Hysteria (conversion or dissociative disorder)

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. In 1990, the first 1000 people presenting to the out-patient clinic of the Institute of Psychiatry of Ain Shams University in Cairo were screened to determine whether they fulfilled DSM–III–R criteria for either conversion or dissociation disorder (Reference Okasha, Seif El Dawla and AsaadOkasha et al, 1993a ), replicating a study undertaken at an Egyptian university hospital 23 years earlier, where hysteria constituted 11.2% of the sample (Reference OkashaOkasha, 1967). The newer study aimed to test the relevance of the diagnosis of ‘hysteria’ (conversion and dissociative disorder). According to its results, many disorders that would formerly have been diagnosed as hysteria would now receive another diagnosis, mostly somatoform disorder. However, some disorders still require the diagnostic label of hysteria to reflect the symptoms and the underlying mechanisms (stress, primary gain, secondary gain, and motor or sensory symptoms that are culturally and symbolically specific for the stress). 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 hysteria cannot be ignored as a diagnostic category. Factors that might contribute to a real decline in the incidence of hysteria could be related to the industrialisation of Egyptian society and its increasing complexity, for which the primitive mechanism of defence against frustration is no longer strong enough to ward off anxieties. However, the decrease in the diagnosis of hysteria could also be attributed to the diagnostic system used. The ICD–10 and DSM–III–R, which do not favour the diagnosis of hysteria because of its dynamic character, contain a number of categories for which the earlier diagnosis would have been hysteria. These categories include other somatoform disorders such as somatisation, psychogenic pain disorder, hypochondriasis, body dysmorphic disorder and undifferentiated somatoform disorder not otherwise specified.

Anxiety disorders

Earlier studies of psychiatric morbidity among university students in Egypt showed that anxiety states were diagnosed in 36% of the study sample (Reference Okasha, Kamel and SadekOkasha et al, 1977). In 1981 Okasha & Ashour undertook the first attempt to study the socio-demographic aspects of anxiety disorders in Egypt and to apply the Arabic version of the Present State Examination in evaluating the profiles of clusters and symptoms of anxiety in a sample of 120 patients with anxiety (Reference Okasha and AshourOkasha & Ashour, 1981). The findings revealed that the most common symptoms were worrying (82%), irritability (73%), free-floating anxiety (70%), depressed mood (65%), tiredness (64%), restlessness (63%), and anergia and retardation (61%). Panic attacks were present in 30%, situational anxiety in 35%, specific phobias in 37% and avoidance in 53% of the sample. Male patients showed significantly more hypochondriasis and anxiety on meeting people than females. This can be explained by the fact that men in our culture tend to somatise their psychological symptoms, as the latter may lower their prestige and degrade their pride, because of the belief that ‘real’ men do not have psychological symptoms. Female patients showed significantly more increased free-floating anxiety, loss of weight and conversion symptoms (Reference Okasha and AshourOkasha & Ashour, 1981). In 1993 anxiety states represented about 22.6% of diagnoses made in a psychiatric out-patient clinic in a selective Egyptian sample (Reference Okasha, Seif El Dawla and AsaadOkasha et al, 1993a ).

Obsessive–compulsive disorder

A study investigating the demographic profile and symptoms of Egyptian patients with obsessive–compulsive disorder found that more than two-thirds of the patients were male. The most commonly occurring obsessions were religion and contamination (60%) and somatic obsessions (49%), whereas the most commonly occurring compulsions were repeating rituals (68%), cleaning and washing compulsions (63%) and checking compulsions (58%). A third of patients had a comorbid depressive disorder. A comparison was drawn between the most prevalent symptoms in our sample and those of other studies performed in India, England and Jerusalem. Obsessions were found to be similar in content in Muslims and Jews, differing from those in Hindus and Christians, signifying the role of cultural and religious rituals in the presentation of obsessive–compulsive disorder. The obsessions of the patients 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 (Reference Okasha, Khalil and Seif El DawlaOkasha et al, 1994).

Depressive disorders

The prevalence rates of depression among selected samples from an urban and a rural population in Egypt were found to be 11.4% and 19.7%, respectively. Dysthymic disorder was the most common diagnostic category in the urban population (4.1%), whereas adjustment disorder with depressed mood was more frequently encountered in the rural population (6.7%). Major affective disorder according to DSM–III criteria was diagnosed in 1.9% of the urban population compared with 3.3% of the rural population; the total prevalence was 2.5% (Reference Okasha, Khalil and El FikyOkasha et al, 1988).

