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In religions with extensive codes, rituals pervade many areas of daily life.

Nevertheless, OCD symptoms of a religious nature are not found in all ar-eas of ritual, nor necessarily in the arar-eas of ritual most hallowed by the re-ligion. In our experience with religious Jewish patients, for example, Sabbath observance is a very important feature of religious life associated with many detailed laws but does not appear frequently among the reli-gious obsessions of OCD in our clinic. However, cleaning the perianal re-gion before prayer gets one line in the footnote of a latterday code of Jewish law, but this ritual presents often in patients with OCD in our prac-tice (Greenberg and Witztum 1994a).

The presentation of OCD in a religious context is less typically reli-gious than it is classically obsessive-compulsive. The psychiatrist ac-quainted with OCD cannot fail to recognize in religious OCD patients familiar obsessions (e.g., dirt and contamination, aggression, sex, and me-ticulousness) and compulsive behaviors (e.g., washing, checking, repeat-ing, and slowness) that present in any other sample of patients with OCD (Rachman and Hodgson 1980). However, therapists treating strictly reli-gious patients with OCD may benefit from recognizing relireli-gious practice areas that seem especially prone to obsessive-compulsive symptoms. A survey of the literature on religious presentations in OCD reveals two main areas: 1) cleanliness and purity and 2) liturgy.

Cleanliness and Purity

Symptoms of OCD related to religious cleanliness and purity have been noted across many religions. Dietary, menstrual, and preprayer ablutions and checking have been reported in Jewish and Islamic patients. Some ex-amples arise out of our clinical experience with Jewish patients. Meat can only come from certain animals (known as kosher), which must be slaugh-tered and prepared in a particular way, and milk and meat foods must be kept separate (the presentation of these symptoms in OCD is described in detail in the case report). All bread must be removed from every Jewish home before the festival of Passover; for weeks before this festival, reli-gious housewives meticulously clean their homes. Patients with OCD may clean repeatedly and for lengthy periods and may then return and start again. Children are checked for crumbs, marks, or hints of “bread,” and the cleaning starts over again (Greenberg et al. 1987). An awareness of the possibility of excessive concern can be found in the earliest Rabbinic guide to Jewish law, the Mishna, which wrote on this point 1800 years ago:

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One is not to be concerned that, having completed the pre-Passover clean-ing in one room of the house, a rat from another (as yet uncleaned) room may drag a crumb into the cleaned room. Why not?—because if such a thought could be entertained, then why not the additional possibility that the crumb may be brought from one house to another, or from one town to another—and there would be no end to the matter! (Mishna Succa, 1:2)

For women, menstrual purity is another potential focus for obsessive-compulsive symptoms. They may check themselves repeatedly during the days before ritual immersion; clean and check themselves excessively im-mediately before the immersion; and repeat the immersion over and over, to the exasperation of the ritual bath attendant, because they are con-cerned that they may not have soaked themselves completely (Greenberg and Witztum 1994a). Maimonides, the twelfth-century physician, philoso-pher, and codifier of Jewish law, wrote in Mishne Tora: “No woman can di-vest herself of her ritual impurity or cease being forbidden from having relations unless and until she immerses herself in a ritual bath. Nor may anything interpose between herself and the water…if she does not, she is liable to excision” (Laws of Forbidden Relations, 11:16). The importance of this topic is stressed by the mystical text, the Zohar: “There is no stronger ritual impurity in the world than that of the menstrually unclean woman”

(on Exod. 1:1). Men are expected to be clean before prayer; a common pre-senting symptom is repeated wiping and washing of the perianal region before prayers, sometimes taking so long that the patient arrives too late in the day to pray.

In Islamic law, similar issues are stressed. In Al Woodo, specific parts of the body are washed three times before daily prayers, which are per-formed five times each day. Particular emphasis is placed on cleanliness of the anal region, and Okasha (1970) described patients with OCD spending hours cleaning themselves before prayer. Menstrual impurity is very sig-nificant; women are forbidden to fast or pray at such times, and their un-derwear is washed separately. Clothes must be changed if they have been in contact with urine or feces, and for this reason, underwear must be changed before prayer. Okasha (1970) described a patient who fell asleep in the bath during her extensive washes during menstruation. It is inter-esting to note that Islamic women with OCD are concerned about the con-taminating effects of menstrual blood during menstruation, whereas Jewish women with OCD are concerned about the presence of blood after the end of menstruation while they are counting “seven clean days”

(Greenberg and Witztum 1994a); these concerns are each consistent with the concerns of their codes of law.

