Rethinking Schizophrenia

By Uma Adhye, Nia Banouvong, Caden Gaffaney, and Elliot Stack

All humans are born with unique traits. Some inherited traits are simple, like eye color or hair color, but some inherited traits can be life-altering. In the case of being blind or losing a limb, obvious treatments are available: getting retinal transplants or using a prosthetic. But, what is the approach for treating mental disorders such as schizophrenia? Doctors often focus heavily on observable, clear-cut symptoms instead of investigating how a patient’s experience impacts their current condition. This method of diagnosis often lacks personalization, which is crucial for mental disorders heavily influenced by culture and social context. This raises the question: are there cases, specifically in the mental health realm, in which medical treatment is better paired with socio-cultural approaches?

A concern with conformative diagnosis lies in the mindset brought to the ethical consideration of schizophrenia treatment. With hallucinations that are largely dependent on culture, the condition of schizophrenia is a mental disorder that is viewed differently in different parts of the world. Some cultures favor caring for the individual with schizophrenia in a community. In the US, these patients are treated independently. Knowing that a patient could naturally learn to adapt their perception of reality to society by themselves, what is the ethicality behind conforming all patients to the same treatment? 

Take the case study of a 35-year-old Indian woman, who felt her body become controlled by vengeful Hindu gods after making a decision to explore Christianity (Dhanasekaran et al., 2017). In the cultural context of her family’s traditional Hindu faith, she was soon viewed as an outsider, and these traumatic events shaped her schizophrenic episodes. 

with the content and severity of delusions often reflecting the culture in which they occur. In this woman’s case, her family had expressed worry about punishment from vindictive Gods. Just a few months later, her hallucinations proved her family right. The very same Gods she feared appeared to the woman to scold her and reprimand her for her actions. The woman started praying and chanting to spirits in an effort to appease them. To an outsider, these actions might seem irrational, but in the context of religious hallucinations, her efforts to rid herself of the spirits seem like a logical step.

The woman suffered for years, her community unable to help, until medical workers finally administered a cultural formation interview. In this interview, workers assessed the woman’s personal, religious, and cultural factors that might be contributing to her schizophrenia manifestation. Specifically, they developed an idea of each major delusion the woman was experiencing, and asked her which religious practices she had employed to cope. They created a plan that allowed the woman to continue going to church, experience beneficial faith healing, and attend psychoeducation and therapy. This was a beneficial departure from previous interventions, which focused only on either psychoeducation or religion but not all of the woman’s unique factors in conjunction with each other. 

 Since hallucinations in schizophrenia are often shaped by an individual’s beliefs, there is no universal treatment that works for all patients. After weeks of psychotherapy, in conjunction with the antipsychotics she was previously prescribed, the woman finally returned to normal functioning — a success story which demonstrates the effectiveness of a treatment tailored to someone’s specific symptoms and culture.

This experience can be expanded to a larger lens: schizophrenia manifests itself in unique ways among differing cultures and regions around the world. Her experience parallels broader patterns. Ceylan and Alkar (2023), in a systematic review, found that cultural factors can influence how schizophrenia symptoms manifest and are expressed. The authors reported significant differences in symptom presentation in regions of Asia, Africa, the Middle East, and the Caribbean compared to Europe and North America (Ceylan, Alkar 2023). This study breaks down the perils of schizophrenia among different cultures and regions by pathoplastic, pathofacilitative, and social kindling. 

The pathoplastic effect is described as the influence of culture on the specific content of schizophrenic hallucinations in conjunction with the pathofacilitative effect that outlines the increased or decreased likelihood of schizophrenic symptoms based on cultural practices and traditions. The social kindling effect emphasizes the effect of constant cultural and social stressors on more frequent and persistent hallucinations, characteristic of schizophrenia. 

Although auditory hallucinations are more common, visual hallucinations drastically vary even among different regions of the same country. For example, individuals in the central regions of Turkey experience predominantly religion-centered hallucinations as compared to the western regions of Turkey. Divergences in cultural beliefs shape the way in which diverse individuals both view and interpret the symptoms of schizophrenia. A previous study examines patterns of treatment and interpretation of schizophrenia specifically in the regions of China. The “bio-psycho-spiritual-social” model of mental illness outlines considerations of biological, stress, religious, and social dynamics in the understanding and treatment of schizophrenia, highlighting the potentials of incorporating cultural connotations and relationships into treatment methods to increase effectiveness (Li et al., 2017). 

In collectivist cultures, the voices heard can be spiritual or those of family members. In the West, voices can be violent and intrusive. A cultural phenomenon that has been theorized to impact how schizophrenia manifests is social defeat. Social defeat is the repeated exposure to rejection and humiliation. One study found that chronic social defeat affects primary cilia, small sensory organelles involved in cell signaling (Oh et al., 2023). Social defeat was shown to disrupt primary cilia formation. When the formation of cilia is altered, diseases called ciliopathies can occur. Genes associated with ciliopathies are linked to many psychiatric disorders, such as schizophrenia. One of these genes is PCM1, which encodes for a protein called Pericentriolar material 1. When this protein is ablated, it can lead to cilia deformation and has been linked with  various psychiatric disorders, including schizophrenia (Monroe et al., 2020). 

