder than females during childhood (Lewis, 1996). Generally, it appears that children who later developed schizophrenia demonstrate a significant delay in achieving developmental milestones by the first two years of life. By age two, they were less likely to reach such milestones such as sitting, standing, walking, and talking. Walker, Savoie, and Davis (1994) found that children who later developed schizophrenia demonstrated poor motor skills and had a higher rate of neuromotor abnormalities compared to their healthy siblings. They also reported that abnormalities were predominantly seen on the left side of the body.

In terms of symptomatology, late onset schizophrenia may have a higher proportion of women than early onset illness. Symptom variables such as emotional expressiveness and social activity, gender may play a factor in assessment. Research by Lindmer, Mohr, Caligiuri, and Jeste (2001) indicates that differences exist between patients who manifest schizophrenia for the first time after age 45 (late-onset schizophrenia, LOS) than those with early-onset schizophrenia (EOS).  They found that patients with LOS are more likely to be female, with less negative symptoms, and have a significantly lower duration of illness than other patients.

Avila, Thaker, and Adami (2001) hypothesized that according to evolutionary theory, in the case of schizophrenia, lower rates of reproduction constitute a negative selection factor reduce genes in the population associated with the expression of the illness. In effect, this hypothesis predicts the decrease in the prevalence of schizophrenia. Yet, the rates continue to appear a stable one percent across different geographic locations. Their findings are consistent with a model of reproductive fitness in that the more siblings there are of schizophrenic patients, more genetic material necessary for expression of the disease is maintained. This finding provides some insight to why the prevalence rates remain stable despite lower reproductive rates among individuals with schizophrenia (Avila, Thaker, & Adami, 2001). The risk for the general population is approximately one percent. This is a figure that is consistent in other countries as well.

Gender differences in schizophrenia
While it appears that schizophrenia is equally prevalent in men and women, the two genders show several differences in onset and course of illness. Kaplan et al. (1994) describe differences such as peak ages of onset. Men seem to have the onset of schizophrenia from ages 15 to 25 years. The peak ages of onset for women are from 25 to 35 years. The mean age of onset for men was 31.2 years for men and 41.1 years for women. It appears that studies overwhelmingly support an earlier age of onset in males by 3 to 5 years, regardless of culture. Females have several peaks of onset, first in their twenties, one in middle age, and another over age 65 years (Kaplan et al. 1994).

Differences in symptomatology exist between the genders. Studies have found that while men tend to display more negative symptoms, schizophrenic women tend to display more affective symptoms such as dysphoria, depression, irritability, hostility, inappropriate affect, impulsivity, sexually inappropriate or bizarre behaviors, and sexual delusions. Szymanski, Lieberman, Alvir, Mayerhoff, Loebel, and Geisler (1995) found that females displayed significantly less illogical thinking, but more anxiety, inappropriate affect and bizarre behavior. The study reports that women were diagnosed more frequently with paranoid and disorganized subtypes of schizophrenia than men.  Females were found to be more likely than males to express persecutory delusions (Szymanski et al. 1995).

Pre-morbid functioning tends to be better in women than men. Perhaps this is based on more opportunities for women to be more socially adjusted and having greater chances of finding partners and starting families of their own before becoming ill. This may be reflected in the later onset of illness for women. In a study conducted by Rasanen, Nieminen, and Isohanni (1999), it was found that in Finland, men with serious psychiatric illness often stay home with their parents and fail to progress towards higher education, work, or marriage. This is consistent with other findings that may be attributed to the later onset of schizophrenia in women.

In general, the outcome for women who have schizophrenia is better than the outcome for men who have the illness. It appears that women are more likely to seek treatment. Diagnostic criteria have been found to be a factor in gender differences in schizophrenia. Seeman (1985) has observed that the more stringent the diagnostic criteria for schizophrenia are, the more females are excluded. Seeman (1985) further states that gender differences may be attributed to more severe roles stresses on males and social protective factors in females.

Estrogen hypothesis
The presence of estrogen has been hypothesized to protect women from the early onset of the severe symptoms of schizophrenia. As the start of puberty brings on hormonal changes, estrogen may serve to protect a woman against an earlier onset of the illness. Female hormones act on the developing brain to protect its integrity and delay the expression of psychosis.

Epidemiological studies have shown that women with schizophrenia present about five years later than men with the disorder (Kulkarnia, Riedel, deCastella, Fitzgerald, Rolfe, Taffe, & Burger, 2001). Life-cycle studies have suggested that women are more vulnerable for a first episode of psychosis or relapse of an existing illness during two major periods of hormonal change, the post-partum period, and the menopausal period (Kulkarnia et al. 2001). These findings are consistent with the hypothesis that estrogen may reduce dopamine concentration, which can then affect acute psychotic symptoms and general health status (Riecher-Rossler & Hafner,1993).

In a study by Howard et al. (2000), it was found that patients with late onset schizophrenia tend to have somewhat subnormal pre-morbid functioning and generally have a chronic course of illness without full remission. In a similar study by Cohen, Seeman, Gotowiec, and Kopala (1999), findings suggest that there may be an association between pubertal hormones and delayed age of onset of schizophrenia. 

