David Greenberg

Obsessive compulsive disorder in ultra-orthodox Jewish patients: A comparison of religious and non-religious symptoms

Of 28 ultra-orthodox Jewish psychiatric referrals with obsessive compulsive disorder, 26 had religious symptoms, while 18 had non-religious symptoms. On average, each patient had three times more religious symptoms than non-religious symptoms. In only nine cases did the patients view their non-religious symptoms as the main difficulty, and all of these nine cases were ultra-orthodox from birth. There was no significant difference between the distress, resistance, sense of irrationality and hours spent daily of religious and non-religious symptoms. Further, there was no significant difference between the age of onset, age when felt to be a disturbance, and duration until help was sought. They were more likely to turn for help initially to a religious authority for a religious symptom and a mental health worker for a non-religious symptom. It may be concluded that the religious and non-religious symptoms of obsessive compulsive disorder in ultra-orthodox Jews are not experienced in markedly different ways by the sufferers. Two limitations to the study are the sample size, and the selection bias in that all had sought professional help, of itself likely to reflect their attitude to obsessive compulsive disorder.

Interactive effect of Cytochrome p450 17α-hydroxylase and dopamine D3 receptor gene polymorphisms on Abnormal Involuntary movements in chronic Schizophrenia

BACKGROUND Tardive dyskinesia is a chronic adverse effect of anti psychotic drugs, where association with a polymorphic site in the dopamine D3 receptor gene has been previously reported. Cytochrome P 450 17alpha-hydroxylase activity has been implicated with modulation of central dopamine release as well as neuroprotection. We investigated the association of a T -->C variation in the cytochrome P 450 17alpha-hydroxylase gene with tardive dyskinesia in patients with chronic schizophrenia. METHODS Cytochrome P 450 17 allele and genotype frequencies were compared between matched schizophrenia patients with (n = 55) or without tardive dyskinesia (n = 58). Interactive effects of cytochrome P 450 17alpha-hydroxylase with the dopamine D3 Ser9Gly polymorphism on abnormal involuntary movements were examined. RESULTS There was no difference in cytochrome P 450 17alpha-hydroxylase genotype distribution between patients with and without tardive dyskinesia; however, patients carrying the cytochrome P 450 17alpha-hydroxylase A2-A2 genotype and the dopamine D3gly allele had the highest orofacial (p <.04), distal (p <.05), and incapacitation (p <.04) scores on the Abnormal Involuntary Movements Scale. CONCLUSIONS Schizophrenia patients who carry the dopamine D3gly allele and the cytochrome P 450 17alpha-hydroxylase A2-A2 genotype may be more likely to develop abnormal orofoacial and distal involuntary movements and to be incapacitated by these movements when chronically exposed to classical antipsychotic drugs.

Scrupulosity: A Unique Subtype of Obsessive-Compulsive Disorder

The earliest descriptions of obsessive-compulsive disorder (OCD) were religious, as was the understanding of their origins. With the emancipation, religion in OCD was relegated to its status today: a less common symptom of OCD in most Western societies known as scrupulosity. The frequency of scrupulosity in OCD varies in the literature from 0% to 93% of cases, and this variability seems predicated on the importance of religious belief and observance in the community examined. Despite the similarities between religious ritual and compulsions, the evidence to date that religion increases the risk of the development of OCD is scarce. Scrupulosity is presented as a classic version of OCD, with obsessions and compulsions, distress, and diminished functioning similar to those of other forms of OCD. The differentiation between normal religiosity and scrupulosity is presented, and the unique aspects of cognitive-behavioral therapy in treating scrupulosity, especially in religious populations, are reviewed.

Compulsive prayer and its management.

Religious symptoms have been recognized as a presentation of obsessive-compulsive disorder (OCD) for centuries. The two main treatment strategies for OCD, cognitive behavior therapy (exposure and response prevention [ERP]), and SSRIs have been shown to be effective in religious OCD. The presentation of religious OCD within formal prayer, reported in Judaism and Islam, poses special challenges of inaccessibility of personal prayer, sanctity of the symptom, and the status of the therapist. A method of guided-prayer repetition, a variant of ERP, is described, and its successful application is reported in three cases of ultra-orthodox Jewish men with prayer as the main symptom of their religious OCD.

