Auditory Hallucinations, Posttraumatic Disorder, and Ethnicity
Stress
James Wilcox, David Briones, and Larry Suess The occurrence of intrusive auditory perceptions has rarely been addressed in the study of posttraumatic stress disorder. This study examined the background of 59 individuals with combat-related posttraumatic stress disorder. Subjects with and without auditory hallucinations were compared on demographic military and symptom variables. The occurrence of hallucinations among veterans with posttraumatic stress disorder appears to be more frequent among subjects of Hispanic ethnicity. This may have been related to higher combat exposure or social stresses. The occurrence of hallucinations was unrelated to drug abuse and did not appear to be associated with any particular war. Copyright 0 1991 by W.B. Saunders Company
P
OSTTRAUMATIC STRESS DISORDER can present with a variety of symptoms. The differences between individual veterans and their symptoms is poorly understood. These symptoms present in varying degrees. However, reexperiencing the traumatic event is a core characteristic that occurs in many veterans. It often takes the form of recurrent unpleasant images, nightmares, and intrusive feelings.‘.’ Clinical reports have documented intrusive visual experiences among posttraumatic stress disorder combat veterans.3.4 Other phenomenon, including hypnagogic hallucinations and other visual phenomenon, have been described,5 but auditory hallucinations have rarely been discussed in the literature. Van Putten and Emory6 described cases of Vietnam veterans with “traumatic neuroses” who experienced auditory hallucinations. A recent study by Mueser and Butler examined the characteristics of several veterans who presented at an inpatient facility with auditory hallucinations and posttraumatic stress disorder. These investigators suggested that auditory hallucinations among veterans with posttraumatic stress disorder may be more common in Hispanic populations, and suggested that cultural factors play a role in the development of this symptom.7 The present report focuses on the prevalence of auditory hallucinations in combat veterans with posttraumatic stress disorder. This study differs from previous work, because it looks at lifetime prevalence data rather than point prevalence information. It also differs from previous studies because a large percentage of the subjects in this study were of Hispanic ethnicity. METHOD The subjects were 59 male psychiatric outpatients in treatment at the El Paso Veterans Administration Outpatient Clinic. This represented all consecutively treated veterans with posttraumatic stress disorder at the clinic in a 3-month period. All subjects had been in treatment for posttraumatic stress disorder for more than 1 year. All patients met DSM-III criteria for posttraumatic stress disorder and had detailed interviews conducted by at least three Board-certified psychiatrists at different intervals. The kappa coefficient of agreement on diagnosis by different psychiatrists was .90.
From the Depatiment of Psychiatry, Texas Tech University Health Sciences Center, El Paso, TX. Address reprint requests to James WVcox, D.O., MS., Department of Psychiatry, Texas Tech University Health Sciences Center, 4800 Alberta Ave, El Paso, TX 79905. Copyright 0 1991 by WE. Saunders Company 0010-440X19113204-001 7$03.00/O 320
Comprehensive
Psychiatry, Vol. 32, No. 4 (July/August),
1991: pp 320-323
POS-ITRAUMATIC
STRESS AND ETHNICITY
321
The principal investigator (J.W.) had access to all clinical Veterans Administration records concerning these subjects. None of the subjects refused to participate. The principal investigator also conducted a detailed interview with all subjects. This interview confirmed the previous diagnosis of posttraumatic stress disorder using DMS-III operational criteria, and gathered information concerning demographic characteristics, including age of combat exposure and age of onset of illness. For this study, ethnic@ was defined according to the group that the subject claimed membership in (black, Asian, Hispanic, and non-Hispanic white). Agreement between the subject self-report on ethnicity and ethnicity noted in the medical record was 100%. Other information collected included pre- and post-military functioning, use of drugs, history of head injury, and family history of psychiatric illness.
Statistics The primary focus of attention was the occurrence of auditory hallucinations in posttraumatic stress disorder veterans who were of Hispanic ethnic@ compared with other groups. This was examined using the chi-square test statistic with the Yates correction factor. The chi-square test statistic was also used to evaluate the impact of other variables, such as age of combat, age of onset of illness, history of drug abuse. etc., with the occurrence of auditory hallucinations. Where appropriate, correlation procedures were performed to look for interactions using Kendall’s correlation.
