Delusions, odd and common: Living in the prodrome, part 2

Author Rachel Aviv talked at length with a number of young people who had been identified as being ‘prodromal’ for schizophrenia, experiencing periodic delusions and at risk of converting to full-blown schizophrenia, following some of the at-risk individuals for a year.  In December’s Harper’s, Aviv offered a sensitive, insightful account of their day-to-day struggles to maintain insight, recognizing which of their experiences are not real: Which way madness lies: Can psychosis be prevented? (Freely accessible pdf available here.)

Psychiatric Research by Ted Watson

Aviv’s piece was really moving and inspired this post and an earlier one. The first part (Slipping into psychosis: living in the prodrome (part 1)) provides some sense of Aviv’s interviews, especially the story of ‘Anna,’ a woman who feared that she, like her mother before her, might be losing her grasp on reality.  In addition, the earlier post covered the controversy surrounding the attempt to formalize a diagnosis in the DSM-V of ‘prodrome’ and the ethical problems created by trying to identify who is at risk of ‘going mad.’

This post is my more speculative offering, contemplating the relation of the content of delusions to the cultural context in which they occur. How do the specific details of delusions arise and how might the particularity of any one person’s delusions affect the way that a delusional individual is treated by others?  Are you mad if everyone around you talks as if they, too, were experiencing the same delusions?

Aviv’s remarkable detailed account of prodrome, especially because it’s so strongly based in sensitive biographies of living on the boundary with schizophrenia, offers an opportunity to reflect on how the specific content of delusions — not simply the fact of having delusions — might provide the sufferer with different avenues to relate with others.

This piece, however, unlike the first, comes with a pretty serious caveat that this is not my area of expertise by any stretch.  As I mentioned at the end of the other post, bloggers rush in where fools fear to tread.   Moreover, as I try to finish off this piece, news from Tucscon about the shooting of US Congresswoman Gabrielle Giffords is provoking a much more heated discussion of the role of society in shaping the thoughts of delusional individuals. I won’t be talking about Jared Lee Loughner, the suspect apprehended at the scene where six people were killed and almost twenty others injured, in this post, but I may have to write a third piece separate from the discussion of Aviv and the people she presents.

Daniel has already begun the discussion of the recent shooting in Jared Lee Loughner – Is Mental Illness the Explanation for What He Did? Daniel’s piece comments on an article in Slate by Dr. Vaughan Bell, the writer behind the excellent blog Mind Hacks.  Bell’s Slate piece on Loughner and the attribution of mental illness to him is entitled Crazy Talk.

But I can’t help but think about prodromal delusion as Aviv’s article is so reminiscent of anthropological accounts, with sensitivity to the worldview of the subjects, in this case, individuals who are at the fraying edge of a shared reality with society around them.  As an anthropologist, I can’t help but wonder how the prodromal-schizophrenic-recovery trajectory might be influenced by different contexts, so I’ll offer some thoughts with the caution that my experience with schizophrenic individuals is severely limited.

The cross-cultural variation in schizophrenia

In 1977, anthropologist Arthur Kleinman (1977: 9) influentially called for an injection of cultural sophistication into medicine, a recognition that some cross-cultural psychiatrists took that they needed to better understand the complicated relationship between ‘disease,’ the psychological and biological problems leading to disturbance, and ‘illness,’ ‘the personal, interpersonal, and cultural reaction to disease.’

This awareness that social worlds entered into the experience of disease helped bring together cross-cultural psychology and psychological anthropology and cleared the ground for the cross-cultural analysis of schizophrenia.

In the case of schizophrenia research, López and Guarnaccia (2000) point out that cross-cultural research has tended to focus on two issues: prognosis and family emotional structure.

First, early findings from global mental health surveys like the World Health Organization’s (1979) International Pilot Study of Schizophrenia (IPSS) seemed to indicate that schizophrenia in developing countries has a more favorable course than in developed countries’ (López and Guarnaccia 2000: 582).

Lin and Kleinman (1988: 555), for example, reviewed discussions by mental health practitioners and suggested that,

Concurrently, a number of psychiatrists with extensive clinical experiences in various parts of Asia and Africa have reported that the majority of psychotic patients they treated in these “Third World” countries tended to suffer from a disease process that was characterized by acute onset, fulminant but typically short clinical course, and, more often than not, complete remission…

Those who believe schizophrenic individuals are more likely to fully remit in developing countries point to a number of possible reasons (see for example Lin and Kleinman 1988: 561-563):

1) without clinical definitions of disorders, both sufferers and those around them are more likely to believe the condition is temporary whereas the expectation in industrialized societies is often that mental illness will be either chronic or even identity-defining;

2) industrialized societies demand greater individual autonomy and expose individuals to greater isolation and changing circumstances;

3) social roles exist for impaired individuals in developing economies that are not heavily stigmatized, especially in the workplace where individuals who have been institutionalized in industrialized communities can find it very difficult to reestablish employment;

4) smaller families and higher expectations on individuals in industrialized societies subjects mentally ill individuals to greater criticism and negative emotion; and

5) families are more invested in recovery of individual members who suffer psychotic symptoms and work actively to integrate the individual into social interaction.  (Paraphrasing and summary with some elaboration of Lin and Kleinman, not a direct quote.)

