Zar Spirit Possession in Iran and African Countries: Group Distress, Culture-Bound Syndrome or Cultural Concept of Distress?

Headnote

Zar is the term used to describe a form of spirit possession common in northern African, eastern African, and some Middle-Eastern societies. Although these regions share some cultural similarities arising from their history of slavery, in these places, zar varies in prevalence, clinical characteristics, and social context. Based on a selective review of the literature, this paper looks at the place of zar spirit possession in both DSM-IV and DSM-V; it also examines how zar is manifested in Iran and in African countries including Sudan, Ethiopia, and Egypt; and it aims to provide practical information to mental health clinicians so that they can better understand how this cultural concept is practiced by Iranians and Middle Eastern and African immigrants living near the Persian Gulf coast.

Keywords: Zar, Spirit Possession, Culture-Bound Syndrome, Cultural Concepts of Distress, Mental Illness, Globalization, African Countries, Iran

Zar refers to a type of spirit, to the illness caused by those spirits who possess humans, and to the rituals needed to pacify those spirits (1). The zar cult is found throughout northern and eastern African countries such as Sudan (2-4), Egypt (5-8), Ethiopia (9-11), and Somalia, where it is called sar (12, 13), as well as some Middle-Eastern countries such as Kuwait (14, 15), Israel (16) and southern Iran (17-20). In these cultures, spirit possession is associated with dissociative episodes such as sudden changes in consciousness or identity that may include periods of shouting, banging of the head against the wall, laughing, singing, or crying. Possessed people may become apathetic or withdrawn, or may not be able to accomplish their usual responsibilities (21).

In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), zar is addressed as a culture-bound syndrome. DSM-IV contains symptomatic descriptions of 25 culture-bound syndromes. According to the Glossary of Culture-Bound Syndromes in appendix I of DSM-IV (p. 844), -[T]he term culture-bound syndrome denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be ?illnesses' or at least afflictions and most [of them] have local names. . . . [C]ulture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations." Although zar is not considered pathological in local cultures, depending on its severity, it can be perceived outside of the cults in which it develops as a symptom of more serious mental health problems (22), such as psychosis and/or dissociative identity disorder.

Similar to DSM-IV, in DSM-V, there are comments on specific culturally shaped syndromes-those few disorders around the world that are truly "bound" to one culture-but there are also discussions about the cultural concepts of illness and a deconstructed notion of culture-bound syndromes, which many believe were a legacy of colonial psychiatry. Based on the most recent change in DSM-V, culture-bound syndromes are actually better understood as some forms of Cultural Concepts of Distress such as cultural syndromes, cultural idioms of distress, and/or cultural explanations. According to DSM-V, "Cultural Concepts of Distress refers to ways that cultural groups experience, understand and communicate suffering, behavioral problems, or troubling thoughts and emotions. (23). This is one of the subjects that changed in DSM-V: rather than the long glossary of different syndromes, including z.r, offered by DSM-IV, there are examples providing more details that aim to clarify the concepts of culturally shaped or influenced symptom clusters (syndromes), of common modes of expressing distress that may not involve specific symptoms (idiom), and of explicit causal models, attributions, or explanations (explanatory model), with the acknowledgment that these concepts often overlap (24).

Although in DSM-V the z.r is not listed among the examples of the cultural concept of distress, it is still crucial to be aware that in the places where the z.r ritual is practiced, the patients clinical presentations may be influenced by the cultural concepts and modes of expression explained in DSM-V. People in the cults where z.r is believed and practiced use it when they face difficult circumstances such as marital conflicts, gender and social inequalities or in response to social and cultural changes (1, 15). Believing in z.r illness and following the z.r ritual as a therapy can therefore act as a method of coping with disruptive physiological, psychological, social, or supernatural conditions (16). Although the best known spirit possession within Islam is the z.r in northern and eastern Africa, possession cults are common and not confined to Muslims in Africa. Contrary to the common belief, z.r is not just an Islamic form of spirit possession, and the spirit possession is not always a positive experience (1, 25). Boddy (1989) has shown that z.r is practiced in Christian Ethiopia (which is different from what is practiced in Sudan). Also, Hamer found a similar cult in the south of that country called shatana (devil) (26); and Edelstain studied z.r among Jewish Ethiopians in Israel (16).

