Cross-cultural differences in indicators of improvement from psychosis: the case of betel nut chewing.
This paper uses a case from the Micronesian Island of Yap to illustrate that indicators of improvement from an episode of schizophrenic psychosis can vary tremendously from culture to culture. At times, the clinician must search diligently for such indicators since the patient will not verbalize any perception of improvement. A 39-year-old Yapese woman was evaluated by a psychiatrist and was found to have been psychotic for several years, suffering from gross delusions, and auditory hallucinations, flattened affect, and social isolation. In addition, she had discontinued chewing betel nut that was used daily by virtually all of her fellow islanders on Yap. Two months after beginning treatment with twice monthly injectable antipsychotic medication she was still delusional, with flat affect, and heard the same voices. She was slightly less socially withdrawn and she had interestingly resumed chewing betel nut. It seemed that she had given up betel nut chewing during the socially withdrawn phase of her illness and had resumed it as she improved and became less autistically preoccupied. In her culture, betel chewing was a main avenue of social intercourse and an intrinsic part of almost all social activities. In her particular case, the resumption of betel chewing was a primary indicator of her improvement from psychosis and reintegration into her social group.