Treatment of Islamic Religious Obsessive Compulsive Disorder WALID

Treatment of Islamic Religious Obsessive Compulsive Disorder WALID SARHAN F. R. C. Psych. Amman-Jordan

OCD Prevalence • Obsessive-compulsive disorder was once believed to be a rare condition. The prevalence rate of OCD in three catchment areas in a U. S. study ranged between 1. 9% and 3. 3% (Robins et al. , 1984). • In comparison, a study conducted in Cairo, Egypt, of 1, 000 psychiatric patients attending a university clinic showed an incidence of OCD of 2. 5% (Okasha et al. , 1968). • A replication of this study showed an incidence of 2. 3%, indicating the stability of the prevalence of the disorder over time (Okasha and Raafat, 1991).

Prevalence • 2% to 3% afflicted worldwide. • The rates are consistent across most cultures. • Males with an earlier onset - have a worse course than females. • Symptoms are present an average of 10 years prior to clinical presentation.

Prevalence Contd. • Sex: Equal in males and females. • Childhood-onset OCD is more common in males and more likely to be linked genetically with ADHD and Tourette syndrome. • Age: Symptoms usually begin in individuals aged 10 -24 years.

Religion • Religion is defined as ‘the belief in and worship of a superhuman controlling power, especially a personal God or Gods’ (Oxford English Dictionary, 2006). • The putative link between religion and OCD was first put forward by Freud ? ?

Religious Rituals There are several aspects of the three main monotheistic religions which related closely to the symptoms of OCD. It could even be argued that religion represents a culturally accepted form of OCD, which is encouraged in order to gain favor with God.

Is there a link between religiosity and OCD symptomatology? Whilst the question of whether religiosity causes or predisposes to OCD is still unresolved, there does seem to be considerable evidence in favor of a more subtle effect of religiosity on OCD. It has been reported that religious patients are more likely to complain of religious symptoms of OCD. This implies that religiosity may have an impact on OCD via symptomatology.

Most people with OCD have multiple OCD symptoms Frequency of obsessive – compulsive symptons Obsessions (% of 200 OCD patients) Contamination 45 Pathologic doubt 42 Disgust with bodily functions 36 Need for order/symmetry 31 Aggression 28 Sexual 26 Multiple obsessions 60

Multiple Compulsions (%of 200 OCD patients) Checking Washing Counting Asking/precision Symmetry/precision Hoarding Multiple compulsions 63 50 36 31 28 18 48

Common Symptoms Common Obsessions Common Compulsions - Contamination fears of germs, dirt, - Washing. etc. - Imagining having harmed self or others. - Repeating. - Imagining losing control of aggressive urges. - Checking. - Intrusive sexual thoughts or urges. - Touching. - Excessive religious or moral doubt. - Counting. - Forbidden thoughts. - A need to have things “just so”. - A need to tell, ask, and confess. - Ordering/Arranging. - Hoarding or saving. - Praying.

RELIGION &OCD • In this study, Turkish Muslim subjects were compared with Canadian Christian subjects on religiosity and obsessive-compulsive symptoms. Both groups were found to be equally religious. • No difference was found between highly religious subjects from either group and incidence of obsessional thoughts and compulsive actions, implying that ‘religiosity’ broadly predisposes to obsessive-compulsive symptoms. • Yorulmaz et al. , 2009).

The five pillars of Islam • Testimony that God is the one and only one God (with no partner, no son, no father, no companion, and no resemblance) and that prophet Muhammad is God's Messenger and prophet. • Praying • Paying zakat (specific compulsory charity) • Fasting month of Ramadan • Performing Hajj by whom who can afford it

Ghusl (Major Ablution) • Ghusl means major canonical ablution or a complete washing of the body. It becomes obligatory after sexual intercourse, even if only the head of the penis disappears into the vagina. Any discharge of semen, and the completion of menses and post-childbirth bleeding. • Before beginning ghusl, one should make the intention to perform it and, if one will pray after performing it, also the prayer

Wudu (Ablution) • Muslims, are required to wash five times per day before prayer. This washing is known as Wudu and is a form of ritual ablution. which involves washing several parts of the body in a specific order, each three times If a mistake is made, then the whole process must be begun again.

Islamic praying • Moslems, are required to pray five times a day. Each prayer is preceded with a ritualistic cleansing process (Wudu or ablution), . This ablution is invalidated by any form of excretion or ejaculation and, for some radical Moslems, by any contact with the opposite sex. The prayers themselves vary in length and consist of certain phrases and suras from the Holy Koran that have to be read in a certain sequence.

Religious symptoms -Egypt • Religious and contamination obsessions (60%) and somatic obsessions (49%) were the most common. The most common compulsions were repeating rituals (68%), cleaning and washing (63%), and checking (58%), mostly related to religious beliefs • The emphasis on religious rituals and the warding-off of blasphemous thoughts through repeated religious phrases could explain the high prevalence of religious obsessions and repeating compulsions among Egyptian.

Types of religious obsession • • Person has sinned or broken a religious ritual. Prayers have been recited incorrectly Repetitive blasphemous thoughts. Person think that has lost touch with God or their beliefs in some way. • Intrusive "bad" thoughts or images that occur during prayer, or reciting Quran or anytime. • Believing that one's religious practice must be 100% perfect, or else it is worthless. • Questions about God , existences and doubting the religion or some of its details.

Types of religious compulsions 1 • Saying prayers, or carrying out religious acts repetitively until they are done perfectly. • Constantly asking for God's forgiveness. • Rereading passages from holy Quran over and over to make sure that it is correct. • Double checking different religious acts or observances to be sure they were done correctly. • Protecting religious symbols, ornaments, books, or pictures from "contamination’’. --hoarding

Types of religious compulsions 2 • Trying to imagine special "good" religious images or thoughts to cancel out "bad" and irreligious images or thoughts. • When any activity was performed with a blasphemous thought in mind, having to redo it with a "good" thought.

