[Cultural aspects in depression masked by psychotic symptoms in Maghreb countries: three case reports]

In this study, we will describe three observations of depression "masked" by persecution delirium and/or hallucinations, to illustrate the role that the cultural factor could play in the expression and care of depression. In the first two observations, the persecutor was a group that was apparently difficult to circumscribe: the persecution appeared more important than the persecutor. In these two cases, persecution also had a depreciating role for the patient. In the third observation, the hallucinatory manifestations cast a slur on self-esteem and caused narcissistic injury.

Analysis of the cultural context allows us to understand the depressive significance of such psychotic symptoms. In the traditional societies, depression is strongly related to the cultural context, it is often expressed by the fear of being punished or denied by the group, and a feeling of treason towards the community. The punishment can be direct or indirect, carried out by imaginary beings, "the djinn", or by any disease. According to Freud, the guilt is expressed by the fear of the vengeance of a dead man's spirit, which is then going to persecute the culprit. This persecution, which has a value of punishment, is based on the mechanism of the projection. In the same sense, Freud explained that the death, as a sequel of the disease, is the vengeance of the dead man's spirit in the living. In all religions, the impulses, the thoughts disapproved by the community, are attributed to Satan who etymologically means "the enemy" or "the opponent". This latter plays an important role in relieving fears, the sense of guilt and the disapproved thoughts. There is also involvement of the projection mechanism. So, guilt could be expressed by delirious ideas such as the conviction of being the victim of a demonic possession, to be under a spell or to be persecuted.

Thus, taking the cultural context into account would allow us to fundamentally understand the depressive meaning of the delirious symptomatology of persecution, which is taken from a popular theory of misfortune shared and validated by the familial and the social circle of acquaintances. Plantine postulates that the psychotic conflict takes the subject away from the standards of his own culture. In the case of our three patients, we should try to establish a form of communication, to prevent them from falling into alienation. Thus, we must think about our attitude facing a patient who is diagnosed as depressed or even psychotic, while the patient believes he/she is possessed by a "Djinn". The therapeutic attitude should be adapted to the cultural dimension of the case. Thus, in situations similar to the studied cases, the therapy should be essentially based on the development of a psychotherapeutic relationship, rather than a pharmacotherapy, one should be careful not to compromise the cultural means of restoring psychic disorders such as the traditional therapy.