Obsessive–Compulsive Disorder

It has been noted by some of the counselors from our Cyber Counselor service that there seems to be a growing number of Obsessive-Compulsive Disorder (OCD) cases surfacing amongst the Muslim communities around the world. This article is intended to provide some information about OCD to those who are suffering from this disorder. As such, the symptoms of this disorder, some contributing factors, and some treatment alternatives will be discussed. Both the Western and Islamic perspectives will be presented.

Obsessive-Compulsive Disorder is characterized by unabated recurrent thoughts and images that are invariably distressing because they are violent, loathsome, threatening, or obscene in nature. They are recognized as the individual's own thoughts, even though they are involuntary and often repugnant. They are largely out of the person's control and often, the more the person tries to resist them, the worse they become. These unwanted thoughts generally produce a very high amount of anxiety. This is the obsessive component of the disorder.These thoughts lead a person to engage in behaviors that will relieve the anxiety or threat. Since the thoughts are recurrent, the resultant defensive behavior is also repetitive. For example, if the obsessions are about catching germs or becoming unclean, the person frequently washes himself/herself. If the obsessions are about personal safety and security, the person engages in repeatedly checking the doors and locks his/her house. These repetitive behaviors take up so much time from their daily life that they become unable to live normally. Paradoxically, the more they engage in these defensive behaviors, the more they are attacked by these obsessions. Thus, the obsession, followed by the compulsion, becomes such a vicious cycle that one cannot easily break out of it.Here is a case example that illustrates the nature of this disorder and how it renders a person totally helpless and dysfunctional. The person states:

I always feel that there is urine on my clothes so I feel unclean (napak) and keep checking my clothes to see if they are wet. I keep changing my clothes. I always feel that if I step on something wet and my feet get wet, then it is urine. If I burp, cough, then throw up, I think that my clothes are now dirty and I feel unclean; so I change my clothes and keep washing my mouth. When I make wudu’ (ablutions), I keep thinking it is not done right. When I do salah (ritual Prayer), I keep thinking that my hands are dirty because my mind keeps telling me that I have touched my private parts and so I am unclean; so I keep washing my hands. The same thing happens when I recite Qur’an. When I drive, I keep wiping my hands with damp tissues because I feel my hands are dirty. When I cook, I keep washing my hands because, again, I keep thinking that I have touched my private parts and have become unclean. I always carry tissues in my hands so I know I did not touch my private parts. I put safety pins on my dress to hold my dress down to ensure that I don't touch my private parts. Because of the fear of throwing up, I have started putting tissues in my mouth, so I don’t throw up. I know all of these things are weird, but if I don’t do it, I feel scared and unclean and very anxious. I feel that I am crazy, my husband and kids think so too. I try to stop thinking about these feelings, but they keep getting stronger, so I give in to the washing so the feelings will go away, but they keep coming back.

From an Islamic perspective, these unwanted thoughts are called wasawis (plural of waswasah), which are whispered into the minds and hearts of people by Ash-Shaytan (Satan). We find evidence of this in the holy Qur’an and hadith. Allah says,

[Then Shaytan whispered suggestions to them both, in order to uncover that which was hidden from them of their private parts"] (Al-A`raf 7:20).

[Then Shaytan whispered to him saying, 'O Adam! Shall I lead you to the tree of eternity and to a kingdom that will never waste away?] (Ta-Ha 20:120).

[Say: 'I seek refuge with Allah, the Lord of mankind, the King of mankind the God of mankind, from the evil of the whispers of the Devil, who whispers in the hearts of men] (An-Nas 114:1-4).

And the Prophet (peace and blessings be upon him) said,Abu Hurairah (may Allah be pleased with him) narrated that Allah's Apostle said, “Shaytan comes to one of you and says, ‘Who created so-and-so and so-and-so?’ till he says, ‘Who has created your Lord?’ So, when he inspires such a question, one should seek refuge with Allah and give up such thoughts” (Al-Bukhari and Muslim).These waswawis play a significant role in many mental disorders that involve anxiety and cognitive distortions.

