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Culture and the Prevalence of Hallucinations in Schizophrenia

Article  in  Comprehensive psychiatry · May 2011

DOI: 10.1016/j.comppsych.2010.06.008 · Source: PubMed

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Comprehensive Psychiatry xx (2010) xxx – xxx

www.elsevier.com/locate/comppsych

Culture and the prevalence of hallucinations in schizophrenia

Susanne M. Bauera,b,⁎, Hans Schandab , Hanna Karakulac , Luiza Olajossy-Hilkesbergera,b ,
Palmira Rudaleviciened , Nino Okribelashvilie , Haroon R. Chaudhryf , Sunday E. Idemudiag ,
Sharon Gscheiderh , Kristina Ritteri , Thomas Stompeb,j
a
Division of Biological Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria
b
High Security Hospital Göllersdorf, Austria
c
Department of Psychiatry, Medical Academy of Lublin, Poland
d
Vilnius Mental Health Center and Mykolas Romeris University, Vilnius, Lithuania
e
Asatiani Medical Center, Tiflis, Georgia
f
Fountain House Lahore, Pakistan
g
Department of Psychology, University of Ibadan, Nigeria
h
Department of Psychology, University of Innsbruck, Austria
i
Neurological Centre Rosenhügel, Vienna, Austria
j
Division of Social Psychiatry, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Austria

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.
© 2010 Elsevier Inc. All rights reserved.

1. Introduction hallucinations to possession by spirits or to an attempt to

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
⁎ Corresponding author. Tel.: +43 1 40400 3547.
E-mail address: susanne.m.bauer@meduniwien.ac.at (S.M. Bauer).
0010-440X/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.comppsych.2010.06.008
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 schizophre-
nia were carried out (Table 1).
2 S.M. Bauer et al. / Comprehensive Psychiatry xx (2010) xxx–xxx

Table 1
Epidemiology of hallucinations in schizophrenia
Author Year Country Diagnosis Kinds of hallucinations
Auditory Visual Cenesthetic Tactile Olfactory Gustatory
Bowman and Raymond [4] 1931 US Schizophrenia, male 50% 18% 3% 1% 2% 0.3%
Schizophrenia, female 56% 24% 4% 1.6% 3% 1%
Arnold [5] 1949 – Schizophrenia 78% 14%
Malitz et al [6] 1962 GB Schizophrenia 50% 9% 2%
Peretz et al [7] 1964 – Schizophrenia 40%-50%
Small et al [8] 1966 – Schizophrenia 66% 30% 42% 38%
Jansson [9] 1968 – Schizophrenia 50%
Conolly and Gittleson [10] 1971 – Schizophrenia 39% 31%
McCabe et al [11] 1972 – Schizophrenia, good prognosis 52% 50% 36%
Schizophrenia, bad prognosis 36% 12% 14%
Eggers [12] 1973 Germany Schizophrenia in children 71.9% 43.9% 29.8% 12.3% 8.8%
Young [13] 1974 – Schizophrenia 18%
Zarroug [14] 1975 Saudi Arabia Schizophrenia 68% 62%
Ciompi and Müller [15] 1976 Germany Schizophrenia, first assessment 70.9% 28.4% 22.5% 5.9% 16.3%
Schizophrenia, follow-up 44.6% 8.7% 11.1% 1.7% 6.2%
Huber et al [16] 1979 Germany Schizophrenia, 2 rank hall. 74.9% 33.3% 73.2% 13.2% 11.0%
Schizophrenia, 1 rank hall. 39.5%
Ndetei and Singh [17] 1983 Kenya Schizophrenia 43% 43%
Ihezue and 1984 Nigeria Schizophrenia 68%
Kumaraswamy [18]
Ndetei and Vadher [19] 1984 English Schizophrenia 44% 15% 3%
African 88% 33% 6%
Jamaican 70% 37% 5%
Continental Europe 33% 17% 0%
Asian 69% 31% 0%
Caribbean 59% 24% 12%
Winokur et al [20] 1985 Switzerland Schizophrenia 78% 32%
Mueser et al [21] 1990 USA white and Schizophrenia 71% 16% 15% 11% 3%
black Schizoaffective 21% 7% 7%

