150
LAY EXPLANATIONS OF SYMPTOMS OF MENTAL ILL HEALTH IN KUWAIT
M. FAKHR EL-ISLAM &
SANAA I. ABU-DAGGA
SUMMARY
cognitive schemas of 208 subjects were elicited in relation to 12 hypothetical symptoms which are most commonly presented by patients suffering from psychiatric disorder. Three types of explaining schemas were recognised as physical, psychosocial and supernatural explanations. Somatic symptoms tended to have physical explanations and emotional symptoms tended to have psychosocial explanations although both are known in clinical practice to indicate psychiatric disorder and to disappear together when the disorder recovers. Supernatural explanations were most likely in elderly males and in extended families. Symptoms associated with supernatural cognitive schemas fit in with the cultural background and not with the level of modern education achieved. The
INTRODUCTION are defined as ’disvalued changes in states of being and in social function’ (Eisenberg, 1977) the study of processes involved in the valuing or disvaluing of changes
If illnesses
should be of major interest to health professionals and sociologists alike. Culture plays a role in the definition, cognitive meaning and management of whatever is interpreted as illness. The cognitive schema evoked by a symptom is responsible for qualifying it as an adverse change and deciding the nature of action required (if any) because the meaning and seriousness of a symptom are deeply embedded in cultural assumptions (Mechanic,
1977; 1986). Little research has examined the cognitive schemas used for evaluation of mental ill health in ways parallel to those for physical disorder (Angel & Thoits, 1987). The present study aims at elucidation of the correlates of various components of these schemas in relation to the commonest symptoms of mental ill health in Kuwait. Patients may be reluctant to express to health professionals their basic assumptions and naive schemas about their symptoms for fear of being considered foolish or unsophisticated (~toecl~lc & Barsky, 1 81). Failure of the doctors to understand the basis of patients’ illness behaviour may lead them astray into unnecessary medical procedures. Thus western-trained doctors who examine the heart and offer reassurance that nothing is wrong to Middle Easterners who report ’heart distress’ cannot help their patients because they fail to understand the culturally shared schema of emotional distress symbolised by this bodily expression
(Good, 1977).
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
151
The present study explores lay appraisals of common symptoms of mental ill health in Kuwait. The population of this oil exporting country is 1.7 millions, of whom 57% are males and 60% are expatriates (Ministry of Planning, 1986).
METHOD
Symptoms of mental ill health A list of the symptoms most commonly presented by psychiatric outpatients was prepared from the complaints in the records of 50 successive patients at Mubarak Al-Kabeer psychiatric outpatient clinic in Kuwait. This list comprised the twelve most commonly presented symptoms. Of these symptoms six were somatic symptoms and six were emotional symptoms. These symptoms are also found respectively in the somatic and emotional symptom subgroups of international mental health screening instruments eg. the scaled version of the General Health Questionnaire (Goldberg & Hillier, 1979) and the Langner Index (Langner, 1962) with the notable exception of breathlessness. Breathlessness or chest-tightness has been included in our list because it is one of the commonest presenting symptoms among Arabic-speaking patients. It is literally described as a feeling that the chest can no longer accommodate the patient’s breath; as though it has become too small or too tight to contain a deep inspiration. This is a common somatic expression of tension. A similar item appears in Hopkins Checklist (Derogatis et cal. 1974). Items included in our list were: Somatic 1. breathlessness/tightness 2. head pain 3. faintness 4. spells of hotness and/or excessive 5. lack of energy 6. loss of appetite
perspiration
Emotional 1. poor sleep 2. irritability 3. reduced ability to cope with usual life requirements 4. fears or worries for no good reason 5. depressed mood ie. low spirits or lack of enjoyment
6.
forgetfulness
The items were presented to subjects as hypothetical symptoms and their appraisal of the meaning was elicited in relation to each item should the subjects have it continuously for two weeks. A stratified random sample was obtained from individuals aged 20-59 years in public service institutions including two ministries and a private business enterprise. A random choice was made from lists of employees in these institutions in order to obtain a quota representing the age, sex, nationality and educational distribution
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
152
in the community according to the Kuwait census of population 1985 (Ministry of Planning, 1986). In order to complete the quota of illiterate individuals required it was necessary to extend the same selection procedure to four ’Centres for Adult Education and Eradication of Illiteracy.’ These centres also supplied our sample with housewives.
