1. WALID SARHAN
Consultant Psychiatrist
Amman-Jordan

2. Culture influences the sources, the
symptoms and the idioms of distress;
the individuals’ explanatory models,
their coping mechanisms and their
help-seeking behavior; as well as the
social response to distress and to
disability.
(Kirmayer, 2001).

3.  Depression will be the second most
important cause of disability after ischemic
heart disease worldwide (WHO, 2002).
 The problem of depression crosses cultural,
international and socioeconomic
boundaries, and is one of the great
challenges of mental health care today.

4.  Although depression is considered to
be the most common disorder in
Western cultures. Some scholars regard
depression as a disorder of the Western
world, which lacks universal
applicability .
 Depression in the Arab population is
prevalent with classical or modified
clinical presentation.
(Marsella, 1978 ,Fernando, 1988).

5.  As the world is being gripped by economic
depression, international psychological
epidemiologists have amassed evidence to
suggest that psychological depression and
its variants are becoming leading
contributors to the global burden of disease
with the Middle East and North Africa
(MENA) region being no exception.
Sultan Qaboos Univ Med J. 2009 April; 9(1): 5–15.
Published online 2009 March 16.

6.  The value of individual independence is often
balanced or outweighed by that interdependence
within the family unit.
 While the structural extended family, in which several
generations reside in a single household, is no longer
as common in these communities as it was a few
decades ago
 Functional extended faqmily
M. Fakhr El-Islam
Transcultural Psychiatry 2008 45: 671

7.  Cultural factors may condition the development
of depression in women who cannot fulfil their
culturally-prescribed - monorole of marriage
and motherhood. Having no husband or children
or living under a threat thereof, may be a 'potent
factor in the genesis of depressive symptoms in
women.
 In the Arabian Gulf area, especially among the
illiterate. They ultimately develop' a chronic
culture conditioned form of neurosis, where
neurasthenic and hypochondriacal symptoms
dominate the clinical picture.

8.  Loss of a mate and love failure, which figure
prominently among depressed western
patients, are uncommon precipitating factors
among Arab depressives.
 Culturally-shared religious beliefs and
prescribed ritual practices reduce the
pathogenic effect of grief.
 Responsibility for failure in arranging marriage
is shared by the whole family so its impact on
the individual' is greatly reduced.

9.  Many Arab/Muslims believe that way to seek
help would be from healers, or Shekhes, to
exorcise the Jinn or to undo the influence of
the evil eye or black magic through amulets
or certain rituals.
 Depressed patients seek help of medical
practitioners late.
 Psychiatric help will only be reached very late
in the majority of cases.
 Very small percentage will start by psychiatric
consultation but this is on the rise .

10.  The only responsibility the patient has is to
avoid sinning, and, after such an illness, to
submit herself to religious healers (Shekhes)
in order to exorcize the Jinn.
 These beliefs, of course, prevent the patient
from playing an active role in psychotherapy
based on self-responsibility and on “working
on the self.”

11.  This disorder is reactive and involves a
variety of symptoms such as anxiety,
depression, dissociation, psychosis, and
also somatic symptoms
 Mixed rather than distinct syndromes seem to
be a very common clinical picture among
Arab/Muslims.
 It creates a lot of sympathy from the
community.

12.  Patients develop patterns of symptoms
in keeping with what medical
practitioners consider illness.
 A somatic concept of illness that
concerns the medical profession is
entertained by most Arab patients and
medical practitioners alike.
 Therefore, presentation of patients with
somatic symptoms is the rule.

13.  Depressed patients complain of pains, aches or
symptoms of autonomic dysfunction rather than
psychological symptoms that are differentiated
from associated bodily symptoms.
 The majority of medical practitioners in the Arab
world, who have been biometrically trained to think
of the human being as an assemblage of parts and
particles, resort to a multitude of physical
investigations for their patients' bodily symptoms
in their search for an organic etiology
 Commonly reassurance and psychotropic
prescription at times and rarely referral.

14.  The term somatization is therefore
misleading, because in these cultures there
are no distinct and pure psychological
distresses in the first place, and therefore
there is no place for somatization.
 Arab/Muslims, are somatizing therefore a
diagnosis of somatoform disorder is almost
useless in relation to Arab/Muslims.

