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18

December

1971

S.A.

MEDICAL

JOURNAL

1391

Auditory

Hallucinations

in

Polyglots

*

R.E.HEMPHILL,

MA,

M.D.,

D.P.M.,

F.R.C.PSYCH.,

ConsultantPsychiatrist,GrooteSchuurHospitaland

V a l k e n b ~ r g

Hospital,CapeTown

-

SUMMARY

Ina

study

of

White

and

Colouredschizophrenic

patients,

auditory

hallucinations

werereported

tooccur

inonelanguageonly,

theearliest

thepatientshadlearned.Thepatients'mentalperformancewas

relativelybetter

when

the

non-homelanguagewasused.In

thepsychosis

of

toxic,

drug,and

organicorigin

andinepilepsy,

hallucinationsmay

bemultilingual,in

contrastto

schizophrenia.This

is

of

valuein

differential

diagnosis.Acase

of

paranoid

psychosis

inwhicha

White

manhadextensive

delusions

with

auditory

hallucinationsinhisnativelanguage,

but

was

non-psychotic

anddeniedhisdelusionswhen

conversing

inanother,

is

described.Hallucinations

that

alternatedbetweenEnglish,

Afrikaans

andXhosainacase

of

non-schizophrenic

hallucinosis

is

discussed.

It

is

suggested

that

a

defect

of

the

system

for

verbal

thought

is

implicatedin

the

production

of

'voices'in

schizophrenia,

involvingthecoding

andprocessing

of

language.

S.

AIr.Med.

l.,

45,

1391

(1971).

Thisarticle.reports

some

earlyfindingsinastudy

of

auditoryhallucinationsinpolyglotpatients

atGroote

Schuurand

ValkenbergHospitals,

CapeTown.

Polyglotsarepersonswho

canspeak

fluently,

understandand

think,in

more

than

onelanguage.

H a l l u c i n a t i o ~ s

of

human

voices

are

experiencedbypatientsintheir

own

language,

the

languageinwhichtheythink

and

talk

to

themselves.

It

is

generallyassumed

that

hallucinations

in

polyglots

are

multilingual

to

correspondwiththepatient'slanguages

and

verbalthinking.

In

fact,this

is

not

so.Auditoryhallucinationsinpolyglots

areoften

confined

to

onelanguage

and

inittheassociateddisorder

of

thinkingmaybe

more

severe

than

inthepatient's

other

languages.Indeed,a

patientmaybe

franklypsychotic

and

expressdelusions

in

one

of

hislanguages

but

appear

to

benon-

psychotic

when

he

thinks

and

conversesinanother.

Many

psychiatricpatientsseenin

CapeTownare

bilingual

or

polyglot.

Most

of

thepatientsreferred

to

here

areCape

Coloured,

but

as

the

researchproceedsmoreWhites

andBantu

willbestudied.

In

South

AfricaEnglish

and

Afrikaansare

officiallanguages

andare

taughtinschools.

In

Cape

Town

themajority

of

South

African-bornWhites

can

understand

eachtosomeextent,

andsome

are

fluent

in

both.

Accordingtothe

individualbackground,

Afrikaans

or

Englishwill

be

the

major

or

home

language.All

the

Colouredsspeak

Afrikaans

asa

major

language

and

many

are

fluentinEnglish.

Unedu-

catedColouredsconverseinaslang

that

is

incomprehen-

"Date

received:8

October

1971.

sibletoothers,

but

they

can

switcheasily

into

conventionallanguage.Malays

are

oftenbilingual

but

some

speak

Englishonly.

Bantu

patientsin

Cape

Town

usuallyspeak

Xhosa

or

anotherBantu

language

and

somebecome

veryfluentinEnglish

andAfrikaansandmay

speak3languageswell.Inspite

of

thegrowth

of

Afrikaans,noone

can

avoid

the

verbalinfluence

of

Anglo-American

through

entertainment,popsongs,cinema,

radio

features,advertising

and

the

contemporary

slang

that

isthe

idiomatic

speech

of

youngpeople.