Symptom explanations Symptom explanation symptom -
was
recorded
according
to
whether the subject attributed each
to:
physical causes ie. bodily disease, psychosocial causes ie. problems related
to emotional and/or social life; and/or ie. God’s will, envy by others, the devil (Shaitan) or sorcery. Individuals could attribute any symptoms to one, two or all of the three groups of causes. Scores were given for varieties of explanations as the total numbers of symptoms ~0-12) in which an explanation was selected. -
-
supernatural
causes
C’ult~ral background The presence of supernatural forces is culturally recognised in an abstract way (EI-Islam, 1982). The belief in God’s will as a fatalistic determinant of events is quite common among Moslem Arabs. Symptoms, like any other event, may be part of this attribution which leads individuals no further in attempts to formulate any knowledge about them. Part of this fatalistic belief may be that whatever appeared through God’s will eg. symptoms, will also disappear by God’s will eg. through prayers of affected individuals. Envy involves the evil wish that a person deteriorates behaviourally, economically or healthwise. Unpleasant personal changes, especially sudden changes which are out of keeping with a person’s usual self, are attributed to the envy of others’ evil eyes. In competitive societies unequal achievements by various individuals call for increased effort of the less achieving in order to go up to the level of better achievers. On the other hand, in this noncompetitive society, envy removes the inequality by the almost magical envious wish-fulfilling powers of low achievers that make better achievers come down to their level ie. lose their precedence. Culturally-shared beliefs endow the devil with the ability to exert an adverse influence on those with weak religious faith to make them do wrong or be malevolent. Therefore behavioural disturbances or forgetfulness may be culturally attributed to the devil. Sorcery is believed to be a means of inducing harmful effects on others by humans who employ supernatural forces eg. spirits (jinn) for revenge or out of spite (Al-Ansari et at.
1989). Variables examined in relation
to
cognitive schemas included sex,
age, marital status,
education, occupation, family household size and nationality background. For the purpose of
our study, the more educated who exceeded the eighth standard were from the less educated subgroup. Occupationally, individuals were divided into separated housewives and students, clerical workers, skilled labourers, professionals and unskilled labourers. Family households were considered big if they included more than five individuals. Kuwaiti nationals were separated from other Arab nationals who come from other Arab countries for employment and are allowed to reside in Kuwait as long as they
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
153 Table 1 Median numbers of explanations for all 12 symptoms
Figures in brackets indicate the number of subjects * Mann-Whitney Test t Kruskall Wallis Test
in each group
hold a job. Many of these non-Kuwaiti Arabs left their wives and children in their countries of origin and their marital status was designated ’separate-married.’ The above discussed probes of cognitive schemas were administered through a structured interview. This was preferred to questionnaire administration to avoid linguistic bias. RESULTS
The relationship of demographic variables to lay explanations of symptoms is shown in Table 1. Older individuals and males attributed significantly more symptoms to physical causes (p = 0.0441 and 0.0034 respectively). Both educational subgroups adopted similar numbers of all three explanations. Stepwise logistic regression pointed to sex and marital status as the best predictors of physical explanations (which were least likely in divorced and widowed females) and pointed to nationality and household size as the best predictors of supernatural explanations (which were most likely in Kuwaitis living in larger households).
