Cultural differences of experiencing hallucinations (0)

Cultural differences of experiencing hallucinations  Introduction  In this literature review I am going to examine the cultural differences of hallucinations. I chose  this topic because I had briefly heard that such differences exist but had not researched further so  this was a perfect opportunity to satisfy my curiosity. I had heard that in India, hallucinations are  mostly experienced as benign or even helpful like the embodiment of a wise ancestor, whereas in  western culture hallucinations are mainly experienced as malicious and threatening. This seems  interesting because malicious hallucinations seem to me to be one of the worst symptoms of  schizophrenia and if there is a possibility of making hallucinations easier to cope with without  the use of antipsychotics then that seems like a possibility worth investigating. Antipsychotics  are necessary for many patients but they also have many side effects and using them less would  be preferable. Most of the literature focuses on schizophrenia and auditory hallucinations but  other reasons for hallucinating and types of hallucinations are also included.    Discussion  One finding about cultural differences of hallucinations has to do with the rate of different  hallucinations in certain disorders. Bauer et al. (2011) studied seven independent samples of  schizophrenia patients from Austria, Lithuania, Poland, Georgia, Ghana, Nigeria, and Pakistan  using identical inclusion/exclusion criteria and assessment procedures (N = 1080 patients total)  and found that though the rank of different hallucinations were the same (auditory being most  common etc.) the rates themselves varied significantly. Auditory hallucinations were relatively  infrequent in Austria and Georgia, visual hallucinations were more frequently reported by the  West African patients compared with subjects from the other 5 countries and cenesthetic  hallucinations were most prevalent in Ghana. They concluded that culture should be considered  more in the pathogenesis of psychotic symptoms because besides different clinical parameters,  cultural patterns also play a large role in schizophrenia. More interesting though in my opinion  was a previous finding by Thomas et al. (2007) which eliminated the diagnostic differences by  using DSM IV criteria and identical inclusion/exclusion for 1287 clinically diagnosed  patients  with schizophrenia or schizoaffective disorder (807 Indian and 480 US participants). Similarly to  Bauer et al. the rank order of different modalities of hallucinations remained the same but the 


overall prevalence differed. The main goal for Thomas et al. however, was to find whether the  cultural difference would be relevant to the known factors that influence the manifestations of  hallucinations. They found that the influence patterns did differ which is to say that the risk  factors may be the same overall, but the relevance of those risk factors differ significantly. To me  this seems to indicate that the known risk factors that correlate with the manifestation of  hallucinations are also correlated to some smaller life experiences that have a more causal role  but are not identified and are more correlated to the known factors in some cultures than others.   Most interesting to me however was the content of hallucinations. Luhrmann, Padmavati,  Tharoor and A. Osei (2014) conducted in depth interviews with 60 patients with auditory  hallucinations and clinically diagnosed with schizophrenia or schizoaffective disorder form San  Matteo California USA, Chennai India and Accra Ghana (20 from each) and asked about their  voices. Although all groups had both good and bad experiences and each group had some  participants that had predominately bad experiences there was a very big overall difference in  their experiences and even more so in their attitudes towards the voices. The US participants  described the voices as bombardment and symptoms of brain disease, readily using psychiatric  terms and diagnostic labels. Fourteen of them described voices that told them to hurt other  people or themselves and five of them described the experience as a battle or war. None of them  reported predominantly positive experiences though half of them reported some positive  dimensions. Five reported hearing God two hearing family members and few described a  personal relationship with the voices. Of the Indian participants, only three used diagnostic labels  and only four described their voices telling them to hurt someone. Contrary to US participants,  they usually had a personal relationship with the voices and fourteen of them heard the voices of  people close to them, which behaved as relatives do - giving guidance but also scolding. Nine  participants also described the voices as having physical experiences such as vomiting when they  had sex or being in pain for their actions. Nine persons described their voices as significantly  good though only five were judged to have a predominantly good experience. Nine heard spirits  talking and six audibly heard God. One quirk was that 13 participants reported distress from  hearing the voices talking about sex. Several people seemed to experience their main voice as  playful which none did from the other groups. Accra participants mostly thought of the voices as  spirits though many understood that hearing voices could be a sign of psychiatric illness. Only  two used diagnostic labels. Only two described their voices as asking them to hurt someone, 