A cross-cultural comparison between Western and Egyptian patients with depressive illness reveals some differences. Depression among Egyptian patients is manifested mainly by agitation, somatic symptoms, hypochondriasis, physiological changes such as decreased libido, anorexia and insomnia, which is not characterised by early morning awakening. Egyptian patients mask their affect with multiple somatic symptoms, which occupy the foreground, and the affective component of their illness recedes to the background. This may be because of the greater social acceptance of physical complaints than of psychological complaints, which are either not taken seriously or are believed to be cured by rest or extra praying. The increase in somatic symptoms can be explained by the seriousness with which people in a given culture view ‘psychological stress’ compared with physical illness. Non-Western cultures emphasise social integration rather than autonomy. When affiliation is more important than achievement, how one appears to others is vital, and shame becomes more of a driving force than guilt. In the same way, physical illness and somatic manifestations of psychological distress are more acceptable and likely to evoke a caring response than vague complaints of psychological symptoms, which can be either disregarded or considered a stigma of being ‘soft’ – or, even worse, insane (Reference Okasha, Kamel and SadekOkasha et al, 1977; Reference Gawad and ArafaGawad & Arafa, 1980). Egyptians who are depressed either resort to their primary health care physician, who is likely to request unneeded and costly investigations, or ask traditional healers to alleviate their suffering. A considerable number do not ask for help at all, especially in rural populations, among which absenteeism from work or inability to face day-to-day affairs is largely tolerated by the community.

Suicide and parasuicide

Feelings of hopelessness and the intention to kill oneself are not common among Muslims, for whom losing hope in relief by God and self-inflicted death are blasphemous and punishable in the afterlife. However, rates of suicide attempts (parasuicide), which are more likely to be intended to elicit care, have no significant associations with religiousness among Arabs. Although the wish to die is not uncommon among people with depression in Arab cultures, it usually remains at the level of wishing that God would terminate their life, and does not progress to the wish to kill themselves (Reference Okasha and MajFakhr el Islam, 2000).

The crude rate of suicide attempts in Cairo was found to be 38.5 per 100 000. There was a high percentage in the age group 15–44 years, 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 commonly used method (80%). Official government reports are misleading and do not represent the true rate; assuming that one in ten suicide attempts ends with actual suicide, a crude estimate of suicide in Egypt would be about 3.5 per 100 000 (Reference Okasha and LotaiefOkasha & Lotaief, 1979). A study in 1981–1982 showed that the majority of suicide attempters were young women 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 method most commonly used. The majority made their attempt at home when there was somebody nearby, and 31% had made previous non-serious attempts. Dysthymic disorders and adjustment, affective and personality disorders were the most common diagnoses encountered (Reference Okasha, Lotaief and El MahallawyOkasha et al, 1986).

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 (Reference Wig and ParheeWig & Parhee, 1984). The prevailing symptoms were delusions, worry, irritability, mood changes and disturbed behaviour. Almost two-thirds (64%) of the patients were symptom-free when assessed 1 year later. The category of acute and transient polymorphic psychotic disorder with or without stress in ICD–10 encompasses these clinical syndromes in different cultures (Reference Okasha, Seif El Dawla and AsaadOkasha et al, 1993a ).

Schizophrenia

Schizophrenia is the most common chronic psychosis in Egypt and accounts for the majority of in-patients in our mental hospitals. The nature of their delusions reflects the individual characteristics of the patients in relation to Egyptian culture. 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. Persecutory delusions with ideas of reference are the rule; religious, political, scientific and sexual delusions are frequent; financial, social, health-related, emotional and autistic delusions are less common, and delusions of grandeur are uncommon. Religious delusions are frequent, owing to the highly religious nature of Egyptian society. Political delusions are positively correlated with the level of political sanctions and pressure. Sexual delusions are more common in groups in whom sexual behaviour is severely suppressed, for example single and rural patients.

