Disease models of mental illness and after-care patient education:
Critical observations from cross-cultural practice
Dr. Juli McGruder
(Ph.D. Sociocultural anthropology, B.S. occupational therapy)
School of Occupational Therapy and Physical Therapy
University of Puget Sound
Paper presented at the Qualitative Evidence-based Practice Conference, Taking a Critical Stance. Coventry University, May 14-16 2001
Introduction: After-care articles of faith
Based on my experience attending support and psychoeducational groups for persons with serious mental illness and their families, reading extensively in the psychiatric literature for the 21 years I have taught psychosocial occupational therapy, serving as a guardian to an elder non-relative diagnosed with paranoid schizophrenia, watching a loved one undergo involuntary commitment and treatment, and generally being attuned to how psychiatry represents itself in the popular mass media, I would parse the messages of psychiatric after care, for the segment of the population in which I am most interested, thus:
The patient has a permanent brain disease: schizophrenia. The brain disease causes a biochemical imbalance, most notably in overactive or over-sensitive dopaminergic cell systems. Traces of this brain disease can also be seen in physical findings like enlarged cerebral ventricles. The chemical imbalance accounts for all of the patient's unusual ideas and behaviors, which are to be viewed as symptoms. Anti-psychotic medications go a long way in righting the chemical imbalance and, thereby, will control the patient's disease much in the way that insulin controls diabetes, although they will not cure it. These medications may make the patient uncomfortable and have certain risks, but the risk of recurring mental illness is far worse than these side effects. The doctor can prescribe more medications to counteract the difficult side effects of the anti-psychotic medications. Therefore, virtually all patients with schizophrenia should remain on these medications for life. The doctor's job is to find the right combination of anti-psychotic and anti-dyskinetic medications for each patient. Families can assist by helping to convince the patient that he has a brain disease and encouraging him to take medication, by being understanding and tolerant, and by being vigilant in watching for relapse. The treatment is not perfect yet, but medical science will eventually solve this problem and cure this disease.
If this message to the patient and family seems overstated to you, please consider the findings of Victor Sauna (1991). Based on a comparative discourse analysis of statements from American and European psychiatrists, popular press accounts about psychiatric advances and the statements of consumer advocacy groups (i.e. the U.S. group National Alliance for the Mentally Ill and its subgroup National Alliance for Research on Depression and Schizophrenia ) v. the U.K.'s National Schizophrenia Fellowship ), Sauna concluded that:
Europeans are aware of the limitations in attributing schizophrenia solely to organic etiological factors and are aware of the limitations of the neuroleptic drugs. In contrast, Americans appear absolutely sure that the disorder is caused by organic factors and that neuroleptic drugs have revolutionized psychiatry... One can find evidence of this [dominant American] ideology in the psychiatric journals, in periodicals and in newspapers...[and on] television....Of course, journalists and lay persons believe in the scientific truth of these statements which are often based on little more than speculation. (p 362)
When I criticize positivistic, reductionistic approaches to psychiatric after care for persons with schizophrenia, I ask that the listeners consider the source as the other side of the pond, and reflect for themselves on the degree to which these same articles of faith in the disease model shape after care in Britain. The book, The Dialectics of Schizophrenia by Dr. Philip Thomas of Manchester (1997), has convinced me that organic etiology assumptions drive practice here as well, though perhaps in a way that is more open to doubting questions about the efficacy of biological psychiatry.
Questioning biological psychiatry
Dr. Thomas' book provides a review of how we got to this place in psychiatry and interrogates the quantitative research conclusions that led the way. Certainly, the efficacy of dopamine blocking medications has been well established in double blind, placebo controlled trials from the 1960s forward. Yet in each study there are subjects who recover on placebo and those who do not benefit from neuroleptic medication. Meta-analyses, like that of Wyatt (1991), show that, for the majority, early and steady treatment with neuroleptics reduces hospitalizations. Wyatt, in fact, concluded that neuroleptics taken during the early stages of schizophrenia were not only effective in decreasing positive symptoms but might even moderate the course of the disorder over time.
