Rituals, purity, scrupulosity— these are words that come to mind when speaking about religion. They also come to mind when tackling the gnarly subject of Obsessive Compulsive Disorder (OCD), a mental disorder that affects approximately 1-2% of the global population. While often characterised in popular media by one of its better-known manifestations—compulsive hand washing or cleaning— OCD is a complex, multi-faceted disorder.
Each year, the second week of October is set aside to raise awareness and promote understanding of this disorder; this year’s edition took place from October 8 to 14. As it winds down, here’s looking at some of the dimensions of OCD disorder, and how it may affect individual existences.
What is OCD?
OCD is a disorder characterised by frequent, unwelcome intrusive thoughts— the obsessions — and repeated actions to bring relief for the distress generated by these thoughts — the compulsions.
While previously considered a part of the anxiety spectrum of disorders, the fifth version of Diagnostic and Statistical Manual of Mental Disorders (DSM-5),published by the American Psychiatric Association, places Obsessive-Compulsive Disorder in its own category titled ‘Obsessive-Compulsive and Related Disorders,’along with a host of other conditions such as body dysmorphic disorder, trichotillomania (hair pulling disorder) and hoarding disorder.
OCD thoughts are ego-dystonic— not in line with a person’s self-perception or what they believe to be fundamental to their being. Individual sufferers may present different levels and types of obsessions and compulsions— some may seemingly suffer from obsessional thoughts alone, a form sometimes separately described known as ‘Pure O‘ by some researchers and writers.
Compulsions may run the gamut from the more well-known repeated cleaning and hand-washing rituals, to checking and mental compulsions. The eventual goal of these is to enable the sufferer to ‘set things right’ mentally— not performing the compulsion may feel like not preventing a terrible incident from occurring, or continuing to feel distress. OCD can centre around a host of subjects — contamination (both internal and external), checking, sexual subjects, religion or scrupulosity, harm, and symmetry. It may also alter throughout a patient’s life-time.
The jury is still out on the exact causes for OCD; theories centre around abnormalities in brain structure and functions, genetics, and the environment.
A common theme reported among OCD patients is feeling ashamed, guilty or embarrassed. In some cases, it can be debilitating to professional and personal life, with persons requiring hospitalisation. As with several mental illnesses, there is also a heightened risk for suicidal tendencies.
Obsessive thoughts and history
The term obsessive compulsive disorder is noted to have come into being in the 20th century, following on the heels of the term obsessive neurosis described by Sigmund Freud.
Obsessive thoughts and ideas themselves have been a part of historical description in many cultures, a paper notes. The word obsession itself, it highlights was derived from the Larin obsidere, which means being possessed, occupied or preoccupied by something.
Religious ideas as the focal point of obsession have been described in texts belonging to various cultures and religions; some examples cited include an Arabic manuscript entitled Sustenance of the Body and Soul written by Muslim scholar Abu Zayd al-Balkhi in the 9th century AD and an ascetic text entitled The Ladder of Divine Ascent, written by Saint John Climacus, abbot of St. Catherine Monastery, Sinai, in 7th century AD— which talks of blasphemous thoughts.
It was Sigmund Freud who came up with the hypothesis that there was a relation between what he described as obsessive-compulsive (OC) neurosis and religiosity, referring to it in multiple writings starting from 1907. He notably described religion as a universal obsessional ritual.
This hypothesis did not find favour among religious leaders or psychologists; indeed there was also the counter-argument that religion contributed to social connection and cohesion. And now, science and psychology have progressed through multiple evolutions; many of Mr. Freud’s theories were discarded as psychological and physiological investigations into mental illnesses progressed. Advancements included a growing understanding of the nature of thoughts, their pathological basis and clinical descriptions. Indeed in the 1980s, Rachman and Hodgson suggested that “[t]he concept of obsession has survived three historical states – religious, medical, and psychological.”
Morality and religion often express a pre-occupation with purity and contamination; the idea of purity and pollution was a part of theological traditions ranging from ancient Greek religion to Protestantism and Hinduism. Rituals and traditions are often ways to guide “right living” and “right action” — for example, the concept of living a certain way ensuring good karma in Hinduism, or the concept of ridding oneself of sin in Catholicism. There is a broad overlap in linguistic terminologies, and social advice prescribed for the mentally ill may track along concepts of discipline, moral living and righteousness; an OCD patient interviewed by The Hindu earlier spoke about needing to accept that OCD is “not an extension of the self.”
It does not help that while reading of OCD, there exists a specific manifestation which may be broadly called ‘religious OCD.’ So how does the twain intersect? I asked the authorities.
Religious OCD: What are the specific set of behaviours associated with scrupulosity?
“When people say religious OCD, what they mean is blasphemy-related thoughts,” says Dr. Y.C. Janardhan Reddy, Head of the Department of Psychiatry and OCD Clinic at the National Institute of Mental Health & Neurosciences (NIMHANS) in Bengaluru.
He adds that these are broadly related to scrupulosity: “the fear of doing something sinful, perhaps something that is an insult to religious beliefs…people very commonly have certain thoughts or that they have said or done something which may be considered blasphemy.” OCD thoughts may also overlap; as noted above the class of symptoms may include thoughts of internal impurity and contamination, sexual thoughts, and thoughts related to religion, blasphemy and morality —the cluster known as scrupulosity.
