Schizophrenia and African-Caribbeans: a conceptual model of aetiology

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<ul><li><p>International Review of Psychiatry (1999) 11, 145 - 152</p><p>Schizophrenia and African-Caribbeans: a conceptual model of</p><p>aetiology</p><p>DINESH BHUGRA, ROSEMARIE MALLETT &amp; JULIAN LEFF</p><p>Institute of Psychiatry, London, UK</p><p>Summary</p><p>Several studies in the UK have obser ved that the incep tion rates of schizophrenia among the Afr ican-Caribbeans are well elevated when</p><p>compared withWhite populations. However, on the basis of available data on biological factors it appears that social factors play a more</p><p>important role in the aetiolog y of schizophrenia in this group. Reviewing the current state of literature on self-esteem and socia l factors</p><p>it is proposed that lack of early attachments and prolonged separation from one or both parents may well play a signi cant role in the</p><p>genesis of schizophrenia in this group. It is proposed that some of these factors mediate through low self-esteem and the clinicians and</p><p>researchers alike are urged to explore further the role of self-esteem in genesis and maintenance of symptoms of schizophrenia.</p><p>Introduction</p><p>Several studies in the UK have highlighted the</p><p>differential in rates of schizophrenia in African-</p><p>Caribbeans when compared with the native White</p><p>population (Littlewood &amp; Lipsedge, 1981a, 1981b;</p><p>Harrison et al., 1988; King et al., 1994; Bhugra et al.,</p><p>1997; Harrison et al., 1997). The reasons for this</p><p>increase have not always been clear. Among various</p><p>hypotheses put forward has been the suggestion that</p><p>the rates of schizophrenia in sending countries are</p><p>high but several studies from the Caribbean have</p><p>proved that this is not the case (Hickling &amp; Rodgers-</p><p>Johnson, 1995; Bhugra et al., 1996; Mahy et al., 1999).</p><p>When biological factors are studied in this group</p><p>once again the rates of biological events like pregnancy</p><p>and birth complications are lower in the patients in</p><p>the Caribbean (Bhugra et al., submitted) whereas the</p><p>rates of pregnancy and birth complications are lower</p><p>than expected in the African-Caribbeans in the UK</p><p>(Hutchinson et al., 1997). However, these authors</p><p>(Hutchinson et al., 1996) also showed that rates of</p><p>schizophrenia among the siblings of patients with</p><p>schizophrenia are way too high when compared with</p><p>White populations.These authors went on to suggest</p><p>that social factors like unemployment, living alone,</p><p>socio-economic disadvantage may well play a role in</p><p>the genesis of schizophrenia a suggestion also put</p><p>forward by Bhugra et al. (1997).</p><p>It would appear that most of these factors are likely</p><p>to mediate through poor self-esteem. An additional</p><p>factor which emerged as a possible causative factor</p><p>was childhood separation from one or both parents.</p><p>In the study referred to above Bhugra et al. (1997)</p><p>also studied the length of separation from one or</p><p>both parents in childhood of patients presenting for</p><p>the rst time ever with schizophrenia which was</p><p>diagnosed by using Presen t State Examination</p><p>(PSE-9) criteria (Wing et al., 1974).</p><p>Of the 38 patients of African-Caribbean origin</p><p>(ethnicity was de ned by the individuals themselves)</p><p>12 (34%) had been separated from their mothers for</p><p>more than 4 years and 19 (53%) had been separated</p><p>from their fathers. These differences were signi cant</p><p>when compared with the White subjects of whom 6</p><p>(17%) and 12 (34%) had been separated from their</p><p>mothers and fathers, respectively. In addition, of the</p><p>Afr ican-Caribbean sample, 18 (48%) had been living</p><p>alone, and 80% were unemployed and only 10% had</p><p>regular contact with their partner.The detailed results</p><p>are presented elsewhere. Here we propose to highlight</p><p>the role of social isolation and the interaction with</p><p>prolonged separation in their formative years leading</p><p>to poor self-esteem and poor attachment formations.