Auditory hallucinations in women and men

Schkophreniu

Research.

$3 1992 Elsevier

SCHIZO

7 (1992)

233

233-236

Science Publishers

B.V. All rights reserved

0920-9964/92/$05.00

00244

Auditory

hallucinations Neil A. Rector”

Schizophrenia

Research

in women and men

and Mary V. Seemanb

Programme, Clarke Institute of Psychiatry. University of Toronto, Canada, Psychiatry. Mount Sinai Hospital, University of Toronto, Canada

(Received

3 February

1992; revised received

9 April

1992; accepted

14 April

and hDcpartment

of

1992)

The total population of a community schizophrenia registry sample yielded information about the relative lifetime frequency of hallucinations in women and men. Whereas hallucinations in non-auditory modalities were equally distributed between the two sexes, auditory hallucinations were significantly more common in women. These results will be considered in relation to the existing literature on hallucinations and gender. K~JJ wor&

Hallucinations;

Gender;

(Schizophrenia)

INTRODUCTION

Sex differences in the phenomenology of an illness can decode important elements of etiology (Lewine et al., 1990; Castle and Murray, 1991) and point to effective intervention (Seeman, 1983; Haas et al., 1990; Test et al., 1990). It is with these goals in mind that sex differences in schizophrenia are being increasingly explored (Bogerts et al., 1990, 1991; Hafner et al., 1991a, 1991 b). Interested by the observation of Leonhard (1979) that females suffering from chronic schizophrenia are ‘hallucinatory, illusionary’ while males tend to be ‘dull, autistic’, (quoted by Flor-Henry, 1990) and by similar reports in the recent literature (Lewine, 1985; Goldstein and Link, 1988) we set out to compare the sex distribution of all hallucinatory phenomena endorsed by our sample population of community schizophrenics.

to: M. V. Seeman, Department of Psychiatry, Hospital, 600 University Avenue, Toronto, 1X5, Canada.

Correspondence

Mount Ontario

Sinai M5G

METHOD Subjects and procedure The sample consisted of all 94 participants in the Toronto Schizophrenia Registry (57 men and 37 women). Recruitment into the Registry originated from several sources: family doctors, psychiatrists, family members of local chapters of the Schizophrenia Society of Canada, community agencies, outpatient general hospital clinics, university teaching centres, inpatient wards, psychiatric group homes, newspaper and radio advertisements. As such, the Registry sample constitutes a broad source of ‘schizophrenia’ referrals. Some subgroups are not represented, as is true in most schizophrenia research studies. These are the uncooperative and suspicious, who refuse to participate, and the very lethargic, the disorganized, and the markedly unmotivated, who do not follow through on appointments and protocols. Since our subjects, all of whom live in the community, were invited to come on their own to Registry appointments (they were paid minimum wage for their time), certain patients, included in hospital-based populations, were not represented in our sample. With this proviso, the Registry sample can be characterized as accurately reflecting the heterogeneous nature of ‘schizophrenia’ in an urban, Canadian, multicultural community.

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Upon admission to the Registry, clinical diagnosis was refined by using the Structured Clinical Interview for DSM-IIIR disorders (SCID: Spitzer and Endicott, 1987) in order to arrive at a DSMTTTR diagnosis. The SCTD covered lifetime prevalence of all modes of hallucinatory experience, allowing for itemized description of both frequency and content of the particular hallucination. It also allowed for the differentiation of those hallucinations which were secondary to substance abuse which, for the purposes of this investigation, were excluded from study. Hospital records were also used to support information from the SCID. Current age, medication history, and age of onset of illness (age when first psychotic symptom appeared, and/or age at first hospitalization) were among the data gathered for the present study. Table I shows the distribution of male and female demographic data.

sample. As shown in Table 2, 60 (64%) of the 94 Registry subjects reported having auditory hallucinations and 35 (37%) endorsed visual hallucinations. 29 (3 1%) endorsed both auditory and visual hallucinations. Of those subjects who experienced visual hallucinations, a majority (80%) also experienced auditory hallucinations. Additionally, 29 (31%) reported tactile hallucinations, 36 (38%) reported olfactory hallucinations and, finally, only one subject reported the presence of gustatory hallucinations. Although males, as a group, had a somewhat longer duration of illness and, therefore, more potential time during which to experience auditory hallucinations, the females reported this phenomenon significantly more frequently (X=4.23, df= 1, p < 0.05). While hallucinations were coded present only in the absence of an organic precipitant, it is known from scores on the Michigan Alcohol Screening Test (MAST: Selzer, 1971) and the Drug Abuse Screening Test (DAST: Skinner, 1982) that amongst the 24 subjects with a possible dual diagnosis of substance abuse, 13 (ten males, three females) or 52% experienced auditory hallucinations. No sex difference was found in the other hallucinatory modalities.

