The role of magical thinking in hallucinations. Comparisons of clinical and non-clinical groups
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JOSÉ M. GARCÍA-MONTES, MARINO PÉREZ-ÁLVAREZ, PAULA ODRIOZOLA-GONZÁLEZ, OSCAR VALLINA-FERNÁNDEZ, SALVADOR PERONA-GARCELÁN
García-Montes JM, Pérez-Álvarez M, Odriozola-González P, Vallina-Fernández O, PeronaGarcelán S. The role of magical thinking in hallucinations. Comparisons of clinical and nonclinical groups. Nord J Psychiatry 2014;68:605–610. Background: Magical thinking consists of accepting the possibility that events that, according to the causal concepts of a culture, cannot have any causal relationship, but might somehow nevertheless have one. Magical thinking has been related to both obsessive–compulsive disorder and schizophrenia. Aims: The purpose of this study was to investigate the role of magical thinking in hallucinations of patients diagnosed with schizophrenia. Methods: Four groups were recruited for this purpose from a clinical population (hallucinating schizophrenic patients, patients diagnosed with psychoses who had never hallucinated, obsessive–compulsive disorder patients and a clinical control group) and a non-clinical control group, who were given the Magical Ideation Scale. Results: The results show that magical ideation differentiates the group of schizophrenic patients with auditory hallucinations from the rest of the groups that participated in the design. Items related to “mind reading”, to the presence of auditory illusions in response to sound stimuli, and to the sense of sometimes being accompanied by an evil presence are the most closely related to the presence of auditory hallucinations. Conclusions: Magical thinking, understood as beliefs in non-consensual modes of causation, is closely linked to auditory hallucinations in patients diagnosed with schizophrenia. • Hallucinations, Obsessive–compulsive Disorder, Schizophrenia. José M. García Montes, Departamento de Psicología, Universidad de Almería, Carretera de Sacramento, s/n. 04120-La Cañada de San Urbano, Almería, Spain. E-mail: [email protected]; Accepted 4 March 2014.
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ince the term “hallucination”, a disorder in which the subject reports perceiving an event, or a series of events, in the absence of appropriate stimulus, was introduced in medical vocabulary by Esquirol in 1917, it has been considered among the most mysterious and serious of psychological disorders (1). Schneider (2) considered them a top-ranking symptom of schizophrenia if found in the absence of brain pathology. In fact, in a study funded by the WHO, auditory hallucinations were shown to be the second most frequent symptom in diagnosing schizophrenia (present in 74% of cases) after lack of insight (present in 97% of cases) (3). However, in addition to persons diagnosed with schizophrenia or schizophrenia spectrum, they may also appear in other diagnoses, such as affective bipolar disorder and unipolar depression, in borderline personality disorders, © 2014 Informa Healthcare
post-traumatic disorder, dissociative disorders, and in people without any psychiatric disorder at all (4). Apart from this, magical thinking may be defined as a “belief, quasi-belief, or semiserious entertainment of the possibility that events which, according to the causal concepts of this culture, cannot have a causal relation with each other, might somehow nevertheless do so” (5). Children (6) and so-called “primitive societies” (7, 8) are supposedly particularly disposed to magical thinking. Empirical research has demonstrated that such beliefs are also found in adults in Western societies (9). For example, about one quarter of Americans believe in astrology, clairvoyance, ghosts and communication with the dead (10). However, it is generally understood that this kind of beliefs play a minimal role in normal adult behaviour, emerging only in situations of stress (11). In the DSM DOI: 10.3109/08039488.2014.902500
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JM GARCÍA-MONTES ET AL.
IV-TR, magical thinking was one of the defining characteristics of schizotypal personality disorder when the person’s behaviour was affected and inconsistent with social norms (12). Its role in adult psychological disorders, such as Obsessive–compulsive Disorder (OCD) and schizophrenia should be emphasized. In fact, it seems clear that magical thinking has a relevant role in OCD (13), and it has even been affirmed that the strong presence of magical thinking distinguishes OCD from other anxiety disorders (11). It also appears to be a factor in poor prognosis for OCD treatment (14). Adult patients with schizophrenia also seem to have a stronger tendency for magical thinking than either the normal population (15) or nonschizophrenic psychiatric patients (16). In this regard, magical thinking is considered one of the most influential predictors of later development of a schizophrenic disorder (17), and has been linked to the appearance of visual and auditory hallucinations (18). The relevance of magical thinking in auditory hallucinations of psychotic and OCD patients has been stressed by García-Montes et al. (19). These authors found that metacognitive beliefs about punishment and responsibility in relation to one’s own thoughts emerged as key factors in understanding both auditory hallucinations in psychotic patients and OCD. This type of metacognitive belief (e.g. “If I did not control a worrying thought, and then it happened, it would be my fault”) are interpreted by the authors as clear examples of magical thinking. However, it is clear that there are differences between the type of metacognitive belief that overvalues the power of certain private events, and other more culturally dissonant forms of magical thought, such as belief in mind reading, amulets or other paranormal beliefs that violate the fundamental and scientifically founded principles of nature.
Aims The purpose of this study was to determine the role of magical thinking in hallucinations of patients diagnosed with a schizophrenia spectrum disorder. To do this, we start out from the hypothesis that magical thinking is a characteristic defining psychotic patients with auditory hallucinations compared with another group of patients.