In

thiswayEnglishexpressions

may

con

taminateother

languagesinspeech

and

hallucinations.

CapeTown

offers

an

exceptionallyrich

and

interestingfieldforthestudy

of

polyglotpsychiatry.

Perhaps

nowhereelsearetwolanguagesusedsoreadily,evenindiscriminately,by

ordinary

citizensintheirdailylife.

There

arealsosizeable

groups

of

Dutch,German,

Italian,

Greek,

Portuguese,Spanish

and

other

settlers

from

European

countrieswho

retain

their

own

language

inaddition

toEnglish

and

Afrikaans.

Noneof

thesehavebeenstudied

for

auditoryhallucinations.

AUDITORYHALLUCINATIONS

Auditoryhallucinations

are

ausual

phenomenon

inschizophrenia

among

allraces,

and

inpatients

of

allages.

In

acuteschizophreniathey

may

be

an

unintelligiblejumble

of

fragments

of

sentences

or

words,songs,

pop

music,

machine

and

other

noises.

If

theacuteattack

does

not

resolvecompletely

but

subsides,the

inanimate

hallucinationsusually

disappear

but

the

voicesremain.Otherwisehallucinations

appear

insidiously

tothepatient

ashis

own

thoughtsspokenaloud,

or

voices

of

others,conversations,

or

remarks

directed

at

him.Psychotics

attribute

them

tosome

sourceoutsidethemselves

and

thusdelusions

are

builtup,whichindicates

that

there

mustbe

a

disorder

of

theprocess

of

logicalthinking.

Butwhetherthe

hallucinationsspring

from

sucha

disorder

or

viceversa

has

beenmuch

and

inconclusivelyargued.

In

any

case,thefeedback

of

hallucinationsinfluencesthe

patient's

thinking

and

impairshisability

to

concentrate

andto

learn.Patientsare

not

concerned

that

other

people

areunabletohear

thevoices

nordeaf

psychotics

tha

tthey

canhear

thevoices

but

are

unabletohearanything

else.Auditoryhallucinations

due

to

organic

causes,forexampledrugs,toxicfactors

and

epilepsy,

disappearas

thebasicconditionsresolves;the

patient

realizesinretrospect

that

theywerefalse.Schizophrenics

on

the

contrary,

inremission,

or

freefromhallucinationsasaresult

of

treatment,maystillbelieve

that

the

hallucinatory

experienceswerereal.Hallucinations

and

delusionsinschizophrenia

donot

seem

to

change

from

theirgeneral

topic

and

imaginedorigin

to

another

though

they

mayextendto

in-

1392

S.-A.

MEDIESETYDSKRIF

18

Desember

1971cludeothers,

and

when

a

patient

relapses,

the

previoushallucinations

and

delusionsusually

reappear

inthesamegeneralform,like

an

out-of-date

film

or

tape

recordingbrought

out

of

store

and

played

again.

The

rigidity

of

thepsychotic

materialand

itsstereotyped

nature

whenitreappearsinrelapse

argueagainst

thehypothesis

that

adisorder

of

thinkingprocessesisprimarilyresponsible.Otherwise

the

material

wouldchange

and

developaccordingto

thepatient's

continuous

lifeexperienceswhenhis

mentalstate

is

normal

betweenattacks.

Yet

although

the

patient

may

appear

tohave

acquired

knowledgein

other

respects,

the

hallucinations

and

delusionsevenintheir

formal

aspects

are

notbrought

up

to

date

or

modifiedcorrespondingly.

In

a

normalhuman

thereis

some

arrangement

wherebythoughts

are

codified

and

processedintolanguagewithwhich

hecan

communicate

verballywithhimselfaswellaswithothers.

The

verbalthoughts

are

recognized

and

identified

and

theyinfluence

the

progression

of

thought.

They

play

a

part

inalllearning

and

in

the

formation

of

memory.

Verbal

aswellasnon-verbalthinkingisemployed

by

everyone,

andprobably

is

essentialinthe

forma

tion

of

memory

patterns.

