ChapterPDF Available

Cultural manifestations of obsessive-compulsive disorder


Abstract and Figures

Background: The study and understanding of symptom presentation in Obsessive-Compulsive Disorder (OCD), has become increasingly important in the scientific literature. Through circumnavigation of the globe, this article details differences in OCD between Western, Middle Eastern, Jewish, Hispanic, Asian, and other cultures. Methods: The review involved a systematic search of research literature published from samples in several different countries of markedly different cultural backgrounds. Critical summaries and analyses were taken of featured texts and compiled to illustrate differences and similarities in symptom presentation cross-culturally. Results: There were a number of noticeable differences between cultures in terms of symptom expression, obsessive cognitions, cultural influences on behavior, ritualistic beliefs, and other issues. Differences included symptoms surrounding thought control, the relationship between beliefs, and cleaning and checking compulsions. Studies conducted in highly religious cultures emphasized purity, cleanliness, and religion as well as thought control, morality, and sexuality. Differences in lifetime prevalence of OCD were also found to vary from country to country from 0.30%-2.7%. Conclusion: Evidence suggests that a culturally-informed approach may be needed to best understand the relationship between culture and OCD. Future research is needed to further explain and understand differences between cultures.
Content may be subject to copyright.
Caleb W. Lack, Editor
AbouttheAuthors 191
AbouttheEditor 197
Chapter Four
Cultural Manifestations of Obsessive-
Compulsive Disorder
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
CW Lack
by a large group of people that is usually communicated generationally (Shiraev &
Levy, 2010).
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
at 57%.
Obsessive-Compulsive Disorder
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
CW Lack
(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
Obsessive-Compulsive Disorder
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 &
Mahmood, 2009).
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
CW Lack
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
Obsessive-Compulsive Disorder
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
CW Lack
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
Obsessive-Compulsive Disorder
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
CW Lack
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.
Obsessive-Compulsive Disorder
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.
CW Lack
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,
Obsessive-Compulsive Disorder
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%.
CW Lack
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).
Obsessive-Compulsive Disorder
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.
Religious Differences
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
CW Lack
contamination found in multiple other studies (Girishchandra & Sumant, 2011;
Reddy et al., 2005).
Regional Differences
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.
Obsessive-Compulsive Disorder
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.
Future Directions
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.
Acknowledgements: The authors would like to thank Beth Mugno, M.A., and Carolina
Santillán, Ph.D. for assistance with the literature review.
Abramowitz, J. S., Deacon, B. J., Woods, C. M., & Tolin, D. F. (2004).
Association between protestant religiosity and obsessive-compulsive
symptoms and cognitions. Depression and Anxiety, 20(2), 70-76.
Bloch M.H., Landeros-Weisenberger, A., Rosario, M.C., Pittenge, C., & Leckman,
J.F. (2008). Meta-analysis of the symptom structure of obsessive-
compulsive disorder. American Journal of Psychiatry, 165, 1532–1542.
Chavira, D. A., Garrido, H., Bagnarello, M., Azzam, A., Reus, V. I., & Mathews,
C. A. (2008). A comparative study of obsessive-compulsive disorder in
CW Lack
Costa Rica and the United States. Depression and Anxiety, 25(7), 609-619.
Coles, M. E. & Coleman, S.L. (2010). Barriers to treatment seeking for anxiety
disorders: initial data on the role of mental health literacy. Depression and
Anxiety, 27, 63–71. doi:10.1002/da.20620
Foa, E. B., Kozak, M. J., Goodman, W. K., Hollander, E., Jenike, M. A., &
Rasmussen, S. A. (1995). DSM-IV field trial: Obsessive-compulsive
disorder. American Journal of Psychiatry, 152(1), 90–96.
Fontenelle, L. F., Mendlowicz, M. V., Marques, C., & Versiani, M. (2004). Trans-
cultural aspects of obsessive-compulsive disorder: A description of a
Brazilian sample and a systematic review of international clinical studies.
Journal of Psychiatric Research, 38(4), 403-411.
Ghassencadeh, Moitabia, Khamseh, Ebrahimkhani, Issazadegan, & Saif-Nobakht.
(2002) Symptoms of obsessive-compulsive disorder in a sample of Iranian
patients. International Journal of Social Psychiatry, 48(1), 20-28.
Girischandra, B.G., & Sumant, K. (2001). Phenomenology of obsessive-
compulsive disorder: a factor analytic approach. Indian Journal of Psychiatry,
43(4), 306-316.
Hatch, M. L., Friedman, S., & Paradis, C. M. (1996). Behavioral treatment of
obsessive-compulsive disorder in African Americans. Cognitive and
Behavioral Practice, 3(2), 303-315. doi:10.1016/S1077-7229(96)80020-4
Himle, J. A., Muroff, J. R., Taylor, R. J., Baser, R. E., Abelson, J. M., Hanna, G. L.,
…Jackson, J.S. (2008). Obsessive-compulsive disorder among African
Americans and blacks of Caribbean descent: Results from the national
survey of American life. Depression and Anxiety, 25, 993–1005.
