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Clinical Psychology Review, Vol. 19, No. 8, pp.

917933, 1999
Copyright 1999 Elsevier Science Ltd
Printed in the USA. All rights reserved
0272-7358/99/$see front matter

PII S0272-7358(99)00003-3

MENTAL HEALTH IN THE MIDDLE EAST:


AN EGYPTIAN PERSPECTIVE
Ahmed Okasha
Institute of Psychiatry, Ain Shams University, Cairo, Egypt

ABSTRACT. This article introduces the reader to mental health in the Middle East with an
Egyptian perspective, from the Pharaonic era through the Islamic Renaissance, up until the current state. During Pharaonic times, mental illness was not known as such, as there was no separator between Soma and Psyche. Actually, mental disorders were described as symptoms of the
heart and uterine diseases, as stated in Ebers and Kahouns papyri. In spite of the mystical culture, mental disorders were attributed and treated on a somatic basis. In the Islamic era, mental
patients were never subjected to any torture or maltreatment because of the inherited belief that
they may be possessed by a good Moslem genie. The first mental hospital in Europe was located in
Spain, following the Arab invasion, and from then on it propagated to other European countries.
The 14th century Kalawoon Hospital in Cairo had four departments, including medicine, surgery, ophthalmology, and mental disorders. Six centuries earlier, psychiatry in general hospitals
was recognized in Europe. The influence of Avicenna and Elrazi and their contributions to European medicine is well-known. This article discusses further the current state of the mental health
services in Egypt and the transcultural studies of the prevalence and phenomenology of anxiety,
schizophrenia, depression, suicide, conversion, and obsessive compulsive disorders. An outline of
psychiatric disorders in children is discussed. The problem of drug abuse is also addressed, especially that in Egypt after 1983, where drugs like heroine replaced the common habit of
hashish. 1999 Elsevier Science Ltd
KEY WORDS. Arab world, Egypt, Pharaonic, Islamic era, Present mental health services.

MENTAL ILLNESS IN PHARAONIC TIMES


NO KNOWN PHYSICIANS title in the Pharaonic times suggests specialization in
mental diseases, although psychic and mental symptoms are mentioned in many clinical observations, mainly in the book of the heart (Ebbell, 1937). In Ebbells translation of Ebers papyrus, the words heart and mind occur in 14 prescriptions, but it

Correspondence should be addressed to Prof. Ahmed Okasha, MD, FRCP, FRCPsych, FAPA,
DPM, Ain Shams University, 3 Shawarby Street, Kasr El Nil, Cairo, Egypt. E-mail: aokasha@
internetegypt.com

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must be added that while this author translates ib by mind and he, tj by heart,
Grapow (1954) translates both by heart, so it seems that the heart and the mind
meant the same thing in Ancient Egypt.
One of the psychotherapeutic methods used in Ancient Egypt was incubation or
the Temple sleep. This was associated with the same name of imhotep, the earliest
known physician in history. I.em.ho.tep., he who comes in peace, was the physician vizier of the Zoser who built the Sakkara pyramid, 29802900 BC. He was worshiped at
Memphis, and a temple was constructed in his honor on the island of Philae. The temple was a busy center for sleep treatment. The course of treatment depended greatly
on the manifestations and contents of dreams, which were, of course, highly affected
by the psycho-religious climate of the temple, or the confidence in the supernatural
powers of the deity, and on the suggestive procedures carried out by divine healers
(Baasher, 1975).
The available medical papyri from which ancient Egyptian medicine was derived
are the following:
Kahun Papyrus (1900 BC): Rather incomplete and fragmentary, it deals with the
morbid states attributed to the displacement of the uterus.
Eber Papyrus (1600 BC): The greatest Egyptian medical document. Translated by
Ebbell in 1937.
Edwin Smith Papyrus (1600 BC): Deals mainly with surgery.
Heart Papyrus: Similar to that of Ebers.
Berlin Medical Papyrus (1250 BC): Again, this deals with prescriptions in unsystematic arrangement.
London Medical Papyrus (1350 BC): This contains mainly incantations against a variety of diseases and few prescriptions.

Hysteria
The oldest of these papyri deal specifically with the subject of hysteria. This document
is known as the Kahun Papyrus, after the ancient Egyptian city in the ruins of which it
was found, and dates back to about 1900 BC. It is lamentably incomplete, only fragments have survived. Most of these diseases are defined clearly enough to be recognized today as hysterical disorders. A few illustrated cases are cited: (a) a woman who
loves bed, she does not rise and does not shake it; (b) another woman who is ill in
seeing, who has pain in her neck; (c) a third woman pained in her teeth and jaws,
she does not know how to open her mouth; (d) and finally, a woman aching in her
all limbs with pain in the sockets of her eyes.
These and similar disturbances were believed to be starvation of the uterus or by
its upward displacement with a consequent crowding of other organs. The genital
parts were fumigated with precious and sweet-smelling substances to attract the womb,
or evil-tasting and foul-smelling substances were injected or inhaled to repel the organ
and drive it away from the upper part of the body, where it was thought to have wandered. These suggestive methods are still carried out in recent times.

Depression
Depression was described in many tales. Two such descriptions cite the following
(Ghaliongui, 1963, 1983): he huddled up his clothes and lay, not knowing where he

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was. His wife inserted her hand under his clothing, she said: my brother, no fever in
your chest and limbs, but sadness of the heart. Despair in the darkest fashion is reflected in this dismal ode: Now death is to me like health to the sick, like the smell of
a lotus, like the wish of a man to see this house after years of captivity.

