Dissociative Disorder in the Iranian Culture: The Lawless Utopia.

Epidemiologic and etiological studies of dissociative disorders are a challenging area in psychiatry. These challenges become more complex when noting that the existing theories cannot explain the differences observed in certain cases; for example, studies in Iran have reported the prevalence of dissociative disorders (dissociative amnesia, dissociative fugue, and depersonalization disorder) as less than 0.6%, and there has been no reported case of dissociative identity disorder (DID) in this country; meanwhile, the prevalence of all dissociative disorders in the general population of the US has been reported as 18.3%, and the prevalence of DID as about 1.1%. Although several studies indicate the high prevalence of dissociative symptoms in many Iranian psychiatric illnesses, dissociative disorders as a stand-alone disorder have a very low prevalence in Iran. The present article attempts to propose a possible hypothesis for the answer to the above questions through a different cultural conceptualization and seeks to be of some help to future studies in this area. Certainly, this hypothesis requires a careful study to be validated.

"Dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. These disorders include dissociative identity disorder, dissociative amnesia, depersonalization/derealization disorder, other specified dissociative disorder, and unspecified dissociative disorder (1). "

Dissociative disorders are a highly challenging area in psychiatry, a challenge that is observed in both the substantial difference in the prevalence of the disorder in different countries (2, 3) and also the conceptualization of their etiology (3). These challenges are exacerbated when the conceptualization of cultural psychiatry also makes its way into the given explanations. From the point of view of cultural formulation, the acceptance and conceptualization of certain types of dissociative disorders by a given culture lead to the higher prevalence of these types of disorders compared to the rest of dissociative disorders. For instance, dissociative trance and dissociative possession are highly prevalent in traditional societies, which are in contrast to Western societies, and dissociative identity disorder (DID) is seldom witnessed in traditional societies (2-5). This contradiction in the prevalence of these 2 disorders (dissociative trance and dissociative possession versus DID) is assumed to a compensatory nature because a reduction in the prevalence of one exhibits itself via an increase in the prevalence of the other. As a matter of fact, these 2 disorders are different definitions of the same phenomenon; this may be because there is a relationship between individuals’ interpretation of the causes of disease (supernatural vs modernism) in different cultures, and the dissociative symptoms of DID develop in opposition to dissociative trance and dissociative possession. In the first (DID), the cause of this personality change is assumed to be an intrapsychic phenomenon, while in the second, it is an extrapsychic and supernatural phenomenon, and both of them are different ways of dissociative escape (avoidance) from accepting responsibility, expressing suppressed emotions, managing stress, and coming to terms with trauma –ways that have been accepted by the society (4).

From the perspective of cross-cultural conceptualization, the traditional society has accepted that a patient in a changing state of consciousness is not responsible for his conduct, and this escape route for expressing suppressed emotions has been accepted in this society. This acceptance has led to experiences of trance and possession, while this phenomenon has not been accepted in Western societies. Meanwhile, although the modern world has granted man no cultural license to experience trance and possession as a dissociative experience, the Western man’s need to find a way to escape for expressing suppressed emotions persist and he has therefore found another way out, an inner route for experiencing the possession of part of oneself by another part as a phenomenon that ultimately culminates in DID (4). This cultural conceptualization can be used in both the trauma model and the fantasy model that explain the etiology of dissociative disorders (2, 3), an approach that has been seriously considered in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM5) (6) and has added to the complexity of this field of psychiatry.