Material and methods Participants We formed five groups of patients diagnosed with various disorders according to DSM IV TR criteria (12). Group 1 (schizophrenic patients with hallucinations; n ⫽ 37; gender: male (M) ⫽ 24, female (F) ⫽ 13; age mean ⫽ 35.37 years), was made up of patients diagnosed with schizophrenia who reported currently having auditory hallucinations. The criterion taken to determine
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whether a patient diagnosed with schizophrenia suffered from auditory hallucinations was a score ⱖ 4 on the auditory hallucinations item of the Positive and Negative Syndrome Scale (20). Schizophrenic patients who did not meet this criterion were discarded from the group, as our purpose was to study the relationship of magical thinking to a possible symptom of schizophrenia such as hallucinations and not the disorder itself. Group 2 (patients diagnosed with psychoses; n ⫽ 30; gender: M ⫽ 27, F ⫽ 3; age mean ⫽ 36.73 years) was composed of patients diagnosed with a psychosis who at no time had reported hallucinatory experiences in any sensory mode. A total of 20 patients diagnosed with schizophrenia were included in this group, five with persecutory delusional disorder, four with schizo-affective disorder and one diagnosed with a bipolar disorder. Group 3 (OCD; n ⫽ 37; gender: M ⫽ 22, F ⫽ 15; age mean ⫽ 31.27 years) was made up of patients who had been diagnosed with OCD. The mean score of this group of patients on the Maudsley Obsessive–Compulsive Inventory (21) was 11.49, with a standard deviation of 5.83. The most common obsessions in the group had to do with conscience/doubting, followed by checking. Group 4 (clinical control group, n ⫽ 41; gender: M ⫽ 20, F ⫽ 21; age mean ⫽ 31.48 years) was composed of patients treated by mental health services for a diversity of problems (adjustment disorder, n ⫽ 7; generalized anxiety disorder, n ⫽ 6; major depressive disorder, n ⫽ 5; personality disorder, n ⫽ 4; dysthymia, n ⫽ 3; anxiety disorder with agoraphobia, n ⫽ 3; marital problems, n ⫽ 2; anorexia nervosa, n ⫽ 1; bulimia nervosa, n ⫽ 1; substance abuse, n ⫽ 1; alcohol dependence disorder, n ⫽ 1; primary insomnia, n ⫽ 1; social phobia, n ⫽ 1; specific phobia, n ⫽ 1; post-traumatic stress disorder, n ⫽ 1; severe stress disorder, n ⫽ 1; anxiety disorder with no agoraphobia, n ⫽ 1, unspecified depressive disorder, n ⫽ 1). Obviously, patients who had previously suffered from some psychotic disorder or OCD were excluded. Finally, Group 5 (non-clinical control group; n ⫽ 42; gender: M ⫽ 24, F ⫽ 18; age mean ⫽ 35.11 years) was made up of people who went to a psychotechnical evaluation centre for a certificate to renew their driving licence. We excluded those who had sought psychiatric attention or had received psychoactive medication. All the patients diagnosed with psychoses in this study were taking neuroleptic medication. Some were also taking benzodiazepines or, in fewer cases, antidepressants.
Instruments The Magical Ideation Scale (MIS) (17) is a 30-item true– false measure that contains items pertaining to idiosyncratic perceptions of cause-effect relationships. It is important to note that superstition and paranormal beliefs are not the only features of MIS. The concept of magical NORD J PSYCHIATRY·VOL 68 NO 8·2014
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thinking as defined by this scale includes a number of unusual forms of thought that are associated with schizotypal personality disorder. For example, there are questions that address ideas of reference (“I have sometimes had the passing thought that strangers are in love with me”) or that describe unusual perceptual experiences (“I have had the momentary feeling that I might not be human”) (10). In fact, the MIS correlates with other schizotypy measures, such as the Perceptual Aberration Scale and it is reported to have good internal consistency with coefficients ranging from 0.82 to 0.93 (22). In this study, the Spanish adaptation was used (22).
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Procedure After agreeing to take part in the study, all the patients were checked to see whether they fulfilled the DSM IV TR diagnostic criteria (12) for their group at that time. They were then administered the questionnaire described above. The person who administered the test was the psychologist who normally attended the patient. Participants received no compensation for their involvement in the study.
Results Comparative participant statistics Statistically significant differences found in the ages of the members of each group [F(4, 182) ⫽ 2.80, P ⫽ 0.027] were not significant after the post hoc Bonferroni correction was applied. A statistically significant difference in distribution of the patients within the groups by gender [chi-square ⫽ 13.73, d.f. ⫽ 4, P ⬍ 0.01], particularly the few women participants in the group of “patients diagnosed with psychoses who had never hallucinated,” should be mentioned.
Tests prior to analysis of the results Before analysing the results, a Levene’s test was done to check for homogeneity of error variances. Participant scores on the MIS did not fulfil the hypothesis of equal group variance either [F(4,182) ⫽ 3.247, P ⬍ 0.01]. Data were therefore analysed using the Welch’s test and post hoc analyses were done with the Tamhane test. In this regard, it should be mentioned that Welch’s t-test is an adaptation of the Student’s t-intended for use with two or
more samples having unequal variances to detect whether there are significant differences in group means. As there were five groups in the study, the Tamhane test was used post hoc to determine among which groups of patients there were differences in the mean MIS scores.
Data analysis The results of applying the Welch’s test showed significant differences between groups [T(4, 90.27) ⫽ 7.62, P ⬍ 0.01]. Table 1 shows mean scores and 95% confidence intervals for the groups. It may be observed that the group of “schizophrenic patients with hallucinations” scored significantly higher in magical thinking than the rest of the groups that took part in this study. To determine which of the items on the MIS are most directly related to the presence of hallucinations in patients diagnosed with schizophrenia, a contingency table was made in which the different groups the participants were classified in were the columns and the rows were the items on the MIS. A Z-test was done to determine whether there were differences in the proportions of participants in the different groups that had answered affirmatively or negatively on each of the items in the MIS, and a Bonferroni correction to adjust significance levels. Table 2 summarizes the results. As observed, the patients with voices showed statistically significant differences from the rest of the patients taking part in the study on items 8 (“I have occasionally had the silly feeling that a TV or radio broadcaster knew I was listening to him”), 14 (“I have noticed sounds on my records that are not there other times”), 19 (“I have sometimes sensed an evil presence around me although I could not see it”) and 30 (“I have sometimes felt that strangers were reading my mind”). The Goodman–Kruskal’s τ coefficient was used to find the strength of the relationships among these items and the group to which they belong. This coefficient is an asymmetric coefficient similar to the Lambda coefficient by the same authors, but unlike that, is based on errors made in random assignment of cases to the categories of the dependent variable, in our case, the group. The results of this analysis showed that Item 8 (“I have occasionally had the silly feeling that a TV or radio broadcaster knew I was listening to him”)
Table 1. Mean scores and 95% confidence intervals for the Magical Ideation Scale (MIS).
