King Edward Medical University

Lahore – Pakistan

Page 1 of 6
Research Article Proposal:
Comparing Schizophrenic Severity Between Patients in
Rural and Urban Areas of Pakistan
Zoyah Imran Khan, et al.
LGS 55 Main, Gulberg, Lahore.

Page 2 of 6
ABSTRACT:
Background: Schizophrenia is a highly prevalent mental disorder, affecting up to 1% of the
population. Due to factors such as differences in the level of interpersonal sensitivity, shifting
societal norms and social acceptance levels, there is a sizable difference between the severity of
schizophrenia in rural and urban areas.
Objectives: This study aims to quantify the contrast between the severity of schizophrenia
between rural and urban locations in Pakistan, and to identify potential risk/exacerbating factors.
Methods: A total of 100 participants from 3 rural and 3 urban cities in Pakistan will be studied.
A questionnaire BPRS scale will be used to determine the level of schizophrenia in each patient.
The study will be conducted over 3 months with 3 sessions per month and data collected through
the questionnaire will be analysed and inputted into graphs to compare results between the two
populations.

INTRODUCTION:
Schizophrenia is a highly prevalent mental disorder, affecting up to 1% of the world’s
population. It can be best described as a behavioural psychotic disorder, with symptoms ranging
from avolition and lack of motivation to persistent delusions and hallucinations. Due to factors
such as differences in the level of interpersonal sensitivity, shifting societal norms and social
acceptance levels, there is a sizable difference between the severity of schizophrenia in rural and
urban areas. Urban areas may be defined as areas with high population density and developed
infrastructure, and a rural area is one with low population density, small settlements, and are
geographically isolated. This study aims to quantify this contrast between the two populations,
and to identify potential risk/exacerbating factors. Studying the relationship between the urban-
rural divide, in this case, is particularly important, as insights into its reasoning is an effective
method of studying the causes of schizophrenia, and by studying the causes one contributes
towards finding a more successful solution to the disorder. The rationale behind the topic of the
paper is that this divide has not been explored at all in Pakistan, and with it being a lower-middle
income country, the socioeconomic divide between the rural and urban populations is massive,
hinting at a highly positive correlation between dopamine levels and schizophrenic severity.
Pakistan also has recently been experiencing a boom in schizophrenic cases, and it has a very
high rate of the disorder occurring when compared to the world average.[1] This only supports
the argument that this study is of the utmost importance. The results of this study are highly
generalised, as the locations chosen are from a variety of provinces, all with their own cultures
and social structures. The sample includes an equal number of males and females with ages
ranging from 23-45.

Hypothesis: The participants in the rural areas are predicted to have higher levels of
schizophrenia.

Page 3 of 6
METHODS:
The study will be conducted as cohort research as the participants will be those patients who
have been living in either rural or urban areas and have been diagnosed with schizophrenia. The
study will take place in a laboratory environment, such as clinics in Lahore, Quetta and Karachi,
which are urban areas and clinics in small villages such as Raikot in Gilgit Baltistan, Kathri in
Sindh and Khawaspur in Punjab. Researchers will have control over all variables and can
experiment without any extraneous or confounding variables. The research will be a longitudinal
study which will take place over 3 months with 3 sessions per month. The sample will consist of
100 patients who have been diagnosed with schizophrenia; out of those, 50 will be from rural
areas and 50 from urban areas. The sample will also have an equal number of males and females
in each group and the ages will range from 23 to 45. An independent measures design will be
used in which there will be 2 groups, rural and urban. Volunteer sampling will be used as
participants will sign up for the experiment through advertisement posters in the clinics. Only
participants who have been diagnosed from the respective clinics will be included in the study
and those who were self-diagnosed or diagnosed through other clinics will not be included to
increase the validity of the study. The researcher will have the patients come into the clinic thrice
a month for 3 months during which patients will be taken to a separate room with an
observer/psychiatrist where they will be sat down at a table and will be given a questionnaire, the
Brief Psychiatric Rating Scale (BPRS) on a piece of paper which will assess the level of
schizophrenia the patient has through 18 questions with answer options ranging on a scale from 1
(not present) to 7 (extremely severe)[2]. The time taken to complete the test will be 20 to 30
minutes. The researcher will then collect the data and analyse the quantitative data collected by
finding the mean for each question and then comparing that between the answers from different
regions. The findings will be imputed into a spreadsheet on Microsoft Excel where they will be
converted into bar graphs in which the region will be on the x-axis and the mean answers will be
on the y-axis.

DISCUSSION:
Previous studies have shown that schizophrenic patients have an excess of dopamine receptors in
certain parts of their brain which cause an increase in mesolimbic activity, which results in their
symptoms, which are related to whether participants live in rural or urban areas. Those from
cities showed an increased response in brain regions which are involved in processes such as
reward processing and regulating stress and emotions, these regions include the amygdala,
orbitofrontal, and pregenual anterior cingulate cortex [3]. This shows that urban environments
affect the mesolimbic dopamine system and limbic system which may increase the risk of
developing mental disorders such as schizophrenia. By conducting our experiment, we can find a
relationship between the environment a participant is living in, such as the level of interpersonal
sensitivity they have, and find a way to develop further studies on the disorder, especially in rural
areas of Pakistan as no prior studies have been carried out there. This will help us to gain a better
understanding of how exposure to changes in society is important to reduce interpersonal
sensitivity levels and reduce chances of schizophrenia as a traditionally conservative country like
Pakistan’s rural areas have little exposure to global change and trends which leads to a high level
of interpersonal sensitivity and therefore higher chances of severe schizophrenia and so in the

Page 4 of 6
future research and therapy can be conducted in these areas to reduce chances of
schizophrenia[4].

REFERENCES:
1. Gadit A.A. Psychiatry in Pakistan: 1947-2006: a new balance sheet. J. Pakistan Med.
Assoc. 2007;57:453–463
2. BELL, MORRIS Ph.D.; MILSTEIN, ROBERT M.D., Ph.D.; BEAM-GOULET, JOSEPH M.S.;
LYSAKER, PAUL Ph.D.; CICCHETTI, DOMENIC Ph.D. The Positive and Negative Syndrome
Scale and the Brief Psychiatric Rating Scale - Reliability, Comparability, and Predictive
Validity The Journal of Nervous and Mental Disease 180(11):p 723-728, November 1992.
3. Bernd Krämer, Esther K. Diekhof and Oliver Gruber. Effects of city living on the
mesolimbic reward system FMRI study. Hum Brain Mapp. 2017 Jul; 38(7): 3444–3453.
4. Solmi, F; Dykxhoorn, J; Kirkbride, J; Urban-Rural Differences in Major Mental Health
Conditions. UCL Discovery, published online 2017

Page 5 of 6
DATA COLLECTION INSTRUMENT:
The BPRS test:

Page 6 of 6