Spirituality, OCD, and life-threatening illness.

Primary care physicians are taking an increasing interest in both the mental health and spiritual needs of patients as part of medical treatment. Dealing with spiritual distress has long been central to palliative care, (1) which recently became recognized as a board-certified subspecialty (via the American Academy of Hospice and Palliative Medicine). The following case study illustrates how to approach spiritual concerns mixed with lifelong obsessive compulsive disorder (OCD) in the context of a life-threatening illness.

OCD is an anxiety disorder characterized by the presence of either obsessions and/or compulsions that are excessive and which cause marked distress or which interfere with normal functioning. Obsessions are recurrent and persistent thoughts, impulses, or images which are experienced as intrusive, excessive, or inappropriate, but which are not psychotic. Compulsions are repetitive behaviors (such as hand-washing, ordering, or checking) or mental acts (such as praying, counting, or repeating words silently) that are performed to neutralize obsessions and thus decrease anxiety. OCD has a lifetime prevalence of about 2 to 3% in the United States. Mean age of onset is 20 to 24 years, and over 80% of patients develop symptoms by age 35. Clinically, the most common obsessions are repetitive thoughts of violence, contamination, or doubt (such as having accidentally hurt someone); many patients manage to hide their symptoms for 5 to 10 years before coming to psychiatric attention. (2)

The relationship between OCD and religiousness is complex. Some studies have found a correlation between religiousness and severity of OCD, but most research to date suggests that religiousness is not causally linked with OCD. (3,4) However, religious beliefs and practices can affect the content of obsessions and compulsions in religiously minded people with OCD. (5) For example, Muslim and Jewish patients from the Middle East who have OCD have been found to engage in more compulsive religious rituals (usually related to cleanliness and purity) than other populations with OCD; their obsessions tend to focus more on themes of religion and cleanliness, as compared with themes of orderliness and aggression in Christian and Hindu samples. (6-8)

Clinically, the main treatments for OCD are cognitive-behavior therapy (exposure and response prevention), and/or serotonin reuptake inhibitors (SRIs). There is one case report of cognitive therapy delivered in a faith-based manner (ie, asking the patient to invoke Christ) that led to rapid resolution of obsessions in a religious patient, (9) and a small case series of patients whose excessive religious scrupulosity responded to treatment with serotonin reuptake inhibitors. (10) Also, there is some evidence that the presence of sexual or religious obsessions, at least in samples from Europe, predicts poorer response to treatment for OCD. (11,12) Although the literature lacks guidelines for bringing spirituality to bear as a resource in OCD, clinical wisdom suggests that it is important to help patients distinguish normal religiousness from OCD-related religious obsessions and compulsions that may be maladaptive. (8)

Case Presentation

Dr. Sheila Smith was a 35-year old primary care physician who presented for help coping with treatment for recurrent left frontal glioblastoma multiforme. As a doctor, she knew that her prognosis was grim. She had already survived 5 years since her initial diagnosis and had been through two craniotomies, two courses of brain radiation, and several different types of chemotherapy.

I began my work with Dr. Smith by addressing symptom control, which is important in the face of terminal illness. I started her on sertraline 25 mg daily (she was petite and sensitive to psychotropic medications, so only a low dose was needed) for symptoms of depression and anxiety, and done-pezil 2.5 mg daily for treatment-related fatigue and cognitive overload. She responded well to both medications, and did not need a psychostimulant as she did not have much frontal apathy.

I then proceeded to explore Dr. Smith's emotional concerns, which unexpectedly included the fact that she had struggled with low-grade, compulsive hand-washing behaviors since her early 20s. Fortunately, these signs of OCD also responded well to the sertraline. This was a great relief to Dr. Smith, as she had always been embarrassed by these behaviors and tried to conceal them from friends and family. In fact, she revealed that for her it was as helpful to talk about her OCD as it was to discuss her concerns around death and dying, because the former had always been so shameful to her.

As our therapeutic alliance deepened, Dr. Smith also began to speak about her Christian faith and her abiding sense that some inner, deeper part of herself was not ill and would survive death. She shared spiritual experiences of how she sometimes felt God's presence in her heart, and felt connected to "a larger Being" while spending time in nature. I was receptive to these spiritual experiences, echoing her statement that these constituted the "real Sheila," and her trust in me grew. Eventually she decided to share some more frightening experiences as well. She explained that since early childhood she had had recurring spells characterized by a horrible sense of impending doom, feeling a sort of "darkness" close in around her, and having intrusive, frightening mental images of terrible things happening to people she loved, such as being stabbed or shot or run over by a car. She did not see herself perpetrating these violent acts, but felt extremely guilty for having such images in her mind. Her entire life she had wished and prayed for these spells to cease, but to no avail. She was not aware of any relationship between these spells and her hand-washing behaviors.

Given Dr. Smith's religious background, I asked whether she worried that these episodes might be visitations from the Devil or some evil force. She confessed that she had, and that her fear and shame in this regard had been so profound that she had never discussed her experiences with anyone before me. I therefore encouraged her to speak more about these feelings, and to recount in detail the history of both her positive and negative spiritual experiences over the course of her life. In the process of doing so, she related another significant phenomenon: when her brain tumor was first diagnosed, she had undergone a lumbar puncture that was complicated by brainstem herniation and a left occipital lobe infarct. Upon awakening from the coma, she was both puzzled and relieved to find that her compulsive hand-washing had resolved completely, and that she no longer experienced the distressing episodes of negative imagery. She enjoyed complete peace of mind for about 6 months, after which both the hand-washing behaviors and the intrusive mental imagery slowly returned to baseline frequency and intensity.

After gathering this history and evaluating it in the context of the "whole person" before me, I explained to Dr. Smith that OCD can entail obsessive, intrusive negative thoughts of various types, and that likely both her compulsive hand-washing and intrusive mental images were manifestations of OCD, not evidence of possession or of a religious failing.