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
154
Total numbers of
Table 2 for somatic and emotional
explanations
symptoms
p < 0.000 1
(Chi-square test) Table 3
Explanations of individual symptoms
* This cell contributes the value
highest fraction
of the total
Chi-square
Physical symptoms in general were more likely to be attributed to physical explanations whereas emotional symptoms were more likely to be attributed to psychosocial and supernatural explanations (Table 2). Psychosocial explanations were significantly overrepresented in relation to symptoms of breathlessness and reduced coping, whereas forgetfulness and lack of energy were the most likely to have supernatural explanations (Table 3). DISCUSSION Somatization ie. the tendency to express psychiatric disorder in physical symptoms is most prominent in developing countries (Kirmayer, 1984). Somatic symptoms are usually
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
155
of the body to which symptoms belong. The somatic orientation of older individuals is evidenced by their excessive attribution of all symptoms to physical factors. It seems that in this culture psychosocial explanations are too abstract for the Moslem traditional elderly. Psychosocial genesis of symptoms which is often considered a sign of weakness of self or weakness of faith is less likely to be entertained by males who are conditioned to feel that they are the stronger sex. Better education was not associated with lower prevalence of supernatural explanations in the community sample studied. This tallies with similar findings in psychiatric patients where educated patients (including those who resided in developed countries for long periods) were found to be as likely as the uneducated to hold onto supernatural schemas as symptom explanations (El-Islarn ~ Malasi, 1985). Beliefs in supernatural explanations of illness seem to be too deeply imprinted during child-rearing to be erased by school education. Divorce as a prominent psychosocial event seems to have oriented affected individuals to a psychosocial explanation of symptoms. Extended families as represented by Kuwaitis who live in large households are known to be more traditional and hence more adherent than nuclear families to culturally-shared beliefs about supernatural explanations of symptoms. Somatic symptoms are generally believed to be more serious health hazards than emotional symptoms. This belief is entertained by both patients and medical professionals in this community where the majority of medical practitioners had little or no psychiatric education during their training (El-Islam, 1990). This patient-doctor collusion seems to sustain not only the preponderance of presentation with somatic symptoms but also their attribution to physical disorders. The dominant psychosocial explanation of the somatic symptom of breathlessness is remarkable. It confirms that this symptom is traditionally regarded as a physical metaphoric expression of emotional distress (El-Islam et cal. 1988). Our findings support other reports (Daniels, 1986; El-Islam & Ahmed, 1971) that emotional symptoms are more likely than somatic symptoms to have supernatural explanations. Reduced ability to cope with environmental demands is expectedly attributed to psychosocial causes because of the very nature of its contents that involve the social environment. Forgetfulness and fears are culturally attributed to the devil as stated in certain Koraanic verses and hence the preponderance of forgetfulness among supernaturally explained symptoms. Lack or reduction of one’s energy, on the other hand, is often regarded as the product of others’ envy or malicious acts through sorcery and therefore it has an obvious share of supernatural explanations.
explained by physical illness involving the part
CONCLUSIONS In this community study individuals’ responses suggest a tendency to adopt physical explanations for the somatic symptoms studied. Emotional symptoms however were the major candidates for psychosocial and/or supernatural explanatory concepts. Since most people in this culture (including patients and professionals) are somatically orientated in explaining health problems or symptoms it is not surprising that individuals who adopted
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
156
supernatural explanations were in the minority. Older individuals were over-represented among those who would attribute symptoms to supernatural explanations but this is not due to their tendency to be among the less educated. ACKNOWLEDGEMENT This research was supported by Kuwait University Grant MQ 015. The authors would like to thank Ms. Vera Marcovic for her generous librarian help. REFERENCES
AL-ANSARI, E.A., EMARA, M.M., MIRZA, I.A. & EL-ISLAM, M.F. (1989) Schizophrenia in ICD-10: a field trial of suggested diagnostic guidelines. Comprehensive Psychiatry, 30, 416-419. ANGEL, R. & THOITS, P. (1987) The impact of culture on cognitive structure of illness. Culture, Medicine & Psychiatry, 11, 465-494. DANIELS, C.S. (1986) Generational changes in conceptions of mental illness. Cross-cultural Psychology, 17, 493-505.
DEROGATIS, L.R., LIPMAN, R.S., RICKELS, K., UHLENHUTH, E.H. & COVI, L. (1974) The Hopkins Symptom Check List (HSCL): a self-report symptom inventory. Behavioral Science, 19, 1-15. EISENBERG, L. (1977) Disease and illness: distinctions between professional and popular ideas of sickness. Culture, Medicine & Psychiatry, 1, 9-23. EL-ISLAM, M.F. (1982) Arabic cultural psychiatry. Transcultural Psychiatric Research Review, 19, 5-24. EL-ISLAM, M.F. (1990) Psychiatry for Medical Students. Kuwait: Kuwait University Press. EL-ISLAM, M.F. & AHMED, S.A. (1971) Traditional interpretation and treatment of mental illness. Journal of Crosscultural Psychology, 2, 150-154. EL-ISLAM, M.F. & MALASI, T.H. (1985) Delusions and education. Journal of Operational Psychiatry, 16, 2931.