Jaisoorya, T. S., Reddy, Y., Srinath, S. S., & Thennarasu, K. K. (2009). Sex
differences in Indian patients with obsessive-compulsive disorder.
Comprehensive Psychiatry, 50(1), 70-75.
Karadaĝ, F., Oğuzhanoğlu, N., Özdel, O., Ateşci, F. Ç., & Amuk, T. (2006). OCD
Symptoms in a Sample of Turkish Patients: A Phenomenological Picture.
Depression and Anxiety, 23(3), 145-152. doi:10.1002/da.20148
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E.
E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV
disorders in the National Comorbidity Survey Replication.Archives of
General Psychiatry, 62(6), 593–602. doi:10.1001/archpsyc.62.6.593
Kessler, R. C., Chiu, W. T., Demler, O., Merikangas, K. R., & Walters, E. E.
(2005).Prevalence, severity, and comorbidity of 12-month DSM-IV
disorders in the National Comorbidity Survey Replication.Archives of
General Psychiatry, 62(6), 617–627. doi:10.1001/archpsyc.62.6.617
Obsessive-Compulsive Disorder
Kessler, R. C., & Üsütun, T. B. (2004). The World Mental Health (WMH) Survey
initiative version of the World Health Organization (WHO) Composite
International Diagnostic Interview (CIDI). International Journal of Methods in
Psychiatric Research, 13, 93-121. doi:10.1002/mpr.168
Kim, S. J., Lee, H. S., & Kim, C. H. (2005). Obsessive-compulsive disorder, factor
analyzed symptom dimensions and serotonin transporter polymorphism.
Neuropsychobiology, 52, 176–182. doi:10.1159/000088860
Labad, J., Mencho, J., Alonso, P., Segalas, C., Jimenez, S., Jaurrieta, N., & ...
Vallejo, J. (2008). Gender differences in obsessive-compulsive symptom
dimensions. Depression and Anxiety, 25(10), 832-838. doi:10.1002/da.20332
Lemelson, R. (2003). Obsessive-compulsive disorder in Bali: The cultural shaping
of a neuropsychiatric disorder. Transcultural Psychiatry, 40(3), 377-408.
Li, Y., Marques, L., Hinton D.E., Wang, Y., & Xiao, Z. (2009). Symptom
dimensions in Chinese patients with obsessive-compulsive disorder. CNS
Neuroscience and Therapeutics, 15(3), 276-282. doi:10.1111/j.1755-
Nicolini, H., Benilde, O., Giuffra, L., Paez, F., Mejia, J., Sanchez de Carmona, M.,
Sidenberg, D., & Ramon de la Fuente, J. (1997). Age of onset, gender and
severity in obsessive-compulsive disorder: a study on a Mexican
population. Salud Mental, 20(3), 1-4.
Ninan, P. T. & Shelton, S. (1993). Managing psychotic symptoms when the
diagnosis is unclear. Hosp Community Psychiatry, 44, 107–8.
Okasha, A. A., Saad, A. A., Khalil, A. H., & Dawla, A. (1994). Phenomenology of
obsessive-compulsive disorder: A transcultural study. Comprehensive
Psychiatry, 35(3), 191-197. doi:10.1016/0010-440X(94)90191-0
Reddy, Y. C.,Janardhan, Jaideep, T.,Khanna, S, & Srinath, S. (2005). Obsessive-
Compulsive Disorder Research in India: A Review. In Obsessive compulsive
disorder research. (pp. 93-120). ix, 284 pp. Ling, B. E [Ed]. Hauppauge, NY,
US: Nova Biomedical Books; US.
Rosmarin, D. H., Pirutinsky, S., & Siev, J. (2010). Recognition of scrupulosity and
non-religious OCD by Orthodox and non-Orthodox Jews. Journal of Social
and Clinical Psychology, 29(8), 930-944. doi:10.1521/jscp.2010.29.8.930
Saleem, S., & Mahmood, Z. (2009). OCD in a cultural context: A
phenomenological approach. Pakistan Journal of Psychological Research, 24(1-
2), 27-42.
Simonds, L.M., & Thorpe, S.J. (2003). Attitudes toward obsessive-compulsive
disorders: An experimental investigation. Social Psychiatry and Psychiatric
Epidemiology, 38, 331–336.
Shiraev, E.B. & Levy, D.A. (2010). Cross-Cultural Psychology: Critical Thinking and
Contemporary Applications, 4th Edition. Pearson.
