Tuesday, October 28, 2008


"Mechanic and Volkart (1961) define 'illness behaviour' as 'the way in which symptoms are perceived, evaluated and acted upon by a person who recognizes some pain, discomfort or other signal organic malfunction'."

"In a pioneering study conducted in New York, Zborowski (1952) found that patients of Old-American or Irish origin displayed a stoical, matter-of-fact attitude towards pain and, if it was intense, a tendency to withdraw from the company of others. In contrast, patients of Italian or Jewish background were more demanding and dependent and tended to seek, rather than shun, public sympathy."

Donald L. Patrick & Graham Scambler. (1982) Sociology as Applied to Medicine. London: Bailliere Tindall.

I felt I should go home after I ended my work late that afternoon but I thought about having a rest for few minutes in the hospital's garden. Patients took their rest either in the television hall where they usually keep silent, or in this garden. I like to see how they act in the garden. I was shocked many times before of how some patients look very different in the garden than in the examination room. What I liked the most in the garden is that they don't care about my existence and act the way they like.

That day I found an old lady burping frequently. She drew my attention with her frequent loud widely opened mouth burps. She was sitting on the ground with a bottle of something next to her. When I sat I tried to know what the bottle contains. It is something brownish. Is it soil and water? I asked myself, couldn't be! I answered myself. The woman took the bottle and drank from it. After that she vomited many times. I looked around and saw her family, a man and three young women sitting just on the other side of the garden and asking her to join them, but she was not answering. One of the young women went and sat next to the old lady who continued to do the same. She must be psychotic, I said to myself. And that must be a bottle of soil mixed with water. God help me.

They did not stop her from drinking from her bottle. Instead, one of three women was giggling while looking at me. That giggling woman, maybe her daughter as I supposed, is knowing what is going in my mind and laughing at my panic wide opened eyes. This giggling woman seemed the only one who understood that this is wrong. Maybe she knows that it is better not to interfere. She is maybe the only educated woman in her family. She may be tried to change their way of behaving before but in vain. Now she giggles at my surprise of her family dynamics she may be aware of.

I felt annoyed. We are in a hospital and we should not allow this to happen.

Something told me to be cautious. The giggling woman seems examining what I would do.

Something told me that this maybe a traditional healing method. So I should show them some respect while asking them to take the bottle from her. I decided to go to her first and have some talking to see how she would respond.

- My stomach, doctor. Or wait, you call it something, ehhh colon? (she said while putting her hands on her upper abdomen area)
- Yes, colon. (I said while I was now sitting in a chair near her).
- Yes, colon. Food poisoning. I am a case of food poisoning.

Her reaction to me was very normal. Her reaction was a mixture of being surprised about me asking about her health, showing respect to a young inexperienced doctor (or is he a student? Or a nurse? Or what? He'd better be a doctor or I would burp in his face), silence and waiting to see what will come next.

Totally normal.

She didn't feel shy from her burping, vomiting, her bottle, or sitting on the ground. She is not shy either because she is ill and do not have space in her mind to shyness at time being, or because she is just behaving culturally normal. Well it is a little mixture of both.

Being poisoned by food to any naïve psychiatrist would mean the patient may have persecutory delusions. But I felt this lady is not psychotic.

- What is this? I asked.

- It is soil taken from near Imam Al Hussain grave dissolved in water. (she said that while her eye contact was lost. She is now looking at her feet. Moving her toes. She was saying to me something like "you'd better go now young man, I am little ill for this conversation" but maybe I was wrong cause she looked at me again and added): people say it helps to heal many diseases (a shadow of a smile around her eyes).

And oops, the old woman's behavior seems to be clearer now. But to be sure I asked her if she is an inpatient. She said that she is a mother of a new patient that had just entered the women ward. I looked at the three women. That woman is still giggling. Still looking at me. From a small opening in her Abaya (= a traditional woman dress) I saw her holding red, purple, and yellow pieces of clothes which seemed to be woman's underwear. He father was examining me. His eyes were far but I knew how sad he was. The giggling continued.

- Do you want me to bring you any medications Youm? (Youm= Mom).
- No, son thank you for your care, I will be ok in few minutes. (She nodded her head with a slow and clear up and down movement which means "we are grateful").
- Ok mom, sorry to disturb you, just try not to drink much from this bottle now, I think you drank too much till now, anyway…. (I stood, took a breath)… it is up to you…you know….
- Yes….I understand
(Her smile is clearer now, still a bitter smile).

I went walking slowly to my previous place while the daughter whom I thought was the only mindful aware woman in the family was giggling while looking at me.

Monday, October 27, 2008

shaking hands

"In Italy, expressive movements of the hands are a natural accompaniment of speech and certain standard verbal expressions are accompanied with gestures…."

"In English, on the other hand, the use of the hands in speech is considered to be vulgar…"

"The wide expansive gestures and cheerful mien of the mildly happy Neapolitan would be indicative of mania if seen in an English public-school 'man', who may allow a flicker of a smile on his lips if pleased".

