Caleb W. Lack, Editor
Cultural Manifestations of Obsessive-
Monnica T. Williams & Ashleigh Steever
Obsessive-compulsive disorder (OCD) is a severe anxiety disorder involving
distressing obsessions and repetitive compulsions. Obsessions are intrusive,
unwanted thoughts, images, or impulses that increase anxiety, whereas
compulsions are repetitive behaviors or mental acts used to decrease anxiety.
OCD is highly disabling, with nearly two-thirds of those afflicted reporting severe
role impairment (Ruscio, Stein, Chiu, & Kessler, 2010).
In the United States, the National Comorbidity Survey Replication (NCS-R)
showed that approximately 1.6% of the population met criteria for OCD at some
point in their lives (Kessler, Berglund, et al., 2005), with 1% of the sample meeting
criteria within the last year (Kessler, Chiu, Demler, Merikangas, & Walters, 2005).
The prevalence of OCD appears to be roughly consistent across ethnic groups in
the US. For example, a recent epidemiological study of African and Caribbean
Americans showed an OCD lifetime prevalence of 1.6% (Himle, et al., 2008).
Epidemiologic studies conducted in other countries find similar rates cross-
nationally (Weismann et al., 1994), as presented in Figure 1. The rates range from
0.3% in Brazil to 2.7% in Hungary. Based on the current world population (US
Census Bureau, 2011), it can be estimated that 112 million people worldwide are
afflicted with OCD during their lifetime.
Although many with OCD worry about cleanliness, symmetry, arranging, and
perfectionism, OCD is a complex disorder that can manifest itself in a variety of
symptom dimensions, including unacceptable thoughts, ruminations about
morality, and hoarding (e.g., Bloch et al, 2008; Williams et al., 2011). It is
important that cultural differences be taken into account when conducting
psychopathology research, as culture can have profound effects on the
manifestation of psychopathology, particularly in a disorder as multi-faceted as
OCD. Culture can be defined as a set of attitudes, behaviors, and symbols shared
by a large group of people that is usually communicated generationally (Shiraev &
The aim of the current study is to present a survey of the cross-cultural
manifestation of OCD worldwide, based on a systematic review of the
psychological literature. Critical summaries and analyses were taken of featured
texts and compiled to illustrate differences and similarities in symptom
presentation cross-culturally. We include an examination of differences found
based on factors such as ethnicity, nationality, and religion. In the United States,
OCD tends to be regarded by laypeople as a quirky disorder that results in
excessive cleaning, checking, and arranging. Preconceived notions about this
disorder may affect the symptom profiles of treatment-seeking samples (Sussman,
2003). Therefore, we present findings from epidemiological studies whenever
possible, followed by findings from large national multi-site studies and meta-
analyses. When such studies are not available for a given population, findings are
presented from single site studies.
OCD in European Americans & Western Cultures
An investigation of OCD in the US by the National Comorbidity Survey
Replication (NCS-R; Ruscio et al., 2010), found a wide range of symptoms,
illustrated in Table 1. This was an epidemiological sample that was assessed for
psychopathology using a computer-guided structured interview. It should be
noted, however, that the symptom categories used in the NCS-R were not
empirically derived; rather, they represent symptoms commonly reported by
individuals diagnosed with OCD. These findings are subject to a number of study
limitations, including a small sample size (N=73), problems with the computerized
data collection procedures, and the lack of a clear categorical distinction between
obsessive and compulsive symptoms.
Additional information about symptom profiles can be garnered from clinical
samples. Symptom distributions obtained from the DSM-IV Field Trial of OCD,
a large treatment-seeking sample (N=431; Foa, Kozak, Goodman, Hollander,
Jenike, & Rasmussen, 1995) differed from NCS-R findings. For example, the data
from the NCS-R shows that 62.3% reported Hoarding as a symptom while in the
DSM-IV Field Trial sample this symptom was only reported by 4.8% of the
participants. This same trend is seen again with the symptom of Checking, with
only 28.2% of the sample reporting it versus 79.3% in the NCS-R sample.
Moreover, the symptom of Ordering was only reported by 5.7% of the DSM-IV
Field Trial participants, while in the NCS-R data set it was ten times as prevalent
These differences are partially accounted for by differences in study methodology
and category classification. The DSM-IV Field Trial reported percentages based
on the total number of primary symptoms reported by participants. Additionally,
Ruscio et al. drew from a community-derived sample whereas Foa et al. utilized
clinical samples. Thus, caution must be taken when generalizing from one study to
the other, given that the treatment-seeking individuals in the Foa et al. study may
not be representative of the OCD population as a whole. Secondly, methodology
differed with regard to diagnostic procedures. Ruscio and colleagues utilized the
World Health Organization’s Composite International Diagnostic Interview
(CIDI 3.0; Kessler & Üsütun, 2004), intended to be administered by lay-persons,
whereas Foa and colleagues used the OCD section of the Structured Clinical
Interview for DSM-III-R (SCID; First, Spitzer, Gibbon, & Williams, 1997) and an
expanded version of the Yale-Brown Obsessive Compulsive Symptom Checklist
(YBOCS-SC; Goodman et al., 1989), which is administered by clinicians
experienced with OCD.
