'Psiquiatría: situación actual y perspectivas de futuro'. Este es el título del simposio internacional que organizamos el 20 de junio de 2016 en la Fundación Ramón Areces con las fundaciones Juan José López-Ibor y Lilly en homenaje al doctor Juan José López-Ibor, fallecido en enero de 2015. Durante esta jornada, expertos internacionales abordaron la profunda crisis que atraviesa la psiquiatría como disciplina científica y especialidad médica. Además, se presentó el libro con el mismo título del simposio, también en recuerdo del doctor López-Ibor.

1. Transcultural Aspects of
Obsessive Compulsive
Disorder; An Egyptian
Perspective
Professor Tarek A. Okasha
M.D., Ph.D., M.S. (N&P), D.P.P., F.A.P.A., Dip. I.A.B.M.C.P.
Professor of Psychiatry
Director of the WPA Collaborating Center for Research and Training in
Psychiatry
Institute of Psychiatry, Faculty of Medicine,
Ain Shams University, Cairo, Egypt

2. Profiles of the global “village”
Assume that 100 people are living on earth:
• 60 are Asians
• 11 are Europeans
• 15 are Africans
• 14 are Americans (5 North and 9 South)
• 50 are men, 50 are women
• 25 are white, 75 are non white
• 26 children and 74 adults (8 of them 65
and older)
• 70 have shelter and 30 have no shelter

3. • 6 people own 59% of the community
wealth, all North Americans.
• 80 live in poverty.
• 83 can read and write & 17 cannot read
• 50 die in famine.
• 7 have a college degree & 93 do not
• 22 own or share a computer
• 30 have access to the internet & 70 do
not
• 48 live on less than 2 USD per day
Profiles of the global “village” (cont.)

4. Culture
• Culture is a matrix that constitutes the
background against which we should
understand the biological, psychological and
social dimensions of mental disorder.
• Lack of awareness of important cultural
differences can undermine the development
of a therapeutic alliance and the negotiations
and delivery of effective treatment

5. Arab Culture
• Arab culture includes traditional beliefs in devils,
jinn, the evil eye, and so on.
• The family structure is characterized by affiliated
behavior at the expense of differentiating
behavior.
• Rearing is oriented toward accommodation,
conformity, cooperation, affection, and
interdependence as opposed to individuation,
intellectualization, independence, and
compartmentalization.
Okasha, A. & Okasha, T. 2011

6. • The humanitarian nature of the doctor’s
interaction depends on the way the doctor
deals with the patient and the family, and
the extent to which the doctor expresses
respect for, and acceptance of the local
cultural and spiritual norms.
Okasha & Maj 2001

7. Differences between Traditional and
Non-Traditional Societies
Traditional Societies Non-traditional
Societies
Family & group oriented Individually oriented
Extended family Nuclear family
Status determined by
age, position in family
and care of elderly
Status achieved by
ones own efforts
Okasha, 2000

8. Relationship between
kin is obligatory
Relationship between
kin is a matter of
individual choice
Extensive knowledge of
distant relations
Knowledge of close
relatives only
Family decision making Individual autonomy
External locus of control Internal locus control
Physician's decision
making is respected
Doubt in doctor-patient
relationship
Rare suing for
malpractice
Common suing for
malpractice
Okasha, 2000

9. Deference to God’s will Self determination
Trust in doctor patient
relationship
Mistrust in doctor
patient relationship
Individual can be
replaced, pride is in the
family
Individual is
irreplaceable,
Pride is in self
Pride in family care of
mentally ill patients
Community care of
mentally ill patients
Illness and recovery
attributed to God
Self determined
recovery
Okasha, 2000

10. CRITICAL COMMENTS IN
DIFFERENT CULTURES
• English studies: Two critical comments1
• USA studies: Three critical comments2
• Los Angeles: Six critical comments3
• Egyptian studies: Seven critical comments4
1.Vaughn CE and Leff JP. Br J Psychiatry. 1976;129:125-137. 2. Hooley et al, 1986.
3. Montero I, et al. Br J Psychiatry. 1992;161:217-222.
4. Okasha A, et al. Am J Psychiatry. 1994;151(7):1001-1005.

11. WARMTH VS. CRITICAL COMMENTS
• It seems a disadvantage that little is known
about the role of warmth and positive remarks
in family life and patients’ outcome especially in
traditional societies.
• It may be possible that a clinically significant
level of warmth could protect the patient
against relapse.
Okasha A, et al. Am J Psychiatry. 1994;151(7):1001-1005.

12. CULTURE & RELAPSE
• High expressed emotion can be viewed as a
kind of social trait in many Egyptian families
• Criticism may sometimes be taken as a sign of
care, interest and love in any Egyptian
enmeshed family
Okasha A, et al. Am J Psychiatry. 1994;151(7):1001-1005.

13. Transcultural Aspects of OCD
• The impact of Egyptian culture is evident in
many aspects of transcultural studies in Egypt.
• The religious nature of upbringing and education
in Egypt, with emphasis on practicing religious
rituals has influenced many of the OCD
symptoms in our Egyptian sample, even if the
subjects are not practicing their religious duties
with diligence.