Suicide
By destroying the body (instead of having it embalmed according to traditions and
nourished by offerings) the soul would lose the house into which, according to the
Egyptian belief, it must return every night in order to be renewed and to be reborn
the following morning at sunrise, so as to live eternally. Here we are confronted with
the very essence of Egyptian ethics. The Egyptian felt that not only the Ba (Soul),
but also the whole body and its organs, heart, kidneys, etc., came under the responsibility of the Gods and were the dwelling places of the divine powers to the extent that
eating and drinking became virtually a duty of man toward these divine powers. The
question of whether or not suicide is sinful and thus subject to eternal reprobation becomes irrelevant, if the mere preservation of the corpse by embalming it and supplying it with offerings suffices to keep the soul alive.

Etiology of psychiatric symptomatology.


1.
2.
3.
4.
5.

In seven observations the course of the symptoms is vascular.


One is due to purulence.
One is due to fecal matter.
One is due to obscure causes.
One is due to a mysterious substance. Translated from hieroglyphics, the name
of the substance would be AAA.
6. On one the cause is not mentioned.
7. On only two the cause is said to be demoniac or spiritual order.
Under these causes, we find disturbances of thinking, emotions, intellect, and behavior similar to formal thought disorder, poverty of thinking, retardation and excitement, forgetfulness, etc., which can be labeled in our time as schizophrenia, catatonia, or dementia.
To sum up, in ancient Egypt the concept of hysterical disorders was known and ascribed to the movement of the uterus, long before Hippocrates described it under the
term hysteria. The therapeutic approach to this disorder was physical rather than mystical.
Depression, dementia, psychomotor retardation, negativism and subacute delirious
states, and thought disorders similar to schizophrenia were described in details in the
Book of Heart in Ebers papyrus. The heart and mind were synonymous, and the etiology of all these states was ascribed to vascular causes, purulence, fecal matter, the poison AAA, and in only two conditions the etiology was believed to be spiritual..
So we can infer that the concept of mental illness in Pharaonic Egypt was monistic
and, in a mystical culture, it was attributed to bodily etiology and treated physically
and psychotherapeutically (magicoreligious).

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A. Okasha

MENTAL ILLNESS IN THE ISLAMIC ERA


The approach of Islam to mental illness can be traced to two main sources:
1. The Holy Text (the Koran): The most common word used to refer to the mad
person, for example, insane or psychotic, in the Koran is majnoon. This is mentioned five times in the Koran to ascribe how prophets were perceived.
2. Common convictions at the popular level: The same word is used by the masses
to describe the perceived eccentricity of all prophets when they attempt to guide
their people to enlightenment. It is sometimes coupled with being a magician or
a teacher. In a sense, there seems to be a positive connotation to madness that
would flatter the antipsychiatry concept of madness, that flourished in the mid60s (Shaalan, personal communication, 1989).
The word majnoon is originally derived from the word jinn (the word jinn in Arabic
has a common origin with overlapping words with different connotations and can be
traced to refer to a shelter, screen, shield, paradise, embryo, and madness). The current belief that the Islamic concept of the insane is that he is possessed by a jinn
should not be confused with the concept of the Middle Ages. In Islam, the jinn is not
necessarily a demon or evil spirit. It is a supernatural spirit, lower than the angels, and
has the power of assuming human and animal forms that can be either good or bad.
Some jinn are believers; listen to the Koran and help human fairness. Moreover, Islam
is not devoted to human beings but also to the spiritual world at large. In the Koran,
almost always, the jinn and the human being are mentioned together. This has altered
the concept and the management of the insane, although they may be perceived as
being possessed because the possession may be by a good or a bad spirit. Consequently, there is no place to generalize punishment or give to condemnation unconditionally.
Apart from the concept of the insane as being possessed, we have another positive
concept where the insane is taken as the one who dares to be innovative, original, creative, or attempts to find alternatives to a static and stagnant mode of living. It is also
to be found in various attitudes toward certain mystics, such as Sufism, where the expansion of self and consciousness has been taken as a rationale to label some of the
Sufis as psychotic. The autobiographies of some Sufis reveal the occurrence of psychotic symptoms and many mental sufferings in their paths to self-salvation (Rakhawy,
personal communication, 1989).
The third concept of mental illness is the consequence of the disharmony or constriction of consciousness, to which non-believers are susceptible. It is related to denaturing of our basic structure (Al Fitrah) and disruption of our harmonious existence
by egoism, detachment, or alienation, partly presented by the loss of integrative insight.
The prevailing concept of mental illness at a particular stage in the Islamic World
depends on the dominance of development or deterioration of genuine Islamic issues. For instance, during deterioration, the negative concepts of the insane as being
possessed by evil spirits dominates, whereas during periods of enlightenment and creative epochs, the disharmony concept dominates, and so forth.
Islam also identified the unity of body and psyche. The psyche (Elnafs) was mentioned 185 times in the Koran as a broad reference to human existence, meaning at

