Abstract: The present study tried to find, if there is higher co-occurrence of panic disorder and living as a wife in a polygamous family (a model of separation in adult life)?. The sample of this descriptive study included 66 married women who came to the clinic of psychiatry in Zahedan with panic disorder in 2003. We performed a semi structural interview for all of them. Thirty one of patients where members of polygamous families and 26 were the sole wives, 8 cases were widowed and 1 was divorced. The most common symptom was tachycardia (palpitation). It seems that polygamy can be seen as a risk factor for mental health of women, especially in societies where women are dependent to their husbands in all aspects of life.
INTRODUCTION
Panic disorder is characterized by the spontaneous, unexpected occurrence of panic attacks, that is, discrete periods of intense fear, accompanied by its numerous somatic and mental symptoms (Sadock and Sadock, 2003). Lifetime prevalence rates for panic disorder are thought to be between 1 and 3.5%, with significantly higher prevalence rates found in general medical settings (e.g., patients with chest pain, asthma, headaches, epilepsy) (Plewa, 2002). Prevalence is also higher for women (2:1). Panic disorder results in considerable morbidity (e.g., 10-20% attempt suicide, 7-28% have history of substance abuse) and increased mortality (Malisia et al., 1998; Plewa, 2002). Panic as a separation anxiety reaction has been declared since the development of this concept by Klein (1996) on the basis of attachment theory of Bowelby. Despite strong evidences for a genetic basis of panic disorder, the condition cannot be ascribed entirely to inheritance. Even among monozygotic twins, the concordance rate for panic is less than 50%, making it almost certain that environmental factors are involved (Gorman, 2001). There have been many efforts to find the relationship between life events and panic disorder. Faravelli and Pallanti (1989) in their study showed that 62.5% of patients with panic disorder had at least one loss event, which was significantly higher than 28.2% of control group who had the same experience. In general they declared that the panic patients experienced a significantly greater amount of life stresses in every way it was measured (Faravelli and Pallanti, 1989). Many authors believe that separation phenomena play the most important role as an environmental factor in causing panic disorder, through inducing functional disturbance in CNS and especially the amygdala, cingulate and septal nuclei (Faravelli and Pallanti, 1989; Gorman, 2001; Pacchierotti et al., 2002; Roy-Byrne and Cowley, 1998). Bowlby's pivotal contribution was that attachment to others is a powerful, ethologically based instinctive drive. The maternal-infant relationship serves as a prototype for attachment later in life and a foundation for development of a sense of controllability and predictability. Separation from an attachment figure during early childhood regularly evokes an intensely distressing affective response called separation anxiety. As the child grows, separation anxiety attenuates in intensity and in responsiveness to simple separation (Shear et al., 1996). Those adults whose parents had separated or divorced before they were 10 years old, also, had a greater likelihood of being diagnosed with agoraphobia with panic attacks, almost four times the rate of those without a history of early parental separation (Keltner et al., 2003). Bowlby asserts that fear of being separated unwillingly from an attachment figure at any phase of life is a normal instinctive response (Shear, 1996).
Polygamy is legally and widely practiced in 850 societies (Elbedour et al., 2002). Living in Sistan and Balouchistan province of Iran has a coarse face due to specific socio-economic and geographic characteristics. We have found that about 8.3-12.7% of marriages in Sistan and Balouchistan province are polygamous (Unpublished data). Perhaps, polygamy as a social mechanism provide social balance in certain situation; on the other hand, this pattern of marriage makes an especial condition which asks for specific coping abilities for maintaining mental health of those people involved (Mojahed and Birashk, 1995). Similarly Chaleby argued that there is an overpresentation of women from polygamous families in mental health clinics (Chaleby, 1985; 1987), also Al-Krenawi (2004) found that women in polygamous marriages suffer more from certain Psychological symptoms. A woman that her husband has another wife, experiences separation at least 3 days in a week. The on and off absence of the spouse can decrease the threshold of developing panic attacks (Roy-Byrne and Cowley, 1998).
According to high rate of polygamous marriages in Sistan and Balouchistan province and the role of separation in development of severe anxiety or panic response, the aim of the present study was to determine whether wieves of polygamous marriages suffer disproportionally from panic disorder than monogamous wives. The hypothesis that a conspicuous proportion of married women with panic disorder in this region belongs to polygamous families.
MATERIALS AND METHODS
This cross-sectional and descriptive study was performed on patients who referred to the outpatient's ward of Zahedan Psychiatry Hospital in 2003. Hundred out of 683 cases were panic disorder which 21 cases were excludes (12 men and 9 single women). Remaining 79 cases were evaluated by another psychiatrist that 66 of them meet DSM IV criteria for panic disorder. A general practitioner performed a semi structural interview and filled a questionnaire for all of the 66 married women with established panic disorder. The structural interview was done on the basis of DSM IV criteria for panic attacks and detailed demographic information with specific attention to marital status as well as the nature of experienced symptoms during attacks and the impact of symptoms on patients was considered.