MIS
Schizophrenic patients with hallucinations
Psychotic patients who never hallucinated
OCD
Clinical control
Non-clinical control
11.48a,b,c,d (9.54–13.43)
5.30a (4.00–6.59)
5.94b (4.58–7.30)
6.60c (4.99–8.22)
6.50d (4.88–8.11)
*Values sharing the same letter are significantly different, based on Tamhane’s T2. NORD J PSYCHIATRY·VOL 68 NO 8·2014
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Table 2. Percentages of affirmative (T) or negative (F) responses to each of the items on the Magical Ideation Scale (MIS) by group. MIS items 1 2 3 4 5 6
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7* 8 9 10 11 12* 13* 14 15 16* 17 18* 19 20 21 22* 23* 24 25 26 27 28 29 30
T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F
Schizophrenic patients with hallucinations
Psychotic patients who never hallucinated
OCD
Clinical control
Non-clinical control
48.6%a 51.4%a 29.7%a 70.3%a 24.3%a 75.7%a 29.7%a 70.3%a 29.7%a 70.3%a 32.4%a 67.6%a 18.9%a 81.1%a 67.6%a 32.4%a 24.3%a 75.7%a 32.4%a 67.6%a 29.7%a 70.3%a 29.7%a 70.3%a 35.1%a 64.9%a 35.1%a 64.9%a 37.8%a 62.2%a 35.1%a 64.9%a 27.0%a 73.0%a 45.9%a 54.1%a 64.9%a 35.1%a 40.5%a 59.5%a 35.1%a 64.9%a 54.1%a 45.9%a 45.9%a 54.1%a 24.3%a 75.7%a 35.1%a 64.9%a 29.7%a 70.3%a 45.9%a 54.1%a 59.5%a 40.5%a 35.1%a 64.9%a 64.9%a 35.1%a
23.3%a,b 76.7%a,b 13.3%a,b 86.7%a,b 30.0%a 70.0%a 6.7%a,b 93.3%a,b 10.0%a 90.0%a 6.7%a 93.3%a 30.0%a 70.0%a 20.0%b 80.0%b 0.0%b 100.0%b 26.7%a 73.3%a 10.0%a 90.0%a 26.7%a 73.3%a 20.0%a 80.0%a 3.3%b 96.7%b 6.7%b 93.3%b 33.3%a 66.7%a 3.3%a 96.7%a 20.0%a 80.0%a 26.7%b 73.3%b 13.3%a 86.7%a 16.7%a 83.3%a 30.0%a 70.0%a 23.3%a 76.7%a 13.3%a 86.7%a 10.0%a 90.0%a 20.0%a,b 80.0%a,b 26.7%a 73.3%a 30.0%a 70.0%a 10.0%a 90.0%a 20.0%b 80.0%b
18.9%a,b 81.1%a,b 8.1%a,b 91.9%a,b 24.3%a 75.7%a 2.7%b 97.3%b 8.1%a 91.9%a 13.5%a 86.5%a 27.0%a 73.0%a 8.1%b 91.9%b 5.4%a,b 94.6%a,b 18.9%a 81.1%a 5.4%a 94.6%a 27.0%a 73.0%a 29.7%a 70.3%a 2.7%b 97.3%b 8.1%b 91.9%b 29.7%a 70.3%a 8.1%a 91.9%a 29.7%a 70.3%a 24.3%b 75.7%b 21.6%a 78.4%a 13.5%a 86.5%a 37.8%a 62.2%a 27.0%a 73.0%a 21.6%a 78.4%a 21.6%a 78.4%a 27.0%a,b 73.0%a,b 35.1%a 64.9%a 43.2%a 56.8%a 29.7%a 70.3%a 16.2%b 83.8%b
19.5%a,b 80.5%a,b 4.9%b 95.1%b 24.4%a 75.6%a 19.5%a,b 80.5%a,b 7.3%a 92.7%a 14.6%a 85.4%a 14.6%a 85.4%a 17.1%b 82.9%b 22.0%a,b 78.0%a,b 24.4%a 75.6%a 19.5%a 80.5%a 46.3%a 53.7%a 12.2%a 87.8%a 2.4%b 97.6%b 22.0%a,b 78.0%a,b 29.3%a 70.7%a 14.6%a 85.4%a 26.8%a 73.2%a 29.3%b 70.7%b 14.6%a 85.4%a 39.0%a 61.0%a 31.7%a 68.3%a 22.0%a 78.0%a 29.3%a 70.7%a 22.0%a 78.0%a 4.9%b 95.1%b 43.9%a 56.1%a 31.7%a 68.3%a 34.1%a 65.9%a 17.1%b 82.9%b
2.4%b 97.6%b 14.3%a,b 85.7%a,b 23.8%a 76.2%a 14.3%a,b 85.7%a,b 26.2%a 73.8%a 11.9%a 88.1%a 33.3%a 66.7%a 14.3%b 85.7%b 14.3%a,b 85.7%a,b 16.7%a 83.3%a 11.9%a 88.1%a 40.5%a 59.5%a 21.4%a 78.6%a 0.0%b 100.0%b 11.9%a,b 88.1%a,b 35.7%a 64.3%a 11.9%a 88.1%a 21.4%a 78.6%a 28.6%b 71.4%b 19.0%a 81.0%a 23.8%a 76.2%a 33.3%a 66.7%a 23.8%a 76.2%a 26.2%a 73.8%a 38.1%a 61.9%a 19.0%a,b 81.0%a,b 28.6%a 71.4%a 31.0%a 69.0%a 35.7%a 64.3%a 16.7%b 83.3%b
Values for a given group followed by the same letter are not significantly different from each other (P ⬍ 0.05). *Reversed scored.