Similarity in the names of this spirit possession suggests that many of the cults are historically related although evidence has not directly addressed this claim. For example, in Chad, there is the liban sheitan (27, 28); among the Digo of the south Kenya coast, there is shaitani (29, 30); and among Segeju Swahili speakers in Tanzania, there is shetani (31). Moreover, the form of Masabe spirit possession among the Tonga of Zambia (32, 33) resembles the Sudanese z.r; the bori in Nigeria and North Africa; trumba and patros in Mayotte, Comoro Islands; saka or pepo among the Wataita of Kenya; takuka among the Ndembu of Zambia; holey (specifically, hauka) among the Songhay; and jnun curing activities, Iamadsha in Morocco (1, 28). Sudanese and West African pilgrims in and en route to Mecca have been seen to participate in each other es spirit rituals (following the Ottoman conquest in 1820). Moreover, in several cults, possessive spirits and z.r are associated with winds.: pepo in Swahili, iska in Hausa, rih/rowhan in Arabic (1, 34 and 35). Similarly, in southern coastal regions of Iran near the Persian Gulf such as Bandar-e-Abb.s, Bandar-e Lengeh and Qeshm Islan, z.r is known as the harmful wind. (b.d or Hava) associated with spirit possession beliefs. It is believed that these winds can be either fearsome or peaceful, Muslim or infidel. In these regions, z.r is the infidel winds which are considered harmful. Among the local people, there are various winds known z.rs, most of which cause disease, discomfort, and mental illness in their victims. Some of these z.rs are called Maturi, .ay. angar, Dingem.ru, Omag.re, Bumaryom, Pepe, B.bur, Bibi, and Namrud (19, 20).

Considering the globalization and the migration of a large number of people from rural areas and small cities to larger cities, as well as immigration from low- and middle-income countries to high-income countries, it is important that mental health clinicians familiarize themselves with z.r, this formerly-called culture-bound syndrome, and its historical roots in different contexts. Based on a selective review of cultural psychiatry and medical anthropology literature, this paper aims to provide clinicians and researchers with a sociocultural and historical understanding of z.r spirit possession that will help them identify this condition in clinical settings in order to avoid misinterpreting it as a psychosis and/or dissociative identity disorder and to increase intervention efficiency.

Forms and Variations of Z.rs in African Countries

Ethiopia:

According to a well-known Ethiopian story, Adam and Eve had thirty children and to protect the most beautiful ones from the Divine envy, Eve tried to hide fifteen of them in the Garden of Eden, out of God es sight. God, who was all-seeing, got angry with Eve and declared that those children would remain invisible for eternity. The fifteen invisible children became the ancestors of resentful and unpredictable spirits like z.rs, and the other fifteen became the ancestors of humanity. In Ethiopia, if a z.r chooses a person, then that person would be a member of the z.r cult. The z.res intention almost always would be identified by the physiological symptoms that have not effectively responded to the existing medical options. The most common symptoms include headaches, lethargy, or infertility, which different types of healers, including biomedical doctors, could not treat (9, 16). Researching on group psychotherapy in an Ethiopian possession cult, Allan Young describes that the Amhara are Christian minorities who mainly live in the central and northern provinces of Ethiopia such as Shoa, Gojam, Wollo, and Begemder. Traditionally, Amhara men have such occupations as farmers, clergy, civil servants, soldiers, and petty traders. Young also emphasizes that the spirit possession cult is not a unitary phenomenon throughout this area and that there are important ritual and cosmological differences from place to place. In most African areas where zar is prevalent, women are the majority of the sufferers, whereas in Ethiopia, a greater proportion of men are afflicted with zar .

Although spirit-possession-related illnesses are treated as an ancillary concern by most cult members, in the Amhara, zar-related illnesses are considered important in terms of the relations between cult spirits and cult members both during and after initiation. In fact, participating in illness episodes provides members with the adaptive strategies that the cult offers (9).