Fish (1985) Clinical Psychopathology. Bristol: Jon Wright

He put his right hand on his chest after we shake hands. That was strange for me. I didn't like the movement. I thought he should stop doing that. We are in Baghdad and not in his city. He should follow our ways of behaving. Why is he insisting on that? I never put my hand on my chest for all the first year we knew each other in 1996 while we were students in the first year in college. He, on the other side, kept spreading his long fingered hands on his chest after we shake our hands with smile on his face that seemed to me that it was getting wider and wider while my anger on this gesture was getting darker and darker. After all he was the one that I chose to befriend. We decided that we meet before our second year in the college would start. He offered that we go to Al Najaf to visit Imam Ali grave. I accepted happily. We went to find his friends waiting for us. The Imam was so crowded to a degree that I felt hemmed in. I went out fast. To my surprise they all came to me worried about me and asked what was wrong. I told them it is so crowded. They said they are sorry they brought me in this crowded hour, and that they should knew this before. I was shocked by their kindness. I didn't expect that from them. They are religious. I expected them to be mad on me. To be angry on me. But they started to go outside offering to go and have lunch. I stopped stunned and asked them to go and do their prayers. I told them I like to wait outside looking at the golden shrine from outside. They said that I am a guest and they should not leave me. So we went to have lunch in one of my friend's friends' houses. Before lunch was complete they wanted to pray together. They asked me if I want to pray. I said: "yes!" and you know what? They asked me to be their imam in the prayer. That means I stood in front of them and do the prayer in loud voice and slow movements and they follow my movements while hearing my prayer. I said no way. They said that I am their guest. My friend told me that if I don't want to pray I can just say that and they would pray without me, but if I want to pray, I should be the Imam. I agreed. I start doing the prayer in front of them and they follow my movement and the slow modulation of the Holy Quran. I ended it, looked at them, I felt there was something wrong. They didn't speak. At lunch, my friend said: "Sami, when you are in a journey and want to do a prayer, you prostrate only twice".
I stopped eating looking widely into their faces. I thought they would be so angry on me. But they were suffering to hide a laughter. But my friend, the religious, added with a serious tone: "you did four prostrations."
"I am not in a travel", I said and added: "I am in my home with these lovely friends".
They did not welcome this remark. They just acted as if nothing happened. They started to speak to me about other things but religion. They knew that I am a good person, just not that religious. Their kindness was strange for me. I thought that my behavior would make them angry on me. But they were wiser than to be angry on me. I felt they were older than me. They were calmer and seemed more experienced than me and my Baghdadi friends. When me and my friend were leaving they all shake hands with us. They put their hands on their chest. And for the first time in my life, I put my hand on my chest after shaking hands. while we were on our way home, while over the Euphrates river which I saw for the first time and see that it is more calm than Tigris in Baghdad, I asked my friend why some put their hands on their chest?
"Not on the chest" he said, "it is mainly on the heart. It means you are in my heart".
Since then and I love to put my hands on my chest after I shake hands.

Sunday, October 26, 2008

Allah Bil Khair

Culture is learned ways of acting and thinking, which are transmitted by group members to other group members and which provide for each individual ready made and tested solutions for vital life problem (walter,1952)
(Cox J.L.(1977). Aspects of transcultural psychiatry. British Journal of Psychiatry. 130,211-212)

Allah Bil Khair means literally "God with good". It is the commonly used short version of the original version which means "May God makes your evening full with good". It is the used greeting in traditional cafes and other man social gathering in Iraq. Used by men more often. I have never heard a woman saying "Allah Bil Khair" only when trying to use it its other meaning. Its other use is to mean "are you with me?" so if somebody talks to you and you seem not listening s/he may say: "Allah Bil Khair!?"

My father told me once his story with "Allah Bil Khair". He didn't like it, he said. He liked to say "good evening". It is short, nice, informative, understood, with no religious flavor. Why should God be inserted into our daily life, into our greeting? My father explained. But as my father graduated from university he had to work in a village named "Khirnabat". The road to Khirnabat was unpaved by then. The village was full of scorpions as they told my father by then. It was my father's first trip away from home. He was advised to sleep in a bed with long feet and to put rat poison around the bed feet so that no scorpion would go up to him. He worked for few hours in the morning, but he spent all the other time in his room, as he told me. One day, he felt hemmed in. He needed to go out. He went walking, found a café, went and sat down between the men of the village. The men went silent for some moments. My father felt frightened as he said. The silence became so intense that he felt he is unwelcomed till somebody raised his right hand in the air, looked at my father, raised his body from the chair a little and said: "Allah Bil Khair". My father raised his right hand, raised his body a little from the chair and said with a wide smile: "Alla Bil Khair Akhouya (=brother)". Other men started saying "Allah Bil Khair" to my father after that welcoming him among them. The silence did break into an atmosphere of warm welcoming. My father said to me: "It was only by then that I finally understood what Allah Bil Khair means!"Since then and I love Allah Bil Khair.

The first picture above "a man with a narjela" is one of my father's paintings. The second is taken from the web as a picture representing an old Baghdadi cafe named "Khan Jkhan".

Saturday, October 25, 2008


"Your eyes are two palm tree forests in early light,

Or two balconies from which the moonlight recedes

When they smile, your eyes, the vines put forth their leaves,

And lights dance . . . like moons in a river

Rippled by the blade of an oar at break of day;

As if stars were throbbing in the depths of them . . ."

