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e British Journal of psychiatry
(2015)
206, 41-44.
doi:
10.1192/bjp.bp.113.139048
Results
Participants in the
USA
w~rf? rnQr~ lik(illy to U$~ ~ig~no~tic
labels and to report violent c\'lmmfJnd~ th1JnthQ1le in Inlii€!
and Ghana, who were more Iik~ly th€!n
the
Amllrj(j€!m; to
report rich relationships with the.ir voices and
less
likely to
describe the voices as the Sign Of
i;l
viol§lted mino, .
Conclusions
These observations suggest that the VQice,heiilrinl:!
experiences of people with serious psychotic oiggrd&f af~
shaped by local culture. These differences may haVe clinical
implications. .
Declaration of interest
None.
fferences
in voice-hearing
experiences
people with psychosis in the USA, India
nd Ghana: interview-based study
. Luhrmann, R. Padmavati, H. Tharoor and A. Osei
ound
·n
know little about whether and how the auditory
. ations associated with serious psychotic disorder shift
cultural boundaries.
pare auditory hallucinations across three different
es, by means of an interview-based study.
od
ropologist and several psychiatrists interviewed
:cbants from the
USA,
India and Ghana, each sample
. ing 20 persons who heard voices and met the
criteria of schizophrenia, about their experience
oces.
whether the phenomenology of hearing voices by
serious psychotic disorder may be shaped by local
- report here on the first structured interview-based
.;;;:;;:sa:. of hearing voices in three different cultures, comparing
"~':l::O
adults each living respectively in or around San Mateo,
L"SA;Accra, Ghana; and Chennai, India. The experience
- '"{licesis complex and varies from person to person.' A
.!::::::s:-ion
of cultural variations in the kinds of relationships
rt with their voices may offer a natural experiment
of recent research suggesting that the voice-hearing
is mutable.
Method
met our inclusion criteria if different sources (interview,
- brief psychosis screen from the Structured Clinical
_ •.••• ~:iJr••.
DSM-IV Axis I Disorders," and, if available, medical
_""', •....-. clinicians' reports) together provided evidence that
aad experienced at least two positive symptoms (such
"'~~1i·,ons and delusions) and had been ill for at least
prior signs of illness for at least 6 months (in most
.cipants had been ill for years) to the degree that
been seriously disrupted. These are the inclusion
schizophrenia.' However, we did not rule out individuals
symptoms in addition to their psychosis. Many of
"CJ:=;l2nts were diagnosed at some point with schizo affective
••• 0:::;. .•••.• 111
some - particularly those in Accra - carried chart
both bipolar disorder and schizophrenia. We also
_c.. ~~
out people who reported using cannabis and other
.iu:ring the course of their illness; doing so would have
our American and African participant pooL
_ included only those who heard voices in the absence
ceo
Yateo participants were recruited primarily through
at the San Mateo County Psychiatric Hospital and
'Y
T.1., an anthropologist with extensive experience
among people with serious psychotic disorder. They were almost
all supported by disability stipend and lived in supported housing.
All had been ill for years. There were 10 men and 10 women; their
average age was 43 years. In Chennai participants were recruited
from the Schizophrenia Research Foundation (SCARF), where
they were either receiving out-patient treatment or in long-term
residential care. All had been ill for many years. They were
interviewed by R.P. and H.T., senior research psychiatrists,
primarily in TamiL There were 9 women and 11 men; their average
age was 41 years. In Accra participants were in-patients at the
Accra General Psychiatric Hospital. They were recruited by staff
following the direction of A.O., its medical director and chief
psychiatrist. All were interviewed by T.1. in English, although in
two cases the bulk of the interview was conducted in Twi by
T.1.'s research assistant. There were 12 women and 8 men; their
average age was 34 years. This group was thus younger and more
seriously ill than people in the Chennai and San Mateo samples.