RESULTS
The findings showed that 14.5% (100/683) of those who came to the psychiatric clinic of Zahedan center received the diagnosis of panic disorder. We also found that the rate of developing the panic disorder in women is 7.5 times than men. As shown in Fig. 1, the maximum of patients (47%) were between 20-30 years of age.
As regards education, 59% (39/66) of women with panic disorder were illiterate and about 7.6% (5/66) had high-school or higher education and the level education of remaining 33.4% (22/66) was primary or guidance school. With respect to socio-economic status, 60% of patients belong to low and 10% had a high socio-economic class. Only 3.2% of the cases had a job by their own and 65% were living in rural or marginal areas of the city.
Figure 2 summarized information obtained by the semi structural interview. Regarding signs and symptoms experienced by the patients during panic attacks showed that the most common symptoms are palpitation, tremor, and shortness of breath, respectively also 24.5% of patients had also agoraphobia and about 14% had superimposed depression (data not showed).
Also our results showed that 27% of the cases had positive family history of panic disorder, especially in their mother or sister. Regarding marital status, the husbands of 31 women had at least another wife (Table 1). Statistical analysis (Chi-square) showed that there are no relationship between age, social class and presence of agoraphobia with co-occurrence of panic disorder and being women in polygamous family.
DISCUSSION
Panic disorder is a common complain among patients referred to psychiatric clinic especially in women.
In this study 14.5% of patients who referred for the first time to Zahedan psychiatric center were diagnosed as panic disorder. The aim of this research was to study the significance of socio-cultural characteristics (polygamous) which lead to panic disorder. The striking finding was the higher proportion of female than male (7.5/1) with panic disorder which, this ratio is about 2.5-3.5 times that of western countries (Plewa, 2002; Sadock and Sadock, 2003). This discrepancy can be explained by the psychosocial differences of women in this region with particular social situation. The cultural position and social role of women living in Sistan and Balouchistan province of Iran is somewhat similar to traditional Arabs societies. Some characteristics of these societies are: 1) women are secluded and segregated. 2) Limited roles are available to women, notably those of daughter, sister, wife, mother and mother-in-law. 3) Personal status codes discriminate against women, particularly in such areas as marriage, divorce and inheritance (Barkat, 1993).
| Table 1: | Distribution of marital status among panic ladies |
| Fig. 1: | Age distribution of women with panic disorder |
| Fig. 2: | Distribution of common symptoms in women with panic disorders |
On the other hand as many believes, fitness for successful competition for resources form the basis for explaining several behaviors in human development, including attachment (Ligh, 2003; Wilmoth, 2001). So, it is not surprising those women in this culture move toward excessive dependency to men as a mechanism which provides a more trustful and easier living. Since loss of attachment figure is a normally frightening stimulus throughout the life (Bowlby, 1973). It is acceptable that the high ratio of panic female/male is the continuous fear of loosing attachment figure for women in this culture.
Present results showed that 47% of cases were in polygamous families which support the role of separation as an effective environmental factor in pathogenesis of panic disorder.
Shear and his colleagues hypothesized in their psychodynamic model of panic disorder that inborn fear of unfamiliar situations, augmented by frightening, over-controlling parental behaviors, predisposes to incomplete resolutions of conflicts between dependence and independence, a problem regularly observed in patients with panic disorder. The manifestations of dependency conflict may vary. Some panic-vulnerable individuals are sensitive to separation and overly reliant on others, but others are sensitive to suffocation and overly reliant on a sense of independence. In both instances, object relations are characterized by weak representations of self and powerful representations of others. Avoidance of the unfamiliar results in little opportunity for learning to predict threats accurately or for developing maximally adaptive defensive and coping strategies. Instead, defenses remain immature and focused on the problem of maintaining a tolerable distance (not too close and not too far) from overly powerful others (Shear et al., 1993). Considering the picture of polygamous families, we conclude that the uttered theory can easily explain the high concordance rate of panic disorder and being a wife in polygamous family.
We emphasize that our sample is not a representative of the whole community, but a sample from those referring to psychiatric clinic; therefore the results should be interpreted cautiously, considering the limitations of methodology.
In conclusion, in countries similar to Iran and particularly regions with socio-cultural structures like Sistan and Balouchistan, the relationship between separation and panic disorder is more relevant. In this traditional way of marital life, wives are completely dependent to their husbands as a strong and supportive replacement of father figure and man is the main provider of family resources, the woman looks for every aspect of fortune in her husband.