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different times body, behavior, affect, and/or conduct (i.e., a total psychosomatic
unity).
The teaching of the great clinician Rhazes had a profound influence on Arab as
well as European medicine. The two most important books of Rhazes are El Mansuri
and Al-Hawi. The first consisting of 10 chapters, includes the definition and nature of
temperaments, the dominant numerous, and comprehensive guides to physiognomy.
Al-Hawi is the greatest medical encyclopedia produced by a Moslem physician. It was
translated into Latin in 1279 and published in 1486. It is the first clinical book presenting the complaints, signs, differential diagnosis, and the effective treatment of illness. One hundred years later, El-Canoon of medicine by Avicenna was a monumental,
educational, and scientific book with better classification.
The first Islamic hospital appears to have been established by the early 9th century
in Baghdad and to have been modeled on the East Christian institutions, which seem
to have been mainly monastic infirmaries.
Among the hospitals that appeared throughout the Islamic world, perhaps the most
famous one was that created in Cairo by the Egyptian Sultan al-Mansour Kalaoon in
683/1284 (Dols, 1992).
The 14th-century Kalaoon Hospital in Cairo had sections for surgery, ophthalmology, medical, and mental illnesses. Contributions by the wealthy of Cairo allowed a
high standard of medical care and provided for patients during convalescence until
they were gainfully occupied. Two features were striking: the care of mental patients
in a general hospital, and the involvement of the community in the welfare of the patients; and foreshadowed modern trends by 6 centuries (Baasher, 1975).

CURRENT MENTAL HEALTH SERVICES IN EGYPT


Egypt is divided into 24 governerates, 19 with psychiatric clinics and outpatient units
and 5 with no psychiatric services. The latter include Matrouh, Red Sea, New Valley,
and North and South Sinai.
The population of Egypt is 60,000,000. There are approximately 120,000 doctors, 1
for every 500 citizens; 500 psychiatrists, including those under training, 1 for every
130,000 citizens; and about 9,000 psychiatric beds, 1 bed for every 7,000 citizens (i.e.,
15 beds/100,000 population). The number of psychiatric beds in Egypt constitutes
less than 10% of the total hospital beds (110,000).
The two largest mental hospitals, Abbassia and Khanka, are facing great difficulties
regarding care, finances, treatment, and rehabilitation, while accommodating about
5,000 patients. The new policy of deinstitutionalization and provision of community
care may reduce the number of psychiatric inpatients but will not solve the problem
(Okasha, 1988). In 1967, a third mental hospital was established in Alexandria, in
1979 another was founded in Helwan, and in 1990 yet another near the airport.
Egypt has approximately 250 clinical psychologists, with hundreds of general psychologists working in field unrelated to mental health services. There are many social
workers practicing in all psychiatric facilities, but unfortunately they are generic social
workers with minimal graduate training in psychiatric social work. In 1960, there was
an attempt to educate psychiatric social workers at the institute of Social Services in
Cairo. It lasted for only 2 years because of a shortage of applicants.

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There are 13 medical schools in Egypt and each has a psychiatric unit with inpatient
and outpatient psychiatric services. For the last 55 years, Egypt has had a diploma in
psychological medicine, and for 35 years a masters and doctorate degree in psychiatry. Egypt is one of the few Arab countries with its own postgraduate degrees and education in psychiatry.
There are four higher institutes of nursing in Egypt, equivalent to medical schools,
that graduate highly qualified psychiatric nurses. Unfortunately, the majority of nurses
leave the country to work in the petrodollar Arabian gulf states with their high salaries.
Most nurses working in mental health facilities are general nurses who graduated from
nursing schools, but the numbers are insufficient to cover psychiatric services.
In spite of rapid social changes in Egypt, the majority of people, especially in rural
areas, belong to the extended family hierarchy. It is considered shameful to care for
an elderly demented person away from family surroundings. The parents of retarded
or hyperkinetic children feel a primary responsibility toward them rather than having
them looked after in an institution.
Traditional and religious healers play a major role in primary psychiatric care in
Egypt. They deal with minor neurotic, psychosomatic, and transitory psychotic states
using religious and group psychotherapies, suggestion, and devices such as amulets
and incantations (Okasha, 1966). It was estimated that 60% of outpatients at the university clinic in Cairo serving low socioeconomic classes have been to traditional healers before coming to the psychiatrist (Okasha & Hassan, 1968). In rural areas, community care is implemented without the need for health-care workers. Egyptians,
especially those living in the countryside, have a special tolerance for mental disorders
and an ability to assimilate chronic mental patients. These patients, and those with
mild or moderate mental retardation, are rehabilitated daily by cultivating and planting the countryside along with, and under supervision of, family members.
Aftercare services in Egypt are still limited due to the poor understanding of most
people for the need for follow-up care after initial improvement. Community care in
the form of hostels, day centers, rehabilitation centers, and health visitors is only available in big cities. A good example in applying community care is in the prevention of
drug abuse. There has been an increase in the abuse of heroin and other narcotics
since the early 1980s. The media, legislative acts, the General Administration of Drug
Combats seizures of traffickers, initiation of centers all over Egypt and deployment of
social workers, religious people, and politicians to educate the masses about the hazards of drug abuse have triggered an interest in psychiatry and mental disorders. Although community care started in the 1960s, active participation exploded with the
increase of drug abuse among young people.
The priorities for community health care services in Egypt are not for mental
health, but rather bilharziasis (schistosomiasis), birth control, infection diseases in
children, and smoking and illicit drug abuse. The programs for community care in
big cities take the form of outpatient clinics, hostels for the elderly, institutions for the
mentally retarded, and centers for drug abuse, school, and university mental health.
The National Mental Health Program, 19911996, for Egypt, emphasizes the role of
primary health care looking after 80% of psychiatric patients. It will focus on decentralization of mental health care and community care in different governerates. Emphasis is on recruiting mental health teams, especially psychiatric nurses, psychiatric
social workers, occupational therapists, and clinical psychologists.