Our observations revealed that catatonic forms of the disorder are relatively common compared with other varieties. The main symptoms are retardation, withdrawal, mutism and stupor, which may be interrupted by outbursts of excitement. Many patients present with an undifferentiated type of schizophrenia, exhibiting a wide variety of symptoms such as confused thinking and a turmoil of emotion manifested by perplexity, ideas of reference, fear, dream states and dissociative phenomena (Okasha, 1993b).

Child and adolescent psychiatry

Egyptian children under 5 years old (9.5 million) and those aged 5–16 years (14.5 million) constitute 14.8% and 24.7% of the total population, respectively. Thus, almost 40% of the Egyptian population of 67 million are under 16 years old. The number of working children under 12 years of age is more than 1 million. Egyptian children constitute 7% of the country's labour force (Central Agency for Public Mobilization and Statistics, 1992). The general public does not favour the inclusion of disorders of children and adolescents within the province of psychiatrists, although prevalence rates indicate that such disorders constitute a considerable percentage of the profile of psychiatric illness in Egypt.

Drug misuse

The 1980s witnessed a sharp rise in morbidity due to drug misuse. Since then, Egyptian community leaders at all levels have demonstrated intense concern over this problem. Estimates of the magnitude of substance addiction and the changing pattern of drug availability showed that the most commonly used drugs in the 1980s were cannabis, opium, solid and liquid hypnosedatives, heroin and finally cocaine, in descending order of frequency (Okasha, 1996). Although epidemiological data on drug misuse in Egypt are scarce, health professionals report a multitude of reasons for such concern, including an increase in the rate of addicts seeking psychiatric treatment (Reference Al Azayem and Ez EldinAl Azayem & Ez Eldin, 1996), increases in drug-related health problems (mainly overdose toxicity; Reference SalemSalem, 1998) and an alarming drop in age at initiation of drug use, with a consequent rise in adolescent addicts (Reference Amer, Saleh and GuirguisAmer et al, 1986). The average amount of heroin seized annually is about 50 kg; this represents about 10% of total consumption. Therefore, it is safe to assume that 500 kg are consumed annually. If we calculate that the average daily intake is 0.25–0.5 g per addict, we arrive at an estimate of about 7000–10 000 heroin users in Egypt (Reference OkashaOkasha, 1996b ).

During the 1990s synthetic psychoactive drug use increased exponentially to become the third most commonly available drug following cannabis and alcoholic beverages. Towards the second half of the 1990s cannabis became prevalent in the form of bango, which is prepared from leaves of Cannabis sativa. The plant is increasingly widely cultivated in Egypt, especially in the Sinai peninsula.

Epidemiological research and clinical studies of known addicts show that those who use more than one drug are double in number compared with those who use one drug exclusively. Thus, experts are rightly inclined to consider the estimate that drug seizures represent a fifth of drug use in society as more plausible. Using this formula, one can safely estimate the rate of ‘experimentation’ with drugs in this group to be about 10–12% in the age group 15–25 years; the rate for drug ‘misuse’ would be 2.5–3%, whereas those identified as drug ‘addicts’ would constitute less than 1% of the population (65 million in 1998). Such estimates are alarming, and are a warning to policymakers and service providers.

The present scene in Egypt is characterised by an unprecedented shift towards ‘demand reduction’ at the primary prevention level, hand in hand with efforts to provide services at both secondary and tertiary health care levels. Supply control mechanisms are duly and seriously implemented (Reference Al Akabawi, Okasha and MajAl Akabawi, 2001).

Soueif (Reference Soueif1994) reports different reasons for the different user categories. For secondary school students the main reason for drug use was as entertainment on happy social occasions, and the substance mostly used was hashish. Sedatives and hypnotics were the next most frequently used substances; these substances were used 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 examinations.

Egyptian surveys have found a gradual increase in the consumption of alcohol, leading to the prediction that this will be the most common form of substance misuse in the coming years. It is interesting to note that despite the relative availability of alcohol in Egypt compared with the Gulf states, the incidence of alcohol misuse is much higher in the latter countries, where the sale of alcohol is strictly prohibited on religious grounds (Reference Youssef, Attia and KamelOkasha, 1996b ).

Geriatric psychiatry

Health care systems in Egypt have largely ignored the needs of the elderly. There are only sporadic programmes to care for the elderly, mainly initiated by the community or within the private sector. Those above 65 years old represent 4.4% of Egypt's population. The country has 34 old people's homes for over a million elderly people, and some homes have waiting lists of over 1000 persons (Reference Abyad, Ashour, Abou-Saleh, Okasha and MajAbyad et al, 2001).