The idea that an individual was more likely to recover from schizophrenia if living in the developing world than in a wealthy, industrialized country is widespread in the area of public mental health, although some critics think that the prognosis is not so positive among the poor (see Cohen et al. 2007; see also Lin and Kleinman 1988 for a discussion of methodological complications).

In fact, even if the pattern found in the WHO study holds, the contrast between industrialized and developing economies is overly broad, as there are exceptions in both cases — for example, developing economies where mental illness is heavily stigmatized and industrialized countries with greater optimism about recovery (Cohen et al. 2007).

Cohen and colleagues’ (2007) review significantly complicates the picture for understanding global schizophrenia across cultures and economic status.  If this post were really to consider the global epidemiology of schizophrenia, Cohen et al.’s review would be central to asking some penetrating questions about the forces that affect the emergence and prognosis for schizophrenic individuals around the world.  But that’s a different post…

The second area of concentration in cross-cultural research is that a number of researchers have explored whether emotional expression and interaction patterns in the family increase the chances of a relapse when schizophrenic patients return home. This research explores whether inter-ethnic differences in households may affect patient susceptibility to relapse (see Weisman 1997).

I’ll come back to this point in a bit, but the basic discussion revolves around the observation that the small nuclear family residence structure in many industrialized countries can place extraordinary burdens on immediate family members to care for schizophrenic kin. The resulting friction, especially combined with an individualized, medicalized understanding of the origins of schizophrenia, can produce resentment, criticism, family stress and a host of other dynamics that may contribute to relapse in individuals at risk.

Delusions from different realities

Rather than discuss cross-cultural epidemiology (that other, separate piece), this post reflects instead on evidence about cultural variation in the content of delusions and how different groups of ‘normal’ people might respond to an individual who starts to have specific sorts of delusions.  How do the specific form of the delusions affect the way others respond to prodromal individuals? One’s ideas may seem more or less crazy depending on what others around you believe.

The study of how culture influences delusions is still relatively underdeveloped according to practitioners, even though anecdotal evidence for cultural inflection is strong:

Data on psychotic symptoms like content of delusions, hallucinations, or Schneider’s first rank symptoms evoke the existence of a remarkable influence of culture (Stompe et al., 2006). For the content of delusions the personal and cultural system of values of an individual is of particular importance. The discussion whether and to which extent the prevalence and shape of psychotic symptoms depends on culture has longstanding tradition. Zutt established the term pathoplasticity in German psychiatry in order to describe the culture-sensitive part of the symptomatology of mental disorders. However, until today this term has more or less a methaphoric character. Although most professionals would agree that a cultural pattern may influence psychotic features, it is an unsolved question to what extent the variability of psychotic symptoms is caused by culture in a wide sense (socialization, religion, symbols, values, but also values and nutrition). A number of recent case reports published during the last 20 years described a quick inclusion of new technologies and cultural innovations into schizophrenic delusions which led to the conclusion of creating a new delusional content… (Rudaleviciene et al. 2008: 96-97)

Even in patterns of hallucinations (rather than more ideational and elaborate delusions), cultural differences intrude.   Bauer and colleagues (2010) found that, although auditory and visual hallucinations were most common across a number of sites (more than 1000 subjects in Austria, Poland, Lithuania, Georgia, Pakistan, Nigeria, and Ghana), the rates of auditory and visual hallucination varied quite a bit: visual hallucinations, for example, were most common in certain West African populations with patients in Nigeria and Ghana demonstrating more than 10 times the prevalence of Pakistani subjects (the rate was also high in European countries).  Significant differences in frequency of hallucinations were found in every sense modality: auditory, visual, cenesthetic (or proprioceptive), olfactory, tactile and gustatory (ibid.: 4).

