Elsevier

Comprehensive Psychiatry

Volume 52, Issue 3, May–June 2011, Pages 319-325
Comprehensive Psychiatry

Culture and the prevalence of hallucinations in schizophrenia

https://doi.org/10.1016/j.comppsych.2010.06.008Get rights and content

Abstract

Objective

Besides demographic, clinical, familial, and biographical factors, culture and ethnicity may plausibly influence the manifestation of hallucinations. The purpose of this study was to investigate the influence of culture on the frequency of different kinds of hallucinations in schizophrenia.

Method

Patients with a clinical diagnosis of schizophrenia were diagnosed by means of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria. Seven independent samples were consecutively recruited in Austria, Lithuania, Poland, Georgia, Ghana, Nigeria, and Pakistan using identical inclusion/exclusion criteria and assessment procedures (N = 1080 patients total). The association of key demographic factors (sex and age), clinical factors (age at onset and duration of illness), and country of origin with hallucinations of different kinds was examined.

Results

The prevalence of various kinds of hallucinations was substantially different in the samples; however, the rank order of their occurrence was similar. Auditory hallucinations were relatively infrequent in Austria and Georgia and more prevalent in patients with an early age at onset of disease. Visual hallucinations were more frequently reported by the West African patients compared with subjects from the other 5 countries. Cenesthetic hallucinations were most prevalent in Ghana and in patients with a long duration of illness.

Conclusion

We hypothesize that the prevalence of the different kinds of hallucinations in schizophrenia is the result of the interaction of a variety of factors like cultural patterns as well as clinical parameters. According to our study, culture seems to play a decisive role and should be taken into account to a greater extent in considerations concerning the pathogenesis of psychotic symptoms.

Introduction

Hallucinations are common phenomena in traditional as well as in modern societies. However, prevalence and notions concerning etiology, course, and the need for treatment differ to a large extent [1]. Whereas non-Western cultures often attribute altered states of perception like hallucinations to possession by spirits or to an attempt to establish a contact to spirits, modern Western societies regard these phenomena as symptoms of mental illness. Some of them, the auditory first-rank hallucinations, are seen as pathognomic for schizophrenia.

In Europe, the first large investigations on the frequency of hallucinations in the general population and in mentally ill people were carried out in the 19th century by Griesinger [2] and Parish [3]. During the following decades, numerous studies on the epidemiology of hallucinations in schizophrenia were carried out (Table 1).

Despite divergent numbers, a stable pattern is recognizable: In all study sites, auditory hallucinations were the most common ones, followed by visual and cenesthetic hallucinations, whereas tactile, olfactory, and gustatory hallucinations were reported rather infrequently.

The early cultural-comparative investigations on psychotic symptoms in schizophrenia focused more on delusions than on hallucinations. One reason for this preference might be the fact that delusionally impaired beliefs are easier to evaluate than impaired perceptions. The first cross-cultural surveys on the frequency of different kinds of hallucinations were carried out in the 1960s by Murphy et al [22]. The researchers sent out questionnaires to psychiatric centers all over the world to gain information about the local distribution of psychotic features. The results showed clear evidence of a relationship between culture and the prevalence of different types of hallucinations. Visual as well as tactile hallucinations occurred most frequently in patients from Africa and the Near East, a finding that was confirmed by Ndetei and Vadher [19] 20 years later. The authors carried out a cross-cultural study in patients with schizophrenia from different ethnic groups admitted to a London mental hospital. They found higher frequencies for both auditory as well as visual hallucinations in non-European patients compared with English and Continental Europeans (Table 1). To differentiate the influence of the culture of origin from the influence of the environment of the second home, Suhail and Cochrane [23] compared 3 groups of patients: (1) Pakistani patients living in Pakistan, (2) Pakistani migrants living in Great Britain, and (3) patients of white British origin. Compared with both British groups, patients living in Pakistan reported a higher rate of visual hallucinations interpreted as visions of spirits or ghosts. In contrast, auditory hallucinations were substantially less frequent in the Pakistani group. These data suggest that the influence of the immediate environment on the phenomenology of hallucinations is more important than the influence of culture of origin. This interpretation was supported by Wang et al [24], who found that migrants hear voices not only in their first language, but also in their second or third ones depending on the delusional content.

Reviewing the literature we found differing, partly controversial theoretical positions and inconclusive empirical evidence concerning hallucinations in different cultures. Van Dusen [25] interpreted hallucinations as phenomena that transcend cultures and remain stable over time. In contrast, Kiev [26] claimed that culture has pathoplastic effects at least on the content of hallucinations. Even the question of whether or not hallucinations are pathognomic for mental illness in general or may occur under certain conditions also in healthy people is still under discussion [27]. One reason for these debates is the lack of a valid definition of hallucinations generally accepted in all cultures [28], [29]. Especially cultural-comparative studies are difficult to evaluate because most authors did not explicate their concept of hallucinations (Table 2).

So one task before carrying out cross-cultural–comparative survey is to properly define the term hallucinations used for the study. A second methodological problem why transcultural investigations on hallucinations are difficult to compare are the different periods of time under study. Some authors refer to point prevalence rates and others to 1-year or even to lifetime prevalence rates; some did not report the time at all (Table 2). Most studies conducted so far are retrospective and based on case reports [11], [17], [23].

Taking into account these methodical problems, the aim of our study was to investigate (a) the relationship between culture and the 1-year prevalence of different kinds of hallucinations in patients suffering from schizophrenia born and living in 1 of 7 different countries and (b) the frequency in which different kinds of hallucinations occurred during the last year.

Section snippets

Definitions

One can distinguish a dimensional and a categorical approach to define hallucinations [28], [31]. Although the dimensional approach avoids the strict definition of the term hallucinations, the problem to find a clear cutoff point to distinguish between normal perceptions or physiologic phenomena like hypnagogic states and hallucinations remains unsolved. But without a cutoff point, the term hallucination is losing any semantic as well as nosological significance. For this reason, we decided to

One-year prevalence of hallucinations

In the total sample, auditory hallucinations yielded the highest 1-year prevalence (74.8%), followed by visual hallucinations (39.1%); cenesthetic hallucinations (28.9%); and tactile, olfactory, and gustatory hallucinations (1.3%-6.6%). Significant differences in the distribution of hallucinations were found for all modalities (Table 4, Fig. 1). Auditory hallucinations were most prevalent in all sites (between 66.9% and 90.8%). The highest rates were found in both West African countries (Ghana:

Discussion

This study had the aim to explore the 1-year prevalence and the frequency of different kinds of hallucinations in a sample of patients suffering from schizophrenia from 7 different cultures (Table 3). The uneven sex distribution in the local sites may have varying reasons like (a) effectively existing culture-specific variations in the sex prevalence of schizophrenia and (b) some study sides included facilities selectively treating only men or only women. This was for example the case in

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