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(τ ⫽ 0.061, P ⬍ 0.01), was the most strongly associated with the group of schizophrenic patients with auditory hallucinations, followed by 14 (“I have noticed sounds on my records that are not there other times”) (τ ⫽ 0.56, P ⬍ 0.01). The next item that best predicted belonging to the group was 30 (“I have sometimes felt that strangers were reading my mind”) (τ ⫽ 0.46, P ⬍ 0.01) and finally, Item 19 (“I have sometimes sensed an evil presence around me although I could not see it”) (τ ⫽ 0.025, P ⬍ 0.01).
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Discussion This study was based on the hypothesis that magical thinking distinguishes schizophrenic patients with auditory hallucinations from other groups of patients and non-patients. The results found have corroborated this hypothesis. Thus, whereas in the study by García-Montes et al. (19) both patients diagnosed with schizophrenia with auditory hallucinations and patients with OCD showed superstitious beliefs consistent with an exaggerated sense of responsibility for their own thoughts, this study differentiates these two groups of patients. Magical thinking, understood as beliefs in non-consensual modes of causation, is the superstitious belief most closely linked to auditory hallucinations in patients diagnosed with schizophrenia. Moreover, when the items on the magic ideation scale that most clearly differentiated the group of schizophrenic patients with hallucinations from the rest were analysed in detail, the questions related to belief in “mind reading”, the presence of auditory illusions in response to sound stimuli, and the sense of sometimes being accompanied by an evil presence are the most outstanding. It is also worth mentioning that compared with the classic work by George & Neufeld (16) on magical thinking and schizophrenia, this study showed that patients with disorders in the schizophrenia spectrum, but not auditory hallucinations, were not characterized by magical thinking any more than the other clinical or normal population groups. This result is coherent with the findings of Dubal & Viaud-Delmon (23), in which they mention hyperacusis, a subjective phenomenon, which refers to a strong intolerance to ordinary environmental sound although hearing thresholds are normal. It can be deduced from the study by Dubal & Viaud-Delmon (23) that the participants who showed high levels of magical thinking were also characterized by strong auditory sensitivity, to the point where these authors suggest that hyperacusis associated with high MIS scores may be a factor predisposing to deviant auditory experiences, such as auditory hallucinations. Although based on the design employed it is risky to seek any type of explanation for the relationship between hallucinations in schizophrenic patients and NORD J PSYCHIATRY·VOL 68 NO 8·2014
magical thinking, it might be mentioned that hallucinations have traditionally been understood to be influenced by top-down processes, among which are the beliefs a person has about what causal relationships are possible in the world. Top-down processes reflect the influence of internal factors and stored representations on perception, which includes magical beliefs. Empirical studies done from the paradigm of signal detection using verbal stimulus detection tasks masked by white noise (24), or tasks in which variables such as suggestibility and expectations are manipulated (25), have shown more top-down processing in schizophrenic patients with auditory hallucinations. At the same time, these hallucinatory experiences corroborate in some way the subject’s belief in the magical entities, thus forming a loop in which belief and experience are mutually sustained. This explanation would again take up the position expressed by William James in The Will to Believe and other Essays in Popular Philosophy (26, p.103), according to which: “The belief creates its verification. The thought becomes literally father to the fact, as the wish was father to the thought.” This note by James, attributing both the person’s beliefs, and then his experiences to desire, has been, in our opinion, empirically confirmed in the study carried out by Berenbaum et al. (27). According to this study, among individuals for whom the objects of the belief–magical thinking were highly emotionally salient and who had high levels of attention to emotion, higher levels of emotional clarity were associated with increased peculiar beliefs–magical thinking. In contrast, among individuals for whom the objects of the belief–magical thinking were not emotionally salient and who had high levels of attention to emotion, higher levels of emotional clarity were associated with diminished peculiar beliefs–magical thinking. Finally, it is important to mention a series of problems presented by our study that make it difficult to draw straightforward conclusions. Firstly, its crosssectional nature prevents us from establishing any type of causal relationships. Auditory hallucinations, magical ideation and schizophrenia spectrum disorders are connected in complicated networks, and the conclusions of this study in no way suggest that MIS may be taken as a direct diagnostic criterion of the presence of auditory hallucinations, much less as indicative of a schizophrenia spectrum disorder. It is also important to point out that the Groups 1 and 2 were being treated with antipsychotic medication, while the rest of the groups were not. At the present time, the impact of this type of medication on the magical ideation under study is unknown. Neither was the use of illegal drugs by participants controlled for. There are data showing that people who are using or have used cannabis usually present higher
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levels of magical thinking (28) and predisposition to hallucinations (29). It might be advisable to determine whether results are similar with other clinical population groups. In any case, there is a need for research on these possible implications, in particular evolutionary studies, considering the personal history related to magical thinking. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This work was done in the framework of research project PSI2009-09453, funded by the Spanish Ministry of Science and Technology; and by the Regional Government of Andalusia (Excellence Research Projects SEJ-7204). The third author wishes to acknowledge Grant UNOV-06-BECDOC-4.
