Introduction
Obsessive–compulsive disorder (OCD) is included in the neurotic, stress-related and somatoform disorders category in the ICD-10 (WHO, 1992), and is considered a genuine member of the anxiety disorders category in the DSM-IVTR but the presence of psychotic symptoms in OCD was reported nearly 70 years ago (Dowling etal. Reference Dowling, Pato and Pato1995). However, the precise nature of ‘psychotic symptoms’ is often confusing and their detection does not mean that there is a psychotic process associated with the disorder.
Lack of insight and perceptual disturbances are considered major components of psychoses. Lack of insight was the first most common symptom observed in schizophrenia (occurring in 97% of patients) followed by auditory hallucinations (74% of patients), which was the second most common symptom (Sartorius etal. Reference Sartorius, Shapiro and Jablensky1974). The first observation is different in OCD when the change of the patient's insight into the absurdity of the obsessive thought might change its categorisation, and the illness would be classified as OCD with poor insight. Lack of insight does not mean that there is an equivalent psychotic process or the illness has progressed into a psychotic phase.
Perceptual disturbances that are observed in psychotic disorders have also been reported in individuals with OCD (Fontenelle etal. Reference Fontenelle, Lopes, Borges, Pacheco, Nascimento and Versiani2008). These perceptual disturbances or hallucinations are not exclusive to psychotic disorders. In a large sample of psychiatric patients, hallucinations occurred in 53% of schizophrenic patients, 28% of patients with mood disorders, 80% of patients with dissociative disorders and 13% of patients with personality disorders (Romme & Escher, Reference Romme and Escher1996). Sensory phenomena are more frequently found in patients with OCD in Tourette's disorder than in patients with OCD alone (Miguel etal. Reference Miguel, Coffey, Baer, Savage, Rauch and Jenike1995).
The precise nature of these perceptual disturbances in OCD is poorly understood, and they could be classified as hallucinations regardless of their content. However, examination of the content of these experiences might reveal a strong transcultural dimension and the classification of the form as a hallucination becomes doubtful. For that reason using the term ‘sensory experiences’ is preferable in this series of cases.
In the following cases we describe what could be referred to as abnormal sensations or sensory phenomena rather than hallucinations in practicing Arab Muslim patients. They are often troubled by anal or penile sensations interfering with prayers and ablution. Ablution is performed five times daily before prayers, and is invalidated by passing urine or flatus. It is not uncommon for an individual to have doubts about these functions, but many become troubled with obsessional thoughts about cleanliness and compulsions (Karadaĝ etal. Reference Karadaĝ, Oguzhanoglu, Özdel, Ateşci and Amuk2006) to repeat the ablution. These obsessional doubts may be referred to as abnormal sensations or hallucinations. However, these sensory perceptions are not only limited to the religious rituals of ablution or prayers, and could be conceptualised as secondary to anxiety associated with obsessional thoughts or images. The latter concept is not readily accepted by many patients, who argue that their anxiety and obsessions are secondary to the sensations per se. The cases described below discuss the occurrence of these abnormal perceptions in different sensory modalities.
Cases
Case 1: visceral and penile sensations
A 21-year-old student presented with depression and severe social avoidance associated with religious obsessions and compulsions of few years duration. He spent 90 minutes on average using the toilet, 30–60 minutes in ablution, and a further 30–60 minutes practising each of the five Muslim daily prayers. His main complaint was anal and penile sensations of passing fluid, which he insisted were real, and unrelated to anxiety. He had a history of transient vocal tics at the age of 8 years. His mother suffered from anankastic personality disorder, and his older sister had an identical OCD with the exception of tics.
He also used deodorants to excess, avoiding social interactions and persistently seeking reassurance that he was not emitting bad odours. He was diagnosed as OCD with partial insight and was successfully treated by a combination of cognitive behavioural therapy (CBT) and pharmacotherapy (Clomipramine 150 mg daily and Sulpiride 150 mg daily). His condition remained stable for a few years.
Case 2: olfactory sensations
A 25-year-old university student who presented with panic attacks associated with extreme sense of depersonalisation. He had a history of OCD since adolescence characterised by checking behaviour and a variety of rituals as well as searching for symmetry. He was mostly troubled with ablution associated with visceral as well olfactory sensations of gas emitting from the kitchen area. He was helped by combined CBT and pharmacotherapy (150 mg Clomipramine, 100 mg Fluvoxamine and 5 mg Aripiprazole).
Case 3: joint sensations
A 22-year-old female presented with severe obsessions and compulsions mainly related to checking. She had a past history of transient trichotillomania and compulsive onychophagia (fingers and toes) of mild severity. She complained of being unable to prevent herself from repetitive clicking of her ankle joints and fingers triggered by a strange uncomfortable joint feeling that only subsided after exhausting the joint by repeated clicking. The condition improved on adding Pimozide to her double therapy of Sertraline and Clomipramine.
Case 4: auditory sensations
A 29-year-old single man presented with blasphemous ruminations during prayer times. He had a history of OCD since the age of 17 years. He complained of hearing the voice of the devil reciting during his prayers. His condition improved with antidepressant medication and psychotherapeutic input, but the devil's voice continued unchanged. He responded by adding Amisulipride titrated to 300 mg daily in divided doses.