Upon an extensive review of the literature, Palmer, McClure, and Jeste (2001) conclude that although there may be a link between menopause and the onset of schizophrenia, as estrogen may act as an endogenous anti-psychotic, masking symptoms of schizophrenia in women who are otherwise predisposed to developing the disorder at some point in their lives. Psychosocial factors, the environment, and other influences may combine to serve as protectors or inhibitors of the disorder. Based on this estrogen hypothesis, investigators have begun exploring the possibility of estrogen replacement therapy as an effective supplement to antipsychotic medication in an effort to control the psychotic symptoms of postmenopausal women with schizophrenia (Palmer et al. 2001). 

Hochman and Lewine (2004) investigated if this hormone, indeed, serves as a protective factor in the development of schizophrenia and posited that the earlier the age of menarche, the later the onset of schizophrenia. Although the results of their study suggest that an earlier age at menarche might predict improved clinical outcome after schizophrenia onset (in support of the estrogen hypothesis), the authors could not conclude that a causal relationship exists between age at menarche, and the timing of the onset of the disorder.

While it has been determined that schizophrenia affects men and women in equal frequency, there are some gender differences that occur, in terms of manifestations of symptoms. No cultures or ethnic groups are excluded from the illness, which is often misunderstood. Some cultural expectations may influence the interpretation of symptoms. But as symptoms of this disorder rarely present themselves in a sudden manner, onset of illness can be difficult to determine.  

Socioeconomic factors  
Socioeconomic reasons may become a barrier if treatment cannot be afforded. The cost of psychotropic medications and adverse side effects may result in treatment non-compliance or self-medication. However, there are community and state resources available for those uninsured who are in need of treatment. If symptoms progress and interfere with the individual’s ability to function, involuntary commitment and/or forensic involvement become likely.

Tsuang, Stone, and Faraone (2001) modified the description of the term schizotaxia, which is the liability produced by schizophrenia genes, by incorporating biological and psychosocial factors. This concept may provide a basis for development of treatment strategies in non-psychotic individuals who may vulnerable to developing schizophrenia. The disorder appears to be more prevalent in groups that are considered lower socioeconomic class within urban areas. Perhaps this may be due to the relationship between downward mobility and the debilitating effects of the illness. At this time the relationship is unclear, but researchers continue to investigate the effects of stress and development of the illness. Poorer educational achievement is associated in individuals with schizophrenia. However, this may be attributed to attentional deficit, learning disabilities, major neurological conditions, or onset of schizophrenia before the age of 18 years (Tsuang et al. 2001). 

Lefley (1990) researched insights from Third World cultures and suggested that patients may function better in developing countries because more kinship networks, buffering mechanisms, and apparently greater respect to tolerance of difficult behaviors may exist within social dynamics. For individuals with schizophrenia, there are also more opportunities for low-stress, non-competitive productive roles in communal societies and agrarian economics. It is possible that Lefley’s (1990) comments may be applicable to the parallel conditions that exist in the rural setting.

Lefley (1990) further opined that the two-tiered system of care exists in the United States, private and public, in other words, for the “rich” and “not-rich” (including middle-class America). The author notes that astronomical costs of psychiatric care together with limits on private insurance can insure that ultimately, almost all chronic patients will end up in the public sector (Lefley, 1990). Almost all community support services are in the public sector, including psychosocial rehabilitation programs.

The presence of community support programs does not, however, insure their utility. Galanti (2004) reported that per capita income for Hispanic Americans is among the lowest of the minority groups in the US. This group is the least likely ethnic group to have health insurance, which impacts the delivery of health services. Limited access to mental health services among many Hispanic Americans is related to their lack of health insurance. Locke (1992) notes the cultural group with the lowest average income, least educated, and lowest standard of living, is the Native American population. This group represents the most economically disadvantaged and underserved group in the U.S. Geographical isolation has resulted in a lack of transportation, lack of employment, lack of skilled labor, and absence of capital. Therefore, the mental health problems of uninsured Hispanic Americans and Native Americans often go undetected and untreated because of the low rates of contact with, and access to, health care providers (Gonzalez, 1997).        

In a study by Sullivan, Jackson and Spritzer (1996), clinical characteristics and service uses patterns were examined between individuals with schizophrenia who live in rural areas of one state and those who live in non-rural areas of the same state. The researchers found that rural subjects were more likely to live with family members. It was noted rural subjects were less likely to receive opportunities for psychosocial rehabilitation. A similar study by Sorgaard, Hansson, Heikkila, Vinding and Bjarnason (2001) found that while rural regions are said to be better arranged and have more well-functioning social networks, urban areas tend to offer better chances to establish voluntary relationships, resulting in greater satisfaction with emotional relations. The Sorgaard et al. (2001) concluded that women with schizophrenia generally function better socially than men, but this can be attributed to the later onset and development of family dynamics. Sullivan et al. (1996) report that their findings should not be generalized because rural populations across the U.S. differ in levels of poverty, percentage of minority clients, and quality of care provided by local mental health systems.