Most studies of symptom dimensions in US samples utilize the YBOCS-SC, as it
includes a comprehensive list of obsessions and compulsions that represent the
majority of OC symptoms observed clinically in Western samples (Goodman et
al., 1989). Since its development, there have been several attempts to establish an
empirically-based classification system that corresponds to the symptoms listed
within it. Baer (1994) was the first to conduct a principal components analysis
(PCA) of the 13 major Y-BOCS-SC symptom categories. Three factors were
identified: Symmetry/Hoarding, Contamination/Cleaning, and Pure Obsessions.
Pure Obsessions corresponded to individuals with religious, aggressive, and/or
sexual obsessions, for whom no compulsions were identified. In a meta-analysis of
21 clinical studies involving 5,124 participants, Bloch, Landeros-Weisenberger,
Rosario, Pittenge, and Leckman (2008) found few differences with respect to
symptom dimensions cross-culturally, especially among the three quarters of the
studies (76%) from Western nations. Still, while most of those studies found a
four-factor model, more recent studies that have included other types of
compulsions, such as mental compulsions and reassurance, tend to find five
specific dimensions: Contamination/Cleaning, Hoarding, Symmetry/Ordering,
Taboo Thoughts/Mental Compulsions, and Doubt/Checking (e.g., Abramowitz
et al., 2003; Pinto et al., 2007; Williams et al., 2011).
In Western cultures, it is widely believed that OCD is a mental disorder caused by
biological factors (Coles & Coleman, 2010). Washing, checking, and symmetry
related dimensions are more quickly recognized as OCD symptoms than
aggressive, religious or sexual symptoms. It also appears that the taboo obsessions
are less well-accepted, which could lead to delays in treatment seeking or hiding
symptoms due to increased fears of stigma and shame (Simonds & Thorpe, 2003).
Thus it is possible that this symptom presentation is underrepresented in the
treatment-seeking population. Alternately, it could be that people with these
symptoms may be more motivated to seek treatment due to the high-levels of
distress caused by such thoughts (e.g., Williams, Wetterneck, Tellawi, & Duque, in
press). More work is needed to determine the impact of these issues on help-
OCD in African Americans
Until recently, not much was known about African Americans with OCD, as US
ethnic minorities have been underrepresented in many types of OCD studies,
including the factor analytic studies included in meta-analyses such as those
described above (Williams, Powers, Yun, & Foa, 2010). Hatch, Friedman, and
Paradis (1996) were among the first to report their observations about OCD in
African Americans in a naturalistic study of treatment-seeking adults in an urban
clinic. The authors noted differences in treatment-seeking patterns, as only 2% of
Black patients out of their entire clientele were diagnosed with OCD. This could
be attributed to a lack of treatment-seeking in African Americans, who instead
tended to obtain help from informal social networks such as members of the
clergy. It is also possible that OCD may be misdiagnosed in African Americans,
especially in cases where the obsessional content is unusual. African Americans
tend to be over diagnosed with psychotic disorders compared to European
Americans and are more likely to hospitalized, even after controlling for severity
of illness and SES (Snowden, Hastings, & Alvidrez, 2009; Whaley & Hall, 2009).
Thus, unusual symptoms may be considered symptoms of psychosis rather than
OCD (i.e., Ninan & Shelton, 1993).
New insights into African American health have been uncovered through a series
of investigations sponsored by the Program for Research on Black Americans.
The National Survey of American Life (NSAL; Heeringa et al., 2004) is the most
in-depth study of mental health disorders in African Americans and other U.S.
racial and ethnic minorities ever completed. The study primarily drew from three
nationally representative adult samples, including African Americans (N=3,570),
Blacks of Caribbean descent (N=1,623), and Non-Hispanic Whites (N=1,006). In
examining OCD specifically in this group, Himle et al. (2008) found that 1.6%
met diagnostic criteria for the disorder. OCD is highly associated with overall
mental health impairment, and the majority of the participants also met the criteria
for at least one other lifetime psychiatric disorder, with 93.2% of African
Americans and 95.6% of Caribbean Blacks also experiencing symptoms for major
depressive disorder, social phobia, and generalized anxiety disorder, among others.