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TRANSCULTURAL ASPECTS OF PSYCHIATRIC DISORDERS IN EGYPT

Depressive Disorders
The prevalence of depression among a selected sample of an urban and rural population was found to be 11.4% and 19.7%, respectively. Dysthymic disorder was the most
common diagnostic category in the urban population (4.1%), while adjustment disorder with depressed mood was more frequently encountered in rural population
(6.7%). Of the urban population, 1.9% was given the diagnosis of major affective disorder according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R; American Psychiatric Association, 1987), compared to 3.3% of the rural subjects. The total prevalence was 2.5% (Okasha, Khalil, El
Fiky, Ghanem, & Abdel Hakeem, 1988).
The cross-cultural comparison between Western and Egyptian populations revealed
some differences. As was previously found in Egypt by Okasha, Kamel, Sadek, Lotaief,
and Bishry (1977), and Gawad and Arafa (1980), depression is manifested mainly by
agitation; somatic symptoms; hypochondriasis; physiological changes, such as decreased libido and anorexia; and insomnia, which is not characterized by early morning awakening. Symptoms such as ideas of guilt, sin, and reproach are not common in
Egyptian patients. Egyptian subjects tend to translate their feelings into body language. This may be because of a greater social acceptance for physical complaints
than psychological complaints, which are either not taken seriously or are believed to
recover with some rest or extra praying, etc. They mask their affect with multiple somatic symptoms that occupy the foreground and the affective component of their illness recedes to the background. Accordingly, they either resort to the general practitioner or the primary health-care physician asking unneeded investigations, which are
costly for a developing country, or they ask the traditional healers to alleviate their sufferings. A considerable number did not ask for help at all, especially in rural populations, where absenteeism from work or inability to face day-to-day affairs are not much
criticized by their community.
Gawad and Arafa (1980) attempted to compare the Egyptian study with a similar Indian one and two British studies to find any variable qualitative differences between
the Egyptian depressive and others. They observed the following features:
1. Symptoms of depressed mood, anxiety, somatic complaints, and suicidal tendency are significantly more frequent among Egyptians compared to the British.
In contrast, guilt, insomnia, and hypochondriasis are significantly more frequent in the British study.
2. No significant difference was found between the Egyptian sample and the British regarding initial insomnia, retardation, diurnal variation, and paranoid
trends. Guilt was higher in the British but statistically insignificant. Agitation, hypochondriasis, late insomnia, and obsessive trends were also higher among the
British, while those of depressed mood, suicidal tendency, and anxiety were
more frequent in the Egyptian study.
3. The comparison between the Egyptian and Indian studies indicates that symptoms of guilt, insomnia, retardation, agitation, hypochondriasis, and diurnal
variation are significantly more frequent in the Indian sample. It is especially
marked in agitation (68% vs. 8%).

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A. Okasha

The increase in somatic symptoms can be explained by the seriousness with which
people in a given culture view psychological stress as compared to physical illness.
Eastern cultures emphasize social integration more than autonomy (i.e., the family
and not the individual is the unit of society). Dependence is more natural and infirmity less alien in these cultures. When affiliation is more important than achievement,
how one appears to others becomes vital and shame becomes a driving force more
than guilt. In the same manner, physical illness and somatic manifestations of psychological distress become better understood, more acceptable, and evoke a caring response rather than a vague complaint of psychological symptoms that can be either
disregarded or considered a stigma of being soft or, worse even, insane.

Anxiety Disorders
In the DSM-III-R (American Psychiatric Association, 1987), anxiety disorders are estimated to range from 2% to 4% of the general population. A study on psychiatric morbidity among university students in Egypt showed that anxiety states were diagnosed in
36% of the total sample (Okasha et al., 1977). In 1993, anxiety states represented
about 22.6% of the psychiatric outpatient clinic in a selective Egyptian sample
(Okasha, Seif El-Dawla, Khalil, & Saad, 1993). In 1981, Okasha and Ashour undertook
the first attempt to study the sociodemographic aspects of anxiety disorders in Egypt
and to apply the Arabic version of the Present state examination (PSE) in evaluating
the profiles of clusters and symptoms of anxiety in a sample of 120 patients with anxiety. The findings revealed that the most common symptoms were worrying (82 %), irritability (73%), free-floating anxiety (70%), depressed mood (65%), tiredness (64%),
restlessness (63%), anergia, and retardation (61%). The rarest were alcohol abuse
(2%) and drug abuse (5%). Suicidal plans were uncommon (9%), delayed sleep (49%)
was more common than early waking (22%). Panic attacks were represented in 30%,
situational anxiety in 35%, specific phobias in 37%, and avoidance in 53%. Males
showed significantly more hypochondriasis and anxiety on meeting people than females (p , .01). This can be explained by the fact that males in our culture tend to somatize their psychological symptoms, as the alternative may lower their prestige and
degrade their pride, because the belief is that real men should not have psychological symptoms. The man is required to play a superior, confident, dignified role, which
may challenge his power of adaptation and accentuate his anxiety about meeting people. Females showed significantly more increased free-floating anxiety, loss of weight,
and conversion symptoms.
There were highly significant differences between illiterates and high school graduates. Poor concentration, loss of weight, delayed sleep, anergia, retardation, obsessional checking, fugues, and amnesia were more common in the educated group,
while the illiterates more often suffered from depersonalization, dissociative, and conversion symptoms. This is in accordance with the familiar clinical observation that hysterical symptoms are more frequent among the uneducated population with average
and below average intelligence.
Statistical analysis showed significant variation in the profile of anxiety symptoms regarding crowding. Patients living in severely crowded places exhibited highly significant differences from those living in mildly crowded areas. Symptoms like worrying,
restlessness, free-floating anxiety, specific phobias, neglect due to brooding, expansive

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mood, ideomotor pressure, grandiose ideas, fugues, amnesia, and conversion symptoms, were more manifest in severe crowding.