though six who did not had been hospitalized because of violence. Only four said they did not  know who talked to them and they had predominantly bad experiences. All the rest (16) said they  heard God speak audibly. Ten of them described the experience as predominantly good. Though  it took some time for many of them to admit hearing bad voices too. The most common theme  was that the God voice told them to ignore the other voices and even though they were often loud  and annoying the participants felt that the God voice is more powerful and therefore the bad  voices don’t bother them much. Also they mostly described a relationship with even the bad  voices – talked to them as people not as intrusive noise. The authors were quite convinced that  most of the difference can be attributed to the difference in the way these cultures define the  “self” – in US it is about being separate and in India and Ghana it is about relationships with  others. Though Ghana and India samples differed too, they were quite similar in the sense that  the participants had relationships with their voices and it seems that this makes them experience  the voices in a more positive manner. Larøi et al. (2019) noted in a review article that negative  voice-content in auditory hallucinations is the best predictor of distress from the hallucinations  and observed that negative interactions between voices and their hearers further drive negative  content. In my opinion this may be the underlying cause of the cultural difference – in India and  Ghana the people hearing voices strive to have good relationships with the voices and this  reduces the amount of negative interactions and therefore negative content.   Attributing auditory hallucinations to “someone” seems to be quite prevalent in non-Western  cultures. Lim et al. (2018) examined the attribution of hallucinatory voices to jinn by Muslim  patients in a transcultural psychiatric outpatient clinic. Of the 118 eligible participants 49 were  interviewed and 43% of them were positive that their psychiatric symptoms were caused by a  jinn and many who did not participate expressed fear of metaphysical repercussions if they spoke  about jinn. Unfortunately I did not find relevant research about the hallucination content and  whether it is mostly good or bad but since they also seem to attribute some agency to the voices  and try to have a relationship with them (since they are reluctant to talk about them if it might  anger them), I hypothesize that their experiences would also be more positive than in Western  cultures.   Another example of attributing the voices to spirits comes from a quite intriguing case of a  young Maori man who received joint Maori healing and psychiatric assessment (NiaNia, Bush & 


Epston, 2019). Jake (the patient) had recently had an incident where he harmed himself  impulsively and although he did not have other significant symptoms, he frequently heard  voices.  I will give my own short take since the article had viewpoints form all the participants.  First the Maori healer asked who Jake lives with. The Maori healer then said that he feels three  distinct entities, described some of them and Jake indicated a corner of the room and the healer  confirmed that this is one of the entities. He also noted that the entity is related to one of the  occupants of the house and asked Jake to take care around that person. The healer then indicated  to both sides of Jake and said that there are two of his ancestor’s spirits and Jake confirmed that  he knew them. The healer said that the two ancestors are there protecting Jake from the third  spirit and advised that even though the “evil” spirit is not there for Jake he should take care of  himself spiritually. Jake himself said that the two spirits were often there – sometimes offering  reassurance but other times correcting him, such as telling him “Don’t have that extra drink”  which he said could be irritating at times. Jake noted that the healing process made him feel less  crazy since his own experiences matched with the healer’s. He remained healthy six years later.  The conclusion was that the importance of cultural experiences should be considered when  making psychiatric assessments. I am unsure what to make of this article – I am tempted to think  that this was all somehow part of a setup, but the motivations for such a thing seem unclear. It  does seem possible that Jake was manifesting some of his culture as hallucinations and in this  regard, it seems appropriate that the hallucinations are reframed in a positive manner by someone  who knows this cultural background. Lifshitz, Elk & Luhrmann (n.d.) have hypothesized that  hearing God speak could be a skill that can be practiced and if this is true then culture would  play a very large role in manifesting benign auditory hallucinations. This is also supported by  Fortier and Proust in “Metacognitive Diversity: An Interdisciplinary Approach” where they tie  this to a gradual switch from a top-down pattern of connectivity defining imagination to a more  bottom-up pattern defining perception (Dentico et al., 2014) which basically leads to the  metacognitive perception that God is actually speaking to them. It is important to note though  that the hallucinations induced by this process do not cause psychiatric disorders by themselves  and should be considered separate from them. I think this sort of cultural intervention as  described by NiaNia, Bush & Epston (2019) could and even should be used in cases where  problems seem to come from hallucinations induced by this metacognitive switch but I am less  sure about this sort of involvement in actual clinical processes, though I suspend my disbelief.  