Thomas' discussion of such findings points up several important questions. Is re-hospitalization the best or most sensitive measure of relapse? Have subjects in these studies stopped taking medications and relapsed, or begun to relapse and then stopped taking medication? If no studies of dose reduction extend beyond 7 years (the average period of time for tardive dyskinesia to emerge), do we really know what the risk-benefit profile of neuroleptics is, as regards iatrogenic dyskinesias v. relapse? It is clear that as studies have grown longer and more sophisticated, the gap between prognosis with and without medications has grown less dramatic. (See Table 1.)
Thomas reinvigorates an 20 year old, and under-researched, hypothesis regarding differential relapse rates. Chouinard and Jones (1980) speculated that meso-limbic system receptor supersensitivity, caused by dopamine blocking medications, could trigger relapse via a withdrawal syndrome; that is, pharmacological stress factors might cause relapse. Gilbert and colleagues' 1995 meta-analysis supported this idea in that those who are on larger doses of neuroleptics or who withdrew from them over a 2 week time course relapsed more frequently than those who were on lower doses or withdrew more gradually over 8 weeks. (This phenomenon appears to account for incidents of extreme behavior in one man in my case studies from Zanzibar.) Thomas concluded:
... no research study has seriously addressed the possibility that symptom recurrance in schizophrenia is effectively a drug withdrawal syndrome....the drug withdrawal explanation for "relapse" has been overwhelmingly neglected in the psychiatric literature...All doctors are familiar with the phenomenon of drug withdrawal syndrome, and although Chouinard's work has been in the literature for 16 years, this explanation for the link between relapse and medication has been glossed over. The implications of this are just too frightening for psychiatry to contemplate. It means that for many patients, "relapse" may be iatrogenic, a consequence of drug treatment and not an inevitable part of the disease process." (Thomas, 1997, p 120 - 121)
[For documentation of psychiatry's failure to acknowledge the shortcomings and dangers of neuroleptic medications see Sheldon Gelman's Medicating Schizophrenia: A history (1999)]
Even the most biologically oriented of psychiatrists would admit that neuroleptics do not control positive symptoms in all patients diagnosed with schizophrenia. A substantial group of patients derives no benefit at all from them. For the most part neuroleptics, even the newer and highly touted "atypical" ones, do not alter negative symptoms. To the contrary, older classical neuroleptics increase negative symptoms, may interfere with efforts at psychosocial and vocational rehabilitation, and cause movement disorders and other pathologies. Of course, mental health service consumers do not want to comply with directions to take medications, and many do not. Does all this make a case for finding new and better neuroleptics or, instead, for more investigation of approaches to treatment that an not pharmacological? With so much of schizophrenia research funded or performed by pharmaceutical companies, industry standards have evolved in favor of quantitative research models to the neglect of qualitative approaches that could take into account consumers' experiences and quality of life. Quantitative clinical trials of treatment protocols of necessity narrow their focus to a few aspects of performance or use the same gross outcome measure of re-hospitalization popularized by drug trials. Still, there is ample evidence that underscores the utility of non-pharmacological treatment.