RESULTS
We found that veterans with auditory hallucinations were much more likely to be of Hispanic ethnic@ than other ethnicity (x’ = 49.42, P < .OOl, u” = 1). Further breakdown of the Hispanic group into those individuals of MexicanAmerican descent and those of Puerto Rican descent found no difference between these groups regarding hallucinations. Age of combat, length of exposure to combat, and age of onset of posttraumatic stress disorder symptoms did not appear to be related to the occurrence of hallucinations in a significant way. Similarly, history of drug abuse, history of head injury, and family history of psychiatric illness also did not appear to be significantly associated with auditory hallucinations for the group as a whole. Duration of combat exposure and history of prisoner of war status were not significantly related to the occurrence of auditory hallucinations. The occurrence of hallucinations was not associated with a particular combat event or war. In regard to the report of symptomology, Hispanics did not report more symptoms that other ethnic groups, but, within the Hispanic population, the subgroup of individuals with Puerto Rican ethnicity reported more symptoms than both subjects of Mexican-American descent and other non-Hispanic individuals (x’ = 24.06, P < .OOl, df = 1). There was no significant correlation between risk factors. The life prevalence of auditory hallucinations in our sample was 28.9%. This is a statistic reflecting the occurrence of hallucinations over a long period of time following the combat trauma (mean time since combat, 22 + 2.8 [SD] years). Although Hispanic ethnicity was correlated to hallucinations (P < .Ol), no other significant correlations were found. DISCUSSION
Our experience suggests that persistent auditory hallucinations can accompany posttraumatic stress disorder in a significant number of cases. It also seems that a significantly greater proportion of veterans with auditory hallucinations were of Hispanic ethnic@, 38.8% compared with 13%. These findings are consistent with the findings of Mueser and Butler.’ Our findings differ from the previous study, because our subject selection process allowed us to collect more cases and also
322
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BRIONES, AND SUESS
involve a greater percentage of veterans of Hispanic ethnic@. We also have a more longitudinal view of the cases, due to the extensive chart review and emphasis on prevalence information. The presence of auditory hallucinations in posttraumatic stress disorder is interesting. It seemed unlikely that our subjects were experiencing hallucinations due to some other illness, since there was no gross impairment of reality testing nor were there any major symptoms of other psychotic or affective disorders. Hallucinations were typically reminiscent of the veterans’ traumatic experience. Frequently, hallucinations were characterized by hearing cries for help or conversations concerning battle. Our sample size was too small to allow us to comment on differences between Puerto Rican and other Hispanics, Although our sample size was small, it is important to realize that the findings were consistent with the previous study.’ Our sample was demographically and ethnically representative of our general clinic population. One must appreciate that a small study in an atypical (border area) city may have some selection bias that would make generalization to other populations difficult. Furthermore, there is a possibility that the experiences of a clinical population may be influenced by help-seeking behaviors, making comparison to nonclinical populations difficult. A follow-up study on a nonclinical population is needed to clarify this issue. The higher occurrence of hallucinations among Hispanic veterans suggests that cultural factors may play a role in the development of this symptom. Previous work on Hispanic veterans has found that many of those with posttraumatic stress disorder appeared to feel alienated from their cultural heritage.* We are unable to comment on this possibility, since we did not measure level of acculturation in our subjects. Previous research conducted by Kolb has suggested a subtype of posttraumatic stress disorder that is characterized by heightened response to environmental stimuli.9 This subtype may be similar to that of the subjects with posttraumatic stress disorder and auditory hallucinations. If this is the case, then combat exposure and cultural upbringing could mediate the occurrence of hallucinations. The observations of this study are still preliminary, but are significant because they support findings of prior independent research.