CW Lack
Shooka, A. A., Al-Haddad, M. K., & Raees, A. A. (1998). OCD in Bahrain: A
phenomenological profile. International Journal of Social Psychiatry, 44(2),
147-154. doi:10.1177/002076409804400207
Sica, C., Novara, C., & Sanavio, E. (2002). Religiousness and obsessive-
compulsive cognitions and symptoms in an Italian population. Behaviour
Research and Therapy, 40(7), 813-823. doi:10.1016/S0005-7967(01)00120-6
Snowden, L.R., Hastings, J.F., Alvidrez, J. (2009). Overrepresentation of Black
Americans in Psychiatric Inpatient Care. Psychiatr Serv, 60(6), 779-785.
Stein, D.J., Carey, P.D., Lochner, C., Seedat, S., Fineberg, N., Andersen, E.W.
(2008). Escitalopram in obsessive-compulsive disorder: response of
symptom dimensions to pharmacotherapy. CNS Spectrums, 13(6), 492-8.
Sussman, N. (2003). Obsessive-Compulsive Disorder: A Commonly Missed
Diagnosis in Primary Care, Primary Psychiatry, 10(12), 14.
U.S. Census Bureau. (2011). Population Clock. Retrieved from
Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Hwu, H. G., Chung
… Yeh, E. K. (1994). The cross national epidemiology of obsessive
compulsive disorder: The Cross National Collaborative Group. Journal of
Clinical Psychiatry, 55(3 Suppl.), 5–10.
Wetterneck, C., Little, T., Rinehart, K., Cervantes, M. E., Hyde, E., & Williams,
M. T. (2012). Latinos with Obsessive-Compulsive Disorder: Mental
Healthcare Utilization and Inclusion in Clinical Trials, Journal of Obsessive-
Compulsive & Related Disorders, 1(2), 85-97.
Whaley, A. L., & Hall, B. N. (2009). Effects of cultural themes in psychotic
symptoms on the diagnosis of schizophrenia in African Americans. Mental
Health, Religion & Culture, 12(5), 457-471.
Williams, M. T., Abramowitz, J. S., & Olatunji, B. O. (2012).The Relationship
between Contamination Cognitions, Anxiety, and Disgust in Two Ethnic
Groups. Journal of Behavior Therapy and Experimental Psychiatry, 43, 632-637.
doi: 10.1016/j.jbtep.2011.09.003
Williams, M.T., Elstein, J., Buckner, E., Abelson, J., Himle, J. (2012). Symptom
Dimensions in Two Samples of African Americans with Obsessive-
Compulsive Disorder, Journal of Obsessive-Compulsive & Related Disorders,
1(3), 145-152. doi: 10.1016/j.jocrd.2012.03.004
Williams, M. T., Farris, S. G., Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M.
E., Simpson, H. B., Liebowitz, M., & Foa, E. B. (2011). The Myth of the
Pure Obsessional Type in Obsessive-Compulsive Disorder, Depression &
Anxiety, 28(6), 495–500.
Williams, M., Powers, M., Yun, Y. G., & Foa, E. B. (2010). Minority
representation in clinical trials for obsessive-compulsive disorder. Journal
of Anxiety Disorders, 24, 171-177.
Obsessive-Compulsive Disorder
Williams, M. T., Proetto, D., Casiano, D., & Franklin, M. E. (2012). Recruitment
of a Hidden Population: African Americans with Obsessive-Compulsive
Disorder, Contemporary Clinical Trials, 33(1), 67-75.
Williams, M. T., & Turkheimer, E. (2007) Identification and explanation of racial
differences on contamination measures. Behavior Research and Therapy,
45(12), 3041-3050. doi:10.1016/j.brat.2007.08.013
Williams, M.T., Turkheimer, E, Magee, E., & Guterbock, T. (2008). The effects of
race and racial priming on self-report of contamination anxiety. Personality
and Individual Differences, 44(3), 744-755. doi:10.1016/j.paid.2007.10.009
Williams, M. T., Wetterneck, C., Tellawi, G., & Duque, G. (in press). Domains of
Distress Among People with Sexual Orientation Obsessions. Archives of
Sexual Behavior. doi: 10.1007/s10508-014-0421-0
... The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) 20 which is incorporated into WMH-CIDI 3.0 was used to determine clinical severity of 12-month cases. We employed the cutoffs for symptoms suggested by Storch et al 21 that ranged from mild (0-13) to moderate (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25), moderate-severe (26)(27)(28)(29)(30)(31)(32)(33)(34) and severe (35)(36)(37)(38)(39)(40). The Sheehan Disability Scale (SDS) was used to assess functional impairment in respondents diagnosed with 12-month OCD and classified as mild, moderate and serious. ...
... 39 In the African-American population, it was hypothesised that the compulsions linked to cleanliness are rooted in the political history of racial segregation in the US. 40 Further research is needed on the role culture plays in O/C symptoms in Singapore. ...
