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Cothran and Harvey (1986) evaluated the influence of religious orientations, beliefs and demographic variables on delusional content among psychiatric patients in the USA diagnosed with schizophrenia or mania. A total of 51 patients were allocated to three groups according to the existence or otherwise of delusions as assessed with the Affective Disorders Schedule (SADS). The first group was non-deluded patients (9 mania and 8 schizophrenia). The second group was deluded patients without religious content (11 mania and 6 schizophrenia). The third group was deluded patients with religious content (13 mania and 4 schizophrenia). In addition, a control group consisted of 53 persons. The measures used were a personal values questionnaire to measure religious interests and activates, also a self- report scale which was conducted on patient groups. The results showed that delusions with religious content were equally represented across patients groups, despite a prediction from Bleuler (1950) cited in Cothan and Harvey (1986) that religious delusions arise from affective disturbances.

However, the findings within the patients groups showed that deluded patients with religious content had high religious values, but they reported less faith and support for those religious beliefs compared with non-deluded patients and control groups, thus the relationship between religious background and religious delusions is complex.

Regarding demographic variables and their relationship with content of delusions, they were not significant particularly with regards to sexual and doctrine or credo. The authors concluded that the results did not show any differences in demographic factors but this may be due to the limitations of their own study.

Weisman, et al., (2000) compared ten psychotic symptoms, assessed using semi-structured interview (PSE) and Psychiatric Assessment Scale (PAS) in a sample of 116 schizophrenic patients drawn from out-patients of public mental health services

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agencies in Los Angeles. The sample comprised 63 Anglo-Americans and 53 Mexican-Americans who were diagnosed as schizophrenic based on DSM-IV criteria. The results showed that Mexican-American patients experienced fewer symptom types compared with Anglo-Americans patients. Anglo-American patients tended to experience significantly more somatic symptoms of nervous tension than Mexican-American patients. However, Mexican-American patients had higher rates of hypochondria symptoms in general. The findings about delusions and hallucinations showed that there were no significant differences between groups in frequency of auditory hallucinations, persecutory delusions or religious delusions. However, Anglo-American patients had more scientific and supernatural content in their delusions than Mexican-American patients. Moreover, the Anglo-American group had more negative symptoms (self-neglect and blunted affect), with comparison to Mexican-American group. The authors emphasised that their results corresponded with cultural assumptions about the two groups, and concluded that social and cultural factors can affect psychiatric symptoms and may shape them.

Whaley & Hall (2009) investigated the relationship between cultural background and expression of psychotic symptoms particularly delusions and hallucinations among African- American patients in the USA. A total of 156 psychotic patients (69% male and 31% female) with delusions and hallucinations were studied. The researchers used a structured-interview based on DSM-IV. Delusions were classified into the following categories: reference; persecutory; grandiose; somatic; religious; being controlled;

broadcast; bizarre; and other. Hallucinations were also categorized as: auditory; visual;

tactile; and other. In order to identify the effects of cultural background on delusions and hallucinations a content analysis was made. The analysis showed two types of race-related content, the first was general racial content, and the second was racism-race-related content. The results showed generally that both types of race-related content reflected patients’ racial problems and experience of discrimination. The cultural effects appeared most distinctly in persecutory delusions, especially, race-related themes, while religious content manifested in other types of delusions and hallucinations. Moreover, the race-related content was associated more with delusions than with hallucinations. Whaley and Hall concluded that their results shed some light on the cultural influences on the expression of psychotic symptoms, and they recommended that observational scales are important to elicit such data in combination with self-report measures.

61 3: Studies in Saudi Arabia

Zarroug (1975) measured the frequency of visual hallucinations in schizophrenia in Saudi patients. The sample consisted of 69 schizophrenic patients, 52 male and 17 female. Interviews were conducted to elicit reports of visual hallucinations. The results showed that 62% of patients had visual hallucinations. The analysis of content of visual hallucinations revealed that among 29 male patients reported that the object of their hallucinations to be within their ordinary visual range, three reported that the location of their visual hallucinations was centred on their bodies, and three mentioned that locations were somewhere near, or in far place in town out of their sensory range.