EL-ISLAM, M.F., MOUSSA, M.A.A., MALASI, T.H. & MIRZA, I.A. (1988) Assessment of depression in Kuwait by principal component analysis. Journal of Affective Disorders, 14, 109-114. GOLDBERG, D.P. & HILLIER, V.F. (1979) A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139-145. 25-58. GOOD, B.J. (1977) The heart of what’s the matter. Culture, Medicine & Psychiatry, 1, KIRMAYER, L.J. (1984) Culture, affect and somatization. Transcultural Psychiatric Research Review, 21, 159-177.
LANGNER, T.S. (1962) A twenty-two item screening score of psychiatric symptoms indicating impairment. Journal of Health and Human Behavior, 3, 269-276. MECHANIC, D. (1977) Illness behavior, social adaptation and the management of illness. Journal of Nervous & Mental Disease, 165, 79-87. MECHANIC, D. (1986) Role of social factors in health and well being: biopsychosocial model from a social perspective. Integrative Psychiatry, 4, 2-11. MINISTRY OF PLANNING (1986) Annual Statistical Abstract, Edition XXIII. Kuwait: Publication Research and Training Department. STOECKLE, J.D. & BARSKY, A.J. (1981) Attributions: uses of social science knowledge in the ’doctoring’ of A.M. Kleinman). primary care. In The Relevance of Social Science for Medicine (eds. L. Kisenberg & Dordrecht: Reidel.
M. Fakhr El-Islam, FRCP, FRCPsych, DPM, Faculty of Medicine, Kuwait University.
formerly Professor and Chairman, Department of Psychiatry,
Abu-Dagga, BA, Scientific Assistant, Department of Psychiatry, Faculty of Medicine, Kuwait University. Correspondence to Dr. El-Islam, Department of Psychiatry, Hamad Medical Corporation, PO Box 3050, Doha-Qatar, Arabian Gulf. Sanaa I.
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
LAY EXPLANATIONS OF SYMPTOMS OF MENTAL ILL HEALTH IN KUWAIT
M. FAKHR EL-ISLAM &
SANAA I. ABU-DAGGA
SUMMARY
cognitive schemas of 208 subjects were elicited in relation to 12 hypothetical symptoms which are most commonly presented by patients suffering from psychiatric disorder. Three types of explaining schemas were recognised as physical, psychosocial and supernatural explanations. Somatic symptoms tended to have physical explanations and emotional symptoms tended to have psychosocial explanations although both are known in clinical practice to indicate psychiatric disorder and to disappear together when the disorder recovers. Supernatural explanations were most likely in elderly males and in extended families. Symptoms associated with supernatural cognitive schemas fit in with the cultural background and not with the level of modern education achieved. The
INTRODUCTION are defined as ’disvalued changes in states of being and in social function’ (Eisenberg, 1977) the study of processes involved in the valuing or disvaluing of changes
If illnesses
should be of major interest to health professionals and sociologists alike. Culture plays a role in the definition, cognitive meaning and management of whatever is interpreted as illness. The cognitive schema evoked by a symptom is responsible for qualifying it as an adverse change and deciding the nature of action required (if any) because the meaning and seriousness of a symptom are deeply embedded in cultural assumptions (Mechanic,
1977; 1986). Little research has examined the cognitive schemas used for evaluation of mental ill health in ways parallel to those for physical disorder (Angel & Thoits, 1987). The present study aims at elucidation of the correlates of various components of these schemas in relation to the commonest symptoms of mental ill health in Kuwait. Patients may be reluctant to express to health professionals their basic assumptions and naive schemas about their symptoms for fear of being considered foolish or unsophisticated (~toecl~lc & Barsky, 1 81). Failure of the doctors to understand the basis of patients’ illness behaviour may lead them astray into unnecessary medical procedures. Thus western-trained doctors who examine the heart and offer reassurance that nothing is wrong to Middle Easterners who report ’heart distress’ cannot help their patients because they fail to understand the culturally shared schema of emotional distress symbolised by this bodily expression
(Good, 1977).