As Aviv discusses, delusional concepts may appear to be divorced from reality, but they are acutely sensitive to the zeitgeist, elaborating upon society’s own contemporary fears and anxieties:

The raw material of delusions tends to evolve with the times, and over the past century, literature about psychosis reflects a steady thematic progression: delusions about communing with prophets and kings gave way to fears of being manipulated by the secret powers of factories, UFOs, radio DJs, fax machines, Al Qaeda, the Internet. (Aviv 2010: 41)

A number of researchers have traced these sorts of changes.  Stompe and colleagues (2006), for example, discuss the evidence for pathoplasticity, the culturally malleable aspects of mental disorder symptomology, over both time (for extensive exploration, see Jenkins and Barrett 2004).  In a review of psychiatric reports in Austria over the last 150 years, Stompe and colleagues (2006: 161) found that the rate of ‘guilt, hypochondria and especially of religious delusions’ decreased slowly but markedly over this time.

They take this decrease as evidence that ‘globalization’ is likely causing a ‘reduction of the impact of culture on the phenomenology of psychotic symptoms’ (161).  Although I don’t agree with the interpretation (their argument seems to assume that Westerners don’t have ‘culture’ of their own or that ‘culture’ is slowly winding down), I do think it’s quite likely that changes in broad cultural trends like increasing secularism in some regions quite likely influence the types of delusions individuals suffer.

The prevalence of religion in delusions

In a study in Taiwan, however, Huang and colleagues (in press: 3) found that religious delusions were no more common among religious Taiwanese than their non-religious counter-parts, a finding that I think points to the way that religion becomes culturally pervasive, not entirely a personal choice.  In Aviv’s article, for example, she discusses the case of ‘Melanie,’ a young woman raised Mormon who had become a long-term atheist (2010: 41).  Melanie was ‘dismayed to find the God of her childhood reentering her life’ as she became prodromal, interpreting events around her as religious omens.

The point is simply that one’s own express religious affiliation may not capture the complexity of religious imagery available for delusion, especially in a multi-religious, multi-cultural society.  ‘Jorge,’ another one of the young people Aviv interviewed, became increasingly obsessed with the occult and his own magical powers as he lost his grasp on reality (2010: 39).  Huang et al. (in press) did find that the most severe psychotics tended disproportionately to have magico-religious delusions and that especially religious individuals tended to be less satisfied with conventional psychiatric care, but, at least in Taiwan, self identifying as being religious does not necessarily lead to having more religious delusions.

In contrast, Rudaleviciene et al. (2008: 100) found that end of world delusions were much more common in schizophrenic Lithuanians who had strong personal religious beliefs than in those for whom personal faith was judged not important.  Having been divorced also increased the likelihood of believing in the end of times (I’ve been there after my first marriage).

Rudaleviciene and colleagues (2008: 102) coded patients’ accounts for the specific content of apocalyptic delusions, noting that ‘modern’ end of times delusions — fear of nuclear accident, environmental catastrophe, asteroid collision with Earth — were just as frequent in religious and non-religious subjects.  The difference was created by the much higher frequency of specifically religious, especially New Testament-based, apocalyptic delusions — final judgment, the return of Jesus Christ, and other images from the Book of Revelations.

Rudaleviciene and colleagues (2008: 103): ‘In our study we found that those individuals, for whom their faith was no of personal importance, felt the upcoming end of the world less frequently. It seems that the Bible offers symbolic patterns for schizophrenic patients in order to help them to concretize acute psychotic fears’ (emphasis added).

But it’s also clear from Huang and colleagues’ (in press: 1) review that the content of delusions is culturally specific and often religious: they site Yip’s (2003) study suggesting that, in the Chinese context, ‘traditional Chinese religious beliefs and superstitions, such as fortune telling, Buddhist gods, historical heroic gods and ancestor worship, have important influence on subjective psychotic experience, in particular delusions and hallucination’ (in Huang et al., in press: 2).

Stompe and colleagues (2006: 157), for example, mention that ‘delusions of grandeur can hardly be found in village communities where it is regarded as reprehensible and dangerous to strive for a given social level… While religious delusions and delusional guilt are primarily found in societies with a Jewish-Christian tradition, these contents are infrequent in Islamic, Hindu or Buddhist societies…’ Gearing and colleagues (2010) likewise found Catholic schizophrenics more likely to have delusions of guilt, Christians more generally to have religious delusions than non-Christians, both religious and atheist (see also Koenig 2009: 288).

Some patterns of delusion appear to be cross-culturally robust but interesting wrinkles make we wonder if social norms and mores don’t exert more influence that we might assume over psychotic experiences.  For example, reviewing existing research, Stompe et al. (2006: 159) found first that,

Independent of culture, persecution was the most common delusional theme in all sites followed by grandeur. Pakistan, the only pure Islamic country, showed a pattern of delusional contents remarkably different from the other sites with Christian majorities: low rates of religious delusions, delusions of grandeur and delusions of guilt…

According to Stompe and colleagues, Pakistani cases of schizophrenia seemed to avoid delusions of ‘religious grandiosity’ (being an angel or prophet), whereas African Christians often demonstrated these sorts of delusions of spiritual centrality (see also Gearing et al. 2010: 4).

