The content of delusions in a sample of South African Xhosa people with schizophrenia

The core symptoms of schizophrenia have shown consistency across cultural contexts [1, 2], and while the categories of types of delusions (e.g.,: persecutory, grandiose etc.) appear stable, they demonstrate cultural plasticity in their content [3, 4]. For example, transcultural studies have identified universal delusional experiences amongst people with schizophrenia [5] with persecutory delusions being the most commonly reported across a diverse range of samples drawn from Austria [6]; China, Japan and South Korea [7]; India [8]; Lithuania [9]; Pakistan [10] Turkey [11] and the United States [12]. However socio-cultural factors such as religious belief systems [6, 13, 14] and more collective or individualistic conceptualizations of self [15] as well as environmental factors [16], historical events [12] and political contexts [7,9,] have been shown to influence the content of delusions. Within particular cultural groups factors such as sex, age, education and socio-economic status [8, 10], geography [11, 15], urban and rural living contexts [6, 8] have also demonstrated influence. Consistent with international cross-cultural studies, persecutory delusions, including the belief that others are plotting against or planning to hurt the individual, appear to be the most frequently reported type of delusion in South African Xhosa people with schizophrenia [17, 18]. However, to date qualitative exploration of the content of these delusions remains relatively limited. It’s likely that the widely accepted belief in the Xhosa culture that mental illness has its root cause in witchcraft plays an integral role in the content of these delusions [18, 19]. These cultural beliefs also have a broader impact on how schizophrenia is explained and understood in the Xhosa community, influencing help-seeking behaviors and treatment, as well as medication compliance [17, 20, 21].

Improved understanding of the content of persecutory and other delusions of Xhosa people with schizophrenia has implications for better empathy and understanding of these patients and potentially their treatment needs. Furthermore, little is currently known about the interaction between culture and the formation of delusions [3]. Some aspects of delusional thought may be the result of cognitive processes that are biological and universal human experiences, others may demonstrate considerable cultural variability [3, 4]. Consideration of aspects of delusional thought across different cultural contents may prove valuable to the cognitive theory of delusions. This paper aims to contribute to understanding about the relationship between culture and delusional content by exploring the content of delusions reported within a sample of 200 Xhosa people with schizophrenia recruited for a genomics of schizophrenia study in South Africa.

The aim of this article was to explore the content of delusions reported by a sample of Xhosa people with schizophrenia, recruited for the SAX study. The sample included the first 200 participants who were recruited between January and July 2015 on the SAX study across both the Eastern and Western Cape provinces of South Africa. The Eastern Cape is typically associated with rural, traditional Xhosa contexts, while the Western Cape is considered more urban. However, the population tends to migrate between the Eastern Cape where family relatives are based, and the Western Cape where most work opportunities are.

The sample of 200 Xhosa people with schizophrenia recruited for the SAX study included 104 (52%) in-patients and 96 (48%) out-patients from Eastern (n = 142, 71%) and Western (n = 58, 29%) Cape provincial psychiatric hospitals and out-patient clinics in South Africa. Of the total sample, 168 (84%) were male and 32 (16%) were female, ranging in age from 20-54 years with a mean age of 35 years. Of the total sample, most participants (187, 93.5%) were non-reactive to HIV testing. Majority of the sample (n = 83, 41.5%) reported their highest level of education between Grades 1-7, while 57 (28.5%) had completed Grades 8-10 and 53 (26.5%) Grades 11-12. Only 7 (3.5%) participants had participated in higher education or training.

The total sample included 197 (98.5%) Xhosa people who met the diagnostic criteria for schizophrenia, of which over half were paranoid type (n = 105, 52.5%). The other 3 (1.5%) participants met the criteria for schizoaffective disorder. The majority of participants (n = 128, 64%) were assessed as having moderate symptom severity, while most participants’ (n = 121, 60.5%) Global Assessment of Functioning (GAF) scores fell in the 31-70 point range. Over half of the total sample (n = 120, 60%) met criteria for a co-morbid substance-use disorder. Of these cannabis (n = 55, 46%), alcohol (n = 16, 13%), cannabis and alcohol (n = 35, 29%) were the most frequently reported substances. These demographics are summarized in Table 2. Resultant themes of the analysis of the content of delusions are presented in Table 3 and described below.