Despite divergent numbers, a stable pattern is recogniz-
able: In all study sites, auditory hallucinations were the most
common ones, followed by visual and cenesthetic hallucina-
tions, whereas tactile, olfactory, and gustatory hallucinations
were reported rather infrequently.
The early cultural-comparative investigations on psy-
chotic 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 phenome-
nology 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 empir-
ical 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
 S.M. Bauer et al. / Comprehensive Psychiatry xx (2010) xxx–xxx
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–compar-
ative 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.
2. Material and methods
2.1. 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 hal-
lucination is losing any semantic as well as nosological
significance. For this reason, we decided to use a categorical
approach. Starting from the distinction between (a) “true”
perceptual experiences and “false” perceptions in general,
we followed a (b) conceptual discrimination between
different types of false perceptions.
(a) Any perceptual experience has phenomenal character.
But it is not true by definition that every perceptual
experience has an object in the external world: hallucinatory
and other disturbed experiences like illusions count as
Table 2
Information to the definition of hallucinations and to the period of investigation in cultural-comparative studies on the prevalence of hallucinations in
schizophrenia
Author Year
Murphy et al [22] 1963
Ihezue and Kumaraswamy [18] 1984
Ndetei and Vadher [19] 1984
Mueser et al [21] 1990
Lindal et al [27] 1994
Kent and Wahass [30] 1996
Suhail and Cochrane [23] 2002
3
perceptual experiences, too. Perceptual experiences can be
veridical or falsidical: they can represent the world correctly
or incorrectly. Perceptual illusions and hallucinations are
falsidical, whereas normal perceptual experiences of objects
in the external world are veridical [32].
(b) In his General Psychopathology, Jaspers distin-
guished 4 types of “false perceptions”: pareidolias, illusions,
pseudohallucinations, and true hallucinations. He defined
hallucinations as actual false perceptions that are not in any
way distortions of real perceptions but spring up on their
own as something quite new and occur simultaneously with
and alongside real perceptions [33]. This distinction is
important because illusions and pseudohallucinations are
nosologically unspecific and occur in patients suffering from
personality disorder as well as from affective psychosis,
whereas “true” hallucinations are much more pathognomic
for functional and organic psychoses [34]. Concerning the
use of rating scales or standardized interviews, one has to
keep in mind that the lack of clear definitions may lead to an
overestimation of the prevalence of hallucinations in
traditional cultures. Following Spitzer, we distinguished
true hallucinations and pseudohallucinations by defining
hallucinations as a deficit symptom. A hallucinating person
is not able to integrate a perception into his or her experience
because of affective-cognitive deficits in chronic psychotic
illness or overwhelming affects in acute psychosis [28]. This
phenomenological definition of hallucinations corresponds
with the etiologic theory that schizophrenia arises from
reductions in connectivity between brain regions as a result
of development disturbances during synaptogenesis [35-37].
In contrast, pseudohallucinations are close to subjects' usual
conscious imaginations and fantasies.
2.2. Subjects
The population under study consisted of 1080 patients
with schizophrenia according to the Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edition
[38] from 7 countries, consecutively recruited between the
years 1996 and 2001: 350 patients from Austria, 80 from
Poland, 73 from Lithuania, 74 patients from Georgia, 103
from Pakistan, 324 from Nigeria, and 76 from Ghana
(Table 3). Mean age was 32 years (range, 18-62 years).
Subjects with organic brain disorders or severe infections as
Method Definition of hallucination Explicit prevalence
Interview No information No information
Case report study No information 6-mo prevalence
Case report study No information No information
Interview No information No information
Interview No information No information
Interview No information No information
Case report study No information No information
4 S.M. Bauer et al. / Comprehensive Psychiatry xx (2010) xxx–xxx

Table 3
Demographic and clinical data of the study sample (N total = 1080)
Male Female Age Age at onset Duration of illness Acute course Chronic course
Austria (n = 350) 258 (73.7%) 92 (26.3%) 33.0 ± 10.0 22.3 ± 6.4 10.6 ± 9.1 78 (22.3%) 272 (77.7%)
Poland (n = 80) 59 (73.7%) 21 (26.3%) 31.1 ± 7.2 22.5 ± 6.4 8.5 ± 6.0 5 (6.2%) 75 (93.8%)
Lithuania (n = 73) 33 (45.2%) 40 (54.8%) 35.3 ± 13.1 23.2 ± 6.1 12.1 ± 10.5 6 (8.2%) 67 (91.8%)
Georgia (n = 74) 25 (32.9%) 51 (67.1%) 37.2 ± 10.9 24.4 ± 5.5 12.8 ± 10.5 29 (39.2%) 37 (48.7%)
Pakistan (n = 103) 65 (63.1%) 38 (36.9%) 32.8 ± 9.6 25.2 ± 7.0 7.7 ± 6.4 17 (16.5%) 86 (83.5%)
Nigeria (n = 324) 198 (61.1%) 126 (38.9%) 30.8 ± 10.9 25.1 ± 8.3 6.3 ± 7.5 209 (64.5%) 115 (35.5%)
Ghana (n = 76) 39 (51.3%) 37 (48.7%) 33.8 ± 9.9 25.9 ± 7.5 7.9 ± 6.6 39 (51.3%) 37 (48.7%)