This is not unexpected given that diagnoses of OCD have often been found to
overlap with other psychological disorders (Ruscio et al., 2010; Saleem &
Williams, Proetto, Casiano, and Franklin (2012) conducted the largest study of
clinically diagnosed African Americans with OCD to date (N=75). In studying the
characteristics of the sample, six discrete symptom dimensions were identified,
which included Contamination/Washing, Hoarding, Sexual/Reassurance,
Aggression/Mental Compulsions, Symmetry/Perfectionism, and
Doubt/Checking. Factors identified were similar to those of previous studies in
primarily White samples, however African Americans with OCD reported
contamination symptoms at double the rate of European Americans, and were
twice as likely to report excessive concerns about animals. These findings were
compared to symptom data from the NSAL study, which also noted increased
contamination concerns (Williams, Elstein, Buckner, Abelson, & Himle, 2012).
The study found cultural differences with respect to cleanliness and animal
concerns, which is consistent with findings among non-clinical samples (Williams,
Abramowitz, & Olatuni, 2012; Williams & Turkheimer, 2007). A higher level of
obsessions and compulsions linked to cleanliness may be culturally relevant as
African Americans historically experienced segregation, where it was thought that
European Americans would be contaminated through close contact or sharing
items (i.e., drinking fountains, swimming pools, etc.) Additionally, Williams et al.
found that participants with a lower SES reported greater concern with
contamination, which is consistent with the hypothesis that lower incomes could
be associated with more exposure to contaminants, resulting in greater
contamination concerns and cleaning behaviors in this cultural group (Williams &
Turkheimer, 2007; Williams, Abramowitz, & Olatunji, 2011).
OCD in Western Christian Samples
Abramowitz, Deacon, Woods, and Tolin (2004) conducted a study of
undergraduates to better understand the relationship between Protestant religiosity
and an assortment of OCD symptoms, such as washing, checking, and the
importance of controlling one’s thoughts. The participants were given self-report
questionnaires to determine their degree of religiosity and the prevalence of OCD
symptoms. The resulting feedback divided the students into three groups of
varying religiosity (from atheist/agnostic to highly religious). Students reporting
high levels of religiosity reported more obsessional symptoms than the moderately
religious and atheist/agnostic subgroups (Abramowitz et al., 2004). The highly
religious participants also reported greater levels of certain cognitions like the
importance of their thoughts as well as the need to control them relative to the
reports of the other participants. The authors referenced the Book of Matthew in
the Bible with respect to the Sermon on the Mount, in which Jesus Christ makes
the assertion that the thought of committing a sinful act is equal to having already
done it. This could help explain the importance placed on thought control for the
highly religious participants.
In a similar study by Sica, Novara, and Sanavio (2002), the aim was to understand
the role of religion in OCD phenomenology. A community sample of Italian
participants ascribing to the Catholic faith was surveyed for degree of religiosity
and prevalence of certain OCD cognitions and obsessions. Those participants
who reported a high or medium degree of religiosity also reported high levels of
obsessions like the importance of thought control compared to those reporting
low levels of religiosity. The authors cited Catholic precepts such as the equality of
thoughts and behaviors, as well as Catholic teaching about purity and
perfectionism as the reason for these findings. In sum, the findings indicate
differences with respect to the importance of thought control and the idea that
thoughts and actions are interchangeable.
OCD in Jewish Communities
Scrupulosity is a form of OCD in which individual obsessions are focused on
moral or religious issues like sin and divine retribution (Huppert, Siev, & Kushner,
2007). As Judaism is a religion oriented around traditions and customarily focuses
on rituals and laws that are fundamental to Jewish life, many Jewish OCD
sufferers experience scrupulosity and will rely upon rabbinical help with their
symptoms. Huppert et al. (2007) found that in treating Jewish patients who suffer
from scrupulosity, there may be difficulties in distinguishing between religious
rituals and compulsive behaviors. What is normally a religious ritual, if found in
the extreme and outside of the religious context, could be scrupulosity rather than
simply increased religious devotion.
Rosmarin, Pirutinsky, and Siev (2010) conducted a community study that
examined attitudes towards OCD symptoms in Orthodox and non-Orthodox
Jews in the US. Participants were given descriptions of either religious
(scrupulosity) or non-religious OCD symptoms. When confronted with the
religious themes in the descriptions (such as excessive prayer, repeated crossings,
and sky-gazing toward God) the Orthodox participants more often recognized the
scrupulosity as OCD and recommend psychological treatment than did the non-
Orthodox participants. This was in direct opposition to the hypothesis set forth in
the study, which was that Orthodox Jews, because of the value they place on
careful adherence to religious laws, would be less likely to recognize scrupulosity
than the Non-Orthodox Jews and less likely to recommend some form of
treatment. One reason could have been that the Orthodox participants had a
more stringent awareness of normal religious practices due to a more “strict
adherence to religious law” and were thereby able to identify scrupulosity more
easily. Conversely, the non-Orthodox participants may have been less likely to
identify scrupulosity as OCD or recommend psychological evaluation due to not
wanting to offend other religious individuals or “disrespecting bona fide religious
standards” (Rosmarin et al., 2010).