Conclusion  Culture has a large role in many aspects of hallucinations. The prevalence of different modalities  of hallucinations in clinical patients as well as the factors correlated to their emergence differ  across cultures. The content of hallucinations is highly culture related and psychiatric patients  from cultures with more focus on inter-personal relationships seem to have more positive  auditory hallucinations, possibly because they have less negative interactions with the voices.  Hallucinations may also be induced by a switch in metacognitive perception in the right  circumstances and in this case it may be beneficial to use culture specific approaches to dealing  with problems if the person hallucinating does not have a disorder.     References    Bauer, S. M., Schanda, H., Karakula, H., Olajossy-Hilkesberger, L., Rudaleviciene, P.,  Okribelashvili, N., Chaudhry, H. R., Idemudia, S. E., Gscheider, S., Ritter, K., & Stompe, T.  (2011). Culture and the prevalence of hallucinations in schizophrenia. Comprehensive  Psychiatry, 52(3), 319–325. https://doi.org/10.1016/j.comppsych.2010.06.008    Dentico, D., Cheung, B. L., Chang, J.-Y., Guokas, J., Boly, M., Tononi, G., & Van Veen, B.  (2014). Reversal of cortical information flow during visual imagery as compared to visual  perception. NeuroImage, 100, 237–243. https://doi.org/10.1016/j.neuroimage.2014.05.081    Larøi, F., Thomas, N., Aleman, A., Fernyhough, C., Wilkinson, S., Deamer, F., & McCarthy- Jones, S. (2019). The ice in voices: Understanding negative content in auditory-verbal  hallucinations. Clinical Psychology Review, 1.   


Lifshitz, M., van Elk, M., & Luhrmann, T. M. (n.d.). Absorption and spiritual experience: A  review of evidence and potential mechanisms. CONSCIOUSNESS AND COGNITION, 73.  https://doi.org/10.1016/j.concog.2019.05.008    Lim, A., Hoek, H. W., Ghane, S., Deen, M., & Blom, J. D. (n.d.). The attribution of Mental  health Problems to Jinn: an explorative study in a Transcultural Psychiatric Outpatient  clinic. FRONTIERS IN PSYCHIATRY, 9. https://doi.org/10.3389/fpsyt.2018.00089    Luhrmann, T. M., Padmavati, R., Tharoor, H., & Osei, A. (2015). Differences in voice-hearing  experiences of people with psychosis in the USA, India and Ghana: interview-based  study. BRITISH JOURNAL OF PSYCHIATRY, 1, 41.    NiaNia, W. ( 1 ), Bush, A. ( 2 ), & Epston, D. ( 3 ). (n.d.). He korowai o ngā tīpuna: Voice  hearing and communication from ancestors. Australasian Psychiatry, 27(4), 345–347.  https://doi.org/10.1177/1039856219833792    Thomas, P., Mathur, P., Gottesman, I., Nagpal, R., Nimgaonkar, V., & Deshpande, S. (2007).  Correlates of hallucinations in schizophrenia: A cross‐cultural evaluation. Schizophrenia  Research, 92(1-3), 41–49. doi: 10.1016/j.schres.2007.01.017