How some religious practitioners may be suffering from OCD

 

Moshe and David seem to have a similar morning routine.  This includes washing their hands when they get out of bed, getting dressed and walking to shul.  Each kisses the mezuzah on the door post when he enters the shul and dons his tefillin before beginning his daily, morning prayers.  

This sequence of events, including the average forty minute dovening (prayer service), takes Moshe about an hour to complete.  Why does the same routine take David about three times as long?  Why is David washing each hand 12 times instead of three?  Why is he kissing the mezuzah exactly six times before entering the shul and why is it taking him over an hour to center his tefillin on his head?

Finally, why does dovening take him twice as long as it takes anyone else in shul?  Does David have more kavana (concentration) than everyone else in shul?  Are his religious convictions stronger than Moshe’s or is something else motivating this behavior which to some seems devout and to others appears fanatical?

Yes, there are people in this world who are able to perform mitzvot with greater kavana than most, with a higher degree of understanding than others, with a love of Hashem that many of us can only wish to attain.  However, unfortunately, there are also those who appear to be engaged in hiddur mitzvah (enhancement of the mitzvah), when, in reality, there is another  underlying motivation that they, themselves, possibly do not even recognize. This distinction is not usually detectable by a layman and it often takes a properly trained therapist or doctor to diagnose. 

There are two major differences between the Moshe and David’s routines – in addition to the significant difference in the time it takes each to complete the sequence of tasks.  These are:  the reason why each is doing the various activities and the amount of distress experienced when the actions are not completed perfectly.  Put more succinctly, Moshe’s reasons for performing the halachot (laws) and minhagim (customs) is purely a belief in G-d and Judaism. He feels a sense of love, pride and satisfaction when he completes the rituals and, hopefully, looks forward to doing the same mitzvot, again, tomorrow.  David, on the other hand, is motivated by the fear of the discomfort that he anticipates he will experience if he does not perform the rituals properly.  It is this debilitating fear- this tremendous discomfort – caused by the sense of lack of having completed these rituals that has taken over David’s love of the mitzvot and replaced it with a huge burden of which he will endlessly attempt to be rid. This 

is part of the obsessive/compulsive cycle in Obsessive Compulsive Disorder (OCD).

The MediLexicon medical dictionary defines OCD as ”recurrent obsessions, persistent intrusive ideas, thoughts, impulses or images, or compulsions (repetitive, purposeful, and intentional behaviors performed to decrease anxiety in response to an obsession) sufficiently severe to cause marked distress, be time-consuming, or significantly interfere with the person’s normal routine, occupational functioning, or usual social activities or relationships with others.”

 In our scenario, the amount of time and effort that David devotes to his morning rituals is above and beyond what other (orthodox!) people deem necessary and, likely, delays other daily activities such as studying, working, socializing and playing.

Obsessive Compulsive Disorder is a condition which was previously considered an anxiety disorder, but is currently regarded as part of a separate, wider category of obsessive compulsive-related disorders.  According to the American Psychiatric Association, the justification of a new specific category of disorders is the presence of repetitive thoughts (obsessions) and repetitive behaviors (compulsions) present in the different, but related conditions which comprise this new classification. Among these conditions are: hair pulling (trichotillomania), skin picking (excoriation), body dysmorphic disorder, and hoarding. Sufferers of any of these disorders are plagued by obsessions and/or compulsions which cause marked distress and can severely interfere with their social, educational and occupational lives. It is not the specific content of the obsession or manifestation of the compulsion that defines the disease as obsessive compulsive, but rather, the common etiology behind the obsessions and compulsions.  In David’s case, the manifestation of his compulsions is Jewish rituals.

Although people often think of OCD as the “cleanliness” or “neatness” disease, in reality, OCD symptoms present themselves in many diversified areas of life.  Culture is a main factor in determining which particular obsessions and compulsions will be present in a particular sufferer’s symptoms.  Although OCD is a chemical disorder, it is influenced by one’s lifestyle. Therefore, it makes sense that Just as people who spend much of their time at home might exhibit compulsions and rituals surrounding cleanliness in their homes, so, too, individuals who devote a large part of their time practicing religion might exhibit OCD symptoms in this area of their lives.

Obsessions and compulsions centered on religious or moral issues have been given the term scrupulosity and scrupulosity may occur in any given religion.

  

People are often embarrassed to talk about issues that they consider “mental health” or “psychological” problems.  Unfortunately, even though many of these disorders have been proven to have a medical/chemical origin, the stigma attached to them is still felt universally.  There is also an additional challenge for people suffering from scrupulosity.  Sufferers and observers (teachers, parents, clergy, and friends) often misinterpret the compulsive rituals as pious, religious rituals and, therefore, fail to diagnosis them as symptoms of a larger problem.

Because of the complexity of the disease and its closely-related appearance to religious observance, a diagnosis of scrupulosity in OCD must be left to a trained professional.  Using diagnostic screening questions, questionnaires, patient self –reports and various other methods of information-gathering, a psychiatrist, psychologist or social worker can make this differential diagnosis.

Fortunately, once a positive diagnosis has been made, proven, significant, symptom reduction methods are available.  Among the two recommended treatments for OCD are various, specific medications (prescribed by a psychiatrist) and/or cognitive behavioral therapy (CBT).  Each approach has its pros and cons and reasons for opting for one versus the other or for both should be carefully discussed with a health professional.

CBT for OCD utilizes a technique called exposure and response prevention.  The treatment requires patients to face their feared obsessions, rather than avoiding them. Often, to escape the distress caused by obsessions, patients attempt to avoid thinking about the obsessive topics.  This is called avoidance. By exposing the patients to the obsessions, rather than allowing them to avoid them, they will learn the obsessive thoughts, themselves, are not harmful. 

Alternatively, avoiding obsessions, sufferers often try to counter-act (or fight) the obsessions using ritual behaviors.  These behaviors are referred to as compulsions and these are treated with response prevention.  This requires preventing patients from engaging in the rituals that they have come to believe protect them from the alleged (imagined) harm that will be caused by the obsessions. Although the avoidance and ritualistic behaviors seem to provide temporary relief from the obsessions, in fact, the long term effects are the opposite.  They serve to reinforce the obsessions and do not allow the patients to learn that their strategies for ridding themselves of the obsessions actually do not work.  Patients continue to associate any decrease in distress to the use of avoidance and rituals and fail to internalize the fact the obsessions were never dangerous to begin with!  In order for sufferers to break the association between the obsessions and the falsely-believed-to-be-helpful rituals, the patients must be prevented from engaging in those rituals.  This should be done in a supervised, setting, with a trained professional! Yes, initially this can – and will! – be extremely stressful.  But, eventually, the distress level goes down… and stays down!  

OCD sufferers have to ask themselves which they prefer: to have temporary relief from their distress, occasionally (due to avoiding and ritualizing) or to have interim distress which can lead to permanent relief by focusing on their worst fears.  Although it is not easy to face their obsessions, once suffers agree that having temporary discomfort is a fair exchange for a better quality of life, then a healthy treatment program can begin!