I also speculated that the OCD had resolved temporarily because the diffusely decreased cerebral metabolism during her coma may have transiently decreased metabolism in her caudate nuclei, which has been shown to occur in successful treatment of OCD using either cognitive-behavior therapy or SRIs. (13) Dr. Smith found this explanation enormously reassuring, and breathed an audible sigh of relief. I then instructed her in some visualization exercises to help her dissipate the feelings of guilt, shame, and failure she had privately harbored for most of her life as a result of the OCD. She practiced these diligently and found them helpful.

At our last session, Dr. Smith reported feeling more at peace with herself and with God than ever in her life. She still had occasional brief episodes of intrusive negative images, but she was able to witness these in a more detached fashion and understand them as just "brain noise," rather than as being part of the "real Sheila." She gave me a big hug to say goodbye, as she had decided to move back home to enter hospice. We both left the clinic that day feeling sad about having to let go of a meaningful relationship, but thankful that we had managed to find the proverbial silver lining to the otherwise dark cloud of her illness.

Comment

This case highlights how discussing spirituality in an open-minded fashion can deepen the doctor-patient relationship, elicit patients' central concerns, and distill unexpected meaning and personal growth from a life-threatening illness. Although I am a psychiatrist, everything I did (except, perhaps, the visualization exercises) could be done by any interested physician who takes the time to ask sincere questions and listen empathically. Taking a simple spiritual history is much like taking a psychosocial history, and can be used to find or infer ongoing concerns that are on a patient's mind.

Physicians do not need to disclose their own religious or spiritual views to do this, and there is no reason to worry that supporting a patient's spiritual worldview is unscientific. Because neither science nor philosophy has thus far proved or disproved the existence of God, theistic worldviews remain as rational and potentially valid as atheistic or agnostic views. Keeping this important fact in mind can help physicians interact respectfully with patients of all worldviews. (14)

If the process of taking a spiritual history leads the clinician into unfamiliar territory, he or she can use the information obtained to identify an appropriate referral for further consultation, such as a chaplain, priest, rabbi, or other appropriate spiritual or religious figure. Finally, in the rare event that the patient is psychotic, remember that even the severely mentally ill deserve to have their spiritual needs supported by healthcare providers, so long as doing so is not dangerous to themselves or others. In such cases, collaborating with mental health professionals can help the primary physician achieve these goals of care. (3)

Note: Certain details of this case study were altered to protect the confidentiality of the patient, who gave permission to publish her story. Michael Miovic, MD is an attending psychiatrist at the Dana Farber Cancer Institute, Boston.

References

1. Sulmasy DP. Spiritual issues in the care of dying patients: "... it's okay between me and god". JAMA 2006;296:1385-1392.

2. Otto MW, Pollack MH, Jenike MA, et al. Anxiety disorders and their treatment. In: Nicholi AM, Jr (ed). The Harvard Guide to Psychiatry. Cambridge, Belknap Press, 1999, pp 229-232.

3. Koenig HG. Faith and Mental Health: Religious Resources for Healing. Philadelphia, Templeton Foundation Press, 2005, pp 88-90, 150-53.

4. Tek C, Ulug B. Religiosity and religious obsessions in obsessive-compulsive disorder. Psychiatry Res 2001;104:99-108.

5. Fontenelle LF, Mendlowicz MV, Marques C, et al. Trans-cultural aspects of obsessive-compulsive disorder: a description of a Brazilian sample and a systematic review of international clinical studies. J Psych Research 2004;38:403-411.

6. Okasha A, Saad A, Khalil AH, et al. Phenomenology of obsessive-compulsive disorder: a transcultural study. Compr Psychiatry 1994;35:191-197.

7. De Bilbao F, Giannakopoulos P. [Effect of religious culture on obsessive compulsive disorder symptomatology. A transcultural study in monotheistic religions] Rev Med Suisse 2005;1:2818-2821.

8. Greenberg D, Witztum E. The influence of cultural factors on obsessive compulsive disorder: religious symptoms in a religious society. Israel J Psych & Related Sciences 1994;31:211-220.

9. Gangdev PS. Faith-assisted cognitive therapy of obsessive-compulsive disorder. Aust N Z J Psychiatry 1998;32:575-578.

10. Fallon BA, Liebowitz MR, Hollander E, et al. The pharmacotherapy of moral or religious scrupulosity. J Clin Psychiatry 1990;51:517-521.

11. Alonso P, Menchon JM, Pifarre J, et al. Long-term follow-up and predictors of clinical outcome in obsessive-compulsive patients treated with serotonin reuptake inhibitors and behavioral therapy. J Clin Psychiatry 2001;62:535-540.

12. Mataix-Cols D, Marks IM, Greist JH, et al. Obsessive-compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: results from a controlled trial. Psychotherapy and Psychosomatics 2002;71:255-262.

13. Linden DE. How psychotherapy changes the brain-the contribution of functional neuroimaging. Mol Psychiatry 2006;11:528-538.

14. Miovic MM. An introduction to spiritual psychology: overview of the literature, east and west. Harv Rev Psychiatry 2004;12:105-115.

Great spirits have always encountered opposition from mediocre minds.
The mediocre mind is incapable of understanding the man who refuses to
bow blindly to conventional prejudices and chooses instead to express
his opinions courageously and honestly.
--Albert Einstein

Michael Miovic, MD

From the Dana Farber Cancer Institute, Psychosocial Oncology Program, Boston, MA.

Reprint requests to Michael Miovic, MD, Dana Farber Cancer Institute, Psychosocial Oncology Program, 44 Binney Street, G420, Boston, MA 02115. Email: [e-mail]