The

individual

can

alwaysrecognize

the

languagein

whichhe

is

thinking

verbally.

To

understand

thestereotypes

and

some

features

of

schizophrenicauditoryhallucinations

and

theformation

of

the

associateddelusions,one

can

postulate

that

thereis

an

impairment

of

thearrangementsfor

verbalprocessing

of

thoughts

and

for

thecorrection

and

codification

of

verbalmemories.

Incorrect

and

obsoletematerialisthusfed

back

continuouslyinto

thoughtduring

psychoticepisodes,therebyimpairing

the

ability

to

evaluatereality

andtothink

logicallyas

far

asthis

material

isconcerned,

or

tolearnand

toevaluate

past

experiencesreliably.Somesuchhypothesiswouldexplaintheusually

poor

performance

of

schizophrenics.

Even

whenthey

are

free

from

hallucinations,theyhave

some

over-all

impairment

inability

to

learn

and

evaluateconcepts,aswellas

more

specificdefects

in

pathologicalareas

of

mental

life.

Voices

It

is

remarkablethat

schizophrenicpatients

ofmanyor

possiblyallraces

refer

toauditory

hallucinationsas'voices'

and

not

asnoises

or

statements

or

conversation.

The

expression

'Do

youhear

voices?'

is

immediatelyunder

stood

by

patients

and

there

is

an

equivalent

for

thisexpression

inmany

languages,includingXhosa.

This

suggests

thatthe

hallucinatory

experiences

are

so

much

alike

that

they

can

be

characterized

by

awell-understood

common

term.

The

voices

may

be

incomprehensible

or

maydevelopintointelligiblestatements.

Excluding

technical,

poetical

or

metaphorical

meanings,avoice

is

a

sound

vocally

produced

by

a

human

forthepurposes

of

speech

or

vocal

communication.

Avoice

has

variousqualities.

It

may

be

old,young,male,female,angry,

happy,

terrified,

or

otherwise,

loud

or

soft,

harsh

or

musical,

and

servingaforeign

or

nativelanguage.

Although

what

the

voice

says

maybe

unintelligible,the

speakermay

be

recognizedbyhisvoice,e.g.

in

acroWd,witha

bad

telephoneline,

or

whilesinging,even

by

animalsas

in

the

famous

advertisement

forHis

Master's

Voicegramophones.Alistener

whohas

had

some

experience

of

aforeignlanguage,

may

wellguess

thenationality

of

a

speakerfrom

hisvoice

although

hemaynotbe

able

tounderstanda

word

of

what

he

says.

Children

learn

themeaning

of

the

word

'voice'

from

an

earlyage

and

grasp

the

conceptaccordingly.

In

romantic

language

the

voiceisusedtosuggesta

communicationbetween

nature

and

man,

e.g.thevoice

of

thesea,

the

voice

of

nature,

and

inreligious

metaphor

God

speaks,

or

useshisvoicetotheworshipper.Aliteralbelief

that

spiritvoices

can

be

heard

isimplicitin

some

forms

of

religion,inwitchcraft

and

magic,so

that

insomecircumstancesthereis

no

sharpboundary

between

an

acceptablebelief

and

psychosis.

Hearing

avoice,alistener

may

recognize

the

voice

and

understand

what

issaid;recognize

the

voice

butbe

unable

to

understand

what

issaid;

beunableto

recognizethevoice

but

understandwhat

issaid;

hear

the

voice

but

be

unable

torecognize

it

orunderstandwhat

issaid.

This

alsoapplies

to

hallucinatory

voices

in

schizophrenia.

The

listenermay

be

abletorecognize

the

nationalitywhethernative

or

foreign,

and

he

maybeable

to

deducesome

qualities

or

emotions

suchas

anger

or

joy

or

threats

fromthe

voicealone.

What

thevoiceconveys,

depends

both

on

theclarity

of

theperception

andon

the

listener'spreviousknowledge

and

experience.

When

patientssaythey

hear

voicesthey

meanthat

they

are

hearingsomething

that

theyrecognizeas

human,for

what

they

hear

isderived

from

their

own

self.