However, it seems that this compensatory theory to explain the difference in the prevalence of dissociative disorders cannot justify the low prevalence of all types of dissociative disorders in Iran. Studies in Iran have reported the prevalence of dissociative disorders (dissociative amnesia, dissociative fugue, and depersonalization disorder) as less than 0.6% (7, 8) and there has been no reported case of DID in this country; meanwhile, the prevalence of all dissociative disorders in the general population of the US has been reported as 18.3% and the prevalence of DID as about 1.1% (9, 10). Although several studies indicate the high prevalence of dissociative symptoms in many Iranian psychiatric illnesses, and there have even been reports of culture-related dissociative disorders in some parts of Iran (11), these culture-bound syndromes have still been associated with a low prevalence (12). Overall, it seems that dissociative disorders as a stand-alone disorder have a very low prevalence in Iran (13-15). Explaining how all dissociative disorders have such low prevalence in Iran is a delicate job that has not been completed. If the theory of a compensatory and inverse relationship between the prevalence of dissociative disorders is accepted, then how come the lack of DID in Iran has not compensated itself by an increase in other dissociative disorders, like the pattern observed in other traditional and eastern countries? Cultural psychiatry states that there is still a need for “dissociative escape” in the modern world, but its form and method depend on each country’s distinct culture. For instance, the prevalence of dissociative possession alone reaches 4% of the general population in India (9, 16, 17), or in Puerto Rico, 14% of people experience dissociative trance (called Ataque de nervios) during their lifetime (18). If the cultural psychiatry explanation is accepted that mankind still needs “dissociative escape,” then why are all forms of dissociative disorders practically rare in Iran and why is there no dissociative escape in this country?

A popular answer that could explain the low prevalence of dissociative disorders in Iran is that Iranian psychiatrists and psychologists refuse to diagnose anything they witness in their patients as a dissociative disorder and symptom (13). However, there are very few studies corroborating this answer. Given that the statistics on these disorders are the result of nationwide studies on the prevalence of psychiatric disorders performed under the supervision of Iran’s Ministry of Health, Treatment, and Medical Education and guided by prominent Iranian specialists (7, 8), suggesting the studies’ failure or weakness in identifying these disorders is an overstatement. Nonetheless, the questionnaire used in one of these national studies was GHQ_28(8), which could not accurately examine the dissociative disorders, and this could be a justification for the low report of the prevalence of dissociative disorders in this study, but this objection is not included in another national study (7).

Moreover, the main question still remains: Given the low prevalence of all dissociative disorders in Iran, if we accept that the Iranian people need to find a dissociative escape, then what dissociative outlets or routes exist in Iran to escape from suppressed emotions, responsibilities, and severe stresses, avoiding mental exhaustion, and perhaps more important of all, tolerating the suffering of trauma? Outlets that are not recognizable by DSM5 criteria. Surely it is somewhat far-fetched to think that there is no need for a dissociative escape route in Iran, a country in which the prevalence of psychiatric disorders is among the highest in the world (19). Investigating these issues in Iran becomes more important when we acknowledge that Iran is one of the 4 most traumatic-event-prone countries in the world in terms of both natural and human traumas (20, 21).

Materials and Methods

The present narrative review article attempts to propose a possible hypothesis for the answer to the above questions through a different conceptualization and seeks to be of some help to future studies in this area. Certainly, this hypothesis requires careful study to be validated.

A search was conducted on these disorders in English and Persian articles and books published between 1960 and 2020 in MEDLINE, Web of Science, EMBASE, PsychInfo, Google Scholar, and SID databases using the following keywords: dissociative identity disorder, dissociative amnesia, depersonalization/derealization disorder, other specified dissociative disorder, and unspecified dissociative disorder, possession state, culture-bound syndromes, Iranian culture, and Iranian families.

The term “utopia” is used to conceptualize and discuss the very low prevalence of dissociative disorders in Iran, as this concept seems to be the missing link to the above questions: A heavenly city with ethereal laws that is free from the bitter experiences of loss, mourning, and trauma. The concept and elements of this utopia are frequently present in the Iranian culture (22, 23).

Results

In the Iranian culture, utopia has 2 different dimensions: religious utopia, which indicates a city based on religious principles with the leadership of religious authorities; and philosophical-political utopia, which indicates a city based on wisdom and knowledge with the leadership of philosophical-political authorities (24).