Schizophrenia
Schizophrenia is the most common chronic variety of psychosis in Egypt, and represents the major bulk of inpatients in our mental hospitals.
The figure of 15.3% of the total newly examined cases at University Hospitals in
Egypt presents a different sample from those attending to mental hospitals. The
former are more representative of psychiatric patients seen in the community without
the necessity of their admission to mental hospitals (Okasha & Hassan, 1968).
Delusions were affected by the individual characteristics of the patients in relation
to the Egyptian culture. Religious, political, scientific, and sexual delusions were the
most frequent types. Financial, social delusions related to health, emotional, and autistic delusions were less common. Religious delusions were frequent due to the
highly religious standards in Egypt. Political delusions were positively correlated to
the level of political sanctions and pressure. Sexual delusions were more common in
groups in whom sexual behavior is severely suppressed (e.g., single and rural patients). Mixing males and females at the university level might increase the frequency
of sexual delusions among the highly educated. Delusions of sin were present in masturbators in the younger, single, and the student-group, and among those with high
religious values.
Persecutory delusions with ideas of reference are the rule, delusions of grandeur
are not common. The delusional content greatly differs in relation to the cultural
background. What strikes one first and foremost in schizophrenia occurring among
natives of the countryside is the belief in the intervention of supernatural beings, occult forces, or of magic. Systematized delusions are not common except in the educated group.
Our observations revealed that catatonic forms are relatively common compared to
other varieties. The main symptoms were retardation, withdrawal, mutism, and stupor. This may be interrupted by outbursts of excitement. A large group of patients
presented with an undifferentiated type of schizophrenia, exhibiting a wide variety of
symptoms such as confusion of thinking and turmoil of emotion manifested by perplexity, ideas of reference, fear, dream states, and dissociative phenomena.
Withdrawal and retardation with ideas of reference were more common among
Christian than Moslem schizophrenics. Schizophrenia was more prevalent in males
(94) than females (59) from a total sample of 153. It was more common in single individuals and showed a shift toward age groups below 30 years.
A study of the family structure of Egyptian schizophrenics (El Shirbini, 1975)
showed that schizophrenics were exposed to multiple stressful family experiences, to
which the control-group was not equally subjected. Both parents showed a high incidence of mental illness, abnormal personality traits, and disturbed interaction with
their children and with themselves. The most prominent feature of emotional interaction in these families was a symbiotic relationship between the pre-schizophrenic child
and the parent of the opposite sex. Fathers were more responsible for this family pathology. They either push their sons to a symbiotic relationship with their mother, or
they themselves fall into such a relationship with their daughters. As a result, the preschizophrenic fails to identify with the parent of the same sex and to develop an ade-

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quate and strong gender-identity, which may predispose to later withdrawal and disintegration.

Acute Psychosis
The symptomatological and diagnostic differentiation and outcome of acute psychosis
were studied in 50 Egyptian patients using the Schedule of Clinical Assessment of
Acute Psychotic States (SCAAPS; Wig & Parhee, 1984). The prevailing symptoms
were delusions, worry, irritability, mood changes, and disturbed behavior. Sixty-four
percent of the patients were symptom-free at 1-year follow-up assessment. Various factors that affect clinical and social outcome were discussed. The problem of diagnostic
terms was also studied comparing SCAAPS terms with those of DSM-III-R (American
Psychiatric Association, 1987) and the International Classification of Diseases, 10th edition (ICD-10 ; World Health Organization, 1992). The most frequent diagnosis was
psychogenic or brief reactive psychosis using the DSM-III-R. However, the category of
acute and transient polymorphic psychotic disorders with or without stress in ICD-10
encompassed those clinical syndromes in different cultures (Okasha et al., 1993).

Parasuicide
There is a dearth of literature regarding suicide in Moslem countries, to the extent of
denial of its existence. An Egyptian investigation, a descriptive study of parasuicide in
Cairo (Okasha & Lotaief, 1979) comprised 200 cases from a total of 1,155 patients
who attempted suicide in 1975. Those were the patients admitted to the causality department of Ain Shams University Hospital in Cairo, which has a catchment area comprising approximately 3 million people. A crude rate of suicide attempts in Cairo was
found to be 38.5/100,000. There was a high percentage among the age group of 15to 44-year-olds, with no major difference between the genders. Single patients represented 53% of the total, with students showing the highest risk (40%). Depressive illnesses, hysterical reactions, and adjustment disorders, in that order of frequency, were
the main causes of the attempt. Overdose by tablet ingestion was the most common
method used (80%). Official government reports are misleading and do not represent the true rate. A crude estimate of suicide in Egypt would be about 3.5/100.000,
assuming that 1 in 10 suicide attempts ends with actual suicide.
Another study of a sample of 91 persons who were admitted for attempted suicide
to the causality department of three hospitals in Cairo from 1981 to 1982 was carried
out by Okasha, Lotaief, and El Mahallawy (1986). The majority of attempters were
young women (age range, 1534 years) belonging to large overcrowded families. They
showed a higher tendency to be single, literate, and unemployed than the corresponding age group in the general population. Drug overdose was the most common
method used. The majority made their attempts at home when there was somebody
nearby, and 31% had previous non-serious attempts. Dysthymic disorders, adjustment,
affective, and personality disorders were the most common diagnoses encountered.
Attempters scored higher in neuroticism, extroversion, and psychoticism.