Interview
The interview protocol (see online Appendix DSl) began by
asking the participants about the phenomenology of their
hallucination experience: how many voices they heard, how often,
and whether they experienced hallucinations in other sensory
modalities. The interview was loosely based on the Maastricht
interview developed by Romme
&
Escher:" we also consulted a
series of other established interviews about voice-hearing, such
as the Leudar-Thomas Voices Pragmatics Assessment Interview,"
We then asked the participants whether they knew who was
speaking, whether they had conversations with the voices, and
what the voices said. We asked people what they found most
distressing about the voices, whether they had any positive
experiences of voices and whether the voice spoke about sex or
God. We asked what caused the voices and what caused their
illness. Not all participants completed the full interview protocol,
but all spoke about their experience in detail. All interviews were
digitally recorded, transcribed and if necessary translated by a
41
LUhrmannet al
42
-------
professional, and checked for word-for-word accuracy by a
researcher competent in both English and the speaker's native
language.
In all cases participants gave informed consent for the interview
and the research was approved by the Stanford University
institutional review board, the SCARF ethics committee and the
medical director of the Accra General Psychiatric Hospital.
Results
Broadly speaking the voice-hearing experience was similar in all
three settings. Many of those interviewed reported good and
bad voices; many reported conversations with their voices, and
many reported whispering, hissing or voices they could not quite
hear. In all settings there were people who reported that God had
spoken to them and in all settings there were people who hated
their voices and experienced them as an assault. Nevertheless,
there were striking differences in the quality of the voice-hearing
experience, and particularly in the quality of relationship with
the speaker of the voice. Many participants in the Chennai and
Accra samples insisted that their predominant or even only
experience of the voices was positive - a report supported by chart
review and clinical observation. Not one American did so. Many
in the Chennai and Accra samples seemed to experience their
voices as people: the voice was that of a human the participant
knew, such as a brother or a neighbour, or a human-like spirit
whom the participant also knew. These respondents seemed to
have real human relationships with the voices - sometimes even
when they did not like them. This was less typical of the San
Mateo sample, whose reported experiences were markedly more
violent, harsher and more hated.
San Mateo
In general the American sample experienced voices as bombard-
ment and as symptoms of a brain disease caused by genes or
trauma. They used diagnostic labels readily: all but three
spontaneously described themselves as diagnosed with 'schizo-
phrenia' or 'schizo affective disorder' and every single person used
diagnostic categories in conversation. Fourteen described voices
that told them to hurt other people or themselves, sometimes in
disturbing detail: for example,
'usually.it'sliketorturingpeople,totaketheireye outwitha fork,or cutsorneone's
headand drinktheirblood,reallynastystuft.'
Five people even described their voice-hearing experience as a
battle or war, as in 'the warfare of everyone just yelling'. Finally,
the Americans talked about their voices as unreal thoughts in
which there is a disrupted relationship between their thoughts
and their mind. They said things such as,
'I
don't thinkthere's anythingthere or anything.
1
thinkit's justthe way mymind
works.'
None of the San Mateo sample reported predominantly positive
experiences, although half reported some positive dimensions to
the voice-hearing. These participants tended to do so as throw-
away remarks. One man described his voice as mean and insulting
but said, when asked if there were any voices that liked him, 'Yeah
... that's what I live for'. Then he returned to describing the voices
he did not like. Five reported hearing God speak audibly, although
15 were clearly religious. Only two reported that they heard family
members on a regular basis, and both these were women molested
by their father (or stepfather) who heard their (negative)
molester's voice. Only one person reported that she heard
primarily people she knew: 'my therapist, my best friend, a friend
from high school and this horrible guy'. Eight people said that they
did not know who their voices were. Even when they said they
knew them, the names they sometimes gave them suggested that
they did not consider their voices to be human, as in 'their name
is M' or 'Demon and Entity'. Few described personal relationships
with their voices. The participant with the most positive experience
described voices that seemed sometimes magical and sometimes
horrific: For her, sounds seemed to resolve themselves into voices,
so she heard voices all the time - 'I think I have friends in the
wind' - but she could not really communicate with them because
they spoke a language she did not know. She talked with God -
'he's very nice' - but her only account of their interaction was this:
'Sometimesitseemsthe Lordgivesmethe thoughtand
gives
methe light,
gives
rre
the say-soas to
have
myownthoughtsand
have
myownmind,andthensometimes
he'llerase it whenhe wantsto
give
itto someoneelse.'
Meanwhile, she emphasised the bad voices: 'Someone is like
yelling loudly in my ear'.