well as patients with affective disorders or substance-
induced disorders were excluded. All patients were under
antipsychotic medication.
2.3. Instruments
Written informed consent was taken from the patient or an
adult relative in case a patient was considered unable to sign.
Diagnosis was derived by Structured Clinical Interview for
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition Axis I Disorders interviews, supplemented
by case reports and collateral information [39]. The local
interviewers were experienced psychiatrists or clinical psy-
chologists who completed a part of their training in the United
States, the United Kingdom, or Austria. As a second
instrument for the assessment of psychotic symptoms, the
“Fragebogen zur Erfassung psychotischer Symptome” was
applied. The instrument and its psychometric properties had
already been described [38,40,41]. The “Fragebogen zur
Erfassung psychotischer Symptome” was developed for cross-
cultural comparison studies on psychotic symptoms in
schizophrenia in 1994. The instrument includes 3 chapters
on (a) delusions, (b) hallucinations, and (c) Schneider first-
rank symptoms. The instrument was translated, retranslated,
and tested for interrater reliability at the single sites as well as
cross-sectionally, yielding a Cohen α for interrater reliability
for the different kinds of hallucinations between 0.75 and 0.98.
2.4. Statistical analysis
The cultural differences of the prevalence of the various
kinds of hallucinations were analyzed using χ2 test (with
continuity correction when appropriate). Because of the
unequal sample sizes, Fisher exact test (2-tailed) was used,
too. The influence of culture and demographic and clinical
variable (countries of origin, sex, age, age at onset of illness,
duration of illness) on the 1-year prevalence of the different
kinds of hallucinations was analyzed by means of logistic
regression analysis. The mean prevalence of the different
kinds of hallucinations during the last year was compared by
Kruskal-Wallis 1-way analysis of variance. Analyses were
carried out by means of the Statistical Package for the Social
Sciences (version 14.0; SPSS, Chicago, IL) for Windows.
3. Results
3.1. 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 halluci-
nations 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: 90.8%; Nigeria:
85.4%); the lowest rate was in Austria (66.9%). The
prevalence of visual hallucinations in the developing
countries was inhomogeneous. Whereas visual hallucina-
tions were most frequently reported in West African patients
(Nigeria: 50.8%, Ghana: 53.9%), the prevalence for
Pakistani patients was only 3.9%. In contrast to many
other studies, visual hallucinations were prevalent not only in
the West African samples but also in European patients: 37%

Table 4
One-year prevalence (in percentage) of hallucinations in Austria, Poland, Lithuania, Georgia, Pakistan, Nigeria, and Ghana (N total = 1080)
Austria Poland Lithuania Georgia Pakistan Nigeria Ghana P
(n = 350) (n = 80) (n = 73) (n = 74) (n = 103) (n = 324) (n = 76)
†
Auditory 66.9% 83.3% 82.2% 71.6% 72.8% 85.4% 90.8%
†
Visual 39.1% 45.0% 37.0% 9.5% 3.9% 50.8% 53.9%
Cenesthetic 36.3% 28.8% 31.5% 20.3% 23.3% 18.8% 18.7% *
Tactile 5.1% 7.5% 11.0% 8.1% 2.9% 10.6% 6.6% NS
Olfactory 8.6% 10.0% 12.3% 6.8% – 8.3% 6.6% *
Gustatory 3.7% 8.8% 13.7% 8.1% – 8.3% 6.6% *
NS indicates not significant.
χ2 test: *P b .01 and †P b .001.
 S.M. Bauer et al. / Comprehensive Psychiatry xx (2010) xxx–xxx 5

