157
SOCIO-CULTURAL AND CLINICAL DETERMINANTS OF
SYMPTOMATOLOGY IN OBSESSIONAL NEUROSIS
*SALMAN AKHTAR, M.D.,
Resident
N. N.
WIG,
M.D., F.R.C.PYCH., F.A.M.S., F.A.P.A.,
D.P.M.
(Eng. and Scot.)
Professor and Chairman
VIJOY K. VARMA, M.B., B.S., M.R.C.PYCH., D.P.M. (Eng.),
Associate Professor
DWARKA PERSHAD, M.A., D.M.S.P.
Clinical Psychologist
F.A.P.A.,
S. K. VERMA, M.A., D.M.S.P., D.G.P.,
Clinical Psychologist, Department ofPsychiatry,
Institute ofPostgraduate Medical Education and Research, Chandigarh, India
SUMMARY
Eighty-two obsessional neurotics were studied from a phenomenological viewpoint ir order to unmask the clinical and socio-cultural determinants of symptomchoice in this disorder. The form of obsessions and compulsions seemed to be
affected primarily by intrinsic factors (age, sex, I.Q.) while their content was
affected equally, if not more, by extrinsic factors (religion, locality, social class).
Patient’s age at the onset of illness seemed to be an extremely relevant factor insofar
as
it affected both the form and the content of symptoms. Some socio-cultural
offered these findings. The data is important insofar as it
cross-cultural studies of the phenomenology of obsessional
explanations have been
provides a baseline for
illness.
HE natural history of obsessional neurosis has been studied in detail (6, 9, 12,
17) and many investigators (5, 7, 11, 16, 19, 20) have commented upon the
diversity of form and content in obsessional symptomatology. None has, however,
studied the clinical, demographic and socio-cultural determinants of the phenomenological aspects of obsessional neurosis. One such attempt is being reported here.
T
METHODS
conducted at the psychiatric clinic of the Institute of Poststudy
Medical
Education
and Research, Chandigarh, India. Eighty-two obsesgraduate
sional neurotics were studied. Information was collected from each in semi-structured
personal interviews. Seventy-six were interviewed independently by at least two of
the three psychiatrists among the investigators. The remaining six, who lived
remotely and had to be seen at their homes, were interviewed by the senior author
only. Verbatim records preserved the precise language the patient used to describe
his symptoms. These were discussed at the study groups bi-weekly meetings and the
presence of various forms and contents of obsessions and compulsions noted (see
results). Operational definitions and illustrative examples of these appear elsewhere
The
was
(2).
*Presently, Assistant Professor, Department ofPsychiatrv,
University off Virginia Medical Center, Charlottesville, Virginia 22901,USA
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158
Information on seven clinical and demographic variables was collected in each
instance. These were : age, sex, religion, age at the onset of the illness, locality, I.Q.
and socio-economic status. Only urban patients could be assigned to various socioeconomic classes as, in India, the only standardized tool for this purpose (10)
pertains to urban population. Intelligence was measured in each instance with the
help of an indigenously constructed, standardized battery of tests (4). This, however,
could be done for 48 patients only, as the remaining 34 failed to keep their appointments with the clinical psychologist.
The frequency with which various forms and contents of obsessive-compulsive
phenomena occurred along the above-mentioned variables, was computed. Chisquares were calculated to determine the significance of the results.
The entire sample of 82 differed little from the catchment area’s general
population with which comparisons were made n the variables of age, sex, religion,
locality, marital and socio-economic status. Obsessionals, however, tended to belong
to higher strata of society; implications of this have been discussed elsewhere (1).
RESULTS
I.
Thought Content in Obsessions and Its Determinants
The content of obsessions could be classified into five broad
categories
as
dirt and contamination, aggression, inanimate-impersonal themes such
as mathematical figures and their totals, religion and sex. Obsession not classifiable
in any of these categories were grouped under a ’miscellaneous’ category. The
frequency distribution of various thought contents was computed along the seven
clinical and demographic variables (Table 1). This revealed the following:
(1) Of the 38 patients displaying an obsessive preoccupation with dirt and
contamination, 30 (79.1 %) were females. This preponderance was significant at .01
level.