An increasing number of elderly people live alone, or with elderly spouses and/or with only one or two other family members. The ‘Care With Love’ programme was established to create a sustainable, well-trained cadre of home health care providers in Egypt in order to staff units delivering such services. It was developed at the Centre for Geriatric Services in partnership with the Coptic Evangelical Organization for Social Services and As'salam Hospital in Cairo. The first training course was run in 1996, and about 500 trainees have joined the programme, taking various courses between 1996 and 2003. Ain Shams University in Cairo has started a series of courses on old age psychiatry; in addition, the Malta Institute on Ageing runs a course (in Egypt), and medical schools have started slowly to introduce lectures on ageing for undergraduates (Reference IskandarIskandar, 1999). Egyptian universities offer a master's degree and doctorates in geriatrics, focusing on psychogeriatrics, which is addressed as a multidisciplinary issue.

Psychotherapy

Psychotherapy is an important element of psychiatric management in Egypt, with a strong religious (Muslim or Coptic) emphasis. The behaviour of individuals in Arab culture is determined more by group needs and thinking rather than by those of the individual, so that the source of control of behaviour is external rather than internal. Sources of distress and suffering on the one hand, and happiness on the other, are related to personal failure or success to achieve the expectations of significant others or of society at large. The emphasis is on conformity rather than self-actualisation. One of the objectives of psychotherapy with Arab patients is to improve adaptation by whatever means available and to focus the therapy on the manifest stress or disability. The strategy is to deal primarily with conscious problems, symptoms, thoughts, feelings and memories. Contrary to Western cultures, Arab culture is based on shame rather than guilt, so that an important motivation in social interactions is to save face and avoid being shamed. Inner desires, wishes and conflicts that are socially unacceptable must be kept secret. Inner exploration may threaten the integrity of the psyche. At the same time, gaining insight and self-realisation is socially isolating. Affects already consciously experienced by the patient should be expressed and dealt with. The therapeutic relationship should be maintained at a positive level of rapport, with deeper transference responses remaining unconscious and out of the patient's awareness. Negative transference is discussed early so that it can be dissipated as promptly as possible, allowing the patient to experience the therapist as accepting, permissive and comfortable with hostile feelings. If the patient's defences are useful and acceptable, they can be strengthened and acknowledged; if the defences are maladaptive, new ones are suggested. The therapist also tries to improve the patient's self-image by minimising the discrepancy between the patient's expectations of himself or herself (derived from the expectations of significant others) and his or her ability to realise these expectations (Reference El Leithy, Okasha and MajEl Leithy, 2000).

Alternative therapies

In spite of rapid social change in Egypt, the majority of people – especially in rural areas – belong to an extended family hierarchy. It is considered shameful to care for an elderly person with dementia away from family surroundings. The parents of children with learning disabilities or hyper-kinetic disorders accept primary responsibility for them, rather than having them looked after in an institution. Traditional and religious healers have 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 (Reference OkashaOkasha, 1966). About 60% of out-patients at the university clinic in Cairo serving a population of low socioeconomic status had consulted a traditional healer before coming to the psychiatrist (Reference Okasha, Kamel and HassanOkasha et al, 1968). In rural areas of Egypt, community care is implemented without the need for health care workers. Those living in the countryside have a special tolerance of people with mental disorders and an ability to assimilate them into their community. These people, and those with mild or moderate learning disabilities, are rehabilitated daily by cultivating and planting the countryside along with, and under the supervision of, family members.

The need to add mental health care to the traditional priorities for public health care services, of bilharziasis (schistosomiasis), birth control, infectious diseases of children, smoking and illicit drug use has been gradually attracting the attention of decision-makers. Programmes for community care in big cities have been introduced in the form of out-patient psychiatric clinics, hostels for the elderly, institutions for people with learning disabilities, centres for the treatment of drug misuse, and school and university mental health services.

The National Mental Health Programme for Egypt emphasises the role of primary health care looking after 80% of psychiatric patients. Its focus is on decentralisation of mental health care and community care in different governorates. Emphasis is on recruiting mental health teams, especially psychiatric nurses, psychiatric social workers, occupational therapists and clinical psychologists.