80 75.3 75.4 in all 7 countries in nearly the same frequency (from 2.2 ±
70 0.3 in Austria to 2.8 ± 0.6 in Ghana), whereas Africans
60 reported statistically significant higher mean frequencies of
visual hallucinations during the last year before interview.
50
No significant differences were found for the remaining
40
kinds of perception.
}
35.1
32.2 31.4 32
30

20

10 8.4
5.4
7.2 7.2 8.2
6.3
4. Discussion
0
auditory visual cenesthetic tactile olfactory gustatory This study had the aim to explore the 1-year prevalence
acute chronic
and the frequency of different kinds of hallucinations in a
sample of patients suffering from schizophrenia from 7
Fig. 1. Course and 1-year prevalence (in percentage) of hallucinations in
different cultures (Table 3). The uneven sex distribution in
Austria, Poland, Lithuania, Georgia, Pakistan, Nigeria, and Ghana (N total =
1080). 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
of the Lithuanian, 39% of the Austrian, and 45% of the selectively treating only men or only women. This was for
Polish patients reported visual hallucinations at any time example the case in Austria, where we included a hospital for
during the last year (Table 4). male mentally ill offenders. In addition, the data may point at
Cenesthetic hallucinations were most prevalent in Ghana, (c) a sex-specific utilization of mental hospitals in different
followed by the European countries and Pakistan. No cultures. However, as our statistical analyses of the
statistically significant differences were found for tactile prevalence of hallucinations did not reveal significant sex
hallucinations. Olfactory and gustatory hallucinations were differences, we can postulate that the main results of the total
frequently reported in the European countries and, with the are not biased by the local sex distribution, too.
exception of Nigeria, relatively rarely in the non-European We tried to avoid the main methodological shortcomings
societies. Controlling for demographic (age, sex) and clinical of previous cultural-comparative studies like the lack of
(age at onset of illness, duration of illness factors) factors, we definition of hallucinations and unclear time interval under
found that patients living in Austria or Georgia show study. Illusions and pseudohallucinations lack any pathog-
significantly lower rates of auditory hallucinations (Table 5). nomic significance for psychoses in general and for
Patients with an earlier age at onset of illness more often schizophrenia in particular, occurring also in patients
reported auditory hallucinations; patients of West African diagnosed with dissociative disorders [42] as well as
origins more often reported visual hallucinations. In personality disorders [34] and probably also in healthy
addition, younger patients more often reported visual subjects depending on their cultural attitudes toward health
hallucinations. Cenesthetic hallucinations are more prevalent and illness. To definitely exclude these phenomena, we used
after a long course of illness and in patients living in Ghana a restrictive definition of hallucination [28].
or Austria (Table 5). Auditory and visual hallucinations as so called distant-
Table 6 shows the mean frequency of hallucinations perceiving hallucinations had the highest 1-year prevalence
during the last year. Auditory hallucinations were perceived followed by tactile, olfactory, and gustatory hallucinations
in a comparable distribution within the sample (Table 4). In
line with Murphy et al [22], auditory hallucinations were
Table 5
The impact of cultural, demographic, and clinical variables on the
most prevalent in all countries. Interestingly, we found a
prevalence of different kinds of hallucinations quite high percentage of visual hallucinations of partici-
Kinds of Dependent Odds-ratio 95% CI Significance
pants from European countries compared with other
hallucinations variable investigators (compare Table 1). However, the highest
rates of visual hallucinations were reported in the West
Auditory Austria 0.33 0.22-0.50 .000
hallucinations Georgia 0.44 0.23-0.78 .006 African countries. This is in line with a large body of
Age at onset 0.97 0.94-1.00 .028 literature showing that visual hallucinations are reported
of illness frequently in traditional cultures [22,23,29]. Whereas in
Visual Ghana 1.87 1.13-3.09 .015 European and Pakistani patients visual hallucinations occur
hallucinations Nigeria 1.64 1.02-2.64 .028
only several times during a year, in Nigeria as well as in
Age 0.98 0.97-1.00 .035
Cenesthetic Ghana 2.67 1.57-4.50 .000 Ghana, these experiences occur much more often (Table 6).
hallucinations Duration 1.02 1.01-1.04 .009 Independent of the country of origin, the age of the patient
of illness has a certain influence on the 1-year prevalence of visual
Austria 1.61 1.12-2.31 .010 hallucinations. Younger patients more often reported this
Logistic regression, forward method. type of hallucinatory perception.
6 S.M. Bauer et al. / Comprehensive Psychiatry xx (2010) xxx–xxx