</p><p>Conceptual model of aetiology of</p><p>schizophrenia</p><p>From the present research several strands which could</p><p>contribute to the inception rates of schizophrenia</p><p>begin to emerge. For the African-Caribbeans, early</p><p>and prolonged separation from father, living alone in</p><p>adulthood and not having close con dants have been</p><p>identi ed as possible factors in the aetiology of</p><p>schizophren ia. Unemployment remains a key</p><p>candidate in contributing to the genesis of illness and</p><p>remains to be studied carefu lly. In addition to</p><p>assessing rates and reasons for unemployment, these</p><p>studies must compare these with the rates of</p><p>Dinesh Bhugra, Senior Lecturer in Psychiatry, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF,UK.Tel: +44 171 919 3500; Fax: +44 171 277 1586.</p><p>0954 0261/99/02/30145 08 1999, Institute of Psychiatry</p><p>Int R</p><p>ev P</p><p>sych</p><p>iatr</p><p>y D</p><p>ownl</p><p>oade</p><p>d fr</p><p>om in</p><p>form</p><p>ahea</p><p>lthca</p><p>re.c</p><p>om b</p><p>y Q</p><p>UT</p><p> Que</p><p>ensl</p><p>and </p><p>Uni</p><p>vers</p><p>ity o</p><p>f T</p><p>ech </p><p>on 1</p><p>1/01</p><p>/14</p><p>For </p><p>pers</p><p>onal</p><p> use</p><p> onl</p><p>y.</p></li><li><p>unemployment and its impact on the general popula-</p><p>tion as controls.The role of unemployment in affecting</p><p>self-esteem and as a chronic difficulty needs to be</p><p>studied. In addition the role of the unemployment</p><p>and other social factors like housing need to be studied</p><p>at the time of inception as well as at the time of</p><p>follow-up.</p><p>Con cept s o f the se lf and se lf-es teem have</p><p>been used in social psychology for a considerable</p><p>length of time. However, the agreement on de ni-</p><p>tions and its measurements remains elusive . The</p><p>`self as a concept remains confusing and although</p><p>identity and ego have been used as describing the</p><p>inner or essential nature of mankind (Rosenberg,</p><p>1979). The distinction between self as an object of</p><p>the person s own knowledge and evaluation and as</p><p>a subject or agent is not dissim ilar to concepts of</p><p>ethnic identity and its ascription. Ethnic identity is</p><p>only one par t of the concept of the self. Unlike</p><p>ethnic identity, however, self can be both a subject</p><p>and an object.</p><p>When we use the term self-concept, we mean the</p><p>totality of the individuals thoughts and feelings having</p><p>references to himself as an object. This is not the</p><p>concept for the real self but a picture, a perception</p><p>and an observation. Although self has been used as</p><p>ego-identity (Erikson, 1959) this is a conscious sense</p><p>of individual identity. Hence, self-ascription becomes</p><p>even more relevant in trying to understand identity.</p><p>The contents of the self-concept include social</p><p>identity (which includes age, sex, race, nationality,</p><p>religion, family status, legal status) which then gets</p><p>expressed in categories. The individual society may</p><p>grow so big that individuals may break off into smaller</p><p>membership groups. The third aspect is based on</p><p>social labelling. Other aspects of social identity include</p><p>categories affecting life in a myriad of ways such as</p><p>being an ex-convict or eminent professor.These social</p><p>types are perceived as characteristics. The nal</p><p>component of the social identity is personal identity</p><p>which is used to refer to individuals deepest thoughts</p><p>and wishes. It is more importantly a matter of social</p><p>classi cation by giving the individual a unique label</p><p>(such as name) which could be as complex as needed.</p><p>The self-concept emerges and develops gradually</p><p>primarily out of social experience and may well have</p><p>very abstract qualities.The signi cance of a particular</p><p>component depends upon its location in the self-</p><p>concept structure whether it is peripheral, cardinal or</p><p>secondary. The self-attitudes include self-con dence</p><p>which refers to the anticipation of successfu lly</p><p>mastering challenges or overcoming obstacles whereas</p><p>self-esteem implies self-acceptance, self-respect and</p><p>feelings of self-worth. A person with high self-esteem</p><p>is fundamentally satis ed with the type of person he</p><p>is, yet may acknowledge his faults while hoping to</p><p>overcome them. Self-esteem uses both positive and</p><p>negative evaluations of the self and is not to be</p><p>confused with self-con dence.