Keywords

1 Introduction

After the collapse of communist rule in 1989, democratic changes occurred in Bulgaria. These involved renewal not only of freedom of speech but also of freedom of movement of people to other European countries. Over one million people left the country either permanently or as temporary workforce resulting in the greatest demographic collapse in Bulgarian history. Initially those who left the country were proud to taste freedom and live the western dream. At that time, few thought about the difficulties with cross-cultural adaptation and the price they would have to pay…

We report the case of a young Bulgarian woman, who lived and worked in Germany for 10 years before she presented with symptoms of brief psychotic disorder . Her story is based on that of a real person but with her name and other biographical details changed to protect confidentiality. It illustrates the possible contribution of cultural values interacting with her premorbid personality and experiences of expatriation as risk factors in the etiology of the condition.

2 Alice’s Story

At the time of her emergency admission to an inpatient psychiatric facility in Cologne, Germany, Alice (not her real name) was a 29-year-old single Bulgarian woman with no prior psychiatric history. Her family and general medical history were unremarkable and she had no unhealthy lifestyle habits other than smoking about 5 cigarettes a day. Although she was born with signs of perinatal asphyxia, Alice reached all major developmental milestones as expected.

Alice was brought up in a family with a dominant, authoritarian father and a passive, submissive mother. She went to a German language school in Bulgaria from which she graduated with top marks. She was also a keen basketball player. Ten years prior to her admission Alice moved to Germany and obtained a master’s degree in finance while working in a number of part-time jobs. After she finished her studies she worked simultaneously as a stock analyst and a private tutor. A year and a half before the admission she started work as an event organizer for a catering company because she could not find a job in her field of competence. At that time she enjoyed a good standard of living. Her family described Alice as “active, enterprising and independent.”

About a week prior to her admission Alice became increasingly tense and irritable. According to her housemate she worked more than 12 h a day and hardly got any sleep. On the morning of the admission she became visibly agitated and emotionally unstable and confided that she had sensations of electricity passing through her body. She felt that she could connect with her colleagues through this electricity. When an ambulance was called she became aggressive, threw apples at the medical staff and bit her housemate’s arm. At the hospital she was diagnosed with brief psychotic disorder with marked stressors. She was treated with Perphenazine 4 mg t.i.d. and discharged in 6 days with a marked reduction of psychotic symptoms.

After the discharge Alice went back to her family in Plovdiv, Bulgaria. She adhered to treatment for about 10 days after which she discontinued the medication because she could not obtain a timely resupply. In a matter of days she grew tense and verbally aggressive to her family. She insisted her mother helped her “chase away the Devil.” She left her home, switched off her mobile phone and went to the city’s ancient amphitheater where she scattered her belongings and stuck advertising stickers on the stones. She talked about Bulgarian traditions, ancient rituals and attributed symbolic meanings to current events. She was admitted to the university psychiatric clinic in Plovdiv where laboratory work-up and a CT brain scan showed no clinically significant findings. The patient was treated with Olanzapine 10 mg q.d., consequently tapered to 5 mg q.d. due to sedation. The psychotic symptoms resolved relatively quickly and the patient was discharged calm, free of psychotic symptoms and with good insight.

In view of the importance of personality disorders in brief psychotic disorder upon resolution of psychotic symptoms the patient was referred for psychological assessment and testing. Schmieschek’s personality accentuation test showed signs of accentuation of the demonstrative and pedantic type, a tendency for accentuation of the suspicious and emotive type, and a significant accentuation of the hyperthymic and anxious and fearful type. Psychological exploration identified the patient’s habitually excessive level of activity as a coping mechanism to deal with negative thoughts and feelings. A strong drive for independence coexisted with a low level of emotional differentiation. The patient returned to her premorbid level of functioning but refused to go back to Germany.

However, her father thought Alice must work and prosper in Germany. He himself had dreamt of a good life in Germany during his youth and had tried to escape from Bulgaria to Germany via Yugoslavia but was detained and arrested. The dream should be realized at any cost. He refused to recognize that Alice had really been ill and was convinced “it was just too much stress; she is a brave girl and will make it.”At her father’s insistence Alice went back to Germany and tried to begin work there. Despite strict medication adherence, every time she started a new job, her condition worsened with depressed mood, ideas of reference and vague persecutory ideation associated with her superiors and colleagues. A year later she moved home to Sofia, Bulgaria and started a job as a financial auditor. She continued her treatment with Olanzapine 5 mg q.d. for a year. Three years ago she was tapered off her medication by her psychiatrist and has had no mental health problems since.

3 Discussion

Brief Psychotic Disorder is a transient, sometimes recurrent, psychotic disorder in which symptoms persist for at least 1 day and resolve in less than a month with a return to the former level of functioning [1]. The condition is uncommon, typically occurs in adolescence or young adulthood and is twice as frequent in women as in men. In the majority of cases, brief psychotic disorder is precipitated by marked stressors that overwhelm the individual’s coping skills. Thus, both acute and chronic stress , underdeveloped social skills, isolation and lack of social support may increase the risk for brief psychotic disorder . According to the DSM-5, the presence of a personality disorder is also a recognized risk factor [1].

Traveling and living abroad have long been recognized as risk factors for psychotic disorders. In view of the established association between stress and brief psychotic disorder , it is not surprising the disorder has often been described in relation to travel stress. It is hypothesized that the isolation of long-distance travel, jet lag, alcohol and substance misuse, and insomnia may contribute to its occurrence in some cases [2]. In Alice’s story, however, it seems that a key factor was the interaction between her premorbid personality and the particular constellation of cultural and other values associated with her expatriation.