Dixon and Lehman concluded from a meta-analysis of published studies of family interventions in schizophrenia that such treatment had positive consistent and robust effects on relapse frequency, delaying if not completely preventing relapse; and had modest effects on the patient's functional status and on the family's well being over time. The most successful programs were: 1) more than merely psychoeducational in emphasis; 2) focused on practical coping strategies, support, emotional expression and conflict resolution and 3) ongoing rather than brief. (1995, p 642-3)
Listening to first person accounts
The second version of the International Classification of Impairments, Disabilities and Handicaps (ICIDH-2) mandates attention to insider perspectives of persons with disability in health research. Meanwhile, mental health service users in the U.S. are fighting proposed new legislation in several states that would legally enforce compliance with medication orders outside the hospital under pain of revocation of release. The battle in the press over "outpatient commitment," as it is called, is being fueled with overblown claims of medication efficacy and safety and sensationalistic accounts of schizophrenic madmen off their medications committing deplorable acts of violence. (See the recovery movement web-site, www.power2U.org, and the Bazelon Law Center web-site, www.webcom.com/bazelon/opcstud.html for updates.) The disease model is being used as a cudgel against consumers who have organized around discourse that emphasizes the social aspects of their experiences over the biological. Sally Clay, in addressing the First National Forum on Recovery from Mental Illness said:
Those of us who have had the experience called "mental illness" know in our hearts that something profound is missing in these diagnoses. They do not take into account what we have actually endured. Even if the "bad" chemical or the "defective" gene is someday found, madness has its own reality that demands attention. (1994)
I am moved by John Modrow's first person account of mental illness, How to Become a Schizophrenic, in which he wrote:
I cannot think of anything more destructive of one's sense of worth as a human being than to believe that the inner core of one's being is sick--that one's thoughts, values, feelings, and beliefs are merely the meaningless symptoms of a sick mind. Undoubtedly the single most important causal factor behind my mental breakdown was a sense of worth so badly shaken that not even the most florid delusions of grandeur could save it. What the concept of "mental illness" offered me was "scientific proof" that I was utterly worthless, and would always be worthless. It was just the nature of my genes, chemistry and brain processes--something I could do nothing about. (1992, p 147)
Jay Neugeboren, called the notion of "no-fault brain diseases" absurd, argued against the "dead-end scientific materialism that would reduce [his brother] to a flawed heretical biological inheritance that somehow determines his behavior and his fate" (1997, p 302) and asked the following questions about what would become of his elder brother if some new medication suddenly medication eradicated his symptoms:
What does he do with his history? What does he do with his memories, doubts, habits, and fears? The sad truth is that who he is--his identity as Robert Neugeboren and nobody else, a human being forever in process, forever growing, changing and evolving--is made up, to this point in time, largely of what most of us have come to call his illness. And if he gives that up, as it were--if he denies that this so-called illness is central to his life and being (and if he merely fixes his symptoms instead of understanding their causes), and does not hold on to his illness and its history as a legitimate, real and unique part of his ongoing self--what of him, at fifty two years old, will be left? (1997, p 303, emphasis in the original)
Mental health professionals have embraced a neurobiological view of schizophrenia and some of us have done so because it seemed this view would eventually destigmatize the disorder, would someday make it just like diabetes. Here, Clay, Modrow and Neugeboren tell us that it is simply not so. Moreover, seeing oneself as having a "brain disease" may not facilitate recovery at all, as it did not for Modrow. Instead, resisting this view energized his recovery. Deegan also emphasized that "accepting that one has an illness is not a necessary part of the recovery process" (1998, p 2).
Of all the precepts of the recovery movement, the disjuncture between the disease model with symptom eradication via psychotropic drugs and model of recovery as a social and psychological journey, may be the most important and yet, perhaps, the most difficult for health professionals to accept. As Rhodes has observed:
Medicine, because of its bias toward the uncovering of natural facts, represents the body in ways that are powerfully suggestive of a natural reality separate from the social.... The effect, if not the intention, is to make the social invisible, and to place the sickness, as a natural process or entity, inside the individual....By placing the body and bodily experience in the realm of nature, biomedicine conceals both the social causes of sickness and the social embeddedness of the experience of sickness. (1990, p 167 - 168)
Estroff et al. (1991) examined 169 informants' own constructions of identity and ideas about illness in the face of diagnosis with a major psychiatric disorder, following each for a two year period. Participants' illness accounts and self-labels were mutable and situational, affected by social processes, such as hospitalization and inclusion or exclusion from family households. Macro-social factors, like race and gender, interacted with the social processes of psychiatric care and could facilitate acceptance of a disease label or energize resistance to it. During the initial interviews, Black men were the least likely of all groups to accept an illness label, while White men were more likely to identify with authority structures and to accept psychiatric labels more readily. Black women and White women were more similar to one another in their proportions of accepting or resisting disease labels, and in accounts of the causes of illness. Their odds of accepting a diagnostic label were intermediate between those of White and Black men. Overall, Whites of both genders made more statements that reflected belief in medical or clinical causes for their problems while Blacks used a broader range of kinds of ideas to account for their difficulties, including more social and more spiritual explanations.
