Schizophrenia and Other Psychotic Disorders 551
more attempts by their family members to try to minimize the psychotic, disorga-
nized, or negative symptoms. And then these behaviors lead the family to be classifi ed
as high in EE. This explanation may apply, in part, to the Genain family: Among the
four sisters, Hester’s symptoms were the most chronic and debilitating. She received
the most physical punishment, including being whipped and having her head dunked
in water, often in response to behaviors that her father wanted her to stop.
Researchers have also discovered ethnic differences in how patients perceivecritical and intrusive family behaviors. Among black American families, for instance,
behaviors by family members that focus on problem solving are associated with a
better outcome for the schizophrenic individual, perhaps because the behavior is in-
terpreted as refl ecting caring and concern (Rosenfarb, Bellack, & Aziz, 2006). Thus,
what is important is not the family behavior in and of itself, but how such behavior
is perceived and interpreted by family members.
Immigration
A well-replicated fi nding is that schizophrenia is more common among immigrants,
compared both to people who stayed in the immigrants’ original country and to
people who are natives in the immigrants’ adopted country (Cantor-Graae & Selten,
2005; Lundberg et al., 2007). This higher rate of schizophrenia among immigrants
occurs among people who have left a wide range of countries and among people
who fi nd new homes in a range of European countries. In fact, one meta-analysis
found that being an immigrant was the second largest risk factor for schizophrenia,
after a family history of this disorder (Cantor-Graae & Selten, 2005). Both fi rst-
generation immigrants—that is, those who left their native country and moved to
another country—and their children have relatively high rates of schizophrenia; this
is especially true for immigrants and their children who have darker skin color than
the natives of the adopted country, which is consistent with the role of social stres-
sors (discrimination in particular) in schizophrenia (Selten, Cantor-Graae, & Kahn,
2007). For instance, the increased rate of schizophrenia among African-Caribbean
immigrants to Britain (compared to British and Caribbean residents who are not
immigrants) may arise from the stresses of immigration, socioeconomic disadvan-
tage, and racism (Jarvis, 1998). Researchers have sought to rule out potential con-
founds such as illness or nutrition, but have yet to fi nd such an explanation for the
higher risk of schizophrenia among immigrants. Case 12.3 describes the symptoms
of schizophrenia in an immigrant from Haiti to the United States.
P SNP SNSchizophrenia occurs more frequently among
immigrants (and their children) than among
people who live in their native country. The
various stresses of the immigration process,
including fi nancial problems and discrimination,
are thought to account, at least in part, for this
increased risk. The people in this photo are begin-
ning the process of becoming legal immigrants.Spencer Platt/Getty ImagesCASE 12.3 • FROM THE OUTSIDE: Schizophrenia
Within a year after immigrating to the United States, a 21-year-old Haitian woman was referred
to a psychiatrist by her schoolteacher because of hallucinations and withdrawn behavior. The
patient was fl uent in English, although her fi rst language was Creole. Her history revealed that
she had seen an ear, nose, and throat specialist in Haiti after her family doctor could not fi nd
any medical pathology other than a mild sinus infection. No hearing problems were noted
and no treatment was offered. Examination revealed extensive auditory hallucinations, fl at
affect, and peculiar delusional references to voodoo. The psychiatrist wondered if symptoms
of hearing voices and references to voodoo could be explained by her Haitian background,
although the negative symptoms seem unrelated. As a result, he consulted with a Creole-
speaking, Haitian psychiatrist.
The Haitian psychiatrist interviewed the patient in English, French, and Creole. Communi-
cation was not a problem in any language. He discovered that in Haiti, the patient was con-
sidered “odd” by both peers and family, as she frequently talked to herself and did not work
or participate in school activities. He felt that culture may have infl uenced the content of her
hallucinations and delusions (i.e., references to voodoo) but that the bizarre content of the
delusions, extensive hallucinations, and associated negative symptoms were consistent with
the diagnosis of schizophrenia.
(Takeshita, 1997, pp. 124–125)