‘.” Our findings suggest that there may be a subtype of posttraumatic stress disorder where auditory hallucinations occur in the absence of other psychotic or major affective symptomology. The finding of an ethnic variation in this syndrome is still difficult to account for. It may be related to confounding variables associated with ethnicity such as poverty or disadvantaged social status. Further work on the occurrence of posttraumatic stress disorder in ethnic populations is encouraged. Research using a full range of psychological and biological variables, including conditions of acculturation, would help clarify these issues. REFERENCES 1. Horowitz MJ: Stress Response Syndromes. New York, NY, Aronson, 1976 2. Atkinson RM, Sparr LF, Sheff AG, et al: Diagnosis of posttraumatic stress disorder in Viet Nam veterans: Preliminary findings. Am J Psychiatry 141:694-696,1984 3. Laufer RS, Brett E, Gallops MS: Dimensions of posttraumatic stress disorder among Vietnam veterans. J Nerv Ment Dis 1973:538-545, 1985 4. Brett EA, Ostroff R: Imaginary and posttraumatic stress disorder: An overview. Am J Psychiatry 142:417-424, 1985
POSlTRAUMATlC STRESS AND ETHNICITY
323
5. Grinker R, Spiegel J: Men Under Stress. Philadelphia, PA, Blakiston, 1945 6. Van Putten T, Emory WH: Traumatic neuroses in Vietnam returnees. Arch Gen Psychiatry 29:695-698,1973 7. Mueser K, Butler R: Auditory hallucinations in combat-related chronic posttraumatic stress disorder. Am J Psychiatry 144:299-302, 1987 8. Escobar J, Randolph E, Puente G, et al: Posttraumatic stress disorder in Hispanic Vietnam veterans. J Nerv Ment Dis 171:585-596,1983 9. Kolb LC: The posttraumatic stress disorders of combat: A subgroup with a conditioned emotional response. Milit Med 149:237-243, 1984 10. Kulka RJ: Contractual Report of Findings From the National Vietnam Veterans Readjustment Study. Research Triangle Park, NC, Research Triangle Institute, 1988 11. Cervantes RC, Salgado de Snyder VN, Padilla AM: Posttraumatic stress in immigrants from Central America and Mexico. Hosp Community Psychiatry 40~615-619,1989
Stress
James Wilcox, David Briones, and Larry Suess The occurrence of intrusive auditory perceptions has rarely been addressed in the study of posttraumatic stress disorder. This study examined the background of 59 individuals with combat-related posttraumatic stress disorder. Subjects with and without auditory hallucinations were compared on demographic military and symptom variables. The occurrence of hallucinations among veterans with posttraumatic stress disorder appears to be more frequent among subjects of Hispanic ethnicity. This may have been related to higher combat exposure or social stresses. The occurrence of hallucinations was unrelated to drug abuse and did not appear to be associated with any particular war. Copyright 0 1991 by W.B. Saunders Company
P
OSTTRAUMATIC STRESS DISORDER can present with a variety of symptoms. The differences between individual veterans and their symptoms is poorly understood. These symptoms present in varying degrees. However, reexperiencing the traumatic event is a core characteristic that occurs in many veterans. It often takes the form of recurrent unpleasant images, nightmares, and intrusive feelings.‘.’ Clinical reports have documented intrusive visual experiences among posttraumatic stress disorder combat veterans.3.4 Other phenomenon, including hypnagogic hallucinations and other visual phenomenon, have been described,5 but auditory hallucinations have rarely been discussed in the literature. Van Putten and Emory6 described cases of Vietnam veterans with “traumatic neuroses” who experienced auditory hallucinations. A recent study by Mueser and Butler examined the characteristics of several veterans who presented at an inpatient facility with auditory hallucinations and posttraumatic stress disorder. These investigators suggested that auditory hallucinations among veterans with posttraumatic stress disorder may be more common in Hispanic populations, and suggested that cultural factors play a role in the development of this symptom.7 The present report focuses on the prevalence of auditory hallucinations in combat veterans with posttraumatic stress disorder. This study differs from previous work, because it looks at lifetime prevalence data rather than point prevalence information. It also differs from previous studies because a large percentage of the subjects in this study were of Hispanic ethnicity. METHOD The subjects were 59 male psychiatric outpatients in treatment at the El Paso Veterans Administration Outpatient Clinic. This represented all consecutively treated veterans with posttraumatic stress disorder at the clinic in a 3-month period. All subjects had been in treatment for posttraumatic stress disorder for more than 1 year. All patients met DSM-III criteria for posttraumatic stress disorder and had detailed interviews conducted by at least three Board-certified psychiatrists at different intervals. The kappa coefficient of agreement on diagnosis by different psychiatrists was .90.