Dr. Reddy offers examples of such scrupulosity-related OCD thoughts— you may be a very religious person, but in a sacred setting you may get a sudden, intrusive thought of spitting, or throwing shoes, or, even more painfully, nude images of gods or goddesses. The key marker are that these thoughts are “against their wish,” Dr. Reddy explains. “They know they are silly irrational thoughts, and they try to neutralise these thoughts.”
This could take the form of avoiding going to the temple, stopping prayers, replacing the bad thought about god with a good thoughts. An OCD sufferer could spend “hours and hours in this vicious cycle,” Dr. Reddy says. They may feel “anxious, distress and ashamed,” and believe the thoughts may be due to one’s character— believing that “the very fact that I get these thoughts means that I am a bad person.”
OCD rituals vs religious rituals
Dr. Reddy is emphatic in stating that no particular religion or religiosity predisposes a person to OCD, although there have been some unconfirmed reports, he says.
Indeed, multiple papers have sought to explore this domain. In a June 2021 paper published in the Psychopharmocology Bulletin, researchers examined the interplay of religiosity, guilt and OCD symptoms, specifically in the Indian context. Its stated objectives were “to seek the role of religiosity and guilt in symptomatology and outcome of OCD.” and to “assess the pattern of symptomatology of patients with OCD and the relation between religiosity and guilt.”
The study lasted for a year, and comprised of 50 subjects of both genders aged between 18-45. A majority of the patients belonged to the Sikh religion (70%) followed by the Hindu religion (28%) and only 1 patient was from another religion. They were assessed on 3 scales: the Yale-Brown Obsessive Compulsive Scale for severity of OCD, the Belief into Action Scale for religiosity and The Guilt Inventory instruments for guilt. The results, in a nutshell, were that OCD severity was positively corelated with religiosity and guilt at the baseline. But after a 6-month follow up, OCD severity was negatively correlated with religiosity and positively correlated with guilt
The study itself noted that the “equivocal nature of the findings reflected religiosity is a potential sphere for the development of OCD phenomena rather than a specific determinant of this disorder.”
Similarly studies have sought to highlight differences across cultures; a paper noted more religious obsessions in samples from the Middle East; other studies have suggested Catholics may be at a greater risk for OCD and higher severity, and differences in OCD manifestations among Orthodox Jews and Muslims.
As a paper noted, a review of academic literature and study seemingly “do not associate religion itself as an etiological factor for OCD”, noting, however, that “they do refer religion as a part of the person’s culture, which seems to play an important role in how OCD is manifested.”
The more cogent link, however, lies elsewhere. Dr. Reddy highlights that “if you are a religious person and you get OCD, you might get religious obsessions.” He highlights instances in the past of highly respected, religious people— priests, persons performing pujas, mullahs— getting these “obnoxious thoughts,” due to suffering from OCD. He has lots of patients with religious obsessions— but not belonging to any one particular religion. “Religiosity may influence content of obsessions,” he says.
“No religion is exempt from them,” he says of rituals and traditions. “These are sanctioned by the religion.” He cites examples— don’t go into a puja room with shoes, a specific method to clean before entering a mosque. “These are socially accepted religious rituals,” he says,” They are not interfering, time-consuming, or distressing.”
But in the case of OCD rituals, he says that they are “excessive, exhausting, and not sanctioned by religion.” For example, if one is doing a puja and feels that they have not done it correctly, they may keep repeating the steps again and again— to the point of exhaustion, pointlessness. In a similar way, “you can wash once, or you can wash for two hours,” he points out. “Religious rituals are sanctioned by society, we don’t keep on doing them.....but OCD rituals arise from intrusive thoughts, and a need to negate them.”
Another element is that of contamination OCD— a perceived contamination can be physical or it can be mental. It can be that a patient has what they consider sinful thoughts, and so they keep washing, to get rid of the thought— irrational though this action may be. “The themes in OCD are in themselves excessive,” Dr. Reddy highlights. A patient “always gets doubts…persistent beyond a point of relevance.”
The content is not the problem— an average person may have an angry thought about god, and be able to diffuse it. It is in the excesses that the OCD sufferer finds themselves trapped— and one of the themes of these excessive thoughts and compulsions may be religion.
What next?
In a previous interview with The Hindu, Dr. Reddy explained, “At one level, all these occur in normal people. Occasionally, some people are more fussy about cleanliness and dismiss random thoughts. A vast majority don’t develop OCD. If it is a source of anxiety, comes in the way of your life as an impairment, and is time consuming, one must seek help.”
Help may start with getting diagnosed by an accredited mental health professional; a common diagnostic tool is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Following this, interventions may involve therapy or pharmacological treatments or both. Some find relief through Cognitive Behavioural Therapy (CBT), Exposure Response Prevention (ERP) therapy, and other measures suggested by a trained and licensed psychologists; other may need the added intervention of medication prescribed by a psychiatrist.
The OCD Clinic at NIMHANS, Bangalore, which completed 25 years last year, is one location where OCD sufferers may seek guidance and treatment. General mental health guidance may also be obtained through Tele-MANAS, India’s round-the-clock mental health helpline, at 14416 and 18008914416. A comprehensive list of mental health helplines collated by Center for Social Research in New Delhi is available here.
Published - October 16, 2023 12:00 pm IST
