Fear and Anxiety in the Arab World


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The final Arabic version was back translated by a bilingual senior psychiatrist specialized in anxiety, who did not have access to the original English version, then we compared the back translation to the original. Using this, subjects were divided into two groups: those with social phobia and those without social phobia.

Subjects were recruited during the academic year All those meeting the inclusion criteria and consenting to participate were included. Purpose of the study was explained to all participants.


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Demographic, clinical data were collected. Linear regression was used to test and estimate the dependence of a quantitative variable based on its relationship with a set of independent variables, while logistic regression was used to test the dependence of a qualitative variable based on its relationship with a set of independent variables.

Of the 2, subjects who participated in the study, Out of these, 0. Of the 2, subjects screened using the BSPS, 1, subjects Table 1 shows socio-demographic and descriptive characteristics of students with and without social phobia. It showed a statistically significant difference between subjects with and without social phobia on all individual items, all the total subdomain scores and the total BSPS score.

Screening of social phobia symptoms in a sample of Egyptian university students

BMI: body mass index; SD: standard deviation; p : p -value. Correlation of socio-demographic and descriptive characteristics with BSPS scores.


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Logistic regression analysis was carried out to investigate the predictive factors for the occurrence of social phobia in our sample. Linear regression analysis was also carried to investigate various factors affecting the total BSPS score. We found that being female and being a student in the Faculty of Medicine were independent risk factors for the development of social phobia and also significantly affected the total BSPS score Table 4.

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Linear regression analysis was carried to investigate which factors affected fear, avoidance and physiologic scores on the BSPS in our sample. We found that BMI significantly affected physiologic scores, being female significantly affected fear, avoidance and physiologic scores, being a student in the Faculty of Medicine significantly affected avoidance and physiologic scores and number of years at university significantly affected fear scores Table 5. There is a growing body of literature revealing that social anxiety disorder is highly prevalent among adolescents.

Yet, most available studies were conducted in Western countries. The current study investigated 2, undergraduate university students representing 9 different faculties using the BSPS and found that a total of Compared to those without social phobia, there was a statistically significant difference regarding gender, past medical, past psychiatric and family history.

Our results showed that This is in line with a previous study done in Al Azhar University students in Egypt where prevalence of social phobia symptoms reached as high as Moreover Ragahb et al. This is also in line with other Egyptian studies 18 , where a This points out the magnitude of the problem especially in a country like Egypt, where high rates of Social Phobia might be attributed to the socioeconomic situation that prolongs the duration of dependence on family and where attempts at independent living are met with major challenges, foremost economic ones While in other Middle Eastern countries a rate of In a sample of university students in India, they found social phobia in In Western countries, the rate of social phobia among Swedish university students was estimated at Similarly, in the general population, the rate of social phobia varies across different cultures with Asian cultures showing the lowest rate 3 , with 0.

Our study showed significantly higher rates of social phobia compared to many other studies. This might reflect the genuine underestimated magnitude of the problem amongst Egyptian university students, given our large sample size. This also might be the difficulty in separating social phobia from poor social skills or shyness developmentally, some studies have shown large ranges in prevalence with prevalence of social phobia depending heavily on where the diagnostic threshold is set 27 , Another important factor to consider is the impact of the culture especially as the defining feature of social phobia is fear of negative evaluation by others which is directly linked to social standards and role expectations, which are culture dependent.

Also, This might have had an impact on the development of social phobia, which may stem from the social change associated with urbanization and adapting to new social norms. Another contributing factor to the prevalence of social phobia in students might be the role of perfectionism. This might be explained by the fact that students experience pressure on many life issues, especially on personal choices such as college studies, where they may be required to comply with pressure from families and feel a need to become perfect in their eyes.