14. Transcultural Aspects of OCD
• The warding-off of blasphemous thoughts
through repeated religious phrases such as "I
seek refuge with the Lord from the accursed
Satan" may explain the high prevalence of
religious obsessions in Egypt

15. Praying in Islam
FIVE PRAYERS /DAY
DAWN 2 GENU FLEXION
FOLLOWED BY PROSTRENATION
NOON 4
AFTERNOON 4
SUNSET 3
EVENING 4
Okasha et al, 2004

16. ABLUTION = “WOODOO”
• WASHING IN THE FOLLOWING ORDER:
HANDS, MOUTH, NOSE, FACE, EARS, ARMS
TO ELBOWS , HEAD THEN FEET
• 3 TIMES EACH
Okasha et al, 2004
Rituals of Ablution in Islam

17. CLEANINESS = RELIGIOUS PURITY
“ANNULMENT OF ABLUTION”
 EJACULATION
 MENSTRUATION
 URINATION
 FLATUS & DEFECATION
Okasha et al, 2004

18. PREVALENCE OF OCD IN EGYPT
1968  2.5%
1991  2.30%
)Okasha and Hassan 1968& Okasha and Rafaat 1991(

19. Previous Egyptian studies on psychiatric
phenomenology have shown a prevalence of
culturally determined symptomatology.
Religion and prevailing traditions seemed to
colour not only the clinical picture of the
condition, but also the patients’ attitudes
about their disorder
(Okasha 1966 – 1967 – 1973).

20. AN EGYPTIAN STUDY ON OCD
• 84 patients with OCD
• Follow up for 3-5 years
• 54 males, 30 females
• University clinic: Middle & Lower social class
• Private practice: Upper and Middle social class
• 68% of Middle and lower social class patients
sought help with traditional healers
• 18% Upper and middle social class patients sought
help with traditional healers
Okasha et al. 1994

21. 69% males , 31% females
The mean age of the sample was 23.7 years,
with a mean duration of OCD of 3.2 years.
 20% of patients had a positive family history
for OCD.
Cont..
Okasha et al 1994

22. 40% Mixture of obsessions & compulsions
29% Obsessions
31% Compulsions.
SYMPTOMATOLOGY
Okasha et al 1994
Cont..

23. Religious (blasphemous) and contamination
obsessions (60%),
Somatic obsessions (49%),
The most commonly occurring compulsions were
repeating rituals (68%),
Cleaning and washing (63%),
Checking (58%), mostly related to religious beliefs.

24. • 71% of patients were rated severe on the Y-BOCS.
• A surprising finding in our study was the fact that
none of the patients had good insight.
• Insight was mildly affected in 26%, moderately
affected in 50%, and severely affected in 14.4% of
cases. .
One third of patients had a comorbid
depressive disorder.
Okasha et al. 1994

25. • 14% had obsessive personality disorder
• 34% had paranoid, anxious, or emotionally
labile personality disorders
• 52% had no specific premorbid personality
disorder.
PRE MORBID PERSONALITY
Okasha et al. 1994

26. • The presenting symptoms in Egyptian
Muslims and Christians were almost similar
in terms of obsessions, where religious and
sexual thoughts were predominant.
• The difference was in compulsions in
Muslims regarding washing in ablution.
MUSLIMS AND CHRISTIANS
IN EGYPT
Okasha et al. 1994

27. No.
Contam-
ination
Aggre-
ssion
Ordering Sexual Religious
EGYPT 90 60% 41% 53% 47% 60%
INDIA 82 46% 29% 27% 10% 11%
ENGLAND 45 38% 23% 11% 9% ---
JERUSALEM
10 40% 20% 10% 10% 50%
Common themes of obsessions in Egypt,
India, England and Jerusalem
Okasha, 1994; Akhtar, 1975; Stem, 1978; Greenberg, 1984

28. The sample was selected using a multistage
stratified random sample of students from El
Abassyia educational area in Cairo.
PREVALENCE OF OCS IN
EGYPTIAN ADOLESCENTS
Okasha et al 2001

29. Psychiatric morbidity among the total sample
was 51.7%,
Obsessive traits was 26.2 %.
Obsessive compulsive symptoms was 43.1 %.
OCS were more prevalent among the younger
students, among female students and first
born subjects.
Okasha et al 2001

30.  Aggressive, contamination and religious
obsessions and cleaning compulsions were
the commonest among the sample,
 19.6% of subjects with OCS fulfilled ICD-10
criteria for OCD.
))Okasha, et al 2001((

31. A sample of 372 psychiatric outpatients using
the Arabic version of Yale Brown obsessive-
compulsive symptom (Y-BOCS) checklist
compared to a control group composed of
308 non-psychiatric subjects.
Okasha et al 2000
PREVALENCE OF OCS IN
PSYCHIATRIC PATIENTS

32. Patients found to have OCS symptomatology
were:
•83 % of patients with neurotic, stress related and
somatoform disorders.
•51 % of patients with mood disorders
•47 % of patients with schizophrenia, schizotypal
and delusional disorders
Okasha et al 2000

33. Higher prevalence of OCS (62.4 %) in the
clinical psychiatric population tends to
confirm the validity of the subsyndromal
forms of OCD which are labeled OCS, which
seem to represent a clinically valid subgroup,
which the modern classifications fail to
recognize.
Okasha et al 2000

34. Conclusion
1. To focus on cultural psychiatry issues broadly for
all people in their own society – beyond the matter
of minorities and migrants
2. To strengthen the training of cultural psychiatry at
different levels for medical students, residents and
the future cultural psychiatrists
3. To enhance clinical application – by improving
culture-relevant, culture-competent psychotherapy
for every patient
4. To work on theoretical issues – to expand our
knowledge and theoretical understanding for
universal and culture-specific applications