(2) Seventeen (77.2%) of the 22 patients having obsessions with ’inanimateimpersonal’ themes, were males. The male preponderance in this group was highly
relating
to :
significant (p=.O1).
(3) The preoccupation with dirt and contamination occurred significantly more
often (p=.O1) among Sikhs as compared to Hindus.
(4) Obsessions with aggressive thought contents were more frequently displayed
by rural patients (p =.05) in comparison to their urban counterparts.
(5) Significantly more patients from socio-economic class III, as against other
socio-economic classes, displayed obsessions with ’inanimate-impersonal’ themes
(p=.05). Content of symptoms was otherwise not significantly different among
various social classes.
(6) The mental contents in obsessions seemed to differ in relation to the age
at the onset of the illness. Thus, aggressive (p=.05), sexual (p=.05) and ’miscellaneous (p. *01) thought contents were more frequent when the illness had started
before the age 20, while preoccupation with dirt (p=.05) and religion (p=.05) were
more frequent among those who developed the condition after the age 30.
(7) Age of the patient and his or her I.Q. did not seem to have any bearing on
the occurrence of various thought contents.
Form of Symptoms and Its Determinants
Five types of obsessions were identified : doubts, obsessive thinking, fears,
impulses and images, in order of frequency of their occurrence. Comulsive acts, when
present, could be classified into two types, depending upon whether they yielded to
II.
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159
diverted and controlled the underlying obsessive urge. The operational definitions
and illustrative case examples of these phenomena have been cited elsewhere (2).
Table 2 shows their frequency distribution along th various clinical and demographic
variables. This table reveals :
(1) Obsessive doubts were more frequent (p=.05) among females as compared
to males.
(2) Obsessive impulses and obsessive thinking were more frequent (p=.O1)
among males as compared to females.
(3) Obsessive impulses and images both were more frequent (p=.01) among
patients whose illness had started before the age 20.
(4) Six patients with an I.Q. above 100 suffered from obsessive images, as
against none among those with an I.Q. below this level. The difference was significant at .05 level.
(5) Age, religion, locality and socio-economic status of the patient did not seem
to have any bearing on the occurrence of various forms of obsessions and compulsions.
(6) Neither the presence, nor the form of compulsions was affected by any of
the seven variables.
or
DISCUSSION
I.
Thought
Content and Its Determinants
(Table 1)
TABLE I
distribution of the Mental Contents in Obsessions
by the Clinical and Demographic Variables
Frequency
**
Significant
at
or
below .01 level
*
Significant at
or
below .05 level
+ Socio-economic Status
The observation that some thought contents occur more frequently than others
(Table 1) raises certain questions, the most important being whether such frequency
reflects cultural characteristics of the patients studied or an inherent function of the
disease itself. We contend that a cultural basis affects the frequency with which
various thought content occurs in a given group of obsessionals. The preponderance
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160
in this sample of obsessions concerning dirt and contamination seems due to the
socio-cultural background of the patients involved since Indians in general are preoccupied with matters of purity and cleanliness. The Hindu code of ethics provides
for a great variety of purification rituals; the ’celebration’ in many Indian festivals
consists of bathing in a certain way or at a certain place. Their scriptures regard
the human body as basically dirty and an object for disgust. The society suffers
from what Berkley-Hill (3) designated as a ’pollution-complex’. There can be no
better evidence for this assumption than the presence of a social class of ’untouchables’. It did not, therefore, surprise us to see many patients suffering from doubts
and fears about the possibility of physical contact with beggars, sweepers, and other
such people of lower castes.
Women were more often (p=.O1) preoccupied with matters of dirt and cleanliness. This is understandable. Indian woman are greatly exposed to material that
really is dirty. Most woman are not employed and stay at home preparing meals,
sweeping floors, washing the utensils and clothes and looking after their children.
