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Comprehensive Psychiatry 52 (2011) 319 – 325


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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.
© 2011 Elsevier Inc. All rights reserved.

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


establish a contact to spirits, modern Western societies
Hallucinations are common phenomena in traditional as regard these phenomena as symptoms of mental illness.
well as in modern societies. However, prevalence and Some of them, the auditory first-rank hallucinations, are seen
notions concerning etiology, course, and the need for as pathognomic for schizophrenia.
treatment differ to a large extent [1]. Whereas non-Western In Europe, the first large investigations on the frequency
cultures often attribute altered states of perception like 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
⁎ Corresponding author. Tel.: +43 1 40400 3547. studies on the epidemiology of hallucinations in schizophre-
E-mail address: susanne.m.bauer@meduniwien.ac.at (S.M. Bauer). nia were carried out (Table 1).
0010-440X/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.comppsych.2010.06.008
320 S.M. Bauer et al. / Comprehensive Psychiatry 52 (2011) 319–325

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- Europeans (Table 1). To differentiate the influence of the
able: In all study sites, auditory hallucinations were the most culture of origin from the influence of the environment of the
common ones, followed by visual and cenesthetic hallucina- second home, Suhail and Cochrane [23] compared 3 groups
tions, whereas tactile, olfactory, and gustatory hallucinations of patients: (1) Pakistani patients living in Pakistan, (2)
were reported rather infrequently. Pakistani migrants living in Great Britain, and (3) patients of
The early cultural-comparative investigations on psy- white British origin. Compared with both British groups,
chotic symptoms in schizophrenia focused more on patients living in Pakistan reported a higher rate of visual
delusions than on hallucinations. One reason for this hallucinations interpreted as visions of spirits or ghosts. In
preference might be the fact that delusionally impaired contrast, auditory hallucinations were substantially less
beliefs are easier to evaluate than impaired perceptions. The frequent in the Pakistani group. These data suggest that the
first cross-cultural surveys on the frequency of different influence of the immediate environment on the phenome-
kinds of hallucinations were carried out in the 1960s by nology of hallucinations is more important than the influence
Murphy et al [22]. The researchers sent out questionnaires to of culture of origin. This interpretation was supported by
psychiatric centers all over the world to gain information Wang et al [24], who found that migrants hear voices not
about the local distribution of psychotic features. The results only in their first language, but also in their second or third
showed clear evidence of a relationship between culture and ones depending on the delusional content.
the prevalence of different types of hallucinations. Visual as Reviewing the literature we found differing, partly
well as tactile hallucinations occurred most frequently in controversial theoretical positions and inconclusive empir-
patients from Africa and the Near East, a finding that was ical evidence concerning hallucinations in different cultures.
confirmed by Ndetei and Vadher [19] 20 years later. The Van Dusen [25] interpreted hallucinations as phenomena that
authors carried out a cross-cultural study in patients with transcend cultures and remain stable over time. In contrast,
schizophrenia from different ethnic groups admitted to a Kiev [26] claimed that culture has pathoplastic effects at least
London mental hospital. They found higher frequencies for on the content of hallucinations. Even the question of
both auditory as well as visual hallucinations in non- whether or not hallucinations are pathognomic for mental
European patients compared with English and Continental illness in general or may occur under certain conditions also
S.M. Bauer et al. / Comprehensive Psychiatry 52 (2011) 319–325 321

