دینداری و وسواس مذهبی در اختلال وسواسی- اجباری

Religious obsessions constitute an interesting component of the phenomenology of obsessive–compulsive disorder (OCD). Perhaps in their most severe and continuous form, termed as ‘scrupulosity’, they attracted the attention of spiritual authorities long before the definition of ‘obsessional neurosis’ and at times were correctly recognized as a disease state (Greenberg et al., 1987). Early psychiatric theoreticians like Janet readily classified these as psychiatric rather than religious problems (cited in Greenberg et al., 1987). Freud (1961) (originally 1907), without limiting his theory to religious obsessions, went further and proposed a relationship between obsessive–compulsive symptoms and religious practices, calling obsessional neurosis an ‘individual religion’ and religion ‘a universal obsessional neurosis’. Knowledge about OCD has significantly increased in the last two decades. Despite this, systematic studies of religious obsessions, and of the relationship between religious and obsessive–compulsive phenomena, have rarely been performed. Although the epidemiology of OCD appears to be stable across cultures (Weissman et al., 1994), patients with religious obsessions may be over-represented in clinical populations of Muslim and Jewish Middle Eastern cultures, as compared with clinical populations from the West, India and the Far East. The frequency of religious obsessions in clinical populations diagnosed with OCD is reported to be 10% in the United States (Eisen et al., 1999), 5% in England (Dowson, 1977), 11% in India (Akhtar et al., 1975), and 7% in Singapore (Chia, 1996) as compared with 60% in Egypt (Okasha et al., 1994), 50% in Saudi Arabia (Mahgoub and Abdel-Hafeiz, 1991), 50% in Israel (Greenberg, 1984), and 40% in Bahrain (Shooka et al., 1998). There are exceptions to this trend such as a recent report of a large US sample in which 27% of OCD patients suffered from religious obsessions (Mataix-Cols et al., 1999) and a smaller US study that found 33% of OCD patients to have religious obsessions (Steketee et al., 1991). Turkey, with its geographical location bridging between Western Europe and the Middle East, its strictly secular state, and a predominantly liberal Muslim population, presents a unique opportunity for the study of religious obsessions. Two studies from the west coast of Turkey reported that religious obsessions in their clinical populations were 5 and 11.1%, respectively, rates similar to those found in Western studies (Egrilmez et al., 1997 and Alptekin, 1991, unpublished dissertation). We have previously reported a high frequency of OCD patients (48%) suffering from religious obsessions in Turkey's capital city, Ankara, which is located in the middle of the Anatolian peninsula (Tek et al., 1998). It should be noted that Hacettepe University Hospital, where this study was conducted, is a tertiary care center with an overabundance of referrals due to treatment resistance and/or complexity, with patients from all over the country, although with more from the middle and eastern parts of Turkey. Finally, a 34% rate was reported from eastern Turkey (Tezcan and Millet, 1997). It appears that the frequency of religious obsessions in Turkish OCD samples changes depending on the geographical location, possibly becoming higher when the site of the study is closer to other countries where high rates of religious obsessions are reported. Certainly many confounding factors may be at play, as there are vast socioeconomic differences between different parts of Turkey (e.g. the West is richer and more modernized than the East). In this study, we attempted to further explore this interesting clinical phenomenon, especially in the context of the relationship between religiosity and the presence of religious obsessions and other disease variables.

Religious obsessions constitute an interesting component of the phenomenology of obsessive–compulsive disorder (OCD). Perhaps in their most severe and continuous form, termed as ‘scrupulosity’, they attracted the attention of spiritual authorities long before the definition of ‘obsessional neurosis’ and at times were correctly recognized as a disease state (Greenberg et al., 1987). Early psychiatric theoreticians like Janet readily classified these as psychiatric rather than religious problems (cited in Greenberg et al., 1987). Freud (1961) (originally 1907), without limiting his theory to religious obsessions, went further and proposed a relationship between obsessive–compulsive symptoms and religious practices, calling obsessional neurosis an ‘individual religion’ and religion ‘a universal obsessional neurosis’. Knowledge about OCD has significantly increased in the last two decades. Despite this, systematic studies of religious obsessions, and of the relationship between religious and obsessive–compulsive phenomena, have rarely been performed. Although the epidemiology of OCD appears to be stable