It was so dry. I have never lived in such an environment. Iraq is changing in its weather for sure. Dust storms were very frequent last summer. And it was a matter of discussion between Iraqis everywhere. Many have proposed some theories about it. Those who are satellite dish addicts always propose global warming as a cause. Some would add to the global warming more CO2 excreted from the old cars and electricity generators which all entered Baghdad in increasing amounts after 2003. Those who are less satellite dish oriented would often raise the possibility of the deterioration of agriculture in Iraq as a cause of leaving the land uncovered with plants, hence wind will easily take the unsupported soil and make a dust storm with it.

"And they drown in a mist of sorrow translucent

Like the sea stroked by the hand of nightfall;"

I quit cleaning some parts of my house. Especially those not that frequently used. But a little by little the neglect extended his dirty hand over most of my house. Water shortage encouraged me to leave things take the shape they want to be. And on the last few days I started to neglect my shape. My hair is always the first thing to be neglected. My clothes come next.

"The warmth of winter is in it, the shudder of autumn,

And death and birth, darkness and light;

A sobbing flares up to tremble in my soul

And a savage elation embracing the sky,

Frenzy of a child frightened by the moon."

If you type "rain in Baghdad" in the google search you will have the first results talking about "bombs rain in Baghdad" or "rockets rain in Baghdad". How ugly!
If somebody knows that bombs had rained in Baghdad, then he should know that badr shakir al sayab had wrote "the rain chant" or "rain song", one of the most famous pioneer poems of the new school in Arabic poetry. A school named "the free association school" of poets, where the lines can go with no rhymes. Lines with some musical rhythm.

"It is as if archways of mist drank the clouds

And drop by drop dissolved in the rain . . .

As if children snickered in the vineyard bowers,

The song of the rain

Rippled the silence of birds in the trees . . .Drop, drop, the rain


Drop the rain"

Today it rained generously. I felt energetic. I could not resist the idea of going outside. I watched the rain silently. It washed the depression dust away offering me a new day. I will go clean my house now.

The poet in italic fonts is part of badr shakr al sayad's "rain song" translated by Lena jayyusi and Christopher Middleton and published completely at the web site: http://www.jehat.com/ar/sayab/sub6e.htm

Wednesday, October 22, 2008

In search for my Rosalie

He left his North African home in search for a better life in Europe. He got older and knew that he is in love with Rosalie. Rosalie, that lady living in that Mediterranean city lying between the west and east, between north and south. When he reached that city he found that there is no such a woman. All those who he thought they knew her once upon a time denied knowing a woman with that name. He kept searching till, little by little, started being paranoid. A delusion started to be formed.
Writing about a delusion, while being formed, is really difficult. Reading about that is frightening.

"I suspected her long eye contacts. Her eye brows contain white hairs. Her blinking is so frequent when our eyes met and a slowly developing smile always draws my attention to her lips. Her calm is the rule. She can calm me just by her slow walking. She was the only one to tell me: You are not well these days! She didn't ask why. I knew she didn't want me to comment. A smile was a defense against a threatening tear. The silence was so long. She is wise enough to know how silence can intense our feelings. She may say something and then feel guilty. I may say something bad enough. So she broke the silence and said in a whisper : if you like I got a new white coat, I will borrow it for you today so that you can continue your work, you give me your white coat I will clean it for you if you like!"

Hasouna Musbahi's novel "Adieu Rosalie" is boring at the beginning. You feel that he just writes everything. Things are not going into any order. No clear aim. No clear message, but a tasty flow of memories. You will feel there a man from North Africa telling you about his memories. You would listen, don't you? But he is not that man that I can like. He disappointed his family. I was going to my job one morning when I reached the lines talking about his father's death and how he visited his family. I was going to job carrying my headache over my head, while the nostalgia to my family rests so wide in my heart, and Hasouna Musbahi's novel in my hands. He told me about that day he visited his family after a long period out of home. He made me angry that day on his irresponsibility. He likes Albert Camus's novel "the stranger" and thinks that he learned to be cold and unreactive, a way he took it as model to follow. What can we learn in our era from Albert Camus? To believe the world is meaningless? Absurd? And then?

"she avoids my eye contacts. Her eye brows are so slim and small. Sometimes I suspect she has any. When we meet our voices deepen. We can feel each other having shortness of breath. She is not calm as she wants us to think of her. She is hiding untold stories God only knows since her husband had been a martyr of his ideas. When we met finally after those years she asked me: Is there any thing new?"

Some writers want to write "naked truth". Being "true" to a degree that is "naked" is not that good. It destroys our defense mechanisms. It can help some people sometimes in their life, but it seems stupid to take it as a model to follow through one's life.
So was Hasouna Musbahi's novel talking about meaninglessness and absurdity? Yes, in some of its lines. So what did I like in it? And why did I keep taking it with me in the minibus to my work for five consecutive days?
In its first part I liked his memories about his homeland (Tunisia?) mixed with his anxious diaries in his second home? (Germany?). No strong sense of identity of the main character Mr. Meloud can be felt in the novel. His emotions are continuously burning and in many times is theatrical. He fell in his great love stories from the first sight.