in healthy people is still under discussion [27]. One reason perceptual experiences, too. Perceptual experiences can be
for these debates is the lack of a valid definition of veridical or falsidical: they can represent the world correctly
hallucinations generally accepted in all cultures [28,29]. or incorrectly. Perceptual illusions and hallucinations are
Especially cultural-comparative studies are difficult to falsidical, whereas normal perceptual experiences of objects
evaluate because most authors did not explicate their concept in the external world are veridical [32].
of hallucinations (Table 2). (b) In his General Psychopathology, Jaspers distin-
So one task before carrying out cross-cultural–compar- guished 4 types of “false perceptions”: pareidolias, illusions,
ative survey is to properly define the term hallucinations pseudohallucinations, and true hallucinations. He defined
used for the study. A second methodological problem why hallucinations as actual false perceptions that are not in any
transcultural investigations on hallucinations are difficult to way distortions of real perceptions but spring up on their
compare are the different periods of time under study. Some own as something quite new and occur simultaneously with
authors refer to point prevalence rates and others to 1-year or and alongside real perceptions [33]. This distinction is
even to lifetime prevalence rates; some did not report the important because illusions and pseudohallucinations are
time at all (Table 2). Most studies conducted so far are nosologically unspecific and occur in patients suffering from
retrospective and based on case reports [11,17,23]. personality disorder as well as from affective psychosis,
Taking into account these methodical problems, the aim whereas “true” hallucinations are much more pathognomic
of our study was to investigate (a) the relationship between for functional and organic psychoses [34]. Concerning the
culture and the 1-year prevalence of different kinds of use of rating scales or standardized interviews, one has to
hallucinations in patients suffering from schizophrenia born keep in mind that the lack of clear definitions may lead to an
and living in 1 of 7 different countries and (b) the frequency overestimation of the prevalence of hallucinations in
in which different kinds of hallucinations occurred during traditional cultures. Following Spitzer, we distinguished
the last year. 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
2. Material and methods because of affective-cognitive deficits in chronic psychotic
2.1. Definitions illness or overwhelming affects in acute psychosis [28]. This
phenomenological definition of hallucinations corresponds
One can distinguish a dimensional and a categorical with the etiologic theory that schizophrenia arises from
approach to define hallucinations [28,31]. Although the reductions in connectivity between brain regions as a result
dimensional approach avoids the strict definition of the term of development disturbances during synaptogenesis [35-37].
hallucinations, the problem to find a clear cutoff point to In contrast, pseudohallucinations are close to subjects' usual
distinguish between normal perceptions or physiologic conscious imaginations and fantasies.
phenomena like hypnagogic states and hallucinations
remains unsolved. But without a cutoff point, the term hal- 2.2. Subjects
lucination is losing any semantic as well as nosological
significance. For this reason, we decided to use a categorical The population under study consisted of 1080 patients
approach. Starting from the distinction between (a) “true” with schizophrenia according to the Diagnostic and
perceptual experiences and “false” perceptions in general, Statistical Manual of Mental Disorders, Fourth Edition
we followed a (b) conceptual discrimination between [38] from 7 countries, consecutively recruited between the
different types of false perceptions. years 1996 and 2001: 350 patients from Austria, 80 from
(a) Any perceptual experience has phenomenal character. Poland, 73 from Lithuania, 74 patients from Georgia, 103
But it is not true by definition that every perceptual from Pakistan, 324 from Nigeria, and 76 from Ghana
experience has an object in the external world: hallucinatory (Table 3). Mean age was 32 years (range, 18-62 years).
and other disturbed experiences like illusions count as Subjects with organic brain disorders or severe infections 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 Method Definition of hallucination Explicit prevalence
Murphy et al [22] 1963 Interview No information No information
Ihezue and Kumaraswamy [18] 1984 Case report study No information 6-mo prevalence
Ndetei and Vadher [19] 1984 Case report study No information No information
Mueser et al [21] 1990 Interview No information No information
Lindal et al [27] 1994 Interview No information No information
Kent and Wahass [30] 1996 Interview No information No information
Suhail and Cochrane [23] 2002 Case report study No information No information
322 S.M. Bauer et al. / Comprehensive Psychiatry 52 (2011) 319–325