Table 6
Frequency of the occurrence of hallucinations during the last year in Austria, Poland, Lithuania, Georgia, Pakistan, Nigeria, and Ghana (N total = 1080)
Austria Poland Lithuania Georgia Pakistan Nigeria Ghana P
(n = 350) (n = 80) (n = 73) (n = 74) (n = 103) (n = 324) (n = 76)
Auditory 2.2 ± 0.3 2.5 ± 0.6 2.4 ± 0.6 2.3 ± 0.6 2.4 ± 0.7 2.6 ± 0.5 2.8 ± 0.6 NS
Visual 1.2 ± 0.8 1.3 ± 0.9 1.2 ± 0.9 1.0 ± 0.9 1.1 ± 0.5 2.5 ± 1.3 2.3 ± 1.5 **
Cenesthetic 1.8 ± 0.6 1.7 ± 0.6 1.8 ± 0.7 1.9 ± 0.8 1.8 ± 0.6 1.6 ± 0.5 1.7 ± 0.8 NS
Tactile 1.4 ± 0.9 1.2 ± 1.0 1.4 ± 0.7 1.2 ± 0.6 1.1 ± 0.8 1.5 ± 0.9 1.6 ± 0.8 NS
Olfactory 1.2 ± 1.0 1.3 ± 0.9 1.4 ± 1.0 1.2 ± 0.9 – 1.4 ± 0.8 1.3 ± 0.7 NS
Gustatory 1.2 ± 1.1 1.2 ± 0.9 1.3 ± 1.0 1.1 ± 1.0 – 1.5 ± 0.9 1.4 ± 1.0 NS
1 = 1 to 5 times during the last year, 2 = 6 to 10 times during the last year, 3 = more than 10 times during the last year.
Kruskal-Wallis 1-way analysis of variance: **P b .001.