"The first thing to attract your attention to her is her long blond hair. Her nose is a God's masterpiece. Her lips were telling me something. She told me about him. She complained about him. He took her breath away she said. I didn't think I would be so silly to fall in love via yahoo chatting. So silly to fall in love again. I thought I can control it by reading what Ellis had said about love. He said it is deliberate. Then let us stop deliberating. Love from a first sight is a big lie. Let us be mature I said before I sleep. But when at 4 a.m. a table lamp fall on my forehead, I woke up and asked her: Why?"

I wasn't in the mood maybe to welcome Mr. Meloud's personality which was talking to me daily in the morning while I take the minibus in my one to one a half hour journey from my home to work. My sleep is not that good these days. My mood is not that clear. My behaviors is not that social. And Mr. Meloud is accompanying me in the minibus while a go to my work each morning. Did I like Mr. Meloud? Am I denying some shared characters between me and him? I don't think so.

"I got a great respect to women with depression. And if they hide it with a smile, if they struggle to hide the tear, I will easily fall in love"

The second part of the novel starts with that journey to the south of the Mediterranean searching for Rosalie and her Motel. Psychic suffering started to be expressed in immature defenses like projection and denial to end up in delusions and disturbed behavior. I felt finally that Hasouna Musbahi is a professional? writer because he was talking to me with the mouth of Mr. Meloud who lost his insight writing his diaries in a disorganized manner that let me feel indirectly, and a little late, that he is psychotic.

"She had psychosis when I was just a teenager. I thought I can understand. I thought I can help. I don't know what happened. All I know is I was way too much wrong."

There is no such a woman named Rosalie, nor anybody did hear of her motel. And Mr. Meloud is thinking that everybody is in a conspiracy against him to hide Rosalie from him. A novel that I hated to a degree that is strange.

Tuesday, October 21, 2008

strawberrian shadow

I never wanted to publish a name of a person without telling him/her in advance. But how can I meet her now? What life had done to her? Where is she now? Is her huge crowded family house still there? Is that Grindeizer big poster still hanged at the back of one of her many brothers room door. Were all those children in that house her sisters and brothers? They were all welcoming her back with great happiness. When we took her to her home I felt that her sisters, brothers and parents were waiting us to go so that they can really welcome her, embrace her, and ask her about the days she spent in our house.
We were taking her to her home every two weeks as far as I can remember. She spent few days there, less than 3. And we go back there to bring her. Was she going sometimes to her home on her own? Did she comeback someday on her own? I cannot remember. I was just a child below 6 years. Wasn't at school yet. My parents had to go to their work. She must come to take care of me and my young sister in their absence. She used to take care of my baby sister but I was treated differently. I knew that she was not a physical beauty since I first met her. I remember that my female cousin did not like her. I was treating my cousin as my older sister.
One day we were examining our stamps together. There was a series of stamps telling the story of Jesus. They were stamps from the United Arab Emirates. I asked:
- Who is this?
She started to tell me about him. She wanted to say more and more but wasn't encouraged by some as I can remember faintly.
So when the other day my cousin invented that rhyme and told me to sing it to her I felt so happy to annoy her. A wicked evil smile draws itself in our faces, me and my cousin.
I still remember how she just came inside smiling when I, in the existence of my silent cousin, stood and sang: "Mariam Al Athraa, tateer fil sahraa" (mean: the Virgin Mary, is flying in the desert). I felt while I said that that my cousin, who was behind me, went to the kitchen down casting her head hiding a smile , while her….she looked at me with a wounded look, turned as fast as she can, my smile faded in my childish stupidity, she walked, she run out of the door she just came in from, my heart sank in a newly discovered sorrow, I could see her face crying, my eyes opened wide in a stunted feeling of guilt, fear, sadness, and anger mixed all together in my growing brain.
I asked her for forgiveness. She accepted to forgive me after just saw how I looked so sorry. I loved that Christian girl, I discovered for the first time that my cousin can make terrible mistakes; I knew that I can take another point of view different from my cousin's.
I even stopped telling my cousin about what happens between her and our boy neighbor who loved to talk to her under that huge strawberry tree shadows. And we started to have some secrets. I was against her frequent increasing meetings with that boy. She felt annoyed because I was so alert on her. My cousin was asking me more and more intensely about those meetings under that tree. I was becoming more silent and angrier on her when she went to meet him. She used to wait for him sometimes behind the nearby fence. I used to become irritable and start making some actions to annoy her. She told me then about that "STAR WAR" thing. She claimed that a war will happen between the stars and that the whole universe will explode and all of we will die. She knew how afraid I felt. She kept telling me that till her boy came. And since then, every time I tried to annoy her when she waits for him she would start talking about that STAR WAR.
Our alliance started to be threatened by the continuous interrogations done by my cousin with me, trying to make me confess. Till one day something happened and those meetings were stopped by themselves. I confess to my lady about the secret talking between my parents about her. They were not happy about the way she acts. I did feel how sad she felt. It was Iraq-Iran war, the weather was gloomy, and lights in our silent small house were faint. I took the stamps and told her to tell me the story again….
One day she told me:
- Oh I miss Sami.
- Sami? (I said smilingly confused).
- Yes, I love him.
- Who is he? (I asked annoyed).
- Sami our neighbor.
- …….(if I was sitting, then I think I stood up).
- He got huge muscles, his biceps is the biggest I ever seen.
- I got muscles too, see!!!
- Naaa, his muscles are of a man, you are still a kid (she said that and laughed as far as I can remember).
She didn't repeat that "Sami" story very often. A fact that made me hope that this was a faked story.
- We had taken you many times to your home.
- Yes, how much I miss my home.
- And I can remember that poster of "I am a disco dancer".
- Yeah, how much I like this film, Indian films are really romantic.
- I can remember I saw the hero wearing a red clothes in his head.
- Yeah.
- I can remember the picture of Grindizer in your brothers' room door, and I can remember your brothers' names.
- And sister?
- And sisters' names too. But there is something I cannot remember.
- Which is? You big rememberer?
- I cannot remember a man named Sami in your neighborhood.
She felt sad. I felt great. After a while I was sad too. I asked my father to accept that we play that cassette in his huge JVC recorder. He agreed. "I am a disco dancer" started its dancing rhythm and she agreed to dance with me again that day.

