552 CHAPTER 12
In Case 12.3, notice that, although the women had odd and prodromal behaviors in
Haiti, her full-blown symptoms did not emerge until she immigrated to the United States.
Also notice that these symptoms could have emerged when she got older, even if she had
stayed in Haiti. As compelling as single cases can be, full–scale studies—with adequate
controls—must play a central role in helping us understand psychological disorders.Economic Factors
Another social factor associated with schizophrenia is socioeconomic status: A dis-
proportionately large number of people with schizophrenia live in urban areas and
among lower economic classes (Hudson, 2005; Mortensen et al., 1999). As discussed
in Chapter 2, researchers have offered two possible explanations for this associa-
tion between the disorder and economic status: social selection and social causa-
tion (Dauncey et al., 1993). The social selection hypothesis proposes that those who
are mentally ill “drift” to a lower socioeconomic level because of their impairments
(and hence social selection is sometimes called social drift). Most vulnerable to so-
cial selection would be those whose illness prevents them from working or those
who do not have—or do not make use of—family members who can care for them
(Dohrenwend et al., 1992). Consider a young woman who grows up in a middle-
class family and moves to a distant city after college, and where, after she graduates,
she supports herself reasonably well working full time. She subsequently develops
schizophrenia, but refuses to return home to her family, who cannot afford to send
her much money. Her income now consists primarily of meager checks from gov-
ernmental programs—barely enough to cover food and housing in a poor section of
town where rent is cheapest. She has drifted from the middle class to a lower class.
Another explanation is social causation: The daily stressors of urban life, espe-
cially for the poor, trigger mental illness in those who are vulnerable (Freeman, 1994;
Hudson, 2005). Social causation would explain cases of schizophrenia in people who
grew up in a lower social class. The stressors these people experience include poverty
or fi nancial insecurity, as well as and living in neighborhoods with higher crime rates.
In a study designed to investigate the infl uence of social selection versus social
causation, researchers in Ireland examined the relationship between social class at
birth and later schizophrenia. These researchers found no differences in the rates
of schizophrenia among the children of those in different social classes in Ireland
(Mulvany et al., 2001). If social causation were at work, there should be more cases
of schizophrenia among children born into lower social classes.
However, the data on this issue are not clear-cut. A similar study that included a
more ethnically diverse sample in Israel found a higher rate of schizophrenia among
those born into a lower social class, as would be predicted by social causation (Wer-
ner, Malaspina, & Rabinowitz, 2007). Note, however, that the social causation hy-
pothesis focuses solely on social class. It does not address ethnicity or race, and so
does not take into account the stressful effects of discrimination that arise for non-
White immigrants.Cultural Factors: Recovery in Different Countries
Although the prevalence of schizophrenia is remarkably similar across countries
and cultures, the same cannot be said about recovery rates. Some studies report that
people in developing countries have higher recovery rates than do people in industri-
alized countries (American Psychiatric Association, 2000; Kulhara & Chakrabarti,
2001), although this was not found in all earlier studies (Edgerton & Cohen, 1994;
von Zerssen et al., 1990).
What accounts for this cultural difference? The important distinction may not
be the level of industrial and technological development of a country, but how in-
dividualist its culture is. Individualist cultures stress values of individual autonomy
and independence. In contrast, collectivist cultures emphasize the needs of the group,
group cohesion, and interdependence. People with schizophrenia in collectivist cul-
tures, such as those of Japan, Hong Kong, and Singapore, have a more favorable
course and prognosis than people with schizophrenia in individualist cultures such as
that of the United States (Lee et al., 1991; Ogawa et al., 1987; Tsoi & Wong, 1991).Social selection
The hypothesis that those who are mentally
ill “drift” to a lower socioeconomic level
because of their impairments.
Social causation
The hypothesis that the daily stressors of
urban life, especially as experienced by
people in a lower socioeconomic level, trigger
mental illness in those who are vulnerable.