The important point in the formation of the idea of this utopia in the Iranian culture is that this idea has generally been formed in encounters with external and pervasive traumas, such as the despotism of kings and the cruelty of religious rulers (22), and given that the Iranian culture is a hierarchical and authoritarian one from top to bottom (25, 26) and that the concept of “self” against the concept of “other” forms a small element of the individual’s identity (27), in the Iranian culture, traumas are mainly the result of the conduct of “that authoritarian other,” which is political or religious. This issue has been frequently considered in studies, the best of which are articles and books on the history of crises in Iran (28). In studies conducted in Iran, the most important causes of stress and trauma in individuals have been related to the performance and decisions of the authorities (29, 30). Consequently, traumas are mainly extrapsychic rather than intrapsychic and are often public rather than personal. The experience of personal dissociation therefore seems to have been incapable of responding to the need for escaping these collective traumas and stresses. Thus, when faced with traumas that have been mainly influenced by the ruling authorities’ conduct (25), Iranians create a utopia through a collective solution assisted by different cultural tools. Although other countries and cultures certainly face similar challenges and this hypothesis cannot be made specifically for Iran, given the cultural differences between Iran and other countries (31, 32), it may be conceivable that solutions to Iranians in the face of these external and collective stresses are slightly different from other cultures. However, it should be borne in mind that the effort of this article is merely a kind of theoretical ideation and conceptualization for future studies. The very low prevalence of dissociative disorders in the Iranian culture can thus perhaps be summarized as such: Given the collective nature of these experiences of stress and trauma in the Iranian context, there has been a need for collective escape routes, so that individuals can support each other in a collective world parallel to the real world, which is referred to as utopia in this article, and consequently, personal solutions such as dissociative disorders, have not been applicable to these circumstances.

Although utopia has frequently been contemplated in Iranian studies, an important and overlooked point is that there appear to be 2 utopias in this culture for escaping external day-to-day traumas:

The “ideal utopia”: A city based on religion and absolute wisdom whose main solution for the prosperity and happiness of its people is to set up rational and religion-oriented idealism through the integration of reason, feeling, and behavior, and total obedience to virtuous authority. This utopia forms itself through total obedience to political-religious authority and with the least deviation from this path. The path to prosperity in this utopia is thus the absolute acceptance of the proposed truth.

The “lawless utopia”: A city with none of the moral and logical laws of the ideal utopia in which people are free from religious and moral taboos and constraints and whose aim is to disintegrate and dismantle the conventional structures and taboos, disobey authority, and not recognize it as official without actually engaging with them. While in the ideal utopia, this parallel world and new reality appears as lawless, it is indeed very lawful, but its hidden and metaphorical laws are not tangible and open to judgment for the real world authorities. This arrangement enables the expression of suppressed emotions without engaging with the dominant authoritarian culture and could perhaps be called a dissociative utopia, a dissociative city within a real city, known in the Iranian culture as “Penetralia”, and a structure that is most explicitly manifested in Iranian architecture as a more private structure, hidden from the eyes of that stranger “other,” with totally different laws from those of the outside world (33).