Egypt: In a study on the spirit possession cult in Nubia, Egypt, Kennedy (1967) provided a clear picture of the Nubian zar cult mentioning several methods that the Nubians use to deal with their health disturbances. Among those methods, zar is known as the most powerful therapeutic practice; it is effective for several types of illnesses and is specialized for alleviating states of hysteria and anxiety. According to the Nubian disease theory, illnesses are caused by the evil eyes of envy, the breaking of taboos, and sorcery, which all are associated with spirits; mental illnesses are mainly caused by spirits or jinn. Nubians believe that the spirits or jinn occupy rooms and houses when no one is at home. They will then enter the person's body-specifically angry or aggressive persons, who are more attractive to the jinn. However, the spirits or jinn, rather than the possessed person, would be blamed for the erratic behaviour (6, 36). The Nubian zar ritual deals with the demonic powers of bad spirits such as sheytan, jinn, or zar. Similar to the Ethiopians, Egyptians use the zar ritual only when other curing methods have not succeeded. It means that the demons have succeeded. The ceremony aims to persuade the spirits rather than coerce them. The patient is usually associated for the rest of his life with the particular spirit or spirits that caused the illness. Because there are overtones of an alliance with evil powers, the patient has the responsibility to satisfy this zar or jinn with a special ritual at least once per year .

According to Kennedy, the zar ritual in Nubia, which is mainly an adult female activity, reflects Nubian social conditions in terms of sex segregation, gender inequality, low female status, the restriction of women from religious participation, relative isolation, and marital insecurity. By observing the non-sick participants, he also supports his hypothesis that zar and other ritual activities allow not only the sick persons (possessed ones) but also the normal persons to be relieved of persistent and regular anxieties and tensions arising from Nubian life conditions. The common symptoms of the zar-possessed person include apathy, withdrawal from human company, minimal communication, refusal to work, strong desire to die, anorexia, and insomnia. Anxiety reactions or hysteria reactions like paralysis are also seen among the majority of the zar patients, and dissociative states are an outstanding characteristic of the zar ceremony. Although the zar ritual is specialized for healing these cases, a few psychotic patients are reported to have been healed as well. It is also assumed that the ceremony is like an acting-out of wish-fulfillment fantasies on the part of the women participating; the spirit who possessed the person demands material favours such as jewellery, new clothes, or expensive food, which the husband is expected to provide. The audience's responses provide social support and temporarily indulge the possessed person's wish fulfillment. Although ethnographers suggest that most patients are prone to hysteria or anxiety, the cult members feel that wass wassa (a depressive condition) is healed by zar (6, 36).

Sudan:

In Sudan, possession is usually associated with an illness that can be caused or intensified by spirits. However, it is not the case of every sickness. Doing ethnography on zar possession in the Hofriyati community of northern Sudan, Boddy states that the villagers attributed the illnesses to the variety of factors resulting from natural causes and that only the stubborn symptoms such as persistent headaches, nausea, anorexia, lassitude, apathy and depression, sleeplessness, anxiety, unspecified aches and pains, being easily saddened, and fertility problems may be ascribed to zayran (different kinds of zar). Similar to Kennedy's observations in Nubia, some hysterical conversion disorders (as defined in the West) are reported in Hofriyati (e.g., blindness or paralysis of one or more limbs without diagnosed biological cause). These conditions are mainly associated with the zar possession. However, Hofriyati people might also link them to other supernatural causes, like sorcery (amal) or the evil eye (ayn harra), that make people more susceptible to spirit possession. In the Hofriyati, someone who is considered to be zar-affected is called either inda zar or inda dastur, which means -she has a spirit," or is said to be mazur or madastir, which means -with a spirit," possessed. Zar possession is known as an affliction and is expressed as an illness. Moreover, it is believed that zayran never abandon their hosts' body, which means a person who is possessed will be always possessed and will be affected by her spirit(s) at any time. Villagers say if zayran infiltrate their hosts' body, it will coincide with the latter's entrancement. The spirit's forceful entry into the body, which Hofriyatis called ghaybiya or ghaybuba (possession trance), displaces the person's self to another perceptual stage. A trance is only one of many manifestations of possession as zayran affect their hosts in various ways (see also 4, 28). The possession trance usually occurs inside of the ritual contexts. In this situation, -One is not diagnosed as possessed because she becomes entranced; rather, she becomes entranced because she is possessed" (34, 35).