Introduction: Using data from Singapore Mental Health Study 2016 (SMHS 2016), we examined the prevalence of lifetime and 12-month obsessive-compulsive disorder (OCD), its sociodemographic correlates and association with comorbid psychiatric disorders and physical conditions, perceived social support and quality of life. Materials and methods: The World Mental Health Composite International Diagnostic Interview (version 3.0) was administered by trained interviewers to 6126 residents aged ≥18 years old to assess OCD prevalence and that of other select psychiatric disorders. Details on sociodemographics, perceived social support and health-related quality of life were obtained. Results: Lifetime and 12-month prevalence of OCD was 3.6% and 2.9%, respectively. Adjusted regression analysis showed that those with OCD had significantly higher odds of major depressive disorder (odds ratio [OR], 5.4), bipolar disorder (OR, 8.9), generalised anxiety disorder (OR, 7.3) and alcohol abuse (OR, 2.7). OCD was significantly associated with suicidal ideation and suicidality (OR, 5.1). OCD subjects also had higher odds of chronic pain (OR, 2.4) and diabetes (OR, 3.1). Finally, OCD subjects had lower mean mental composite summary scores than controls (respondents without any of the psychiatric disorders and physical conditions included in SMHS 2016) and those with other lifetime psychiatric disorders and physical conditions. Conclusion: OCD prevalence in Singapore is high. Most people with OCD do not seek treatment despite experiencing significant comorbidity and loss of quality of life.
... Recently, Canino et al. (2019) reported a 12-month prevalence rate of 22.5% of Puerto Ricans with a psychiatric disorder living in Puerto Rico, suggesting an increased incidence of psychopathology on the island. Studies in Latin America revealed a lifetime prevalence rate of 3.2% of OCD in Puerto Rico (Canino et al., 1987), compared to 1.4% in Mexico City and 1.2% in Chile (Williams & Steever, 2015). The data shown in these studies suggest higher lifetime and annual prevalence rates of OCD in Puerto Rico, compared to other Latin American countries, highlighting the increase of individuals with this disorder in a small island with approximately 3.337 million people. ...
Full-text available
Trasfondo:El control ejecutivo de la atención media la resolución de problemas y la acción voluntaria y está implicado en la regulación de las emociones. Se ha reportado que el control atencional está afectado en personas con trastorno obsesivo-compulsivo (TOC). Sin embargo, no se ha considerado la influencia de la carga cognitiva y la distracción en la ejecución de tareas, lo que pudiera tener un impacto en el control atencional. En este estudio evaluamos si la carga cognitiva alta y baja influyen en el control atencional de personas con TOC, en comparación con un grupo control. Método:Quince adultos puertorriqueños con TOC (M=31.60, DE=10.70) y 26 saludables (M=28.42, DE=10.73) participaron en el estudio. Se administró el Attention Network Test y una tarea de carga cognitiva para evaluar el control atencional. Resultados:No se observaron diferencias significativas en las puntuaciones de alerta, orientación y control atencional entre los grupos en ambas condiciones de carga cognitiva (p>0.05). Solo se observó una diferencia significativa en el control atencional de los participantes con TOC (z=1.99, p=0.047) y del grupo control (z=-2.83, p=0.005) durante tareas con carga cognitiva baja y alta. Conclusiones:Ambos grupos experimentaron menor interferencia de distractores bajo alta carga cognitiva, lo que sugiere un mayor control de la atención durante esta condición. Es posible que el aumento de carga cognitiva pueda reducir la distracción en puertorriqueños saludables y aquellos con TOC. Tomar en cuenta la carga cognitiva puede facilitar el entrenamiento cognitivo para el control atencional y aumentar la flexibilidad cognitiva, mejorando la respuesta al tratamiento.
... [5][6][7] It is a cross-cultural and crosssocioeconomic phenomenon. 8 Geographical and cultural factors contribute to variability in symptom presentation and frequency. 9 At its core, it features persistent obsessions and/or compulsions. ...
Full-text available
Introduction While there is considerable and growing research in the individual fields of obsessive–compulsive disorder (OCD) and chronic pain, focused research into their potential association remains limited. By exploring this potential association, better theoretical understanding of and better therapeutic approaches to chronic pain management could be developed. The study’s aim is to explore the prevalence and impact of obsessions–compulsions on the experience and rehabilitation of chronic pain among individuals attending different branches of a New Zealand pain service. Methods and analysis This is a cohort study using well-validated questionnaires and semistructured interviews. Participants will be recruited through community pain services from a private rehabilitation-focused company with branches across New Zealand. Participants will complete an OCD screening measure (Obsessive–Compulsive Inventory-Revised (OCI-R)). These results will be used to compare results from the specialist pain services benchmarking electronic Persistent Pain Outcomes Collaboration measure sets, at both participant intake and completion of each Pain Service Programme. Prevalence rates of OCD caseness from the OCI-R will be estimated with 95% CI. Generalised linear regression models will be used to explore differences in pain baseline and outcome factors between those with high and low obsessive–compulsive symptoms. Semistructured interviews, assessed through interpretative phenomenological analysis (IPA), will be used to provide information on lived experiences of individuals with comorbid chronic pain and OCD. This will be supported through the administration of an Obsessive Beliefs Questionnaire 44. Ethics and dissemination Ethical approval has been obtained from the Health and Disability Ethics Committee (HDEC20/CEN/82). Study results will be disseminated at professional conferences and in peer-reviewed journals. A lay summary of findings will be provided to requesting participants or through attendance at a local hui (gathering). Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN12621000758808).