Over the illness course studied, Black men typically continued to resist diagnostic labels and White men gradually distanced themselves from such labels. Over time, more White women in the study labeled themselves as mentally ill while the proportion of Black women who would accept such a label for themselves remained low but consistent at about 37%. Resistance against authority may have been part of a habitual self-preserving strategy in a hostile environment for Black men and women. Estroff noted the overrepresentation of Black male participants in the sample, referred to the well documented tendency to overdiagnose schizophrenia in minority populations and concluded that several participants were probably mis-diagnosed. (See Whaley, 1998, for insights on the adaptive utility of some behaviors labeled as symptoms.)
Estroff reported that interviews with participants of both genders and races elicited a much talk about the ways in which the participants were just like other people. Their difficulties and reactions were perceived by themselves as essentially "normal" or on a continuum with other kinds of problems experienced by other people. Estroff and colleagues drew this important lesson:
The enormous amount of normalizing talk we elicited was at times defiant, urgent, plaintive, and even whimsical. Regardless of tone, this kind of discourse was always meant to persuade us, and no doubt our informants themselves, that whether mentally ill or not, the individual was worthwhile, one of us--normal. Perhaps chronicity and disability begin when normalizing talk ends, or when the individual thinks no one is listening. One compelling challenge for anthropologists and clinicians alike is to keep the conversation going. (1991, p 363)
Taking into account international quantitative research on psychiatric treatment
One set of quantitative research findings can be seen as a serious barrier to the hegemony of neurobiological disease model of mental illness. Since 1967, the World Health Organization has completed a series of multi-national studies on the incidence and prognosis of schizophrenia involving, over time, 30 research sites in 19 countries. The conclusion of these studies again and again has been that persons diagnosed with schizophrenia in developing countries have a better prognosis for recovery and higher social functioning than do persons so diagnosed and treated in Europe and the U.S. There are many speculations as to what these finding means, presented in Table 2. Most involve the notion that meaningful work and family social roles are more available to people with schizophrenia in the third world, that task demands are lighter in simpler material cultures, or that supernatural explanations for the problem of madness exonerate the family and enhance the patient's acceptance (Table 2). Conspicuous by its absence in these speculations is the idea that something about the way Western psychiatry is practiced may produce the poorer outcomes in industrialized countries. Prominent cross-cultural psychiatrist both espouse the idea that spiritual and social explanations of mental illness support recovery from it and argue that psychiatry should help patients to understand their problems as diseases (cf. Desjarlais, Eisenberg, Good & Kleinman, 1995).
In addition a large body of research on "expressed emotion," begun in England by Brown (1962) and replicated cross-culturally for four decades, finds poorer prognosis in patients whose family environments are marked by criticism, hostility or emotional overinvolvment. Yet this research explores prognosis in a theoretically impoverished way, focused on "prediction without meaning" ns, 1991, p 393; Karno & Jenkins, 1993. Critical and hostile comments or indicators of emotional overinvolvement emanating from key relatives are counted and cut-off scores for high and low expressed emotion households are derived post-hoc.
Attention to Jenkins' cross-cultural observations of expressed emotion brings us to Figure 1, and what I attempted to do in my own research. (See also Table 3 for an inventory of my research methods and periods.)
Considering observations of after-care in East Africa
In Figure 1 the replicated quantitative findings described in ovals marked "Durable Finding" A and B are linked and explicated by the qualitative observations of Jenkins and others, presented in the center circle and in the box marked "C." Several periods of prolonged engagement with psychiatric health workers, traditional healers and identified patients and families in Zanzibar have convinced me that it is not necessary for families or others in the consumers' social-emotional surround to accept the language of disordered brains, chemical imbalances and defective genes in order to give love and support in ways that moderate prognosis. Moreover, allegiance to a disease model explanations is not necessary for compliance with after-care and even medication use, if that is the goal.