15.  Lack of education about depression
lack of availability of appropriate therapies,
competing clinical demands, social issues,
and the lack of patient acceptance of the
diagnosis were among the most important
barriers to the identification, diagnosis, and
treatment of patients with depression in this
population
Nasir LS, Al-Qutob R.
J Am Board Fam Pract. 2005 Mar-Apr;18(2):125-31.
PMID: 15798141 [PubMed - indexed for MEDLINE]
Barriers to the Diagnosis and Treatment of
Depression in Jordan. A Nationwide
Qualitative Study

16.  Continuing medical education for providers about
depression, provision of counseling services and
antidepressant medications at the primary care level.
 Efforts to destigmatize depression may result in
increased rates of recognition and treatment of
depression in this population.
 Systematizing traditional social support behaviors may
be effective in reducing the numbers of patients
referred for medical care.
Nasir LS, Al-Qutob R.
J Am Board Fam Pract. 2005 Mar-Apr;18(2):125-31.
PMID: 15798141 [PubMed - indexed for MEDLINE]

17. The level of awareness of depression was
acceptable. However, further efforts are
necessary to establish public educational
programs related to depression in order
to raise awareness regarding the disease.
Sayer Al-Azzam et al
International Journal of Occupational Medicine and Environmental Health
Volume 26, Issue 4 , pp 545-554 -2013

18.  The 'evil eyes' of others Who notice or hear
about one's happiness, success or
possessions are believed to be capable of
causing him to lose them.
 Anhedonic depressed patients who have lost
their capacity to experience happiness or
pleasure attribute the loss to envy, and they
easily talk about their emotional loss to ward
off the possibility of further envy by others

19.  A comparison between depressive patients
in Egypt, India, and Britain revealed that the
Egyptian Arab/Muslim and Indian patients
displayed more anxiety and somatic
symptoms than did the British.
 Anxiety was displayed in 99% and somatic
symptoms in 87% of the Egyptian sample
(Abd El-Gawad, 1995)

20.  Suicide is a major sin, the punishment for which is
eternal hell during the afterlife of the person who
commits it.
 Depressed Muslims, including Arabs, may
passively wish they were dead or 'pray to God to
take their life away.
 Parasuicidal acts of pathological care-eliciting
were found to have no relationship to the degree
of adherence to Islamic religious practice.
(Abd El-Gawad, 1995)

21.  suicidal thoughts in the Egyptian
depressives were relatively high
compared with the low rates of suicide
and attempted suicide.
 Guilt feelings among the Egyptian
sample were relatively few.
(Abd El-Gawad, 1995)

22. Bazzoui and Al-Issall found that Arab
depressives in Iraq, rather than
expressing guilt feelings, are more likely
to be aggressive to others on whom they
project responsibility for the illness.

23. Okasha (1999) reported similar findings,
He found that Egyptian depressed
patients mask their affect with multiple
somatic symptoms that occupy the
foreground, and the affective component
of their illness recedes into the
background.

24.  The Islamic religion provides a
comprehensive code of conduct and
interpersonal relationships, the guilt
attached to wrongdoing nearly always has a
religious component.
 Some Arab depressives combine projection
and guilt when they attribute their illness to
God's punishment in retribution for their real
or imaginary wrongdoing.

25.  According to Islamic culture it is
blasphemous to give up hope for
relief of suffering because patient
endurance is rewarded in the afterlife.
 Hopelessness was not a prominent
symptom experienced by depressed
inpatients (both natives and
expatriates) surveyed in Kuwait .
(El-Islam, Moussa, Malasi, & Mirza, 1988).

26. The patient may find it impossible to cry.
Male depressed patients deliberately
prevent themselves from crying because
they feel that weeping would undermine
their masculinity.

27.  Breathlessness is one of the common somatic
complaints in depressed Arab patients. The
patient has difficulty in taking in air during
inspiration, which is sometimes described as if it
were air hunger.
 Breathlessness is often attributed to the
experience of tightening up of the chest.
Repeated sighing, which assures the patient of his
ability to take in enough air by deep inspiration
now and again, has a temporary comforting effect.

28. The depressed mood is more likely to find
expression in dream contents which center
around death and the dead
for example:
A dead relative would call the patient to his side
or tell him off for his real or imaginary
wrongdoings.

29.  Heartache' is a common complaint among
female depressed patients. It usually refers
to the loss or inability to achieve or maintain
a loving relationship to a key figure.
 Depressed men complaining of back pain
usually have sexual problems, for the back is
believed to be the origin of their virility and
procreativity.

30.  In a study about the effect of the evil eye in
Lebanon, 81.3% of the mothers reported that
they believed that evil eye had had a harmful
effect on their infants (Harfouche, 1981).
 Arab/Muslims perform several rituals that are
intended to protect them from the evil eye,
some of which may seem bizarre, such as
incantation, and the use of amulets, blue
beads, or a horseshoe
(Donaldson, 1981; Harfouche, 1981).