... Individuals with obsessive-compulsive disorder (OCD) consistently experience unwanted intrusions and intense fear and anxiety. OCD is characterized by recurrent and persistent thoughts and repetitive behaviors that cause significant distress (American Psychological Association, 2013; Williams & Steever, 2015). Given the difficulty of controlling anxiety, individuals with OCD find immediate relief in the repetitive performance of compulsions or rituals that end up increasing distress and reinforcing fear and avoidance (Van Noppen et al., 2006). ...
Full-text available
Background: Although culture can affect emotional and behavioral reactions, there is little research on the manifestations of obsessive-compulsive disorder (OCD) among Latinos. Previous studies using a fear extinction model with a non-Latino population showed that individuals with OCD have difficulty maintaining safety memories. Their neuropsychological performance has shown inconsistent findings. We compared Puerto Ricans with OCD and healthy controls on fear extinction retention, neuropsychological performance, and psychological self-reports. Methods: 17 healthy and 11 Puerto Rican adults with OCD underwent a fear conditioning and extinction paradigm using neutral visual cues that were paired or unpaired with an electric stimulus to elicit skin conductance responses. Neuropsychological tests (WCST,EST,MSIT) and psychological self-reports (BAI,BDI,STAI,PANAS,EDS)were administered. Results: OCD subjects did not show impaired extinction recall. However, they showed higher reaction times towards neutral than threat-related words on the EST, compared to healthy controls. No differences on neuropsychological tests that lacked emotional content were observed. OCD subjects showed increased symptoms of anxiety, trait anxiety, depression, negative affect, and emotional dysregulation. Conclusions: Puerto Ricans with OCD may have physiological and neuropsychological characteristics that are similar to healthy subjects, but a different psychological profile, which can be used to tailor cultural adaptations of evidence-based treatments for OCD.
... Sexual obsessions are extremely common in OCD worldwide (Williams & Steever, 2015), but these types of thoughts are considered taboo or embarrassing in most cultures. Thus, the stigma and shame attached to the experience of sexual symptoms of OCD are exceptionally distressing (Glazier, Wetterneck, Singh, & Williams, 2015). ...
Full-text available
This chapter provides an overview and framework for understanding race, ethnicity, and culture as factors that affect adult psychopathology. Of primary interest are the assessment and treatment of psychopathology that integrates culturally salient values, ideologies, and behaviors into the mental health care of ethnic minorities. Moreover, the chapter is organized into two sections. In the first section, we present a model that highlights relevant multicultural factors that should be considered when working with ethnic minorities. The second section provides a discussion of how to effectively apply the knowledge of these multicultural factors when assessing or treating individuals with diverse ethnic backgrounds. Ultimately, the main objective of this chapter is to encourage mental health professionals to acknowledge the impact of race, ethnicity, and culture on adult psychopathology in order to optimize the efficaciousness of mental health services provided to ethnic minority individuals.
... It has been proposed that this phenomenon is linked to their religion, in which purification and cleansing rituals play an important role [41]. In African American population, the compulsions linked to cleanliness may be relevant as this ethnic group historically has experienced segregation, and other groups avoided to be "contaminated" through direct contact with them [42]. ...
Full-text available
Background: The aspects of cultural identity and its impact on obsessive-compulsive disorder (OCD) have been understudied. There are different opinions, ranging from the idea that culture does not affect the symptoms of this condition to the idea that cultures with high religiosity may have more severity of OCD. Also, the concept of OCD has considerably varied across history and cultures, from being considered an issue related to lack of control of blasphemous ideas, and a part of anxious issues, to the description of complex neurobiological systems in its causation. Objective: The aim of this review was to address OCD as a well-characterized disorder with a proposed neurobiological basis which may or may not have variations depending on cultural diversity. The question that was asked in this review is whether or not there are cultural differences in the manifestations of the OCD symptomatology and which factors of cultural diversity have a major influence on such manifestations along with the differences among some cultures regarding OCD issues, where the difference among countries has also been highlighted. Methods: A review of the literature was conducted that includes the following words: obsessivecompulsive disorder, culture, cultural identity and religion in a period of 10 years. Conclusion: Cultural variations do not seem to differ from symptomatic clusters of OCD, which may be indicating that a series of adaptive behaviors is evolutionarily evolving to be constantly altered, perhaps by well-determined pathophysiological mechanisms. Some aspects that have been related to some dimensions of OCD symptomatology are religion and religiosity, affecting the content of obsessions and the severity of manifestations. Properly evaluating the education background, access to health services, food, and the genetic structure of populations, using investigational instruments sensitive to these cultural elements, will increase our understanding of the importance of culture on OCD and its treatment.