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- unequal sample sizes, Fisher exact test (2-tailed) was used,
induced disorders were excluded. All patients were under too. The influence of culture and demographic and clinical
antipsychotic medication. variable (countries of origin, sex, age, age at onset of illness,
duration of illness) on the 1-year prevalence of the different
2.3. Instruments kinds of hallucinations was analyzed by means of logistic
regression analysis. The mean prevalence of the different
Written informed consent was taken from the patient or an
kinds of hallucinations during the last year was compared by
adult relative in case a patient was considered unable to sign.
Kruskal-Wallis 1-way analysis of variance. Analyses were
Diagnosis was derived by Structured Clinical Interview for
carried out by means of the Statistical Package for the Social
Diagnostic and Statistical Manual of Mental Disorders,
Sciences (version 14.0; SPSS, Chicago, IL) for Windows.
Fourth Edition Axis I Disorders interviews, supplemented
by case reports and collateral information [39]. The local
interviewers were experienced psychiatrists or clinical psy- 3. Results
chologists who completed a part of their training in the United
States, the United Kingdom, or Austria. As a second 3.1. One-year prevalence of hallucinations
instrument for the assessment of psychotic symptoms, the
In the total sample, auditory hallucinations yielded the
“Fragebogen zur Erfassung psychotischer Symptome” was
highest 1-year prevalence (74.8%), followed by visual
applied. The instrument and its psychometric properties had
hallucinations (39.1%); cenesthetic hallucinations (28.9%);
already been described [38,40,41]. The “Fragebogen zur
and tactile, olfactory, and gustatory hallucinations (1.3%-
Erfassung psychotischer Symptome” was developed for cross-
6.6%). Significant differences in the distribution of halluci-
cultural comparison studies on psychotic symptoms in
nations were found for all modalities (Table 4, Fig. 1).
schizophrenia in 1994. The instrument includes 3 chapters
Auditory hallucinations were most prevalent in all sites
on (a) delusions, (b) hallucinations, and (c) Schneider first-
(between 66.9% and 90.8%). The highest rates were found in
rank symptoms. The instrument was translated, retranslated,
both West African countries (Ghana: 90.8%; Nigeria:
and tested for interrater reliability at the single sites as well as
85.4%); the lowest rate was in Austria (66.9%). The
cross-sectionally, yielding a Cohen α for interrater reliability
prevalence of visual hallucinations in the developing
for the different kinds of hallucinations between 0.75 and 0.98.
countries was inhomogeneous. Whereas visual hallucina-
2.4. Statistical analysis tions were most frequently reported in West African patients
(Nigeria: 50.8%, Ghana: 53.9%), the prevalence for
The cultural differences of the prevalence of the various Pakistani patients was only 3.9%. In contrast to many
kinds of hallucinations were analyzed using χ2 test (with other studies, visual hallucinations were prevalent not only in
continuity correction when appropriate). Because of the 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 52 (2011) 319–325 323

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.
324 S.M. Bauer et al. / Comprehensive Psychiatry 52 (2011) 319–325

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 In this study, we were able to show that culture has a
with schizophrenia from non-Western societies may be decisive impact on the prevalence of the kinds of
explained physiologically. In these cultures, somatic or hallucinatory experiences. However, there are also other
nutritive agents may have a higher pathogenetic impact than factors like age, age at onset, and duration of illness that
in Western societies where emotional stress is held responsible influence the rates of hallucinations.
for the outbreak of the illness. [1] Compared with schizo- Although we have tried to avoid some methodological
phrenic disorders, the higher prevalence of visual hallucina- problems of previous cross-cultural comparative investiga-
tions could be ascribed to psychotic derailments associated tions, our study too is subject to the inherent limitations of
with organic conditions that are more often associated with any survey-based data. Although the sample is quit large, it is
visual hallucinations. However, all patients included in our impossible to control for all factors that might influence the
study were somatically examined accurately to avoid this bias. prevalence of hallucinations in schizophrenia.
Therefore, we hypothesize that the variety of the All patients were under antipsychotic medication. This fact
prevalence of visual hallucinations in terms of cultural may cause another limitation insofar as we recently do not
differences of the cognitive styles is the result of cultural know whether there exists something like a culture-bound
differences in perceptual and attentional processing between medical response of the phenomenology of psychotic illnesses.
European Americans (who are Westerners) and East Asians Further studies in other societies are necessary to establish
[43]. Specifically, Westerners seem to be inclined to pay a consistent theory concerning the impact of culture on the
more attention to salient objects than to contextual back- frequency and shape of hallucinations in schizophrenia.
ground, whereas East Asians seem to attend more to relations
and contexts than to salient objects [44,45]. First results of
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