From the Depatiment of Psychiatry, Texas Tech University Health Sciences Center, El Paso, TX. Address reprint requests to James WVcox, D.O., MS., Department of Psychiatry, Texas Tech University Health Sciences Center, 4800 Alberta Ave, El Paso, TX 79905. Copyright 0 1991 by WE. Saunders Company 0010-440X19113204-001 7$03.00/O 320
Comprehensive
Psychiatry, Vol. 32, No. 4 (July/August),
1991: pp 320-323
POS-ITRAUMATIC
STRESS AND ETHNICITY
321
The principal investigator (J.W.) had access to all clinical Veterans Administration records concerning these subjects. None of the subjects refused to participate. The principal investigator also conducted a detailed interview with all subjects. This interview confirmed the previous diagnosis of posttraumatic stress disorder using DMS-III operational criteria, and gathered information concerning demographic characteristics, including age of combat exposure and age of onset of illness. For this study, ethnic@ was defined according to the group that the subject claimed membership in (black, Asian, Hispanic, and non-Hispanic white). Agreement between the subject self-report on ethnicity and ethnicity noted in the medical record was 100%. Other information collected included pre- and post-military functioning, use of drugs, history of head injury, and family history of psychiatric illness.
Statistics The primary focus of attention was the occurrence of auditory hallucinations in posttraumatic stress disorder veterans who were of Hispanic ethnic@ compared with other groups. This was examined using the chi-square test statistic with the Yates correction factor. The chi-square test statistic was also used to evaluate the impact of other variables, such as age of combat, age of onset of illness, history of drug abuse. etc., with the occurrence of auditory hallucinations. Where appropriate, correlation procedures were performed to look for interactions using Kendall’s correlation.
RESULTS
We found that veterans with auditory hallucinations were much more likely to be of Hispanic ethnic@ than other ethnicity (x’ = 49.42, P < .OOl, u” = 1). Further breakdown of the Hispanic group into those individuals of MexicanAmerican descent and those of Puerto Rican descent found no difference between these groups regarding hallucinations. Age of combat, length of exposure to combat, and age of onset of posttraumatic stress disorder symptoms did not appear to be related to the occurrence of hallucinations in a significant way. Similarly, history of drug abuse, history of head injury, and family history of psychiatric illness also did not appear to be significantly associated with auditory hallucinations for the group as a whole. Duration of combat exposure and history of prisoner of war status were not significantly related to the occurrence of auditory hallucinations. The occurrence of hallucinations was not associated with a particular combat event or war. In regard to the report of symptomology, Hispanics did not report more symptoms that other ethnic groups, but, within the Hispanic population, the subgroup of individuals with Puerto Rican ethnicity reported more symptoms than both subjects of Mexican-American descent and other non-Hispanic individuals (x’ = 24.06, P < .OOl, df = 1). There was no significant correlation between risk factors. The life prevalence of auditory hallucinations in our sample was 28.9%. This is a statistic reflecting the occurrence of hallucinations over a long period of time following the combat trauma (mean time since combat, 22 + 2.8 [SD] years). Although Hispanic ethnicity was correlated to hallucinations (P < .Ol), no other significant correlations were found. DISCUSSION
Our experience suggests that persistent auditory hallucinations can accompany posttraumatic stress disorder in a significant number of cases. It also seems that a significantly greater proportion of veterans with auditory hallucinations were of Hispanic ethnic@, 38.8% compared with 13%. These findings are consistent with the findings of Mueser and Butler.’ Our findings differ from the previous study, because our subject selection process allowed us to collect more cases and also
322
WILCOX,
BRIONES, AND SUESS