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
151
The present study explores lay appraisals of common symptoms of mental ill health in Kuwait. The population of this oil exporting country is 1.7 millions, of whom 57% are males and 60% are expatriates (Ministry of Planning, 1986).
METHOD
Symptoms of mental ill health A list of the symptoms most commonly presented by psychiatric outpatients was prepared from the complaints in the records of 50 successive patients at Mubarak Al-Kabeer psychiatric outpatient clinic in Kuwait. This list comprised the twelve most commonly presented symptoms. Of these symptoms six were somatic symptoms and six were emotional symptoms. These symptoms are also found respectively in the somatic and emotional symptom subgroups of international mental health screening instruments eg. the scaled version of the General Health Questionnaire (Goldberg & Hillier, 1979) and the Langner Index (Langner, 1962) with the notable exception of breathlessness. Breathlessness or chest-tightness has been included in our list because it is one of the commonest presenting symptoms among Arabic-speaking patients. It is literally described as a feeling that the chest can no longer accommodate the patient’s breath; as though it has become too small or too tight to contain a deep inspiration. This is a common somatic expression of tension. A similar item appears in Hopkins Checklist (Derogatis et cal. 1974). Items included in our list were: Somatic 1. breathlessness/tightness 2. head pain 3. faintness 4. spells of hotness and/or excessive 5. lack of energy 6. loss of appetite
perspiration
Emotional 1. poor sleep 2. irritability 3. reduced ability to cope with usual life requirements 4. fears or worries for no good reason 5. depressed mood ie. low spirits or lack of enjoyment
6.
forgetfulness
The items were presented to subjects as hypothetical symptoms and their appraisal of the meaning was elicited in relation to each item should the subjects have it continuously for two weeks. A stratified random sample was obtained from individuals aged 20-59 years in public service institutions including two ministries and a private business enterprise. A random choice was made from lists of employees in these institutions in order to obtain a quota representing the age, sex, nationality and educational distribution
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
152
in the community according to the Kuwait census of population 1985 (Ministry of Planning, 1986). In order to complete the quota of illiterate individuals required it was necessary to extend the same selection procedure to four ’Centres for Adult Education and Eradication of Illiteracy.’ These centres also supplied our sample with housewives.
Symptom explanations Symptom explanation symptom -
was
recorded
according
to
whether the subject attributed each
to:
physical causes ie. bodily disease, psychosocial causes ie. problems related
to emotional and/or social life; and/or ie. God’s will, envy by others, the devil (Shaitan) or sorcery. Individuals could attribute any symptoms to one, two or all of the three groups of causes. Scores were given for varieties of explanations as the total numbers of symptoms ~0-12) in which an explanation was selected. -
-
supernatural
causes
C’ult~ral background The presence of supernatural forces is culturally recognised in an abstract way (EI-Islam, 1982). The belief in God’s will as a fatalistic determinant of events is quite common among Moslem Arabs. Symptoms, like any other event, may be part of this attribution which leads individuals no further in attempts to formulate any knowledge about them. Part of this fatalistic belief may be that whatever appeared through God’s will eg. symptoms, will also disappear by God’s will eg. through prayers of affected individuals. Envy involves the evil wish that a person deteriorates behaviourally, economically or healthwise. Unpleasant personal changes, especially sudden changes which are out of keeping with a person’s usual self, are attributed to the envy of others’ evil eyes. In competitive societies unequal achievements by various individuals call for increased effort of the less achieving in order to go up to the level of better achievers. On the other hand, in this noncompetitive society, envy removes the inequality by the almost magical envious wish-fulfilling powers of low achievers that make better achievers come down to their level ie. lose their precedence. Culturally-shared beliefs endow the devil with the ability to exert an adverse influence on those with weak religious faith to make them do wrong or be malevolent. Therefore behavioural disturbances or forgetfulness may be culturally attributed to the devil. Sorcery is believed to be a means of inducing harmful effects on others by humans who employ supernatural forces eg. spirits (jinn) for revenge or out of spite (Al-Ansari et at.