They

can

usuallyidentify

the

language.

This

is

to

beexpected

for

itis

the

languagewhichtheythemselvesuse,

or

in

the

case

of

polyglots,

theparticular

languagein

whichthe

thought

processes

aremost

disturbed.

The

extent

to

which

the

hallucinations

are

incomprehensible,puzzling

and

bizarre,

is

an

i n d i c a t i o ~

of

the

degree

of

impairment

of

the

process

of

verbalization

of

thoughtsaswellas

of

apossibleunderlying

disorder

of

thethinkingprocess.

MATERIAL

This

preliminary

report

refers

to

aseries

of

30bilingualpatients

who

had

developedschizophreniawith

auditory

hallucinations,inadolescence

or

early

adult

life.

They

wereWhite,

Coloured

and

Malay,male

and

female,in-

and

outpatients

at

GrooteSchuurHospital,and

male

Colouredinpatients

at

Valkenberg

Hospital.

One

Xhosa

outpatient

willbe

referred

to

separately.

There

wereno

Indians.Allheard,

or

had

heard

'voices'.

They

could

identifythe

language

of

the

'voices'

and

sometimes

the

source,

and

afewunderstood

the

general

meaning

of

what

theyheard.

Most

of

thehallucinationsweredisjointed,

fragmentary,

and

notcoherent

statements.

The

object

of

the

studywas

to

ascertain

if

polyglots

heard

hallucinatoryvoices

inone

or

all

their

languages;whichlanguagewasusual;if'voices'switched

fromone

to

another;the

effect

of

phenothiazones;

and

other

relatedmatters.

The

study

was

concerned

with

the

language

andnot

the

content

of

thehallucinations

and

associateddelu-

18

December

1971

S.A.

MEDICAL

JOURNAL

1393

sions.

Patients

werequestioned

about

the

hallucinations,their

languagebackgroundand

languagepreference.Some'havebeenobserved

for

more

than

twoyears.As

the

researchproceeds,

other

classes

of

patients

not

studiedsofarwill

be

included.

FINDINGS

AND

EXAMPLES

Patients

heard

'voices'

inone

languageonly,thefirsttheyhadlearned,regardless

of

whichthey

now

preferredspeaking,

or

habitually

used-this

willbereferredtoas

the

homelanguage.'Voices'were

heardinthehome

languageonalloccasions,alsowhenthey

re-appearedduring

arelapse

or

recurrence

of

the

illness.'Voices'attributedto

God

and

spirits

and

to

perS0nswho,infact.could

not

speakit,used

thehome

language.

Phenothiazines

suppressedthevoicesas

inmonoglot

patients.

The

followingexamples

occurred

among

our

patients:

HomeLanguageAfrikaans

A

paranoid

schizophrenic

Colouredmale

teacher,aged

32

years,'Nho

taught

inEnglish

heardAfrikaans

'voices'duringhis

attacks

of

schizophrenia.Ahebephrenic

Coloured

male,aged

18

years,

heard

'voices'

of

QueenElizabethand

Princess

Anne,

among

others,speaking

Afrikaans.

A

catatonic

schizophrenic

White

female,aged24years,married,

heardAfrikaans

'voices',evenin

an

Englishnursing

home.

A

hebrephrenicColoured

male,aged

18

years,

heard

female'voices'speakingin

Afrikaansand

using

'pop'

slang

andswear

wordsinEnglish.

HomeLanguageEnglish

A

paranoid

schizophrenicWhitehousewife,aged35years,with

Afrikaans

friends,

heard

Englishvoices

during

fluctuations

of

the

illness

for

5years.A

paranoid

schizophrenic

Whitemaleaccountant,

aged

38

years,

heard

English'voices'

attributedtoAfrikaans

enemies

andlater

tospiritsaswell,

at

intervals

for

14years.A

paranoid

schizophrenic

Coloured

male,aged30years,whowasalay

preacherworked

in

an

Afrikaans

office

and

preachedin

Afrikaans

inamission,

but

prayed

inEnglish.