Hysteria (Conversion or Dissociative Disorders)


Hysteria occupies a position at the top of the list of psychiatric diagnoses. There has
been much controversy as to the relevance of its nosological status. The first 1,000

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people who presented to the outpatient clinic of the Institute of Psychiatry, Ain Shams
University in Cairo in 1990 were screened to determine those who fulfilled DSM-III-R
(American Psychiatric Association, 1987) criteria for either conversion or dissociation
disorder (Okasha, Seif El-Dawla, & Asaad, 1993). That study was a replication of a previous one undertaken at an Egyptian University Hospital 23 years earlier (Okasha,
1967). The study aimed to test the relevance of the diagnosis of hysteria (conversion
and dissociative disorders). According to those results, many disorders that would
have been earlier diagnosed as hysteria would, at present, receive another diagnosis,
mostly somatoform disorder. However, some disorders still require the category of
hysteria to reflect the symptomatology and underlying mechanisms (stress, primary
gain, secondary gain, motor, or sensory symptoms etc. that are very culturally and symbolically specific for the stress, etc.). The prevalence of 5% in that study is comparable
with that of organic mental disorders (5.1%), personality disorders (4.9%), and anxiety disorders (7.9%), indicating that it is a diagnostic category whose prevalence cannot be ignored.
Results in 1967 revealed an incidence of 11.2%, with 61% motor presentation,
33.3% sensory presentation, 6% dissociation, and 80.6% visceral and somatic. The total of these presentations is more than 100%, because apart from patients with dissociative disorder, those with conversion disorder tended to present with more than one
symptom. In the 1990 survey, cases presented most commonly with single symptoms.
There could be no explanation for this discrepancy, except for the fact that multiple
symptom presentations are diagnosed elsewhere in the DSM-III-R (American Psychiatric Association, 1987), either under somatization, hypochondriasis, or undifferentiated somatoform disorder.
Such a decrease in the incidence of hysteria can be a true phenomenon related to
the diagnostic systems used in both studies. Factors that might contribute to a real decline
in the incidence of hysteria could be related to the industrialization of our society and
its increasing complexity, for which the primitive mechanism of defense against frustration is no longer strong enough to ward off unwanted anxieties. Tewfik and Okasha
(1965) reported hysterical spells to be related to sexual rivalry, jealousy, and domestic
quarrels in the setting of closed, fervently religious communities where a belief in possession by external agencies exists, or where people are easily excitable and emotional
with a high level of acceptance for each others outbursts. Hysterical disorders also affect a large proportion of the patients who attend traditional healers in our region. In
a study conducted by Okasha in 1966 about the El Zar cult in Egypt (a musical, semireligious dance in a group setting for exorcising evil spirits) it was found that 52% of
Zar adherents had a hysterical personality and 40% of them had, at the time of their
attendance, a diagnosis of hysteria, with one or more of its presentations. The increasing complexity of our society and the intrusion of values that accompany the industrialized Western example has led to a social context where competition and rivalry are gradually becoming hallmarks of everyday behavior, with an increasing stress
on individuality and single personal achievements, especially in the work sphere. People shut out of this sphere for one reason or another, or those who fail to cope with
this new alien pattern frequently resort to mental symptoms for defense. The decline
in the prevalence of hysteria over this time period from 11% to 5% indicates that this
primitive mental mechanism no longer suffices, with people tending more toward
other behaviors that can be grouped under parasuicide. An example of this is substance abuse, a phenomenon which has been increasing in our society during the past
decade, from 1.5% in 1986 to 9% of the clinic patients in 1990. This transition is not

928

A. Okasha

unique and has been mentioned previously by Guinness (1992), who stated that the
profile of neurosis characterized by somatic and spiritual symptoms is a feature of a
preindustrial society that, with increases in industrialization and urbanization, tends
to merge into another type of help-seeking behavior similar to parasuicide in industrialized societies.
Although social change does play a role in the presentation of psychiatric disorders,
the decrease in the diagnosis of hysteria could also be attributed to the diagnostic system used. The DSM-III- R (American Psychiatric Association, 1987), not favoring the
diagnosis of hysteria because of its dynamic character, contains a number of categories for which the proper diagnosis would have been hysteria in the past. Such categories include other somatoform disorders like somatization, psychogenic pain disorder,
hypochondriasis, body dysmorphic, and undifferentiated somatoform disorder not
otherwise specified. If we add prevalence of those disorders to that of hysteria, the total percentage in the sample increases to 10% of the total 1,000 patients, a little less
than, although rather close to, the figure reported in 1967.
Another category that used to be diagnosed as hysteria in our context is a condition
presenting with bizarre behavior, pseudohallucinations that have a wish-fulfilling
character, and a culturally bound delusional system characterized by a belief that one
is possessed and controlled by paranatural forces (jinn, devils, etc.). This possession
can sometimes lead the individual to live a double life: one that is his/hers and another that belongs to the possessing agent. Although this picture greatly overlaps with
the definition of multiple personality given by Ellenberger (1970), this category is
more likely to be included under brief reactive psychosis, schizophreniform disorder,
or atypical psychosis in DSM-IV (American Psychiatric Association, 1994) or acute and
transient polymorphic psychotic disorders in ICD-10 (World Health Organization,
1992). These categories comprised another 6.7% of the total sample.