RESULTS

Table 2 shows the lifetime the various hallucinatory TABLE

reported prevalence of modalities over the

1

Demographic

,formaleand,female

distribution

su/~jec~s (n = 94)

DISCUSSION MUk

FWNik~

in=371

in=57)

Age

Onset age Years of illness No. of admissions Current CP2 g eq/‘d *Significant

TABLE

.y

SD

B

34.0 21.6 14.7 6.6 595.4

(7.7) (4.6) (7.9) (7.4) (727.9)

36.3 24.0 13.9 4.6 712.9

SD

A report from the early 1930s using global clinical criteria for diagnosis, had already noted the predominance of hallucinatory activity among women across three distinct diagnostic categories: manicdepressive illness, schizophrenia, and general Paresis (neurosyphilis) (Bowman and Raymond, 193 1). Mott et al., in the 1960s (1965) comparing

(8.0) (6.5)* (6.1 I) (3.9) (1415.1)

at p < 0.05 level.

2

Distribution

of

hallucinution

tnodulities

Olfactory % (n)

Gustatory % (n)

32 (18)

32 (18)

0

30 (11) 31 (29)

49 (18) 38 (36)

3 (I)

% (n)

Visual % (n)

Tactile % (n)

Male (n = 57)

54 (31)

39 (22)

Female (n = 37) Total (n = 94)

78 (29) 64 (60)

35 (13) 37 (35)

Auditory

*Significant

at pi

0.05 level.

1 (1)

235

hallucination prevalence in three clinical groupings: schizophrenia, alcoholism, and ‘physical illness’ (selected on the basis of every fourth admission to medical wards of a general hospital), found no sex difference in the mental illness groups but reported an increased tendency to both auditory and visual hallucinations among the physically ill women. One potential confound in this study is the degree to which pain and/or the presence of medications played a part in the production of hallucinatory behaviour in the physically ill group. A more recent study examining Schneiderian first rank symptoms in a large sample of patients hospitalized for schizophrenia for the first time (n = 1208) found a significantly higher prevalence of auditory hallucinations among women with schizophrenia than among men (Marneros, 1984). 25% of the women, versus 15% of the men, reported auditory hallucinations. A recent cross-cultural study (Cetingok, 1990) found that hallucinations were more frequent among Turkish women with schizophrenia who had been married than among the comparison groups: single Turkish women, Turkish men, or Americans of either sex, all fulfilling DSM criteria for schizophrenia. Other recent studies of hallucination prevalence in clinical populations have not addressed or reported sex differences (Bracha et al., 1989; Mueser et al., 1990). It remains unclear whether sex differences were not found and therefore not reported or whether the sex differences were ignored in the analyses. Because relatively fewer subjects in our sample reported non-auditory as compared to auditory hallucinations, it is possible that this study did not have the statistical power to detect sex differences in the other modalities. Should the overrepresentation of women prove to be confined to the auditory modality of hallucinatory activity and not be true of the other modalities, it would set the stage for the exploration of explanatory hypotheses. One such hypothesis might be that auditory hallucinations are more ‘functional’; olfactory, visual, tactile and gustatory hallucinations being more ‘organic’. This is conventional wisdom although it is being challenged by recent data (Bracha et al., 1989; Mueser et al., 1990) and is not supported by our own results. Nevertheless, should this hypothesis have merit, male vulnerabil-

ity to neurodevelopmental difficulty (Castle and Murray, 1991) should lead to increased frequency of non-auditory hallucinations in men. Women’s greater tendency toward emotionality and reactivity to stress (Endler and Parker, 1990) should, by contrast, lead to what this study has found: a greater frequency of auditory hallucinations in women. Potentially important supporting evidence is found in studies reporting on ‘hallucination disposition’ in non-clinical populations. This disposition is measured by actual reports of auditory hallucinations and additional items that are thought to represent sub-clinical forms of hallucinatory experience (Launay and Slade, 1981). Muntaner et al. (1990) in a sample of 735 firstyear university students (355 males and 380 females), when examining the relationship between personality and psychopathological traits of psychosis proneness, found that women scored significantly higher than men on Chapman and Chapman’s perceptual aberration scale, a selfreport measure of hallucinatory-like phenomena. Similarly, Young et al. (1986) in a sample of 204 undergraduates using the Launay and Slade scale (198 1), found that women had a significantly greater disposition than men to hallucinate. Tien (1991) examined data from the NIMH Epidemiologic Catchment Area Program (Eaton and Kessler, 1985) on the distribution of incident hallucinations in the community (n= 18,572 at baseline). Women had approximately a 50% higher overall incidence of hallucinations than men (14.9% vs. 10.2%, p < 0.05). While visual hallucinations were found to be slightly more frequent in men, women were found to report more auditory and olfactory hallucinations. Further, the incidence of auditory hallucinations across age and sex categories was highest in women under the age of 25. Recognizing the importance of these malefemale differences, Tien (1991) concluded ‘the age and gender variations also suggest different etiologic stressors as well as perhaps gender related vulnerabilities for different modalities of hallucinations’. Psychosocial cues from birth onward may predispose women to the expression and/or disclosure of material of an intimate, personal nature (Block, 1983). Women ‘own up’ more readily than men to symptoms such as ‘voices’ which are generally

236

equated with ‘being crazy’. Alternatively, there may be neuroanatomical bases for these findings. Additional research examining the distribution of hallucinations should focus on the identification of potential psychosocial stressors and developmental stages and the interaction of these components in men and women which may help, in part, to explain the etiological basis of sexually dimorphic phenomena. Further, the continued identification of sex differences in schizophrenia symptoms may aid in unravelling the etiological components of the illness.

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