In Sudan, the possession ritual is not considered exclusive to women. However, spirits are attracted to married women, mostly between the ages of thirty-five and fifty-five, and rarely affect unwed women, whose fertility has not been activated yet. Spirits are also known to covet those women who use henna, perfumes, soaps, and scented oils, and wear gold jewelry and diaphanous wraps. As Boddy observed (1989), -[T]he proclivities of zayran are symmetrical to those of Hofriyati women: both are regarded as consumers of goods provided by men (p.141) (1)." Lewis (12, 15) claims women use zar possession as a strategy to cope with their subaltern social position. However, Boddy argues that this sexual disproportion among possessed persons is attributed to the link between the possession and fertility, which women are identified with and are responsible for (1).

Zar in Iran

Despite the variety of spirit possession rituals, people from southwestern to southeastern Iran believe in metaphysical forces. In these regions, people believe in and practice zar; however, there are varieties in the zar cults. In Baluchistan, in the southeast of Iran, these harmful winds are usually called Gowat (wind or air), which is equal to zar in the south (37). According to the people in these regions, most types of zar cause disease, discomfort, and serious chronic illnesses for the afflicted. They believe that the zars could be contagious and people can give their zar to those whom they love or hate. Similar to the African zar cults, these people also believe in the eternality of zars, which means that one who is possessed will be always possessed but can only come to terms with the spirits to leave the victim alone. In these cults, the zar ritual is not a female practice, and the poor and deprived people such as fishermen seem to be the most common victims (38, 39).

The origin of Iran's Zar: The word -zar" in Farsi means desolate, feeble, languid, and weak; and it is derived from Persian rather Arabic (18) or more plausibly-given the long establishment of the cult in Gondar and vicinity-Amharic (6). However, according to Boddy (1989), the term zar probably originated from the Arabic zahar, meaning ?he visited.' In Hofriyat, it is often pronounced as zahr, meaning ?he became visible, perceptible, or manifest.' Both shifts are applicable in the possession context, where spirits become visible by entering the human realm via human bodies, temporarily displacing those bodies' human selves. Although there is a marked resemblance amongst the Zar rituals in Iran and many African countries, the origins of the zar cult and its name are obscure .

These similarities suggest a common origin for this belief and practice (19). In the 20th century, scholars pointed to an Ethiopian or Abyssinian origin for zar; however, other origins, like Persian, have been also theorized (40, 41). Frobenius assumed common cultural traits between Persia, northeast Africa and the Sudan region and hypothesized that zar and bori were manifestations of an early system of beliefs originated in Persia (42), but because of the dominant presence of Africans amongst the cult members, it has been suggested that this belief and ritual might have been imported from Africa to the southwest of Iran (18, 40, 43). Studying the historical roots of the zar-bori cults, Lewis states, -[T]his cult or complex of cults, has its roots in Islamic West Africa (principally Nigeria and Niger), source of the bori component, and in Ethiopia, with its mixed Christian and Islamic heritage, source of zar. In Sudan, both these currents flow together forming, in the presence of local tumbura and other local cults, the hybrid zar-bori which has in turn spread to north Africa and Middle East"(15). Not all scholars agree with this hypothesis about the origin of Zar cults, and some believe that this spirit possession cult originated in Persia (39). It has been said that Persians applied the name zar to the cult when African sailors from the southeast coast of Africa introduced this ritual to them in the 16th century (18, 19). However, Mirzai Asl (2002) stresses that spirit-possession beliefs and practices such as zar, gowat, and liwa derived from Africa and spread wherever the enslaved settled. Based on this assumption, in the 19th century, as a result of the slave trade from Africa to Iran, the zar rituals have been kept in Iran as part of the heritage of African slaves, allowing them to reconstruct their identity.

Slavery and Persian Zars: Africans were enslaved, transported, and sold through the slave trade network in the African interior. Most enslaved Africans were shipped through the sea trade route of the Indian Ocean, which ran from the Swahili coast to Muscat, the Ottoman Empire, the Arab States, and Iran. Thus, most of the Africans sent to Iran through the slave trade came from northern and eastern Africa through the Persian Gulf. Moreover, Iranian pilgrims brought another group of slaves from the Arabian cities of Baghdad, Karbala, Mecca and Medina to western and southwestern Iran. The landed slaves were taken to the customs houses at the Iranian ports and were sent from there to various cities of Iran, which had specialized slave markets in the 19th century. Local people in southern cities bought most of the enslaved Africans. A small number of slaves were also sent from southern ports to other parts of the country and were absorbed in different socioeconomic sectors. Most of the slaves who settled along the Persian Gulf coast worked as pearl fishers, laborers, or domestics. Some of them settled in the capital city and other big cities and were engaged in specific tasks in the harems of the Shah and princes. In harems, African male slaves served as lala (male nurses) and female slaves as daya (nanny) and dada (female nurses) and their children were called khanazad (house-born) (39).