It has been shown that negative perfectionism fear of failure and self-criticism in students was associated with high anxiety scores and it has also been shown that socially prescribed perfectionism among students is associated with low self-efficacy and ineffective resource management and decrease odds of seeking help Our study showed that being female was a significant predictive factor for the occurrence of social phobia and for fear, avoidance, physiologic and total BSPS scores. That is consistent with the study by Turk et al. As far as Arab countries are concerned, a previous study done in Kuwait investigating the gender difference in anxiety among volunteer undergraduates recruited from 10 Arab countries, showed that females had higher mean anxiety scores than their male counterparts This can also perhaps be explained in the context of traditional gender-role expectations where, as far as Arab countries are concerned, it has been hypothesized that both child rearing practices and orthodox traditions both have an impact, where shyness is considered a virtue, and where it has been shown that there is high correlation between shyness and social phobia, so that they may not be separate phenomenon but rather an overlapping conditions 29 , 31 , Some have also argued that this difference could be due to the collectivistic and orthodox nature of Arab culture where there is respect for authority figures, a fear from criticism and judgment in general and where men generally have more power and authority so that it might increase fear and anxiety in women, especially in social situations Contrary to our findings Shah and Kataria found no gender difference for social phobia Interestingly, a study from Pakistan aimed to explore the prevalence and trend of social anxiety in female university students from 32 colleges and universities who were observing the veil and found a very low and almost non-significant level of social anxiety in female students who wore the veil A significant negative correlation was found between age and avoidance scores and between scholastic year at university and fear, avoidance and physiologic scores on the BSPS.

Younger people perhaps feel more anxious amongst older peers in social situations and use avoidance more frequently as reinforcement in the face of social anxiety especially amongst students, where social phobia is associated with more avoidant behavior in anticipation of a public speaking situation As regards scholastic years, Inam et al.

This can perhaps be explained by the shift from the traditional spoon-feeding teaching methods that students experience in high school and the eventual decline in social phobia occurs as students get used to the different teaching methods at university In our study, being a medical student was a significant predictive factor for the occurrence of social phobia and for total, avoidance and physiologic scores on the BSPS. The high prevalence The link between being a medical student and high levels of social anxiety might be explained by perceived stress. Medical students face unique academic challenges that render them more vulnerable to stress and anxiety than students of other disciplines which probably stems from the environment of medical school itself where there is a high pressure, authoritarian and rigid system that encourages competition rather than cooperation between learners.

Our study was contrary to the study by Shah and Kataria 21 where social phobia was reported maximally in the faculties of Commerce, Arts and Science, while it was reported to be least in the faculties of Medicine and Engineering. Our study demonstrated a number of findings in a large sample of university students namely the high rate of social phobia.

It also demonstrated a number of significant associated factors such as gender, BMI, scholastic year and faculty type with total and subdomain scores on the BSPS.


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Our study had a number of limitations. The participants were recruited from one university within Cairo Ain Shams University , so these findings may not be generalizable to other universities within Egypt.

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The results of these measures tend to be more subjective than the objective ones; if two dentists are observing the behavior of the same patient on the same time there is no guarantee that both will score the patient in a similar way. The differences in scoring could depend on the time of the appointment, the experience, the temperament, the age, and the gender of the dentist. Hence, the reliability of these measures will not be strong enough if they are used for research purposes.

The use of the physiological measures were found to be less appropriate for assessing dental fear in children[ 5 ] for several reasons: the standard normal reading for children will vary and depend on age of the child; the results of these measures could be overlapped with current medical problems; the requirement of knowledge and training on how to use these equipments; wrong results by faulty machines; it is not available in all dental clinics; the practicality of using it in terms of cost, time, maintenance and a space in the clinic; last but not least.

These measures are the most reliable measures for children who are able to read and have the cognitive ability to understand how to report their anxiety on the scale. Previous studies found that, in adult patients, the self reported anxiety scale can distinguish between high or low dental anxiety in terms of avoidance or distress behaviors. This may not be the case in preschool children; the ability of the young children may not be fully developed and they tend to report more fears regardless of the situation and more likely to show anxiety at separation from the parent. For those young children, the use of the behavioral measures is the best option[ 8 ].

Studies of dental anxiety in children rather than in adults may allow us to more reliably investigate the causes and management of dental anxiety. This is due to the limited reliability and validity of adult dental anxiety studies and to the extensive time span between the onset of the anxiety during the childhood and these studies[ 9 ]. Although measurement of dental anxiety is important for research and delivery of high quality clinical care, it is the corner stone of dental anxiety management. The development of self-reported measures was started in early s and has continued up until the present.

