Some reflexion on the chronicity of the two Japanese-American schizophrenics - from the viewpoint of transcultural psychiatry.

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The recent development of transcultural psychiatry has questioned the assumption that schizophrenia is an illness which takes a chronic course, eventually terminating in clinical deterioration, as a result of an irreversible disease process. This paper attempts to elucidate cultural impact on chronicity of schizophrenia, through two case analyses of male Japanese- Americans. Value saturation in group-oriented culture and persisting diffusion in ethnic iden tity were identified to be two different modes of impact of culture on the chronicity of schizophrenia. It has been assumed that schizophrenia is an illness which takes a chronic course, even tually terminating in clinical deterioration. This chronicity of schizophrenia is assumed to result from irreversible disease process. However, recent studies in transcultural psychiatry have revealed different courses of schizophrenic illness in developing countries. Rin and Lin (1962) found few severely deteriorated patients among aborigines in Taiwan; their psychotic episodes are characteristically acute in onset and short in duration. In rural Ghana also, Field (1968) hardly found any deteriorated cases. However, these are not studies to follow-up the outcome of schizophrenics; the first well-designed investigation of this kind was by Murphy and Ramon (1971). They reported the results of a twelve-year follow-up survey of schizophrenics from Mauritius and compared them with the outcome of schizophrenics in London. This revealed that schizophrenics in Mauritius had a better outcome, which could not be accounted for in terms of better treatment, shorter hospitalisation, easier environmental conditions or more liberal standards of outcome. They suggested, therefore, that the question of chronicity in schizophrenia needed re-examination, with more attention being paid to the course of the disease in non-European peoples. However, there are difficulties in conducting cross-cultural studies in mental illness — diagnostic criteria for mental illness vary from country to country, while sampling of psychiatric patients may be biased, because the concept of mental illness and attitudes to it vary with cultures. Minimising these difficulties, IPSS (The International Pilot Study of Schizophrenia) in its world-wide survey, reported differences between schizophrenic patients in different cultural settings, with patients in developing countries having more favourable courses and outcome than their counterparts in developed countries (Sartorius. et al, 1978). Thus, cultural factors cannot be excluded in determining the course of schizophrenic illness. The present author (1980) has reported that male Japanese-American schizophrenics tended to take on more chronic courses than Caucasian ones in the Hawaii State Hospital. However, the mode of operation of cultural factors on the course of schizophrenic illness has never been clarified. The present study will attempt to elucidate it through case analyses. The following two cases of Japanese-Americans were treated by the author, while he was on the staff of a community mental health system in the State of Hawaii from 1976 to 1977. The focus will be on cultural factors, rather than on predisposition or psychological make-up.