The higher prevalence of visual hallucinations in patients
with schizophrenia from non-Western societies may be
explained physiologically. In these cultures, somatic or
nutritive agents may have a higher pathogenetic impact than
in Western societies where emotional stress is held responsible
for the outbreak of the illness. [1] Compared with schizo-
phrenic disorders, the higher prevalence of visual hallucina-
tions could be ascribed to psychotic derailments associated
with organic conditions that are more often associated with
visual hallucinations. However, all patients included in our
study were somatically examined accurately to avoid this bias.
Therefore, we hypothesize that the variety of the
prevalence of visual hallucinations in terms of cultural
differences of the cognitive styles is the result of cultural
differences in perceptual and attentional processing between
European Americans (who are Westerners) and East Asians
[43]. Specifically, Westerners seem to be inclined to pay
more attention to salient objects than to contextual back-
ground, whereas East Asians seem to attend more to relations
and contexts than to salient objects [44,45]. First results of
neuroimaging studies suggest that there might be cultural
differences even in the way brain regions are engaged during
perception processing pointing at culture-sensitive neural
substrates of human cognition [46]. Similar considerations
concern the level of abstraction in single cultures. It is not
unreasonable to suggest that the prevalence of visual
hallucinations in non-Western patients may be relevant to a
general orientation toward the perceptual (concrete) rather
than the conceptual (abstract) aspect of the environment [47].
The difference between Nigeria and Ghana concerning
the 1-year prevalence of cenesthetic hallucinations was
unexpected. This fact may be related to the high prevalence
of hypochondriac delusions we found in Ghana in a previous
study [48]. Hypochondriac delusions were strongly associ-
ated with cenesthetic hallucinations [49].
Compared with auditory, visual, and cenesthetic halluci-
nations, tactile, olfactory, and gustatory hallucinations were
relatively infrequent. Like cenesthetic hallucinations, the
other hallucinatory experiences of the direct contact senses
are closely related to certain delusional contents: gustatory
and olfactory hallucinations are usually associated with
delusions of being poisoned, tactile hallucinations with
delusional parasitosis, or certain types of delusions of
persecution, like impairment by x-rays [49].
In this study, we were able to show that culture has a
decisive impact on the prevalence of the kinds of
hallucinatory experiences. However, there are also other
factors like age, age at onset, and duration of illness that
influence the rates of hallucinations.
Although we have tried to avoid some methodological
problems of previous cross-cultural comparative investiga-
tions, our study too is subject to the inherent limitations of
any survey-based data. Although the sample is quit large, it is
impossible to control for all factors that might influence the
prevalence of hallucinations in schizophrenia.
All patients were under antipsychotic medication. This fact
may cause another limitation insofar as we recently do not
know whether there exists something like a culture-bound
medical response of the phenomenology of psychotic illnesses.
Further studies in other societies are necessary to establish
a consistent theory concerning the impact of culture on the
frequency and shape of hallucinations in schizophrenia.
References
[1] Al-Issa I. The illusion of reality or the reality of illusion, hallucinations
and culture. Br J Psychiatry 1995;166:368-73.
[2] Griesinger W. Pathologie und Therapie der psychischen Krankheiten,
5. Braunschweig: Aufl., Verlag von Friedrich Wreden; 1892.
[3] Parish E. Die Trugwahrnehmung. Leipzig: Verlag von Ambr. Abel;
1894.
[4] Bowman KM, Raymond AF. A statistical study of hallucinations in the
manic-depressive psychoses. Am J Psychiatry 1931;11:299-309.
[5] Arnold OH. Die symptomgesetzliche Stellung der schizophrenen
akustischen Halluzinationen. Z Nervenheilkunde 1949;2:528.
[6] Malitz S, Wilkens B, Esecover H. A comparison of drug-induced
hallucinations with those seen in spontaneously occurring psychosis. In:
West LJ, editor. Hallucinations. New York: Grune & Stratton; 1962.
[7] Peretz D, Alpert M, Friedhoff AJ. Prognostic factors in the evaluation
of therapy, in evaluation of psychiatric treatment. In: Hoch P, Zubin J,
editors. New York: Grune & Stratton; 1964.
[8] Small IF, Small JG, Andersen JM. Clinical characteristics of
hallucinations of schizophrenia. Dis Nerv System 1966;27:349-53.
[9] Jansson B. The prognostic significance of various types of hallucina-
tions in young people. Acta Psychiatr Scand 1968;44:401-9.
[10] Conolly FH, Gittleson NL. The relationship between delusions of
sexual change and olfactory and gustatory hallucinations in schizo-
phrenia. Br J Psychiatry 1971;119:443-4.
[11] McCabe MS, Fowler RC, Cadoretr J, Winokur G. Symptom differences
in schizophrenia with good and poor prognosis. Am J Psychiatry