Wednesday, October 15, 2008

Presentaion of Depression in Iraq

I am in my final year of my study. To fulfill the criteria of fellowship to the Iraqi board of psychiatry, I should do a research. I have chosen I subject I found myself fond of, cross-cultural psychiatry. "presentation of depression in Iraq" or "symptom profile of major depressive disorder in Iraqi patients" is the title of my thesis. I have gathered till today about 65 patients. It is time to start writing the introduction. It is not easy at all. I have changed it many times since I have started writing it before 2 days. This is my introduction as I chose to make it today. Please I would feel grateful if any got an idea to make it better. I started before two days only and I want my introduction to be much longer than this, but this will stay, as I think, the main skeleton on which I will add.


"Depression is one of today’s most common, and most commonly misdiagnosed, psychological illnesses."

Gorden Parker, Dealing With Depression

"90% of DSM-IV categories are culture-bound to North America and Western Europe"(1)
A drowning shirt in Al Rashad hospital:

Depressive illness is common, painful, and dangerous. Untreated depressive illness can lead to personal, familial, and social disasters. Depression can be lethal. The ability to recognize depression may be a matter of life or death. Failure to recognize depression is a global problem.

Depression involves a different combination of symptoms and reveals itself in slightly different ways. Different authors have commented on different aspects of these disorders, and variations in their incidence, symptomatology and course have aroused widespread speculation regarding possible cultural influences on aetiology and clinical picture.

Socio-cultural aspects

A rosy neglected jacket in Al Rashad hospital

Mental illness is called generally as "Jinoon" in Arabic. A word that is derived from the word "Jin" which refers to supranatural beings believed to have the ability to possess a human.
Cases of "possession" are said to be less common in western countries. It seems that there is a negative relationship between civilization and reported cases of "possession". If you work as a psychiatrist in Iraq these days, you will still be able to see some of those "possession" cases. Unfortunately there is no recorded prevalence rate of such cases. More commonly you will encounter different cases of various mental illnesses that will attribute their illness to a "possession".
There is a belief that a man or a woman who unwittingly steps on a Jinni (Bazzouiand Al-Issa,1966) or across his path is seized by this particular spirit in act of revenge manifesting itself in manic or depressive states, depending on the nature of this Jinni. Is this believe still existing, and to what degree? This is one aim of this study as patients will be asked about what they think is the cause of their illness.

The fast strides of change in the new millennium are affecting people's beliefs and values. How many cases of depression in Iraq are still believed that their illness is due to a "possession"? Internet and satellite channels are invading our homes with their various contents. People in Iraq usually use these media resources for entertainment. But recently a more and more percentage is trying to open a window to see the world through it. Educational satellite channels are succeeding in attracting more viewers. Educational websites in Arabic are still not that much developed but still they do make some change. Many patients are aware these days of the names of mental illnesses. Depression, Schizophrenia, Obsessions, Autism, Hyperkinetic child, and some more terms are used by people more than before.

Traditional healers, on the other side, are still visited very often by those who feel psychologically upset or abnormal. Visiting a holy shrine is still a commonly used way to treat the mentally ill by people of Iraq.
Are the average Iraqis still psychologically naïve like Dr Widad Bazoui had stated in his studies on psychiatry in Iraq between 1966 and 1970? This is another aim of this study as the patients will be given time to express themselves, and to comment on what they think had caused they state they are in, and what do they call the state they are in, and what treatment they believe can help.

Affective Illness Across Time

Runing trousers, lost in time in Al Rashad hospital

Affective illness is not a new entity in the medical history of this land. Although sometimes its description is primitive. The Sumerians had mentioned mental illness in their writings. Avicenna, in his Canon of Medicine, described cases that share many aspects with the modern concept of depressive disorders a thousand years ago.

The black bile theory of Hippocrates was the explanation for this phenomenon for those doctors who lived in Baghdad since one thousand years ago.

A strongly held belief, that may still exist so strong, is that depression is due to weakness, and specifically, being a "not enough" believer in God.