Females reported that the place of their visual hallucinations were either in their near sensory range or beyond it. The types of content identified in these visual hallucinations were: bizarre, supernatural spirit (Jinni, half human), religious, and family members.

Verbal activities in response to visual hallucinations were common among patients. The author noted that visual hallucinations in schizophrenic patients were rare, according to the literature. However, they were common in Saudi Arabia, for unclear reasons, which may reflect the role of culture in this matter. The author also emphasised the important need for more investigation due to the rapid socio-economic developments in this part of the world, and the increases of immigration and increased contact with people from different ethnic and cultural backgrounds. Thus, such factors may play a great role in generating social stresses which they argue has led to an increase the rate of schizophrenia in Saudi Arabia, where approximately 85% of psychiatric in-patients were schizophrenic.

Qureshi, et al., (2001) presented a case study of seven Saudi females who had delusions of pregnancy, five of whom had a diagnosis of schizophrenia and two a diagnosis of mood disorder. Cases were aged between 29 and 56 years old, they were illiterate, and their marital status was either unmarried (single or divorced), or married. All the women reported delusions of pregnancy and experienced the false physical changes corresponding to their false beliefs. Some of them experienced more than one type of delusion, like delusions of nihilism, persecutory delusions and delusions of thought insertion. The authors indicated that religion in Saudi Arabia is an important ruling principle which organizes the relationship between males and females, marital life and

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love affairs among Saudi society. Furthermore, as a male-dominated, closed culture, and a conservatively religious society, these factors are particularly concerned to regulate the behaviour of women, and this may develop distress in Saudi females. Hence, most of the observed symptoms among Saudi females were somatic symptoms, and delusions of pregnancy are one of those symptoms. Some of the female patients ascribed these symptoms to psychological and others to supernatural factors. The case study also showed that all patients suffered from social and environmental stresses, marital problems, poverty and illiteracy problems. The authors argued that delusions of pregnancy may serve a psychological function in seeming to solve the patient’s social and marital problems, and attracting more positive attention from their families.

Furthermore, delusions of pregnancy in Saudi female patients may reflect cultural anxieties. The delusion of pregnancy might result from the anxiety of Saudi females to seek males’ satisfaction, and to fulfil males’ wish to have a lot of children according to the norms of a male-dominated culture. Also, female patients may resort to this delusion unconsciously as an attempt to keep their husbands, and to prevent them from marrying second, or third, or fourth wives according to Islamic rules which give a male the right to marry four wives. These delusions often contain sexual content which might give patients some satisfactory sexual feelings for whom seeking for love and sex in their locked society. Moreover, supernatural (magical pregnancy by evil eye, or spirit- Jinni), and religious content were more common among Saudi female patients.

4: Studies in south and south-east Asia

Kala & Wig (1982) evaluated delusions in Indian patients, to assess the effects of cultural, social and demographic variables on content of delusions. A total of 200 patients were studied, comprising 190 patients diagnosed as schizophrenic and 10 patients diagnosed as paranoid based on ICD-8 criteria. The method used was a semi-structured interview based on the Present State Examination Schedule (PSE). The delusions were classified into 12 categories. Delusions of persecution and delusions of reference were the two most commonly recorded types among all patients. Bodily control delusions, and delusions of poisoning of food came the next in frequency. The prevalence of delusions was estimated according to demographic variables (sex, age, marital status, rural and urban, family type, educational status and socio-economic