Chennai
More than half of the Chennai sample
(n
=
11) heard voices of kin,
such as parents, mother-in-law, sister-in-law or sisters. Another
two experienced a voice as husband or wife, and yet another
reported that the voice said he should listen to his father. These
voices behaved as relatives do: they gave guidance, but they also
scolded. They often gave commands to do domestic tasks.
Although people did not always like them, they spoke about them
as relationships. One man explained, 'They talk as if elder people
advising younger people'. A woman heard seven or eight of her
female relatives scold her constantly. They told her that she should
die; but they also told her to bathe, to shop, and to go into the
kitchen and prepare food. Another woman explained that her
voice took on the form of different family members - it 'talks like
all the familiar persons in my house'. Although the voice
frightened her and sometimes, she clamed, even beat her, she
insisted that the voice was good: 'It teaches me what I don't know:
Only four persons in the Chennai sample said that they did not
know who spoke to them. These voices did not even seem
particularly disembodied. At least nine Chennai participants
described their voices as if the voice itself acted physically or
had physical experience. For example, one man described his
voices as souls in hell who needed him to ease their suffering. They
complained that he dragged them along with him when he went
out and that it hurt them. He said that the voices vomited when
he had sex. Another man used this vivid metaphor:
'I
wentto Bangaloreand
1
couldhearthe
voices
thereaswell,canbe heardlikeithas
beensoakedand
stuck
to mybody.'
Only four of the Chennai sample used the term 'schizophrenia';
indeed, the lesser use of diagnostic labels by patients and their
families in South Asia has previously been described in the
ethnographic literature." Only three - and occasionally a fourth
- described their voices as commanding them to hurt other people
or themselves (although more people than that heard voices with
threatening content). Instead, what more participants (at least 13)
reported as distressing about their voices was that their voices
spoke about sex. Nine persons understood their voices as spirits
or magical (although only six had heard a god speak audibly).
Nine described voices that were significantly good, even though
we judged only five to have had voice-hearing experiences that
were predominantly good, They made comments that suggested
that these voices were both social relationships and entertainment:
'I like my mother's voice'; later, this woman added 'I have a
companion to talk [to] ... [laughs] I need not go out to speak.
I can talk within myself!' A man who in general found his voices
difficult still said that they were interesting: 'I will play with my
mind'. Another man, who heard two or three women he thought
were wives, said, 'Voices, I like it. It will keep talking which is
enjoyable.' In fact, several Indian participants seemed to
experience their main voice as playful - true for none of the San
Mateo or Accra group to any notable degree, One woman spoke
exe
cell
he,
'He
of
jt
pea
Shl
wa
giv
bee
thE
Shl
AC
All
aU!
wo
car
USE
vo:
no
vie
to
to
he:
f01
eXI
WE
eXI
tlu
po
ha
vo
'rh
de,
It
ba
sir
('l
ad
he
hi
ba
'th
vo
sp
vii
WI
to
hi
hi
hi
to
m
he
de
as
sa:
se<
'II'
tw
he
m
sh
as
excitedly about her voices as if she was living in the pages of a
celebrity gossip magazine. When another woman first fell ill, she
heard Hanuman, the Hindu god represented as part monkey:
'Heishalfmonkey.halfman;he isa godandhe wearsa reddhotiandhe wearsa lot
ofjewellery.Andhe carriesa bigstickwitha bigroundthingbecausehe protects
peoplefromwickedpeople.'
She was very clear that in the beginning he was not ni~ to her and
was always trying to punish her. 'Such horrible orders he used to
give me' - for example, to drink water from the toilet. Then he
became fun. She described him as her baby brother. She said that
they have parties and throw pillows and she pinches his bottom.
She still heard him speak audibly.