The wife of God.

The case was presented of an ultra-orthodox Jewish woman who believed that she is the wife of God. Such a belief may be normative in some religions, but not in Judaism, where closeness to God is understood as a metaphor. Although the patients beliefs are not acceptable within ultra-orthodox beliefs, there are examples of such ideas within the history of religious Judaism. The deviance of her delusions from the religious norm would appear to be deceptively minor. The similarities in content and underlying factors with possession states such as dybbuk and maggid are considered. Being the wife of God may be understood in terms of her disappointments and represent gaining control over the uncontrollable in her life and society. The details of the case management are presented to demonstrate the importance of discussing her ideas with her and working with community authority figures while respecting their status and rulings.

Religion and psychiatry: beyond boundaries, edited by P.J. Verhagen, H.M. van Praag, J.J. Lopez-Ibor Jnr, J.L. Cox, and D. Moussaoui

Asking a psychiatrist to write about religion or spirituality is not simple. As professionals we are moulded into a world view, and if we have a religious identity, it may be encapsulated in a space apart from our professional identity. Further, there is little reason why a mental health professional should be an authority on religion, his/her own or that of anyone else. For these reasons it is difficult to write good books on the subject. Pargament (2007) has written an inspiring book, Spiritually Integrated Psychotherapy: Understanding and addressing the sacred, with the clear voice of a single author who has researched the subject for decades and is a committed therapist. The Royal College of Psychiatrists has published a gem, Spirituality and Psychiatry (ed. Cook, Powell & Sims, 2009), and, although an edited work with 23 authors, it is based on a decade of discussions by a spirituality forum. Very different works, they have a coherence that is remarkable for this complex marriage of subjects. The World Psychiatric Association has been publishing a series of edited works on a range of subjects. The volume on spirituality and religion has 33 chapters and 55 authors from 17 countries. From some of the editorial comments, it would appear that an attempt was made to impose focus and consistency, but, for better and worse, this was often lost. The list of authors includes many who have written extensively on these topics and their contributions are solid, stimulating and up-to-date. By contrast, there are chapters in which the material is gathered in an idiosyncratic way, and topics are returned to several times in the course of the book. An example of the former, Bill Fulford, one of the ‘‘usual suspects’’ in any book on psychiatry and religion, presents the contribution of linguistic analysis, looks at the meaning of words in clinical psychiatry, and introduces the concept of values-based practice. So much clinical work involves putting together a range of world views. The four practice skills he lists in values-based practice are awareness, reasoning, knowledge and communication. Awareness is of the values in a given situation, with careful attention to language. A personal example, when asking a patient in Hebrew if they hear voices (is there a not-silly way of asking this question?), I must be aware that the Hebrew word for a voice is the same as a sound. Questioning and stimulating as always, Fulford leaves you with a taste for more. The section on the different religions is particularly uneven. Peteet, another ‘‘usual suspect,’’ writes a thoughtful account of the difficulties Christians may encounter in seeking help, and the difficulties faced by therapists. He includes the impact of clergy abuse, and discusses the differences between a therapist and a spiritual guide. On Islam, Okasha presents seven articles of the Cairo Declaration of Human Rights in Islam from

Pharmacotherapy Trials in Posttraumatic Stress Disorder: Prospects and Problems

Although a clinical symptom picture resembling the currently accepted DSM-III diagnosis of posttraumatic stress disorder (PTSD) has been recognized for decades, focused trials of psychopharmacological agents are a relatively recent development. The initial report by Hogben and Cornfield1 of a dramatic effect of treatment with the monoamine oxidase inhibitor phenelzine in patients with “traumatic war neurosis” has been followed by a spate of positive reports. These reports have attributed beneficial effects to a variety of drugs including tricyclic antidepressants,2,3 the limbic anticonvulsant carbamazepine,4 and the β-receptor blocker propranolol.5 Contrary to these generally optimistic reports, our experience with psychotropic agents in Israeli samples of PTSD patients has been less encouraging. This experience has been for the most part prospective and, in two studies, double-blind in nature using a drug/placebo crossover design.