Whoever is attacked by this illness suffers great agony. The person has painful intrusive thoughts and useless repetition of action. Both these symptoms may occur simultaneously or separately. Sometimes it may appear as a symptom in other illnesses also and then treatment of both illnesses need treatment accordingly.

Obsession

The brain is tormented continuously as unwanted, unpleasant thoughts keep coming all the time. These should be differentiated from the pessimistic and sad thoughts of a patient with depression. On the contrary in obsessive illness the human brain is filled with thoughts which are unwanted, painful, distressing and guilt provoking. They can neither be stopped nor can be forgotten. These unrealistic thoughts cannot be discussed with others because the sufferer considers them as sinful and shameful but his brain remains filled with these obscene thoughts and the patient sometimes gets depressed also and may plan to commit suicide to get rid of these thoughts. The thoughts may be blasphemous or incestuous and lead the patient to believe that he or she is trapped by Satan and there is no hope of forgiveness from Allah. He assumes that he has to suffer not only here, but also after death as he will be punished in hell.

The thoughts may be directed against God, Quran, Prophet or some other revered person; Sometimes the patient has thoughts of disbelief in Allah, Prophet, Islam etc. These thoughts sometimes increase in intensity when the patient starts reciting the Holy Quran or offers prayers.

The other type of obsessions are ideas regarding over-concern for cleanliness. Some people have the fear that when they touch others or after washing or after passing stool or urine they are contaminated and will then clean for hours. Some have a fear that they may develop serious illnesses like cardiac illness, cancer or sexual illness. Some are tormented with the thought that they should kill close relatives, so they try to hide knifes and other arms.

Compulsions

The above mentioned complaints are only the recurrent thoughts but compulsions are in addition to these painful thoughts. The patient may start doing some specific acts under the false assumption that by doing so he would be saved from the severe anxiety. He also feels that if he doesn’t do these actions harm will come to him or his near and dear ones.

Their most usual action is the frequent washing of hands, hours are spent in handwashing but the feeling of cleanliness is not attained. Some people take hours in ablution or bathing but sill don’t think they are clean. After passing urine and stool, handwashing is a very lengthy process and a few may even take a bath after every such event. In this disease the patient mostly has obsessions regarding pollution, he keeps washing his hands and clothes, room, carpets but still remains unsatisfied. Walls, doors or floor are also excessively washed by him but the obsessive thoughts regarding pollution remain intact. The patient also avoids sex as there is a feeling that this will cause pollution.

Some patients may have the fantasy that if they do not perform a particular act some family member may die. Then this person repeatedly performs this act, for example calling some one, or calling him at least 3 times. Some need to touch the wall 3 times, or walk in a certain fixed manner.

Despite performing these actions repeatedly the patient still has a strong belief that these actions are irrational and absurd but still cannot stop them.

Aetiology

There is no confirmed cause of this illness. Some of the possible reasons are as follows:

1. Feelings of guilt for the sexual thoughts

Conscious or unconscious incestuous thoughts occur in the mind, especially at adolescence. Most people consider these thoughts as “not clean” or a sin. The patient then unconsciously tries to “wash away” these ‘dirty’ thoughts.

2. Genetic

Sometimes this illness is inherited directly or indirectly.

3. Biological

Some specific brain malformations have also been discovered in patients of this illness.

Treatment

(a) Psychotherapy: The goal is to make the patient realise that the obsession is only a disease and is not related to Satan. The most important principle in the treatment is based on the concept that this ideation is not produced by the person himself and it comes in the brain automatically, has no relation with sin so there is no question of forgiveness.

The Prophet1 of Allah once said that “If a Muslim has an intention of doing some good deed, he is awarded a virtue for this, but if he plans to do something bad, no sin is recorded till such time that he actually commits that bad act.” In another hadees the prophet1 stated “when a Muslim gets sick his sins are shed like the leaves are shed from a tree”. These should be stated to the patient to relieve him from the feelings of guilt which make him feel guilty, nervous and depressed. Thus, it should be pointed out, these thoughts are the symptoms of an illness, which make him less sinful, not more. Moreover he should be told that this illness is treatable.

Family members should also be educated regarding the nature of this illness.

They should be made to realize that the patient, because of his illness, is not responsible for these obsessive thoughts and bothersome compulsions and therefore they should not express anger because this will only increase the pain and misery of the patient and not help in solving the problem at all. However they should also be strictly forbidden to participate in, or facilitate in any way the rituals and washing that the patient engages in.

(b) Thought Blocking: The patient should be advised to challenge these obsessions. He should be advised to say “STOP” when these thoughts come to his mind; out aloud when he is alone, and in imagination if in company.

(c) Response Prevention: The patient should be advised to resist the temptation for compulsions as much as possible. If he washes hands ten times he should make it nine, and gradually reduce further. For resistant cases hospitalization for a few weeks is very helpful to provide an ideal controlled environment.

(d) Modelling: The thing that results in compulsive behavior in the patient should be touched by the therapist, or he may hold the thing in front of patient so that the patient gets assurance that by touching or holding that object no harm is done and no washing or ritual is required.

(e) Medicines: (i) Antidepressants specially clomipramine (clomipril) and all the SSRIs are effective. If insomnia is present start with Clomipramine otherwise give an SSRI. (The details about these medicines is present in the chapter on Anti depressants)

(ii) If Antidepressants alone are not effective in a month or two add small doses of anti psychotics.

(f) ECT: Some patients get relief with Electro convulsive treatment. It may be combined with medicines and given twice a week for a total of ten or twenty treatments.

(g) Leucotomy: A few patients do not get any benefit from any of the above treatments. For such patient this type of surgery may be beneficial.

Case history

Nasreen said that since the last 10 years she has been suffering from the obsessive feelings of uncleanliness. She will never sit on a sofa because someone had used it which made it unclean. She is living on the second floor but at times when she hears that some truck has passed in the street she feels that some dirt has touched her clothes. Immediately after returning from college she changes her clothes, and before taking a bath she first washes the bathroom. If she touches an electric switch she washes her hand immediate afterwards because of the thought that some lizard must have touched the switch in the passing and made it dirty.

She never allows others to sit on her bed. If someone sits on her bed she changes her bed sheet at once. She takes at least one hour to bathe. After the bath she sometimes develops the obsession that she touched the wall which made her unclean and so she takes the bath once again. She also takes a long time to perform ablution (wazoo) and also has obsessions during the prayers.

Nasreen is 24 years old, unmarried, and a student of BA in a local college, with a good educational record. Father is living and working in Saudi Arabia. She is living with her seven siblings along with her mother. She is very irritable and her prolonged washing and cleaning produces conflict at home. Her younger brother is mentally ill and is taking treatment in some public hospital.

Physical examination and baseline investigations revealed no other illness. She was given Cap. Fluoxitin 20 mg in morning and Tab. Wizen 1mg at night. For the first two weeks the patient showed no improvement so her medication was increased to 40mg of Cap. Fluoxitin in morning and Wizen 2mg at night. She was also advised Thought Stopping and Response Prevention. Finally the treatment showed beneficial effects and the symptoms decreased in intensity. Her duration in the bathroom was reduced upto 70%. She now takes a bath in only 15 minutes. Her irritability has also decreased and other members of family are happy to see her become well.