The prophet Mohammad rejected the idea of slavery. The Quran established rules related to the treatment, sources, marriage, and emancipation of slaves. In Islam's view, slaves have to be considered as a part of the household and had to be absorbed into the society after they converted to Islam. As converting non-Muslims to Islam and freeing the slaves are advocated and valued by Mohammad, Iranians had the religious justification to employ slaves, convert them to Islam, and then treat them as equals with the Iranian employees. This religious belief helped Persians to consciously justify enslavement; however, they might have treated the slaves as a part of their household .

The trade of African slaves to Iran shaped the diaphonic communities of Afro-Iranians along the coast of the Persian Gulf in the southern parts of the country. However, because the slaves were integrated into a society dominated by non-blacks, they were invisible in certain areas of Iran. Nevertheless, the African heritage has been kept alive by the survival of the Afro-Iranian community in a few regions in southern Iran. Slavery and the diasporas of Africans from eastern and northern Africa allowed the slaves to introduce their cultural beliefs and practices to wherever they settled. These cultural features and traditions helped them preserve their heritage (39, 44). In southern Iran, the two societies of Africans and Iranians shared their cultures. As a result, the values and beliefs of enslaved Africans did not dominate the host culture but were integrated into the new culture. Despite the cross-cultural variations, the imported African culture underlined principles representing African unity and Africans' supernatural beliefs. For example, the presence of different African healing cults distributed in different countries bordering the Indian Ocean including Iran exemplifies African cultural exportation (45). As shown earlier in this paper, zar has been practiced in Sudan, Egypt and Ethiopia, especially in the Gurage region and among the people of Gurage and Shoa. Iranian literature also attributed the ritual of the zar spirit possession in Iran to the enslaved Africans (41). However, since the mid-1920s, when the Iranian government (mainly Iran's Ministry of Health) banned the practice of spirit possessions, most of these rituals have gradually become undetectable (18).

Zar Ritual in Iran: The zar ceremony has changed over time and from place to place; however, two common phases are recognized in most of the zar rituals along the Persian Gulf coastline: separation and incorporation. Sabaye Moghaddam in the Encyclopadia Iranica explains these phases (46). According to her, the separation phase that refers to the preparations for the zar begins with a person complaining about feelings of disease and discomfort to Baba zar or Mama zar; Zar cult leaders, who in African countries are called Sheikh (male leader) and Sheikha (female leader), in Iran are called Baba zar or Mama zar. All cult leaders are black, and some of them have already been possessed by zars and have managed to control them. Most of the cult leaders believe that the patients should join the zar only when their doctors cannot treat them. However, there are some cult leaders who believe that the needles from the injections prescribed by the doctor will further agitate the zar and create more problems for the patient. When Baba or Mama zar chooses someone to heal, the patient will stay in the Baba or Mama zar's home for up to seven days. During this separation phase, only Baba zar or Mama zar can visit the patient; moreover, the patient's body is washed with seawater and every night Baba zar or Mama zar rubs a combination of aromatic herbs and spices on the patient's body. In the last day of the separation phase, when the patient's body is cleaned and washed to be prepared for the incorporation phase, one of the cult members, who is usually the one who has formerly been possessed by zar, informs everyone about the upcoming zar ceremony. Ahl-e-Hava (Eve's family), who are people who have already been possessed by the zar and have been treated at least once, have to attend every zar ritual. In addition, other people of the cult, who may or may not be possessed, also participate as it is considered a sin not to attend a zar ritual. Depending on how big the Baba or Mama zar's home is, the ritual can be inside or outside the house. Participants gather in a U-shaped open area-Maidan-with a patient sitting in the center. A piece of tablecloth including eggs, confetti, dates, and aromatic herbs is placed on the floor in the center of Maidan. After Baba or Mama zar covers the patient's head with a piece of white cloth, a big tray holding aromatic herbs on burning charcoal is passed around and the patient and all participants are frequently incensed with the smoke from the mixture. The zar leader-Baba or Mama zar-leads the music, which involves local drums played by musicians and which is followed by others who are present at the ceremony. The leader is someone who knows the name of the zars and its related music (the specific beat of drums). The leaders also sing and the participants respond to them. Songs of the incantations can be in a different language or just melodic sounds without lyrics. During the singing, when the zar hears its related music, it makes itself known through the body of the patient, who feels a strong inner urge to move. Every spirit has its own piece of music and some members of the cult, mainly Ahl-e-Hava, may start moving and shaking with every piece of the music, as they are supposed to be the eternal hosts of the zar. The leader cannot identify the zar until the patient reacts to the music, so musicians change the tune until the zar takes over the afflicted; the signs of this occurrence appear when the upper body and the head swing and the shoulders shake .