4 The Values Impacting on This Story

The principal value held by Alice throughout the story is work. She always attached excessive importance to her job and regarded it as a primary source of self-satisfaction. Her excessive preoccupation with work in the week prior to her first hospital admission can be seen as a futile attempt to respond to chronic stress and feelings of low self-esteem and dissatisfaction with her job. Her desire for independence was hindered by lack of emotional differentiation, fearful avoidance of social contacts, and excessive anxiety in professional interactions. This may explain her inability to return to her level of functioning in the year after her psychotic episode when she tried to live and work in Germany. Arguably, she lacked the personality resources and coping skills to live, work, and manage the chronic stress of acculturation in a foreign country. The return to Bulgaria allowed for a return to premorbid interpersonal and occupational functioning. So, another value that arose for Alice in the aftermath of the brief psychotic disorder was security. The patient needed a more stable and predictable environment in order to function professionally and interpersonally.

Crucial also to Alice’s story was the value her father placed on living the Western dream . He discounted his daughter’s illness and put additional pressure on her “to make it” in Germany. His value was at conflict with her need for security resulting in relapses of her condition.

5 The Cultural Influences on Alice’s Story

Interacting with the values operative in a given case, cultural and personality factors may be important from an etiological perspective. Travel often entails an encounter with a new culture that necessitates adjustment to different customs, lifestyle, and languages. Acculturation is particularly essential when traveling for a long period (such as during expatriation or migration). Cultural change can cause persistent distress in some individuals—this has been termed “culture shock ” [3]. It is important to recognize that acculturation is more stressful when as in the case of Alice the expatriate lacks sufficient social support from friends and family [4].

It is also notable that her psychotic episode developed after a significant overburden in a job for which she was clearly overqualified. Occupational dissatisfaction and lack of opportunities for long-term professional development were arguably a major source of chronic stress for a person who had invested significant time and effort in her education and career abroad. Not surprisingly, some of the delusional themes during the psychotic episode that also resurfaced during the first year of follow-up involved persecutory ideation and delusions of influence associated with her colleagues and superiors. Alice’s return to Bulgaria was marked by a culture-specific shift of delusional content to themes of indigenous traditions and ancient rituals.

Differences in cultural practices and values between Bulgarian society and those of other European countries revealed in a recent comparative [5] study may be relevant to Alice’s story. The study established a distinctive profile of Bulgaria’s societal culture in terms of practices and value orientations and compared these data to EU (European Union) average scores. Three cultural factors identified in the study stand out as being of potential relevance to Alice’s story, “uncertainty avoidance,” “performance orientation,” and “assertiveness.” We will look briefly at these before coming to our conclusions.

Uncertainty avoidance is the degree to which members of society try to avoid uncertainty by relying on social norms, rituals, or bureaucratic practices. In the above study, Bulgarian society scored much lower on practices and much higher on values of “uncertainty avoidance.” This is understandable. In comparison to the EU average, Bulgarian society in the post-communist era is a society of transformation and its members have learned to accept uncertainty as its inherent characteristic. However, they have developed a preference for order and discipline as a way of dealing with the chaos and ambiguities in their new social, political, and economic life. Arguably, security, the second value that became important in Alice’s story overlaps to a substantial degree with uncertainty avoidance. Alice needed a stable and predictable environment to remain symptom-free.

The next two factors, performance orientation and assertiveness, may be considered together in their impact on Alice’s story. Performance orientation reflects the extent to which a society encourages or rewards group members for innovation, high standards, excellence, and performance improvement. The Bulgarian behaviors score in the study on performance orientation was lower than the average EU score due to a communist era heritage of planned economy. Assertiveness is the extent to which individuals in a society are assertive, provocative, or aggressive in their social relationships. In the study, the Bulgarian score on assertiveness was lower than the average EU countries’ score on practices, maybe due to family bonds, favoritism, friendliness, and kindness, all deeply rooted in Orthodox traditions.

It may be speculated that the company with which Alice ended up working in Sofia (when she remained symptom-free) scored as in the study lower on practices of performance orientation and assertiveness than the companies in which she worked in Germany. On a practical level, this would mean that she experienced in Sofia an informal, subtle, and non-judgmental style of communication in the workplace and an emphasis on cooperation, people and relationships, equality, solidarity, tradition, and experience. Any or all of these factors may have contributed positively to Alice’s sustained recovery once she returned home. If so, the possibility that as cultural values they may have wider significance as protective factors against the development of mental disorders would be worth further investigation.

6 Conclusions

A number of factors appear to have contributed to the emergence, development, and resolution of Alice’s condition. Expatriation, insufficient support from friends and family, occupational dissatisfaction, and lack of prospects for professional development escalated into a brief psychotic disorder in a young woman whose preoccupation with her job led her to work for more than 12 h a day hardly getting any sleep at all. Preoccupation with work determined the delusional content of her psychotic disorder while living in Germany, comprising mainly persecutory ideation associated with her superiors and colleagues. Interestingly, a return to Bulgaria saw a dramatic shift in the content of her delusions, now mainly concerning religious themes, ancient rituals, and local traditions. Her need for security was at odds with her father’s insistence that she should return to Germany and make a success of her career. Alice’s low levels of emotional differentiation, avoidance of social contact, and excessive anxiety in professional interactions were responsible for the consequent paranoid and depressive exacerbations of her disorder. With a final return to Sophia, Bulgaria’s capital, Alice was able to find a job that corresponded with her qualifications and she has subsequently remained symptom and medication free.

The findings of a recent comparative study of the cultural values and practices of Bulgaria and other EU countries may be relevant to understanding Alice’s story. Compared with other EU countries, including Germany, Bulgaria scored higher on values of uncertainty avoidance and lower on those of performance orientation and assertiveness. These cultural values, operating in Alice’s final work environment back in Sophia, are likely to have contributed positively to her recovery. It may well be that they have wider significance as protective factors for individuals at risk of mental disorder.