</p><p>Societies which incorporate into their institutions</p><p>and value system that maximum autonomy consistent</p><p>with social control be permitted are likely to foster</p><p>high levels of individuality and such an approach is</p><p>likely to affect concepts of the self and self-esteem.</p><p>There are emotional reactions which are unique to</p><p>the self and yet these have to be seen in the context of</p><p>the individuals interaction with the society as a whole.</p><p>The concepts of self are not xed and rigid, just like</p><p>the concepts of ethnic identity self-esteem and self-</p><p>consistency in relating to the social nornus is affected</p><p>by the larger society.</p><p>Bednar et al. (1991) suggest that self-concept is</p><p>integra l to the indiv idua l implicit ly including</p><p>cognitive-affective structures about ones self that</p><p>determines and creates the meaning of an individuals</p><p>experience. Current concepts of the self are multi-</p><p>faceted conceptualizations. Masterpasqua (1989)</p><p>argues that the self is the essential component in a</p><p>movement toward considering competence (de ned</p><p>as adaptive, cognitive, emotional, behavioural and</p><p>social attributes related to beliefs and expectations)</p><p>as the goal of psychological health. Although the</p><p>de nition of competence is all encompassing it has</p><p>the advan tage of de n ing competence in a</p><p>psychological social manner. Self-esteem can and does</p><p>in uence coping and avo idance and social</p><p>functioning. A different angle in the theory of self-</p><p>esteem was put forward by Wegrocki (1939) who</p><p>proposed that abnormal behaviour could not be</p><p>de ned in terms of behaviour itself nor in terms of</p><p>conformity to social expectations because cultural</p><p>standards vary so widely. He argued instead that</p><p>abnormality must be evaluated in light of its</p><p>underlying motivations, because apparently identical</p><p>and appropriate social behaviours may serve entirely</p><p>d ifferen t psycholog ica l functions for differen t</p><p>individuals. Thus from the universalist position of</p><p>clinicians we begin to move towards a relativist one.</p><p>Wegrocki (1939) goes on to conclude that the essence</p><p>of abnormal behaviour is the tendency to choose a</p><p>type of reaction that represents an attempt to escape</p><p>from a con ict-producing situation.Thus in his view,</p><p>the basic foundation of emotional difficulties and low</p><p>self-esteem is avoidant behaviour. However, it is not</p><p>clear which comes rst emotional difficulties or low</p><p>self-esteem. In the hypothetical model proposed, it is</p><p>likely that emotional difficulties antedate low self-</p><p>esteem . Bednar et a l. (1989) propose that</p><p>interpersonal feedback and especially from the social</p><p>environment play an important role in development</p><p>of self-esteem. Rejection is a major catalyst for other</p><p>psychological processes though not a major cause by</p><p>itself. Hence, it becomes important to look at degrees</p><p>and mixtures of coping and defence.</p><p>Bednar et a l. (1989) argue that when people</p><p>respond to rejection by `impression management</p><p>creating conditions which render most of the favour-</p><p>able feedback to be untrustworthy, unbelievable and</p><p>146 Dinesh Bhugra et al.</p><p>Int R</p><p>ev P</p><p>sych</p><p>iatr</p><p>y D</p><p>ownl</p><p>oade</p><p>d fr</p><p>om in</p><p>form</p><p>ahea</p><p>lthca</p><p>re.c</p><p>om b</p><p>y Q</p><p>UT</p><p> Que</p><p>ensl</p><p>and </p><p>Uni</p><p>vers</p><p>ity o</p><p>f T</p><p>ech </p><p>on 1</p><p>1/01</p><p>/14</p><p>For </p><p>pers</p><p>onal</p><p> use</p><p> onl</p><p>y.</p></li><li><p>psycho log ical impotence . Such an awareness</p><p>combined with poor self-evaluative processes may</p><p>well lead to psychotic experiences. The interaction</p><p>between the individual (his/her self-esteem) culture</p><p>and identity is a complex one. A key part of the</p><p>individuals personality will be their identity which</p><p>will encompass self-esteem but a careful assessment</p><p>is required to make sense of the role self-esteem plays</p><p>in the genesis of psychiatric distress.