When the zar is identified, Baba or Mama zar starts to communicate with the zar in a language that is ordinarily unfamiliar to themselves and the patient. This language is a combination of Persian, Arabic, Swahili, and Indian. Through this communication with the zar, the healer tries to find out the reasons behind the affliction and what the spirit wants in exchange for leaving the patient alone. Through the afflicted, the zar names its demands, which vary from simple things, such as a few prayers or a piece of bamboo (.eyzaran), to something more considerable, such as a sacrifice. Baba/Mama zar assures the zar that its demands will be met by tying a piece of cloth around the patient's arm. It is believed that if the zar's wishes are not granted, the zar will return and make more trouble for the patient. Depending on how easily the demand of the zar can be fulfilled, it will be quickly provided during the ceremony or will be met in a similar ritual later. For example, if the zar requests a sacrifice and that sacrifice can be provided quickly, then the cult members slaughter the animal; and after that, the patient, healer, and Ahl-e-Hava drink the blood. If the animal cannot be provided, then in another zar ceremony, this patient will ride in on an animal, which later will be sacrificed. The patient is then considered a cult member (Ahl-e-Hava) and must participate in all future ceremonies. These ceremonies can last for a week after the separation phase. There are also certain rules for the cult members: their clothing must be always clean and white and they must not touch the animal or human corpses, drink alcohol, or have sex outside their marriages. Also, they cannot sell or give away the object the zar has asked for, and if it is portable (e.g., clothing or an accessory), the patient must bring it to all future ceremonies. Otherwise, the zar will possess the patient again and the ceremony has to be repeated (also see Reading Saedi's AHL-E Hava by (47).

According to the people of southern Iran, the zar practice has changed over time from a simple ceremony that needed only a sheep to sacrifice to a more luxurious and expensive ritual. Moreover, since the mid-1920s, when the Iranian government, through reports provided by the Ministry of Health, forced the spirit believers to reduce the extent of the ceremonies, most of the zar cults disappeared from many regions, including Bushehr. The development of modern medicine and hospitals in Iran has also influenced the way people in these areas viewed and dealt with their health problems; however, zar beliefs and rituals have not completely disappeared from Persian Gulf islands like Queshm (44, 48).

Conclusion

Zar (harmful -wind") refers to the spirit possession that causes illness. Believing in the zar illness and the practice of the zar ritual as a therapy originated in Northern and Eastern Africa and was transported to other countries in the Middle East (such as Kuwait and Iran) through slavery. In most African countries, zar is mainly an adult female activity-involving married women mostly between the ages of thirty-five and fifty-five-which reflects the condition of sex-separation, low female social status, marital insecurity and relative isolation. Young states that the woman seeks remission from a sickness caused by the zar (9). She remains in a cult because she knows that when she is chosen by the zar, she will be vulnerable; and to control the disturbance, she has to participate in the cult activities. However, the psychic and social advantages that a woman gains from participating in the cult are related to the special characteristics attributed to the zars. Similar to the African cults, in Arab countries like Kuwait, it has been reported that zar attracts middle-aged and middle-class women who have become isolated through the westernization of the society and who are looking for their familiar traditional world (15). This sexual disproportion could be due to political, economic, and social transformations in Hausaland that led to the social exclusion of some middle-aged Muslim women. Participation of this group of women in the bori cult is explained as their strategy to deal with a male-dominated world (39).