across cultures (Weissman et al., 1994), patients with religious obsessions may be over-represented in clinical populations of Muslim and Jewish Middle Eastern cultures, as compared with clinical populations from the West, India and the Far East. The frequency of religious obsessions in clinical populations diagnosed with OCD is reported to be 10% in the United States (Eisen et al., 1999), 5% in England (Dowson, 1977), 11% in India (Akhtar et al., 1975), and 7% in Singapore (Chia, 1996) as compared with 60% in Egypt (Okasha et al., 1994), 50% in Saudi Arabia (Mahgoub and Abdel-Hafeiz, 1991), 50% in Israel (Greenberg, 1984), and 40% in Bahrain (Shooka et al., 1998). There are exceptions to this trend such as a recent report of a large US sample in which 27% of OCD patients suffered from religious obsessions (Mataix-Cols et al., 1999) and a smaller US study that found 33% of OCD patients to have religious obsessions (Steketee et al., 1991). Turkey, with its geographical location bridging between Western Europe and the Middle East, its strictly secular state, and a predominantly liberal Muslim population, presents a unique opportunity for the study of religious obsessions. Two studies from the west coast of Turkey reported that religious obsessions in their clinical populations were 5 and 11.1%, respectively, rates similar to those found in Western studies (Egrilmez et al., 1997 and Alptekin, 1991, unpublished dissertation). We have previously reported a high frequency of OCD patients (48%) suffering from religious obsessions in Turkey's capital city, Ankara, which is located in the middle of the Anatolian peninsula (Tek et al., 1998). It should be noted that Hacettepe University Hospital, where this study was conducted, is a tertiary care center with an overabundance of referrals due to treatment resistance and/or complexity, with patients from all over the country, although with more from the middle and eastern parts of Turkey. Finally, a 34% rate was reported from eastern Turkey (Tezcan and Millet, 1997). It appears that the frequency of religious obsessions in Turkish OCD samples changes depending on the geographical location, possibly becoming higher when the site of the study is closer to other countries where high rates of religious obsessions are reported. Certainly many confounding factors may be at play, as there are vast socioeconomic differences between different parts of Turkey (e.g. the West is richer and more modernized than the East). In this study, we attempted to further explore this interesting clinical phenomenon, especially in the context of the relationship between religiosity and the presence of religious obsessions and other disease variables.

Nineteen subjects had religious obsessions, as compared with 26 subjects without them. Table 1 presents relevant socio-demographic variables. Patients with religious obsessions were significantly younger than patients without them (mean difference in age=8.3 years). There were no sex differences between the two groups, though there were more females in both groups. Educational levels, marital status, socioeconomic levels according to physician's evaluation, and residence in a rural or urban location did not differ significantly in the two groups. Mean RPI scores also were not significantly different. Table 1. Sociodemographic characteristics Patients with Patients without Statistic P * religious obsessions religious obsessions N=19 N=26 Age [mean years (S.D.)] 25.9 (7.5) 34.2 (11.9) t=2.66 (d.f.=43) <0.02 Sex [N female (%)] 14 (73.7) 21 (80.8) χ2=0.32 (d.f.=1) NS Education [mean years (S.D.)] 11.2 (5.0) 9.6 (4.6) t=−0.98 (d.f.=43) NS Socioeconomic status 0–5 3.0 (0.9) 2.7 (1.0) t=−0.95 (d.f.=42) NS [mean (S.D.)], range Marital status 8 (42.1) 14 (56.0) χ2=1.90 (d.f.=2) NS [N married (%)] Location lived 16 (84.2) 21 (80.8) χ2=0.89 (d.f.=1) NS [N urban (%)] Religious practices index (RPI) 2.6 (1.1) 2.7 (1.0) t=0.33 (d.f.=42) NS [mean score (S.D.)], range 1–4 * NS means P>0.05. Table options As shown in Table 2, Y–BOCS scores, obsession and compulsion subscores, and MOCI scores were not significantly different between the two groups. The patients with religious obsessions reported significantly more obsession categories but not compulsion categories than the group without religious obsessions. Time since the first diagnosis was longer in the group without religious obsessions, though this difference did not reach statistical significance (mean difference of 33.1 months). A family history of OCD characterized 41% of the patients, a percentage that was similar in the two groups. One patient with religious obsessions met the criteria for accompanying major depression as compared with six patients in the group without religious obsessions. Mean HAM-D scores were not significantly different in the groups, and symptom composition was also similar. Table 2. Clinical characteristics Patients with Patients without Statistic P * religious obsessions religious obsessions N=19 N=26 Time since first diagnosis 41.1 (28.9) 74.2 (70.2) t=1.42 (d.f.