These activities offer convenient displacements for neurotic conflicts. Another factor
that might be contributory to this female preponderance is that of menstruation. In
the belief systems of most cultures a menstruating woman is considered ’dirt’ and
physically unclean. In India the cultural mainstream, with its characteristic preoccupation with such dichotomies as clean-unclean and pure-impure, goes a step
ahead and imposes a large number of rather magical inhibitions on a menstruating
woman. She does not enter the kitchen, prepare meals, put on a new dress, talk to
strangers and so on. These ritualistic avoidances, in themselves, may generate conflicts and precipitate obsessional behaviour or give content to an already existing
obsessional illness. The rich symbolic significance of menstrual blood (8) facilitates
such an occurrence.
Preoccupation with dirt and contamination was found to be more frequent
among Sikhs (p=.O1) than Hindus. This was contrary to the expectations of the
investigators for Sikhs generally lead a much less ritualistic life as compared to
Hindus. The ’false positive’ nature of this observation became clear when it was
found that there was a significant preponderance (p=.O1) of females among sikhs.
This, therefore, seemed to be a ’carry-over’ effect of the variable of sex rather than
the effect of religion itself. Another factor, however, may be partly responsible for
this finding. Sikhism prohibits getting a haircut or shaving any part of the body
throughout life. Its male followers thus all have beard and long hair. This, in turn,
involves a certain preoccupation with cleanliness in general and the care of hair in
particular; this preoccupation may indeed become morbid in times of stress.
Obsessions with aggressive contents were less frequent (p=.05) among urban
patients. Is it attributable to the sublimation that is required by an urban life?
Perhaps. The fact that Chandigarh, the local of this study, has the highest literacy
rate in India may also be contributing to this difference.
Urban patients of socio-economic class III suffered more often from ’inanimateimpersonal’ obsessions than of all the other social classes combined (p=.05). These
obsessions were also more frequent among males (p=.O1). These individuals were
mostly college students, clerks, typists, bookkeepers or schoolteachers. They were thus
more ’exposed’ to mathematical figures and other such themes that constituted this
particular category of thought content (2).
Age at which the obsessional illness had had its onset seemed to play an
important role in determining the content of obsessional symptomatology. Both
aggressive and sexual thought contents, as might be expected, were more frequent
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161
(p =.05) when the illness started before age 20. Obsessions of dirt and contamination
and those with a religious content were more frequent (p=.05) when the illness
developed relatively late in life. These frequency distributions are little understood.
That, age specific social roles and expectations are important not only in determining
the unconscious conflicts, but also in giving content to overt psychopathology, may be
offered as an explanation.
II.
Form
of Symptoms and Its Determinants (Table 2)
TABLE 2
Frequency distribution of the forms of Obsession and Compulsion
by the Clinical and Demographic Variables
* Significant
at
.05 level
~’’&dquo;
Significant
at
.01 level
The differences in the frequency distribution of various forms of obsessions and
compulsions are little understood. The main value of the data presented here remains
in its serving as a baseline. An interesting observation, however, needs consideration.
The f orm of obsession seems to be affected primarily by what one may call ‘intrinsic’
factors (age at onset, sex, intelligence) and is little correlated with the ‘extrinsic’
factors (religion, locality, socio-economic status) which seem to have much greater
a bearing on the content of the symptoms. This is an interesting finding and may
indeed have relevance with regards to the phenomenology of most clinical syndromes
in psychiatry.
A few speculative remarks on the determinants of various forms of obsessions
may be offered. The preponderance of men among those displaying obsessive impulses
(p=.O1), and of women among those suffering from obsessive doubts (p=.05) may
be related to their active-vs-passive role-attributes. Obsessive images, which resemble
what certain psychologists (eg. 13) call ’perseverative-imagery’, were found associated
with both young age and high intelligence (p=.01). The latter association is surprising insofar as neither the predominance nor the lack of controllability of visual
imagery has been found to have any relationship with a superior intelligence (15, 18).
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facility, among those with a higher I.Q., for the verbal expression of such highly
subjective experiences may indeed be partly responsible for the above mentioned
finding.
A
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