Obsessive-Compulsive Disorder
Ninety patients suffering from obsessive-compulsive disorder (OCD) and diagnosed
according to ICD-10 (World Health Organization, 1992) criteria attending the outpatient clinic of the Institute of Psychiatry in Cairo from 1991 to 1992 were assessed by
the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989) for
symptomatology and severity of symptoms (Okasha, Khalil, Seif El-Dawla, Saad, &
Yehia, 1994). Sixty-nine percent of the patients were males, and 32% were females.
The mean age of the sample was 23.7 years, with a mean duration of OCD of 3.2 years.
Twenty percent of patients had a positive family history for OCD. Forty percent of patients presented with a mixture of obsessions and compulsions, whereas 29% presented with obsessions and 31% with compulsions. The most commonly occurring obsessions were religious and contamination obsessions (60%) and somatic obsessions
(49%), and the most commonly occurring compulsions were repeating rituals (68%),
cleaning and washing compulsions (63%), and checking compulsions (58%). The age
of patients was found to correlate positively with the total compulsive score and the total Y-BOCS score, but it correlated negatively with the total obsessive score. One third
of patients had a comorbid depressive disorder. Regarding premorbid personality disorders, 14% had obsessive personality disorder, 34% had paranoid, anxious, or emotionally labile personality disorder, and 52% had no premorbid personality disorder.
A comparison was drawn between the most prevalent symptoms in our sample and
those of other studies performed in India, England, and Jerusalem. Contamination

Mental Health in the Middle East

929

obsessions were the most frequently occurring in all studies. However, the similarities
of the content of obsessions between Moslems and Jews as compared with Hindus and
Christians signify the role played by cultural and religious rituals in the presentation
of OCD. The obsessional contents of the samples from Egypt and Jerusalem were similar, dealing mainly with religious matters and matters related to cleanliness and dirt.
Common themes between the Indian and British samples, on the other hand, were
mostly related to orderliness and aggressive issues.

Psychiatric Disorders in Children


These disorders were not met with frequently. One obvious reason is lack of awareness
in the general public that these problems come within the province of psychiatrists.
Behavior disorders in children represented 5% and 8.2% of all cases attending the
outpatient psychiatric facilities in Ain Shams University hospitals in 1967 and 1990, respectively (Okasha, Seif El-Dawla, & Asaad, 1993). In 1990, the presenting complaints
were mainly in the form of hyperactivity, aggression, stealing, and wandering around.
This was more common in patients from cities than from villages. In the Egyptian village, the conditions are conducive to developing happy and socially secure children.
Such children learn crafts and appropriate conduct smoothly from their everyday coexistence with parents and elders and are gradually initiated into the fuller social responsibilities of the extended family community. If such people move to the cities,
their work becomes mechanized, mothers as well as fathers work away from home.
They pass on to their children little knowledge and fewer skills that could earn them
the childrens respect. In such circumstances, it is difficult for parents to train their
children in social responsibilities, already different from those in which the parents
themselves grew up, hence delinquency and behavior disorders tend to develop out of
lack of modeling and identity crises. Since compulsory schooling is more enforced in
the cities, there is a tendency to see more cases of educational problems.
The total number of schoolchildren aged between 6 and 12 years was the subject of
an epidemiological study investigating the prevalence of anxiety symptoms in childhood and the underlying psychiatric disorder (Okasha & Sayed, 1994). The total
number of children was 8,459. Out of these, 79 stammerers (0.93%) and 80 controls
were selected. Of those schoolchildren, 6,592 were in state schools, of whom 54 were
stammerers (42 males and 12 females); the number from private schools was 1,867, of
whom 20 males and 5 females were stammerers. Prevalence of anxiety disorders was
found to be 7.9%, while that of hyperkinetic disorder is 2.2%. Nocturnal enuresis was
represented in 1.9% of children in Egyptian surveys. Bedwetting was found to be tolerated in a child up to the age of 5 or 6 years. The age at which parents decide to do
something about it depends on their tolerance and their degree of sophistication;
usually it is between 7 and 10 years.
The highest number of stammerers was found in two age groups, 6 to 7 and 11 to 12
years. The apparent rise in the incidence between 6 and 7 years may be due to the
prevalence of the onset of stammering before school entry and soon after beginning
to mix with schoolmates. But the rise between 11 and 12 years may be connected with
the onset of puberty. The problems of independence, widening of the horizon of the
adolescent, fear of the opposite sex, self-criticism, and moral judgment, may be factors
in precipitating the onset of stammering. The low incidence between 8 and 10 years
may be due to cases of early onset that improved spontaneously or with treatment. At
all ages, there were more male than female stammerers, giving a gender ratio of 3.2:1.

930

A. Okasha

TABLE 1. Present Use of Narcotics in Regional States


Country

Substance

Number

Country

Substance

Number

Pakistan
Bahrain
Tunisia
Libya
Iran
Yemen

Op-Her
Op-Her
Narc-Hash
Hash-Her
Hash-Her
Khat

2,000,000
1,806
Infrequent
Infrequent
600,000
Frequent

Gipotti
Afghanistan
Sudan
Oman
Egypt
Lebanon

Khat
Her-Op
Hash-BZ
Her-Op-Drugs
Her-Hash-Drugs
Hash-Narc

Frequent
1,000,000
Frequent
Infrequent
Not available
Not available

Source: World Health Organization, 1993.


Op: opiates; Her: heroin; Khat: a stimulant plant chewed by people mainly in Yemen and Somalia; Narc: narcotics; Hash: hashish; BZ: benzodiazepines.