31.  Metaphoric descriptions of the experience of an
Arab/Muslim patient may add more confusion and
misunderstanding to the assessment of the reality
testing.
 As an example, one expression that is commonly used
by Arab/Muslims is “hwo sammelly badani.” This
expression literally means “He poisoned my body,” while
the intended meaning is “he made me nervous.”
 An unaware therapist or translater who hears a woman
saying “Yesterday my husband became furious and
poisoned my body,” may misinterpret this as delusion or
as a homicide attempt.

32. ‘Sadri dayeq alayya’ =‘My chest feels tight’
‘Tabana’ =‘I am tired, fatigued’
‘Jesmi metkasser’ =‘broken body’
Sulaiman et al (2001)

33.  The usual first stop on the help-seeking
route for mental illness is the traditional
healer.
 In a study of the help-seeking preference for
mental health problems in children, Eapen &
Ghubash (2004) found that only 37%
preferred to consult a mental health
specialist.
 Alternative remedies are also much sought
after,

34.  The effects on mental health of social change
associated with the rapid pace of development
and Western influences have been the subject
of several studies (e.g. Ghubash et al, 1994).
 While education, employment and social
opportunities have started to improve
perceptions of and attitudes to mental illness,
the stigma associated with mental disorder is
still a major factor that prevents individuals
from seeking appropriate treatment.
V. EapenInternational Psychiatry Volume 5
Number 2 April 2008

35. ‘The heart is poisoning me’
‘As if there is hot water over my back’
‘Something is blocking my throat’
Hamdi et al (1997)

36. Arab populations are also more likely
than Westerners to associate
depression with aches, pains and
weakness, and use a variety of
somatic metaphors to describe
depression
(Hamdi et al., 1997; Sulaiman et al., 2001).

38.  Individual agreement to disclosures to family
 Family informed by patient
 Joint interviews
 Family background as a measure of
normality/pathology
 Family psycho-education
 Family members as co-therapists

39. 1. Awareness of the possibility of somatic
presentations, and enquiring about the
patients’ understanding of the somatic
symptoms.
2. Clarifying the patients’ use of specific
cultural idioms of distress to describe the
somatisation process and being familiar
with somatic metaphors.

40. 3. Recognition that somatic symptoms are real
and not imagined.
4. Exploring physical symptoms in the context
of stressors with open-ended questions
such as: "What are the problems that you
are facing now that create difficulty or
distress?"

41. 5. Relevant medical investigations should be
performed but over-investigation should
be avoided. Not conducting any tests may
be negligent or taken as a sign of lack of
caring. Discussion of negative laboratory
or imaging tests with the patient is usually
helpful.

42. 6. Discussing the patient’s physical distress in
relationship to their life situation and
stressors should be discussed. Many
patients will find a biopsychosocial
interpretation helpful.
7. Rare possibilities should be considered e.g.
Somatosensory amplification; patients are
hypervigilant to irrelevant bodily stimuli and
report their awareness of bodily sensations
as physical distress and Alexithymia

43. In keeping with culturally-shared explanations of
depressive manifestations, therapy practices among
traditionally-oriented Arabs include the prescription
of anti-envy amulets, the appeal to shrines of dead
Muslim sheikhs, and occasionally the performance
of pilgrimage and “omra”.
Amulets usually contain verses of the Holy Quran
that ward off others evil.
Visits to shrines of dead religious sheikhs may help
the depressed by imparting a subjective sense of
blessing in return for his humble submission to the
saintness of the sheikh.

44.  Arab patients and their families transfer onto
therapists culturally shared attitudes, especially
those related to age and gender.
 When dealing with intergenerational conflict in
Kuwait, members of both generations would be
surprised if a middle-aged therapist did not reject
younger peoples’ anti-traditionalist and modern
ideas.
 A good or effective therapist in Egypt and Arabian
Gulf countries is expected to be authoritative rather
than to offer choices to patients.
 Patients also expect therapists to take their side,
rather than remain neutral, in family conflicts and
in reports to public authorities
(El-Islam, 2005).

45.  As compared to the reductionist Western nosology
represented in the DSM IV, the psychological
disorders among Arab/Muslims tend to be mixed
rather than distinct syndromes. Anxiety,
depression, dissociation, and somatic symptoms
are highly inter-correlated among Arab/Muslims.
 To avoid misdiagnosis, practitioners who are
familiar with the Western nosology of mental health
are advised to be aware of the uniqueness of each
diagnostic category among Arab/Muslims.
 Almost all the diagnostic categories are manifested
in a unique clinical picture and course that need to
be known to practitioners.

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54. wsarhan34@gmail.com