Biological causes of depression is not that understood, if wellcomed, by people other than the psychiatrists. Even doctors from other branches of medicine do not seem to believe in "Biological" cause of depression. This maybe due to that basic sciences researches are not functioning at all in the field of psychiatry. We never did a cerebrospinal fluid chemical analysis for those who got a mental illness for example. Evidences of biological causes of depression, and other mental illnesses, came just with textbooks from the "west". Some doctors find it easier for them to feel emotionally detached from those biological theories.

So the spiritual east is refusing the biological theories strongly and till now.

Iraq the multi-ethnic

Multi-colored blues

Iraq has a heritage of diverse cultures. Since 7000 years and civilizations are flourishing one time, and then fading again. Multiple ethnicities and religions shared this land. But they share some common values. It is not rare to see a Christian patient visiting a Muslim traditional healer who may use the holy Quran verses while trying to offer therapy. And you can see a Muslim woman in a church asking for being healed from a disease.

Is there a difference in the presentation of depression among different ethnicities and religions in Iraq like Dr. Widad Bazzoui had stated in his study "Affective Disorders in Iraq" in 1970? Dr. Widad Bazzoui had found that Iraqis who are not muslim presents with higher rates of "Guilty feeling" while depressed than the musilms. It is one of the aims of this study to find out wether this is stronly evident.

Somatizing depression/ idiom of distress

The main aim of this study is to find out how Iraqi patients with depression present themselves. It is much stated between psychiatrists in Iraq that Iraqi patients somatise their symptoms. That they do not present with the congitive symptoms as they do more with the physical ones. The aim in this study is to meansure the frequency of each of the Diagnostic and Statistical Manual - forth edition (DSM IV) criteria in Iraqi patients. And to compare the results to studies done on the United States and some other studies done in Asia.

That was the main aim at the start. But as it was found that in Dr Widad Bazzoui study in the 1970s, found that many Iraqi patients with depression presents with other symptoms not mentioned in the DSM IV, other questions were added to the questionnaire.

Questions about: "headache (100% positive answers till now); pain anywhere in the body (100% positive till now); Gastrointestinal symptoms; Respiratory symptoms; Cardiovascular; Neurological; and others)

Questions have been added on paranoia: "ideas of reference, ideas of persecution, ideas of infidility, suspicions and wether they are delusional".

Another question was added on violence and aggressive tendencies and wether it is verbally or physically expressed mainly.

All these were added because they were found to be common in Dr Widad Bazzoui's study.

The prevalence of depression in asia has been reported to be lower than in the west. This has been attributed to somatization. That is to say, that people from asia with depression tend to present themselves with somatic symptoms rather than psychological symptoms. Another explanation was the concept of alexythemia. That is to say, people from non western countries, are less aware of their psychological status, maybe due to ignorance.

Another explanation for presenting depression with physical symptoms is that the diagnosis of depression, and mental illness as a while, is regarded as morally unaccepted and as a weakness a good person must not suffer from.

Arthur Kleinman, a professor of cross-cultural psychiatry, has pointed in his paper "culture and depression" to the experience of depression in the Chinese society where the expression is rather physical than psychological and had stated that: "Culture confounds diagnosis and management by influencing not only the experience of depression, but also the seeking of help, patient-practitioner, communication, and professional practice"(3)
Kleinman, has described somatic symptoms as an “idiom of distress” that is prevalent in culture where psychiatric disorders carry great stigma.
Somatization can be viewed also as a defense mechanism against the awareness of the psychological distress.

Facultative somatization/ a ticket of admission

Patients may feel that reporting a physical complaint is more acceptable as a complaint to a doctor. Many doctors may have answered patients with psychological distress with the answer: "you have nothing wrong; it is all in your head". A commonly used answer in the face of somatization rendering people over time not to complain to doctors about their psychological distress. This has been called "facultative somatization", in which the patient is not in denial, but thinks that physical symptoms is a ticket of admission to the care clinic.
It is a common story to admit a patient with physical symptoms in a hospital in Iraq, then the patient will tell the nurse about a psychological distress. They tell the nurse because they feel him or her more culturally close to them. Doctors are more physical, they are called "physicians", aren't they?
A psychiatrist is a doctor after all and a patient may use facultative somatization with psychiatrists too.
Widad Bazzoui had stated in 1970 that: "In general, the average Iraqi patient describes his depression as a sense of oppression in the chest, a feeling of being hemmed in, or in other cases, a hunger for air. On being asked if he feels sad, downcast or depressed, one is struck in many cases by the unawareness of the patient of his mood. The disorders, especially depression are usually conceptualized not as emotional disturbances but as physical abnormalities affecting various organs of the body. The chest, head and abdomen are frequently considered to be the core of the troubles. Very often the patient describes his complaints in metaphors and similies in an effort to bring his strange experiences within his grasp." (2)

To what degree this is still valid nowadays?

See how this Iraqi patient with schizophrenia expresses himself

On the teared peice of paper he wrote: "the name: unknown, THE IDENTITY". I don't think he is psychologically naive.

NOTE: these pictures won't be used in the thesis paper, nor the comments on them.

(1) Kleinman A. (1997) Triumph or pyrrhic victory? The inclusion of culture in DSM-IV. Harv Rev Psychiatry. 1997 Mar-Apr;4(6):343-4

(2) BAZZOUI, W. (1970). Affective disorders in Iraq. British Journal of psychiatry, 117, 195-203.