The link between social defeat and disrupted cilia is one example of how social experiences can impact your biology. This connection can explain why different cultures might experience schizophrenia at different rates. For example, Ireland had one of the highest rates of hospitalization for schizophrenia in the 1950s. It was almost twice the rate of the United States and Canada (Luhrmann, 2007). When researchers went to one of these rural areas, they found an extremely demoralized society. There was a culture of isolation. Many people were emigrating out of the country, and those who were “not capable” of doing so were ridiculed and criticized. This culture of rejection and social defeat caused by the economic and political instability at that time could contribute to the unusually high incidence of schizophrenia experienced. 

A major concern with antipsychotics, the primary medical treatment for schizophrenia, is their neurological impact on the brain. This involves both personality and brain structure. Neuroimaging has shown that patients with a high risk of schizophrenia often have reduced brain volume, particularly in the prefrontal cortex and temporal lobes, parts of the brain responsible largely for our personality, auditory processing, and emotional regulation, functions that tie to the symptoms of schizophrenia (Goff et al., 2017). In addition, studies have shown a correlation between the severity of the condition and larger loss of grey matter in the brain. However, there is a concern that after continual usage of medication and antipsychotic treatment, the brain becomes desensitized to dopamine, a major neurotransmitter believed to provoke hallucinations. Common side-effects of antipsychotics, aside from their desensitization to dopamine, include low motivation and energy, slow cognitive function, and lack of emotion (Mosolov et al., 2022). 

Although antipsychotics combat hallucinations, these types of medication are not always a one-size-fits-all solution and can lead to disruptive side effects that impact a patient’s quality of life.

and therefore reduced risk of harmful long-term effects of taking medication.

Conclusively, our discussion of schizophrenia acts as a call to neuroscientists to evaluate their work from a broader perspective. The goal of a doctor is to help and, surely, all forms of help are positive. But, there are always non-traditional routes to be taken: in the case of schizophrenia, that route can be a larger socio-cultural approach. The work of a community, evidently, often has a larger positive effect on individuals than the sole use of antipsychotics. Instead of suppressing hallucinations, uncovering the root of the cause in society can lead to a better understanding of why an individual experiences reality in a certain way.  

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Written by Uma Adhye, Nia Banouvong, Caden Gaffaney, and Elliot Stack

Illustrated by Emily Haile

Edited by Monserrat Orozco, Vidya Saravanapandian, Sarah Wade

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References

Ceylan, A. C., & Yalçınkaya Alkar, Ö. (2023). The cross-cultural differences in symptoms of schizophrenia: A systematic review. Journal of Cognitive Behavioral Psychotherapies and Research, 12(2), 179–187. https://doi.org/10.5455/JCBPR.129188Scilit+4JCBP+4ResearchGate+4

Dhanasekaran, S., Loganathan, S., Dahale, A., & Varghese, M. (2017). Cultural considerations in the diagnosis and treatment of schizophrenia: A case example from India. Asian journal of psychiatry, 27, 113–114. https://doi.org/10.1016/j.ajp.2017.02.019

Goff, D. C., Falkai, P., Fleischhacker, W. W., Girgis, R. R., Kahn, R. M., Uchida, H., Zhao, J., & Lieberman, J. A. (2017). The long-term effects of antipsychotic medication on clinical course in schizophrenia. American Journal of Psychiatry, 174(9), 840–849. https://doi.org/10.1176/appi.ajp.2017.16091016

Li, W., Zhang, L., Luo, X., Liu, B., Liu, Z., Lin, F., Liu, Z., Xie, Y., Hudson, M., Rathod, S., Kingdon, D., Husain, N., Liu, X., Ayub, M., & Naeem, F. (2017). A qualitative study to explore views of patients’, carers’ and mental health professionals’ to inform cultural adaptation of CBT for psychosis (CBTp) in China. BMC Psychiatry, 17(1), 131. https://doi.org/10.1186/s12888-017-1290-6

Luhrmann T. M. (2007). Social defeat and the culture of chronicity: or, why schizophrenia does so well over there and so badly here. Culture, medicine and psychiatry, 31(2), 135–172. https://doi.org/10.1007/s11013-007-9049-z

Monroe, T. O., Garrett, M. E., Kousi, M., et al. (2020). PCM1 is necessary for focal ciliary integrity and is a candidate for severe schizophrenia. Nature Communications, 11, 5903. https://doi.org/10.1038/s41467-020-19637-5

Mosolov, S. N., & Yaltonskaya, P. A. (2022). Primary and secondary negative symptoms in schizophrenia. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.766692

Oh, J., Choi, S., & Chun, S. (2023). Abnormalities in primary cilia formation through chronic social defeat stress may contribute to the onset of schizophrenia. IBRO Neuroscience Reports, 15, 546-547. https://doi.org/10.1016/j.ibneur.2023.08.1079