Influence of Culture in Obsessive-compulsive Disorder and Its Treatment
Using self-report questionnaires, we compared differences in these OCD-related phenomena between highly religious Protestants, moderately. The study examined the relationship between religion and symptoms of psychopathology, particularly obsessive–compulsive (OC) and. In fact, many religions have behaviors that may look like OCD to an outsider. .. disorder: Relationship to clinical and cognitive phenomena, Journal of Anxiety.
Also, the dopamine hypothesis emerged, given the beneficial effect of some antipsychotics; in many cases of SSRIs-resistant, particularly in those having comorbid tics [ 3637 ]. In this sense, it is clear that obsessive-compulsive symptoms are common in movement disorders such as Sydenham chorea or Huntington's disease.
Evidence of hyper activation in corticostriatal pathways has also highlighted the involvement of the glutamate system, along with molecular genetics findings [ 38 ]. The type of obsessions seems to vary according to the cultural context. In Middle Eastern countries, religious themes prevail, meanwhile in Brazil, there is a predominance of aggressive obsessions [ 39 ] and in most countries, the issues of contamination are the most predominant, an example of this is the Indian population, where it has been described that the compulsions related to cleanliness and pollution are more prevalent in comparison with other types of compulsions [ 40 ].
It has been proposed that this phenomenon is linked to their religion, in which purification and cleansing rituals play an important role [ 41 ]. The explanation that the patient finds most satisfactory will determine who will contact for receiving treatment; in this case, those subjects who attribute their disorder to supernatural factors contact a faith healer [ 43 ].
It is a fact that patients often turn towards religion, spirituality and moral traditions to understand and respond to mental illness; for example, for the OCD case, this may determine the extent to which a type of treatment is acceptable exposure and response preventionas well as the duration pharmacotherapy [ 44 ]. In addition, patients with OCD have higher levels of perceived stress compared with subjects without this disorder [ 46 ].
The types of stressors vary according to the cultural context, for example the population of industrialized countries develop in an environment different from those of developing countries. The latter frequently face poor services, overcrowding and limited resources. In addition to the variation in the type of stressors, the response to these could be influenced by cultural factors, for example the response to work stress and certain psychopathological features seem to be related to a collectivist or individualistic culture.
Both models have advantages and disadvantages that could influence the mental health of individuals.
Scrupulosity: Blackmailed by OCD in the Name of God
A collectivist context promotes greater ties with other individuals in society, as well as increases anxiety by increasing the sense of responsibility with other individuals. On the other hand, an individualistic environment promotes competition with other individuals and social isolation [ 4748 ].
The response to stress seems to be influenced by cultural factors, for example, the way of interpreting stress generated by a problem may vary according to the cultural background.
Subjects from a collectivist community tend to give greater importance to social resources and face any stressful situation more easily compared to subjects from an individualistic community [ 4950 ]. A model proposed by Neblett et al. For example, in Latino population, familismo, which is described as a connection with relatives, may help Latin students to deal with stressful situations [ 52 ].
In other ethnic groups, other strategies are chosen. African American students considered their participation in religious activities to be more important in managing stress, while Asians were reported to more likely use emotion-focused responses [ 53 ]. From an evolutionary outlook, it may be speculated that some characteristics of obsessive-compulsive personality, such as being organized, meticulous, perfectionistic, may represent a certain adaptive advantage, in the same way as inflexibility, exaggerated rigidity or conscientiousness would be oriented to a maladaptive sense.
Several arguments have been discussed; in this regard, sub-threshold OCD symptoms would make a certain adaptive sense as an evolutionary advantage [ 54 ]. Additionally, variants of the personality seen under the Research Domain Criteria RDoC perspective, in which emphasis is made on the dimensional characteristics and their neurobiological basis, may provide a better understanding of how personality influences the clinical OCD presentation [ 55 ].
A common neurobiological substrate has been mentioned for the impulsiveness and compulsiveness dimensions [ 56 ]. More recently, it has even been postulated that the obsession for proper nutrition may be a present dimension both in OCD and in the autism spectrum [ 57 ].
The cases of hikikomori are an example of cultural variation that does not have a referent in the West, as such because it implies a sense of family shame, and this traps the sick and the family, who become accomplices so that people do not point them out as an abnormal family. In a study it was seen that the family of the hikikomoris prevent the neighbors from learning about the situation at home.
Physician-patient Relationship There is evidence that race, ethnicity, and language have substantial influence on the quality of the doctor-patient relation-ship. These cultural factors will impact the development of empathy from physician, communication and participation in medical decision making [ 59 ].
Some recommendations to emphasize culture are only made if there is a disparity between the patient culture and of the clinician. However, the assessment of these aspects may be laborious and time-consuming, added to the fact that it is not clear how this directly affects the treatment plan to be followed with the patient. Some of the clinical consequences of the lack of understanding of culture have been misunderstandings in clinical recommendations, incomplete assessments, misdiagnoses, lack of rapport in the doctor-patient relationship, poor adherence and improper treatment [ 60 ].