=42) NS [mean months (S.D.)] Family history of OCD 8 (42.1) 10 (40.0) χ2=0.02 (d.f.=1) NS [N positive (%)] MOCI total score 20.2 (5.95) 21.9 (7.1) t=0.82 (d.f.=42) NS [mean (S.D.)] Y–BOCS total score 24.8 (6.2) 25.0 (8.3) t=0.11 (d.f.=43) NS [mean (S.D.)] Y–BOCS obsession score 12.2 (3.5) 12.5 (4.1) t=0.25 (d.f.=43) NS [mean (S.D.)] Y–BOCS compulsion score 12.6 (3.4) 12.6 (5.2) t=−0.03 (d.f.=43) NS [mean (S.D.)] Y–BOCC number of obsessions 3.84 (0.90) 2.19 (0.80) t=−6.48 (d.f.=43) <0.001 [main categories mean (S.D.)] Y–BOCC number of compulsions 3.37 (1.12) 2.81 (1.47) t=−1.39 (d.f.=43) NS [main categories mean (S.D.)] HAM-D total score 7.32 (4.83) 10.88 (6.87) t=1.94 (d.f.=43) NS [mean (S.D.)] Major depression 1 (5.3) 6 (23.1) χ2=2.65 (d.f.=1) NS (DSM-IV), [N diagnosed (%)] Y–BOCS, Yale–Brown Obsessive-Compulsive Scale; Y–BOCC, Yale–Brown Obsessive-Compulsive Checklist; MOCI, Maudsley Obsessive-Compulsive Inventory; HAM-D, Hamilton Depression Scale (17 items). * NS means P>0.05. Table options Principal component analysis revealed a five-factor solution, which explained 65.5% of the variance. The first factor (contamination/cleaning) explained 17.8% of the variance and included contamination obsessions, cleaning and repeating compulsion categories with loadings ranging between 0.82 and 0.60. The second factor (symmetry/ordering, 15.2% of the variance) included symmetry and somatic obsessions and ordering compulsions with loadings 0.87–0.5. The third factor (aggressive/counting, 13.7% of the variance) included aggressive obsessions and counting compulsions with loadings of 0.72 and 0.54, respectively. Hoarding compulsions were also found in this group, with a weaker 0.19 loading. The fourth factor (sexual/religious obsessions, 9.7% of the variance) included sexual and religious obsessions with loadings of 0.69 and 0.55, respectively. This factor was the only pure obsessive factor. The fifth factor (checking/hoarding compulsions, 9.2% of the variance) included checking and hoarding compulsions with loadings of 0.88 and 0.18, respectively, and was the only pure compulsive factor. This five-factor solution is very similar to that found in the much larger study of Mataix-Cols et al. (1999) and other similar studies (Baer, 1994 and Leckman et al., 1997). Table 3 presents scores derived from this solution as well as the level of insight about symptoms for the groups with and without religious obsessions. Table 3. Major symptom factors Symptom factors Patients with Patients without t P * religious obsessions religious obsessions N=19 N=26 Mean (S.D.) Mean (S.D.) Contamination/cleaning 2.74 (0.56) 2.27 (1.08) t=−1.72 (d.f.=43) NS Symmetry/ordering 1.47 (1.17) 0.96 (1.0) t=−1.58 (d.f.=43) NS Aggressive/counting 1.37 (0.68) 1.08 (0.8) t=−1.29 (d.f.=43) NS Sexual/religious obsessions 1.37 (0.5) 0.27 (0.45) t=−7.73 (d.f.=43) <0.001 Checking/hoarding compulsions 0.26 (0.45) 0.42 (0.58) t=1.00 (d.f.=43) NS Level of insight into symptoms 1.00 (1.05) 1.12 (1.18) t=0.34 (d.f.=43) NS (Y–BOCS item 11, range 0–4) * NS means P>0.05 Table options There were no correlations between RPI scores and Y–BOCS total scores and subscores, MOCI total scores, or the total number of categories of obsessions or compulsions (highest r=0.25, lowest P=0.10). Interestingly, the RPI score was negatively correlated with years of education (r=−0.56, P<0.001) and socioeconomic level (r=−0.33, P<0.05). For this reason we felt the need to take into account demographic variables (age, sex, educational level, and socioeconomic level) before we explored the relationship between religiosity and major symptom factors. A linear regression analysis with the RPI score as the dependent variable, and the four demographic variables and the five symptom factors as the independent variables, confirmed a significant negative association between educational level and RPI score (β=−0.50, partial r=−0.46, d.f.=9,34, P<0.005). There was a strong but non-significant association between the contamination/cleaning factor and the RPI score (β=0.30, partial r=0.32, P=0.055). The remaining independent variables, including the religious/sexual obsessions factor, were not significantly associated with RPI scores (highest β=0.19, lowest P=0.17). The presence of religious obsessions, on the one hand, and age, sex, educational level, socioeconomic level, time since first diagnosis, RPI score, Y–BOCS score, and number of categories of obsessions and compulsions, separately as rated on the Y–BOCC, on the other hand, entered a logistic regression analysis. The total number of categories of obsessions emerged as the single significant predictor for the presence of religious obsessions (R=0.32, Wald χ2=8.00, d.f.=1, P<0.005). The remaining variables, including the total number of compulsions and the RPI score, were not significant predictors (highest R=0.09, highest Wald χ2=2.43, d.f.=1, lowest P=0.12)