The large central box summarizes my research. There were five people diagnosed with schizophrenia among the three families I studied. (I have known one of the families since 1988.) All but one of them used mental hospital outpatient services during the period of the study. I accompanied most of their hospital visits. Most complied with taking neuroleptic medication albeit with self initiated drug holidays. While all of the patients in the study were diagnosed with schizophrenia and this was documented in their medical files, none of the families were familiar with or employed the term "schizophrenia." After care appointments were fairly cursory checks on symptoms and renewals of prescriptions. Families and patients were not introduced to disease models of mental illness. All three families had used and periodically continued to use illness explanations and remedies that were based on spirit practices or on Islamic medicine.
Two of the households were low in expressed emotion; the third was marked by high expressed emotion. Zanzibari Swahili social norms for expression and resolution of conflict valorize face saving and emotional reserve. At least two, and probably three, of the patients in the families with low expressed emotion functioned fairly well and would have been considered in WHO prognosis studies to have good outcomes. (One patient in a low expressed emotion family had suffered two cerebral vascular accidents and was very old. This made most of the WHO study dependent variables inappropriate for use in characterizing his outcome.) The third family included a caretaker half brother and ill half sister whose relationship was marked by dramatic emotional overinvolvement. This particular patient also endured quite a bit of hostility and criticism. Her brother used ideas culled from psychiatry to justify his treatment of her. When, for example, she wept in apparent frustration at his control of her, he took this as a sign of depression and sought to add anti-depressants to her medication regimen.
My observations of after-care in Zanzibar lead me to believe that socializing families into the biomedical frame for viewing their loved ones may do more harm than good (McGruder, 1999). At the bottom of Figure 1 are my three conclusions as regards after-care. Cultural notions about the nature of self, family and adversity mediate how family support is given. Biological positivism situates the problem wholly inside the individual, ignores social realities and competes with religious traditions that provide succor and meaning to families in difficulty. Poor prognosis schizophrenia and aggressively adopted disease models co-occur. Therefore, pushing disease models in after-care my be counter-therapeutic. If we want to build a whole picture of recovery from schizophrenia that takes into account data from the WHO studies, expressed emotion research and anthropological inquiry, we need more qualitative and ethnographically grounded accounts of family life when a member has schizophrenia.
Table 1. Neuroleptic medication effectiveness studies reviewed in Thomas (1997)
Johnson , 1979
Johnson et al. , 1983
Johnstone et al, 1986; Crow et al., 1986 (Northwick Park Study) [2 yr.]
70% (on placebo)
Table 2. Hypotheses advanced to explain more benign prognosis or better treatment outcomes in schizophrenia in developing countries, chronologically arranged.
Murphy and Raman (1971), 12 year follow up study in Mauritius:
cultural beliefs about mental illness may influence course and outcome
Murphy and Taumoepeau (1980) in Tonga:
task demands lighter and models for action clearer in non-industrialized places.
Cooper and Sartorius (1977), WHO researchers:
simpler material cultures, extended family structures, more situated and sociocentric conceptions of self.
Waxler (now Waxler-Morrison) (1976, 1979), Sri Lanka:
lack of expectation of chronicity and concomitant differences in labeling, large and tolerant families, beliefs that external supernatural agents caused the illness
Murphy (1982) review of literature available:
greater social group cohesion, greater attainability of typical rewards, more explicit nature of social rules,
beliefs about the cause of illness that exonerate the patient and family.
Warner (1983, 1985) meta-analysis of reports on 11,000 patients, multiple countries:
Stress resulting from unemployment explains poor prognosis in industrialized nations. Patient is fully integrated socially in non-industrialized nations because of the opportunity to do meaningful work. Consistent availability of work in agrarian subsistence economies and mode of organization of agrarian work allows the ill family member to re-enter the labor force gradually in developing world.
