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The Content of Delusions in a Sample of South African Xhosa People with Schizophrenia Megan M

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The Content of Delusions in a Sample of South African Xhosa People with Schizophrenia Megan M Campbell et al. BMC Psychiatry (2017) 17:41 DOI 10.1186/s12888-017-1196-3 RESEARCHARTICLE Open Access The content of delusions in a sample of South African Xhosa people with schizophrenia Megan M. Campbell1*, Goodman Sibeko1, Sumaya Mall1, Adam Baldinger1, Mohamed Nagdee2, Ezra Susser3 and Dan J. Stein4 Abstract Background: Although the relationship between cultural beliefs and schizophrenia has received some attention, relatively little work has emerged from African contexts. In this study we draw from a sample of South African Xhosa people with schizophrenia, exploring their cultural beliefs and explanations of illness. The purpose of the article is to examine the relationship between this cultural context and the content of delusions. Methods: A sample comprising 200 Xhosa people with schizophrenia participating in a South African schizophrenia genomics study were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Participant delusions were thematically analyzed for recurring themes. Results: The majority of participants (n = 125 72.5%) believed that others had bewitched them in order to bring about their mental illness, because they were in some way jealous of the participant. This explanation aligns well with the understanding of jealousy-induced witchcraft in Southern African communities and highlights the important role that culture plays in their content of delusions. Conclusions: Improved knowledge of these explanatory frameworks highlights the potential value of culturally sensitive assessment tools and stigma interventions in patient recovery. Furthermore such qualitative analyses contribute towards discussion about aspects of delusional thought that may be more universally stable, and those that may be more culturally variable. Keywords: Schizophrenia, Delusions, Illness explanations, South Africa, Xhosa people Background cultural factors such as religious belief systems [6, 13, 14] The core symptoms of schizophrenia have shown and more collective or individualistic conceptualizations consistency across cultural contexts [1, 2], and while the of self [15] as well as environmental factors [16], historical categories of types of delusions (e.g.,: persecutory, grandi- events [12] and political contexts [7,9,] have been shown ose etc.) appear stable, they demonstrate cultural plasticity to influence the content of delusions. Within particular in their content [3, 4]. For example, transcultural studies cultural groups factors such as sex, age, education and have identified universal delusional experiences amongst socio-economic status [8, 10], geography [11, 15], urban people with schizophrenia [5] with persecutory delusions and rural living contexts [6, 8] have also demonstrated being the most commonly reported across a diverse range influence. Consistent with international cross-cultural of samples drawn from Austria [6]; China, Japan and studies, persecutory delusions, including the belief that South Korea [7]; India [8]; Lithuania [9]; Pakistan [10] others are plotting against or planning to hurt the individ- Turkey [11] and the United States [12]. However socio- ual, appear to be the most frequently reported type of de- lusion in South African Xhosa people with schizophrenia [17, 18]. However, to date qualitative exploration of the * Correspondence: [email protected] 1Department of Psychiatry and Mental Health, University of Cape Town, content of these delusions remains relatively limited. It’s J-Block, Groote Schuur Hospital, Observatory, Cape Town 8000, South Africa likely that the widely accepted belief in the Xhosa culture Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Campbell et al. BMC Psychiatry (2017) 17:41 Page 2 of 9 that mental illness has its root cause in witchcraft plays an Bewitchment takes numerous forms. One of these is integral role in the content of these delusions [18, 19]. “isidliso” or poisoning by ingestion which may result in These cultural beliefs also have a broader impact on how physical symptoms such as chronic coughing, chest pain schizophrenia is explained and understood in the Xhosa and blood in the sputum, much like Tuberculosis [26, 29]. community, influencing help-seeking behaviors and treat- Bewitchment also takes the form of possessions by evil ment, as well as medication compliance [17, 20, 21]. spirits, the manifestation of which may be consistent with Improved understanding of the content of persecutory mental illness. One example is “amafufunyana” which and other delusions of Xhosa people with schizophrenia refers to a state of perceived possession by multiple spirits has implications for better empathy and understanding of that may speak or communicate through the possessed these patients and potentially their treatment needs. individual [21]. Another state of bewitchment may involve Furthermore, little is currently known about the interaction the "dirty spirit," known as the “Tikoloshe”, described as a between culture and the formation of delusions [3]. Some small hairy man with a large penis which he carries over aspects of delusional thought may be the result of cognitive his left shoulder [30]. The impact of bewitchment may processes that are biological and universal human experi- then manifest in social misfortunes such as unemploy- ences, others may demonstrate considerable cultural ment, family conflict and a loss of social support within variability [3, 4]. Consideration of aspects of delusional the community [26]. thought across different cultural contents may prove Traditional healing interventions are sought to repel valuable to the cognitive theory of delusions. This paper the bewitchment and protect against further attack [26, aims to contribute to understanding about the relationship 29]. Such interventions include acts aimed at cleansing between culture and delusional content by exploring the the patient and their family of evil spirits [20, 31]. Bio- content of delusions reported within a sample of 200 medical interventions are considered necessary by some Xhosa people with schizophrenia recruited for a genomics patients, their families and traditional healers, in treating of schizophrenia study in South Africa. the symptoms of any illness resulting from bewitchment [26, 29]. Psychiatric assessment, hospitalization and The Xhosa community medication are therefore accepted by some as effective The Xhosa are South African Bantu-speakers, forming ways of managing psychotic symptoms thought to be in- part of the Nguni language tribes, whose ancestors duced by witchcraft [20, 32]. migrated to southern Africa over the last 1500 years, and represent both Bantu-speaking African populations and, The Genomics of Schizophrenia in South African Xhosa through admixture, the ancient Khoisan lineage [22]. The People (SAX) project Xhosa people fall historically within the group of racially Current genetic research under-represents the African segregated and oppressed South Africans discriminated lineage [33], making findings that shape our understand- against during Apartheid governance. As a result many ing of the underlying causes, prevention, and treatment still contend with extreme inequalities with respect to of schizophrenia less directly applicable to African popu- education and economic opportunities, housing and lations. The Genomics of Schizophrenia in South healthcare services amongst others [23]. Xhosa people African Xhosa People (SAX) project seeks to identify with schizophrenia are a small minority within this larger genetic variations or mutations underlying predispos- community, and contend with the discrimination and ition to schizophrenia in the Xhosa people. The SAX stigmatization associated with mental illness, as an added project, initiated in January 2013, aimed to recruit 1100 burden [20, 24, 25]. Xhosa people with a clinical diagnosis of schizophrenia A diverse range of spiritual beliefs underpin the Xhosa or schizoaffective disorder and 1100 matched controls over culture including African traditional healing methods a 5-year period. Participants were recruited from provincial and medicine, ancestor worship, magic and witchcraft, hospitals and clinics in the Eastern and Western Cape along with Christian, Islamic, atheist and agnostic beliefs provinces of South Africa. [17]. Witchcraft is particularly prevalent in congested or over-crowded areas [27] where it is believed to result Methods from the ancestors withdrawing their protection, allowing The aim of this article was to explore the content of de- witches to bring misfortune onto an individual [26, 28]. lusions reported by a sample of Xhosa people with Accusations of bewitchment typically follow a specific schizophrenia, recruited for the SAX study. The sample circumstance or misfortune, where witchcraft, performed included the first 200 participants who were recruited on the grounds of jealousy, is intended to prevent a person
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