Obsessions of Repetitive Blasphemous Thoughts and Images • • • In praying When thinking While reading Quran Images of God in inappropriate manner. Example : bad swearing words , or images are associated with the name of God.

Doubts • • Divorce Faith All rituals Retrospectives memories : Doubts that one did something wrong in the past

weswas • Other evidence of the religious connotation inherent in OCD in Moslem culture lies in the term weswas. This term is used in reference to the devil and, at the same time, is used as a name for obsessions. It is also characteristic of a conservative society like Egypt to expect sexual obsessions to be among the most frequent in female patients Psychiatric Times. Vol. 21 No. 5 April 15, 2004 Ahmed Okasha,

Treatment • During last 20 years, two effective methods for treating OCD have been stablished: – Cognitive-Behavioural Psychotherapy (CBT) – Medication with a serotonin reuptake inhibitor (SRI)

Components of Treatment • Education: Educate family and patients on how to manage OCD and prevent complications. Islamic. • Psychotherapy: Cognitive-Behavioural Therapy (CBT) is the key element of treatment for most patients with OCD. • Medication: Medication with a serotonin reuptake inhibitor is helpful for many OCD patients.

Cognitive Behavioural Psychotherapy (CBT) • Exposure and response intervention. • Exposure – person remains in contact with something they usually fear until their anxiety is diminished. • Response intervention – person’s rituals or avoidance behaviours are blocked (no repetition of ghusul , ablution or praying. • Exposure is usually more helpful in decreasing anxiety and obsessions, while response intervention is better at decreasing compulsive behaviours.

CBT (Cont’d) • Patients who complete CBT report a 5080% reduction in OCD symptoms after 11 -20 sessions. • Using CBT on a weekly basis, can take 2 months or longer to show full effects. • Practiced in therapist’s office, and do daily E/RP homework. • When the OCD is very severe, it is sometimes better to practice CBT in a hospital setting.

Behavioral Techniques • Behavioral techniques are most effective for certain types of OCD symptoms – particularly cleaning or checking rituals. • Best approaches are: Differential Reinforcement in combination with Relaxation Training and Stimulus Control techniques.

Tailoring treatment • Cognitive Behavioral Therapy (CBT) has been shown to be effective in the treatment of OCD • Avariant of CBT known as ‘guided prayer repetition’ has been proposed by Bonchek & Greenberg (2009) which, it is claimed, is a more acceptable and successful form of therapy for religious patients. It will be interesting to determine its use and effectiveness on a wider scale.

The advisory opinion of the legitimacy=fatwa § Not repetition in the purity or ablution or prayer, no matter how skeptical certainty even arrived. § This does not require that the prostration of forgetfulness § Divorce is not valid if there is no intention

blasphemous thoughts ﺗﺄﺘﻴﻨﺎ ﺍﻓﻜﺎﺭ ﻻ : . ﺟﺎﺀ ﺍﻟﺼﺤﺎﺑﻪ ﺭﺿﻮﺍﻥ ﺍﻟﻠﻪ ﻋﻠﻴﻬﻢ ﻭﻗﺎﻟﻮﺍ ﺍﺑﺸﺮﻭﺍ ﻓﻬﻮ : ﻧﺴﺘﻄﻴﻊ ﺍﻟﻨﻄﻖ ﺑﻬﺎ ﻓﻘﺎﻝ ﺍﻟﺮﺳﻮﻝ ﻋﻠﻴﻪ ﺍﻟﺴﻼﻡ ﺻﺮﻳﺢ ﺍﻻﻳﻤﺎﻥ The Companions (God bless them) came the prophet( peace be upon him), , they said. : thoughts come to our minds we can not say them The Prophet (peace be upon him) said: Cheer is an explicit faith

Guided prayer • The patient should not repeat prayers. • The group prayer is advisable. • The patient can pray with radio or television. • The recording of ghusul, wadu, and prayer on a cassette or CD

Obsessions and compulsions • Giving in—transient relief-more obsessions-proliferation of OCD and the complications. • Resistance – extreme tension – repeating resistance and tension—improvement.

Serotonin Reuptake Inhibiting (SRI) drugs • • • CLOMIPRAMINE (225 mg/day) FLUVOXAMINE (300 mg/day) PAROXETINE (60 mg) FLUOXETINE (60 mg) SERTRALINE (200 mg) (CITALOPRAM and ESCITALOPRAM) Copyright L M Drummond

Efficacy of augmentation for OCD with Dopamine Blockers • Overall only 1/3 of SRI refractory patients improve with addition of Dopamine Blockade (Bloch et al 2010). • Most of the studies are small but some better evidence for rispiridone than others Copyright L M Drummond

HIGH DOSE SSRIs in REFRACTORY OCD • Mostly open label studies have shown beneficial effect • A double-blind (non-placebo-controlled trial) of sertraline showed greater symptom reduction between 200 mg -400 mg. (Ninan et al. , 2006) • Retrospective naturalistic survey suggested high dose SSRI is associated with clinical improvement and well tolerated in treatment resistant patients (Pamploni et al. , 2009) Copyright L M Drummond

Deep Brain Stimulation • Approx. 58 patients with “severe” OCD have had DBS treatment in Continental Europe and North America. • 2/3 have a significant response (using 35% reduction as criteria) • One ongoing trial in UK. . . with patients who have failed all other reasonable medication and extensive CBT Copyright L M Drummond

Deep Brain Stimulation Copyright L M Drummond

Transmagnetic Cranial Stimulation Copyright L M Drummond

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