Hearing voices: Social context influences psychosis

“People are always selling the idea that people with mental illness are suffering. I think madness can be an escape. If things are not so good, you maybe want to imagine something better.”

These are the words of John Nash, Jr., the Nobel Laureate who inspired the book and the movie A Beautiful Mind and who suffered from schizophrenia, including paranoid delusions of grandeur during which he felt he could intercept secret messages with important content instructing him on how to rescue the planet.

How individuals experiencing psychotic symptoms come to interpret such messages is a fascinating question. In a recent academic talk, Stanford psychological anthropologist Tanya Luhrmann addressed this question by arguing persuasively for the influence of culture on the symptomatology of psychiatric disorders such as schizophrenia (for a great recap of a similar talk by Luhrmann, see this blog post from PLoS). Strikingly, she claims, positive psychotic symptoms, in particular hearing voices, manifest differently in different cultures. In western cultures, individuals diagnosed with schizophrenia are more likely to hear negative voices of strangers telling them how bad they are or instructing them to inflict harm on self or others; in certain African and Asian cultures, individuals are much more likely to hear the voices of family members chastising them or even voices that are telling them uplifting messages, which may not be bothersome in the slightest.

Dr. Luhrmann purports that schizophrenia, once viewed through the lens of psychoanalysis as a disorder brought about by early unhealthy relationships with one’s mother, has perhaps now become viewed too strictly as a genetic disorder of the brain. By completely rejecting these older notions of schizophrenia, modern science may too strongly discount cultural and environmental influences on schizophrenia. In her essay in the Wilson Quarterly, Luhrmann writes,

“[T]he outcome of two decades of serious psychiatric science is that schizophrenia now appears to be a complex outcome of many unrelated causes—the genes you inherit, but also whether your mother fell ill during her pregnancy, whether you got beaten up as a child or were stressed as an adolescent, even how much sun your skin has seen. It’s not just about the brain. It’s not just about genes. In fact, schizophrenia looks more and more like diabetes.”

That is to say, schizophrenia is not purely a biological disorder in the sense that modern psychiatry may sometimes have us believe. Rather, a diagnosis of schizophrenia represents a cluster of symptoms that is sensitive to social context, which in turn may interact with biology through epigenetics–genes themselves may be altered by one’s environment.

Several recent studies have investigated cross-cultural differences in auditory hallucinations in schizophrenia. For instance, a study conducted on case notes of White patients from the United Kingdom compared to Pakistani patients living in Pakistan found that in the U.K., individuals were more likely to hear voices commanding them to them to inflict harm whereas the negative voices heard by patients in Pakistan were more likely to be criticising or threatening them [Suhail & Cochrane, 2002]. These differences cannot be solely attributed to genetic differences between groups: differences were larger between White U.K. citizens and Pakistani individuals living Pakistan than they were between the White U.K. group and Pakistanis living in the U.K.

As for the striking differences described by Dr. Luhrmann, the pattern is similar. Dr. Luhrmann and colleagues conducted structured interviews in three disparate locations: San Mateo, California; Accra, Ghana; and Chennai, India (see Figure 1). They found that patients who met diagnostic criteria for schizophrenia in all three settings suffered from auditory hallucinations. However, the content of the voices was quite different for each group. Those in the U.S. tended to hear voices that were “markedly more violent, harsher and more hated… For example, ‘Usually, it’s like torturing people, to take their eye out with a fork, or cut someone’s head and drink their blood, really nasty stuff’” [Luhrmann et al., 2014, p.2].

Luhrmann study map

Figure 1. Locations where Luhrmann and colleagues (2014) tested patients who had diagnoses of schizophrenia: San Mateo, CA; Accra, Ghana; and Chennai, India.

In contrast, the other groups contained individuals who were not at all displeased by the voices they heard; this was not the case for any of the patients from San Mateo. In the Accra group, patients were highly likely to accept auditory hallucinations as voices belonging to spirits, a view that is culturally accepted in Ghana. In the Chennai group, more than half of the subjects reported that they voices they heard were those of kin. In her talk, Luhrmann suggested that this may reflect a cultural difference: in India, the opinion of one’s family may matter more than in more western cultures. What’s more, the mind itself may be viewed differently, being viewed less as belonging to a single individual and more as shaped by members of the community. As Luhrmann puts it, “outside Western culture people are more likely to imagine mind and self as interwoven with others” [Luhrmann et al., 2014, p. 3]. Finally, in her Wilson Quarterly essay, Luhrmann emphasizes that families in India are more likely to be involved in the treatment and care of someone who is suffering from mental illness.

One striking example–within a single geographic location–of culture’s potential influence on the content of auditory hallucinations comes from an East Texas study comparing patients at the same mental institution during the 1930s compared to during the 1980s [Mitchell & Vierkant, 1989]. The authors of the study found that patients from the ’30s, during the great depression, most often experienced delusions of wealth and power while patients from the ’80s (a period of relative prosperity in comparison to the 1930s) were more likely to experience auditory hallucinations commanding them to inflict harm or do “perverse things.” For instance, patients from the 1930s were likely to have delusions of great wealth, including oil wells and livestock; patients from the 1980s were less likely overall to have such delusions, and when they did, they were often of a religious nature (e.g., thinking one was God). In terms of hearing voices, however, patients from the 1930s were likely to hear commands to be a better person and to convert others to Christianity; most patients from the 1980s who heard commands were asked to harm themselves or others.

These studies begin to paint a picture in which psychotic symptoms like auditory hallucinations may be shaped by an individual’s long-term environment. Of course, most of this work has its roots in studies with small samples and consists largely of qualitative data involving subjective self-report–however, it cannot be denied that there are striking disparities between populations, with modern Western society faring poorly in terms of individuals suffering severely from deeply painful symptoms. But what of treatment? Luhrmann and colleagues [2014] suggest that some talk therapies may increase the likelihood of patients changing the content of auditory hallucinations, and that when patients actively interact with voices they hear, the voices may become less harsh or negative, or possibly cease entirely. What is clear is that scientists should begin to study quantitatively the impact of culture and society on psychosis. Medical professionals would do well to take such an impact into consideration when defining and describing psychiatric disorders.

Image Source: Wikimedia Commons via CopperKettle.