To a lesser degree, these obsessions and compulsions result in what is known as Obsessive Personality Disorder. A person suffering from this disorder shows peculiar idiosyncrasies. For example, he/she might be quite particular about a specific way of maintaining cleanliness, or washing dishes, or wearing clothes, or making their beds, or doing their work. If things are not done exactly in that way, they become quite annoyed and frustrated. Some end up being perfectionists; they are hard to satisfy. They have very high expectations of themselves and others, and become very disappointed, frustrated, and annoyed if those high expectations are not met.

Recurring thoughts about catching germs, being unclean, and questioning one's faith appear to be the most common forms amongst Muslim men and women. The fear of catching germs and being unclean are most often found among women. Although globally the incidence of OCD appears to be about equal between men and women, in my practice with Muslim clients, I see more women seeking help than men; or it could be that Muslim women suffer from OCD more than men.The definite causes of OCD remain elusive. Genetics, some physical disorders, and environmental factors have been presumed to contribute to this disorder. Although there is no clear genetic evidence, OCD tends to run in families. A person with OCD has a 25 percent chance of having a blood relative who has it. In my practice, I have found that a person's sexual and interpersonal history may also be contributing factors.Often, people suffering from OCD also end up suffering from depression, a lack of self-esteem and self confidence, very weak willpower, relationship problems, and social withdrawal.Before a treatment plan can be devised, a thorough clinical assessment is required to determine the nature and severity of the symptoms and the possible causes and contributing factors.Let's look at a case example that exemplifies the influence of environmental factors in OCD.

I remember that after my son died, I decided that I will be a better Muslim. I looked at the most religious person that I knew. It was my mother-in-law. This person is on the prayer mat all the time—always praying, always fasting. So, I thought that she was a good example. I started thinking about the ways in which she does things and that's because she was so religious, so I thought she must be right. I started to see the behavior that she had towards things. She would not let anyone touch her things, which made me think we were not clean enough. If I washed something like a spoon or pots, then she would wash that item again three times. So I started thinking that everything had to be washed three times to be clean. So I started doing the same thing. Even before my son had died, I was “normal.” My mother-in-law does not put her clothes in the washing machine with ours, hers had to be washed separately. My husband even got her a separate basket for her clothes. Looking at her behavior, I thought that I was not clean enough. So, I began to be like her so that I would go to Jannah and see my son again.

From an Islamic perspective, these wasawis are meant to weaken the will and beliefs of a person. Let us look at some of the verses from the holy Qur’an in this respect.

[O Adam! Dwell you and your wife in Paradise and eat thereof as you both wish, but approach not this tree, otherwise you both would be of the transgressors. Then Shaytan whispered suggestions to them both in order to uncover that which was hidden from them of their private parts before. He said, 'Your Lord did not forbid you this tree save you should become angels or become of the immortals.’ And he swore by Allah to them both saying, 'Verily, I am one of the sincere well-wishers for you both] (Al-A`raf 7:19-21).

Let us also look at a couple of hadith.`Uthman ibn Abu Al-`Aas reported that he went to Allah's Messenger (peace and blessings be upon him) and said, “Allah's Messenger, A shaytan intervenes between me and my prayer and my reciting of the Qur’an and he confounds me.” Thereof, Allah's Messenger said, “That is (the doing of shaytan) who is known as Khinzab, and when you perceive its effect, seek refuge with Allah from it ands pit three times to your left.” “I did that, and Allah dispelled him from me." (Muslim).`Urwah ibn Zubair narrated from `A’ishah (may Allah be pleased with her) that one night the Prophet (peace and blessings be upon him) left her during the night and went out. `A’ishah (may Allah be pleased with her) said that she felt envious. When he returned, he found her in deep thought. He asked, "What happened to you O `A’ishah? Did your shaytan overpower you?” `A’ishah said, “O Prophet of Allah! Why would a woman like me be envious over a man like you? Is there a shaytan with me, O Prophet of Allah?” He responded, “Yes.” She asked, “Is there a shaytan with everyone?” He replied, “Yes.” She said, “Even with you, O Prophet of Allah?” He responded, “Yes, with me also, but Allah has made him obedient to me” (Muslim).