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JOSÉ M. GARCÍA-MONTES, MARINO PÉREZ-ÁLVAREZ, PAULA ODRIOZOLA-GONZÁLEZ, OSCAR VALLINA-FERNÁNDEZ, SALVADOR PERONA-GARCELÁN
García-Montes JM, Pérez-Álvarez M, Odriozola-González P, Vallina-Fernández O, PeronaGarcelán S. The role of magical thinking in hallucinations. Comparisons of clinical and nonclinical groups. Nord J Psychiatry 2014;68:605–610. Background: Magical thinking consists of accepting the possibility that events that, according to the causal concepts of a culture, cannot have any causal relationship, but might somehow nevertheless have one. Magical thinking has been related to both obsessive–compulsive disorder and schizophrenia. Aims: The purpose of this study was to investigate the role of magical thinking in hallucinations of patients diagnosed with schizophrenia. Methods: Four groups were recruited for this purpose from a clinical population (hallucinating schizophrenic patients, patients diagnosed with psychoses who had never hallucinated, obsessive–compulsive disorder patients and a clinical control group) and a non-clinical control group, who were given the Magical Ideation Scale. Results: The results show that magical ideation differentiates the group of schizophrenic patients with auditory hallucinations from the rest of the groups that participated in the design. Items related to “mind reading”, to the presence of auditory illusions in response to sound stimuli, and to the sense of sometimes being accompanied by an evil presence are the most closely related to the presence of auditory hallucinations. Conclusions: Magical thinking, understood as beliefs in non-consensual modes of causation, is closely linked to auditory hallucinations in patients diagnosed with schizophrenia. • Hallucinations, Obsessive–compulsive Disorder, Schizophrenia. José M. García Montes, Departamento de Psicología, Universidad de Almería, Carretera de Sacramento, s/n. 04120-La Cañada de San Urbano, Almería, Spain. E-mail: [email protected]; Accepted 4 March 2014.
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ince the term “hallucination”, a disorder in which the subject reports perceiving an event, or a series of events, in the absence of appropriate stimulus, was introduced in medical vocabulary by Esquirol in 1917, it has been considered among the most mysterious and serious of psychological disorders (1). Schneider (2) considered them a top-ranking symptom of schizophrenia if found in the absence of brain pathology. In fact, in a study funded by the WHO, auditory hallucinations were shown to be the second most frequent symptom in diagnosing schizophrenia (present in 74% of cases) after lack of insight (present in 97% of cases) (3). However, in addition to persons diagnosed with schizophrenia or schizophrenia spectrum, they may also appear in other diagnoses, such as affective bipolar disorder and unipolar depression, in borderline personality disorders, © 2014 Informa Healthcare
post-traumatic disorder, dissociative disorders, and in people without any psychiatric disorder at all (4). Apart from this, magical thinking may be defined as a “belief, quasi-belief, or semiserious entertainment of the possibility that events which, according to the causal concepts of this culture, cannot have a causal relation with each other, might somehow nevertheless do so” (5). Children (6) and so-called “primitive societies” (7, 8) are supposedly particularly disposed to magical thinking. Empirical research has demonstrated that such beliefs are also found in adults in Western societies (9). For example, about one quarter of Americans believe in astrology, clairvoyance, ghosts and communication with the dead (10). However, it is generally understood that this kind of beliefs play a minimal role in normal adult behaviour, emerging only in situations of stress (11). In the DSM DOI: 10.3109/08039488.2014.902500
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JM GARCÍA-MONTES ET AL.
IV-TR, magical thinking was one of the defining characteristics of schizotypal personality disorder when the person’s behaviour was affected and inconsistent with social norms (12). Its role in adult psychological disorders, such as Obsessive–compulsive Disorder (OCD) and schizophrenia should be emphasized. In fact, it seems clear that magical thinking has a relevant role in OCD (13), and it has even been affirmed that the strong presence of magical thinking distinguishes OCD from other anxiety disorders (11). It also appears to be a factor in poor prognosis for OCD treatment (14). Adult patients with schizophrenia also seem to have a stronger tendency for magical thinking than either the normal population (15) or nonschizophrenic psychiatric patients (16). In this regard, magical thinking is considered one of the most influential predictors of later development of a schizophrenic disorder (17), and has been linked to the appearance of visual and auditory hallucinations (18). The relevance of magical thinking in auditory hallucinations of psychotic and OCD patients has been stressed by García-Montes et al. (19). These authors found that metacognitive beliefs about punishment and responsibility in relation to one’s own thoughts emerged as key factors in understanding both auditory hallucinations in psychotic patients and OCD. This type of metacognitive belief (e.g. “If I did not control a worrying thought, and then it happened, it would be my fault”) are interpreted by the authors as clear examples of magical thinking. However, it is clear that there are differences between the type of metacognitive belief that overvalues the power of certain private events, and other more culturally dissonant forms of magical thought, such as belief in mind reading, amulets or other paranormal beliefs that violate the fundamental and scientifically founded principles of nature.
Aims The purpose of this study was to determine the role of magical thinking in hallucinations of patients diagnosed with a schizophrenia spectrum disorder. To do this, we start out from the hypothesis that magical thinking is a characteristic defining psychotic patients with auditory hallucinations compared with another group of patients.
