Obsessive-compulsive disorder was once believed to be a rare condition. The prevalence rate of OCD in three catchment areas in a U.S. study ranged between 1.9% and 3.3% (Robins et al., 1984). In comparison, a study conducted in Cairo, Egypt, of 1,000 psychiatric patients attending a university clinic showed an incidence of OCD of 2.5% (Okasha et al., 1968). A replication of this study showed an incidence of 2.3%, indicating the stability of the prevalence of the disorder over time (Okasha and Raafat, 1991).
Previous Egyptian studies on psychiatric phenomenology have shown a prevalence of culturally determined symptomatology, where religion and prevailing traditions seemed to color not only the clinical picture of the condition, but also patients' attitudes about their disorder (Okasha, 1966).
In one of our studies, 90 patients suffering from OCD (diagnosed according to the ICD-10) attending our outpatient clinic were followed from 1991 to 1992 (Okasha et al., 1994). The patients were assessed by the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) for symptomatology and severity of symptoms. Sixty-nine percent of the patients were males and 32% were females. The mean age was 23.7, with a mean duration of OCD of 3.2 years. Twenty percent of patients had positive family histories for OCD. Forty percent of patients presented with a mixture of obsessions and compulsions, whereas 29% presented with only obsessions and 31% with only compulsions. Religious and contamination obsessions (60%) and somatic obsessions (49%) were the most common. The most common compulsions were repeating rituals (68%), cleaning and washing (63%), and checking (58%), mostly related to religious beliefs. Seventy-one percent of patients were rated as severe on the Y-BOCS. While all patients showed some lack of insight into their disorder, 9% had no insight whatsoever. 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 disorders, and 52% had no specific premorbid personality disorder.
The role of religious upbringing has been evident in the phenomenology of OCD in Egypt. The psychosociocultural factors are so varied that they can affect the onset, phenomenology and outcome of OCD. They can even affect response to treatment. The emphasis on religious rituals and the warding-off of blasphemous thoughts through repeated religious phrases could explain the high prevalence of religious obsessions and repeating compulsions among our Egyptian sample. This is true even if the participants in the study were not practicing their religious duties.
To elaborate further, Moslems, who constitute almost 90% of the Egyptian population, are required to pray five times a day. Each prayer is preceded with a ritualistic cleansing process (Wudu or ablution), which involves washing several parts of the body in a specific order, each three times. This ablution is invalidated by any form of excretion or ejaculation and, for some radical Moslems, by any contact with the opposite sex. Women are not allowed to pray or touch the Koran during their menstruation, after which they should clean their bodies through a ritualistic bath. The prayers themselves vary in length and consist of certain phrases and suras from the Holy Koran that have to be read in a certain sequence.
The emphasis on cleanliness or ritual purity is the cornerstone of most of the compulsive rituals. The number of prayers and their verbal content can be the subject of scrupulousness, checking and repetition. The ritualistic cleansing procedures can also be a source of obsessions and compulsions about religious purity. Other evidence of the religious connotation inherent in OCD in Moslem culture lies in the term weswas. This term is used in reference to the devil and, at the same time, is used as a name for obsessions. It is also characteristic of a conservative society like Egypt to expect sexual obsessions to be among the most frequent in female patients. Although it is accepted socially (but prohibited religiously) for Egyptian males to have a wide range of sexual freedom in all stages of their lives, sexual matters remain an issue of prohibition, sin, impurity and shame for Egyptian women. The female gender is surrounded by so many religious and sexual taboos that the issue becomes a rich pool for worries, ruminations and cleansing compulsions in women susceptible to developing OCD.
Christians represent approximately 10% of the population in Egypt, which was equivalent to the percentage in our study sample population. The presenting symptoms for these patients were almost similar in terms of obsessions, where religious and sexual thoughts were predominant. However, there was a marked difference in rituals, which were more frequent in Moslems. This emphasizes the roleof ritualistic Islamic upbringing, as compared with a Christian upbringing, in our community.