He

heard

the'voice'

ofGod

in

English.

Patients

found

it

difficult

to

describe

the

'voices'whenquestionedfirstin

the

non-home

language-some

saidthey

had

not

heard

any,

or

could

not

remember.

But

whenaskedinthe

home

language,they

could

discuss

them

easily,evenifthey

had

justdenied,in

theother

language,having

heard

them.'Voices'

spoke

continuallyto

one

6

Afrikaans

patientinthehospitalwaiting

room,

but

stopped

immediatelythe

doctor

usedEnglish.

Some

patientsappearedtobenon-psychotic,logical,realistic,with

normal

emotional

rapport

and

able

toperformnormally

at

busi-'ness,

home

or

teaching,provided

thenon-home

languagewasspoken.A

paranoid

schizophrenic

Coloured

female,aged40years,veryintelligent,leftschool

when

12

yearsold,

but

developed

her

English

sothat

shewasableto

readand

writewell,

and

appreciateseriousEnglishliterature.Sheworkedcontinuously

for

25

years,livingin

E n g l i s h - s p e a k ~

inghouseholds.

For

15

years

Afrikaans

'voices'

have

persecutedher.

Theycome

whenshereads

or

conversesinEnglish

andare

controlledbyphenothiazines.

Her

mental

performance

is

normal

as

long

as

the

'voices'

are

suppressed.

The

languagespoken

around

apolyglot

patientas

wellastohim,actsasaset

or

key

for

his

verbal

thinking.

It

will

determine

whichlanguage

he

willthinkin,

andmay

imitate

the

'voices'.

This

isillustrated

byanunusual

case

of

hallucinosis,whichshowed

noother

features

of

schizophrenia.A

Xhosawoman,

aged40yearswasveryfluentinXhosa,

Afrikaansand

English.Shewashighlyefficient

and

wouldlook

after

her

employer'sflat

aloneformonths

at

atime.

For

15

years.she

heard

'voices'

that

spoke

her

thoughtsinEnglish

or

Afrikaans

accordingtowhichlanguageshehadlast

heardspoken

inthestreetoutside.

The

'voices'ceasedwhenshe

spoke

topeople,listened

tothe

radio,

and

sometimeswhen

she

read,using

theother

language.

When

shewas

alone

at

night,

wakenedfrom

asleep,the'voices'usedXhosa,

her

originalnativelanguage,

until

she

heard

English

or

Afrikaans.

Shebelieved

the

'voices'werereal

but

was

not

concerned

about

how

they

came

about.

In

other

respectsshelived

and

behavednormally.

Auditory

hallucinations

due

toorganic

and

toxiccauses

and

epilepsy

canbe

multilingual.Asindelirium,they

are

distortions

of

perceptions

or

of

memories.

This

canbe

ahelpinthedifferentialdiagnosisbetweena

drug

(cannabis)psychosis

and

schizophrenia

in

polyglotadolescents.

Mono

glot'voices'

tend

toindicate

thelatter

condition.A

White

femalewithdeliriumtremens,

sawandheard

Whites

and

non-Whitesspeakinginvarious

languages:

English,

Dutch,Afrikaansand'Indian'.

A20-year-old

Australian

male

with

cannabis

psychosissawvisions

andheard

God

andothers

speakinginEnglish,

AfrikaansandFrench,

usuallywith

an

Australian

accent.A

White

girl,aged22years,with

temporallobe

epilepsy,sawfiguresinwhitewho

spoke

inEnglish,

or

Afrikaans,and

thendisappeared.Afemale

Dutch

settlerin

Montreal

with

temporal

lobeepilepsyregularly

heard

carol-singing

from

Holland

inEnglish

orDutch,

whichinitiatedafit.AColouredmale,aged

18

years,

after

alefttemporal

trauma

episodically

heard

his

fatherand

mother

speakingin

Afrikaansand

English.

He

isbilingual

but

theycanonlyspeak

Afrikaans.

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Auditory Hallucinations in Polyglots

Hemphill RE. S Afr Med J. 1971 Dec 18;45(48):1391-4.

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