(3) Kleinman A. (2004) Culture and depression. N ENGL J MED 2004 September 2, 31;10

Saturday, October 11, 2008

Al Mishwar Restaurant

"Winters cityside Crystal bits of snowflakes all around my head and in the wind"

Going to Al Mishwar restaurant in Al Mansour was my favorite tour with my father and mother and young sister. That big screen in that restaurant and all those songs filled my heart with passion. Steve Wonder called just to declare his love while Lionel Richie answered with his magical heart melting hello. European final countdown to a modern talking were making brothers going louie louie louie letting A-Ha hunting high and low alone.

"I had no illusions. That Id ever find a glimps of summers heatwaves in your eyes"

I was crazy loving Susana who had just graduated from the Art school to sit on the sofa while the music was way down low while my mother was protesting helplessly: "you're too young for this, go do your homework". I took my copy book and wrote: when I look back upon my life, it is always with a sense of shame, …. It's a sin. A boy came from a pet shop and took my copybook and went west.

"You did what you did to me, now its history I see. Heres my comeback on the road again"

Boys in Al Mishwar restaurant were looking at girls' legs from behind. I was thinking they were looking at the girls' shoes. I still remember that I liked red shoes with high heels. I took a bite from my hamburger and took a look on her red shoes with an eye of a little tiger who survived the torture of his older teenage female neighbor and smiled. My mother told me to stop.

"Things will happen while they can. I will wait here for my man tonight, its easy when your big in japan"

The Cheri cheri lady in red took chris de burg out of his mind and scream: I'll never be Maria Magdalena, while Sandra took Madonna the innocent to la isla bonita where they worked as dancers in Kaoma band dancing the lambada leaving me viewing a song in the Iraqi second channel by 2 unknown singers singing in some unknown language "FELICITA"!!!

"When your big in japan, tonight, Big in japan, be tight, big in japan where the eastern seas so blue. Big in japan, alright, pay, then Ill sleep by your side, Things are easy when youre big in japan, when youre big in japan"

Those were happy days where my life was like a happy cartoon moment where Sandi Bell was walking hand in hand with Kuji who had just land on earth from his yellow space ship.

"Neon on my naked skin. Passing silhouettes of strange illuminated mannequins"

I got little older and scorpions rocked me like a hurricane. Bon Jovi was there for me when I get bored from all that screaming to offer me a bed of roses to put my biology teacher fantasy image and taste that poison offered by Alice Cooper.

"Shall I stay here at the zoo. Or shall I go and change my point of view for other ugly scenes"

Some Jazz refreshed my musical ears to let my brain FM radio find the wave of that Qween whose show must go on destroying all the pink floyd walls in front of those little dusty Beatles playing from my alarm clock at 5:30 am "yesterday" tune.

"You did what you did to me, now its history I see...Things will happen while they canI will wait here for my man tonight, its easy when youre big in japan"

Wednesday, October 08, 2008

Wake up so that your eyes see things green

I just woke up from a strange dream again. A panoramic dream in which I saw many things. As far as I can remember I went to Bab Il Sharjie (the eastern gate, a place in Baghdad near the liberty monument). I started looking at the churchs. There was a long church (not existing in reality) of many floors and a modern look. I knew in the dream that it has elevators (elevators in my Iraqi mind means Modernism, or maybe postmodernism. Or something that is still not firmly existing even at the era of postmodernism). Its windows were narrow as if made to let people to see though it from the inside but not to let people from the outside to see through it. I kept wondering till I saw a friend. A christian friend who left Iraq before weeks (this exists in reality, I mean this is a fact). I greeted him. He was smiling widely and sitting on a high bench. He was talking loudly (as usual) to a nearby sitting man. I asked him about the name of the church. He gazed me for a while with so cautious look then said with a low voice the name which is forgotten now. In the dream, when I heard the name, I asked my self, "is it Krimly?", becuase there is a christian school in Baghdad named Krimly school and I don't know where it exist. I only know that father Anistas Mary Al Krimly was intersted in Arabic language and wrote many books about it and about Iraq culture. I am reading a book about letters between Massignon and father Kerimly, hence why I am thinking about him in my dreams. But the name was not "Krimly". It was something else. When I asked my friend the christian (whom I talked yesterday via the yahoo chatting) about wether this church is a school, he didn't answer. I asked him wether I can take photos. It is not accepted to take photos in many parts of Baghdad. My friend said that he doesn't know really but he can help. He took the camera from me and with a fast movement he took a picture and went back smiling widely.

I went to the market. Many vegetables and meats but some few books there. They were covered with dust and their prices were high. I went to another corner of books and "pee ka boo" a relative of mine living in Algeria came from between the books. (in reality she was the one who adviced me not to read "the prophet" of jibran Khalil Jibran in 1991 because as she said he was a Jew).

The christian friend came and we started to chat. They started to talk about some thing which I failed to follow. Something about sex. I felt annoyed. the christain freind went. She asked me to accompany her during shopping.

After a while i was walking next to a kurdish psychiatrist going to the conference. The conference of all Iraqi psychiatrists.