1972;128:1239-43.
 S.M. Bauer et al. / Comprehensive Psychiatry xx (2010) xxx–xxx
[12] Eggers C. Verlaufsweisen kindlicher und präpubertärer Schizophre-
nien. Berlin: Springer; 1973.
[13] Young BG. A phenomenological comparison of LSD and schizophre-
nia. Br J Psychiatry 1974;124:64-74.
[14] Zarroug EA. The frequency of visual hallucinations in schizophrenic
patients in Saudi Arabia. Br J Psychiatry 1975;127:553-5.
[15] Ciompi L, Müller C. Lebensweg und Alter der Schizophrenen. Berlin:
Springer; 1976.
[16] Huber G, Gross G, Schüttler R. Schizophrenie. Eine verlaufs- und
sozialpsychiatrische Langzeitstudie. Berlin: Springer; 1979.
[17] Ndetei DM, Singh A. Schneider's first rank symptoms of schizophre-
nia in Kenyan patients. Acta Psychiatr Scand 1983;67:148-53.
[18] Ihezue UH, Kumaraswamy N. A psychosocial study of Igbo
schizophrenic patients treated at Nigerian psychiatric hospital. Acta
Psychiatr Scand 1984;70:310-5.
[19] Ndetei DM, Vadher A. A comparative cross-cultural study of the
frequencies of hallucinations in schizophrenia. Acta Psychiatr Scand
1984;70:545-9.
[20] WInokur G, Scharfetter C, Angst J. The diagnostic value in assessing
mood congruence in delusions and hallucinations and their relationship
to the affective state. Eur Arch Psychiatry Neurol Sci 1985;234:
299-302.
[21] Mueser KT, Bellack AS, Brady EU. Hallucinations in schizophrenia.
Acta Psychiatr Scand 1990;82:26-9.
[22] Murphy HB, Wittkower ED, Fried J, Ellenberger HA. Cross-cultural
survey of schizophrenic symptomatology. Int J Soc Psychiatry
1963;10:237-49.
[23] Suhail K, Cochrane R. Effect of culture and environment on the
phenomenology of delusions and hallucinations. Int J Soc Psychiatry
2002;48:126-38.
[24] Wang JH, Morales O, Hsu LKG. Auditory hallucinations in bilingual
immigrants. J Nerv Ment Dis 1998;186:501-3.
[25] Van Dusen W. Hallucinations as a world of spirits. Psychedelic Rev
1970;11:60-9.
[26] Kiev A. Transcultural psychiatry. New York: Free Press; 1972.
[27] Lindal E, Stefansson G, Stefansson SB. The qualitative difference of
visions and visual hallucinations: a comparison of a general-population
sample and clinical sample. Compr Psychiatry 1994;35:405-8.
[28] Spitzer M. Halluzinationen. Berlin: Springer; 1988.
[29] Pfeiffer WM. Transkulturelle Psychiatrie. New York: Thieme, Stuttgart;
1994.
[30] Kent G, Wahass S. The content and characteristics of auditory
hallucinations in Saudi Arabia and the UK: a cross-cultural
comparison. Acta Psychiatr Scand 1996;94:433-7.
[31] Chen E, Berrios GE. Recognition of hallucinations: a new multidi-
mensional model and methodology. Psychopathology 1996;29:54-63.
View publication stats
7
[32] Chalmers DJ. Perception and the fall from Eden. In: Gendler T,
Hawthorne J, editors. Perceptual experience. Oxford: Oxford Univer-
sity Press; 2006.
[33] Jaspers K. General psychopathology, vol. 1. Baltimore: John Hopkins
University Press; 1997.
[34] Sedman G. A comparative study of pseudohallucinations, imagery and
true hallucinations. Br J Psychiatry 1966;112:9-17.
[35] Friston KJ, Frith CD. Schizophrenia: a disconnection syndrome? Clin
Neurosci 1995;3:89-97.
[36] Jalill M, Lavole S, Deppen P, et al. Dysconnection topography in
schizophrenia revealed with state-space analysis of EEG. PLoS ONE
2007;e1059:10.
[37] Van Beveren NJM, De Haan L. A visual metaphor describing neural
dynamics in schizophrenia. PLoS ONE 2008;e2577:3.
[38] Stompe T, Friedmann A, Ortwein G, et al. Comparison of delusions
among schizophrenics in Austria and Pakistan. Psychopathology
1999;32:225-34.
[39] Spitzer RL, Williams JB, Gibbon M, First MB. The structured clinical
interview for DSM-III-R (SCID). I: history, rationale, and description.
Arch Gen Psychiatry 1992;49:624-9.
[40] Stompe T, Ortwein-Swoboda G, Schanda H. Schizophrenia, delusio-
nal symptoms and violence: the threat/control-override-concept
re-examined. Schizophr Bull 2004;30:31-44.
[41] Stompe T, Bauer S, Ortwein-Swoboda G, et al. Delusions of guilt: the
attitude of Christian and Islamic confessions toward good and evil and
the responsibility of men. J Muslim Ment Health 2006;1:43-56.
[42] Sigmund D. Die Phänomenologie der hysterischen Pseudopsychose.
Fortschr Neurol Psychiatr 1997;65:387-95.
[43] Nisbett RE, Miyamoto Y. The influence of culture: holistic versus
analytic perception. Trends Cogn Sci 2005;9:467-73.
[44] Kitayama S, Duffy S, Kawamura T, Larsen JT. Perceiving an object
and its context in different cultures: a cultural look at new look.
Psychol Sci 2003;14:201-6.
[45] Han S, Northoff G. Culture-sensitive neural substrates of human
cognition: a transcultural neuroimaging approach. Neuroscience 2008
[in press].
[46] Masuda T, Nisbett RE. Culture and change blindness. Cogn Sci
2006;30:381-99.
[47] Al-Issa I. Social and cultural aspects of hallucinations. Psychol. Bull
1977;84:570-87.
[48] Stompe T, Friedmann A. Culture and schizophrenia. In: Bhugra D,
Bhui K, editors. Textbook for cultural psychiatry. Cambridge:
Cambridge University Press; 2007.
[49] Stompe T, Bauer S, Karakula H, et al. Paranoid-hallucinatory
syndromes in schizophrenia—results of the International Study on
Psychotic Symptoms. WCPRR 2007;4:63-8.