Accra
Although many of the Accra participants understood that hearing
audible voices could be a sign of psychiatric illness, their social
world accepts that there are human-like non-embodied spirits that
can talk. 'Voices [are] spirits: one man explained. Only two people
used diagnostic labels (schizophrenia). Only two described their
voices as asking them to kill or to fight, although six who did
not were admitted to the hospital because they had committed
violent acts. Only four said that they did not know who spoke
to them. When people talked about their voices they were likely
to emphasise the positive. Fully 16 of the sample of 20 reported
hearing God (or another divinity) speak audibly; the remaining
four were the only interviewees who reported no positive
experiences. (Because many Christians speak of 'hearing' God,
we were careful to establish in the interview whether this
experience was actually audible.) Fully half of the 20 described
their current voice-hearing experience as entirely or primarily
positive. A man admitted with terrible burns because a 'bad' voice
had told him to grab a live electrical wire said that, 'Mostly, the
voices are good'. A man admitted for the first time in 2007 said:
'Theyjust tellmeto do the rightthing.IfIhadn't hadthese voices
I
wouldhavebeen
deadlongago.'
It sometimes took time for participants to admit that they heard
bad voices as well as good ones. One man, in and out of hospital
since 1987, heard many voices speaking to him, among them God
('he's saving my life'), and they gave him helpful and protective
advice. Partway through the interview it became dear that he also
heard horrible voices as he walked across the ward - but God told
him to ignore them, he said, so he did. 'I don't pay attention to the
bad voices when they speak.' Indeed, people often insisted that
their good voice (usually God) was more powerful than any bad
voice. Another man had a special relationship with four river
spirits who gave him authority over the domestic animals in the
village, which he proceeded to kill and eat if they did not stay
within certain bounds (it was this that led his village headman
to send him to hospital). He heard bad voices as well, which gave
him commands he did not want to follow. God, he explained, gave
him the ability to call the good spirits to him, and they protected
him from the bad: 'They can never come back again'. A woman
told us that when God's voice became audible to her about nine
months earlier, she also began to hear demons whispering behind
her back every day. 'They try to tell you to do bad things.' The
demons spoke more loudly than God did (other patients said this
as well). But God's voice came first, and she followed him, she
said. Even when the voices were bad, people often described what
seems like a social relationship with them. Another woman heard
'many, many voices'. She heard God speak, but she dwelt on the
two bad voices she heard more often: her husband's brother and
her manager. They said, 'I like you. I want to kill you. I want to
marry you. I want to kill you.' She disliked them intensely. But
she held ordinary conversations with them. She talked about them
as people, not as intrusive noise: 'I know them'.
voice-hearing experiences in three cultures
Discussion
One of the most robust observations in cultural psychology and
psychological anthropology is that Europeans and Americans
imagine themselves as individuals; as Clifford Geertz put it:
A bounded,unique,moreor less integratedmotivationaland cognitiveuniverse;a
dynamiccenterof awareness,emotionand judgmentorganizedinto a distinctive
wholeandset contrastivelyagainstothersuch
wnoles?
This is a claim about how people conceive of themselves as
persons, not about psychological mechanism, and its point is that
outside Western culture people are more likely to imagine mind
and self as interwoven with others. These are, of course, social
expectations, or cultural 'invitations' - ways in which other people
expect people like themselves to behave. Actual people do not
always follow social norms. Nonetheless, the more 'independent'
emphasis of what we typically call the 'West' and the more
interdependent emphasis of other societies has been demonstrated
ethnographically and experimentally many times in many places -
among them India and Africa.
8,9
For instance, the anthropologist
McKim Marriott wanted to be so dear about how much Hindus
conceive themselves to be made through relationships, compared
with Westerners, that he called the Hindu person a 'dividual,.lo
His observations have been supported by other ethnographers of
South Asia and certainly in south India,
!l,12
and his term
'dividual' was picked up to describe other forms of non-Western
personhood.
13
The psychologist Glenn Adams has shown
experimentally that Ghanaians understand themselves as
intrinsically connected through relationships.Y'P The African
philosopher John Mbiti remarks: 'only in terms of other people
does the [African] individual become conscious of his own being;"
Cultural orientations
These examples do not add up to a single proposition, nor are
they presumed to do so in the anthropological or psychological
literature. Instead, the point this research makes is that relationships
with others are far more salient to the ways non-Westerners
(certainly South Asians and Africans) interpret their experience
than they are to Westerners. We believe that these social expectations
about minds and persons may shape the voice-hearing experience
of those with serious psychotic disorder. Our participants in San
Mateo were more likely to experience their voices as an assault.
The voices were felt to be intrusions into their private world,
and the sense that they could not be controlled upset them deeply.