Material and methods Participants We formed five groups of patients diagnosed with various disorders according to DSM IV TR criteria (12). Group 1 (schizophrenic patients with hallucinations; n ⫽ 37; gender: male (M) ⫽ 24, female (F) ⫽ 13; age mean ⫽ 35.37 years), was made up of patients diagnosed with schizophrenia who reported currently having auditory hallucinations. The criterion taken to determine
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whether a patient diagnosed with schizophrenia suffered from auditory hallucinations was a score ⱖ 4 on the auditory hallucinations item of the Positive and Negative Syndrome Scale (20). Schizophrenic patients who did not meet this criterion were discarded from the group, as our purpose was to study the relationship of magical thinking to a possible symptom of schizophrenia such as hallucinations and not the disorder itself. Group 2 (patients diagnosed with psychoses; n ⫽ 30; gender: M ⫽ 27, F ⫽ 3; age mean ⫽ 36.73 years) was composed of patients diagnosed with a psychosis who at no time had reported hallucinatory experiences in any sensory mode. A total of 20 patients diagnosed with schizophrenia were included in this group, five with persecutory delusional disorder, four with schizo-affective disorder and one diagnosed with a bipolar disorder. Group 3 (OCD; n ⫽ 37; gender: M ⫽ 22, F ⫽ 15; age mean ⫽ 31.27 years) was made up of patients who had been diagnosed with OCD. The mean score of this group of patients on the Maudsley Obsessive–Compulsive Inventory (21) was 11.49, with a standard deviation of 5.83. The most common obsessions in the group had to do with conscience/doubting, followed by checking. Group 4 (clinical control group, n ⫽ 41; gender: M ⫽ 20, F ⫽ 21; age mean ⫽ 31.48 years) was composed of patients treated by mental health services for a diversity of problems (adjustment disorder, n ⫽ 7; generalized anxiety disorder, n ⫽ 6; major depressive disorder, n ⫽ 5; personality disorder, n ⫽ 4; dysthymia, n ⫽ 3; anxiety disorder with agoraphobia, n ⫽ 3; marital problems, n ⫽ 2; anorexia nervosa, n ⫽ 1; bulimia nervosa, n ⫽ 1; substance abuse, n ⫽ 1; alcohol dependence disorder, n ⫽ 1; primary insomnia, n ⫽ 1; social phobia, n ⫽ 1; specific phobia, n ⫽ 1; post-traumatic stress disorder, n ⫽ 1; severe stress disorder, n ⫽ 1; anxiety disorder with no agoraphobia, n ⫽ 1, unspecified depressive disorder, n ⫽ 1). Obviously, patients who had previously suffered from some psychotic disorder or OCD were excluded. Finally, Group 5 (non-clinical control group; n ⫽ 42; gender: M ⫽ 24, F ⫽ 18; age mean ⫽ 35.11 years) was made up of people who went to a psychotechnical evaluation centre for a certificate to renew their driving licence. We excluded those who had sought psychiatric attention or had received psychoactive medication. All the patients diagnosed with psychoses in this study were taking neuroleptic medication. Some were also taking benzodiazepines or, in fewer cases, antidepressants.
Instruments The Magical Ideation Scale (MIS) (17) is a 30-item true– false measure that contains items pertaining to idiosyncratic perceptions of cause-effect relationships. It is important to note that superstition and paranormal beliefs are not the only features of MIS. The concept of magical NORD J PSYCHIATRY·VOL 68 NO 8·2014
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thinking as defined by this scale includes a number of unusual forms of thought that are associated with schizotypal personality disorder. For example, there are questions that address ideas of reference (“I have sometimes had the passing thought that strangers are in love with me”) or that describe unusual perceptual experiences (“I have had the momentary feeling that I might not be human”) (10). In fact, the MIS correlates with other schizotypy measures, such as the Perceptual Aberration Scale and it is reported to have good internal consistency with coefficients ranging from 0.82 to 0.93 (22). In this study, the Spanish adaptation was used (22).
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Procedure After agreeing to take part in the study, all the patients were checked to see whether they fulfilled the DSM IV TR diagnostic criteria (12) for their group at that time. They were then administered the questionnaire described above. The person who administered the test was the psychologist who normally attended the patient. Participants received no compensation for their involvement in the study.
Results Comparative participant statistics Statistically significant differences found in the ages of the members of each group [F(4, 182) ⫽ 2.80, P ⫽ 0.027] were not significant after the post hoc Bonferroni correction was applied. A statistically significant difference in distribution of the patients within the groups by gender [chi-square ⫽ 13.73, d.f. ⫽ 4, P ⬍ 0.01], particularly the few women participants in the group of “patients diagnosed with psychoses who had never hallucinated,” should be mentioned.
Tests prior to analysis of the results Before analysing the results, a Levene’s test was done to check for homogeneity of error variances. Participant scores on the MIS did not fulfil the hypothesis of equal group variance either [F(4,182) ⫽ 3.247, P ⬍ 0.01]. Data were therefore analysed using the Welch’s test and post hoc analyses were done with the Tamhane test. In this regard, it should be mentioned that Welch’s t-test is an adaptation of the Student’s t-intended for use with two or
more samples having unequal variances to detect whether there are significant differences in group means. As there were five groups in the study, the Tamhane test was used post hoc to determine among which groups of patients there were differences in the mean MIS scores.
Data analysis The results of applying the Welch’s test showed significant differences between groups [T(4, 90.27) ⫽ 7.62, P ⬍ 0.01]. Table 1 shows mean scores and 95% confidence intervals for the groups. It may be observed that the group of “schizophrenic patients with hallucinations” scored significantly higher in magical thinking than the rest of the groups that took part in this study. To determine which of the items on the MIS are most directly related to the presence of hallucinations in patients diagnosed with schizophrenia, a contingency table was made in which the different groups the participants were classified in were the columns and the rows were the items on the MIS. A Z-test was done to determine whether there were differences in the proportions of participants in the different groups that had answered affirmatively or negatively on each of the items in the MIS, and a Bonferroni correction to adjust significance levels. Table 2 summarizes the results. As observed, the patients with voices showed statistically significant differences from the rest of the patients taking part in the study on items 8 (“I have occasionally had the silly feeling that a TV or radio broadcaster knew I was listening to him”), 14 (“I have noticed sounds on my records that are not there other times”), 19 (“I have sometimes sensed an evil presence around me although I could not see it”) and 30 (“I have sometimes felt that strangers were reading my mind”). The Goodman–Kruskal’s τ coefficient was used to find the strength of the relationships among these items and the group to which they belong. This coefficient is an asymmetric coefficient similar to the Lambda coefficient by the same authors, but unlike that, is based on errors made in random assignment of cases to the categories of the dependent variable, in our case, the group. The results of this analysis showed that Item 8 (“I have occasionally had the silly feeling that a TV or radio broadcaster knew I was listening to him”)
Table 1. Mean scores and 95% confidence intervals for the Magical Ideation Scale (MIS).