Persecutory delusions were found to be the most commonly reported type of delusion, consistent with the international literature [5]. In addition delusional content drew from cultural explanations of illness and a bewitchment framework, particularly with respect to persecutory delusions, delusions of reference and somatic delusions. For example, of those who reported persecutory delusions, 72.5% (n = 125) believed that others had bewitched them to bring about their mental illness, through evil spirits, “amafufunyana” or the “Tikoloshe”. This bewitchment framework has been reported to influence the content of delusions in other African samples including Sesotho people with schizophrenia from the Free State province of South Africa [Mosotho 40], and in neighboring African countries like Namibia [41], suggesting that this explanatory framework may be common in Southern African cultures. This observation aligns well with epidemiological studies that report the frequent use of spiritual causes as explanations for psychiatric illness in Southern African communities [19]. Three important points emerge from this analysis.

First, a focus on the recurring themes in the content of these delusions provides valuable insight into Xhosa patients’ experiences and potentially their treatment needs, allowing for better empathy and understanding. While participants demonstrated insight into being unwell, it was difficult to determine the extent to which they accepted the label of schizophrenia. Continued research into the content of delusions within African samples may add to increased knowledge and sensitivity about how cultural frameworks of understanding and explaining mental illness impact on the psychotic experiences of these patients. Tools such as the DSM 5 cultural formulation [42] are important aides in bridging the gap between Western and African conceptualisations of psychotic illness experiences. Similarly expanding the bio-psycho-social approach towards illness conceptualization, to include a spiritual element, may play a helpful role in patient recovery [43].

Second, people with schizophrenia represent a vulnerable and socially excluded population who are more likely to be negatively impacted on by poverty, human rights violations, stigma and discrimination [44]. The impact of schizophrenia on an individual’s cognitive, emotional and behavioural functioning may lead to behaviour that draws the attention of others in their community. For example, the referential belief that others were talking about them was the second most frequently reported type of delusion in this sample (n = 127, 63.5%), with some patients voluntarily reporting a sense of being reacted to in a negative way by those around them. The belief that illness was caused by bewitchment might also contribute a further layer of stigma [20, 24]. This experience of alienation and othering surely must compound referential thinking. Stigma interventions are therefore highlighted as an important part of the recovery process.

Third, these findings contribute to the debate about aspects of delusional thought that may be more universally stable, and those that may be more culturally specific and variable [3]. One cognitive theory of delusions, proposed by Garety and colleagues suggests that probabilistic reasoning becomes compromised in delusional thinking, leading individuals to jump to conclusions without sufficient evidence [45]. While this may be a more stable aspect of delusional thought, the framework drawn from to explain a person’s anomalous experiences appear to be more culturally variable, as in this study where bewitchment appears as a dominant explanatory framework in the Xhosa community, which may be applicable to other African communities.

One limitation of this study is that it does not document the verbatim responses of participants. However, findings provide a snapshot of the typical content of delusions. A second limitation is that this sample is not representative of all Xhosa people with schizophrenia but rather provides insight into the content of delusions of a sample of patients, the majority of which were male (84%) and living in the Eastern Cape (71%).

Finally, this paper did not examine how these belief effects extend to other psychotic symptoms including hallucinations. The relation of cultural explanations to auditory and tactile hallucinations in Southern Africa is an especially complex topic, because some kinds of hallucinations (e.g., voices of ancestors) are associated with being apprenticed to become Traditional Healers and continue among those who finish their training. Therefore we believe that these hallucinations merit separate treatment; they will be addressed in future work.

Qualitative exploration of the content of delusions within African samples such as the Xhosa people, contributes to better understanding of the cultural frameworks people draw from in explaining their psychotic illness experiences.

Improved knowledge of these explanatory frameworks has implications for better understanding treatment needs; highlight the value of culturally sensitive assessment tools such as the DSM 5 cultural formulation [42]; and stigma interventions in patient recovery. In addition, qualitative analysis of the content of delusions within specific cultural groups contributes to discussion about aspects of delusional thought that may be more universally stable, and those that may be more culturally variable.