In an intriguing way, Muslim schizophrenics seemed to respect to a significant degree powerful religious norms, avoiding both shirk (the blasphemy of ascribing partners or rivals to God) and kufr (a broader category of religious infidelity).  Alternatively, reports of patient delusions in predominantly Muslim areas might be scrubbed of blasphemous references for any number of reasons.

When a ‘false belief’ is not ‘delusional’

For me, religion brings up much more complicated questions for the delusional, however. As Koenig (2009: 287) points out in an off-handed way: ‘Psychiatric patients with psychotic disorders may report bizarre religious delusions, some of which can be difficult to distinguish from so-called normal religious or cultural beliefs.’  Especially where there is a marked ‘religion gap’ between a patient population and psychiatrists — where psychological health care workers are much more likely to be agnostic or atheist than the people for whom they care — it can be difficult to decide when a ‘false belief’ is delusional and when it’s just, well, the normal kind of irrational (like believing that a person can expect others to read long blog posts).

Aviv discusses the way that the definition of delusion has shifted subtly over the modern history of psychiatry, tracing out some of the subtle changes in the discussion of ‘delusion’ in the various editions of the Diagnostic and Statistical Manual (DSM).  Aviv highlight that, inherent in the definition of ‘delusion,’ is a contextual element.  A ‘false belief’ can be non-delusional if enough people believe:

A “delusion,” one of the five key symptoms listed for schizophrenia, is a “false belief… firmly sustained despite what almost everyone else believes.” A “bizarre delusion,” a more severe symptom, has gone through numerous revisions. In one edition of the manual, it had to have “patently absurd” content with “no possible basis in fact”; in the next, it involved “a phenomenon that the person’s culture would regard as totally implausible.” After the revision, 10 percent of patients who were previously deemed schizophrenic were given a new diagnosis, the majority of them because their delusions were no longer bizarre. (Aviv 2010: 36-37)

What’s implied here is that, for 10 percent of ‘schizophrenic’ patients prior to the revision, their delusions were rendered no longer bizarre with the new edition of the DSM because they lived in societies in which these particular ‘false beliefs’ were widely held.

One of the parents that Corcoran and colleagues (2003) interview offers an interesting metaphor to describe this sense that the schizophrenic is out of step with the beliefs around him or her: ‘I feel that he’s swimming against the tide, not with the tide. There’s a lot for us to do to get him to the point where he’s reasonably treading water.’  If having delusional beliefs not shared by others is pathological, then the specific beliefs one has matter: if you’re going to swim, it matters which way the tide around you is going.

Especially in places where counter-intuitive, non-logical or non-empirical beliefs are widespread, being ‘delusional’ may indicate an inability to believe what others believe, a failure in one’s day-to-day confidence in the taken-for-granted.

I don’t want to diminish the severity of schizophrenia or how people suffer, but when I read some of the concerns of Anna with the nature of reality, I was reminded of the writings of the great skeptic philosophers; when I assigned Sextus Empiricus to my students at Columbia University more than a decade ago, his work contains similar teachings from Pyrrho of Ellis.

Likewise, Anna herself in an email recommended a book by Louis A. Sass, The Paradoxes of Delusion: Wittgenstein, Schreber, and the Schizophrenic Mind.  (Cornell, 1994; click here for Google books link).  That text compares the ‘existential preoccupations’ of the philosopher Wittgenstein to the famous Memoirs of My Nervous Illness by Daniel Paul Schreber, a German judge who suffered what was then called dementia praecox.

The point is not that all schizophrenics are philosophers (or that Wittgenstein was insane), but that not everyone can easily bring their own beliefs about reality into line with the general consensus.  If delusions are, in part, defined by their simple psychological rarity, what then if a ‘false belief’ is widespread?

The illogical around the delusional

In an exploration of the links between religion and schizophrenia, Gearing and colleagues (2010: 3) discuss the way that individual and social processes become confounded:

According to the DSM-IV-TR…, delusions are defined as fixed erroneous or false beliefs usually involving misinterpretation of experiences or perceptions, despite proof to the contrary. Whereas, hallucinations are defined as are sensory perceptions without external stimulation…. Delusions and hallucinations may be a normal part of religious experience within some cultural contexts…. The influence of culture tends to confound this association between religion and schizophrenia.