involve a greater percentage of veterans of Hispanic ethnic@. We also have a more longitudinal view of the cases, due to the extensive chart review and emphasis on prevalence information. The presence of auditory hallucinations in posttraumatic stress disorder is interesting. It seemed unlikely that our subjects were experiencing hallucinations due to some other illness, since there was no gross impairment of reality testing nor were there any major symptoms of other psychotic or affective disorders. Hallucinations were typically reminiscent of the veterans’ traumatic experience. Frequently, hallucinations were characterized by hearing cries for help or conversations concerning battle. Our sample size was too small to allow us to comment on differences between Puerto Rican and other Hispanics, Although our sample size was small, it is important to realize that the findings were consistent with the previous study.’ Our sample was demographically and ethnically representative of our general clinic population. One must appreciate that a small study in an atypical (border area) city may have some selection bias that would make generalization to other populations difficult. Furthermore, there is a possibility that the experiences of a clinical population may be influenced by help-seeking behaviors, making comparison to nonclinical populations difficult. A follow-up study on a nonclinical population is needed to clarify this issue. The higher occurrence of hallucinations among Hispanic veterans suggests that cultural factors may play a role in the development of this symptom. Previous work on Hispanic veterans has found that many of those with posttraumatic stress disorder appeared to feel alienated from their cultural heritage.* We are unable to comment on this possibility, since we did not measure level of acculturation in our subjects. Previous research conducted by Kolb has suggested a subtype of posttraumatic stress disorder that is characterized by heightened response to environmental stimuli.9 This subtype may be similar to that of the subjects with posttraumatic stress disorder and auditory hallucinations. If this is the case, then combat exposure and cultural upbringing could mediate the occurrence of hallucinations. The observations of this study are still preliminary, but are significant because they support findings of prior independent research.‘.” Our findings suggest that there may be a subtype of posttraumatic stress disorder where auditory hallucinations occur in the absence of other psychotic or major affective symptomology. The finding of an ethnic variation in this syndrome is still difficult to account for. It may be related to confounding variables associated with ethnicity such as poverty or disadvantaged social status. Further work on the occurrence of posttraumatic stress disorder in ethnic populations is encouraged. Research using a full range of psychological and biological variables, including conditions of acculturation, would help clarify these issues. REFERENCES 1. Horowitz MJ: Stress Response Syndromes. New York, NY, Aronson, 1976 2. Atkinson RM, Sparr LF, Sheff AG, et al: Diagnosis of posttraumatic stress disorder in Viet Nam veterans: Preliminary findings. Am J Psychiatry 141:694-696,1984 3. Laufer RS, Brett E, Gallops MS: Dimensions of posttraumatic stress disorder among Vietnam veterans. J Nerv Ment Dis 1973:538-545, 1985 4. Brett EA, Ostroff R: Imaginary and posttraumatic stress disorder: An overview. Am J Psychiatry 142:417-424, 1985
POSlTRAUMATlC STRESS AND ETHNICITY
323
5. Grinker R, Spiegel J: Men Under Stress. Philadelphia, PA, Blakiston, 1945 6. Van Putten T, Emory WH: Traumatic neuroses in Vietnam returnees. Arch Gen Psychiatry 29:695-698,1973 7. Mueser K, Butler R: Auditory hallucinations in combat-related chronic posttraumatic stress disorder. Am J Psychiatry 144:299-302, 1987 8. Escobar J, Randolph E, Puente G, et al: Posttraumatic stress disorder in Hispanic Vietnam veterans. J Nerv Ment Dis 171:585-596,1983 9. Kolb LC: The posttraumatic stress disorders of combat: A subgroup with a conditioned emotional response. Milit Med 149:237-243, 1984 10. Kulka RJ: Contractual Report of Findings From the National Vietnam Veterans Readjustment Study. Research Triangle Park, NC, Research Triangle Institute, 1988 11. Cervantes RC, Salgado de Snyder VN, Padilla AM: Posttraumatic stress in immigrants from Central America and Mexico. Hosp Community Psychiatry 40~615-619,1989