1989). Variables examined in relation
to
cognitive schemas included sex,
age, marital status,
education, occupation, family household size and nationality background. For the purpose of
our study, the more educated who exceeded the eighth standard were from the less educated subgroup. Occupationally, individuals were divided into separated housewives and students, clerical workers, skilled labourers, professionals and unskilled labourers. Family households were considered big if they included more than five individuals. Kuwaiti nationals were separated from other Arab nationals who come from other Arab countries for employment and are allowed to reside in Kuwait as long as they
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
153 Table 1 Median numbers of explanations for all 12 symptoms
Figures in brackets indicate the number of subjects * Mann-Whitney Test t Kruskall Wallis Test
in each group
hold a job. Many of these non-Kuwaiti Arabs left their wives and children in their countries of origin and their marital status was designated ’separate-married.’ The above discussed probes of cognitive schemas were administered through a structured interview. This was preferred to questionnaire administration to avoid linguistic bias. RESULTS
The relationship of demographic variables to lay explanations of symptoms is shown in Table 1. Older individuals and males attributed significantly more symptoms to physical causes (p = 0.0441 and 0.0034 respectively). Both educational subgroups adopted similar numbers of all three explanations. Stepwise logistic regression pointed to sex and marital status as the best predictors of physical explanations (which were least likely in divorced and widowed females) and pointed to nationality and household size as the best predictors of supernatural explanations (which were most likely in Kuwaitis living in larger households).
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
154
Total numbers of
Table 2 for somatic and emotional
explanations
symptoms
p < 0.000 1
(Chi-square test) Table 3
Explanations of individual symptoms
* This cell contributes the value
highest fraction
of the total
Chi-square
Physical symptoms in general were more likely to be attributed to physical explanations whereas emotional symptoms were more likely to be attributed to psychosocial and supernatural explanations (Table 2). Psychosocial explanations were significantly overrepresented in relation to symptoms of breathlessness and reduced coping, whereas forgetfulness and lack of energy were the most likely to have supernatural explanations (Table 3). DISCUSSION Somatization ie. the tendency to express psychiatric disorder in physical symptoms is most prominent in developing countries (Kirmayer, 1984). Somatic symptoms are usually
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
155
of the body to which symptoms belong. The somatic orientation of older individuals is evidenced by their excessive attribution of all symptoms to physical factors. It seems that in this culture psychosocial explanations are too abstract for the Moslem traditional elderly. Psychosocial genesis of symptoms which is often considered a sign of weakness of self or weakness of faith is less likely to be entertained by males who are conditioned to feel that they are the stronger sex. Better education was not associated with lower prevalence of supernatural explanations in the community sample studied. This tallies with similar findings in psychiatric patients where educated patients (including those who resided in developed countries for long periods) were found to be as likely as the uneducated to hold onto supernatural schemas as symptom explanations (El-Islarn ~ Malasi, 1985). Beliefs in supernatural explanations of illness seem to be too deeply imprinted during child-rearing to be erased by school education. Divorce as a prominent psychosocial event seems to have oriented affected individuals to a psychosocial explanation of symptoms. Extended families as represented by Kuwaitis who live in large households are known to be more traditional and hence more adherent than nuclear families to culturally-shared beliefs about supernatural explanations of symptoms. Somatic symptoms are generally believed to be more serious health hazards than emotional symptoms. This belief is entertained by both patients and medical professionals in this community where the majority of medical practitioners had little or no psychiatric education during their training (El-Islam, 1990). This patient-doctor collusion seems to sustain not only the preponderance of presentation with somatic symptoms but also their attribution to physical disorders. The dominant psychosocial explanation of the somatic symptom of breathlessness is remarkable. It confirms that this symptom is traditionally regarded as a physical metaphoric expression of emotional distress (El-Islam et cal. 1988). Our findings support other reports (Daniels, 1986; El-Islam & Ahmed, 1971) that emotional symptoms are more likely than somatic symptoms to have supernatural explanations. Reduced ability to cope with environmental demands is expectedly attributed to psychosocial causes because of the very nature of its contents that involve the social environment. Forgetfulness and fears are culturally attributed to the devil as stated in certain Koraanic verses and hence the preponderance of forgetfulness among supernaturally explained symptoms. Lack or reduction of one’s energy, on the other hand, is often regarded as the product of others’ envy or malicious acts through sorcery and therefore it has an obvious share of supernatural explanations.