Corin (1990, p 184), on protective role of multiple identities negotiated via spirit possession:
"...Central African therapeutic possession rituals allow individuals to move between withdrawn and integrated positions during the course of treatment lasting for months or years, as they ground the possibility of further temporary retreats according to circumstances and personal feelings. They provide a cultural idiom that justifies and orients a close attention to inner and bodily states (where the presence of the spirit is revealed); this cultural idiom permits one to articulate and to name feelings of difference and of being marked, while at the same time rearticulating these feelings on a shared cultural space. Initiation into the ritual allows the patient to reintegrate the cultural scene while remaining somewhat different. In our societies, the differences remain trapped at the periphery and that could qualify a withdrawal process with irreversibility."
Jenkins (1991), reviewed cross cultural studies on effect of family emotional environments on patients' relapse:
In all cultures studied, familial criticism of, hostility toward and emotional overinvolvement with the patient produced more frequent relapses and more need for hospitalization. Local norms must be taken into account in ascertaining what constitutes over involvement and how to view criticism and correction as these vary across cultures. Cultural ideas about the nature and cause of mental illness may create a legitimate status for the patient that inhibits high levels of criticism and overinvolvment.
Marsella and Westermeyer (1993, p 412), based on review of available research:
"conceptions of illness that limit personal responsibility and causation, lower social rejection of the ill member, continuous family care and involvement of the ill member, greater emphasis on role performance, reduced stress, lower competency requirements, greater social and religious involvement, lower emphasis on institutionalization and custodial care, reduced substance abuse and alcoholism, and sensitivity to class and ethnic differences between patient and professional."
Table 3. Quantitative and qualitative methods that lead to conclusions at bottom of Figure 1.
I. Periods of fieldwork in East Africa
A. 11 months in 1988
1. Set up Occupational Therapy department at Kidongo Chekundu Mental Hospital, Zanzibar, Tanzania
2. Conducted 2 research projects, 1 quantitative and 1 qualitative
a. Compared 50 patients with schizophrenia and 10 non-dysfunctional subjects on occupational therapy assessments drawn from the model of human occupation, and sensory integration & occupational performance frames of reference
[Evans, J. (1992) "A Cross Cultural Test of the Validity of Occupational Therapy Assessments for Patients with Schizophrenia," American Journal of Occupational Therapy 46: 685-695.]
b. Interviewed 19 patients and two families about their uses of traditional healing. Evans, J. (1992) "Schizophrenia: Living with Madness Here and in Zanzibar" Occupational Therapy in Health Care, 8: 53-71.]
B. 1 month in 1994
1. Interviewed 6 traditional healers
2. Engaged in participant observation with 1 family with 2 members with schizophrenia.
C. 12 months, Summer 1996-Summer 1997
1. Engaged in participant observation with 3 families with 5 members with schizophrenia. Attended outpatient clinic visits with identified patients.
2. Interviewed two other patients with schizophrenia and their families.
3. Provided consultative services at the hospital and at my home.
4. Helped to organize and presided over a seminar with 20 traditional healers and hospital personnel at Micheweni Hospital in Pemba (Zanzibar) to discuss differential diagnosis of psychosis and cerebral malaria.
5. Did archival research about the colonial history of psychiatry in Zanzibar.
6. Held focus groups to discuss emotional expression and conflict resolution in Zanzibar family life.
7. Participated in the cultural life of the community
[McGruder, J. (1999) Madness in Zanzibar: "Schizophrenia" in three families in the "developing" world. Unpublished doctoral dissertation. University of Washington, Dept. of Anthropology, UMI #9924117; McGruder, J (publication pending) "Constituting the Mad Subject in Zanzibar" in Culture, Subjectivity and Schizophrenia, J. H. Jenkins & R. Barrett, eds. New York: Sage Publishing ]
D. 1 month in 2000
1. Returned to bring the 3 research families tokens of esteem and gratitude as I had completed my study.
2. Updated illness histories and genealogies of research family members.
<Figure 1 goes here>
Brown, George, E. Monck, G. Carstairs, and J. Wing. (1962). "Influence of family life on the course of schizophrenic illness." British Journal of Prevention and Social Medicine, 16 , 55-68.