... Although OCD rates are generally invariant crossculturally (Himle et al., 2008;Karno et al., 1988;Ruscio et al., 2010;Williams & Steever, 2015;Zhang et al., 1998), there remains a paucity ofknowledge about the disorder in ethnoracial minority groups (Williams, Powers, et al., 2010). This could be due to underrepresentation of minorities in OCD treatment centers, a major source of symptom data for OCD research (Fernandez de la Cruz et al., 2015;Snowden et al., 1990;Williams, Sawyer, et al., 2015). ...
Full-text available
Obsessive-compulsive disorder (OCD) is a multifaceted and functionally disabling condition involving distressing obsessions and repetitive compulsions. Although OCD rates are generally invariant across U.S. ethnoracial minority groups, there remains a paucity of knowledge about the disorder in minorities. This could be due to underrepresentation of these groups in OCD treatment centers, a major source of symptom data for OCD research. Poor minority participation also suggests stigmatic cultural attitudes toward mental illness and related services, among other barriers to treatment, in these groups. Therefore, in this chapter, we review symptom presentation, various barriers to treatment, and possible cultural considerations for treatment of OCD in three ethnoracial minority groups in the U.S. (African Americans, Latino/Hispanic Americans, and Asian Americans). It is hoped that this chapter can help readers better understand how cultural norms can shape the experience of OCD, as well as influence help-seeking and treatment success in ethnic and racial minorities.
Objective To evaluate the reliability and validity of the traditional Chinese version of the Mild Behavioral Impairment Checklist (MBI-C) among Hong Kong Chinese with mild cognitive impairment (MCI). Methods A total of 172 participants were recruited from 2 community facilities. Cronbach’s alpha (α) was calculated to evaluate internal consistency. Intra-class correlation coefficient (ICC) was used to measure 2-week test–retest reliability. Construct validity was evaluated by conducting exploratory factor analysis to identify the internal structure of MBI-C, and assessing the correlation between theoretically related constructs, including objective and subjective cognitive impairment, neurotic personality, social supports, and maladaptive coping. Concurrent validity was assessed by its correlation with Neuropsychiatric Inventory Questionnaire (NPI-Q). Results The results revealed good internal consistency and test-retest reliability of the MBI-C. Item analysis identified 4 items with low item-to-total correlations. The EFA identified a seven-factor structure. Hypothesis testing identified its significant correlations with subjective cognitive impairment, neurotic personality, social supports, and maladaptive coping. Concurrent validity was supported by its significant correlation with the NPI-Q. Conclusions The traditional Chinese version of MBI-C is a valid and reliable outcome measure to assess the severity of neuropsychiatric symptoms of the MCI population.
Full-text available
Background: Obsessive-compulsive disorder (OCD) is a heterogeneous and debilitating illness. Symptom dimensions of OCD lend homogeneous avenues for research. Variations in one's appraisal of thoughts and emotions can influence symptom dimensions and impairment. However, little is known about the combined influence of these appraisals in OCD. A clear understanding of these relationships has putative treatment implications. Aim: The aim of the study is to examine the associations among obsessive beliefs, emotional appraisals, and OCD symptom dimensions in adults. Materials and methods: We examined 50 drug-naïve/drug-free adults with active OCD. Symptom dimensions and impairment were assessed using the Dimensional Yale-Brown Obsessive-Compulsive Severity Scale. Obsessive beliefs and emotional appraisals were studied using the Obsessive Beliefs Questionnaire-44 and Perception of Threat from Emotion Questionnaire. Results: Tobit regression analysis showed the differential association of obsessive beliefs and symptom dimensions - perfectionism/certainty associated with contamination and responsibility/threat estimation associated with aggressive obsessions. Impairment was associated with dimensional symptom severities and with the perception of threat from anger. This association remained even after controlling for depression severity and obsessive beliefs. Conclusions: OCD symptom dimensions are heterogeneous in underlying obsessive beliefs. Emotional appraisals contribute significantly to impairment alongside symptom severity. Emotion-focused interventions must be included in the psychotherapeutic interventions for OCD.