OCD in Middle Eastern Islamic Cultures
Several studies about the cultural components of OCD and its symptom
expression have been conducted in Middle Eastern countries where there is a high
Islamic population. In the first study of its kind to originate in Saudi Arabia,
Mahghoub and Abdel-Hafeiz (1991) found strong religious themes in the OCD
symptomatology of a conservative Muslim clinical sample. The most often
reported symptoms were obsessions with prayers and washing (50%),
contamination (41%), and faith (34%). Obsessions with prayers and washings
could have stemmed from religious practices that included praying and washing
oneself systematically in a practice called Al-woodo, as the body must be clean
before prayers can be made. The authors cite the frequency of these actions, and
the need for their proper execution as being possibly causative of repeating,
washing, and checking compulsions that were noted at 50%, 37%, and 31%,
respectively in the sample.
A study by Okasha, Saad, Khalil, and Dawla (1994) reported the content of
obsessions in a clinical Egyptian sample to be most often religious in nature, with
60% reporting obsessions with religious themes. To explain this, the researchers
cited the tendency of the participants to feel the need to ward off evil spirits
through various religious rituals and repeated sayings. This could account for the
high frequency of religious obsessions as well as repeating compulsions, which
were reported by 67.7% of the participants. The majority of participants in this
study were rated on the Y-BOCS as having moderate to severe symptom
presentation, which is said to indicate an especially high tolerance in Egyptian
patients for psychiatric morbidity. The study also found that in most cases the
mental health professional is a last resort for help, with the participants instead
seeking help in an informal social network of native healers, friends, elderly family
members, and religious people and then a general practitioner (Okasha et al.,
1994). These same types of help-seeking attitudes have been observed in the
African American treatment-seeking community (Hatch et al., 1996) and suggest a
preference for culturally and religiously relevant assistance with issues concerning
psychological disorders including OCD.
In a similar non-clinical study by Yorulmaz and Işık (2011), the results were much
the same. The majority of the participants, who were of Turkish descent, reported
high levels of obsessions related to fear of contamination and cleanliness. The
dominant religion in Turkey is Islam, which the researchers described as
“ritualistic and rule-based,” and as such the participants were subject to certain
rigid beliefs about purity and cleanliness. The authors in particular described an
aspect of Islam known as “waswas,” which is religious doubt, and how this
concept could affect the content of the obsessions reported.
Participants in the study also experienced what is known as Thought-Action
Fusion (TAF). Also noted in Western cultures (Abramowitz et al., 2004), this
symptom highlights the importance of thoughts and the need to control them.
This could be explained by the prevalence of “superficial similarities” between
certain beliefs in Islam and characteristics of OCD. In Yorulmaz and Işik (2011),
although all of the participants reported an Islamic affiliation, the differences
found in symptom presentation here are culturally significant because they exist
between participants of reportedly equivalent ethnic descent. The participants who
had lived in Turkey since birth reported higher levels of symptom expression,
particularly with respect to contamination/cleaning, when compared to Bulgarian-
born Turkish participants, and Turkish remigrants. The authors cite the possibility
of the rigorous Islamic institution in Turkey as being explanatory of the higher
levels of symptomatology for those participants who were born and raised there.
Ghassenzadeh, Mojtabai, Khamseh, Ebrahimkhani, Issazadegan and Saif-Nobakht
(2002), found the most commonly reported symptoms in their Iranian sample to
be obsessive doubts and indecisiveness, as well as a washing compulsion. There
were also marked differences in reported symptoms between males and females,
with males reporting blasphemous thoughts and compulsions concerning
orderliness and females reporting greater concerns with impurity and
contamination as well as obsessive thoughts centered on personal impurity and
washing compulsions. The authors noted that 70% of the female participants were
housewives. This could possibly influence the content of obsessions as cleaning
would be a part of daily chores associated with housework. The authors also note
the strong cultural affiliation to religion in Iran and the spiritual symbolism of
cleanliness and cleaning behaviors as a way to prepare oneself for daily prayers.