Culture also affects the types of health treatment. Seeking care outside of the medical or psychiatric setting merits attention because this may complement or go against psychiatric care.
The extent to which a psychiatric interview taking culture into account changes the clinical care issues, such as diagnosis, treatment planning, patient adherence, and patient satisfaction with treatment, is still unknown. It is also important to know the identity of the clinician.
Some people may feel uncomfortable when discussing their origins, and if the clinician is not familiar with this empathythe assessment can be more complicated. It is known that the country of origin may be a factor correlating with both physical and emotional health [ 62 ]. Another important aspect to consider is the failure of health systems in not providing interpreters when there are linguistic differences, as this may increase the communication difficulties between doctor and patient.
It is necessary to study other aspects of the doctor-patient relationship where culture could have a relevant role, as is the case of countertransference that has been studied in other human relationships [ 63 ] 4.
Religion Cross-cultural studies have also provided information on different religious contexts and their possible influence on OCD manifestations, for example, some studies suggest that Catholics may be at a greater risk for OCD [ 64 - 66 ] and higher severity in OCD symptoms [ 67 ].
There are reports of differences in the OCD manifestations possibly related to religion, for example, the case of ultra-Orthodox Jews [ 68 ] and Muslims [ 69 ], in whom their religion influences the pattern of actions and thoughts, being those related to their respective rules and rites.
In addition, Freud postulated the hypothesis that religion is a universal obsessive ritual and that there is a relationship between obsessive-compulsive neurosis and religion. This idea was not popular neither among religious leaders nor among psychologists, as it was counter-argued that rather than isolating individuals, religion helped connecting people and integrating them socially [ 2 ].
Also, since the above-mentioned first writings, descriptions for understanding the morbid nature of thoughts have been provided, as well as pathological recognition and clear clinical descriptions. Even some interventions that may be considered as cognitive-behavioral are suggested [ 2930 ]. In other descriptions in Turkey, it has been observed in groups of patients with OCD, that there was no correlation between religiosity and severity in the Y-BOCS scale [ 31 ].
In Islam, practicing patients with OCD, it was found that there was a high frequency of blasphemous obsessive ideas, according to the authors, attributable to the environment rather than to a causal factor, and the same has been suggested when studying other religious groups as Orthodox Jews in Israel and religious people in China [ 71 - 73 ]. Some hypotheses have been proposed in an attempt to explain the relationship between religiosity and OCD, as the strict and scrupulous rules of some religions might encourage misinterpretation of intrusive thoughts, a constant attempt to control these thoughts and guilt [ 74 ].
Pharmacological treatment in different countries The use of pharmacological treatments for OCD varies significantly among countries worldwide [ 73 ]. Similarly, it is thought that in India, only one in 10 individuals receive an evidence-based treatment [ 4 ]. In patients on pharmacotherapy, differences are marked among countries in terms of the types of drugs.
For example, in the case of OCD in Latin America, there was a high use of benzodiazepines, and in some of these countries, many people use Exposure Response Prevention Therapy, as the government subsidizes it. Among OCD patients, one-quarter receiving pharmacotherapy receive antipsychotics [ 6077 ]. It is also important to emphasize the influence of public policies on each country regarding access to treatments, as well as subsidies for drug and interventions.
However, it is very important to continue collecting data regarding response rates, severity measurements and the variety of the condition presentation, adverse effects, the role of other treatments or social interventions, if any, and support networks.
Regarding populations, an interesting argument lies in the OCD pharmacogenomics, where more adverse effects to clomipramine in Asian populations have been described, due to a high frequency of slow metabolizers with a CYP2C19 polymorphism. In another study mainly conducted in European descent population in Canada, more patients with OCD treatment failure were significantly found in phenotypes of slow metabolizers.
In this case for CYP2D6 genotype [ 78 ]. This branch highlights the relevance of ethnicity in the biological response to treatments, beyond culture. However, it is an area that deserves much further research. I would never sell my soul; that is the last thing God would want. They have persistent, irrational, unwanted beliefs and thoughts about not being devout or moral enough, despite all evidence to the contrary.
They believe they have or will sin, disappoint God, or be punished for failing. In response to their disturbing thoughts, they try to calm themselves by using a host of compulsions. Some repeat religious phrases; others call their pastors for reassurance. Many avoid situations—even their beloved church or temple—because it triggers their horrible obsessive thoughts.
Documentation of people with this form of Obsessive-Compulsive Disorder goes back centuries. Studies show that scrupulosity is the fifth most common form of OCD after contamination, aggressive thoughts, symmetry, and somatic concerns Foa, et al, Nevertheless, it affects people from multiple religions whose level of devotion varies, and even affects atheists.
Scrupulosity: Blackmailed by OCD in the Name of God
Some people—religious and not—experience scrupulosity as an irrational moral perfectionism. A graduating law student feared she would be rejected by the Bar for inadvertently providing them with an imperfect resume; she traded hours and days of studying time for the Bar exam to making compulsive calls to former schools and employers to confirm dates she had been there.