Nevertheless, in southern Iran, women are not the only ones who are affected by zar. In the regions where the zar cults still exist, everyone is subject to the action of the zar, but the poor and the deprived, such as fishermen, seem to be the zars' most common targets (18, 39). Although the prevalence of psychological disorders among the people of southern Iran has been attributed to the hardship in their lives (37), people with specific social status or gender participate in parallel spirit possession rituals in different corners of the world; this suggests that participating in such ceremonies has other reasons besides healing. The trance state of patients in the zar ceremony gives them a chance to shift the responsibility of disturbing behaviours and feelings from themselves to the spirits. Connecting to the zar cult also gives people the possibility to connect with the cult members who have suffered similar problems and allows them to observe their cultural values in a culturally safe atmosphere .

Zar was considered as a culture-bound syndrome in DSM-IV; however, due to some innovations in DSM-V that led to a change in the notion of culture-bound syndromes and the appearance of cultural concepts of distress, the zar lost its place on the list of relevant examples. Several generations of anthropologists and cultural psychiatrists have tried to understand whether the languages that people use to explain their suffering can be brought into the psychiatric realm as conceptual tools. In the latest version of DSM, few disorders that are truly -bound" to one culture have been identified. Luis-Fernandez points out that these disorders are seen in different cultural contexts with the similar presentations, and though rarely, there are different cases across very diverse societies. He also emphasizes that all disorders, regardless of the context, are influenced by the cultural concept of the patient (49).

Balhara (2011), in his study on dhat syndrome-another formerly-called culture-bound syndrome and newly-called a cultural concept of distress-adds that even though these psychiatric disorders are classified under the same diagnostic category, various local cultural beliefs, attitudes, and knowledge generate different manifestations and illness models of these disorders in different cultures (50). According to him, one of the reasons behind the limited published literature on these conditions (e.g., no published randomized trial of interventions for dhat) is that they were categorized as culture-bound conditions, which led them to be considered as specific to certain regions. Moreover, categorizing such conditions, e.g., culture-bound syndromes, is unlikely to improve the management of these conditions (51). In contrast, cultural concepts offered by the Cross-Cultural Issues Subgroup (CCIS) of DSM-V bridge this gap by providing clinicians with the opportunity to obtain useful clinical information, to improve clinical rapport and engagement, and to improve therapeutic efficacy (49). Furthermore, cultural concepts guide clinical research that can facilitate the integration between cultural and clinical knowledge by identifying patterns of comorbidity and underlying biological substrates. In terms of cultural epidemiology, -distinguishing syndromes, idioms, and explanations provides an approach for studying the distribution of cultural features of illness across settings and regions, and over time. It also suggests questions about cultural determinants of risk, course, and outcome in clinical and community settings to enhance the evidence base of cultural research" [p.759] DSM-V(23).

Finally, due to the rapid increase in globalization and cultural diversity, particularly in Western societies, cases with any or all of the three new terms listed within the cultural concepts of distress-including culturally shaped or influenced symptom clusters; cultural idioms of distress; and explicit causal models, attributions, or explanations-are more likely to seek mental health care in different cultural contexts. Moreover, as it is mentioned in DSM-V's cultural formulation chapter, cultural concepts provide clinicians with a framework that can help them to avoid misjudging the severity of a problem or assigning the wrong diagnosis because of its cultural variation in symptoms and/or in explanatory models (e.g., unfamiliar spiritual explanations such as zar may be misunderstood as psychosis). Given that clinical presentation of a patient can be influenced by cultural concepts and modes of expression, it is crucial for clinicians to be able to understand the sociocultural and historical contexts of where the illness is developed and how people in those contexts perceive their own mental health suffering.

Funding

Mianji Fahimeh: Doctoral Award; Global Health Research-Capacity Strengthening Program (GHR-CAPS) - Trainee Award; McGill Institute for Health and Social Policy.

Acknowledgment

We would like to thank Stephen MacDonald for revising the paper. The Cultural Psychiatry course organized by Dr. Laurence Kirmayer in the 20th Annual Summer Program in Social and Transcultural Psychiatry, McGill University, contributed to the development of these ideas.

Conflict of Interest

We declare that we have no conflicts of interest in the authorship or publication of this contribution .

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