Drug Abuse
In 1993, the World Health Organization (WHO) reviewed the present use of narcotics
in regional states. The country showing the highest prevalence was Pakistan, and the
substances mostly abused involved heroin, hashish, opium, narcotics, and drugs, in
that order of decreasing frequency (Table 1).
The amounts of substances seized over the period from 1985 to 1995 is illustrated in
Table 2 at the end of the article (General Administration for Drug Combat, 1996).
The average amount of heroin seized annually is about 100 kilograms. This represents about 10% of the consumption. Therefore, it is safe to assume that 1,000 kilograms are consumed annually (i.e., 1,000,000 grams). If we calculate that the average
daily intake is 1/8 to 1/4 gram per addict, we would estimate between 11,000 and
22,000 heroin abusers in Egypt in a population of 60 millions (Table 2).
An integral part of the work of the National Council for Addressing Narcotics in
Egypt was an assessment of the national size of the problem. Surveys were conducted
among secondary school pupils, male and female university students, and industrial
workers regarding their drug habits (see Table 3) (Soueif, 1994). The results revealed
TABLE 2. Narcotics Seized by Egyptian Authorities (19851995)

Year

Hash
(kg)

1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995

50.2
21.3
40.1
14.7
37.8
9.9
10.7
7.9
4.3
1.7
1.03

Opium Heroin Cocaine Tablets Amphetamines Plants


(kg)
(kg)
(gm) (1000)
(L)
(kg)
287
54
211
3,873
89
56
51
48
95
49
17

123
98
78
335
57
67
86
52
191
86
49

1,052
2,439
177
469
6,065
92
615
292
1,358
1,204
225

61.2
58.1
28.8
159.4
144
178.8

133
563
300
164
649
410

5,044
1,451
330
599
1,267
2,420

Cannabis Papaver
trees
trees
(1000)
(1000)

343
381
770
1,672
8,264
5,051

4,754
2,855
3,784
93,139
138,825
17,607

Mental Health in the Middle East

931

TABLE 3. National Prevalence of Narcotic Substance Use (%)


Category
Secondary school
pupils
Male university
students
Female university
students
Industrial workers

Cigarettes Alcohol Hashish Opium Tranquilizers Stimulants Hypnotics

10.77

22.49

5.05

0.84

2.72

1.79

2.26

20.22

22.08

15.45

0.7

5.79

13.98

4.21

0.78
52.4

7.15
20.1

0.76
11.44

0.08
1.36

5.07

4.78
1.8

4.18

that, on average, the most abused substance was nicotine, followed by alcohol, hashish, stimulant drugs, tranquilizers, hypnotics, and finally opium. Female university students abused less substances than male university students except in the case of tranquilizers and hypnotic where the prevalence was similar.
Understanding the pattern of abuse is crucial for developing any strategy that claims
to address the issue. Why is it that people abuse substances in the Egyptian context?
Soueif (1994) reports several reasons for the different user categories . For secondary school students, the main reason was as entertainment in happy social occasions
and socializing with friends, and the substance used most was hashish. Sedatives and
hypnotics were the next most frequently abused substances in situations of physical
exhaustion and fatigue, and to cope with psychosocial problems or difficult working
conditions as well as at times of studying and exams.
For university students, the pattern was relatively similar, with a greater tendency to
use hard drugs (hash and opium). Industrial workers tended to use hard drugs for
recreation and psychoactive substances to overcome exhaustion and to cope with psychosocial problems.
Egyptian surveys (Soueif, 1994) found a gradual increase in the consumption of alcohol among Egyptians, with a prediction that it will be the most common abuse in the
next century. It is interesting to note that in spite of the fact that alcohol is religiously
prohibited in Islamic countries, and despite its availability in Egypt compared to the
Gulf countries, incidence of alcohol abuse is much higher in the Gulf where its sale is
prohibited (Okasha, 1996a).
A recent survey has been carried out in Arab countries regarding the available mental health services, needs and demands, and the needs for psychiatric education and
research in this field (Okasha, 1996b). It is obvious that our region is in great need of
a mental Health act and the implementation of the United Nations General Assembly
(1989) Resolution 46/119 on the protection of persons with mental illness and the
improvement of mental health care, in addition to a change in the medical education
curriculum in psychiatry and a campaign to reduce the stigma of mental illness that
involves professionals, media people, and policy makers.

SUMMARY
Mental health has been identified as an essential component of a persons general
health ever since the time of the Pharaohs. That extent was important enough to

932

A. Okasha

place therapy within the divine boundaries of the spiritual and religious. Since those
days, through the Islamic era to the present day, psychiatry and mental health services
have come a long way. Development of knowledge, introduction of pharmacotherapy,
and continuous development of neuroscientific diagnostic tools and instruments, did
not exclude other factors from assuming responsibility for peoples mental health.
Traditional healers in our region continue to play a crucial role as first line of defense
against unexplained psychological symptoms that people fail to place within the domain of medicine. Culture is a major determinant that does not only color the definition of health and disease, but also colors the disease and determines when and where
help is sought. Although we have 22 Arab countries in the Arab League, mental
health services that are provided in those countries show several variations. Economic,
political, social, and cultural factors seem to play a major role in determining the state
of the psychiatric profession and access of citizens to service.
This article provides a short review of development of the concept of mental health
and illness from the Pharaonic era until today. It reviews the available mental health
resources and services and the impact of culture in determining prevalence and presentation of some common clinical disorders.

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