Dental anxiety measures have been developed in order to help the dentist detect anxious patients in order to provide better management and treatment. The degree of belief in negative cognition is associated with the severity of DA[ 10 ], the negative thinking patterns of the anxious individual is centered on danger and harm. The cognitive measures are widely used as self-report scales that request the patient to respond to list of statements or questions, these measures could be incorporated into pediatric DAM[ 11 ]. Although there are 14 different dental anxiety scales for children, some of them have been validated in many languages[ 13 ]; to date there is no DA scale that validated in Arabic language.

Hence, the objective of this study was to validate the Arabic version of ACDAS in order to extend its benefits to more people and to be the first Arabic dental anxiety scale. This study was made up of two parts, development of a new scale and then validation of this scale. It is made up of three parts Figure 1 : 1 this comprises 13 self-reported questions arranged in logical order.

Each question uses three faces as a response set. The inclusion criteria for this study were children aged of 6 years or over, with no learning disability, and the ability to read Arabic.

The children had to be at least 6 years of age, because younger children do not have the cognitive complexity required to report and react to dental situations accurately and they may not have the experience of dental situations[ 14 ]. A convenience sample of students participated in this study; 96 males The Religious International Institute , and 88 females Al Khansaa Middle School.

The study composed of two parts: assessment of reliability and validity, and assessment of generalizability or external validity. On the first visit, the local department of school health in Dubai gave permission for the study to be conducted on children in specific schools in their jurisdiction. In addition, permission from each school principal and a verbal consent by the students were also obtained prior to the start of the study.

During the class time and in the presence of the teacher for each class, ACDAS-Arabic was completed by each child after being administered twice, once by each of two observers in order to measure the inter-observer reliability, and, in addition, the chief investigator administered ACDAS-Arabic twice, one week apart, to each child in order to measure the intra-observer reliability. Statistical methods for numerical anxiety scores: Initially the scores from Part-A of ACDAS-Arabic the first 13 questions were summed to provide a numerical anxiety score for each child at each visit.

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The ACDAS-Arabic questionnaire results from the second visit of the children were used to determine the sensitivity and the specificity for different cut-off values of the total score for Part A to distinguish anxious from not anxious children. The receiver operating characteristic ROC curve, plotting the sensitivity against , specificity for different cut-offs, was used to select an optimal cut-off value for the new scale. In addition, bootstrapping[ 15 ] was used because data had not been collected at other schools on the visit to Dubai and it was not possible to travel to Dubai to collect additional data.

Bootstrapping is a simulation process which involves estimating the parameter of interest from each of many random samples of size in this instance by sampling with replacement from the original sample of size There was no evidence of a funnel effect in either of the Bland Altman diagrams assessing intra- and inter-observer reliability, and the limits of agreement for them were The sensitivity and the specificity of the ACDAS-Arabic were determined for different cut-off points of the numerical anxiety scores i.

The cut-off point closest to the top left hand corner of the receiver operating characteristic ROC curve is circled in red Figure 4. It gives the optimal results for sensitivity The area under the curve was 0.

A test which is perfect at discriminating between the two outcomes has an area under the curve of one. Convergent validity indicated that there was a strong relationship between DA and cognition. This result compared favorably with the previous result that was obtained from the two schools in London, as shown in Table 1 , which suggested that ACDAS-Arabic is working well in another location for another sample and it is a generalizable scale.

ACDAS was validated as the first cognitive dental anxiety scale for children and adolescents; it included questions about the dental experience in a logical order and not only the most common feared items as the previous scales. Moreover, it included the perception of losing control; embarrassment; self-confidence and the cognitive nature of the child as important factors in anxiety provoking.

This study has shown almost perfect results for both numerical and categorical outcomes; the children had to be at least 6 years of age, because younger children do not have the cognitive complexity required to report and react to dental situations accurately and they may not have the experience of dental situations. Given the significance of the crucial role of negative cognitive patterns in anxiety evocation that could make the person apprehensive and difficult to treat dentally and who also might not easily comply with anxiety treatment techniques, the present results were in line with the previous similar studies on adults.

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Fear and Anxiety in the Arab World
Fear and Anxiety in the Arab World
Fear and Anxiety in the Arab World
Fear and Anxiety in the Arab World
Fear and Anxiety in the Arab World
Fear and Anxiety in the Arab World
Fear and Anxiety in the Arab World
Fear and Anxiety in the Arab World
Fear and Anxiety in the Arab World

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