As any quick reflection will make clear, both the definition of ‘hallucination’ and of ‘delusion’ are quite complicated, as any psychiatrist (or prodromal individual) would be able to describe.  What constitutes ‘proof to the contrary’ with some of the more difficult to disprove theories?  How many hallucinations does one have to have before they undermine one’s sense of reality?  And in the area of something like religion, where even those with the most solid faith admit that there can be no proof (after all, what would be the worth of faith of there were proof?), how can any belief be said to be delusional with absolute certainty?

In the project by Corcoran et al. (2003), we can see how the parents responding to the prodromal child often themselves engage in thoughts that might appear delusional were they not so widely shared. One said in the interview, for example, ‘I knew something wasn’t normal and I had to show others. Prevention is part of my culture – herbs and prayers. A tree doesn’t grow by itself.’  Herbs and prayers are ‘prevention’?  And who exactly do you think is helping the tree to grow?  Do you mean water and sun?  Another parent said that she ‘prayed for’ her child and yet another that the young person with delusions was taken to a ‘healing priest from Boston.’

Admittedly, I’m cherry-picking the examples, but I just want to highlight that the difference between ‘delusion’ and non-‘delusional’ magical thinking may be more about social consensus than empirical substance. For example, one of the subjects Corcoran and colleagues (2003) interviewed wondered about his adopted daughter:

Maybe the devil has something to do with his headaches. That girl’s from a place with witchcraft. Maybe she’s sticking pins. My wife blames the Catholic Church. I think my sons may have trouble because my wife left the Catholic Church. It’s not good to go against God – you can lose your soul.

If a schizophrenic patient said something like this, the comments would likely wind up the permanent file, evidence of delusional thinking, but this was a psychologically healthy member of the family.

These sorts of widespread unsubstantiated beliefs were not restricted to religion — I don’t want our readers to think I’m just picking on those of faith.  Some subjects use a language borrowed from medicine to talk about much more heavily freighted moral understandings of schizophrenia.  One father, for example, worried, ‘Maybe I have a fearful gene for shyness, a bad one that snuck in. Maybe my weakness was too weak and spilled into my son.’  Although using ‘gene’ as a kind of metaphor, the actual description is of moral failings so great that they leak over into the next generation — hardly a scientific understanding of the genetic dimensions of schizophrenia (see Roth et al. 2009).

And I also don’t want readers to think that I’m saying that being illogical or non-empirical is ‘bad’ and should be made fun of or disregarded; in fact, religious beliefs may offer some protection for schizophrenic individuals (see Koenig 2009).  Some researchers have found that a moralizing, overtly religious view of psychological disorder may actually improve long-term prognosis because of the effect it has on family members.  Studies of the course of schizophrenia in Latino families, for example, sometimes find that essentially ‘fatalistic’ religious beliefs can improve compassion toward the suffering individual and buffer the family system that helps patients to avoid relapse:

This belief system supports the perception that there is no protection against adversity and that anything that happens to others can also happen to oneself. It would seem that this external locus of control perspective might impress Latinos with the need to be more compassionate, understanding, and tolerant of other people’s failures, such as mental illness. This orientation may be one of the factors accounting for the low levels of anger and hostility elicited by Mexican American families when presented with schizophrenic relatives… (Weisman 1997: 27)

In a number of societies explored ethnographically, similar sorts of external blame for schizophrenia (suggesting it is the result of possession or supernatural problem) protect individuals from being stigmatized long term by mental illness. Once they regain their capacities, individuals who undergo psychotic breaks can return to their social place with little lingering suspicion that the individual her- or himself is inherently defective.

Other studies indicate that a similar external attribution of responsibility for schizophrenia often occurs in tight-knit families, perhaps because shifting blame for the disorder from the individual helps to preserve family solidarity (ibid.: 28).  Family structures, residence patterns, occupational opportunities and other social factors appear to have some influence on recovery rates in schizophrenia by providing different reinforcement or support mechanisms for the sufferer.

But another issue is simply the ability of people in general to talk about schizophrenia, to recognize it, and to have some meaningful label to describe it (see, for example, Saravanan et al. 2010).  Insight into one’s own psychiatric condition is not purely an individual achievement; insight depends upon being provided with conceptual, linguistic and practical tools that might help to recognize one’s own situation. As Saravanan and colleagues (2010: 458) argue, helping to provide individuals at risk with a culturally appropriate way to understand what they are experiencing may help to achieve positive outcomes even if only by decreasing the delay in seeking treatment when prodromal symptoms starts to occur.

However, some cultural ways of understanding schizophrenia may undermine treatment, discourage compliance with medical advice or pharmacological regimens, or encourage reliance and magical or religious healing treatments.