Al-Salaim and Loewenthal (2011) also found religious themes in the symptoms of
a sample of 15 young women suffering with OCD in Saudi Arabia. There were
trends in help-seeking behavior, with all of the participants reporting first seeking
assistance from a religious leader in the community. This was described as either a
man with a long beard or a woman who covers her face, and was accompanied
with the use of religious rhetoric (e.g., quoting the Qura’an or teachings of the
prophet Muhammad). This was preferable, as a religious professional was
considered less likely to manipulate or harm a patient. One of the causes of OCD
as reported by some of the participants was an “evil eye,” which is described as
being caused by a person admiring one of his or her own possessions. The
authors also found that religious symptoms were reported in the sample as being
more disturbing than other OCD symptoms, and in some instances were the
reason for seeking help with the disorder.
In Bahrain, where the state religion is Islam, Shooka, Al-Haddad, and Raees
(1998) found religious themes in both obsessions and compulsions in a clinical
sample, with religious content in 40% of the symptoms. Obsessional thoughts, the
most commonly reported form of obsession (68%), were followed by an
obsession with images (26%) and doubt (12%). Content of obsessions also
reflected obsessions with dirt/contamination and sexual themes, at 38% and 32%,
respectively. Shook et al. also found a disproportionate male to female ratio in the
sample with women making up 74% of participants as well as higher levels of
reported severity of symptoms in females. The authors believed this could have
influenced the help-seeking behaviors of the women in the study as women would
have sought help for more severe symptoms. There were also higher levels of the
obsession with cleaning and washing in the women, a trend we have seen in other
cultures (Labad et al., 2008; Jaisoorya, et al., 2009); it is also worth noting that 81%
of the female sample worked in the home, similar to Ghassenzadeh et al. (2002).
Saleem and Mahmood (2009) found the most frequently reported compulsion in a
clinical sample of participants from Pakistan, a country where the dominant
religion is also Islam, to be hand-washing. This compulsion was reported by 97%
of participants, and 82% experienced a fear of germs. This is, again, a compulsion
related to cleanliness and purity. The researchers discussed an aspect of Islamic
culture called “Napak,” which is a feeling of contamination that includes religious
connotations of being unclean or unholy. Two-thirds (67%) of the participants in
this study added Napak to the questionnaire as an item within the broader
category of Contamination. When a Muslim is in the state of Napak, he is unable
to take part in religious rituals until he has cleaned himself systematically in an
action is called ablution.
An emphasis on cleanliness, purity, and religion appears to be normative in
cultures with Islamic religious backgrounds. It is important to note, however, that
when the actions surrounding such beliefs are committed in excess, and the beliefs
become obsessions, they can then become culturally significant aspects of OCD
OCD in India
Studies in India have reported typical OCD obsessions to include contamination,
aggression, symmetry, sexual, religious, and pathological doubt. Girishchandra and
Khanna (2001) found that the most commonly reported symptoms in a clinical
sample of 202 Indian participants were doubts about having performed daily
activities (64.9%) and contamination concerns about dirt and germs (50%). In a
comprehensive review of the Indian literature, Reddy, Jaideep, Khanna, and
Srinath (2005) also observed that contamination concerns and pathological doubt
were highly prevalent. Reddy et al. found the lifetime prevalence rate of OCD to
be approximately 0.6% in India. This is relatively low compared to the lifetime
prevalence rate in other countries (Figure 1). Girishchandra and Sumant (2001)
also noted a disproportionate number of males in the study compared to females
at a ratio of over two to one.
Jaisoorya, Reddy, Srinath, and Thennarasu (2009) found differences in in their
clinical study with regard to symptom presentation between men and women of
an Indian sample. Male participants had a tendency to report sexual and symmetry
obsessions coupled with checking and bizarre compulsions, while symptoms
surrounding dirt, contamination, and cleaning were reported more often by
females, a finding similar to Western samples (e.g., Labad et al., 2008). The
authors commented that women were more often subjected to unclean conditions
and as such could be more concerned with contamination than males. In Western
samples, it has been suggested that biological make-up and brain chemistry,
specifically greater numbers of steroid hormone receptors the female brain may be
causing a sexual dimorphism (physical difference), which could possibly explain
the higher level of cleaning and contamination concerns (Labad et al., 2008). The
authors also mentioned that environmental differences could mediate the
differences found, such as females being socialized to do a greater share of the
domestic work such as housecleaning.
The majority of participants in the study by Jaisoorya et al. were men, a
phenomenon also noted in Girishchandra and Sumant (2001). Historically, in
Western samples, there has been no difference in help-seeking between men and
women with OCD (Goodwin et al., 2002; Torres et al., 2007). In the Indian
sample, the authors commented that this was possibly due to differences in male
versus female societal status, and greater access to medical care as a result.