As stated above, much has been said about the ideal utopia and the laws ruling it, but there are very few studies on the lawless utopia and its strategies and dominating rules and it seems that the escape routes of the Iranian culture that have reduced the experience of dissociation are rooted in this lawless city. These 2 different utopias can be experienced in one day and even at the same time by one person. For this reason, it is better to consider the Iranian culture a “dissociative culture” that formally recognizes 2 identities at the same time, one identity that is obedient to authority and one that is rebellious and disobedient at the same time, and the individual maintains this dual identity, which has 2 sides just like a coin, without disintegration. Thus, it develops no need for a dissociative experience, and it suffices for him to turn to the other side of the coin to escape any taboos, traumas, and painful emotions, and he can thus come to terms with any negative feelings and traumas by using the strategies and methods accepted by the culture of this lawless city without needing to dissociate from his own individuality. Although the concept of utopia does not belong exclusively to Iranian culture and it can be considered a global concept and experience (34, 35), the concept of lawless utopia and its active mechanisms are less discussed. Although some of these mechanisms are common in other cultures, we have tried to pay more attention to the differences between these mechanisms in Iranian culture and other cultures. It should be noted, however, that this paper is merely an attempt to provide a theoretical cultural formulation for this challenge, and all propositions require more detailed studies in the future. What follows is some of the most common mechanisms and strategies of this lawless utopia for coming to terms with the traumas of “that authoritarian other” in Iranian culture. These strategies differ in the encounter with each of the political or religious authoritarian others and yet require solutions to maintain the integrity of the citizens’ identity as well. These strategies have been useful for the social conditions of Iran, where one or both authorities have always been dominant. Meanwhile, at certain periods in time, neither of these authorities have been dominant, and different conditions have emerged during these times that have themselves required differing strategies (36).

Given the above conditions, the Iranian people have been constantly experiencing 4 different sociocultural situations (36, 37). The principles of the “lawless utopia” in dealing with these 4 situations are addressed below (Figure 1):

Figure 1

The Principles of the “Lawless Utopia”

Mechanisms of dissociation from the political authoritarian other: satire-gossip

Mechanisms of dissociation from the religious authoritarian other: facetiousness, rebellious mysticism-music

Experience of self-dissociation in the absence of the authoritarian other

Mechanism of maintaining the integrity of identity: calligraphy

Gossip: Gossip is an old social behavior that seems to be thousands of years old; many articles have dealt with gossip and reported several functions for it, including the following (38, 39):

√  Reinforcement or punishment in ethics and accountability;

√  Showing passive rage toward others and isolating or harming others;

√  A means of formation and organization of society;

√  Building and maintaining a sense of community, based on common interests, information, and values;

√  Creating a consultative setting to find the right half to live with;

√  Creating a group system for information dissemination; and

√  An escape route to come to terms with traumas and suppressed emotions.

As evident, gossiping is a complex social mechanism that can have different functions based on the individual’s power in the community (40, 41), and the concept of coping with authority is one of its main elements, and the function of gossip in preventing dissociation experience appears to be similar to the function of “passive rage” against authority, a strategy that has been referred to in Iranian anthropology books as a way of safely dealing with the “political authoritarian other” (26, 42).

Satire: In literary terms, satire refers to a specific kind of poetry or prose that challenges the undesirable aspects or errors of human conduct, sociopolitical corruptions, and even philosophical ideas in a funny way, and criticizes the social weaknesses and indoctrinations of the human society using humor, inversion, anger, and parody (43, 44). This field is deeply rooted in the Iranian culture (45), and studies on the relationship of satire with mental health and the function and components of satire have increased (45, 46). The main challenge in satire is how to deal with political authorities, and for this reason, it is among the major mechanisms of dealing with authority in the lawless utopia.

Witticisms or Facetiousness: In the literature, “bawdry” refers to a writing that is linguistically and thematically vulgar and rude and that openly talks about sexual relationships and mainly deals with cultural taboos. Although the existing books suggest that this kind of narrative has a long history and has been of interest in Western countries, especially during the Renaissance (47), but in Iran, its relationship with health (physical, mental, and social health) has not been examined. Meanwhile, bawdry has been a highly common form in the Iranian culture, especially in the era of authoritarian religious rulers, when it was even taught in formal classes (48), and it appears to have been an informal way of expressing suppressed emotions and has even been used for teaching people about the taboos.

Rebellious Mysticism: Many writings in this field suggest that the creation of new mystical sects in Iran has been associated with the authoritarian religious rulers or the tyrannical domination of certain moral-religious tendencies in Iran. Many researchers regard these mystical sects, which reveal themselves through the violation of the morals and principles of the dominating religion, as a reaction and a way to escape the tyranny and mental pressures of the “religious authoritarian other” of the era (49, 50), a reaction that persists even in today’s world (51).