Are some realities more slippery

One of the patients that Aviv interviews, Melanie, describes how, when she had her first intense experience of delusion, powerful theological interpretations of events around her suddenly seemed compelling even though she had long ago abandoned her natal Mormonism for atheism.  A sign advertising the play Wicked on a taxi, a honking horn like a trumpet announcing the end times – she clung to her religious skepticism and, because of the gulf with her everyday experience, immediately sought help with ideas that she found so illogical to her.

In contrast, Melanie’s grandfather, who suspected his co-workers of spying on him while working as a Cold War-era aerospace engineer for the military, had no such clear break with which to self diagnose.  In a paranoid era and place, the first inklings of paranoia hardly warrant notice. Can some realities be harder to keep hold of than others?

Genetic predisposition clearly contributes to some forms of schizophrenia; siblings of schizophrenics, for example, are ten times more likely to develop the condition than random individuals.  But environmental factors also play a major role and we might ask what sorts of environments are especially ‘schizo-genic’:

Studies have shown that people’s chances of developing the disorder increase after demoralizing events—sexual or physical abuse, emotional neglect, witnessing a bombing or shooting, a mother’s death. Other factors include poverty, growing up with more than three siblings, living in an urban area, and immigration. When people move to a neighborhood where they are the ethnic minority, their chances of becoming schizophrenic increase. As the anthropologist T. M. Luhrmann put it, “If your skin is dark, your risk for schizophrenia rises as your neighborhood whitens.”  (Aviv 2010: 40)

A few years ago, I wrote a review of Robert Desjarlais’ (1997) powerful book, Shelter Blues: Sanity and Selfhood among the Homeless. At the time, I was very much struck by Desjarlais’ description of the ways that the physical space of the homeless shelter for the mentally ill that he studied contributed to the difficulty individuals had keeping hold of reality.  The following passage is from the version of this book review that I have on my hard drive:

Desjarlais carefully details the experiential impact of the homeless shelter itself as an architectural, institutional, and social space.  Housed in the Massachusetts State Service Center, a half-finished complex designed by “brutalist” architect Paul Rudolph, the shelter was, as one psychiatric intern put it, “a crazy place to put crazy people” (50).  The central tower initially planned to anchor the complex architecturally was left instead a gaping hole.  Like the identical surfacing on internal and external walls, the absence of a central focus for the sprawling complex tended to disorient all visitors.  Flowing stairwells, harsh “corduroy” textured concrete walls, unmarked entrances, and shadowy alcoves created an architectural space that many observers likened to the psychological interiors of some of its residents.  Desjarlais argues that constructed spaces contribute to distinctive forms of consciousness, including those forms deemed pathological.  Similarly, the street itself exacerbates many mentally ill individuals’ conditions, Desjarlais suggests, because they live “on the margins of language, communication, and sociability” (122).  As he writes:  “For many the sensorium of the street involved a corporeal existence in which a person’s senses and ability to make sense soon became dulled in response to excessive and brutal demands on those senses” (127).

What Desjarlais’ account suggests is that being diagnosed as insane or schizophrenic or some other medical condition can, through a process that is as much sociological and economic as it is medical, lead a person to become homeless.  In the process, the day-to-day reality of the individual becomes increasingly slippery, increasingly challenging — for a mentally ill individual, this transition might make recovery virtually impossible as they are shorn of all the material supports of normal personhood and pushed into an alternative reality that would severely test the healthiest among us.

Schizophrenia also tends to occur disproportionately among immigrants, which I find both fascinating and deeply troubling (in my own defense, I felt the world was pretty crazy even before I emigrated to Australia).  In Saha and colleagues’ (2005) meta-analysis, the prevalence of schizophrenia among immigrants tends to be almost twice that in majority populations. Some possible sources of bias (such as access to care and language problems affecting diagnosis) undermine certainty, and variation in studies ranges from immigrants being less likely to more than eight times more likely to have schizophrenia, but Saha and colleagues conclude that ‘migrant status is an important risk factor for schizophrenia.’

One of the prodromal patients that Aviv interviews highlights the disconcerting effects of being an immigrant, of having to struggle with profound questions of identity.  ‘Chloe’ explained that her struggles with delusion were continuous with normal identity issues for immigrants, ‘this constant questioning of what my true self is—even though that sounds really cheesy’ (40).

Clearly, immigration does not make people schizophrenic; but for someone with a tendency toward delusion, a recalcitrant relationship to shared social beliefs, a defective reality tester, and perhaps a weakened sense of self, the upheaval of immigration might make schizophrenic departure more likely.

Certainly, as an immigrant, I’m frequently struck by the weirdness around me, that vague sense of being out of place that virtually anyone can get.  This out-of-place-ness could not cause delusions, but it might inspire the searching intellect of the prodromal individual to better see the cracks in the consensus reality.