Case 5: visual sensations
A 23-year-old man who had a 5-year history of OCD centred on checking behaviour started complaining of vivid visual hallucinations during prayer time. He did not accept that these were mental images related to his OCD, and described the blasphemous images as real and only seen when his eyes were opened. His visual perceptions worsened with increasing the dose of Sertraline to 200 mg daily. Sertraline was replaced with Clomipramine, but his condition worsened again on titrating the dose to 75 mg daily. He responded to combination of Citalopram 40 mg daily and Amisulipride 200 mg daily.
Case 6: vaginal sensations
A 26-year-old single lady had a 3-year history of OCD with checking behaviour and ruminations. Her presentation followed a concern of abnormal vaginal sensations occurring during prayer time. The sensations gradually increased over several months and interfered with her ablution. She had to abandon her prayers, and sought help initially for depression. Her condition did not respond to Sertraline or Clomipramine. Adding Risperidone 2 mg daily resulted in remission of her abnormal sensations and OCD symptoms.
Discussion
The six patients with OCD described in this article represent a cross section of many devout Muslims suffering from this disorder that are referred to in the Arabic Middle East as religious OCD. They often complain of physical sensations (visceral, tactile, olfactory or even auditory) associated with the compulsive behaviour prompted by obsessional thoughts. These sensations are distressing, and resemble obsessional mental events. Obsessional mental events are usually restricted to thoughts, images and impulses or urges, but these sensations or sensory obsessive phenomena encountered in some OCD cases appear to a have a cultural religious dimension.
Various types of perceptual disturbances in OCD patients have been widely acknowledged (Romme & Escher, Reference Romme and Escher1996). They are defined as subjective feelings or experiences that precede or accompany compulsions, often observed in patients with tic disorders, and referred to as sensory phenomena (Miguel etal. Reference Miguel, Coffey, Baer, Savage, Rauch and Jenike1995) or sensory tics. They are uncomfortable sensations, feelings or perceptions that may precede compulsions in the absence of obsessions, and arise in the part of the body involved in the subsequent motor act. Sensory tics are defined as transient recurrent somatic sensations experienced at or close to the skin, are readily localisable by the patient to a particular part of the body, recognised as stereotyped and unusual, experienced with or without an associated motor or vocal response, and occurring in the absence of obvious physical pathology (Chee & Sachdev, Reference Chee and Sachdev1997).
Intrusive sensory percept, which is an anal or a penile sensation of something passing out either flatus or a drop of urine or other penile secretions, is often the most distressing symptom of OCD in Muslim patients (Karadaĝ etal. Reference Karadaĝ, Oguzhanoglu, Özdel, Ateşci and Amuk2006). It could be the main presenting complaint overshadowing other symptoms.
The precise form of these sensory percepts is often challenging in clinical practice. They could be defined as hallucinations that are either real or false depending on the level of insight. They could be regarded as obsessional doubts that become conceptualised as abnormal perception by the patient as a result of intense anxiety to achieve perfection in practicing religious rituals. The auditory perceptions described in the above case resemble musical hallucinations in OCD patients that were probably the earliest kind of hallucinations to attract attention. In 2004, a survey by Hermesh etal. Reference Hermesh, Konas, Shiloh, Dar, Marom, Weizman and Gross-Isseroff(2004) in 52 OCD patients found that 30% complained of musical hallucinations compared with 3% in patients with schizophrenia. This indicates that abnormal sensory perceptions are common in patients with OCD.
DSM-IV defines hallucination as a sensory perception that has the compelling sense of reality of a true perception that occurs without external stimulation of the relevant sensory organ. Hallucinations are not amenable to direct and voluntary control by the experiencer, and occur in state of consciousness (Aleman & De Haan, Reference Aleman and De Haan1998). Consequently a true hallucination is a realistic experience (corporeal and assigned to the outside space) associated with impaired reality testing, and can be referred to as a psychotic hallucination. Non-psychotic hallucinations or pseudo-hallucinations on the other hand are not associated with impaired reality testing, and are associated with preserved reality testing. The sensory experiences described in the six cases above could be easily classified as true or false depending on the level of insight. Van Der Zwaard & Polak (Reference Van Der Zwaard and Polak2001) provided some guidelines deemed relevant for disentangling obsessions from hallucinations. They asserted that obsessions are usually associated with preserved reality testing and do not regularly display tactile, olfactory and gustatory qualities in contrast to the cases described above.
There is a cultural dimension to OCD in every society (Yorulmaz & Işık, Reference Yorulmaz and Işık2011). In Muslim culture it is a highly sensitive diagnosis and could be distressing because of the ablution and prayers, which are practiced five times daily. The sensitivity of this diagnosis could be understood by the Arabic term used to describe obsession ‘Waswas’ which means the devil. The occurrence of an abnormal sensory perception often suggests a severe illness adversely impacting on the functional performance of the patient.
Acknowledgment
The authors would like to thank all our patients who suffers from OCD.