Music: There are many articles on the effectiveness of music on improving mental and even physical problems (52), and music has always been a way of expressing suppressed emotions and challenging the authorities (53). This protesting approach has also been of interest in Iranian music (54). Iranians have devised 7 different musical modal systems and each lets one into a different world and provides a different solution for the person’s particular mental state. In other words, it is as if it dissociates one from the real world and takes one into a utopia whose rules are unbeknown and vague to the real-world authorities and where emotions are allowed to be expressed. Of these 7 musical modal systems, 3, namely Sur, Segah, and Cahargah, are specific to Iranian music and do not exist in European music (55), which is itself a key issue. The following addresses the functions of these 3 specific musical modal systems of Iranian music:

√  Sur: Sur is considered the most important modal system in Iranian music, since 5 vocal modes have been derived from Sur, and the influence of Sur is also evident in other modal systems such as Nava and Segah. This modal system addresses “the individual dominated by sorrow” (56-58), as if, by accepting the individual’s pain and suffering, this modal system acts as a gate and lets the person into another world.

√  Segah: This modal system is popular in almost all Islamic countries and is most appropriate for “expressing sadness and sorrow that turns into hope.” The vocal mode of Segah is very sorrowful and despairing and lets the suffering person express his suppressed emotions while infusing him with hope (59).

√  Cahargah: This modal system suggests the rising of the sun, the start of life, the radiation of light, vision, recognition, and knowledge, and it is as if the individual can find his integrity and return to life through a new perception and identity and after passing these stages (60, 61). This modal system appears to refer to an insight into the language of psychiatry and is associated with a sense of self-esteem and acceptance.

Iranian music appears to move the individual on a path from grief, sorrow, and anxiety to acceptance, patience, anticipation, and wonder, and ultimately prepares him/her for returning to the real world, and boasts a type of psychotherapy in this highly complex way.

It seems that in the Iranian culture, only in a circumstance where there is no authoritarian other should one expect to observe personal dissociative experiences; that is, when the political or moral authoritarian other has disappeared or faded and when the society experiences a state of bewilderment and ambiguity. Under these conditions, vulnerable people exposed to traumas suffer dissociative symptoms. It is as if the laws of neither of these 2 utopias are applicable in these instances, and the bewildered person is left alone in his/her individuality and has to respond to all his stresses and sufferings alone in a place that the concept of “self” against the concept of “other” forms a small element of the individual’s identity in Iranian culture (27). Therefore, in the absence of authoritarian other, his lessened individuality cannot handle these stresses and where one is forced to run away from one-self and in such circumstances, one may experience dissociation. This hypothesis can perhaps somewhat explain the increase in psychiatric and dissociative disorders in recent years in Iran when the country has been affected by several social and moral crises (62, 63). During these years, both political and religious types of authority appear to have been challenged and weakened in the country (64), and that authoritarian other seems to have faded and the bewildered person has been left alone to deal with stress, a situation beyond one’s power. Therefore, the prevalence of dissociative disorders has had an ascending trend (13).

So far, the functions and mechanisms in the lawless utopia; that is, the other side of the coin of the Iranian culture have been repeatedly discussed, which coexists and functions simultaneously with the principles of the ideal utopia. Nonetheless, the important point is that the coexistence of these 2 utopian identities does not lead to a dissociative state in the person, and his integrity is preserved. To explain this coherence despite the contradiction in these 2 utopias, one can note an old Iranian art which, unlike the discussed cases, has exactly the same rules and principles in both of these 2 utopias, and this unity has preserved the coherence of this culture and its people against traumas:

Calligraphy: Although perhaps the only calligraphic art that has a prominent name in studies is the art of Chinese calligraphy, and its effectiveness have been studied in various studies, especially in reducing stress (65), controlling nervous arousal after earthquakes (66), et cetera, and even review studies support the effectiveness of this type of complementary therapy (67). However, it seems that Iran’s history of calligraphy is also a turning point in this culture. Calligraphy is an art form with which all the existing treasure of Iranian culture has been recorded and formed and which has been discussed in articles as “the finest and most complete art form among Iranians” (68). These articles describe the transformation of Iranian writing and quote that, following the arrival of Islam and the Arabs’ invasion of Iran, Iranians gave up their writing (cuneiform, etc), and began to develop their own special writing over the centuries following the arrival of Islam and reached the pinnacle of their art in calligraphy by creating the Nastaliq hand in the eighth and ninth centuries AH (Anno Hegirae) (69). This form of art began with one of the biggest adaptations of Iranian culture to a foreign culture, and after improving on the art of another culture and fully integrating it into their own culture, they turned it into one of the greatest arts of their own and shined with it (69, 70). This phenomenon suggests the utmost level of a culture coming to terms with an external trauma and adapting to it and resolving the developed identity crisis. This art form has brought together and consolidated the components of Iranian identity like cement, has become structured through the thousand-year efforts of this country’s geniuses, and has developed precise and very fine principles called the 12 rules of calligraphy (68). In other words, Iranian calligraphy has been a solution for treating and coping with what recent studies refer to as identity confusion and identity crisis, and many studies confirm the effectiveness of this art form in the treatment of the symptoms and problems resulting from trauma (52, 69), and reports indicate that neurological mechanisms are involved in this effectiveness (71). In contrast with the other coping mechanisms discussed, this art form has the same rules and principles in both utopias, which likens its role to the thread holding together the prayer beads, and thus preserves the individual’s integrity of identity by the frequent use of contradictory utopias or both sides of the coin.

Discussion

In this review article, conceptualization and explanation of the possible causes of the low prevalence of dissociative disorders in the Iranian culture were considered. And possible intracultural strategies and mechanisms that could somehow create outlets for expressing and managing repressed emotions and psychological suffering and trauma were discussed. Outlets that make the need to experience dissociative symptoms as noted in the DSM5 criteria less felt in this culture.

Limitation

There were some weaknesses in this article. One of the most important was that to write the article, selected sections of related books that were written specifically about Iran were selected, and it was better that the general view of the book was taken into account in these analyzes. Another problem was the lack of access to a number of related books and articles due to restrictions on their purchase or outdated copies. But despite these problems, it seems that a relatively acceptable number of references used can be the strength of the article and to some extent compensate for these weaknesses.

Conclusion

To conclude, the low prevalence of dissociative disorders in the Iranian culture can perhaps be formulated in the presence of the lawless utopia; it is as if every Iranian has 2 sides, just like a coin, a side that seeks the ideal utopia and thoroughly follows different rules and solutions compatible with the ruling authority, and another side that seeks the lawless utopia, which is a rebellious and taboo-dismantling city. The challenge is that every Iranian possesses and experiences both identities at the same time, as if, in the face of the traumas, stresses and psychological pressures of one side of the coin, he/she quickly turns to the other side of the coin and lives with that side. Therefore, this individual appears to live each moment in a dissociative-like space, but a space that is coherent, and this coherence is maintained by cultural elements such as calligraphy. Nonetheless, this dual coherent identity collapses and dissociation symptoms appear at times of social disorganization caused by an absence of “the authoritarian others,” which indicates the importance of social and cultural evaluations of these people. Therefore, understanding and evaluating this dual identity and space is a challenge that cannot be understood and measured through dissociative symptom questionnaires based on the Western culture, and for this reason, studies that use these tools report a low prevalence for dissociative disorders in Iran. Therefore, it is crucial to design questionnaires that are more adapted to the Iranian culture (72, 73). In addition, by carefully examining these mechanisms, it may be possible to design more therapeutic methods in accordance with Iranian culture. The proposed hypothesis requires further studies to fully.