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OCD
1. Cognitive Behavioral Therapy of
Islamic Religious Obsessive
Compulsive Disorder
WALID SARHAN F.R.C.Psych.
Amman-Jordan
2. 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).
3. 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.
4. 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.
5. 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 ??
6. 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.
7. 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.
8. 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 36
functions
Need for order/symmetry 31
Aggression 28
Sexual 26
Multiple obsessions 60
10. Common Symptoms
Common Obsessions Common Compulsions
- Contamination fears of germs, dirt, - Washing.
etc.
- Imagining having harmed self or - Repeating.
others.
- Imagining losing control of - Checking.
aggressive urges.
- Intrusive sexual thoughts or urges. - Touching.
- Excessive religious or moral doubt. - Counting.
- Forbidden thoughts. - Ordering/Arranging.
- A need to have things “just so”. - Hoarding or saving.
- A need to tell, ask, and confess. - Praying.
11. 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).
12. 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
13. 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
14. 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 .
15. 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.
16. 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.
17. 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.
18. 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
19. 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.
20. 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.
21. Doubts
• Divorce
• Faith
• All rituals
• Retrospectives memories :Doubts that
one did something wrong in the past
22. 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,
23.
24.
25. OCD Impairment & Costs
• Social impairment
– 62% reported difficulty maintaining a relationship (Calvocoressi, et
al., 1995)
– Instrumental role performance and social functioning more
impaired in OCD than general public, depressed, or diabetics.
(Koran, et al., 1996)
• Estimated annual medical costs: 8.2 billion
– Based on detailed analysis of direct treatment expenses,
comorbidity, and mortality (DuPont,, et al., 1995)
• Occupational impairment & lost wages
– 40% unemployed due to OC symptoms (Calvocoressi, et al., 1995)
– Lifetime wages lost: $40 billion (Stein, et al., 1996)
26. Psychological Factors
Implicated in OCD
• Cognitive appraisal of intrusive thoughts
(Salkovskis, 1985; Rachman, 1997)
– Overestimation of danger
– Inflated personal responsibility
– Thought-action fusion
• Thought-suppression (Wegner et al, 1987)
• Cognitive deficits in selective attention
Deficits in inhibiting irrelevant stimuli (particularly internal ones
such as intrusive thoughts) (Clayton et al, 1999)
27. 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)
28. 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.
29. 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.
30. CBT (Cont’d)
• Patients who complete CBT report a 50-
80% 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 the 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.
31. 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.
32. 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.
33.
34. 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
35. blasphemous thoughts
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
36. 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
37. Obsessions and compulsions
• Giving in—transient relief-more
obsessions-proliferation of OCD and the
complications.
• Resistance – extreme tension – repeating
resistance and tension—improvement.
