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  • CULTURAL FACTORS INFLUENCING CONTENT

    OF DELUSIONS AMONG SCHIZOPHRENIC

    PATIENTS IN SAUDI ARABIA

    A thesis submitted for the degree of Doctor of Philosophy

    (Psychology)

    by

    Fatma Mohammed ALNzawi

    School of Social Sciences

    Brunel University

    July 2012

  • ii

    Abstract:

    The present study aimed to investigate the influences of socio-cultural context on

    content of delusions within schizophrenic patients among three different geographical

    areas in Saudi Arabia and to estimate the prevalence of schizotypal personality within

    the non-clinical Saudi population. Methods: 148 patients meeting DSM-IV criteria of

    schizophrenia were drawn from in-patient sections of mental health hospitals in three

    areas of study (Riyadh, Jeddah, and the Eastern Province), and 364 participants were

    recruited for comparison groups from Saudi universities and general medical practices

    in the same areas. The study utilized the following instruments: Scale for the

    Assessment of Positive Symptoms (SAPS), Scale for the Assessment of Negative

    Symptoms (SANS), the MacArthur-Maudsley Delusions Assessment Schedule

    (MMDAS), the World Health Organization (WHO) Life Events Schedule, the

    Aetiological Beliefs Questionnaire (ABQ), and the Schizotypal-Personality

    Questionnaire (SPQ). Results: Firstly: there were significant main effects of residence

    and sex on the three dependent SPQ scales, and females and Riyadh area residents

    scored higher on all dependent SPQ scales especially on the cognitive scale. Secondly:

    persecutory delusions were the most common delusions among schizophrenic patients

    followed by delusions of being controlled, and the frequency of persecutory delusions

    was significantly higher in females and in the Riyadh area. Thirdly: only delusions of

    jealousy were specifically associated with violent behaviours among schizophrenic

    patients. Finally: ABQ showed that both supernatural and psychological explanations of

    illness were common among both control and clinical groups. Qualitative analysis of the

    content of delusions revealed socio-cultural and gender-related issues that were strongly

    reflected in the themes and content of delusions. Conclusion: Content analysis of

    delusions in a Saudi schizophrenic sample showed strong effects of the socio-cultural

    context and stress points such as racism and gender inequality, and gender and regional

    culture affected both the frequency with which persecutory delusions were observed,

    and the mean scores of schizotypal personality in a non-clinical sample.

  • iii

    Content

    Chapter 1: schizophrenia and delusions……………………………………………... 9

    Schizophrenia and delusions: a review of the literature.

    Schizophrenia…………………………………………………………………………... 9

    Schizotypal personality……………………………………………….……………….. 11

    Possible socio-cultural influences on mental health in Saudi Arabia…………………. 14

    Problems with the definition of delusions…………………………………………….. 16

    The explanation of delusions:……………………………………………………….. 18

    1-Social Attribution Explanations of delusions………………………………………. 19

    2- Belief-negative and belief-positive models………………………………………… 21

    3- Anomalous experiences and anxiety……………………………………………..… 22

    4- Delusions as a result of depression and low self-esteem and as a defensive

    mechanism…………………………………………………………………………….. 24

    5- Delusions as a result of trauma and childhood abuse………………………………. 27

    6- Delusions as a result of a cognitive defect…………………………………………. 29

    Cognitive Bias………………………………………..……………………………….. 29

    Reasoning Bias (Jumping to conclusion JTC)………………………………. 31

    Theory of Mind (ToM)………………………………………………………. 33

    Attentional Bias……………………………………………………………… 37

    Cognitive neuropsychological explanations…………………………………. 38

    Neurologically – inspired theories…………………………………………… 40

    The effects of content of delusions on the patient's life…………………………… 42

    Chapter 2: influence of cultural context and demographic variables effects on

    psychotic symptoms:…………………………………………………………………. 45

  • iv

    The effects of cultural and social factors on mental illness……………………….. 45

    The effects of cultural and social factors on schizophrenia symptoms.………….. 47

    The cultural influence on content of delusions…………………………………….. 50

    Studies on variation in the content of delusions across-culture………………...… 53

    Studies on content of delusions within cultures and subcultures………………… 57

    1- Studies in the UK………………………………………………………………….. 57

    2- Studies in the USA……………………………………………………………….... 59

    3- Studies in Saudi Arabia………………………………………………………….... .61

    4- Studies in south and south-east Asia…………………………………………......... 62

    The Cultural Background for the Research……………………………………….. 66

    General overview of geography and history of the Kingdom of Saudi Arabia:… 66

    1- The Central region (Najd)………………………………………………………….. 67

    2- The Western region (Hejaz)………………………………………………………... 67

    3- The Eastern Province………………………………………………………………. 68

    Cultural differences between Saudi regions……………………………………….. 70

    1- Family system, women’s role and socialization…………………………………… 70

    2. Marriage and polygamy in Saudi society…………………………………………... 71

    3- Privacy……………………………………………………………………………… 72

    4- Etiological beliefs concerning illness………………………………………………. 73

    The study questions…………………………………………………………………… 73

    The study importance and aims……………………………………………………… 75

  • v

    Chapter 3: Methods………………………………………………………………….. 77

    The participants………………..…………………………………………………….. 77

    The instruments:..……………………………………………………………………. 78

    1- The World Health Organization (WHO) Life Events Schedule………………….... 78

    2- Scale for the Assessment of Positive Symptoms (SAPS), and Scale for the

    Assessment of Negative Symptoms (SANS)…………………………….………….... 83

    3-The MacArthur-Maudsley Delusions Assessment Schedule (MMDAS)…………... 86

    4- The Aetiological Belief’s Questionnaire (ABQ)…………………………………… 89

    5- Schizotypal- Personality Questionnaire (SPQ)…………………………………….. 90

    Chapter 4: Study 1The influence of residence area and sex on Schizotpy scores in

    the Comparison group………………...…………………………………………….. 93

    Introduction………………………………………………………………………….. 93

    Method:………………………………………………………………………………..94

    Design………………………………………………………………………………… 94

    Participants……………………………………………………………………………. 94

    Materials………………………………………………………………………………. 95

    Procedure……………………………………………………………………………… 95

    Reliability analysis……………………………………………………………………. 95

    Results:……………………………………………………………………………….. 96

    a) Demographic characteristics of the sample……………….……………………….. 96

    b) Factor analysis of SPQ ……………………………………………………………101

    c) Variation in schizotypy scores.………….………………………………………... 103

    Discussion…………………………………………………………………………… 109