In a study by Chowdhury, Mukherjee, Ghosh, and Chowdhury (2003) the authors
found an association between a culture bound disorder termed “puppy
pregnancy” and OCD. Cases uncovered in rural West Bengal India describe fears
of being pregnant with a canine embryo after having been bitten, and symptoms
are comparable to those found in OCD, unusual content notwithstanding. Puppy
pregnancy includes a fear of internal contamination (from the puppy fetus),
disability (impotence due to damage to internal sexual organs), and death. One
case reported a symptom reminiscent of checking after having observed a dog
licking milk cans and being bitten by the same dog. Thereafter, the subject was
fearful that he was being chased by a dog, and would check all milk cans, sure that
they had been licked by a dog. The authors also noted obsessive thoughts
involving fear of dog bites and avoidance.
In general, however, research to date has found few differences in symptom
dimensions in India from those found in studies conducted in Western societies.
One notable exception is Bloch et al. (2008), who noted some differences in
symptom presentation for Indian participants when compared to studies of White
and Non-White clinical samples. In Indian studies, the five-factor model of
symptoms included one described as a need to touch, tap, and rub, which could
possibly be associated with cultural traditions involving touching (i.e., touching the
feet of elders as a sign of respect).
OCD in Indonesia
In Bali, which is primarily Hindu, Lemelson (2003) conducted a study of 19
patients suffering from OCD to understand the degree to which Balinese culture
affected the illness experience. The most common obsession was a need-to-know
obsession, which was literally the necessity of knowing the identities of passers-by.
Lemelson also found obsessions surrounding themes of magic, witchcraft, and
spirits, which are all religious themes entwined in the Balinese culture. These
findings are different from those seen in Western studies where typical symptoms
include concerns about contamination, hoarding, and checking (e.g., Foa et al.,
As a caveat, it is important to note that other than in Bali, where the practiced
religion is Hindu with emphases on magic, witchcraft, and ancestor worship, the
main religious affiliation of Indonesia is Islam. Therefore the phenomenology of
OCD in other parts of Indonesia may be more similar to findings in Islamic
OCD in Hispanic and South American Samples
To date there have been few studies conducted that address OCD with respect to
Hispanic and South American populations. Studies that have compared
prevalence rates of OCD between Latino and European American populations in
the US have yielded inconsistent findings. For instance, one study demonstrated
no significant differences in prevalence rates between European Americans and
Mexicans (Karno et al., 1989), while another found significant differences between
European Americans and Puerto Ricans (Weissman et al., 1994). Studies of OCD
in Latin America note a lifetime prevalence rate of 1.4% in Mexico City, 1.2% in
Chile and 3.2% in Puerto Rico (Canino et al., 1987; Caraveo-Anduaga &
Bermudez, 2004; Vicente, 2006).
Although there have been few studies of symptom dimensions in Hispanic
Americans, one study did note greater contamination concerns in a non-clinical
sample (Williams et al., 2005). In a clinical study conducted in Costa Rica,
participants reported lower levels of symptom severity, including lower levels of
functional impairment and lesser amounts of perceived distress, when compared
to their US counterparts in the same study (Chavira, Garrido, Bagnarello, Azzam,
Reus, & Mathews, 2008). The study cited a number of culturally relevant reasons
for the differences, including a possible lack of psychosocial stressors in the Costa
Rican sample, as the participants were from a primarily agrarian region of the
country. In addition, the lower levels of perceived stress were found to possibly
reflect the ability of the participants to “accommodate” their symptoms. For
example, one participant reported avoiding driving due to the fear of harming
others and this was easily avoided due to the ease of access in Costa Rican society
(Chavira, et al., 2008).
A study conducted on a clinical sample in Rio de Janeiro outlined differences with
respect to content of obsessions, as the most commonly reported obsessions
included the theme of aggression, (69.7%), followed by contamination (53.5%)
(Fontenelle, Mendlowicz, Marques, & Versiani, 2004). This is important because
in many other cultures issues of contamination seem to overshadow others in the
spectrum with respect to the OCD symptom manifestation (i.e. Matsunaga et al.,
2008). The authors discussed possible reasons for the findings of their study, and
cited the climbing rates of mortality and morbidity resulting from violent causes,
and that the population has likely prioritized of avoiding violence. It is important
to note, however, that this study is from a single site and reflects the surrounding
and, in the case of Brazil, the metropolitan culture of the participants.