</p><p>The concepts of self vary across cultures. For</p><p>example, Roland (1980) suggests that child rearing</p><p>and personality development in a given culture and</p><p>society is generally congruent with the basic social</p><p>patterns and cultural values. Stated from a</p><p>psychoanalytic standpoint, the intrapsychic structures</p><p>often of an unconscious nature are consonant with</p><p>the social roles, structures and attitudes and when</p><p>studied in depth may be found to be an important</p><p>mirror of ongoing social processes. Rapid social</p><p>change may well lead to incongruities and con icts</p><p>and challenges to new integrations.</p><p>Using psychoanalytic perspectives of symbiosis and</p><p>separation and individuation in early maternal object</p><p>relations [i.e. within the matrix of the early childhood</p><p>relationship with the mothering person(s)] and central</p><p>role of narcissism, Roland (1980) argues that in Indian</p><p>culture individuation and separation will be inhibited</p><p>and the interpersonal relationships even at early stages</p><p>of life are very important to individuals. He suggests</p><p>that early development of self is totally consonant</p><p>w ith a social structure and roles in which the</p><p>individual remains far more involved and embedded</p><p>within close, well-de ned, hierarchical family relation-</p><p>ships. Because in this group there is a heightened</p><p>sensitivity throughout life as to how others view</p><p>oneself in a wide variety of situations the concept of</p><p>self includes what Roland calls the expanding self.</p><p>From the earliest age there appears to be consider-</p><p>able narcissistic identi cation with the reputation and</p><p>honour of ones family. This narcissistic self is called</p><p>familial self by Roland (1987).While comparing the</p><p>American and Indian concepts of the self, Roland</p><p>(1987) argues that the Indian conscience has an intra-</p><p>psychic structure with radar sensitivity to the norms</p><p>of responsibility and proper behaviour in highly</p><p>complex kinship relationships enabling the person to</p><p>act appropriately in a variety of speci c situations. In</p><p>contrast with the American concepts, central to the</p><p>Indian conscience is the ego-ideal fuelled by the</p><p>enormous we-self regard of early childhood and</p><p>fashioned after familial and mythic models. As there</p><p>exists a great variety of mythic models these are suit-</p><p>able for a diversity of temperaments and aspirations.</p><p>This ego-ideal is geared towards ful lling others</p><p>expectations in a wide variety of complex relation-</p><p>ships, Roland (1987) calls it `socially contextual</p><p>ego-ideal . The familial self is contrasted with the</p><p>American personality where the individualized self</p><p>emerges out of far more autonomy and individua-</p><p>tion. This individualized self has an imposed socio-</p><p>cultural necessity to choose and take actions on a</p><p>number of social opinions ranging from love and</p><p>social relationships to work choices, ideology and</p><p>activities as well as the need to self-create ones own</p><p>identity.Thus intimacy relationships tend to be more</p><p>frag ile.This is not to say that individualized self does</p><p>not exist among Indians or that familial self is not</p><p>seen among Americans and these selves emerge from</p><p>historical and cultural contexts.The third self is called</p><p>transcendental or spir itual self by Roland (1987) and</p><p>this deals with religious or spiritual aspects of the self</p><p>which have been affected by subconscious symbiotic</p><p>relationships.</p><p>The aim of this description is to suggest to the</p><p>reader that concepts of self vary across cultures and</p><p>these concepts are often an integral part of ethnic or</p><p>cultural identity and there are no universal tools of</p><p>measurements to measure concepts of self across</p><p>different ethnic groups and cultures. The role of self-</p><p>esteem within this broad ambit of self is obviously</p><p>related to how the individ...</p></li></ul>

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