Full-text available
This study is an attempt to investigate the phenomenon of Obsessive Compulsive Disorder (OCD) in our culture. Initially, presenting symptoms of OCD were elicited from 20 firmly diagnosed clients through semi structured interviews. The symptoms were validated for their diagnostic relevance by 10 experienced clinicians. A final list of 27 symptoms were individually given to 113 OCD participants. The results showed that the most frequently reported obsessions were repetitive negative thoughts (97%), fear of developing mental illness (92%), indecisiveness (87%), and fear of germs (82%) followed by sexual thoughts (81%). The most frequently occurring compulsions were hand washing (90%), compulsive slowness (86%), counting (73%), checking (64%), and symmetry (53%). It was found that while the types of compulsions were similar to those reported in other studies, the form and the content of obsessions were seem to be influenced by social and religious backgrounds. The phenomenon of OCD is discussed in cultural context, its comorbidity and presenting symptoms.
Full-text available
At the Mexican Institute of Psychiatry (MIP) in Mexico City, which is a tertiary health care facility, we evaluated the age of onset, gender, severity, and other demographic characteristics in 71 affected patients. In the current study, males had a significantly earlier age of onset than females. Also, a significant negative correlation was found between total symptom severity (Y-BOCS) and age of onset (-0.31, p = 0.01, n = 61). Aggression obsessions were associated with a higher age of onset (29.5 ± 14.3 n = 9 vs 21.4 ± 7.7 n = 59, F6.56, p = 0.01) and symmetry obsessions with a lower age of onset (15.1 ± 4.0 n = 12 vs 24.1 ± 9.2 n = 56, F 10.8, p = 0.001). The compulsion subscale was higher in the presence of contamination and cleaning obsessions; and lower in the presence of agression obsessions. Current results are compared with the literature, and future directions of research are suggested.
Errors in Byline, Author Affiliations, and Acknowledgment. In the Original Article titled “Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication,” published in the June issue of the ARCHIVES (2005;62:617-627), an author’s name was inadvertently omitted from the byline on page 617. The byline should have appeared as follows: “Ronald C. Kessler, PhD; Wai Tat Chiu, AM; Olga Demler, MA, MS; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS.” Also on that page, the affiliations paragraph should have appeared as follows: Department of Health Care Policy, Harvard Medical School, Boston, Mass (Drs Kessler, Chiu, Demler, and Walters); Section on Developmental Genetic Epidemiology, National Institute of Mental Health, Bethesda, Md (Dr Merikangas). On page 626, the acknowledgment paragraph should have appeared as follows: We thank Jerry Garcia, BA, Sara Belopavlovich, BA, Eric Bourke, BA, and Todd Strauss, MAT, for assistance with manuscript preparation and the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on the data analysis. We appreciate the helpful comments of William Eaton, PhD, Michael Von Korff, ScD, and Hans-Ulrich Wittchen, PhD, on earlier manuscripts. Online versions of this article on the Archives of General Psychiatry Web site were corrected on June 10, 2005.
Perceptions of psychological symptoms may be influenced by religiousness, particularly when symptom presentation is shaped by a socio-religious context. We therefore examined whether among Jews, Orthodox affiliation was related to recognition of scrupulosity as obsessive compulsive disorder (OCD). Seventy Orthodox and 23 non-Orthodox Jews were randomized to view one of two matched vignettes describing religious or non-religious OCD. Whereas Orthodox Jews were equally likely to recognize both vignettes as OCD, non-Orthodox Jews were less likely to recognize the religious than the non-religious presentation as OCD. Furthermore, Orthodox Jews were equally likely to recommend professional treatment for both scrupulosity and non-religious OCD, whereas non-Orthodox Jews were less likely to recommend professional treatment for scrupulosity compared to non-religious OCD. These findings may suggest that familiarity with Orthodox practices increases sensitivity to distinctions between scrupulosity and normative eligion, thereby increasing recognition of the need for professional treatment.
Although sexual obsessions in obsessive-compulsive disorder (OCD) are not uncommon, obsessions about sexual orientation have not been well studied. These obsessions focus on issues such as the fear of being or becoming gay, fear of being perceived by others as gay, and unwanted mental images involving homosexual acts. Sexual orientation obsessions in OCD are particularly distressing due to the ego-dystonic nature of the obsessions and, often, stigma surrounding a same-sex orientation. The purpose of this study was to better understand distress in people suffering from sexual orientation obsessions in OCD. Data were collected online (n = 1,176) and subjects were 74.6 % male, 72.0 % heterosexual, and 26.4 % with an OCD diagnosis from a professional. The survey consisted of 70 novel questions that were assessed using a principal components analysis and the items separated into six components. These components were then correlated to distress among those with a prior OCD diagnosis and sexual orientation obsessions. Results indicated that sexual orientation obsessions in OCD were related to severe distress, including suicidal ideation. Implications of these findings and future directions for research are discussed.