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status). Delusions of infidelity were significantly more common among females, whereas grandiose delusions and delusions of thought reading were more prevalent in males. Delusions of thought reading and sexual delusions were more frequently found among the youngest patients, those under 30 years, whereas religious delusions and delusions of infidelity were common in the older patients group. Delusions of thought reading, depressive, and sexual delusions had higher frequency among single patients, whilst, delusions of infidelity and delusions of poisoning were more common in married patients, reflecting the source of fears and anxieties amongst single (loneliness, guilt about sexual desires) and married (harm from spouse). In the urban group the most frequent delusions were delusions of reference, sexual delusions and delusions of thought reading. Concerning birth order, delusions of grandiosity, infidelity and depressive delusions more commonly occurred in patients who were the first born, whereas delusions of persecution, bodily control and delusions of reference were significantly more common in last born. However, results regarding intermediate born did not show any significant differences. In extended families the most frequent delusions were delusions of reference, poisoning and sexual delusions. Delusions of bodily control, infidelity, somatic and religious delusions more commonly appeared in illiterate patients, while delusions of grandeur, persecution, reference, thought reading and sexual delusions were more frequently found among the educated group. Finally, delusions of thought reading, reference and depressive delusions occurred more frequently in upper socio-economic class patients, while delusions of bodily control were the commonest delusions in lower socio-economic class patients. The conclusion was drawn that social and cultural factors affect the predominance and content of persecutory delusions among psychotic patients. Moreover, the authors argued that relationship between persecutory delusions and violence as a reaction to these delusions should receive more attention. The authors reported that many of these results are consistent with previous studies in other countries, for example, delusions of infidelity were more common among females in this study and consistent with Taiwanese data on that point. It was concluded that differences in the frequency of different types of delusions according to demographic variables reflected the differing social roles and social expectations of different demographic groups within the same culture.

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Azhar, Varma & Hakim (1995) conducted a comparative study between two different ethnic and cultural groups (Malay and Chinese) in two locations in Malaysia (Penang and Kelantan). Also, they assessed the influence of cultural and ethnic factors on some schizophrenic symptoms and on the content of delusions. A total of 270 schizophrenic patients were recruited, consisting of two groups, 166 in Penang group and 104 in Kota.

The authors applied a semi-structured questionnaire about the illness history and psychiatric symptoms, and patients were interviewed by using PSE. The results showed that persecutory delusions were the most common delusions in all groups. Grandiose delusions were less common in the Chinese group in Kota culture, whereas delusions of guilt and religious delusions were more distinctly presented in the Malay group in Kota culture. Delusions of reference were equal across all groups, but sexual delusions were more frequent in the Penang groups whereas nihilistic delusions were more commonly found in the Kelantan groups. Regarding the content of delusions in Malay patients, in Kelantan culture, these were expressed frequently in religious and supernatural themes (e.g., special power and skill, having ability to tell others about future and being possessed by spiritual power). The content of delusions among Kota groups was similar and religious and supernatural themes were also common in these groups (e.g. chosen by God, being God or prophet of God, having special power and abilities were given by God). On the other hand, the content of grandiose delusions in both Penang groups was about belonging to a high social class. The analysis of persecutors in persecutory delusions revealed that 25% of patients specified their persecutor as a member of their families, 35% of patients believed that their persecutors were either neighbours, colleagues or workmates, but 30% of patients overall and 40% of Malay patients in both locations did not define their persecutors. Moreover 22% of Penang Malay patients and 33% of Penang Chinese patients believed that the reason for their persecution was their high social class. 33% of Kelantan Malay patients believed that the reason behind their persecution was wealth. The results reflected considerable differences between cultural groups in Malaysia. Overall, content of delusions differed consistently with the differences between groups in their cultural values. The Penang area is more developed than Kelantan. Thus, people of Penang were more sophisticated and they had more Western influences in their life style. Also, the people in Kelantan were more religious and they appeared to cling more tenaciously to their old culture.

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Suhail (2003) assessed content of delusions among schizophrenic patients in Pakistan, and explored the role of sex differences and social class. Their sample consisted of 98 patients, 48 male and 50 female, who were diagnosed as schizophrenic according to DSM-IV criteria. The sample was drawn from two psychiatric units in Pakistan. The instrument was a semi-structured interview based on the Present State Examination PSE. The results revealed that persecutory delusions were the most common type in both groups, then grandiose delusions. However, a further analysis was established based on sex and social class. The results showed that there were two subgroups with no significant differences in overall frequency of delusions, but major differences in the content of delusions. The first subgroup was male and wealthy and the second subgroup was female and poor. The most common content of delusions among the male-wealthy group concentrated on having power, being powerful, being a famous star and other grandiose themes. However, the most common content of delusions in female-poor group was delusions of influence, magical, supernatural and persecutory themes. The results confirmed that content of delusions can differ between socio-cultural groups in a way that reflects their social roles, and social and traditional values, norms and rules.