It is late at night and the golden shrine of Emam Al Kathum is nearby. I went to take pictures of it. But was afraid that this is prohibited. I saw the church in the shadows so far. I decided to take a picture that includes the two. I kept gowin back so that I can see them both. A lady came from behind of me and I was startled and the camera moved and the photo spoiled.

The lady told me about her sister who seems frightened. Her sister, aftereating breakfast this morning, started to have things which I forgot now. She told me about those symptoms and my diagnosis was a panic attack. I told her that she need intravenous valium. To take another point of view i asked her to come with me to the conference room. The lady said "conference" with anger and redicule. As if telling me that this is a silly thing to do.

While i was explaing to my colleague the case of the lady's sister, a senior psychiatrist took the microphone and looked at me and said: "may everybody stop this joking".

I took the lady out. Felt annoyed. Came back to the conference room to find a WC door. I went inside the WC and find a long market. I was holding 2 slim books in my hands. I threw them inside the conference room on a chair, but they fall on the ground and made some noise. Everybody in the conference room stopped talking and i felt satisfied.

I reached a book shelf in the market to find a novel by a writer named "musbahi" (there is such a writer whose book is unread by me since i bought it since 2 weeks), entitled "kareem the libian" (my musbahi novel entitled ADIEU ROSALIE).

Then, i don't know how, I heard Musbahi saying to me: "wake up now so that your eyes see things green".

I woke up and saw something blue..... concentrate.....saw green lines on it....concetrate more ..... no blue nor green but a white wall of my room.

Hilla Sweat Hilla

Marjan (or Margan)is a family name. This family is known to be rich in Al Hilla city. They helped the government to open a hospital on a land belonging to Marjan family on the river of Euphrates for the tuberculosis patients early on the 20th century.

I don’t' know if the hospital belongs now to the government of to Marjan family but its name is still "Marjan teaching hospital".

It is no more for the tuberculosis patients. It is now for general medicine. And it contains many subspeciality units.

There is no such a hospital in Baghdad. It is taken for granted in peoples mind that every thing in Baghdad is better, especially the services, and the hospitals are one major example. But in Baghdad you find that people are not serious. They don't consider being responsible on one's work as a good deed. They think that one should only think of himself and not others. Being honest means you are not experienced in Baghdad. Being selfish means you are mature and will be respected.

In Al Hilla, people are still respecting and expecting honesty and truth. That is why their hospitals are more beautiful than Baghdad's.

This sight, from that window in the corridor that takes you to the neurology unit, was a common daily sight in my life when I was working there. At this window I used to stand, alone, or with a friend, to have some rest.

How long is that palm tree. How calm is the river. I swear I just want to be there. Living in calm.

This is our small house of doctors, one of the most warm welcoming house of doctors I ever found

And this waa the site of our late eveing relaxing time, having some drinkings after dinner

Hilla sweat hilla.

Wednesday, October 01, 2008

Iraq is like a Paella dish

Samuel Shimon told us a nice story in his book "An Iraqi in Paris" occurred to him when he met Romero, a man from a Spanish origin, in Paris. Romero was confused by the name of Samuel Shimon. The following dialogue occurred between them:

"- Are you sure it is your name?
- Yes monsieur
- The strange thing is that Jessica Tandy has told me that an Arabic young man will live at her house
- It is me
- An Arab and having a name like this?
- I am an Iraqi and not an Arab
- What do you mean (I am an Iraqi and not an Arab?) the man asked confusingly. I had to repeat the same old boring story of how iraq is composed of different races like the Arabs, the Turkmen, the Assyrians, the Armenians, the Kurd, the Mandaeans, and the Jews. And I have ended my speech by saying "you see, iraq is like a paella dish".
The man bursted into laughter "ha ha ha iraq is like a paella dish" and kept repeating that several times."

I would like to add another flavor to the dish. A flavor called "Gerjeya". Gerjeya, is a female name used in our country. It is a name of old ladies usually because it is not that commonly used these days. I have met in my life few elderly Gerjeyas, but not a young one yet.

I remember what my colleague has told me before months when I was asking about a lady named Gerjeya. My colleague did not answer my question. Instead he asked me:

- Do you know what her name means?
- Not really
- Mean a lady from Georgia.
- Oh!!!
- During the Othman empire rule of Iraq, some soldiers from Georgia region which was under the rule of Othman empire served in Iraq. Some brought their wives with them. They were very beautiful you know. Iraqi people started to name their daughters as Gerjeya, in hope that they become beautiful like the Georgians.

Isn't iraq a paella dish?

By the way, Samuel shimon mother's name in the novel "An Iraqi in Paris" is Gerjeya.

By another way, today my neighbour brought me this dish of rice and some many other things on it, like a Paella, but a real Iraqi one.

They also brought me a dish of Kuleicha on the first day of the Eid, here is its picture

When I ate today the Iraqi Paella dish I felt so happy and held my Ud and played an Iraqi song from the 1970s of Fadhil Awad. Its lyric says:

"Hey you with that Sumerian beauty

Babylonian are your looks

Your sight is an EID for me

And I light your candle with my hands"

This is my Ud sits below one of my father's paintings of a Sudany person. Isn't it wonderful?