Cultural themes focusing on race-related issues and religiosity were identified via content analysis in the delusions and hallucinations of a sample of 118 African American psychiatric patients. The purpose of the study was to determine whether cultural themes in psychotic symptoms influence the diagnosis from different sources (i.e., chart, SCID, and best estimate) of schizophrenia for Black patients. It was hypothesized that the best estimate diagnoses of cultural experts would diagnose schizophrenia in African Americans more frequently when they exhibit race-related themes in their psychotic symptoms. It was also hypothesized that diagnosis of the paranoid subtype would yield a stronger difference among the sources than the broader category of schizophrenia. The results did not support the hypotheses. Implications for understanding the relationship between culture and psychosis among African Americans are discussed.
Previous research has documented that ethnic minorities, particularly Latinos, obtain fewer mental health services than Caucasians (Kearney, Draper, & Baron 2005; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Conceivably, this may be due to a wide array of cultural issues (e.g., negative stigma attached to mental health, and language, socio-economic, and acculturation barriers), symptom disparities across Caucasian and Latino groups, or lack of effective outreach methods by clinicians and researchers. However, research is limited. As a result, Latinos may be insufficiently represented in clinical studies for OCD, making it unclear whether evidence-based treatments demonstrate the same efficacy and effectiveness for Latinos as has been demonstrated for Caucasians. The current study takes an in-depth analysis of 98 efficacy and effectiveness studies for OCD from across the Western hemisphere and reports the rates of Latino inclusion from each sample. Ninety clinical studies in the US and Canada, as well as eight clinical studies in Mexico and Central America were reviewed. Findings showed that only 11 (24%) US and Canadian studies included Latino participants, illustrating an overwhelming underrepresentation of Latinos in clinical studies for OCD. Further explanation of the results and their implications are discussed, along with suggestions for effectively improving access to mental health research and appropriate treatments.
This study compares the presentation and expression of obsessive-compulsive symptoms between a Latin-American and North American sample. In Costa Rica (CR) and the United States (US), respectively, 26 and 52 affected individuals with early-onset obsessive-compulsive disorder (OCD) were recruited. The Yale Brown Obsessive Compulsive Scale (YBOCS), a semi-structured psychiatric interview, and self-report questionnaires were administered. Age of onset and the distribution of OCD across men and women were similar across groups. Both CR and US participants reported obsessions and compulsions, with similar frequencies of symptoms, and contamination, symmetry, and hoarding as the most common symptom subtypes. The US sample had higher YBOCS total severity scores than the Costa Rican group. Similarly, there were significant ethnicity effects for YBOCS compulsion [F(1, 70)=17.88, P<.001] and obsession severity [F(1, 70)=8.78, P<.001], with Caucasians having higher scores than Costa Ricans on both subscales. Comorbidity rates were higher for US Caucasians than Costa Ricans for all disorders; differences were significant for mood disorders [64.7% versus 34.6%], alcohol use [21.3% versus 3.8%], cannabis use disorders [19.1% versus 0%], and other substance use disorders [39.4% versus 0%]. Regression analyses revealed that ethnicity, trait anxiety, and proband status were the only significant predictors of total YBOCS severity. Findings suggest that the core phenotype of OCD is the same in both CR and the US, and perhaps biologically driven. However some features of OCD, such as impairment, may be culturally influenced, leading to differences in prevalence rates and treatment utilization. Depression and Anxiety 0:1–11, 2007. Published 2007 Wiley-Liss, Inc.
Background: Several studies have identified discrete symptom dimensions in obsessive-compulsive disorder (OCD), derived from factor analyses of the individual items or symptom categories of the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC). This study aims to extend previous work on the relationship between obsessions and compulsions by specifically including mental compulsions and reassurance-seeking. Because these compulsions have traditionally been omitted from prior factor analytic studies, their association to what have been called "pure obsessions" may have been overlooked. Method: Participants (N = 201) were recruited from two multi-site randomized clinical treatment trials for OCD. The YBOCS-SC was used to assess OCD symptoms, as it includes a comprehensive list of obsessions and compulsions, arranged by content category. Each category was given a score based on whether symptoms were present and if the symptom was a primary target of clinical concern, and a factor analysis was conducted. Mental compulsions and reassurance-seeking were considered separate categories for the analysis. Results: Using an orthogonal geomin rotation of 16 YBOCS-SC categories/items, we found a five-factor solution that explained 67% of the total variance. Inspection of items that composed each factor suggests five familiar constructs, with mental compulsions and reassurance-seeking included with sexual, aggressive, and religious obsessions (unacceptable/taboo thoughts). Conclusions: This study suggests that the concept of the "pure obsessional" (e.g., patients with unacceptable/taboo thoughts yet no compulsions) may be a misnomer, as these obsessions were factorially associated with mental compulsions and reassurance-seeking in these samples. These findings may have implications for DSM-5 diagnostic criteria.