Seeking Treatment
An understanding of cultural themes is important as they may predominate and less self-disclosure may lead to disjointed information. The difference in health beliefs between the predominant culture provider and the minority client may result in an inappropriate assessment. If practitioners do not understand or respect a client’s traditional health beliefs and find ways to incorporate their beliefs into their treatment, their clients may not participate or become non-compliant with treatment.

Barnes (2004) suggests several factors that may be associated with an over-diagnosis of schizophrenia in African Americans. These include: diagnostic bias of clinicians, lack of cultural understanding between clinicians and minority clients, racial differences in the presentation of psychiatric symptoms. African-Americans may not immediately seek mental health service for a variety of reasons. Not recognizing the need for treatment certainly is a barrier. The onset of psychotic and/or affective symptoms may lead to consultation with spiritual and folk healers, members of clergy, or family members. Perhaps some turn to self-medication via drugs/alcohol. Pugh and Mudd (1971) found that African-American women ranked their mothers, female friends, family physician, and minister as primary sources of help, while African-American men ranked their mothers and their minister, followed by their wife and father. The strong religious and spiritual aspects of African-American culture can be an important part of mental health treatment.

Communication styles may become issues during treatment. A client who has cultural values, beliefs, and customs different from the provider might not only connote a different meaning to symptoms but also express it in a way that can be misunderstood. Out of respect for authority figures, eye contact may not be made when discussing personal issues. Again, out of respect, a patient may turn down an offer to receive services or for further assistance. Several attempts may be made before the patient accepts. Wait time during interaction may be perceived by the therapist as defensiveness or unwillingness to engage, when it may actually be out of respect for authority.

Delivery service style with Hispanic American clients should be sensitive to implications of respeto, personalismo, and platicando, in which informal, individualized attention and how they affect the therapeutic alliance (Santiago-Rivera, 1995).     
  
Kim, Bean, and Harper (2004) present eleven specific guidelines when working with Asian Americans: Assess support systems; assess immigration history; establish professional credibility; provide role induction; facilitate "saving face"; accept somatic complaints; be present/problem focused; be directive; respect family structure; be non-confrontational; and provide positive reframes.

It is important to be aware of fundamental observations when considering the different approaches to the treatment of schizophrenia. Kaplan et al. (1994) propose three observations. First, schizophrenia occurs in a person who possesses unique strengths and limitations. Treatment should be tailored to capitalize on those strengths while corresponding to how the person is affected by the disorder. Second, the fact that numerous studies have suggested that the cause of schizophrenia is probably due to the genetic, environmental, and psychological factors leads clinicians to utilize pharmacological agents to address biological issues while using non-pharmacological strategies to address non-biological issues. Third, just as schizophrenia is a most complex disorder, the individual is also both complex and unique. Limiting the individual to one therapeutic approach rarely, if ever, seems appropriate in addressing this multi-faceted disorder (Kaplan et al. 1994).  

Family Support
Culture shapes the way in which families construe schizophrenia. An understanding of a client's cultural heritage can improve the quality of the relationship between the mental health professional and client. Family education and ongoing support is beneficial in order to maximize the support the family network can provide the individual. This is especially critical when the individual with the disorder is under the direct care of the family. This is noteworthy in the treatment of males, whose onset occurs earlier than females, and are often still living in the family home. The extended family is important, and any illness concerns the entire family. Mental health professionals should be mindful that decision-making varies with kinship structure.

In Asian cultures, like many other cultures, family members generally do not institutionalize members. They care for them in the home. According to Bae and Brekke (2002), Asian families are more likely to accompany the schizophrenic patient on clinic visits and to actively participate in treatment decisions. The authors reviewed the literature regarding participation in treatment among Asians, They found that it is possible that variation such as geographical location, acculturation levels, and diagnostic criteria may account for different findings in the literature. Also, the combining of Asian-Americans into one group may have limited external validity (Bae & Brekke, 2002).

Therefore, the family may be involved in decision-making with the patient. Galanti (2004) recommends that family members be included to allow them to fulfill their familial duty by spending as much time with the patient as possible.          
 
Sociocentric individuals with collectivistic cultural orientation tend to emphasize family integrity, harmonious relationships, and sociability. Bae and Brekke (2002) note the importance of incorporating cultural characteristics into the intervention process. Interventions that are designed to involve families in a collaborative effort may be more appropriate for minority members because of the interdependent nature of their family dynamics.     

Conclusion
Schizophrenia is a severe and persistent mental illness that crosses all racial, ethnic, cultural, and demographic lines. The influence of class status, ethnic and cultural identity in relation to the presentation and the reporting of schizophrenia must be considered. Communication, coping styles, support system, and willingness to seek treatment are also affected. The factors discussed influence beliefs, attitudes, and behaviors regarding the identification of illness and health and in the process of treatment and recovery. The lack of educational and financial resources may create a barrier, in terms of utilization of services and compliance with treatment. Understanding how psychosocial factors within the cultural dynamics of this population would promote more culturally relevant care.

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