All human beings suffer from the wasawis, regardless of age, sex, faith, or creed. However, the nature, content, severity, and influence of these wasawis varies from one person to the other. For some, they only cause mild anxiety and worry, while others are more severely affected to the point of becoming spiritually, mentally, emotionally, psychologically, and socially paralyzed. In my experience, age, faith, family, sexual and religious history all play a significant role in determining the nature and content of these wasawis; while the severity and impact are determined by the pre-morbid spiritual, emotional, and psychological maturity of a person.

Obsessive Compulsive Disorders are treatable. Several treatment modalities have been traditionally used in the treatment of OCD, including drug therapy, cognitive behavior therapy, and relaxation exercises in various combinations, depending upon the nature, the severity, and the history.Most of the drugs used to treat OCD are antidepressants. These drugs have variable effectiveness in the control of the symptoms of OCD and depression. Apparently, these drugs do not completely stop the obsessive thoughts or the compulsive behavior, but reduce the related anxiety and depression, so reducing the felt severity of the disorder. So, they manage the severity of the symptoms, but do not seem to get rid of them. This is why drug treatment is generally used in conjunction with psychological therapies.Psychological therapies, on the other hand, attempt to help the client understand the root, the dynamics, and the possible contributing factors. The stress and anxiety are treated with relaxation exercises. Faulty beliefs arising out of the obsessions and leading to compulsions are examined. Here is a case example.

In the Qur’an, there is a verse that says, “And Allah loves those who purify themselves.” Also, the Prophet (peace and blessings be upon him) said, “Purity is half the iman.” So I keep thinking that I must keep myself clean or I am not good enough.

With relaxation, education, and cognitive behavior therapy, the person is gradually guided in correcting the faulty beliefs. Past traumas (like sexual/physical abuse) and unsavory conduct and lifestyles of the past that may be responsible for severe guilt leading to OCD, are dealt with. Appropriate home assignments are given to promote new and healthy thought process and beliefs. And, over a period of time, the obsessive thoughts and the compulsive behaviors begin to decrease.In cases where the symptoms of OCD are so severe that they render the person completely dysfunctional and lacking control over the thought processes, psychological therapies by themselves are not often very effective. In such cases, drug therapy is combined with psychological therapies to initially reduce the anxiety and depression and then followed by counseling and therapy.

From an Islamic perspective, where Allah Most High has given Ash-Shaytan the power to inject his poisonous whispers into the minds and hearts of the people, He has also guided mankind to defend themselves from these whispers. We find in the holy Qur’an

[So when you intend to recite the Qur’an, seek refuge with Allah from Shaytan, the outcast. Verily! He has no power over those who believe and put their trust only in their Lord (Allah). His power is over those who obey and follow him (Shaytan) and those who join partners with Allah] (An-Nahl 16:99-100).

[And deceive among them those whom you can with your voice. Verily! On my true servants, you would have no authority. Sufficient is your Lord as a guardian] (An-Nahl 17:64–65).

[And whosoever turns away (blinds himself) from the remembrance of the Most Beneficent (Allah), We appoint for him Shaytan to be his intimate companion] (Az-Zukhruf 43:36).

“Allah Most High has forgiven the wasawis that arises in the hearts of the people of my nation until one acts upon them or talks about them" (Al-Bukhari, Muslim).

In summary then, if one lives by his faith according to the guidance provided by the Creator, seeks Allah's protection from devils, does not keep talking about or give into these obsessions, and protects one’s mind and heart from the evil effects of these offensive, threatening, or obsessive thoughts, one will gain the strength to keep them under control.

While treating a believing client, combining these teachings of Islam with modern treatments of OCD has been found to be extremely valuable, effective, and efficient. However, it loses its effect if the therapist and/or the client does not believe in these teachings or is unwilling to live by his faith.