In a clinical study in Mexico by Nicolini, Orozco, Giuffra, Páez, Mejía, Sánchez de
Carmona, Sidenberg, and de la Fuente (1997), contamination obsessions were
reported by 58% of the clinical sample, making it the most common. Sexual and
aggressive obsessions followed, at 31% and 13%, respectively. The proportion of
men to women in the study was uneven with only approximately 37% of the
sample being men. The authors, citing an earlier study, considered a cultural
phenomenon in which Mexican men have the tendency to deny having a mental
illness. An interesting, but marginally reported obsession, was one concerned with
“treasuring,” reported by 3% of the sample. Treasuring is described as keeping
things (i.e., the hair from a hairbrush), and can be understood to be similar to
hoarding. For an excellent review of OCD in Hispanic populations, see
Wetterneck et al. (2012).
OCD in East Asia
Matsunaga et al. (2008) noted the most common obsessions in a clinical Japanese
sample as fear of contamination (48%) followed by obsessions with symmetry or
exactness (42%) and aggression (36%). The most common compulsive symptoms
reported were checking and washing at 47%, followed by repeating rituals at 31%.
The authors’ focus was more psychobiological than cultural, and the authors
described “transcultural stability” in the symptom presentation of OCD.
However, the researchers only compared their results with Western studies rather
than results from other cultures.
The lifetime prevalence rate for OCD in Taiwan is 0.7% (Figure 1). In the first
study of its kind from Taiwan, Juang and Liu (2001) found in a group of 200
outpatient Taiwanese participants the most commonly reported obsessions to be
fears of contamination, pathological doubt, and a need for symmetry, at 37%,
34%, and 19%, respectively. The most commonly reported compulsions
consisted of checking, washing, and orderliness/precision.
Kim, Lee, and Kim (2005) determined symptom dimensions, based on a factor
analysis of the Y-BOCS-SC checklist in a clinical genetic study of Koreans with
OCD. The study outlined the factors as hoarding/repeating,
contamination/cleaning, aggressive/sexual, and religious/somatic. The latter two
dimensions were described as “pure obsessional” due to a lack of identified
corresponding compulsions. Most Western studies group these two in to a single
component termed unacceptable/taboo thoughts (Bloch et al, 2008). The study
also grouped the hoarding obsession together with repeating and counting
compulsions, a combination not seen in a majority of Western samples. Moreover,
unlike the Western samples in Bloch et al. (2008), the Korean sample did not
include in any dimension an obsession with symmetry, which is also at odds with
other studies originating in Asia that have shown symmetry obsessions to be
among those most highly reported (Matsunaga et al., 2008; Li, Marques, Hinton,
Wang, & Xiao 2009).
In the first such study to originate in mainland China, Li et al. (2009) assessed 139
patients with OCD. The study sought to determine if the five symptom
dimensions documented in other studies (unacceptable/taboo thoughts,
symmetry/ordering, contamination/cleaning, and hoarding) were applicable in
this particular culture. The most common symptoms reported were obsessions
with symmetry and contamination at 67.6% and 43.2%, respectively, followed by
aggression at 31.7%. Li et al. cited a cultural propensity towards harmonious
interpersonal relationships due to the presence of Confucianism and its precepts
in China as a possible explanation for fewer reports of aggression when compared
to other cultures. The authors also noted a disproportionate ratio of males to
females in the demographics of the study (almost 2:1). It was unclear whether this
could have possibly been mediated by cultural norms regarding help-seeking
behavior in women as the authors noted that the males of the sample seemed
more willing to participate than their female counterparts. This same trend has
been observed in a number of Indian samples as well (Jaisoorya et al., 2009;
Girishchandra & Sumant, 2001).
In Eastern cultures such as China and Japan there is a cultural emphasis on
conformity, collectivism, and harmony (Li et al., 2009). An emphasis on symmetry
may reflect these tenets to some degree, and cultural norms involving conformity
are instilled from an early age in some Asian cultures. Nonetheless, there are some
important differences in symptoms between Chinese and Japanese with OCD, as
reported by Liu, Cui, and Fang (2008). After studying two groups of patients
hospitalized with OCD, the authors concluded that aggressive and contamination
obsessions were more common in Japanese than Chinese OCD sufferers, while
religious and symmetry/exactness obsessions are more common among Chinese
patients. Likewise, Japanese OCD patients were more likely to have
cleaning/washing and ordering/arranging compulsions, while Chinese
counterparts were more likely to have checking compulsions. Perhaps these
differences are reflective of the greater emphasis on symmetry in Chinese culture
than Japanese culture (Li et al., 2009; Kim et al., 2005).
Through this review we have described differences in OCD symptomatology that
appear to be associated with culture. Obsessional content often stems from that
which is culturally relevant, resulting in a profound effect on symptomatology that
cannot be ignored.