Our participants in Chennai and Accra were not as troubled by the
presence of voices they could not control; they interpreted them,
in effect, as people - who cannot be controlled. The voices seemed
to make more sense to them, and they were more likely to say that
they liked them. There were, of course, many differences between
the voice-hearing experiences of those in Accra and those in
Chennai - the Chennai voice-hearing experience included more
playfulness and more emphasis on sex, for example, whereas the
Accra voice-hearing experience was more likely to involve the
dominant voice of God - but our most striking finding was that
hearing voices in the two non-Western settings seemed less harsh
and more relational than in San Mateo. Although our work
seems to be the first interview-based structured comparison
of the phenomenology of voice-hearing among people with
serious psychotic disorder in three different cultures, previous
anthropological and psychiatric work has also observed that the
voice-hearing experience outside the West may be less harsh.17-20
These differences in experience cannot be ascribed to a difference
in religiosity. Most of the Americans were religious, and the five
Americans who heard God's voice did not, in general, like their
voices. Many of the more pleasurable voice-hearing experiences
43
44
Luhrmann et al
in Chennai were not experiences of hearing God (although they
were in Accra). Nor can the difference be ascribed to differences
in urban living: almost all those interviewed were city-dwellers,
and Accra and Chennai are noisier and more chaotic than San
Mateo. Instead, the difference seems to be that the Chennai and
Accra participants were more comfortable interpreting-their voices
as relationships and not as the sign of a violated mind. We suspect
that the American cultural emphasis on individual autonomy
shapes not only a clinical culture in which patients have the right
to know, and should know, their diagnosis, but a more general
cognitive bias that unusual auditory events are symptoms, rather
than people or spirits.
Many years ago, in a famous paper, Jane Murphy demonstrated
that serious psychotic disorder was recognised by the same
behaviours in many different societies.f ' Altering the social
context of the illness might alter the content of hallucinations
and delusions, she argued, but little else. We believe, however, that
the cultural shaping may be more profound. It seems from our
evidence that auditory hallucinations are not only construed
differently in different cultural settings, but that their affective
tone actually shifts. This is in accord with the new cognitive-
developmental model of psychotic hallucinations, which argues
that cognitive bias, as well as cognitive deficit, shapes the rate,
content and phenomenology of psychotic hallucination.22,23 We
suggest that everyday expectations determine (to some extent)
the way people attend to the messy array of auditory events that
occur for most people with serious psychotic disorder and, in
consequence, alter those auditory phenomena; that everyday,
socially shaped expectations alter not only how what is heard is
interpreted, but what is actually heard.
Implications
These findings may be clinically significant. Researchers have
found that what the hallucinatory voices say affects how well the
person hearing them does?4,2S They have also discovered that
specific therapies may alter what patients hear their voices say.26,27
A new, primarily consumer-driven movement (the Hearing Voices
Network) claims that it is possible to improve a person's relationship
with their voices by teaching them to name their voices, to respect
their voices and to interact with them, and that doing so reduces
the voice's caustic quality.28 There is evidence that schizophrenia
has a more variable outcome than once was thought and that
social environment affects not only the severity but also the rate
of illness?9 The finding that schizophrenia has a more benign
course and outcome outside the West (in India, specifically)
remains robust despite further follow-up and fresh analysis.
30
Our work adds yet another hypothesis (to the many that now
exist) to explain this gentler trajectory, which is that more benign
voices may contribute to more benign course and outcome.
There is clearly more work to be done. Our study is limited by
its small numbers, which are characteristic of qualitative work.
Nevertheless, it suggests that the harsh, violent voices so common
in the West may not be an inevitable feature of schizophrenia,
T. M. Luhrmann, PhD, Stanford university, Stanford, California, USA;R. Padmavati.
MD, H. Tharoor, DNB, MNAMS,SchizophreniaResearch Foundation, Chennai, India;
A.
Osei, MB ChB, FWACP,Accra General Psychiatric Hospital, Accra, Ghana
Correspondence: T. M. Luhrmann, Stanford University, 441 Gerona Road,
Stanford, CA 94305, USA. Email: luhrmann@stanford.edu
First received 19 Sep 2013, final revision Feb 2014, accepted 3 Apr 2014
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