Chouinard, G. & Jones, B.D. (1980). "Neuroleptic induced supersensitivity psychosis: clinical and pharmacological characteristics." American Journal of Psychiatry, 137, 413-420.
Clay, S. (1994) The Wounded Prophet. Paper presented at the First National Forum on Recovery from Mental Illness, National Institute of Mental Health and Ohio Department of Mental Health. April 1994. Unpublished mansucript.
Deegan, P.E. (1998) "Some principles and themes of the recovery process." Handout from the National Empowerment Center, Inc. Lawrence MA. http://www.power2u.org
Desjarlais, R., Eisenberg, L., Good, B., Kleinman, A. (1995). World Mental Health New York: Oxford University Press
Dixon, L.B. & Lehman, A.F. (1995) "Family interventions for schizophrenia." Schizophrenia Bulletin, 21 (4), 631-643.
Evans, J. (1992a). "A cross cultural test of the validity of occupational therapy assessments for patients with schizophrenia." American Journal of Occupational Therapy, 48, 685-695.
Evans, J. (1992b) "Schizophrenia: Living with madness here and in Zanzibar." Occupational Therapy in Health Care, 8, 53-71.
Estroff, S.E. with Lachicotte, W.S., Illingworth L.C., & Johnston, A. (1991). "Everybody's got a little mental illness: Accounts of illness and self among people with severe , persistant, mental illness." Medical Anthropology Quarterly, 5, 331-369.
Gelman, S. (1999). Medicating schizophrenia: A history. New Brunswick, New Jersey: Rutgers University Press.
Gilbert, P.L., Harris, J., McAdams, L.A. and Jeste, D.V. (1995). "Neuroleptic withdrawal in schizophrenic patients: a review of the literature." Archives of General Psychiatry, 52, 173-188.
International Classification of Impairments, Disabilities, and Handicaps. (1980, 1993). Geneva, WHO.
Jenkins, J.H. (1991) "Anthropology, expressed emotion and schizophrenia." Ethos, 19, 387-431.
Karno, M., and J.H. Jenkins. (1993). "Cross-cultural issues in the course and treatment of schizophrenia." Psychiatric Clinics of North America ,16, 339-350.
McGruder, J. (1999). Madness in Zanzibar: "Schizophrenia" in three families in the "developing" world. Unpublished doctoral dissertation, University of Washington, Department of Anthropology.
Modrow, J. (1992). How To Become a Schizophrenic: The Case Against Biological Psychiatry. Everett, Washington: Apollyon Press.
Neugeboren, J. (1997). Imagining Robert: my brother, madness and survival. New York: Henry Holt.
Rhodes, L. A. (1990). Studying biomedicine as a cultural system. In Johnson & Sargent (Eds.), Medical Anthropology, (pp. 160-173). New York: Praeger.
Sauna, V. (1991). "The etiology of schizophrenia as perceived by psychiatrists in Europe and the United States." Current Psychology, 9 (4), 355-362.
Thomas, P. (1997). The Dialectics of Schizophrenia. New York: Free Association Books. Waxler, N.E. (1979). "Is Outcome for Schizophrenia Better in Nonindustrialized Societies? The Case of Sri Lanka." Journal of Nervous and Mental Diseases, 167, 144-158.
Whaley, A. L. (1998). "Cross-Cultural Perspective on Paranoia: A focus on the Black
American experience." Psychiatric Quarterly, 69(4), 325-343.
Wyatt, R.J. (1991) "Neuroleptics and the natural course of schizophrenia." Schizophrenia Bulletin, 17(2), 325-351.