In Christian samples the most often reported symptoms were obsessions with
contamination and thought control. There was also an emphasis on perfectionism
in the Catholic subgroup. As discussed earlier, the presence of religious ritual in
the symptomatology of OCD is generally a manifestation of that ritual in excess of
cultural norms. In the Jewish subgroup, the content of obsessions was also of a
religious nature (Huppert et al., 2007), and involved themes of morality and divine
retribution. There were differences in symptom recognition and thus help-seeking
behaviors between Ultra-Orthodox Jews and their less observant counterparts. In
Middle Eastern cultures we see high Islamic affiliation and symptom dimensions
that reflect this (e.g., Okasha et al., 1994). The content of obsessions in the Islamic
subgroup was centered on purity and religious themes (e.g., Okasha et al., 1994;
Abramowitz et al., 2004). The obsession with physical cleanliness in the
symptomatology of highly religious cultures could be a manifestation of the
emphasis on spiritual purity within the society. OCD in Near Eastern countries
tends to also reflect religious beliefs, as well as familial and societal values (e.g.,
kissing the feet of respected elders) that are an integral part of the culture.
Jaisoorya et al. (2009) cited a possible link between Hinduism, the dominant
religion in India, and the prevalence of obsessions with cleaning and
contamination found in multiple other studies (Girishchandra & Sumant, 2011;
Reddy et al., 2005).
Western studies have shown symptom dimensions that are generally centered
around a four or five factor model, with an emphasis on contamination/cleaning,
hoarding, symmetry/ordering, taboo thoughts/mental compulsions, and
doubt/checking (Abramowitz et al., 2003; Blotch et al., 2008). There is, however,
a dearth of literature concerning differences in symptom dimensions among
ethnic minorities, such as African Americans (Williams et al., 2010). In Hispanic
and Latin American groups, themes of contamination and aggression were
prominent. Indian samples emphasized themes concerning contamination and
pathological doubt, as well as differences in the symptom dimensions reported by
men and women. In East Asian groups, there were greater concerns with
contamination and symmetry. Cultural differences were noted between Japan and
China, with china reporting greater needs for symmetry, and Japan reporting
greater obsessions with contamination and aggression (Liu et al. 2008). In general,
there seem to be thematic elements that cluster in certain regions and religious
groups across the world.
Similarities in Symptoms
Most of the studies presented here exhibit some type of cross-cultural similarity in
addition to noted differences. Almost all of the presented studies and surrounding
cultures include contamination fears as a primary dimension (e.g., Nicolini et al.,
1997; Okasha et al., 1994; Reddy et al., 2005). Fear of contamination manifests as
hand washing compulsions, prevalent in many cultures (Buckner et al., 2011;
Okasha et al., 1994; Kim et al., 2005; Jaisoorya et al., 2009). Each of the 21 studies
included in the meta-analysis performed by Bloch et al. (2008) contained a
symptom factor that included hoarding compulsions and obsessions, although
hoarding was not emphasized in any studies cross-culturally. Each of these
symptoms was also found to in the NCS-R, thus it is not surprising that some
authors cite a “transcultural stability” in the symptomatology of the disorder
(Matsunaga et al., 2008). Matsunaga et al. suggest biology as a determining factor
in the expression of specific OCD symptoms, and highlight similarities across
cultures. The presence of symptom dimensions such as contamination fears and
hoarding that are salient features in multiple cultural contexts supports this
hypothesis. Additionally, Kim et al. (2005) found differences between the two
genotypic groups with respect to religious/somatic obsessions, which provide
additional evidence for a biological basis for symptom dimensions.
It should be noted that the findings herein are limited by the available literature. In
some cases the studies presented are single-site studies and limited in sample size.
Furthermore, many of the studies presented are limited based upon use of the Y-
BOCS-SC in determining symptom dimensions. The individual items that
comprise the measure were selected based on clinical observations in Western
cultures. Furthermore, the a priori structure of the Y-BOCS-SC measure causes it
to rely upon fixed categories of symptoms instead of individual symptoms as they
are presented. Thus the Y-BOCS-SC could potentially restrict recognition of
cross-cultural differences in symptomatology.
The importance of cultural context in the diagnosis and treatment of OCD is
undeniable. Limited extant literature has restricted this study to some measure,
and more research is needed to determine the extent to which culture and beliefs
can magnify, diminish, or change the symptom presentation and experience of
OCD for those diagnosed. There is also a dearth of research in certain regions and
cultures that should be addressed. For example, there is no literature available
from an African sample except the highly Muslim Egyptian region and White
South Africa (e.g., Stein et al., 2008), as well as a lack of literature pertaining to
differences in the symptom presentation of Hispanic Americans. The implications
herein are important for diagnosis and the development of empirically supported
treatments for individuals of different cultural backgrounds as well as for
determining the applicability of contemporary literature to diverse cultural groups.
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