Conclusion, sort of…

I’m not sure that I have a real conclusion.  One of the effects of good anthropological ethnography is that it can show that the odd and culturally distant suddenly make sense, while the familiar and taken-for-granted appears in high relief, revealed for its arbitrariness and peculiarity.

In some ways, Aviv did this for me with prodrome, this mild but frightening drift away from shared reality.  The longer I studied Aviv’s article, rereading the reflections of Melanie and Anna and Jorge and the other people who shared with Aviv, the less exotic their delusions appeared to me, the more I began to marvel that so many of us seem to get by agreeing upon a reality that, on closer examination, also appears pretty damn improbable.

I’m left again with Anna’s discussion of the way that her own recovery seems to make her delusions increasingly difficult to remember, a reality so distant from her non-delusional one that it cannot be recalled or translated.  So perhaps the final delusion is that she never suffered at all: ‘The substance of my experience is thrown into doubt. I am left with this incredibly deep sense that none of these things ever happened to me’ (Aviv 2010: 46).


In the past few days, as I have struggled to finish this piece, a number of events have knocked me around in different directions.  On the one hand, I’ve been diagnosed with a physical problem that will need surgery (god, I hate getting middle-aged!).

On the other hand, I was contacted by ‘Anna,’ the women who talked to Rachel Aviv about her experiences with intermittent delusion that I’ve discussed at length.  She was generous and kind about my reinterpretation of her story, and wrote that she was interested, too, in studying more about delusions.  This news made me profoundly happy, knowing that such an insightful person was turning her mind to help others, including those of us who wish to understand how it feels to live through prodrome or schizophrenia.

Anna recommended to me that I should tell anyone who wants to understand schizophrenia better that the book The Paradoxes of Delusion: Wittgenstein, Schreber, and the Schizophrenic Mind by Louis A. Sass was a remarkable work (Google books).  (Rachel recommended Sass’s book, Madness and Modernism: Insanity in the Light of Modern Art, Literature, and Thought, for anyone wanting to read more; Anna also agreed that this book was especially good.)

The Paradoxes of Delusion, as I mentioned above, pairs the writings of Daniel Paul Schreber, author of Memoirs of My Nervous Illness based on his own experience being periodically institutionalized from 1884 until he passed away in 1911, with those of philosopher Ludwig Wittgenstein, arguably one of the most influential and difficult thinkers of the twentieth century.  I started to read the book and quickly realized that I had to stop if I was going to finish writing this post, so I can recommend it highly as it is compelling from the first page, but I cannot tell you how the book ends (no spoiler here!).

The other thing that happened was that news broke yesterday of the shooting of US Congresswoman Gabrielle Giffords in an incident that has left at least five people dead and many more wounded.  At the centre of the breaking news in Jared Lee Loughner, the suspect apprehended at the scene, who clearly has a history of disturbing and bizarre behaviour, suggesting that he was likely delusional.

This breaking news makes the consideration of the cultural context of delusion all the more important and tragically timely, but I have decided that I need to write a separate piece, possible with a couple more days reflection.  Especially given the generous sharing of their stories that I find in Aviv’s work, I feel that the assumption that only a schizophrenic individual is capable of these sorts of violent crimes or rambling YouTube videos or troubling postings on the Internet is too rash (something both Vaughan of Mind Hacks and Daniel have also argued).

Clearly, some of the discussion here bears direct relevance on the most contentious part of the commentary on the Tucscon shootings: the degree to which society as a whole, the cultural and symbolic context, shapes an individuals’ delusions.  And if society does influence the forms of unreality that different individuals inhabit, what do we wish to do about that…

Image credits:

Aboriginal painting: ‘Psychiatric Research by Ted Watson—this painting, representing collaborative research between people with schizophrenia and mental health professionals, is by an aboriginal mental health service user and was commissioned by the Queensland Centre for Mental Health Research, Australia.’

PLoS Med. 2005 May; 2(5): e151.

Published online 2005 May 31. doi: 10.1371/journal.pmed.0020151.

Suggested further reading

Robert Desjarlais. 1997.  Shelter Blues: Sanity and Selfhood among the Homeless. Philadelphia:  University of Pennsylvania Press.

Louis A. Sass.  1994.  The Paradoxes of Delusion: Wittgenstein, Schreber, and the Schizophrenic Mind.  Cornell University Press. (Google books link)

_____.  1992.  Madness and Modernism: Insanity in the Light of Modern Art, Literature, and Thought.  Basic Books.  (Google books link)

The first book by Sass was recommended especially by ‘Anna,’ whose story was included in the first post.  The second book (Madness and Modernism) was recommended by Rachel Aviv.