MIS
Schizophrenic patients with hallucinations
Psychotic patients who never hallucinated
OCD
Clinical control
Non-clinical control
11.48a,b,c,d (9.54–13.43)
5.30a (4.00–6.59)
5.94b (4.58–7.30)
6.60c (4.99–8.22)
6.50d (4.88–8.11)
*Values sharing the same letter are significantly different, based on Tamhane’s T2. NORD J PSYCHIATRY·VOL 68 NO 8·2014
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Table 2. Percentages of affirmative (T) or negative (F) responses to each of the items on the Magical Ideation Scale (MIS) by group. MIS items 1 2 3 4 5 6
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7* 8 9 10 11 12* 13* 14 15 16* 17 18* 19 20 21 22* 23* 24 25 26 27 28 29 30
T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F T F
Schizophrenic patients with hallucinations
Psychotic patients who never hallucinated
OCD
Clinical control
Non-clinical control
48.6%a 51.4%a 29.7%a 70.3%a 24.3%a 75.7%a 29.7%a 70.3%a 29.7%a 70.3%a 32.4%a 67.6%a 18.9%a 81.1%a 67.6%a 32.4%a 24.3%a 75.7%a 32.4%a 67.6%a 29.7%a 70.3%a 29.7%a 70.3%a 35.1%a 64.9%a 35.1%a 64.9%a 37.8%a 62.2%a 35.1%a 64.9%a 27.0%a 73.0%a 45.9%a 54.1%a 64.9%a 35.1%a 40.5%a 59.5%a 35.1%a 64.9%a 54.1%a 45.9%a 45.9%a 54.1%a 24.3%a 75.7%a 35.1%a 64.9%a 29.7%a 70.3%a 45.9%a 54.1%a 59.5%a 40.5%a 35.1%a 64.9%a 64.9%a 35.1%a
23.3%a,b 76.7%a,b 13.3%a,b 86.7%a,b 30.0%a 70.0%a 6.7%a,b 93.3%a,b 10.0%a 90.0%a 6.7%a 93.3%a 30.0%a 70.0%a 20.0%b 80.0%b 0.0%b 100.0%b 26.7%a 73.3%a 10.0%a 90.0%a 26.7%a 73.3%a 20.0%a 80.0%a 3.3%b 96.7%b 6.7%b 93.3%b 33.3%a 66.7%a 3.3%a 96.7%a 20.0%a 80.0%a 26.7%b 73.3%b 13.3%a 86.7%a 16.7%a 83.3%a 30.0%a 70.0%a 23.3%a 76.7%a 13.3%a 86.7%a 10.0%a 90.0%a 20.0%a,b 80.0%a,b 26.7%a 73.3%a 30.0%a 70.0%a 10.0%a 90.0%a 20.0%b 80.0%b
18.9%a,b 81.1%a,b 8.1%a,b 91.9%a,b 24.3%a 75.7%a 2.7%b 97.3%b 8.1%a 91.9%a 13.5%a 86.5%a 27.0%a 73.0%a 8.1%b 91.9%b 5.4%a,b 94.6%a,b 18.9%a 81.1%a 5.4%a 94.6%a 27.0%a 73.0%a 29.7%a 70.3%a 2.7%b 97.3%b 8.1%b 91.9%b 29.7%a 70.3%a 8.1%a 91.9%a 29.7%a 70.3%a 24.3%b 75.7%b 21.6%a 78.4%a 13.5%a 86.5%a 37.8%a 62.2%a 27.0%a 73.0%a 21.6%a 78.4%a 21.6%a 78.4%a 27.0%a,b 73.0%a,b 35.1%a 64.9%a 43.2%a 56.8%a 29.7%a 70.3%a 16.2%b 83.8%b
19.5%a,b 80.5%a,b 4.9%b 95.1%b 24.4%a 75.6%a 19.5%a,b 80.5%a,b 7.3%a 92.7%a 14.6%a 85.4%a 14.6%a 85.4%a 17.1%b 82.9%b 22.0%a,b 78.0%a,b 24.4%a 75.6%a 19.5%a 80.5%a 46.3%a 53.7%a 12.2%a 87.8%a 2.4%b 97.6%b 22.0%a,b 78.0%a,b 29.3%a 70.7%a 14.6%a 85.4%a 26.8%a 73.2%a 29.3%b 70.7%b 14.6%a 85.4%a 39.0%a 61.0%a 31.7%a 68.3%a 22.0%a 78.0%a 29.3%a 70.7%a 22.0%a 78.0%a 4.9%b 95.1%b 43.9%a 56.1%a 31.7%a 68.3%a 34.1%a 65.9%a 17.1%b 82.9%b
2.4%b 97.6%b 14.3%a,b 85.7%a,b 23.8%a 76.2%a 14.3%a,b 85.7%a,b 26.2%a 73.8%a 11.9%a 88.1%a 33.3%a 66.7%a 14.3%b 85.7%b 14.3%a,b 85.7%a,b 16.7%a 83.3%a 11.9%a 88.1%a 40.5%a 59.5%a 21.4%a 78.6%a 0.0%b 100.0%b 11.9%a,b 88.1%a,b 35.7%a 64.3%a 11.9%a 88.1%a 21.4%a 78.6%a 28.6%b 71.4%b 19.0%a 81.0%a 23.8%a 76.2%a 33.3%a 66.7%a 23.8%a 76.2%a 26.2%a 73.8%a 38.1%a 61.9%a 19.0%a,b 81.0%a,b 28.6%a 71.4%a 31.0%a 69.0%a 35.7%a 64.3%a 16.7%b 83.3%b
Values for a given group followed by the same letter are not significantly different from each other (P ⬍ 0.05). *Reversed scored.