Everyone has such thoughts; people without OCD just dismiss them as unimportant and move on. If you are committed to your religion, morality, or ethics, and want to be as good as you can be, is this scrupulosity? People without OCD may try harder when they feel guilt or disappointment about something they think or do.
But they are not obsessed with their failure. OCD sufferers, on the other hand, dramatically overreact to perceived failures. They are tortured by the intensity of their doubts about their goodness, and the belief that, therefore, they are downright bad.
Their discomfort makes it hard to dismiss the thoughts, which become sticky and hard to chase away. The persistence of the thoughts, and the frequency and anxious intensity with which they return, turn those irrational thoughts into obsessions.
In response, OCD sufferers feel they must get rid of that obsession at any cost. To neutralize those disturbing thoughts, sufferers often use a mental or physical ritual, such as repeating a religious phrase or religious act, seeking reassurance, or doing penance. The obsession may be temporarily relieved by the compulsion, but it soon returns, more powerful than ever, just like a mosquito bite itches more after scratching it than if it is left to itch for awhile.
John, my former client, obsessed about having sold his soul to the Devil in exchange for his wonderful life, and then compulsively repeated religious homilies for hours. Finally he would repeat to himself: I am a good Christian man. For instance, they may focus on saying prayers perfectly instead of developing a relationship with God.
OCD rituals differ from devout religious practice, but it can be hard to tell the difference at first glance. In fact, many religions have behaviors that may look like OCD to an outsider. We kiss the prayer book when we close it, the Torah when we approach it, any religious object when we drop it. Orthodox Jews are motivated by spiritual duty and rewarded by a sense of fulfillment; the scrupulous are motivated by [brain] circuitry and rewarded by chapped hands…Most scrupulous Jews tend to overlook, even violate, the bulk of the laws while observing one or two with excruciating care.
Compulsions tend to come before commandments. I could violate three or four commandments in one fell swoop. I was happy to lie to my dishonored parents while breaking the Sabbath, as long as it was in the service of getting my hands ritually clean. Examples of other religions with beliefs and practices that can be mistaken for scrupulosity abound. But the anguished obsessions and compulsions, the tormenting doubt and guilt distinguish scrupulosity sufferers from morally and religiously inspired people.
Although John was a devoted family man, he focused on the bad, irrational thoughts he had about harming his loved ones. At present researchers believe that OCD is genetic, passed down through families. People with a biological predisposition for OCD will be triggered at some point by an event, experience or environmental stressor and develop full-blown OCD.
But even without that particular incident, they would be triggered eventually by some other stressful experience. John recalled that his OCD began at the age of seven. A teacher at his Catholic school talked about a man who sold his soul to the Devil for riches. That comment triggered a fear that John had done the same.
He responded with hand-washing and checking symptoms to reduce his anxiety, and continued to suffer throughout his childhood. In high school, a psychiatrist diagnosed him with depression and prescribed Prozac, which can also reduce OCD symptoms. He took Prozac through his early 20s, when he decided he no longer needed it. His OCD symptoms ebbed and flowed for the next decade. He came to me 25 years after his OCD had begun, when work stress was wearing him down.
When he began treatment with me, he said he wondered if his phenomenal success now—wonderful kids, wife and career—was evidence that he did sell his soul and that he would go to hell. Irrational thoughts appeared at agonizing moments. John was naturally horrified by these thoughts and the fact that they occurred to him at all seemed proof that he had, in fact, sold his soul to the Devil. Cognitive-Behavioral Therapy John wanted to fight back to regain his family and himself.
In a crash-course in reading about his symptoms, he learned that numerous studies showed Cognitive-Behavioral Therapy was highly effective in beating back OCD. But choosing to begin treatment was still a terrifying decision.
The stakes seemed so high for himself and for his loved ones. What if his thought that he had sold his soul to the Devil was true and he stopped trying to win his soul back? He might go to hell. What if he was right that thinking about harming his family made him more likely to do it? Yet the wise part of him knew that those obsessions came from OCD and were not true.
And with what feels like such high stakes—in this life and after—standing up to the OCD seems especially risky. John took a leap of faith in harnessing his wise mind to enter treatment. Like other CBT therapists, I use two primary tools. One is cognitive therapy, which challenges the thinking errors common to OCD. With ERP, John actively encouraged those nightmarish, irrational, anxiety-producing thoughts and behaviors while refusing to use rituals to chase the anxiety away until his anxiety diminished.
Clergy can help prepare and support their parishioners in this therapeutic work. I would never ask clients to do something that they truly believed would violate their religious beliefs.
But sometimes scrupulosity sufferers can resolve those concerns by meeting with clergy who are educated about OCD. Sometimes it is helpful for a clinician to meet with a client and clergy member together, especially if the religious leader is unfamiliar with scrupulosity.