Aviv, Rachel. (2010) Which way madness lies: Can psychosis be prevented? Harper’s Magazine (December): 35-46.  (or access through Rachel’s website)

Bauer, S., Schanda, H., Karakula, H., Olajossy-Hilkesberger, L., Rudaleviciene, P., Okribelashvili, N., Chaudhry, H., Idemudia, S., Gscheider, S., & Ritter, K. (2010). Culture and the prevalence of hallucinations in schizophrenia Comprehensive Psychiatry DOI: 10.1016/j.comppsych.2010.06.008

Cohen, A., Patel, V., Thara, R., & Gureje, O. (2007). Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World? Schizophrenia Bulletin, 34 (2), 229-244 DOI: 10.1093/schbul/sbm105

Corcoran, C., Davidson, L., Sills-Shahar, R., Nickou, C., Malaspina, D., Miller, T., & McGlashan, T. (2003). A Qualitative Research Study of the Evolution of Symptoms in Individuals Identified as Prodromal to Psychosis Psychiatric Quarterly, 74 (4), 313-332 DOI: 10.1023/A:1026083309607

Gearing, R., Alonzo, D., Smolak, A., McHugh, K., Harmon, S., & Baldwin, S. (2010). Association of religion with delusions and hallucinations in the context of schizophrenia: Implications for engagement and adherence Schizophrenia Research DOI: 10.1016/j.schres.2010.11.005

Huang, C., Shang, C., Shieh, M., Lin, H., & Su, J. (2010). The interactions between religion, religiosity, religious delusion/hallucination, and treatment-seeking behavior among schizophrenic patients in Taiwan Psychiatry Research DOI: 10.1016/j.psychres.2010.07.014

Jenkins, Janis Hunter, and Robert John Barrett, eds. (2006)  Schizophrenia, Culture and Subjectivity: The Edge of Experience. Cambridge: Cambridge University Press.

Kleinman, Arthur M. 1977. Depression, somatization and the ‘‘New Cross-Cultural Psychiatry.’’ Social Science and Medicine 11(1): 3–10. doi:10.1016/0037-7856(77)90138-X

Koenig HG (2009). Research on religion, spirituality, and mental health: a review. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 54 (5), 283-91 PMID: 19497160

Lin KM, & Kleinman AM (1988). Psychopathology and clinical course of schizophrenia: a cross-cultural perspective. Schizophrenia bulletin, 14 (4), 555-67 PMID: 3064282

López SR, & Guarnaccia PJ (2000). Cultural psychopathology: uncovering the social world of mental illness. Annual review of psychology, 51, 571-98 PMID: 10751981

Roth, T., Lubin, F., Sodhi, M., & Kleinman, J. (2009). Epigenetic mechanisms in schizophrenia Biochimica et Biophysica Acta (BBA) – General Subjects, 1790 (9), 869-877 DOI: 10.1016/j.bbagen.2009.06.009

Rudaleviciene, Palmira, Thomas Stompe, Andrius Narbekovas, and Robertas Bunevicius.  (2008) Influence of culture on the world end (apocalyptic) delusions. World Cultural Psychiatry Research Review 3(2): 96-105.

Saha, S., Chant, D., Welham, J., & McGrath, J. (2005). A Systematic Review of the Prevalence of Schizophrenia PLoS Medicine, 2 (5) DOI: 10.1371/journal.pmed.0020141

Saravanan, B., Jacob, K., Johnson, S., Prince, M., Bhugra, D., & David, A. (2010). Outcome of first-episode schizophrenia in India: longitudinal study of effect of insight and psychopathology The British Journal of Psychiatry, 196 (6), 454-459 DOI: 10.1192/bjp.bp.109.068577

Stompe, Thomas, Hanna Karakula, Palmira Rudaleviciene, Nino Okribelashvili, Haroon R. Chaudhry, E. E. Idemudia, S. Gscheider.  (2006) The pathoplastic effect of culture on psychotic symptoms in schizophrenia. World Cultural Psychiatry Research Review 1(3/4): 157-163.  (Available for download here.)

Weisman, A. (1997). Understanding Cross-Cultural Prognostic Variability for Schizophrenia. Cultural Diversity & Mental Health, 3 (1), 23-35 DOI: 10.1037//1099-9809.3.1.23

World Health Organization. (1979). Schizophrenia: An international follow-up study. NewYork: John Wiley & Sons.

Yip, K.S.  (2003) Traditional Chinese religious beliefs and superstitions in delusions and hallucinations of Chinese schizophrenic patients. International Journal of Social Psychiatry 49: 97–111.

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8 Responses to Delusions, odd and common: Living in the prodrome, part 2

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  6. rmb says:

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