Yip (2003) assessed the influence of Chinese traditional religious and supernatural beliefs on the content of delusions and hallucinations in a case study of schizophrenic patients. The author demonstrated the influence of the most important and common religious and supernatural beliefs in Chinese culture (e.g. the Taoist gods, fortune telling and the Buddhist gods.). The sample was 4 schizophrenic patients, 2 male and 2 female.

These cases were studied by establishing three interviews for each patient to collect information about family history, to elicit delusions and hallucinations, and to elicit traditional Chinese religious and supernatural beliefs which were embedded in content of delusion of patient. The results showed that traditional Chinese religious and supernatural beliefs had important effects on the formation and content of delusion and hallucinations, and the special experiences of patients. These beliefs may contribute in the constituting of daily behaviour according to the predominant experiences’ and beliefs in patient’s environments and culture. In addition, patients might constitute themselves as characters in the narrative content of delusions, and then they become part of these beliefs and develop stories based on those beliefs. The details of daily religious practices, religious beliefs, religious stories regarding these religious beliefs and superstitions, and worship were reflected in the context of delusional content,

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therefore, the details of those beliefs became the details of patients’ delusions. These religious beliefs also have given the delusions meaning from patient’s view, and they may help the patient in resolving their inappropriate emotional behaviours, distress and failure by projecting a religious theme on their delusions details.

Finally, it is concluded from the studies reviewed that the content of delusions can best be understood within a cultural context: their manifestation varies across-cultures and within the same cultures across subcultures and according to demographic variables.

Also the content of delusions is strongly influenced by culturally salient events (Ndetei

& Vadher, 1985; Suhail, 2003; Skodlar et al., 2008) Moreover, it was shown that although the persecutory content was the most common type of content in many different cultures, it comes very strongly from the literature review that the delusional source of persecution is likely to depend on culturally prevalent threats or beliefs about malevolent influence. Likewise delusions of grandeur may refer to prevalent cultural beliefs about supernatural or social power and status. Therefore to understand a patient’s delusions it is necessary to understand the cultural and sub-cultural context for the delusional beliefs, and this is also very relevant to clinical practice (Kala & Wig, 1982; Kim & et al. 1993, 2001, 2006; Azhar & et al. 1995; Suhail & Cochrance, 2002).

The Cultural Background for the Research

General overview of geography and history of the Kingdom of Saudi Arabia

Geographically, the Kingdom of Saudi Arabia is located in the southwest of Asia, bounded to the west by the Red sea, by Jordan, Kuwait, and Iraq to the north, in the south by Yemen and the Sultanate of Oman, and in the east by the Arabian Gulf, Qatar, Bahrain and United Arab Emirates. The Kingdom occupies the major part of the Arabian Peninsula; it extends on land area approximately 2.3 million square kilometres.

It comprises several different cities and districts which are divided into five large regions: the Western region which is called Al Hejaz and which includes the holy cities Makkah and Madina; the Northern region which is nearby Jordan and Iraq; the Southern region which is close to Yemen; the central region which is called Najd area including

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the capital of the Kingdom, Riyadh; and the Eastern Province which contains the Saudi oil fields and industries (Mead, 2007).

1- The Central region (Najd)

Najd lies in the middle of a sand desert in the heart of the Arabian Peninsula. Its location led in former time to lack of attraction for foreign people to settle and live on it (Al Rasheed, 2002). However, today Riyadh is considered to be one of the most modern cities in the Middle East. This development of Najd in all life domains led it to attract many people from different countries and from other Saudi provinces seeking jobs and education (Mead, 2007; Menoret, 2005). However, Najd is considered to be one of the most traditional, extreme and conservative societies in Saudi Arabia (Buchele, 2009).

The conservative traditions in this area are related to its geographical, historical and

The conservative traditions in this area are related to its geographical, historical and