explained by physical illness involving the part
CONCLUSIONS In this community study individuals’ responses suggest a tendency to adopt physical explanations for the somatic symptoms studied. Emotional symptoms however were the major candidates for psychosocial and/or supernatural explanatory concepts. Since most people in this culture (including patients and professionals) are somatically orientated in explaining health problems or symptoms it is not surprising that individuals who adopted
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
156
supernatural explanations were in the minority. Older individuals were over-represented among those who would attribute symptoms to supernatural explanations but this is not due to their tendency to be among the less educated. ACKNOWLEDGEMENT This research was supported by Kuwait University Grant MQ 015. The authors would like to thank Ms. Vera Marcovic for her generous librarian help. REFERENCES
AL-ANSARI, E.A., EMARA, M.M., MIRZA, I.A. & EL-ISLAM, M.F. (1989) Schizophrenia in ICD-10: a field trial of suggested diagnostic guidelines. Comprehensive Psychiatry, 30, 416-419. ANGEL, R. & THOITS, P. (1987) The impact of culture on cognitive structure of illness. Culture, Medicine & Psychiatry, 11, 465-494. DANIELS, C.S. (1986) Generational changes in conceptions of mental illness. Cross-cultural Psychology, 17, 493-505.
DEROGATIS, L.R., LIPMAN, R.S., RICKELS, K., UHLENHUTH, E.H. & COVI, L. (1974) The Hopkins Symptom Check List (HSCL): a self-report symptom inventory. Behavioral Science, 19, 1-15. EISENBERG, L. (1977) Disease and illness: distinctions between professional and popular ideas of sickness. Culture, Medicine & Psychiatry, 1, 9-23. EL-ISLAM, M.F. (1982) Arabic cultural psychiatry. Transcultural Psychiatric Research Review, 19, 5-24. EL-ISLAM, M.F. (1990) Psychiatry for Medical Students. Kuwait: Kuwait University Press. EL-ISLAM, M.F. & AHMED, S.A. (1971) Traditional interpretation and treatment of mental illness. Journal of Crosscultural Psychology, 2, 150-154. EL-ISLAM, M.F. & MALASI, T.H. (1985) Delusions and education. Journal of Operational Psychiatry, 16, 2931.
EL-ISLAM, M.F., MOUSSA, M.A.A., MALASI, T.H. & MIRZA, I.A. (1988) Assessment of depression in Kuwait by principal component analysis. Journal of Affective Disorders, 14, 109-114. GOLDBERG, D.P. & HILLIER, V.F. (1979) A scaled version of the General Health Questionnaire. Psychological Medicine, 9, 139-145. 25-58. GOOD, B.J. (1977) The heart of what’s the matter. Culture, Medicine & Psychiatry, 1, KIRMAYER, L.J. (1984) Culture, affect and somatization. Transcultural Psychiatric Research Review, 21, 159-177.
LANGNER, T.S. (1962) A twenty-two item screening score of psychiatric symptoms indicating impairment. Journal of Health and Human Behavior, 3, 269-276. MECHANIC, D. (1977) Illness behavior, social adaptation and the management of illness. Journal of Nervous & Mental Disease, 165, 79-87. MECHANIC, D. (1986) Role of social factors in health and well being: biopsychosocial model from a social perspective. Integrative Psychiatry, 4, 2-11. MINISTRY OF PLANNING (1986) Annual Statistical Abstract, Edition XXIII. Kuwait: Publication Research and Training Department. STOECKLE, J.D. & BARSKY, A.J. (1981) Attributions: uses of social science knowledge in the ’doctoring’ of A.M. Kleinman). primary care. In The Relevance of Social Science for Medicine (eds. L. Kisenberg & Dordrecht: Reidel.
M. Fakhr El-Islam, FRCP, FRCPsych, DPM, Faculty of Medicine, Kuwait University.
formerly Professor and Chairman, Department of Psychiatry,
Abu-Dagga, BA, Scientific Assistant, Department of Psychiatry, Faculty of Medicine, Kuwait University. Correspondence to Dr. El-Islam, Department of Psychiatry, Hamad Medical Corporation, PO Box 3050, Doha-Qatar, Arabian Gulf. Sanaa I.
Downloaded from isp.sagepub.com at DALHOUSIE UNIV on May 19, 2015