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(τ ⫽ 0.061, P ⬍ 0.01), was the most strongly associated with the group of schizophrenic patients with auditory hallucinations, followed by 14 (“I have noticed sounds on my records that are not there other times”) (τ ⫽ 0.56, P ⬍ 0.01). The next item that best predicted belonging to the group was 30 (“I have sometimes felt that strangers were reading my mind”) (τ ⫽ 0.46, P ⬍ 0.01) and finally, Item 19 (“I have sometimes sensed an evil presence around me although I could not see it”) (τ ⫽ 0.025, P ⬍ 0.01).
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Discussion This study was based on the hypothesis that magical thinking distinguishes schizophrenic patients with auditory hallucinations from other groups of patients and non-patients. The results found have corroborated this hypothesis. Thus, whereas in the study by García-Montes et al. (19) both patients diagnosed with schizophrenia with auditory hallucinations and patients with OCD showed superstitious beliefs consistent with an exaggerated sense of responsibility for their own thoughts, this study differentiates these two groups of patients. Magical thinking, understood as beliefs in non-consensual modes of causation, is the superstitious belief most closely linked to auditory hallucinations in patients diagnosed with schizophrenia. Moreover, when the items on the magic ideation scale that most clearly differentiated the group of schizophrenic patients with hallucinations from the rest were analysed in detail, the questions related to belief in “mind reading”, the presence of auditory illusions in response to sound stimuli, and the sense of sometimes being accompanied by an evil presence are the most outstanding. It is also worth mentioning that compared with the classic work by George & Neufeld (16) on magical thinking and schizophrenia, this study showed that patients with disorders in the schizophrenia spectrum, but not auditory hallucinations, were not characterized by magical thinking any more than the other clinical or normal population groups. This result is coherent with the findings of Dubal & Viaud-Delmon (23), in which they mention hyperacusis, a subjective phenomenon, which refers to a strong intolerance to ordinary environmental sound although hearing thresholds are normal. It can be deduced from the study by Dubal & Viaud-Delmon (23) that the participants who showed high levels of magical thinking were also characterized by strong auditory sensitivity, to the point where these authors suggest that hyperacusis associated with high MIS scores may be a factor predisposing to deviant auditory experiences, such as auditory hallucinations. Although based on the design employed it is risky to seek any type of explanation for the relationship between hallucinations in schizophrenic patients and NORD J PSYCHIATRY·VOL 68 NO 8·2014
magical thinking, it might be mentioned that hallucinations have traditionally been understood to be influenced by top-down processes, among which are the beliefs a person has about what causal relationships are possible in the world. Top-down processes reflect the influence of internal factors and stored representations on perception, which includes magical beliefs. Empirical studies done from the paradigm of signal detection using verbal stimulus detection tasks masked by white noise (24), or tasks in which variables such as suggestibility and expectations are manipulated (25), have shown more top-down processing in schizophrenic patients with auditory hallucinations. At the same time, these hallucinatory experiences corroborate in some way the subject’s belief in the magical entities, thus forming a loop in which belief and experience are mutually sustained. This explanation would again take up the position expressed by William James in The Will to Believe and other Essays in Popular Philosophy (26, p.103), according to which: “The belief creates its verification. The thought becomes literally father to the fact, as the wish was father to the thought.” This note by James, attributing both the person’s beliefs, and then his experiences to desire, has been, in our opinion, empirically confirmed in the study carried out by Berenbaum et al. (27). According to this study, among individuals for whom the objects of the belief–magical thinking were highly emotionally salient and who had high levels of attention to emotion, higher levels of emotional clarity were associated with increased peculiar beliefs–magical thinking. In contrast, among individuals for whom the objects of the belief–magical thinking were not emotionally salient and who had high levels of attention to emotion, higher levels of emotional clarity were associated with diminished peculiar beliefs–magical thinking. Finally, it is important to mention a series of problems presented by our study that make it difficult to draw straightforward conclusions. Firstly, its crosssectional nature prevents us from establishing any type of causal relationships. Auditory hallucinations, magical ideation and schizophrenia spectrum disorders are connected in complicated networks, and the conclusions of this study in no way suggest that MIS may be taken as a direct diagnostic criterion of the presence of auditory hallucinations, much less as indicative of a schizophrenia spectrum disorder. It is also important to point out that the Groups 1 and 2 were being treated with antipsychotic medication, while the rest of the groups were not. At the present time, the impact of this type of medication on the magical ideation under study is unknown. Neither was the use of illegal drugs by participants controlled for. There are data showing that people who are using or have used cannabis usually present higher
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levels of magical thinking (28) and predisposition to hallucinations (29). It might be advisable to determine whether results are similar with other clinical population groups. In any case, there is a need for research on these possible implications, in particular evolutionary studies, considering the personal history related to magical thinking. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. This work was done in the framework of research project PSI2009-09453, funded by the Spanish Ministry of Science and Technology; and by the Regional Government of Andalusia (Excellence Research Projects SEJ-7204). The third author wishes to acknowledge Grant UNOV-06-BECDOC-4.
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