Berkeley-Hill (1921) described the Hindus of India as suffering from a

178 Current Treatments of Obsessive-Compulsive Disorder

“pollution complex,” exemplified by the existence of the class of “un-touchables,” and stressed the anal-erotic factors in their philosophy, reli-gion, and character. A prominent part of Hindu festivals is bathing in a certain place at a certain time. The human body is considered to be basi-cally dirty, and repeated washing of the body is encouraged (Akhtar et al.

1975). Nevertheless, the same authors only found 9 patients with religious symptoms in 82 patients with OCD in India. The topics of OCD for these patients were religious practices and festivals or matters of religious belief.

However, 38 of the patients were concerned with dirt and contamination, such as semen, menstrual blood, and excreta, and one of the authors, Pro-fessor Wig (personal communication, 1984), suggested that many of these cases had a religious basis. Thus, the reported figure may be an underesti-mate.

A study of 42 patients with OCD in India (Dutta Ray 1964) found ideas of impurity and uncleanliness in 11 patients, although the author did not mention how many of these ideas were of a religious basis or the form they took. The author did note, however, that three strongly religious patients had dramatic improvement in their symptoms after a religious pilgrimage.

Liturgy

The second major area within religious life that is commonly the focus of obsessive-compulsive symptoms is liturgy. The preeminent role of prayer in Western religions is described by William James (1902/1982) in The Va-rieties of Religious Experience: “Prayer is religion in act; that is, prayer is real religion…wherever this prayer rises and stirs the soul, even in the absence of forms or of doctrines, we have living religion.” In keeping with this pri-mary role of prayer, we have found that the religious topics encountered among Protestant Christians with OCD have been limited to thoughts of blasphemy or of illness and harm coming to other people that arise during prayer.

Confession is one of the two sacraments that must be repeated fre-quently by Roman Catholics, and religious OCD symptoms tend to in-clude repeated and lengthy confessions, as noted in three of the five patients studied by Fallon et al. (1990). Vergote (1988) described this phe-nomenon as the “religious neurosis of culpability.” He states that “obses-sion can take a religious form. In these cases it is guilt that obsesses the individual. Its doubts and ruminations are of an immediately moral order;

his fears relate to the defiances hurled against God…filthy words that in-terrupt his prayers; his means of verification or his ritualism takes the form of religious rites” (p. 51). Vergote, a Catholic philosopher and psy-choanalyst, noted that “discourse on salvation has no effect on the illness”

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and concluded that “this form of obsessive religiosity does not derive from a strictly religious conflict but rather that religion here serves as a means of displacing and expressing the conflict in an indirect way” (p. 51). Echo-ing Freud’s observations, Vergote adds, “Religion could not divert the con-flict if it did not share with the unconscious concon-flict certain analogies of context and structure” (p. 51). Vergote cites the example of a man who was tormented by his fear of committing mortal sins. At certain times, he went to confession every day, sometimes twice a day. Fortunately, his priest saw clearly into the matter and encouraged him to seek out a psychotherapist.

For this man, every incident had become an occasion for torturous doubts of conscience, the themes of which were predominantly sexual; for exam-ple, if he met an attractive married woman and looked at and desired her, he considered this to be a sin (Vergote 1988).

Weisner and Riffel (1960) studied 23 patients with OCD in the form of

“scrupulosity” among Roman Catholic referrals to a child guidance center.

They described the same concerns and behaviors as experienced by Mar-tin Luther at confession, although the high level of functioning at referral and the low level of pathology at follow-up suggested that these were obsessive-compulsive traits in adolescence rather than OCD.

Prayer developed in Judaism in place of daily sacrifice, and certain prayers are given special significance and require particular devotion. Pa-tients with OCD may take the entire day to say their thrice-daily prayers if they have intrusive thoughts of a lewd, aggressive, or blasphemous na-ture, or they may repeat important sections because they feel they have in-adequate devotion (Greenberg 1984; Greenberg et al. 1987).

Whereas confession in Catholicism is a regular ritual involving a com-plete declaration of misdemeanors, in Judaism it is a minor prayer with a fixed impersonal text: I have sinned, I have transgressed, and so on. We have noted that this becomes emphasized only among Jewish patients with agitated depression and not among those with OCD, reconfirming our impression that the topics that are repetitive and are dealt with scru-pulously in normal religious practice become the focus of OCD in different cultures.